Kevin Drum

The Times Takes on Dartmouth

| Thu Jun. 3, 2010 12:23 PM EDT

As you may recall, one of the best known studies of healthcare costs, and one that got a lot of attention over the past year, is the Dartmouth Atlas of Health Care, which shows, for example, that although patients in Miami get a lot more healthcare than people in Minnesota, and they get it a lot more expensively, their health outcomes aren't any better. This suggests that there are lots of possibilities out there for cutting back on healthcare costs without impacting the quality of care.

Last night I came across a New York Times article that questioned whether the Dartmouth folks had really proven anything at all. But lazy bastard that I am, I got this far and then just gave up:

But the real difference in costs between, say, Houston and Bismarck, N.D., may result less from how doctors work than from how patients live. Houstonians may simply be sicker and poorer than their Bismarck counterparts. Also, nurses in Houston tend to be paid more than those in North Dakota because the cost of living is higher in Houston. Neither patients’ health nor differences in prices are fully considered by the Dartmouth Atlas.

WTF? This stuff has been controlled for endlessly, and the Dartmouth data still holds up. But I was tired, so I went to bed instead of posting about this. However, other, more energetic people have now taken the trouble to lay out the evidence, so let's review. Here's one of the co-authors of the Dartmouth study explaining their work a year ago in the New York Times (!):

It is true that some regions of the country experience more illness than others, and of course sick people spend more on health care. To deal with this bias, the Dartmouth group has compared expenditures and frequency of treatment across regions for people with similar diseases. The most extensive study compared spending across regions using a variety of cohorts such as people who had suffered a hip fracture or heart-attack patients. This study examined people who were equally sick, whether they lived in Louisiana or Colorado. The researchers further adjusted for any differences in patient income, race, and prior health. They still found gaps of up to 60 percent in spending among regions.

And here, via Brad DeLong, is David Cutler, who was quoted in support of the writers' point that "failing to make basic data adjustments undermines the geographic variations the atlas purports to show":

[T]he reporter asked ‘what do you make of the fact that the price adjustment changes the ranking of communities?’ I said something to the effect of ‘why do I care about the non-price adjusted data.’... [T]he Dartmouth people have done the price adjustment, so we don’t have to fight about what such an adjustment would do. Hard to tell why my comments are beating up on anything (except a mythical version of the Dartmouth data in which they had never done price adjustment)...

Bottom line: all the "data adjustments" the Times reporters talk about have, in fact, been done. Researchers at Dartmouth and elsewhere have controlled for price levels, for demographics, and for differing rates of sickness, and their results largely hold up. There are big variations in cost that have very little impact on quality of outcome. In the end, then, the authors of the Times piece end up with almost nothing. By the time their piece is done, they've basically only got two things left. First, the Dartmouth researchers admit that, on occasion, they might discuss their findings more broadly than they should when they're talking to a lay audience. Second, there are individual bits and pieces of their dataset that other researchers have disputed. Just as there are with any large, complex dataset.

In other words, there's no there there. The Dartmouth research is not the be-all-end-all of healthcare research, but its basic conclusions are extremely robust and have been confirmed over and over. Why the Times chose to pretend otherwise is a mystery.

POSTSCRIPT: The Dartmouth researchers respond to the Times here.

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Quote of the Day: Obama on Republicans

| Thu Jun. 3, 2010 11:17 AM EDT

From Barack Obama, explaining the Republican attitude toward governing:

It’s a belief that government has little or no role to play in helping this nation meet our collective challenges. It’s an agenda that basically offers two answers to every problem we face: more tax breaks for the wealthy and fewer rules for corporations.

....As November approaches, leaders in the other party will campaign furiously on the same economic arguments they’ve been making for decades. Fortunately, we don't have to look back too many years to see how their agenda turns out. For much of the last 10 years we've tried it their way. They gave us tax cuts that weren’t paid for to millionaires who didn’t need them. They gutted regulations and put industry insiders in charge of industry oversight. They shortchanged investments in clean energy and education, in research and technology. And despite all their current moralizing about the need to curb spending, this is the same crowd who took the record $237 billion surplus that President Clinton left them and turned it into a record $1.3 trillion deficit.

Feisty! But will he keep it up? One speech won't have much of an impact, but if he takes to the campaign trail and starts making this argument repeatedly, it might start to sink in a bit. It's worth a try.

New Life for the Volcker Rule?

| Thu Jun. 3, 2010 1:23 AM EDT

The conference committee for financial reform legislation won't start meeting until next week, but the Financial Times reports that one provision in the bill is already on target to get tightened up:

Congressional negotiators are moving to toughen financial reform legislation, raising the chances that banks will face a strict ban on proprietary trading and a new conflict of interest rule, people involved in the deliberations say....The provision, sponsored by Jeff Merkley and Carl Levin, two Democratic senators, would toughen the “Volcker rule”, which bans banks from trading for their own account or owning hedge funds and private equity firms, but gives regulators time to study the rule and modify it. “That is a very wishy-washy way to approach the issue,” Mr Merkley said.

Mr Levin said even though the Treasury would “probably...want as much power as they can get to...modify [the bill]”, he thought Congress should write a strong final version.

The Wall Street Journal reports that traders are genuinely unnerved:

Since political momentum began building earlier this year to limit trading for profit at Wall Street firms, traders have been exploring their options, and some have already left. Outside the banks, private investment funds looking for skilled traders have been gearing up for a hot talent market.

...."With Volcker, you've got everyone shaking in their boots, so these traders all have an ear to the ground," says John Pierson, a Manhattan-based headhunter for financial firms.

I guess I can live with this. I'd rather have trading being done in hedge funds, where it belongs, than in banks, where it risks blowing up the plumbing of the financial system. One caveat, though: that trading income should be taxed as ordinary income, not capital gains, as it is now. Other people's money, you know. The House has already done its part to change this, and now it's the Senate's turn.

Finding a New Job

| Wed Jun. 2, 2010 5:43 PM EDT

Andrew Sullivan posts a letter today from a reader in England who was laid off a year ago and hasn't had much luck finding a job since. Here's the concluding paragraph:

Several things I've learned: You can't apply for jobs well under what your previous job was; you won't be taken seriously and will be considered over-qualifed. You must fall completely to the bottom and get the occasional minimum wage, temporary job. No one will commit to any training for a new position. If you've done exactly the job advertised before, you'll be considered. But you'll be considered incapable of learning anything new. General experience will not be considered. Stuff learned on your own will be denigrated or discounted. University degree qualification doesn't matter. Age discrimination is alive and well.

Italics mine. This is a surprisingly widespread attitude, even in the white collar sector. Back when I had a real job and frequently hired new staff members, I always looked for people who had the right general background (product management, say, or tech writing) but I didn't worry too much about whether their background precisely matched what they'd be doing for me. This was, however, decidedly not the attitude of most of my peers. Many of my job candidates were interviewed by a few others in the company as well as by me, and I was always surprised by the number of people who would say "But he only has a hardware background" (we were a software company) or "she's never worked in document imaging" (we were a document imaging company). And the folks who said this were consistent when they were hiring for their own departments: they were really meticulous about looking only for people who had exactly the background they needed, whether that meant selling high-volume scanning software (for a sales job) or knowing the precise set of technologies we used to build our software (for a programming job).

This attitude wasn't universal, but it was surprisingly common. And it betrays a real laziness. Sure, someone with exactly the right background can be a plus sometimes, but most of the time all it gets you is a slightly faster learning curve for the first month or two. After that, the more talented person will be better no matter what their background was. (Within reason, of course.) A good product manager can learn a new product line and a good programmer can learn a new set of tools.

Of course, I've always wondered if I was wrong about this. Maybe I overestimated the ability of most people to learn new things. Maybe my department (marketing) was more forgiving of long learning curves than others. Maybe even good programmers struggle with new tools for a long time unless they've previously used something pretty similar. Maybe things are entirely different when you take a step down from the knowledge-intensive jobs that I'm most familiar with. It wouldn't be the first time I was wrong about something. What say you, readers who are also hiring managers? How close a fit do you usually look for in new hires?

Reforming the Senate

| Wed Jun. 2, 2010 2:56 PM EDT

Jonathan Bernstein writes about the growing abuse of the filibuster and then quotes CAP's John Lilly saying that rank-and-file senators will never be willing to give it up:

Lilly thinks the only hope is public outcry, but while I do think it might help a bit, I think it's mostly a pipe dream. The real hope is that senators find the collective frustrations of the current system an even bigger problem than the individual advantages it gives them — and finding a set of reforms that will on balance reduce the frustrations without cutting too deep into individual influence.

I'm with Jonathan on this. There are two almost insurmountable problems here. The first is that the American public is simply never going to get excited about internal Senate procedures. It's true that movement conservatives have shown an impressive ability to work their troops into a frenzy over some pretty peculiar things (repealing the 17th amendment, anyone?), but their more recondite issues still rarely manage to catch fire with more than a small fraction of the public. And that's best case. There are hot buttons that can be turned into mass movements, but dissatisfaction with Senate rules isn't one of them.

Second, even if, against all odds, you managed to get the public riled up over this, it's always going to be intensely partisan. The party out of power will always view the Senate rules as their last bulwark against incipient tyranny, and as long as this remains a partisan issue it has no chance of changing based on public outcry.

No, there's only one way that the filibuster or any of the Senate's other non-majoritarian rules will be changed: if Joe Biden and 51 Democrats decide to change them in January 2011. When the Senate reconvenes, Biden (and, implicitly, his boss) have to agree to make the required parliamentary rulings, the same way Nelson Rockefeller did in 1975, and a majority of the Senate would have to support him. In particular, Biden would have to rule that each new Senate draws up its own rules, and 51 Democrats would then have to approve changes to the existing rules. And since Democrats are likely to have a fairly thin majority next year, this means that practically the entire Democratic caucus would have to support change.

Is this feasible? It's hard to say since Obama hasn't said anything one way or the other about it. But even if he's willing, my guess is that there isn't enough support to change the filibuster rule. However, I wonder if there would be support for at least modifying the rules on holds and appointments? The abuse of holds and the obstruction of Obama's executive branch nominees has been brazen enough that there might be enough support to rein them in. But I'm not even sure of that.

Cars, Trucks, and iPads

| Wed Jun. 2, 2010 12:29 PM EDT

Here is Steve Jobs on the future of PCs:

“When we were an agrarian nation, all cars were trucks because that’s what you needed on the farms.” Cars became more popular as cities rose, and things like power steering and automatic transmission became popular.

“PCs are going to be like trucks,” Jobs said. “They are still going to be around.” However, he said, only “one out of x people will need them.”

I get Jobs's point, and if your definition of "PC" is narrow enough he's probably right.1 But where did this whole truck analogy come from? The first cars were cars, weren't they? And the rise of cities was pretty much unrelated to the rise of cars. What's he talking about here?

1For what it's worth, I think "PC" has a very wide definition indeed. The iPad, for example, is pretty clearly a PC. I get why Jobs wants to pretend otherwise, since he's pretty invested in the whole "magical experience" narrative of iPad ownership, but does anyone else buy this? I mean, it's a free-standing single-user device with a screen, a keyboard, a CPU, connectivity to the internet, and the ability to run lots of different apps. If that's not a PC, what is?

UPDATE: Man, I gotta learn to read to the end of posts. This comes via James Joyner, who makes the exact same point as me about the whole car/truck analogy. He even has links.

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Chart of the Day: Employment by Gender

| Wed Jun. 2, 2010 11:59 AM EDT

This comes from Stuart Staniford, and it's an employment map of the United States by county. Dark areas have high employment and light areas have low employment. Bluish area have relatively high male employment and brownish areas have relatively high female employment.

What does it all mean? Beats me. Basically, it's just data geekery. But kind of interesting anyway, no? Stuart has more speculation over at his place.

The Runaway Jury (Selection Process)

| Wed Jun. 2, 2010 11:41 AM EDT

In a study that should surprise no one, the Equal Justice Institute reports that jury selection in the South is far from colorblind:

Today, the practice of excluding blacks and other minorities from Southern juries remains widespread and, according to defense lawyers and a new study by the Equal Justice Initiative, a nonprofit human rights and legal services organization in Montgomery, Ala., largely unchecked.

....While jury makeup varies widely by jurisdiction, the organization, which studied eight Southern states — Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, South Carolina and Tennessee — found areas in all of them where significant problems persist. In Alabama, courts have found racially discriminatory jury selection in 25 death penalty cases since 1987, and there are counties where more than 75 percent of black jury pool members have been struck in death penalty cases.

....“There’s just this tolerance, there’s indifference to excluding people on the basis of race, and prosecutors are doing it with impunity,” [Bryan] Stevenson said. “Unless you’re in the courtroom, unless you’re a lawyer working on these issues, you’re not going to know whether your local prosecutor consistently bars people of color.”

Most racially-inspired problems are hard to solve, but in this case there's a pretty easy solution: just eliminate the voir dire process entirely. Pick 12 people at random, let the judge interview them and eliminate anyone who's obviously unqualified or has a conflict of interest, and that's that. You have your jury. Not only would this eliminate the most obvious source of racial bias, but it would have plenty of other positive effects too. It would reduce the number of jurors that courts need to summon, for example. And it would speed up trials. I sat on a drunk driving case once where the jury selection process took nearly as long as the trial itself because the defense attorney was desperately trying to eliminate anyone who might not be entirely sympathetic to a middle-aged guy who got behind the wheel after he'd had a few too many and started weaving around the road. It was a waste of our time, a waste of the judge's time, and a waste of taxpayer money. (And we convicted the guy anyway.)

This is the way jury selection works in Britain, and guess what? Justice seems to be served just fine. The only downside, I think, is that John Grisham wouldn't have been able to write his best book. I can live with that.

What Tea Partiers Think

| Wed Jun. 2, 2010 10:52 AM EDT

Bruce Bartlett passes along the results of a recent poll in Washington state that asks for the views of hardcore tea party members, not just those who are generally sympathetic toward tea party goals:

What I think this poll shows is that taxes and spending are not by any means the only issues that define TPM members; they are largely united in being unsympathetic to African Americans, militant in their hostility toward illegal immigrants, and very conservative socially. At a minimum, these data throw cold water on the view that the TPM is essentially libertarian. Based on these data, I would say that TPM members have much more in common with social conservatives that welcome government intervention as long as it’s in support of their agenda.

The serious tea partiers don't think it's the government's job to guarantee equality of opportunity, strongly approve of Arizona's new immigration law, don't like Obama's outreach to Muslims, and believe that gay and lesbian groups have too much political power.

Transparency in Politics

| Tue Jun. 1, 2010 3:42 PM EDT

Carol Leonnig writes in the Washington Post today that many corporations are eager to start funding political ads now that the Supreme Court has ruled that this is legal:

These companies include firms on Wall Street and in the energy sector opposed to stricter regulations as well as fast-food franchise owners fearful of being forced to unionize their shops. They just don't want to be singled out — or have their corporate logo attached.

Some fear the rules on corporate election activities could change, leaving their company exposed; a White House-supported bill likely to be voted on by the House after the Memorial Day recess would require calling out by name the corporations that fund campaign ads. Republicans, who generally rely more heavily on donations from big-business executives, say that Democrats are trying to silence the political speech of corporations with the bill.

....Big corporations are the new whipping boys in the wake of taxpayer-financed bailouts, Republican operatives argue. They say chief executives can't take to the public square to share their unpopular views on legislation without being personally attacked or — worse — dismissed. "You want to speak your peace without political retribution," said David N. Bossie, president of the conservative group Citizens United, whose fight to air its video critical of Hillary Rodham Clinton led to the Supreme Court's ruling.

This is ridiculous. If you're in the arena, you're in the arena — and that means your opponents get to fight back. If you're afraid of that, then you'd better stay out of politics. We already have too little transparency when it comes to political advertising, and the last thing we need is to allow even less.