Kevin Drum

Fighting the Ghosts

| Wed Aug. 19, 2009 1:51 AM EDT

An awful lot of journal articles supposedly written by medical researchers are actually written by pharmaceutical company PR departments.  Someone is finally starting to do something about it:

With a letter last week, a senator who helps oversee public funding for medical research signaled that he was running out of patience with the practice of ghostwriting. Senator Charles E. Grassley, an Iowa Republican who has led a long-running investigation of conflicts of interest in medicine, is starting to put pressure on the National Institutes of Health to crack down on the practice.

....The full scope of the ghostwriting problem is still unclear, but recent revelations suggest that the practice is widespread. Dozens of medical education companies across the country draft scientific papers at the behest of drug makers. And placing such papers in medical journals has become a fundamental marketing practice for most of the large pharmaceutical companies.

“Just three days ago, I got a request to be the author of a ghostwritten article about the effectiveness of a cholesterol-lowering drug,” Dr. James H. Stein, professor of cardiology at the University of Wisconsin School of Medicine, said this month. “This happens all the time.” He declined to attach his name to the paper.

Grassley's a weird dude, and he's been notably unhelpful on the healthcare reform effort.  But at least he's not completely worthless.  Good for him for taking this on.

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Breaking a Public Option Filibuster

| Tue Aug. 18, 2009 6:56 PM EDT

Armando, in his usual restrained way, asks why I think Republicans can filibuster a healthcare bill:

Republicans alone can not filibuster anything. So tell me Kevin, who are the Dem senators who are going to join a GOP filibuster of health care reform? Let's stick to the facts please. Even when you are shilling for a Dem capitulation on health care reform.

Well, it takes 60 votes to break a filibuster, and unless someone gets Teddy Kennedy back on the floor of the Senate, Democrats only have 59 votes right now.  As for the Democratic senators who might join a filibuster if the bill contains a public option, who knows?  But Ben Nelson is certainly a candidate.  So are Evan Bayh, Blanche Lincoln, Mark Pryor and Mary Landrieu.

On the other hand, it's possible that Harry Reid could hold the entire Democratic caucus together and then add a senator or two from Maine to successfully break a Republican filibuster.  Maybe.  Not many people seem to think this is likely, but your guess is as good as mine.

Are We Getting Kicked Out of Iraq?

| Tue Aug. 18, 2009 6:27 PM EDT

Last year the Iraqi parliament approved a Status of Forces Agreement that called for U.S. troops to withdraw from cities by June 2009 and to leave the country completely by December 2011.  At the time, there was a plan to submit the SOFA to a referendum, but that never happened.

Now, Prime Minister Nouri al-Maliki has apparently decided to revive the idea:

If Iraqi lawmakers sign off on Maliki's initiative to hold a referendum in January on the withdrawal timeline, a majority of voters could annul a standing U.S.-Iraqi security agreement, forcing the military to pull out completely by January 2011 under the terms of a previous law.

It is unclear whether parliament, which is in recess until next month, would approve the referendum. Lawmakers have yet to pass a measure laying the basic ground rules for the Jan. 16 national election, their top legislative priority for the remainder of 2009.

If the SOFA is voted down, American troops have to leave within a year.  That means January 16, 2011 instead of December 31, 2011.  It's not at all clear why Maliki is doing this, but Juan Cole takes a guess:

I am just speculating, but I wonder if this measure was pushed by the Islamic Supreme Council of Iraq, which is close to the ayatollahs in Tehran, who in turn may want to speed up the US withdrawal because they have become afraid of a 'color revolution' in Iran promoted by the US. Staging such things from neighboring Iraq would be easier than doing it from a greater distance...

Meanwhile, there's this:

In an effort to defuse mounting Arab-Kurdish tensions, the U.S. military is proposing to deploy troops for the first time in a strip of disputed territory in northern Iraq, the top American general in Iraq said Monday.

....Though the plan is still not finalized, Odierno said that he had discussed it recently with Iraqi Prime Minister Nouri Maliki and with Massoud Barzani, the president of the regional government, and that both had been receptive to the idea.

So on the one hand Maliki is supporting a referendum that might force a faster troop withdrawal, while on the other hand he's supporting renewed U.S. patrols even though the SOFA banned them starting last month.  The fig leaf is that the patrols will be in "mostly rural" areas, but that's a fairly thin excuse.

Anyway, I'm not sure what to make of all this.  But it wouldn't bother me at all if the Iraqi public voted down the SOFA and we ended up withdrawing a year earlier than planned.

Big Bang Healthcare

| Tue Aug. 18, 2009 2:43 PM EDT

I know, I know, healthcare can get tiresome.  But as part of the great debate over whether we need revolutionary change all at once vs. something "good enough" that we can build on, I think it's worth pointing out that most of the great universal healthcare systems of Western Europe took the latter route.  The French, for example, began covering lost wages from illness in the late 20s, and then began constructing a genuine national healthcare system shortly after World War II.  But that was just a start.  It took nearly 50 years before it became truly universal.  Here's the timeline from Wikipedia:

1947: extended social security to government workers.

1948: established three retiree insurance programs for non-salaried, non-farm employees (artisians, industrial and commercial workers, and among the liberal professions).

1952: established mandatory retiree insurance program for farmers, managed by the mutualité sociale agricole (MSA).

1961: established mandatory health insurance for farmers, allowing them choice among providers.

1966: established maternity health insurance for non-salaired, non-farm workers, managed by the CANAM.

1966: established mandatory insurance programs for farm-related accidents, non-work related accidents, and work-related sicknesses with free-choice of provider.

1972: protection enforcement of salaried farm-workers against work-related accidents, written into law.

1975: universalized retiree insurance mandatory for working population.

1978: establishment of unique program for ministers, religious congregation members, and personal insurance other non-covered persons.

1999: the complete institutionalization of universal health care.

2001: additional assistance provided for families who need help with daily tasks.

2002: compensation established for all medical-related accidents whether fault is found or not.

Even now, not everything is covered.  Above the lowest income levels, patients are required to pay 20-30% of the costs of care up to a certain amount, and private insurance is widely used to cover this gap.  There's a similar story in most other countries.  You can find a brief summary of Germany's evolution here, for example.

This is just some food for thought.  All countries are constrained in what they can do by past experience, existing institutions, and powerful interest groups.  But the important thing, I think, is to pass a law that makes the principle of universal coverage the law of the land.  Once that's in place, there's no going back even if the first pass is highly imperfect.

The Shoals of Washington DC

| Tue Aug. 18, 2009 1:40 PM EDT

David Roberts says that Netroots Nation was more subdued this year than last.  That's hardly a surprise.  But it's not just the fact that 2008 was an election year and 2009 isn't:

The sense, rather, is that we are witnessing a tsunami of progressive enthusiasm, organizing, and, um, Hope crash on the shoals of the status quo ... and the status quo isn’t budging. Bit by bit, the giddy high of those days following Obama’s election is dissipating. It’s dispiriting.

For what it's worth, this isn't just a liberal problem.  9/11 and the Iraq war masked a lot of this during George Bush's first term, but conservatives ended up feeling the same way before long.  They wanted a revolution, but instead they got NCLB.  And a wimpy stem cell compromise.  And Sarbanes-Oxley.  And McCain-Feingold.  And a huge Medicare expansion. And complete gridlock on Social Security.

Not exactly what they signed up for.  The tax cuts were great, of course, but what about abortion and gay marriage and entitlement reform and slashing the size of government and ANWR and the Endangered Species Act and everything else on the conservative wish list?  They got most of what they wanted on the national security front (missile defense, big Pentagon budget increases, a couple of nice wars), but on the domestic front most of them felt like Bush ended up delivering almost nothing.

It wasn't quite that bad, of course.  They did get the tax cuts, after all.  And they got a new bankruptcy law and a bunch of right-wing judges.  But for the most part, their domestic agenda crashed on the shoals of the status quo too.  Washington DC is a tough place to get anything done.

District 9

| Tue Aug. 18, 2009 12:45 PM EDT

I saw District 9 the other day, and it was.....odd.  More below the fold if you don't mind reading some spoilers.

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60 Votes

| Tue Aug. 18, 2009 11:36 AM EDT

Quick background: Republicans will filibuster any healthcare bill that reaches the floor of the Senate, and it takes 60 votes to break a filibuster.  If a healthcare bill includes a public option provision, it's vanishingly unlikely that we can find those 60 votes.  But budget reconciliation bills can't be filibustered, so an alternative is to include the public option but then introduce the bill via the reconciliation process, where it needs only 50 votes to pass.

So then: A couple of days ago I asked what would happen if Democrats did this.  The reconciliation process can only be used to pass provisions with direct budget impact, so the question is: which provisions would be deemed to have no budget impact and therefore get tossed out?  Stan Collender is a serious budget wonk of many years' standing, but it turns out that even he really doesn't have any idea:

The question isn't at all clear cut.  Is a provision a line in a bill, a phrase in a line, a whole section of legislation, etc.?  Even if a section of a bill doesn't affect outlays or revenues and, therefore, seems to qualify under #1 to be excluded, is it integral to other parts of the legislation that do change outlays or revenues and, therefore, should be allowed to stay.

As I said, this is complicated and will be extremely controversial.  There are budget experts on both sides of the aisle and this is more of a judgment call than the application of a hard and fast rule.

So to Kevin Drum...if you think you have questions now, just wait.

I don't know if Harry Reid can find 60 votes to break a filibuster of a bill that contains a public option provision.  But if he can't — something that seems pretty likely — and he has to try the reconciliation route, we're in terra incognita.  And once we get to that point, the shape of the bill won't be a matter of negotiating skill, or liberal spine, or presidential leadership, or backroom deal cutting.  It will be a matter of the Senate parliamentarian tossing out provisions randomly based on his good faith understanding of the rules.

Call me gutless, call me chicken, call me whatever.  But that's a process that won't turn out well.  It's just not a realistic option to take a big, complex piece of legislation, toss out individual provisions here and there, and expect to have anything other than a complete hash of a bill that will end up so unworkable it can't pass at all.  Like it or not (and I don't!), we need 60 votes to get healthcare through the Senate.  The question is how best to do that.

The New Pentagon

| Mon Aug. 17, 2009 8:45 PM EDT

In the Washington Post today, Rajiv Chandrasekaran tells us why Gen. David McKiernan was so abruptly fired a few months ago as the top commander in Afghanistan:

Gates and Mullen had been having doubts about McKiernan since the beginning of the year. They regarded him as too languid, too old-school and too removed from Washington. He lacked the charisma and political savvy that Gen. David H. Petraeus brought to the Iraq war....He did not fawn over visiting lawmakers like Petraeus did in Iraq.

...."Blame General Petraeus," a senior Defense Department official said. "He redefined during his tour in Iraq what it means to be a commanding general. He broke the mold. The traditional responsibilities were not enough anymore. You had to be adroit at international politics. You had to be a skilled diplomat. You had to be savvy with the press, and you had to be a really sophisticated leader of a large organization. When you judge McKiernan by Petraeus's standards, he looked old-school by comparison."

There's more to the story than just this, and given the importance of the Afghanistan campaign it was hardly unreasonable for Gates and Mullen to install a new commander they thought was better suited to the job — even if this was based primarily on personal chemistry and even if it involved some level of unfairness to an existing commander who hadn't done anything especially wrong.  That's just the way it goes with top level executive positions sometimes.  What's more, there's evidence in Chandrasekaran's piece that quite a few people in the Pentagon were objectively unimpressed with some of McKiernan's planning, though he's pretty vague about just why that was.

Still, even with all that said, it's a little disturbing that Gates and Mullen apparently placed such a strong emphasis on "charisma and political savvy."  That's only a thin line away from "boot licking empty suit," after all, and it wasn't so very long ago that we were complaining that the Army promoted too many politically savvy generals and too few real warriors.  That's probably not what happened here — McKiernan's replacement, Gen. Stanley McChrystal, has a good reputation — but there's still a slight whiff to the whole thing.  And there's also this:

Before McChrystal left Washington, Gates asked him to deliver an assessment of the war in 60 days. Instead of summoning a team of military strategists to Kabul, McChrystal invited Washington think-tank experts from across the ideological spectrum.

....There were few revolutionary ideas in the document, but McChrystal may have received something far more important through the process: allies in the U.S. capital, on the political left and right, to talk about the need for more troops in Afghanistan — in advance of his assessment to Gates, which will probably be submitted this month.

As Spencer Ackerman points out, this is indeed politically savvy.  Whether it was the right thing to do is another question entirely.

Empty Pockets

| Mon Aug. 17, 2009 2:27 PM EDT

The New York Times reports that Asian stock markets are down and the rest of the world is following:

“It’s almost an Asian flu that the markets caught today,” said Art Hogan, the chief markets analyst at Jeffries & Co. “Creeping into the conversation now is, when do we see top-line revenue growth? When is the consumer going to take over from government stimulus? But the answer is consumer data has been less than spectacular.”

Well, yeah.  That's always been the problem.  Eventually, recovery has to be fueled by consumer demand, and it's just not clear where that's going to come from.  Rising middle class wages?  Nope.  More credit card borrowing?  Obviously not.  Drawing down savings?  Just the opposite is happening.  Tapping into home equity?  Forget it.  Neil Irwin sums things up in the Washington Post today:

"Credit fuels housing. It fuels consumer durable goods. It fuels business investment. It's in every part of the economy," said [Carmen] Reinhart, an economist at the University of Maryland. "Credit makes recessions after a financial crisis longer, and all the signs are that [it] is happening this time as well."

A related head wind comes from American consumers. The financial crisis and recession are reversing a 30-year trend carrying Americans toward a high point in debt. The ratio of consumer debt to the nation's total economic output rose to 97 percent in the first quarter of this year from 45 percent in 1975.

Currently, Americans are saving more and paying down debt; the savings rate was 1.2 percent of disposable income in early 2008. By the second quarter of this year, that rose to 5.2 percent.

"The household sector has never been so stressed," said RGE Monitor Chairman Nouriel Roubini, who predicted the crisis and recession. "Savings has to go much higher, and that is going to slow growth of consumption even once incomes start growing."

Every dollar that Americans save is one fewer dollar for consumption, which means less economic output. When the savings rate goes up by a percentage point, spending decreases by more than $100 billion, according to the McKinsey Global Institute.

My Netroots Nation panelists might have all broken my heart by not opposing the reappointment of Ben Bernanke, but they were also unanimous in calling for a second stimulus.  Politically, that's not in the cards right now, and I think it's defensible to suggest that we wait for the current stimulus to really kick in before considering a new one anyway.  Still, even if the worst is over, no one has been able to point to a mechanism that will cause consumer demand to grow significantly over the next few years, and without that we have a very long, very swampy slog ahead of us.  Until the debt overhang goes away and middle class incomes start to rise, the U.S. economy is going to stay fragile and vulnerable to shocks.  It's hard to see much of a silver lining here.

Making Sense of the Public Option

| Mon Aug. 17, 2009 1:37 PM EDT

Joe Klein on the public option:

I never had much interest in a public option. I think the perils of government-delivered (as opposed to funded) services are obvious and immense....On the other hand,  I am very much in favor of a single-payer system in which the government gives everyone a tax credit, scaled according to income, that enables people to select from an array of government approved and regulated health insurance choices.

There's something very odd going on with the debate over the public option.  Granted, it means different things to different people, but I'm pretty sure that nobody in a position of legislative authority has ever proposed a public option that provides "government delivered" healthcare.  There are various versions of the public option, but all of them are alternatives to the private insurance industry, not the private medical industry.  In some form or another, a public option would be a federally run insurance program, similar to Medicare, that pays for medical services you get from the private sector.

In effect, a public option is a backstop.  The basic point of the healthcare plans currently on the table is to reform the insurance industry (community rating, no recission, no rules about preexisting conditions, out-of-pocket caps, etc.) and then to provide subsidies to low-income households so they can afford to buy this reformed insurance.  But all those new regulations have to be enforced, and a public option would be a way of keeping insurers honest via competition even if the rules turn out to be imperfect.  Ideally, though, the regs would work and very few people would have an incentive to sign up for the public plan in the first place.

Personally, I still think that backstop is pretty important.  New rules never work perfectly, regulatory capture is always right around the corner, and a public option would provide competitive pressure that would keep costs lower.  On the other hand, there's also a downside: a public option provides a kind of safety valve for private insurers.  Maybe they can no longer flatly turn down someone with an expensive preexisting condition, but they can probably slow roll an application pretty effectively — and the victim of the slow rolling is a lot less likely to complain about it if he has the option of just throwing in the towel and signing up for the government plan instead.

So as much as I'd like to have a public option (primarily for its ability to force more robust price competition), I just don't see it as something to threaten nuclear destruction over.  If insurance reforms are robust and low-income subsidies are decent, that's a huge win for millions of people, and it's a win we can build on.  And contra Atrios, social legislation does have a history of getting better after it's first passed.  Just ask Henry Waxman.

There's more to say about this.  For example: most European countries rely on regulated private insurers of one kind or another to provide universal coverage, and they've managed to make this work.  And: a credible threat only works if the opposition is afraid you might carry it out.  But as near as I can tell, the folks who oppose the public option aren't really all that afraid of the possibility that healthcare reform sinks completely.  Plus: the only way to get it is via reconciliation, and various comments to this post make it pretty clear that trying to pass a huge healthcare bill via reconciliation is probably impossible.

It's worth fighting for a public option.  But it's not worth sinking healthcare reform over it.  That would hurt too many real flesh-and-blood people who need this, and a second chance wouldn't come along for a long time.  We've failed on the healthcare front too many times to accept failure again.