Burning Down The Medical Village To Save It: The Folly Of Big Data In Medicine

Rena Xu's recent piece in The Atlantic on physician burnout is mostly interesting for its between-the-lines reporting. Yes, Big Data (i.e. medical coding) is driving a lot of physician burnout:

Regulations governing the use of electronic medical records (EMRs), first introduced in the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, have gotten more and more demanding, while expanded insurance coverage from the Affordable Care Act may have contributed to an uptrend in patient volume at many health centers. These changes are taking a toll on physicians: There’s some evidence that the administrative burden of medicine—and with it, the proportion of burned-out doctors—is on the rise. A study published last year in Health Affairs reported that from 2011 to 2014, physicians spent progressively more time on “desktop medicine” and less on face-to-face patient care. Another study found that the percentage of physicians reporting burnout increased over the same period; by 2014, more than half said they were affected.

But won't we need ever-more new physicians to deal with the aging US population? Yes, we will, but —

A quarter of U.S. physicians are expected to retire over the next decade, while the number of older Americans, who tend to need more health care, is expected to double by 2040. While it might be tempting to point to the historically competitive rates of medical-school admissions as proof that the talent pipeline for physicians won’t run dry, there is no guarantee. Last year, for the first time in at least a decade, the volume of medical school applications dropped—by nearly 14,000, according to data from the Association of American Medical Colleges. By the association’s projections, we may be short 100,000 physicians or more by 2030.

And this despite modest, recent upticks in new physicians, even despite Medicare's meddling in internship slots. In addition, the article cites the "Resident Physician Shortage Reduction Act ... [which] would add 15,000 residency spots over a five-year period." That's a 1.6% increase vs. the 2014 physician population of 916,264, but nothing compared to the gaping hole implied by 100,000 missing doctors. Mandated medical coding — the raw material of Big Data in medicine — contributes to a physician burnout we can scarcely afford.

But this kind of insanity is to be expected. The people who imagine they are helping very frequently do not subject themselves to the consequences of their "help" (viz., Jonathan Gruber, who is not a doctor). The meretricious belief that big data will somehow "bend the cost curve" is deeply embedded, including, especially, in service providers with something to sell. There are costs to acquiring that data, and that cost is, more administrative overhead (emboldening mine):

...[D]octors are most valuable when doing what they were trained to do—treating patients. Likewise, non-physicians are better suited to accomplish many of the tasks that currently fall upon physicians. The use of medical scribes during clinic visits, for instance, not only frees doctors to talk with their patients but also potentially yields better documentation. A study published last month in the World Journal of Urology reported that the introduction of scribes in a urology practice significantly increased physician efficiency, work satisfaction, and revenue.

And who pays for that increased revenue? Ultimately, it's the patients, of course, or the government (taxpayers) if it's Medicare/Medicaid.

Sarah Kliff, Promoter Of Democratic Healthcare Fantasies

Vox's Sarah Kliff, last seen before 2016 election whistling past the Obamacare graveyard, now chirps about the number of Democratic health care proposals! Yay, team!

It’s notable to me that Democrats seem really keen on having another health care debate. They’re preparing for it by putting all these different options on the table, to sort through where a consensus might exist.

And the "options" really boil down to a Hobson's choice: how do you want your government-controlled health care delivered? All from the government right now (single-payer, a consistent loser at the polls)? Pretending that single-payer isn't the endgame right away (Medicare/Medicaid buy-in, i.e. the public option)? However you cut it, the belief in magical government intervention as an elixir is central to all of them. None of these will fix the physician shortage, nor will it fix the patent system, nor the regulatory moats around pharmaceuticals. Kliff doesn't concern herself with those kinds of details; her job is that of cheerleader. We know this because the second half of her article goes on to explain the wonders of the Murphy-Merkley plan, during which she writes the following:

The Choose Medicare Act envisions that individuals and companies would cover their costs for buying into Medicare, meaning actuaries would need to determine what those premiums would look like. There is some reason to expect these premiums would be lower than premiums for private insurance, because Medicare typically pays lower prices.

There are a lot of things to say about that, not least the shifting terrain that a large influx of new "insureds" would look like; recall that the Obamacare cohort was sicker than the general population, i.e. the incentives are for such people to seek out such care. There's hardly a reason to think a "public option" would save material costs, and considerable reasons to think it would do worse (i.e. the Democrats would be sure to goose the actuarial realities by way of further subsidies).

Another problem is the quip sometimes attributed to Stalin, that quantity has a quality all its own. Kliff is right that private payers pay more for their services than Medicare. But assuming Medicare expansion will fix costs also assumes that physicians will continue to accept Medicare patients. While data is hard to come by, Texas Medical Association figures showed a dramatic drop in the acceptance of new Medicare patients from 2000 (when 67% of physicians accepted all comers) to 2010 (only 31%). Moreover, given that Medicare represents a relatively small fraction of physician income (as of 2011, around 40% in Texas, see PDF page 5), expanding it would demand physicians take a substantial pay cut. That they might opt out of accepting new patients or stop seeing Medicare patients altogether. Second-order effects: we can haz them!

Bullety Stuff, Sunday Edition

• The narrative that Republicans are the principle reason why Obamacare isn't working is remarkably durable. Maybe Democrats should have created a system that wouldn't depend on their political enemies implementing it?
• The rise of the employer-provided "exclusive provider" health insurance plan. It eliminates out-of-network options for most things, but at a substantial savings ("double digit").
• Data Gone Odd looks at rape statistics (and particularly false reporting of rape) in a two-part series (part 1, part 2). As Scott Greenfield summarizes,
  
  

  The 2-10% false rape accusations stat is untrue. Actual stats:
  
  True-ish: 35.3%
  Definitively False: 5.9%
  Inconclusive: 58.8% https://t.co/6fMxzd3EaL

  — Scott Greenfield (@ScottGreenfield) July 16, 2017

• Perhaps the first recorded instance of publish or penis, i.e. the theory that getting cited in others' work "contribute[s] to 'white heteromasculinity'". 
• Steven Pinker thinks Harvard's attempt to shut down off-campus clubs starting in 2022 is a terrible idea. 
• Free speech is terrible, says progressive Christina Berchini.
• Even Vox Dep't: Nancy MacLean's hackish attack on the Public Choice school of economics backfires, Vox runs a wholly reasonable response, warning against reading everything as a conspiracy theory.

Obamacare As Bad Slasher Pic

The cliché being that the thing has so many false endings, you never really know when it's over, but Obamacare's demise looks closer than it did before Trump got into office. The Democratic defenders of the law continue to delude themselves about the realities on the ground there, but decreasing numbers of providers (many counties have only one now) and dramatically increasing premiums (around 22-25%, depending on who you listen to) have set in motion real problems that cannot be wished away. Well, they can be wished away, as witness Kevin Drum, one of the bill's big proponents at the time, now a peddler of bizarre counterfactuals that would have been politically impossible at the time. Megan McArdle takes him to task (emboldening all mine):

So “lying” was simply not an option. Neither was “doubling the cost and whacking up the mandate.” Democrats were already having trouble getting their $1 trillion bill passed. This was a bill so unpopular that the state of Massachusetts (!) sent a Republican senator to Congress to stop it.

Let’s stop for a moment and ponder that. It’s common to hear Democratic pundits lament that centrist senators like Ben Nelson and Joe Lieberman held the bill hostage, forcing it to be underpowered to the task and leading to the failures of today. But if Massachusetts balked at signing up for this, then the problem wasn’t just with a few squishy moderates. Had Democrats pushed for a $2 trillion bill with a much larger mandate, as Drum wishes, the issue wouldn’t have been a handful of DINO senators -- it would have been the folks from deep-blue states fleeing for cover ahead of a mob of angry constituents.

Democrats have been running from that mob for three straight Congressional election cycles now, and appear to have learned nothing from it. The most common defense of the bill, one I hear most often from the bill's promoters, essentially amounts to, "I got mine". That is, because the speaker has subsidized insurance (or at times, insurance at all), Obamacare has no perceptible flaws and thus needs no "fixing". I have some sympathy for this position; my autistic brother was ineligible for medical insurance prior to ACA passage, on the bizarre grounds that he had a preexisting condition of some sort that precluded it. (Insofar as I know, autism comes with no other health problems that would make him a bad risk in that way, but the insurers wanted none of him.) So he is one of the "winners" in this game. Ditto Mat Gleason, the retired Angels blogger (and still publisher of Coagula Curatorial), who needed very expensive life-saving heart surgery he could have never afforded otherwise.

But these anecdotal wins are not statistical or electoral wins. By clinging to "I got mine", ACA defenders ignore the real problems the law inflicts on others. This has gone on for a while now; I posted back in August about Sarah Kliff's delusional attempts to woo her way out of that deep well. Well before the late election, Democrats had started to distance themselves from the law:

In October, Minnesota's Democratic governor, Mark Dayton, complained publicly that although the health law had "many good features," it was "no longer affordable to increasing numbers of people." Around the same time, Democratic House Minority Leader Nancy Pelosi, whose determination to pass health care legislation helped push the bill over the congressional finish line in 2010, was asked on Meet the Press about the high price of health insurance premiums under the law. "Let's see how it works, and let's improve it," was her response. She also noted, as she has before, that what she would really "love" is a single-payer system. Just three years before, as the law's coverage expansion kicked in, she had touted it as a path to "more affordability, more accessibility, better-quality care, prevention, wellness, a healthier nation honoring the vows of our founders of life, a healthier life."

Also in October came complaints from former President Bill Clinton about a provision of the law that provides financial assistance to individuals at between 100 and 400 percent of the poverty line. "The people that are getting killed in this deal are small business people and individuals who make just a little too much to get any of these subsidies," he said at a rally in Michigan. He called the subsidy scheme "crazy" and declared that "it doesn't make sense. The insurance model doesn't work here."

 So, will the Republicans repeal the law? It's not clear; as Peter Suderman writes,

Several GOP legislators said that a provision allowing dependents up to age 26 to stay on their parents' plans would almost certainly be kept. In anonymous interviews, GOP aides suggested that the Medicaid expansion, responsible for much of the law's coverage gains, might also stay in place. And any major rollback that did occur would almost certainly be delayed for a year or two while Republicans tried to put a replacement plan together.

"Sen. Lamar Alexander (R–Tenn.), the chair of the Senate Health, Education, Labor, and Pensions Committee, which would be critical to the development of any real plan, suggested that crafting a detailed alternative would take around six years", which tells you that the political struggles are real within the GOP. The political will to change the law is there, but wholesale repeal is another matter, and unlikely. Sadly, it's the popular features of subsidies and mandated issue that cause the most damage in terms of higher premiums, yet those are the least likely to go away. Stay tuned.

Plumbing The Mind Of Obamacare's True Believer

I had the occasion to read two Sarah Kliff pieces on Vox in as many days, and while I can't recommend them for overall content, I do read them as a certain "tell" as to how Obamacare true believers are processing the late news that Aetna will be exiting most exchanges, representing eleven states, as well as Humana paring back its participation from 15 to 11 states. This was no surprise given Aetna warned the Department of Justice that blocking its proposed merger with Humana would result in it exiting Obamacare exchanges.

Kliff is not entirely delusional, as these grafs attest:

The marketplaces' failures to attract a robust group of health plans to many areas suggests that Obamacare’s insurance expansion is on the path to looking like other safety net programs we know, offering limited services to a predominantly low-income population.

"The exchange population — 85 percent of which qualifies for financial assistance — looks a lot like the Medicaid population," says Michael Adelberg, who previously served as the administration’s acting director of the exchange policy. "And with it, we’re seeing the start of the ‘Medicaid-ization’ of exchange plans: narrow networks with no frills."

Which is largely to say, the Medicaid expansion has been a "success", to the extent it has signed new people eligible under the new guidelines. However,

All available evidence suggests that the law is helping these people gain access to medical services that were previously out of reach — and there isn’t much reason to think this will change. Even when there are large premium spikes, more than 80 percent of marketplace enrollees have subsidies that ensure their monthly fees remain affordable.

So, recapping,

1. Subsidies pasting over skyrocketing premiums are Jim dandy, i.e. if someone else pays the freight, the problem of absurd costs no longer exists, Q.E.D.
2. This is true no matter how many insurers exist in these markets. 

The second point is the more important one, because if the number of providers goes to zero, the subsidy will not matter. This elemental fact is apparently lost on her. Kliff is likewise completely baffled by the bureaucratic monster she otherwise endorses (emboldening mine, as usual):

It is the considerable burden our fragmented system puts on patients to coordinate their own care.

I'm not talking about the work of managing one's health, the work that diabetics do to monitor their blood sugar or the healthy eating choices a doctor might recommend for an overweight patient. This can be a significant burden in its own right.

What I didn't understand was the burden patients face in managing the health care system: a massive web of doctors, insurers, pharmacies, and other siloed actors that seem intent on not talking with one another. That unenviable task gets left to the patient, the secret glue that holds the system together.

Kliff naively believes that a cobbled-together system of shreds and patches and bureaucratic fumbling will do otherwise, especially when the payer is some combination of state and private entities. In that case, the most important person in this equation is always the payer, with the beneficiary coming in second, -ish. "Glue" is what we do to unfortunate race horses.

Update: Comes this Vox podcast starting Matt Yglesias, Ezra Klein, and Sarah Kliff in which they gabble on about how Obamacare isn't failing somehow (h/t Catherine Siena). The chirpy, twee tone about collapsing numbers of providers (and, what they don't mention, rising costs) reminds me of teenagers who broke a window without getting caught. No remorse, no apologies, no regrets; their earnest intentions, apparently, are enough.

The Return Of The Mutual Aid Society

The title is probably misleading, as the Odd Fellows and Knights of Columbus are still around, but Reason has a fascinating story in the "reports of my death have been greatly exaggerated" vein: mutual aid societies (in the guise of "sharing ministries") have made a comeback in the wake of Obamacare.

I predicted that Obamacare would lead to the demise of Samaritan and two similar organizations in the U.S. This model, I thought, wouldn’t be able to compete with the heavily subsidized plans soon to become available on the new health-care exchanges.

Wow, did I get that wrong. As The New York Times reported recently,

[M]embership in sharing ministries has more than doubled over the last six years, to 535,000 from about 200,000…The growth seems to have come largely through word of mouth, at churches, schools and workplaces.

There's also this:

The opportunity to help their fellow Christians is something these men and women deeply value. "Instead of wanting to be part of an insurance company, I wanted to be part of something where the body of Christ was banding together and doing what the bible commanded in a more personal and real way," Samaritan's Executive Vice President James Lansberry told me in an interview.

 Yes, this. One of the basic problems I see with the state-centered approach to charity is how much it divorces the giver from the recipient. I'm not sure how real that connection can be in an organization that now numbers 200,000 members, but it certainly seems more likely than a huge bureaucracy numbering millions.

Obamacare Enrollment Is Not The Same Thing As Paid For

Something I came across thanks to a tweet by Rich Weinstein yesterday: it turns out that, while Obamacare enrollment is only a smidge off-target, comparatively, the number of people who have actually paid for coverage is a vastly different thing:

"Facts are stubborn things..."
Jordan Candler: Is the ObamaCare Death Spiral Underway? — The Patriot Post https://t.co/ywv8wQL1tl

— Rich Weinstein (@phillyrich1) March 16, 2016

As The Hill notes, only 8.8 million people have actually paid for their services, "a drop of almost 25 percent compared to the 11.7 million people who were signed up at the beginning of 2015." As the Kaiser Family Foundation report in the story at the tweet above notes,

Affordability remains a challenge. A recent Kaiser poll found that the overwhelming reason why people who are uninsured say they are uncovered is cost – 46% of uninsured, non-elderly adults say they tried to get coverage but found that it was too expensive. However, it is difficult to separate lack of affordability from lack of awareness of financial help that may be available, which could be addressed through more intensive outreach. For example, going into this last open enrollment period, another poll found that 82% of uninsured adults had not been contacted in the previous 6 months about the health law.

Ya think? It was always a bad idea to rely on young adults as the fiscal backbone of Obamacare. Such have poor-paying jobs, and careers delayed by minimum wage hikes keeping young people out of the labor market at near record levels — and thus delaying their advancement to other, better-paying jobs.

Price Controls, The Next Phase Of Health Care "Reform"

Daily Kos has discovered that Medicare isn't a good gauge of medical spending (this is my shocked face), because Medicare reacts to an entirely different set of stimuli and constraints than private actors:

The research looked not only at Medicare but also at a huge, new database drawn from private-insurance plans—the sorts used by most Americans for health care. And it shows that places that spend less on Medicare do not necessarily spend less on health care over all. Grand Junction, as it happens, is one of the most expensive health care markets in the country for the privately insured—despite its unusually low spending on Medicare.

So the answer (you won't be surprised) is cost controls!

All of this boils down to an idea that isn't at all new: in order to really rein in healthcare costs, providers have to be reined in. Existing anti-trust laws need to be enforced when it comes to hospitals and provider groups with near monopolies, and price regulations could be called for where there are already monopolies.

This is not really surprising, and as with all price controls, will end up having the opposite effect than those its architects envision, i.e. shortages and lines. These lines will appear mainly for expensive procedures, i.e. it will predominantly affect older people needing joint replacement surgery, cancer patients, and so on; young, healthy people, whose needs are occasional and generally inexpensive, won't encounter problems, and thus will claim that these things "work", for some value of that word. The comments are a maze of wishful thinking greasing the slippery slope, as though the obvious, much-heralded government meddling in the medical arena hasn't tainted further actions. (Hint: both houses of Congress are now in the hands of the opposition.) (Hat tip: @phillyrich1.)

The Obamacare Smoke Signals From UnitedHealth

The great thing about yesterday's announcement by UnitedHealth that it might just close shop on Obamacare in 2017 is exactly how it brilliantly sends multiple messages to multiple audiences.

The biggest U.S. health insurer said it has suffered major losses on policies sold on the Affordable Care Act’s exchanges and will consider withdrawing from them, adding to worries about the future of the marketplaces at the heart of the Obama administration’s signature health law.

The disclosure by UnitedHealth Group Inc., which had just last month sounded optimistic notes about the segment’s prospects, is the latest sign that many insurers are finding the new business unprofitable, despite an influx of customers that has helped swell revenues.

UnitedHealth Group Chief Executive Stephen J. Hemsley said the company isn’t willing to continue its losses into 2017. UnitedHealth has already locked in its exchange offerings for 2016, but it is pulling back on marketing them during the current open-enrollment period to limit membership, which it said last month totaled around 550,000.

The company will make market-by-market determinations in the first half of next year about whether it will continue selling products on the exchanges.

“We can’t sustain these losses,” he said. “We can’t subsidize a market that doesn’t appear at this point to be sustaining itself.”

 What's useful to know here is the significance of 2017, the first year of a new presidency. While it pretty much amounts to putting words into Mr. Helmsley's mouth, it doesn't seem too difficult to read this as

1. If a Republican wins in 2016, we're cutting these losses, with the help of changes to law (or discretionary executive enforcement).
2. If Hillary (don't kid yourself, Bernie fans) wins in 2016, we're pursuing permanent and higher "risk corridor" payments.

The first will be politically hazardous for Republicans, as a large fraction of the electorate is still sold on Obamacare's perceived merits. The second has lower political costs for Democrats, for whom corrupt "public-private partnerships" of this type generally go unexamined and cost little politically when they inevitably go sour — but are unlikely to materialize in a majority Republican Congress. For insurers, Plan Hillary amounts to a step closer to the worst hazard of Obamacare: increased and permanent subsidies equal a much bigger say in how those companies are operated. (It's already being floated in bureaucratic circles [PDF].) That is, it is a prelude to a quasi-takeover by the federal government.

Unsurprisingly, Jonathan "Frankenstein" Gruber still thinks his undead mess will work out in the end (and works fine now), where National Review Online sees (reasonably) the UnitedHealth announcement as a sign that the death spiral has begun. Older, sicker, and poorer people signed up for the program — and these are not "customers" UH wants. The libertarian-leaning Mercatus Center has more details (emboldening mine):

Low enrollment figures have been driven, in large part, by the exchange plans’ failure to attract middle-class uninsured people. Most recently, CBO projected 3 million unsubsidized enrollees in 2015, when in fact there were only 1.6 million. In early 2015, the Urban Institute estimated that 25 percent of enrollees in 2016 would be earning more than 400 percent of the federal poverty line; at the end of the 2015 open enrollment period, only 2 percent of enrollees fell into that income class. Most strikingly, only 2 percent of eligible individuals earning more than 400 percent of the federal poverty line chose to purchase exchange plans.

Which gets back to something I've said all along about Obamacare: if your plan requires the cooperation and purchasing power of a group both notoriously poor or un-/underemployed, your plan will fail. While it seems likely Obamacare will continue to limp along in some capacity, the ones with the most skin in the game, the insurers, seem rather dour on their role in it.

Why I'm Not Celebrating Obergefell

My Facebook timeline is awash with people who have chosen to rainbow-ize their profile pictures in solidarity with yesterday's momentous Supreme Court decision, Obergefell v. Hodges. In truth, I'm very happy for my gay and lesbian friends, who may now enter into marriage in all fifty states. And yet, the truth also is, I don't feel much like celebrating with Andrew Sullivan, who posted his first entry after announcing his retirement from blogging back in February. For all that the profoundly conservative gay marriage movement has succeeded in extending acceptance to homosexuality, I find the manner with which it was accomplished to be deeply troubling, and for reasons that Sullivan orbits but never quite touches on:

I remember one of the first TV debates I had on the then-strange question of civil marriage for gay couples. It was Crossfire, as I recall, and Gary Bauer’s response to my rather earnest argument after my TNR cover-story on the matter was laughter. “This is the loopiest idea ever to come down the pike,” he joked. “Why are we even discussing it?”

Those were isolating  days. A young fellow named Evan Wolfson who had written a dissertation on the subject in 1983 got in touch, and the world immediately felt less lonely. Then a breakthrough in Hawaii, where the state supreme court ruled for marriage equality on gender equality grounds. No gay group had agreed to support the case, which was regarded at best as hopeless and at worst, a recipe for a massive backlash. A local straight attorney from the ACLU, Dan Foley, took it up instead, one of many straight men and women who helped make this happen. And when we won, and got our first fact on the ground, we indeed faced exactly that backlash and all the major gay rights groups refused to spend a dime on protecting the breakthrough … and we lost.

In fact, we lost and lost and lost again. Much of the gay left was deeply suspicious of this conservative-sounding reform; two thirds of the country were opposed; the religious right saw in the issue a unique opportunity for political leverage – and over time, they put state constitutional amendments against marriage equality on the ballot in countless states, and won every time. Our allies deserted us. The Clintons embraced the Defense of Marriage Act, and their Justice Department declared that DOMA was in no way unconstitutional the morning some of us were testifying against it on Capitol Hill. For his part, president George W. Bush subsequently went even further and embraced the Federal Marriage Amendment to permanently ensure second-class citizenship for gay people in America. Those were dark, dark days.

I recall all this now simply to rebut the entire line of being “on the right side of history.” History does not have such straight lines. Movements do not move relentlessly forward; progress comes and, just as swiftly, goes. For many years, it felt like one step forward, two steps back. History is a miasma of contingency, and courage, and conviction, and chance.

Which is to say, what it really took, frankly, was this:

Gay marriage is nearly as accepted as heterosexual marriage, and among millennials, the numbers are an avalanche, approaching 80%. It is popularly accepted as a right, and therefore acceptable to defend. Justice Anthony Kennedy's opinion for the majority cited four major reasons for accepting the plaintiff's case: individual autonomy, right to intimate association, safeguarding children and families, and marriage as a foundation of American social order. But ironically, it's Justice John Roberts who chooses deference to politically expressed preference in social order. "It can be tempting for judges to confuse our own preferences with the requirements of the law."

It is ... about whether, in our democratic republic, that decision should rest with the people acting through their elected representatives, or with five lawyers who happen to hold commissions authorizing them to resolve legal disputes according to law.

 Which is to say, we have a Supreme Court Chief Justice who believes that rights are subject to popular review. The same man who, in Obergefell, wrote "this Court is not a legislature" only the day before in King v. Burwell felt it meet to substitute policy aims over the literal text of the Affordable Care Act — i.e. to act exactly in the place of a legislature. And if Obamacare isn't exactly popular, it's apparently not unpopular enough for the Republicans to deliver a viable alternative — or for the Court to overturn it. In both cases, Roberts counsels deference, which is to say, he advocates for a kind of slow-motion, legalistic mob rule. For anyone familiar with the historical treatment of homosexuals, Jews, blacks, gypsies, and any other hated minority, that is a deeply terrifying prospect.

Repost: Obamacare's Token Attempt To Adjust Physician Levels

Originally posted to Facebook 2014-04-29, reposted here for the usual reasons.

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Something that came out of a discussion elsewhere ... I have long said that Obamacare does nothing to actually reduce costs, because it does not attempt to increase the supply of providers, either through practice liberalization (as by allowing nurse practitioners to perform certain procedures now only permitted to physicians) or through licensing liberalization (increasing the number of physicians). Mary Cvetan sent me hither, a website (she, at least in part wrote) that makes mention of the following:

Training New Primary Care Providers: The Affordable Care Act invests in the training of new primary care providers, including providing nearly $230 million to increase the number of medical residents, as well as funding to increase the number of nurse practitioners and physician assistants trained in primary care.  With these investments, by 2015, more than 1,700 new primary care providers will have been trained and enter primary care practice. The Fiscal Year 2014 budget includes investments that will expand the capacity of institutions to train 2,800 additional primary care providers over five years.

Is this a significant number? Per the Henry J. Kaiser Family Foundation, the US has 24.2 physicians per 10,000 population, which means, rounding down to 300,000,000 population, that the physician population is 720,000 or so, of which 1,700 would amount to less than one percent (actually 0.2%). It's entirely possible that this actually represents a figure below retirement replacement. If Obamacare wishes to lay claim to fixing the supply side of things, it must needs do better. This, however, runs square against the AMA's interests, and so I have my doubts.

Update 4/30/2014: In a surprisingly candid blog post on Mother Jones, Kevin Drum late last year pointed out that the reason US physicians are paid so much is because there are so few of them relative to other nations; the US is in the bottom third of physicians to population. To get to the OECD mean of 30.6, you would have to increase the US physician population by a quarter. And that's just to arrive at average.

Repost: A Dose Of Honesty: Jonathan Gruber's Retroactive Confessions

Previously posted on November 20, 2014 as a Facebook note, but I'm slowly migrating a lot of this sort of thing out here onto the blog for formatting and search reasons.

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Americans owe Jonathan Gruber a considerable debt for his unintentional honesty about both the means of drafting that law, his role in it, and the endgame -- particularly the destruction of the medical insurance tax deduction, which occurred as a consequence of tying the threshold for the "Cadillac tax" to CPI inflation rather than medical cost inflation. That he was one of the bill's chief architects now is hotly debated by Nancy Pelosi, who suddenly has trouble remembering his name. But not only was he an "adviser", he was much more than that at the time:

Yes, Gruber was an adviser, as Obama describes him, but that significantly understates his role. In addition to the nearly $400,000 he received from the administration (more than Obama's senior staff earns annually), his work was cited repeatedly by the administration as evidence for the law, and Gruber participated in high-level discussions with the president himself about what policies the law should include.

When the bill was being scored by the Congressional Budget Office, Gruber was one of just three outside economists summoned toan Oval Office meeting with the president and CBO director Douglas Elmendorf to look for ways to adjust the law in order to receive a better score, according to The Washington Post. That discussion, Gruber later said in a 2012 PBS documentary on the creation of the law, "became the genesis of what is called the Cadillac tax in the health care bill." Gruber also visited with senior administration officials at the White House on several other ocassions [sic], according to visitor logs.

Gruber's most infamous moment might be expressing the contempt in which he obviously holds the electorate (the subterfuge he and the Democrats foisted on the public were necessary because of "the stupidity of the American voter"). Because he exposed the attitude rampant among Democratic apparatchiks toward their base, he had to be diminished, a process continuing in the press this week. Professional Team Blue flacks like the Los Angeles Times columnist Michael Hiltzik does a particularly poor job of this, one which will be compelling only to Democratic partisans. He wails the standard wail these days "you don't understand insurance" when Avik Roy points out Obamacare is yet another transfer of wealth from the young and poor to the old and richer, following this up with a cynical tu quoque sermon about how bills become law. For a finale, he goes after the Republican straw men of "death panels" while ignoring the meat of real criticism, with a dash of "the Supreme Court has said" the law is Constitutional, conveniently forgetting that National Federation of Independent Business v. Sebelius was not the only challenge to that law.

In fact, the biggest threat to Obamacare at present comes from King v. Burwell, something noticed by the nearly as disingenuous Ezra Klein:

Gruber's initial comments, which emerged a few months back, appear to support the King v. Burwell case, which argues that subsidies can't flow through the federal exchanges that are being used in 36 states. These comments from Gruber are both truly bizarre, and, because they could give justices some justification for ruling for the plaintiffs, genuinely dangerous to the law.

On these comments, I'll pretty much repeat what I said when they first emerged. They contradict literally everything else we know — including from Gruber.

Which of course is the purest nonsense, but it's what Klein is telling his audience. In the land of Obamacare believers, it is not important what the law actually says, but what its supporters want it to say, even if they change their minds after passage. This is the kind of thinking that alcoholics and other substance abusers rely on: I deny reality and substitute my own. And for obvious reasons, it is extremely dangerous when put into positions of power. The situation is so bad that co-fraud Jonathan Chait was obliged to pretend that a telecommuting Gruber did not really "write" the bill.

Maybe all this will play with the law's believers, but I suspect it has less traction with independent voters.

The Fantasist's Pony

Greg Sargent today has a longish piece that pretty well captures the level of pants-down delusion Obamacare supporters are left with in opposing King v. Burwell (which they have to pray goes for the defense). It's pretty harebrained, but most of these arguments are, too:

If Congress intended to threaten states with the loss of subsidies, why were so many government officials — including many Republicans in Congress and even officials in the states themselves — entirely unaware that any such threat existed, for many, many months after the law passed, at the very moment when those state officials were grappling intensely with the implications of the law for them?

The obvious rejoinder to this is, because nobody reads the damned bills.  This is a convenient and bogus excuse for what appears entirely to be either bad drafting, or malicious drafting; the Jonathan Gruber videos make it clear it was the latter. The depressing part, of course, is this:

This week, a number of states will file a brief siding with the government, arguing that nothing in the ACA indicated opting for the federal exchange would cost them subsidies. They will argue — as in a similar, previous brief — that the challengers’ interpretation raises serious constitutional questions: The states were never given clear warning that the failure to set up exchanges could bring them serious harm, and thus the Supreme Court should opt for the Constitutional interpretation — the government’s — when that option exists.

That many of these are Republican-majority states should call into question a lot of the assumptions about that party's bona fides in the small-government department, but no matter.

To this argument, the challengers respond that of course the states didn’t think they’d lose subsidies, because the IRS rule — first proposed in late summer of 2011 and made official in the spring of 2012 — told them so, a key reason many states declined to set up exchanges. Thus, the challengers argue, if invalidating the IRS rule now would hurt millions in these states, that’s the fault of the IRS’s original act of lawlessness, i.e., departing from the ACA’s plain text to make subsidies available in them.

Well, duh.

... [L]aw professor Laurence Tribe suggests, that the Justices could conclude this case is about more than statutory draftsmanship, and see at stake momentous questions about the relationship between the federal government and the states.

Tribe supports very expansive readings of law, which is to say, he is an enemy of textualism. King is about the rule of law in no small way; if it fails, the law is whatever the mandarins say on a given day. Somewhere in the room full of shit is a pony, they're convinced, and will go to their graves believing.

Ezra Klein Finally Admits Obamacare Affects Employment

I confess I was much disappointed to read Reason's Peter Suderman's negative assessment of the recently passed GOP Obamacare "fix". This changed the employer mandate threshold from 30 hours per week to 40, with the net effect that more people will be forced into individual plans, with attendant public subsidy:

The problem is that, far from being a practical improvement, the change the Republicans have chosen makes the health law worse.

For one thing, it would make it more expensive. By rewriting the rules so that businesses no longer have to cover individuals working between 30 and 40 hours a week, the change would shift roughly a million people off of employer coverage. About half would then end up enrolled in coverage either through Medicaid or Obamacare’s subsidized exchanges. The public, in other words, would be picking up the tab. According to the Congressional Budget Office, the change would increase the deficit by about $53 billion by 2025.

In addition, it would probably not end the cutting or limiting of work hours in response to the law. Instead, it would shift the point at which the cutting and capping is done.  Rather than capping employees who might otherwise have worked, say, 30 or 32 hours, employers under this provision would have an incentive to cap hours for employees who work roughly 40 hours each week. That’s an awful lot of workers. As Yuval Levin noted at National Review Online last November, one study found that, amongst the large employers affected by the requirement, about 29 million work between 40 and 44 hours a week. Just seven million work between 30 and 39 hours.

Of course, this assumes that King v. Burwell won't void subsidies for states without exchanges. If that does happen — and there's a significant chance it will (thank you very much, Jonathan Gruber) — the legal, fiscal, and most importantly, political landscape changes considerably. Just as a first-order-of-magnitude thumbnail guess at places that might vote for a measure repealing Obamacare, I first looked at the states with exchanges, and their representation in the House:

• California - 53
• Colorado - 7
• Connecticut - 5
• Hawaii - 2
• Idaho - 2
• Kentucky - 6
• Maryland - 8
• Massachusetts - 9
• Minnesota - 8
• Nevada - 4
• New Mexico - 3
• New York - 27
• Oregon - 5
• Vermont - 1
• Washington - 10

This gives a grand total of 150 Congressional seats, not including Utah, which has promised to open an exchange but has yet to do so. So, subtracting that from the 435 seats in the House, states without exchanges approach a two-thirds, veto-proof supermajority needed to pass overriding legislation. While this is an oversimplification, it shows that the terrain for partial or whole repeal is not, at first glance, as daunting as some might think.

So to Ezra Klein's ill-considered Vox explainer. His is a reactive trap, and moreover, a very bad tactical move for the Democrats. Klein:

The problem, however, is that the mandate creates a cliff from an employer's point of view. As soon as a worker becomes full-time, he becomes much more expensive. That creates strong incentives to cut workers' hours. Thus this issue has become a lynchpin of a conservative narrative about "part-time America" and a key example of how Obamacare is making the economy weaker.

Well, wait just a minute now. Does that finally mean, as conservatives, libertarians, and virtually all economists not named Krueger and Card have been saying for years, that a higher labor cost causes employers to cut hours, i.e. that labor is not magically inelastic? And if it's true that a 40 hour cutoff is dire, why is the 30 hour threshold — other than the absolute number of people affected — less important? This answer to Republican Obamacare critics opens a Pandora's box that its supporters probably don't want to see the light of day.

Harvard Professors Discover Obamacare Realities

Oh, this is rich:

For years, Harvard’s experts on health economics and policy have advised presidents and Congress on how to provide health benefits to the nation at a reasonable cost. But those remedies will now be applied to the Harvard faculty, and the professors are in an uproar.

Members of the Faculty of Arts and Sciences, the heart of the 378-year-old university, voted overwhelmingly in November to oppose changes that would require them and thousands of other Harvard employees to pay more for health care. The university says the increases are in part a result of the Obama administration’s Affordable Care Act, which many Harvard professors championed.

 And what medical hellscape awaits Havahd faculty and staff now?

The university is adopting standard features of most employer-sponsored health plans: Employees will now pay deductibles and a share of the costs, known as coinsurance, for hospitalization, surgery and certain advanced diagnostic tests. The plan has an annual deductible of $250 per individual and $750 for a family. For a doctor’s office visit, the charge is $20. For most other services, patients will pay 10 percent of the cost until they reach the out-of-pocket limit of $1,500 for an individual and $4,500 for a family.

Horrors.

In many states, consumers have complained about health plans that limit their choice of doctors and hospitals. Some Harvard employees have said they will gladly accept a narrower network of health care providers if it lowers their costs. But Harvard’s ability to create such networks is complicated by the fact that some of Boston’s best-known, most expensive hospitals are affiliated with Harvard Medical School. To create a network of high-value providers, Harvard would probably need to exclude some of its own teaching hospitals, or discourage their use.

So, after years of gold-plated everything, they might have to think about costs.

Four Things That Almost Nobody Is Talking About That Need Fixing In Medicine

Obamacare is a farce, but its proponents frequently pull out the fact that it was, in large strokes, derived from a 1993 Heritage Foundation proposal. Significant in that Politifact piece is the following graf:

"The Chafee plan did not spell out how increased coverage would be financed," [Clinton adviser Paul] Starr said. "It was more of a symbolic bill than an actual piece of legislation."

This confirms a sense I've had of the Heritage plan: it always seemed like a half-baked idea that was intended more as a negotiating counter to Hillarycare, i.e. a delaying tactic, rather than a serious proposal. The Heritage plan was always a thing-on-a-thing, scaffolding erecting the next story on an already ungainly building. And of course, therein lay the trouble; its flaws were the flaws of ad hoc tax law manipulations that originated in World War II as a consequence of wartime pay restrictions.

All of which is to say, of course, that the solution for such problems has nothing to do with adding more mandates or subtracting restrictions on insurance, as Avik Roy sadly did, or more recently, John C. Goodman's proposal. Both retain the deep ties to the insurance industry that have done so much to degrade health care in this country, a reality limned by David Goldhill in The Atlantic, an article he later expanded into a book, Catastrophic Care. As I mentioned the other day, the most frequently mentioned repair for Obamacare from the Democratic side is single-payer, which for the reasons Megan McArdle recently outlined, is an economic non-starter (and with the Vermont failure, politically dead). Instead, I want to focus on four things that few people are currently discussing that need repair in medicine that could materially reduce costs. They all have in common the market, the one way we know best that works to reduce actual costs, not apparent costs.

1. End low-deductible insurance.  Goldhill outlines the problems with low-deductible insurance: by shielding prices from consumers, it saps power from and accountability to the patient, and eliminates meaningful cost comparison. This has all kinds of bad consequences, from steady cost inflation, deteriorating service, and adverse outcomes (even including death). The solution is to remove insurers from most transactions, and let people purchase directly their own medical care. The first step should be extending the medical income tax credit as a first-dollar deduction for individuals, rather than making the deduction so high that few ever qualify. The next would be to limit insurance to those things it truly does well: management of extraordinary expenses, i.e. risk.
2. Break the American Medical Association's cartel. It's a rare day when you'll see me agree with anything appearing on the pages of Mother Jones, but their analysis of why US physicians have such high compensation is both simple and spot on: because the US is in roughly the bottom third of OECD countries by physicians per 10,000 population. Their non-solution to this problem is to say, suck it, docs, which won't work; the real answer is that the AMA's ability to limit medical school slots and internships must end. Similarly, the AMA has succeeded in gaining a monopoly on the prescription pad and otherwise limiting practice options by registered nurses (who must attach themselves to a physician or practice for various legal reasons). California came very close to nurse practitioner liberalization just last year, only to have the AMA kill the idea.
3. Limit patents to 17 years, period. As it stands now, devices patented in the 1970's are still getting repatented for various uses that have the net effect of creating long-running monopolies counter to the interests of patients and consumers. An excellent example is the Epi-pen; created by the military for field use, it should have had no patent issued, ever. Instead, its 1977 patent continues to be renewed by various kinds of chicanery; this has the result of making the product in the US cost more than three times that in Canada, and that doesn't include the cost of getting the doctor's prescription.
4. Remove anticompetitive Certificate of Need state laws. Remember the Texas car dealers who bought a law in Austin to keep Tesla out of their state thanks to a business model that dispenses with independent car dealers? Something very like that is in play with Certificate of Need laws, which amount to a "government permission slip" for new competition. By creating a moat around existing hospitals and other medical facilities, governments retard actual competition and thus raise prices:

Studies of the COPN system around the country have confirmed what seems intuitively obvious. A joint examination by the Justice Department and the Federal Trade Commission found that COPN regulations hurt competition, fail to contain costs, and “can actually lead to price increases.” Restricting supply raises prices? Imagine that.

I do not claim this list is complete or even exhaustive. It does seem to me, however, that all are obvious flaws of the current system. Some will require cage-match fights to the death — patent reform particularly is unlikely without it — but all address actual, underlying costs, unlike Obamacare or even the Republican repair proposals.

Correlation != Causality: Porn And Marriage

I've already had several people post this Washington Post Wonkblog piece about porn and marriage which asserts that young men aren't getting married because they are consuming more porn, and thus no longer need women, or something:

Broadly, higher Internet usage was associated with lower marriage rates. But pornography use in particular was more closely linked to those participants who were not married than any other form of Internet use, including regular use of financial websites, news websites, sports websites, and several others. The opposite, for comparison, was true for religious website use, which was positively correlated with marriage.

"The natural reaction might be to dismiss the findings as confirmations of an obviousness", they continue, "that men who are married tend to look at porn less frequently precisely because they are married." Well, duh, but maybe we could lift a finger to see, perhaps, why young men might be unmarried? That, of course, is a question the Wonkblog probably doesn't want answered truthfully, because of their political biases.

Asking young women what they want in a potential mate, a poll by the Pew Research Center in September revealed that 78% want a man with a stable job; no single answer by men was even close to that high. That is to say, young women — despite years of feminist action — overwhelmingly value men for their economic contributions. So why might young men, particularly young and poor men, not be getting married? The answer is obvious if you look at youth labor participation, with some observers speculating that structural youth unemployment may well be permanent. While it's been hotly debated whether Obamacare and a recent minimum wage step increase have contributed toward this, it is incontestable that youth unemployment remains stubbornly high. If young men, especially young men without college degrees, are to marry, their job prospects must improve, and dramatically.

Vermont Learns Why Single-Payer Won't Work

Vermont's Gov. Peter Shumlin today bailed out of a statewide single-payer plan because of "the big tax increases that would be required to pay for it". This should come as utterly no surprise, save to the people for whom single-payer constitutes a panacea. (Extra bonus points in that article to Jonathan Gruber for helping grease along that inevitability.) Megan McArdle back in April wrote a piece giving a lot more reasons than I have, but at its core, the argument is this: if you start from a high basis, and you don't do a good job of controlling cost growth, and your peers applying single-payer (or outright socialized medicine) aren't doing a good job of that, you will not restrain costs.

Once we pulled away from the other countries, even an average growth rate meant that the gap between our spending as a percentage of GDP, and theirs, would continue to widen -- especially if their GDP grew faster than ours for any length of time.

That is why we cannot count on financing single-payer with the fabulous cost savings to be gained by making our system more like Europe's. Europe didn’t gain fabulous cost savings by making their systems more like Europe's: Its nations started from a lower base, and held down cost growth, but they did not actually use single-payer systems to cut what they were spending.

"Once spending is in the system," she continues, "it’s hard to get rid of." Yes. Just ask anyone who's followed the Medicare Sustainable Growth Rate fiasco, which has had no fewer than eight votes post-Obamacare-passage to keep higher rates in place than the required statutory cuts. Vermont was never going to get there from here, and they found out in a big hurry that just papering over the costs with somebody else's money was going to require some very hard choices.

From 2009: Ezra Klein And Jonathan Chait Contract The Thomas Freidman Disease

Introduction

I originally wrote this as a Facebook note on March 24, 2009, and have referred to it multiple times since then. There are a couple of issues that need discussion, not least the fact that the Chait piece does, in fact, link to Rep. Paul Ryan's CBO scoring (though that makes his contemporaneous belief that savings were going to occur due to Obamacare even less tenable). As well, there have been no fewer than eight votes on the Medicare Fee-For-Service "Sustainable Growth Rate" and its successor calculations – all of which have subsequently failed. I will write a followup on this topic eventually.

---

One of the most irritating things I remember about the buildup to the war in Iraq was how thoroughly predictable, and thoroughly mendacious, the whole affair was; there was never any compelling evidence in support of the idea that Saddam Hussein had Weapons of Mass Destruction. Sure, they trotted Colin Powell in front of the dais, but for me it was perfectly plain that there was no there there, Powell reading from a script a dozen or so Q.E.D.'s away from reality the whole time. It was a speech written by an alcoholic, delivered by a team player who clearly disbelieved every word but was duty-bound to give it his best shot.

In the days leading up to the war, you would be hard-pressed to find a bigger cheerleader for it than the New York Times columnist Tom Friedman. Glenn Greenwald, long after that war got started and became a disaster, noticed Friedman's role in the buildup, aided by an unreality field that Friedman himself was all too happy to build:

Just ponder that: Tom Friedman supported the invasion of Iraq even though, by his own reasoning, that war was being done the "wrong way" and would thus -- also by his own reasoning -- create nothing but untold damage on every level. And he did so all because there was some imaginary, hypothetical, fantasy way of doing the war that Friedman thought was good, but that he knew isn't what we would get.

I get the same sense of unreality these days about the health care debate. My friend Steve Timberlake recently mentioned Jonathan Chait's alleged debunking of the complaints that the so-called "doc fix" (about which, more presently) would undo all the savings from the health care bill. It basically mirrors a Washington Post blog piece Ezra Klein wrote back on March 1.

Chait gets his snark on with the claim that Congressman Paul Ryan is being "disingenuous" when the latter says that the bill is "double-counting" savings. I'm not sure about how he gets to "double", but there certainly is a shell game going on, and the various sniff tests say that this time, it's the health care bill's proponents who are being shifty.

Here's Chait (emboldening is all mine) regarding this "double-counting":

This is categorically false. Democrats did not instruct the CBO to credit savings from reducing physician pay toward the health care bill. Every dollar of new health care spending is offset by different savings. The purported cut in physician pay is not part of those savings. There are parts of the CBO score you can legitimately suggest underestimate the cost of health care reform -- most prominently, the slowdown in value of the tax credits over the second ten years. (I'd argue that there are places where CBO is underestimating cost savings, as well.) But the doc fix is simply not a legitimate complaint.

Except that, if you look at the latest CBO report on the health care bill (PDF), it specifically calls out, in Table 2 on page 8, a line item labeled "Reductions in Annual Medicare FFS [Fee for Service] Payment Rates".

If Chait — or Klein, who makes exactly the same argument — wants to explain why that line item is in there, I'm all ears. But the twin facts that (a) neither article provides a link to the CBO summary, and (b) the AMA and AARP aren't bitching about "reform" are both strong indicators that this is utter fabrication.

That Medicare physician reimbursement looks awfully similar to the doc fix that Nancy Pelosi has indicated is going to get passed. The "savings" are 100% illusory, and always were. But maybe that's the plan. Nobody's fired Tom Friedman yet, have they?

Update 3/25/2009: One of the links I wanted to present here but forgot last night was the CBO analysis of HR 3961 (PDF), the so-called "doc fix" bill. What's especially interesting about this is that it shows a line item called "Medicare Physician Fee Schedule" with totals running to $194.6 billion. The claimed savings for Medicare price cuts in the health care bill just passed (FKA HR 3590) is only $186 billion. That means they're $8.6 billion more over that period than if Congress did nothing.