Kevin Drum

Southern White Women Are Apparently in Pretty Bad Shape These Days

| Tue Jan. 19, 2016 2:19 PM EST

Since I happened to mention the famous Case/Deaton mortality study in the previous post, here's the latest from Andrew Gelman. As you may recall, Case and Deaton concluded that mortality among middle-aged whites from suicide, alcohol, and drug poisoning had skyrocketed over the past two decades. This set pundits afire with theories about what was going on, but Gelman has done some age adjustment to the cohorts that Case and Deaton used, and then broken up the data by gender, and then by geographic area. Here's what he gets:

After 2005, there's no effect on middle-aged men at all. It's all women. And if you break it down further, nearly the entire effect is concentrated among women in the South. But why? Gelman punts:

I don’t have any explanations for this. As I told a reporter the other day, I believe in the division of labor: I try to figure out what’s happening, and I’ll let other people explain why.

I think that's wise. For one thing, if you slice the data in a different way, you might get a different result. What's more, as I've mentioned several times, the increased mortality affects the young too, not just the middle aged. So if you spun some brilliant theories about why middle-aged whites are so damn depressed these days, you might want to rethink things. Your new theory needs to explain why the young and the middle-aged are dying in greater numbers, and you also need to explain why it's affecting primarily women in the South. Good luck.

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Study: End-of-Life Care in US Is About Average

| Tue Jan. 19, 2016 1:32 PM EST

Here's a cheeful headline over at Wonkblog:

Dying of Cancer in the U.S. Is Not as Bad as Most People Think

Huh. I'll bet many people beg to differ. Luckily, someone thought better of this claim and changed the headline:

The U.S. is not as bad at end-of-life care as most people think

That's more like it. But is it true? Ezekiel Emanuel1 is part of a team that's done some comparative research on this subject,2 and he says it is. But when I read carefully through the Wonkblog piece, here are the takeaways:

  • End-of-life hospital spending for American cancer patients is pretty high.
  • American cancer patients experience more aggressive (and probably more unwanted) end-of-life interventions than cancer patients in other countries.
  • They are twice as likely to be admitted to the ICU as in other countries.
  • Nearly 40 percent received last-ditch chemotherapy — more than patients in Belgium, Canada, Germany, Norway and the Netherlands.
  • Only 75 percent of cancer patients are hospitalized during their last six months, compared to 89 percent in Belgium.

To my gimlet eye, this looks like four bad things and one good thing: our hospitalization rate is lower than in other countries. That really is good news, and is probably the result of better hospice and palliative care. Still, our hospitalization rate isn't a lot lower. We're making good progress on this, but it's not really something to crow about too much.

Oddly enough, this article bothers me not for any personal reasons, but because it's the second time in the last few months that I've seen a disturbing phenomenon: reporting of scientific papers that passes along the author's spin uncritically. We saw this recently with the Case/Deaton paper, which was widely reported as showing a specifically middle-aged problem even though that's not what the paper demonstrated. But Case and Deaton spun it that way, so that's what showed up everywhere. This time it's a paper that shows only a bit of modestly good news on the end-of-life front, but it's getting reported as a mythbusting finding because that's how one of the authors is spinning it.

In this case, there's another piece of badly misleading data: that the US spends about as much on end-of-life care as other countries. But the study includes only hospital costs, which are obviously lower in the US if we hospitalize less than other countries. What's more, the study also omits physician costs in the US. If that were included, and if hospice costs were included, US spending would look a lot higher. You can sort of figure this out if you read the paper, but the chart that's helpfully included makes no mention of it.

Moral of the story: as usual, be careful reporting about studies. Read the fine print. Don't take the authors' interpretation as gospel.

1Yes, yes, Rahm Emanuel's brother.

2The seven countries he compared were the United States, Germany, Norway, Belgium, Great Britain, Canada, and the Netherlands.

Today's Econ 101 Quiz: What Happens When You Reduce the Cost of Being an Asshole?

| Tue Jan. 19, 2016 11:44 AM EST

Annie Lowrey and Abraham Riesman have decided to quit Twitter. Why? Mostly because it's a soul-draining hive of scum and villainy:

Lowrey: Over the years, as an official woman-on-the-internet, I've encountered some truly insane garbage on Twitter. You write a story about Social Security reform, and then someone tells you to swim out into the ocean until you're too tired to swim anymore and you drown. There's also the persistent nagging by the godforsaken lunatic assholes, like the Obamabots, for instance. But that's not really the stuff that bothers me. It's the little stuff. The mansplaining from well-intentioned friends. The forest-for-the-trees criticism of my grammar. The sincere complaints about my vocal fry every time I go on a radio program, podcast, or television. (Read this in a suuuuupper-scratchy voice? Go fuck yourselves.) The constant, degrading references to me as my husband's wife.

Finally, I decided to wash my hands of the whole thing when I wrote something about poverty and proceeded to get a flood of nasty, sexist tweets and emails — just days and days of it. It was impossible to defend myself, and impossible to work, and impossible to focus, and I just wanted to leave the internet forever. It really messed me up for a few days: Why put things out there if you're not going to be able to have even a semblance of a good conversation about them? Why put things out there if people are going to attack you rather than the work?

Riesman: My "epiphany" came in two parts, both of them pretty bland. I'd tweeted something about Star Wars, and someone I don't know somehow saw it and tweeted a link to it with a snarky comment attached. At that point, a notorious asshole whose name I won't mention saw that person's tweet and retweeted it. All of a sudden, dozens and dozens of the asshole's followers decided to hurl insults at me and do weird stuff like [blah blah blah].

....But the final straw didn't come until my aggravation was compounded the next day. In the mid-afternoon, I got into a fight on Twitter with a reviewer from a low-end culture site who had some idiotic opinions about a cartoonist I enjoy. The reviewer is a person of no major consequence in the critical world, and the site is widely derided, but I still felt compelled to get into an argument with her. I wasted nearly an hour doing so and found myself exhausted afterward.

This is the basic problem with Twitter: It's too damn big and too damn easy to use. Back when dinosaurs roamed the earth, people had to do some work if they wanted to casually trash you. Maybe write a letter to the editor. Or dig up your home address and write a letter to you. On rare occasions, they might even call you on the phone.

Then email came along and made the ALL CAPS insult genre a lot easier: just click a link, pound out a few sentences, and hit Send. Easy peasy. Still, no one saw your brilliance except the target, and you rarely got a response. It was progress, but still not very satisfying.

Then came Twitter. It was even easier than email. Just hit Reply or RT and do your thing. You're limited to 140 characters, so it's not very much work. Everyone who follows you gets to see it, and your target knows it—so they sort of feel obligated to defend themselves. And to make things even better, while the 140-character limit is great for random vituperation, it's a tough limit for reasoned response. And to make things even more better, getting a mob of fellow outrage junkies to follow your lead isn't just easy, it's almost inevitable. It practically happens on its own.

Doesn't that sound great? It sure does!

But on the receiving end? Not so much. You can repeat zen koans to yourself all you want—ignoring an asshole is the first step toward enlightenment—but it's tough. There's just so many of them. Sure, a hundred assholes is only 0.001 percent of the nation's assholes, but mental statistics just aren't enough to overcome the emotional tsunami of raw assholery aimed at you you you.

Basically, Twitter is the perfect platform for two things: snark and assholery. And it's not always easy to tell them apart. I have a pretty firm rule about never replying to assholes, but sometimes I make mistakes. I ignore someone who's asking a good faith question because my asshole detector goes off thanks to the tone of the tweet (most often because it's easy to strike the wrong tone in 140 characters). Likewise, sometimes I engage people who I mistakenly assume have a good faith criticism, only to quickly discover they're just looking for a fight. Life is tough on the internets!

Anyway, in the end this is a lesson about economics. What happens when you vastly reduce the cost of being an asshole? Answer: the supply of assholes goes up. That's what Twitter has done for us. It's also provided a decent platform for entertaining snark; breaking news; and pleasant chatting that's open to anyone who wants to participate. Is the tradeoff worth it? It all depends on how good you are at ignoring assholes and not getting addicted to internet fights. So how good are you? If you'll just wait a moment, I'm sure BuzzFeed will post a quick test to tell you.

Supreme Court to Rule on Obama's Immigration Order

| Tue Jan. 19, 2016 10:35 AM EST

From the New York Times:

The Supreme Court said Tuesday that it would consider a legal challenge to President Obama’s overhaul of the nation’s immigration rules. The court, which has twice rejected challenges to Mr. Obama’s health care law, will now determine the fate of one of his most far-reaching executive actions.

....The administration, fearing that the program could remain frozen through the balance of Mr. Obama’s presidency, had asked the court to move quickly. On that point, at least, the court agreed, and it now appears that the case will be argued in April and decided by the end of June....The court did broaden the scope of the case, asking the parties to address an additional and fundamental question: whether the administration’s plan violates the constitutional command that the president “shall take care that the laws be faithfully executed.

Well, that sure sounds like we can expect the usual partisan 5-4 decision. The liberals will vote with Obama and the conservatives will vote against him, and all the rest is window dressing. And just to twist the knife a bit more, the conservatives are going to use the opportunity to rail against Obama's executive tyranny and issue some kind of broad ruling which eliminates enforcement discretion that every president in history has enjoyed until now.

Maybe. I've been wrong before about how the courts would react to Obama's immigration order, so maybe I'm wrong again. And since I assume that much of the administration's defense will rely not just on constitutional authority, but specifically on statutory interpretation of immigration law—which is fairly unique in the amount of power it gives to the executive—it's hard to say for sure how exercised the conservative majority will actually be. In a few months we'll find out.

Two Corinthians Walk Into a Bar....

| Tue Jan. 19, 2016 1:12 AM EST

Here is a very short history of Donald Trump and the Bible verses that he likes:

August 26: That's very personal. You know, when I talk about the Bible it's very personal. So I don't want to get into verses, I don't want to get into—the Bible means a lot to me, but I don't want to get into specifics.

September 16: Proverbs, the chapter "never bend to envy." I've had that thing all of my life, where people are bending to envy.

January 18: I asked Jerry, and I asked some of the folks, because I hear this is a major theme right here, but Two Corinthians, right? Two Corinthians 3:17, that’s the whole ballgame. Where the spirit of the lord—right? Where the spirit of the lord is, there is liberty. And here there is Liberty College, Liberty University.

See? Trump is willing to study. At first he knew nothing. Then he boned up and kinda sorta named one verse that kinda sorta exists—but not really. Finally he boned up some more and named an actual Bible verse which he quoted accurately. Sure, he had to ask for one, and he had to read it off notes, but still. Progress!

But there's still one more step: learning how to accurately cite Bible references. In front of a crowd of thousands of Christian students at Liberty University, he talked about "Two Corinthians" instead of "Second Corinthians." Here's what's weird about that. It's not just that anyone who's so much as gone to Sunday School knows that you say "Second Corinthians." Even if you'd never been to church in your life, you'd know it from watching movies or TV or listening to ministers at weddings and funerals. It's just standard background knowledge in any culturally Christian country.

Now, nobody with a brain has ever believed that Donald Trump is a Christian in any serious sense. I don't think he could pass a third-grade test of Bible knowledge. But today's gaffe, as trivial as it seems, suggests more: that he literally has paid no attention to Christianity at all. In fact, given how hard that is in a country as awash in religious references as the United States, it suggests much more: Donald Trump has spent most of his life actively trying to avoid religion as completely as possible. And yet, apparently evangelicals love him anyway. Go figure.

We're Still Waiting to Find Out What Happened Off Farsi Island Last Week

| Mon Jan. 18, 2016 3:30 PM EST

A week after two Navy boats were taken into custody in Iranian waters, the Pentagon still doesn't seem to have any idea what happened:

[The two boats] were supposed to follow a course that would keep them in international waters. They were scheduled to refuel at a rendezvous with the Monomoy, a Coast Guard cutter, at about 5 p.m. But the two boats veered off course Into Iranian waters.

....The crews then stopped to try to fix a mechanical problem in one boat’s diesel engine. “This stop occurred in Iranian territorial waters, although it's not clear the crew was aware of their exact location,” the report said.

At about 5:10 p.m., one of the boats apparently sent a brief radio report that Iranian boats were approaching. A second message was garbled. All communications were cut off by 5:45 p.m., the report said

This is all still pretty peculiar. On a trip from Kuwait to Bahrain, all these boats had to do was stay within 60 miles of the shoreline and they would have been fine. Why were they so far out? Where was the Monomoy? Did they really suffer an engine failure, two GPS failures, and two comms failures all at once? I know that a thorough investigation can take some time, but this one doesn't seem very complex. What the hell happened out there?

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George Washington's Cakemaker Gets the Boot

| Mon Jan. 18, 2016 12:11 PM EST

From the New York Times:

Scholastic Publishing said on Sunday that it would halt distribution of a children’s picture book about George Washington and his enslaved household cook amid an outcry over its visual depiction of the former president’s slaves as happy, smiling workers.

....“We do not believe this title meets the standards of appropriate presentation of information to younger children, despite the positive intentions and beliefs of the author, editor and illustrator,” it said in a statement. While defending the team that produced the book, the publisher said that without more historical background, “the book may give a false impression of the reality of the lives of slaves and therefore should be withdrawn.”

I find this whole episode pretty astonishing. How did Scholastic not realize that a whole lot of people were going to find this inappropriate and offensive? It took me about two seconds, and I'm not notably steeped in sensitivity toward racial portrayals.

More generally, is it ever appropriate to depict American slaves in children's books like this? I doubt it. Presenting the reality of slavery is a bit much for 7-year-olds. But sanding down the reality is wrong too. All it does is provide a vague misconception that has to be unlearned later. I'm not really sure there's a middle ground that works well for very young readers.

Maybe some of the parents and schoolteachers reading this will have other opinions. Is there any reasonable way to present slavery in books for young children? And what's the age when you can start to present something at least modestly realistic? Comments are open.

A Second Look at BernieCare

| Mon Jan. 18, 2016 11:23 AM EST

Last night I wrote that Bernie Sanders' universal health care plan was "pretty good." Over at Vox, Ezra Klein says it's vague and unrealistic. Who's right?

Both of us, I'd say. The Sanders plan is mostly a sketch of how he'd fund universal health care, and at that level I'd say it was pretty good if you evaluate it as a campaign document rather than a Brookings white paper. His numbers mostly added up, and from my point of view, his funding sources were roughly appropriate. Half or more of the funding comes from the middle class, with the rest coming from the rich. I'm OK with that.

But how about the actual mechanics of providing health care? Klein is pretty scathing about Sanders' promise that his plan will cover everything with no copays or deductibles:

The implication to most people, I think, is that claim denials will be a thing of the past....What makes that so irresponsible is that it stands in flagrant contradiction to the way single-payer plans actually work....The real way single-payer systems save money isn't through cutting administrative costs. It's through cutting reimbursements to doctors, hospitals, drug companies, and device companies.

....But to get those savings, the government needs to be willing to say no when doctors, hospitals, drug companies, and device companies refuse to meet their prices, and that means the government needs to be willing to say no to people who want those treatments. If the government can't do that — if Sanders is going to stick to the spirit of "no more fighting with insurance companies when they fail to pay for charges" — then it won't be able to control costs.

The issue of how often the government says no leads to all sorts of other key questions — questions Sanders is silent on. For instance, who decides when the government says no? Will there be a cost-effectiveness council, like Britain's National Institute for Health and Care Excellence? Or will the government basically have to cover every treatment that can be proven beneficial, as is true for Medicare now? What will the appeals process be like?

This might sound technical, but it's absolutely critical.

Klein is right that the mechanics of the plan are critical, and I probably should have done more than shrug that off as something that we'd get to later. Still, I think his criticism goes way too far. This is a campaign document. It's obviously aspirational, and asking a presidential candidate to go into deep detail about the drawbacks of his policy is a little much. I can't recall ever seeing that in my life. In a campaign, you sell the high points and then let critics take their shots.

That's not to say that Sanders couldn't have done more than he did. He could have and probably should have. In particular, he should have provided at least an outline of how his plan would work: who it covers, who employs doctors, what drives the cost savings, and so forth.

But my take is that Sanders was trying to accomplish something specific: he wanted to show that universal health care was affordable, and he wanted to stake out a position that Democrats should at least be dedicated to the idea of universal health care. I'd say he accomplished that in credible style. It's fine to hold Sanders to a high standard, but it's unfair to hold him to an Olympian standard that no presidential candidate in history has ever met. We health care wonks may be disappointed not to have more to chew on, but that's life. We'll get it eventually.

Bernie Sanders Releases Outline of Universal Health Care Plan—And It's Pretty Good

| Sun Jan. 17, 2016 8:54 PM EST

With only moments to go before tonight's Democratic debate, Bernie Sanders has finally dropped his universal health care plan. Exciting! I imagine that Team Clinton is poring over it pretty carefully right about now. Here's what he says it does:

Bernie's plan will cover the entire continuum of health care, from inpatient to outpatient care; preventive to emergency care; primary care to specialty care, including long-term and palliative care; vision, hearing and oral health care; mental health and substance abuse services; as well as prescription medications, medical equipment, supplies, diagnostics and treatments…As a patient, all you need to do is go to the doctor and show your insurance card. Bernie's plan means no more copays, no more deductibles and no more fighting with insurance companies when they fail to pay for charges.

....Under this plan, a family of four earning $50,000 would pay just $466 per year to the single-payer program, amounting to a savings of over $5,800 for that family each year.

Well, that sure sounds good. And I'm all in favor of universal health care. But I'm also curious about how he's going to provide comprehensive care like this with no payment by patients at all and at such a low cost. Here are his basic claims:

  • He will raise $630 billion by increasing the employer part of the payroll tax by 6.2 percent.
  • He will raise $220 billion via a 2.2 percent progressive income tax on everyone (he calls it a "premium").
  • He will raise $548 billion in various taxes on the rich along with the end of current tax breaks that subsidize health care.
  • That's a total of $1.4 trillion.
  • Current public spending on health care (mostly Medicare and Medicaid) runs around $1.2 trillion.
  • This means that Sanders is figuring that under his plan total national health care spending will be about $2.6 trillion.

This is considerably less than the $3 trillion we spend now, and Sanders also says his plan will keep spending growth down. This accounts for his claim that his plan will reduce total national spending on health care by $6 trillion over 10 years.

So is this credible? It's close. His taxes will probably raise about what he says. I'm not sure that he can reduce spending as dramatically as he hopes, but he can probably reduce it some. In other words, his sums might not add up perfectly, but they're pretty close.

If there's anything to criticize, it's his statement that the average family of four will pay only $466 per year. The problem here is that while his payroll tax might come from employers, it will end up being paid for by workers—just as existing employer health plans are ultimately paid for by workers. That would cost his family of four about $3,100, putting their total at around $3,600. And if you figure that Sanders is being optimistic about cost savings and will probably need to raise taxes more than he says, our family's total bill probably clocks in at around $4,000.

That's still not bad. An average family pays a whole lot more than that right now via employer health coverage and copays. There's a wee bit of smoke and mirrors here—counting employer plans when he talks about savings but not counting employer taxes when he talks about costs—but that's a small thing. Overall, his numbers are pretty honest.

As for the details of exactly how the plan would work, I don't know. The document on Sanders' website doesn't say much about that. I assume there's another document somewhere, or maybe more to come. Stay tuned.

Can We Spare a Tear for Ted Cruz?

| Sun Jan. 17, 2016 12:32 PM EST

For the past couple of decades conservatives have routinely railed against "coastal elites," "left coast liberalism," and "San Francisco values." The latter is so popular that it has its own Wikipedia page and Bill O'Reilly insists on credit for inventing the term. And it's not just San Francisco that's the target of conservative scorn. It's big cities in general, with Los Angeles, Boston, Washington DC, and New York leading the pack.

Of these, New York City is probably second only to San Francisco. It's home to the soda nazis, the Upper West Side, rent control, the Village, abortion on demand, and, above all, the hated liberal media. Conservatives might live in New York, but they sure don't like its values.

Nonetheless, a whole lot of them are apparently ready to crucify Ted Cruz over his quip about Donald Trump and New York values. They all knew what he meant. Hell, they all agree with him. But any port in a storm, I guess.

Life isn't fair, and Cruz has his share of defenders. And I know it's hard to work up any sympathy for the guy. Anything Cruz does to hasten his own doom is surely karmic justice. But of all the things to go down for, a routine crack about big city liberals surely tops the list for irony.

POSTSCRIPT: But speaking of New York values, has anyone bothered to put together a short montage of Donald Trump saying liberal things throughout the years? It wouldn't be hard, and 60 seconds would be plenty. It seems like a no-brainer, but I don't recall seeing anything like this. Have I just missed it?