Month: August 2009

by Patrick Appel

Dale Carpenter's take on that DOJ DOMA brief from yesterday:

This new position is a gift to the gay-marriage movement, since it was not necessary to support the government's position. It will be cited by litigants in state and federal litigation, and will no doubt make its way into judicial opinions. Indeed, some state court decisions have relied very heavily on procreation and child-rearing rationales to reject SSM claims. The DOJ is helping knock out a leg from under the opposition to gay marriage….While gay-rights groups complain that the DOJ is continuing to defend the constitutionality of DOMA….and are understandably disturbed by the still-unabandoned arguments the DOJ made back in June, they should be delighted by the turn taken in this reply brief. It will serve the cause of SSM in state and especially federal courts for years to come.

by Patrick Appel

Greg Sargent reports on Research 2000 poll that shows the majority of Republicans either believe in or aren't sure about the "death panels."

by Conor Clarke

There's an old Borges short story called "The Library of Babel," about mythical library that contains all possible 410-page books. I mention this only because I'm pretty certain that the Internet has now produced all possible blog posts on the subject of a public option — and, more specifically, the death of the public option. On Saturday, attempting to quell the controversy, President Obama said that "both the right and the left that have become so fixated on [the public option] that they forget everything else," which, naturally, lots of people used as an excuse to further fixate on the public option and forget the remaining few things they had remembered. And now it's reported that the public option teeters at the brink of death.

I don't totally understand the fuss.

Part of my confusion is that the "new" details that have emerged in the last few days — some Senators say they are opposed, the administration says it's flexible, etc — are about as fresh as an April fool's joke. Kent Conrad, believe it or not, has never been enamored with the idea a new government healthcare program. And part of my confusion is that you really can argue the political implications of this situation in just about any direction you want. Maybe the administration is just using the public option as a bargaining chip with the insurance industry. Or maybe lots of congressional democrats really won't vote for a bill without one. Or maybe dropping the public option will satisfy the most vituperative critics and allow the other 600 elements of a health-care bill to slip unscathed through the remaining 7,200 congressional committees. Or maybe not. It's going to be a long month.

But, more importantly, I think the debate over the fate of the public option obscures two substantive debates. The first is that there are big differences between how we might imagine a "public option." (This piece by Time's Karen Tumulty and this NYT column from Richard Thaler do a good job of laying out the big differences.) The second is that the public option is only a means to an end — reducing costs and expanding coverage — and there's little that is unique about a PO's ability to do either of these things. If liberals are picking between, say, a strong individual mandate with generous and well-targeted subsidies, and a public option vitiated by the long August recess, there's absolutely no shame in going with former. Not that anyone's offering that choice, of course. But there's no reason to turn a public option into a political fetish.

In one way, the article is refreshing: At a time when many liberals have been describing the protests at the health care "town halls" as an unprecedented event, even as a sign of incipient fascism, Perlstein reminds readers that flare-ups like this actually happen fairly frequently in American history. But the article is aggravating, too, and not just because it casually conflates the bona fide kooks with anyone who happens to protest at a tea party or a town hall. Reading the piece you get the impression that the crazy tree grows only on the right, and that the health care battle is a simple case of hysterics attacking enlightened reform.

by Patrick Appel

Many readers have asked for all the sickbed stories to be put in one place. Here are links to the posts from week one in mostly chronological order:

Can You Give Me A Ride?: I Can't Afford The Ambulance

The Baby Isn't Insured

Watching My Costs Skyrocket

Seizures In Public Places: Avoiding The Ambulance

Your Newborn Son Has A Preexisting Condition

My Insurance Company Got A 96% Discount!

Working For A National Insurance Company: The Payment Process

The $10,000 Cyst

Gold-Plated Insurance: Denying Vaccination To Premature Babies

And here are week two's posts organized by theme:

Not Starting A Small Business Because Of Health Care Costs

HIV And Entrepreneurship

HIV And Entrepreneurship II

What Does That Cost?

A Bankruptcy Lawyer: Opaque Costs Are The Worst Part Of Our Health Care System

Planning A Pregnancy: Trying To Get The Bill Up Front

Electronic Medical Billing Company: Mark Ups For The Uninsured

Authorizing Treatments: The Whole Gory Process

A $15,000 Needle

The $15,000 Needle II: No Incentive For A Surgeon To Save Money

No Incentive For An Emergency Room Physician To Save Money Either

A Small Practice: The Costs Of Getting Approval

Health Savings Accounts: Pro And Con

Plumbing The Depths of Ignorance: Negotiating Health Care Fees And Health Savings Accounts (HSAs)

HSAs: The Case Against

I Loved My HSA

A HSA Salesman: Separating The Healthy From The Sick

Flexible Spending Accounts (FSAs): Whose Bottom Line?

HSAs: Group vs. Individual Plans

Odds And Ends:

Advance Health Care Directives: I Want To Go Like Mimi Did

At The VA Hospital: In And Out In 45 Minutes

The Underinsured: Between Full Employment And Medicare

Narcolepsy, Drug Costs, And Work: A Catch 22

Approving, Then Rejecting Coverage

Gastric Bypass: Waiting Ten Years

Gastric Bypass II: Don't Blame Insurance?

Bipolar Disorder And Mental Health: Section 14

Please keep sending your stories to andrew@theatlantic.com. Thanks to everyone for sharing.

(Image by Flickr user Romanlilly)

"We wrote it so audiences would have to work at it!" he said in an interview with The Independent. "We were not going to compromise in making it immediately accessible for everyone. It [subtitling] kind of reminds me of scenes from that [1980 disaster film spoof] comedy, Airplane!, when two black guys speak, and subtitles appear on the screen."

by Patrick Appel

A reader writes:

The recent topic of organic farming is one that's very dear to my heart.  A very close family friend of mine raises grass-fed beef in Pennsylvania, and has refused to go "organic" (as defined by the USDA) since the requirements to earn that label are often as inhumane as some of the practices found on the feed lots.  In order to be able to label his beef "organic" he'd be forced to withhold treatments to numerous common ailments that all animals suffer from.

He'd be forbidden to use any antibiotics, even if it was to treat an infection that was easily treatable.  His cattle lead about as good of a life as any animal confined to a farm can have.  They have swaths of grazing land to roam, are never confined to a pen, and the result is some of the finest beef I've ever tasted.  But the reality is that his farm would be much less "sustainable" if he tried to fit the qualifications for organic beef.  He'd be forced to let cows and calves suffer and even die of simple infections even if they could be easily treated with a shot of antibiotics. 

I think you're right to be wary of the label of organic as being the equivalent of the term sustainable.  I buy organic all the time, but the two terms are not necessarily at all related.

by Peter Suderman

As the public plan's prospect dwindle, opposition switches tactics. Here's Phil Klein on why, even without a public option, he still doesn't support health-care reform:

The remaining parts of the proposals in Congress would leave us with a system in which government mandates that individuals buy insurance or pay a tax and that employers offer insurance or pay a tax. Then government would have to define what constitutes insurance. Medicaid would be expanded dramatically. The government would be providing subsidies to individuals to purchase insurance, but even if individuals don't qualify for subsidies, at least under the House bill, they would be forced to purchase their insurance from a government-run exchange.

And though the policies offered at this exchange would be nominally "private" they would be designed by government bureaucrats. In the Senate Health Education Labor and Pensions bill, a new Medical Advisory Council would be tasked with defining “qualifying” coverage; in the House bill, all Americans are required to have coverage that is deemed “acceptable” by a Health Choices Commissioner. No doubt, the creation of a new government-run plan is the easiest way for the country to evolve into a pure single-payer system, but even without one, the proposals being considered would give us a system in which individuals would be forced to purchase government-designed insurance polices from a government store.

As Ramesh Ponnuru pointed out several months ago, the managed competition that would be created by mandates and an exchange would essentially turn insurance companies into regulated, subsidized semi-public utilities.

by Patrick Appel

A reader writes:

I am a pediatric emergency room physician. I want to second what the surgeon said in his comments about saving the system money. In most health care situations, there is absolutely NO incentive for physicians to do so, and in many instances there are incentives to waste/spend as much money as possible.

For example:  when a young teenager comes into the emergency department with chest pain, there is something like a 1 in 10,000 chance that the pain comes from a serious cause in the heart or the lungs.  In almost every case these rare serious causes can be ruled out by talking to the patient and their family and by examining the patient. In the vast majority of cases no tests or specialists are needed. The visit can be brief, reassurance can be offered to the patient and their family, and the bill should be around $200. However, there is nothing to prevent me from ordering a whole battery of tests in this situation, and I have seen other physicians and emergency departments do just that. 

EKG to rule out a heart attack, chest x-ray to look for pneumonia or a collapsed lung, chest CT scan to look for a pulmonary embolus, outpatient cardiac monitoring, referral to a cardiologist, lab work to look for infection or electrolyte abnormalities, etc., etc.  What started as a $200 visit is now closing in on $15,000. 

I can tell you from experience this happens every day in ER's around the country. Furthermore, if I order a lot of tests and give a lot of referrals to specialists, I make more money because I just made the visit more complicated and I bill based on how complicated the visit was, the hospital makes more money because they get to use all those expensive machines they invested in, and I generate business for my colleagues in cardiology. Often, the patients are happier with the "mega work-up" as well. There is absolutely no downside for me to ordering tons of unnecessary tests (the same is true for unnecessary and expensive medications). Rare exceptions to this are the best health care systems in the country (Kaiser, Mayo) that actually do give physicians feedback regarding their efficiency and outcomes. Not coincidentally, these systems spend less money per patient and deliver the best care in the country by pretty much any measure you can come up with.

I'm catching up on the second season of Mad Men this week, which means I'm making an effort to avoid third-season spoilers. But I couldn't help but read through this post about how some women simultaneously find Don Draper sexy and feel guilty for doing so:

Why are we so wild for Draper? By any measure, the character's a cad. He constantly cheats on his wife. He skips town for weeks and won't write or call. He doesn't talk much, and anesthetizes any feelings with copious amounts of booze. He's an enigma, a locked box of a man who resists, maddeningly, easy explanation. And yet he excites an attraction among women—particularly ones my age, women in their late '20s and '30s who were born after the era that Mad Men portrays—that seems unmatched by any leading man on television today…

A man's man. A virile man. A masculine man. Strong terms. And ones that would make our postmodern gender-studies professors blush. After all, we're the generation of women who grew up beating the boys in math class, reading Judith Butler (by choice or by force), celebrating "Grrl" power. Traditional male-female roles were going out the window while we were still toddlers. And maybe that's why we feel a little guilty when we stop to admit to ourselves why Draper excites us. Because we're not supposed to be using those terms anymore to describe our desires. Those words threaten a backsliding—they hint at some deep, unspoken turbulence; that, as if by saying we want a "real man," we threaten to erase all the gains our mothers made in terms of equality in the workplace and the home. After all, we don't believe in that evolutionary "me Tarzan, you Jane" nonsense anymore. We're supposed to want men who are sensitive and respectful; men who emote and help around the house, and talk openly about their feelings.

The fact that Draper is a high-powered, serial-cheating workaholic with crude, old-fashioned notions of gender roles might play some part in why he's so attractive, but it seems to me that this post overthinks the question. Draper isn't sexy so much because he's a cad or a lout or a sexist; he's sexy because he's a fictionalized, idealized fantasy of an iconic form of masculinity. 

Draper's womanizing and crude beliefs aren't what make him appealing so much as his impeccable suits — always carefully pressed and form fitting — and his posed cigarette smoking, his immaculately lit surroundings and the elegant way he holds a glass of scotch. As a fictional dreamboat, Draper never has to participate in the unsexy realities of life: He doesn't change diapers, or use the restroom, or spill coffee on his shirt on the way to work. Thanks to a team of screenwriters, he always has the right words to say, or not say, and those around him always provide him with opportunities for pregnant pauses and dramatic silences. We never see Draper except when he's at his most posed and perfect.

Your average cheating, borderline alcoholic sexist doesn't have these luxuries, and thus isn't nearly as charming or magnetic. Draper, on the other hand, is sexy and cool because he doesn't have to deal with any of the real world's un-sexy, un-cool realities. In other words, he's a product of TV's image-making process — deeply and truly attractive, but in large part because he's made to be.