Kevin Drum - 2013

We Spend a Ton on Health Care, And We Get Lousy Service in Return

| Thu Nov. 21, 2013 3:32 PM EST

The 2013 version of the OECD's "Health at a Glance" is out today, which means that if I'd waited a day I could have posted the very latest data on the number of doctors per capita in the United States compared to other countries. Not to worry, though: nothing much has changed since yesterday. We still don't have very many doctors, even though we pay them far more than in most other countries.

In any case, "at a glance" means 209 pages to the OECD, so there's plenty of other stuff to chew on today. I'll pick out two tidbits for you. First, the chart below shows the number of doctor visits per year. We're very low. Despite spending far, far more on health care than any other country—$8,500 per person compared to about $4,000 for other rich countries—we don't get to see our doctors very often—about four times a year compared to six for the rest of the world. So does this mean that American doctors are lightly worked compared to other countries? As the next chart down shows, yes it does! The average American doc sees about 1,800 patients per year. The average for other rich countries is about 2,500. Again, this is despite the fact that American doctors are very highly paid.

Next up is a chart brought to my attention by Paul Waldman, and it could be one of the greatest and most instructive health care charts ever made. It shows what people think about their health. And despite the fact that by any objective measure, American health is mediocre at best and our health system is both expensive and lousy, Americans think they're in great health. They think they're in the best health of any country in the world!

This is Stockholm Syndrome at its finest. Apparently one of the reasons we don't mind the lousy service and high cost of our health care system is because our health care system has convinced us that it's great and, therefore, our health must be great too. We're Number 1, and we won't put up with anyone who tells us otherwise.

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Once Again, Republican Obstinacy Bites Them in the Ass

| Thu Nov. 21, 2013 1:32 PM EST

So, the filibuster. Did Harry Reid do the right thing getting rid of it for judicial and executive branch nominees?

I'd say so. And yet, I think Republicans missed a bet here. I've never personally been a fan of the idea that the Senate's raison d'être is to be the slowest, most deliberative, and most obstructive branch of government. Hell, legislation already has to pass two houses and get signed by a president and be approved by the Supreme Court before it becomes law. Do we really need even more obstacles in the way of routine legislating?

Still, I'll concede that my own feelings aside, the Senate really was designed with just that in mind. It wasn't designed to be an automatic veto point for minority parties, but it was designed to slow things down and keep the red-hot passions of the mob at bay. So here's what I wonder: why weren't Republicans ever willing to negotiate a reform of the filibuster that might have kept it within the spirit of the original founding intent of the Senate?

What I have in mind is a reform that would have allowed the minority party to slow things down, but would have forced them to pay a price when they did it. Because the real problem with the filibuster as it stands now is that it's basically cost-free. All it takes to start a filibuster is a nod from any member of the Senate, which means that every bill, every judge, every nominee is filibustered. The minority party has the untrammeled power to stop everything, and these days they do.

But what if filibusters came at a cost of some sort? There have been several proposals along these lines, and all of them would have allowed the minority party to obstruct things they truly felt strongly about. But there would have been a limit to how many things could be obstructed, or how long the obstruction could go on, and the majority party could eventually have gotten its way if it felt strongly enough. It would have been ugly, but at least Republicans would have retained some ability to gum up the works.

Instead, by refusing to compromise in any way, they've lost everything. Just as they lost everything on health care by refusing to engage with Democrats on the Affordable Care Act. Just as they lost everything on the government shutdown and the debt ceiling. Just as they lost the 2012 election.

Hard-nosed obstinacy plays well with the base, but it's not a winning strategy in the end. Republicans never seem to learn that lesson.

The Filibuster Is Dead (Partly)

| Thu Nov. 21, 2013 12:36 PM EST

CNN reports that by a vote of 52-48 in the Senate, the filibuster of judicial and executive branch nominees has been eliminated. The nuclear option has been detonated.

UPDATE: I was in the middle of writing a post about this when the vote was taken. Here's what I was writing:

A few minutes before the vote, Dana Bash was on CNN talking about the Democratic effort to eliminate the filibuster for judicial nominees. "It's going to make things a lot more tense in the Senate, if you can believe that," she said. "I imagine it will provoke a lot of anger on the Republican side," said another anchor. This was followed by some back-and-forth about just how angry Republicans would get and how they'd take advantage of this during next year's midterms.

This is typical, and telling. Republican anger is always taken as a given, and always treated as genuine. But for some reason Democrats don't get the same consideration. This despite the fact that Democrats stepped away from this brink several times already earlier this year, and the only reason they're going forward now is because Republicans have finally pissed them off beyond endurance. Even the moderates have reached the end of their ropes. If things are tenser now in the Senate, Republican need only look in the mirror to find the cause. They're no longer even pretending that they'll allow President Obama to perform the normal functions of his office—functions that every other president in history has performed without any serious obstacles.

The Coldest Winter I Ever Spent Was a Summer Reading Mark Twain's Autobiography

| Thu Nov. 21, 2013 12:17 PM EST

Via Andrew Sullivan, here is Ben Tarnoff's review of the second volume of Mark Twain's autobiography, which is now being published 100 years after it was written:

The hundred-year ban seems less about protecting Twain’s reputation than about sparing the feelings of the many people whom he attacks in his autobiography. The list is long. He has total recall of past slights, as well as an undiminished stream of vitriol for those whom he feels disrespected or deceived him. But he wants to make sure that his victims—and their wives and children—are dead before he dismembers them as cruelly as necessary. He feels a special hatred for publishers, especially Charles L. Webster....“The times when he had an opportunity to be an ass and failed to take advantage of it were so few that, in a monarchy, they would have entitled him to a decoration.”....Twain’s rage is unrelenting. He pumps his enemies’ bodies full of bullets when one or two would do the job.

That's kind of fascinating, isn't it? What sort of person can be simultaneously so brimming with rage and so sparing of others' feelings? It's an odd mix. Normally, I'd guess that it was the act of a calculating man who didn't want his contemporaries to know what he was really like, but Tarnoff suggests that's not the case. Instead, it seems to be the case of a man who knew, perhaps, that his rage was unfair, but was vain enough that he couldn't bring himself to let it go unexpressed or unseen forever. Very peculiar.

It's Doctors Who Control the Number of Doctors in America, Not the Government

| Thu Nov. 21, 2013 11:31 AM EST

After writing yesterday about the reason we pay doctors so much, I received a bunch of tweets basically calling me a communist, or a moron, or sometimes a communist moron. I mostly ignored them because that's what I usually do, but Matt Yglesias didn't. You can view some of the reactions he got to a similar post here.

Anyway, the whole thing is kind of amusing. There are certainly some people who would consider Yglesias and me raving redistributionist socialists, and I guess that's fair enough. It's the price you pay in America for advocating modestly more progressive taxes. But in this case, at least, we're the ones taking the side of the free market. American doctors are paid far more than doctors anywhere else in the world, and yet we have fewer doctors per capita than nearly any other rich country. Why is that? One especially misguided tweeter suggested that this was, yet again, the fault of Big Gummint, which controls the number of residency slots for new medical schools grads, and therefore keeps the number of doctors low. There's a certain kernel of truth to this, because the federal government subsidizes residency programs to the tune of $13 billion per year, just as the federal government controls Medicare reimbursement rates via a committee called the RUC. But that's only half the story. Who controls RUC? Physicians do. They have a stranglehold on it. And who controls how many residency slots there are and what specialties they're in? Again, physicians do.

So the number and composition of residencies is controlled by doctors, even as they're subsidized by $13 billion in taxpayer money every year. And doctor pay, which almost everywhere is based on Medicare rates, is controlled by doctors. It's doctors who are directly responsible for both their own high pay and their own low numbers.

Another tweeter suggested that, in fact, the number of med schools and med school grads has been rising steeply over the past decade. But it ain't so. Since 2002, we've opened 13 new MD-granting med schools, an increase of about 10 percent. Likewise the number of med school grads has risen from about 15,000 to about 17,000, again an increase of 10 percent. That's roughly the same as the overall population growth of the United States. The number of medical schools per capita and the number of med school grads per capita has barely budged in that time.

Whatever else you think about our views on the economy or the proper role of government, in this case Yglesias and I are the ones on the side of the free market. Let the number of doctors rise to meet demand. Let the number of nurse practitioners rise to meet demand, and stop artificially restricting what they're allowed to do. That will put downward pressure on prices all by itself. Then we can add some Big Gummint to the mix by taking RUC out of the hands of physicians and using it to set lower prices. But by then we'll be pushing on an open door. The market will have already done all the heavy lifting.

Filibuster Reform May Be Just Hours Away

| Thu Nov. 21, 2013 12:32 AM EST

Is filibuster reform coming as soon as tomorrow? Maybe so:

“We’re not bluffing,” said one senior aide who has spoken with Mr. Reid directly and expects a vote on Thursday, barring any unforeseen breakthrough on blocked judges.

The threat that Democrats could significantly limit how the filibuster can be used against nominees has rattled Republicans. Senator John McCain, the Arizona Republican who has brokered last-minute deals that have averted a change to filibuster rules in the past, visited Mr. Reid in his office on Thursday but failed to strike a compromise.

Of course, as Rick Hasen says, "If Democrats were bluffing, they'd have every incentive to say 'We're not bluffing.'" Still, it sure doesn't look like any serious negotiations are taking place, and Harry Reid wouldn't bring something to the floor unless he knew he had the votes to pass it. Thursday could be a very interesting day in Washington DC.

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The Media Once Again Refuses to Answer Questions From the Media

| Wed Nov. 20, 2013 9:14 PM EST

Personally, I've never really understood the appeal of Mike Allen's "Playbook"—or any of the other morning briefing newsletters. Why would reporters deliberately read something whose explicit goal is to make sure that everyone is saying and chasing the same stories? This has never made any sense to me.

That's not really the topic of this post, though. I just wanted to get it off my chest as a prelude to the latest example of the press going into full stonewall mode whenever they're the ones a story is about. Today, Erik Wemple reported the results of a deep dive into the contents of Playbook, and it wasn't pretty: organizations that advertise with Allen, such as the Chamber of Commerce, get an awful lot of friendly mentions that are presented as straight news. Does Allen do this as part of his deal with his advertisers without telling his readers, or is there a more innocent explanation? We'll never know:

Politico’s leaders didn’t cooperate for this piece. In rejecting a sit-down discussion, Editor-in-Chief John Harris said the premise “is without merit in any shape or form.” Without an interview, it’s impossible to judge Allen’s motivations. For example, does he write nice things about the chamber because he wants more advertisers or because he feels their agenda doesn’t get fair play in other outlets? Did he publish those BP plugs because he thought they were newsworthy or because he’s got a friend at the company?

Of course Harris refused to say anything. It's standard journalistic practice. It's only other people who have to answer questions. It's outrageous to expect news organizations themselves to do the same.

So Far, Obamacare Has Taken Only a Modest Hit in Polls

| Wed Nov. 20, 2013 3:06 PM EST

Yesterday I misread a poll question about Obamacare, initially thinking it was about whether people wanted to make changes to the law. Today, though, CBS has a poll question that really does ask this. Here it is:

This isn't very different from Kaiser tracking polls in the past. In the most recent one, among people who expressed an opinion, 56 percent wanted the law kept as is or enhanced, while 44 percent wanted it repealed. 

So far, Obamacare hasn't really taken that big a hit in public opinion, and as the website problems continue to get fixed I expect that public opinion will improve. It's still early days.

Patent Reform Takes a Hit From the Tech Industry

| Wed Nov. 20, 2013 2:48 PM EST

Tim Lee reports that a key provision in Rep. Bob Goodlatte's patent reform bill has been axed:

One provision would have expanded what's known as the "covered business method" (CBM) program, which provides an expedited process for the Patent Office to get rid of low-quality software patents....The CBM program provides a quick and cost-effective way for a defendant to challenge the validity of a plaintiff's patent. Under the program, litigation over the patent is put on hold while the Patent Office considers a patent's validity. That's important because the high cost of patent litigation is a big source of leverage for patent trolls.

The original CBM program, which was created by the 2011 America Invents Act, was limited to a relatively narrow class of financial patents. The Goodlatte bill would have codified a recent decision opening the program up to more types of patents....But large software companies had other ideas. A September letter signed by IBM, Microsoft and several dozen other firms made the case against expanding the program. The proposal, they wrote, "could harm U.S. innovators by unnecessarily undermining the rights of patent holders. Subjecting data processing patents to the CBM program would create uncertainty and risk that discourage investment in any number of fields where we should be trying to spur continued innovation."

It would be hard to overstate just how self-serving and absurd the IBM-Microsoft position is. The notion that an expedited process for evaluating business process patents would discourage investment is laughable. This is the purest example of special pleading since Rob Ford tried to justify his crack use by explaining that he was hammered at the time.

Which wasn't that long ago, was it? This just goes to show how common special pleading is—and also goes to show just how seriously we should take it. The good news here is that apparently the CBM provision is still alive in the Senate, so there's still a chance it could make it into the final bill. We can hope.

Etymology of the Day: Strategery

| Wed Nov. 20, 2013 12:48 PM EST

My incidental use of the George Bushism "strategery" in a post this morning sparked a Twitter exchange which produced an interesting factlet: George Bush didn't invent the word. Here it is in an 1845 short story by Mark Lemon, the founder of Punch, titled "Never Trust to Outward Appearances":

The particular strategery spoken of here involves one Caleb Botts, who was negotiating to marry away his daughter Fanny for his own benefit, but eventually gets outsmarted. I just thought you'd all like to know.

UPDATE: Sorry. I'm reminded in comments that "strategery" was invented by Will Farrell in an SNL spoof of George Bush. As happens so often, fiction replaces reality in our memories.