More on health reform

The Democrats have to be very careful if a health insurance 'reform' bill is passed and Americans (majority, at least) don't like it. Social Security and Medicare have passed the test of time; that's why to tamper with the benefits is considered to be a political "third-rail." What finally emerges and Obama signs has to have the same positive and enduring reception by the people as social security and medicare. We'll see. I am for a robust public option not any public option (actually, I'm for single payer, but that's off the table due, in my opinion,to the vast sums of money that have been poured into the fight against it and the public option by the health insurance companies). But I'm with Obama on the point that the object of the exercise isn't a public option, per se, but an effective mechanism to control price (premium) gouging by the insurance companies, and to make sure people are insured for all (including pre-existing) conditions with no lifetime maximums imposed. As the saying goes "the devil is in the details," so let's see.

Offhand, it is the older Americans who will have more pre-existing conditions, so taking them into Medicare and out of the pool that the private insurance companies have to insure, will lessen the costs to the private insurance companies since younger people, thankfully, will have fewer pre-existing conditions. This may turn out to be a win-win compromise. The Republicans get to say they like and are supporting the expansion of Medicare (even though it is in fact a public option) while at the same time saying they've defeated the public option. The Democrats get to say they've expanded Medicare to a large segment of our population (and, by the way, while it may not be said - have opened the door to future expansion of Medicare to the entire population, perhaps incrementally, but nevertheless opened, and if Medicare one day becomes open to all, that's the end of the private, for-profit, insurance companies -- that in itself is a hammer that can be dropped if the private companies don't do right by the American people).

But let's see what finally emerges; we're getting closer, but all of this can go down if one of the so-called 'fiscally moderate' (read 'in the pocket of the insurance industry') Democrats doesn't stay on board.

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Yes I agree that single-payer can be the most efficient system if administered properly. Some commentators I heard thought that the leftist Dems should be happy with the Medicare extension to 55-and-overs, because Medicare is America's single-payer plan, and now at least it's available to more Americans. And if the bill passes, insurance will be more or less mandatory, so insurance companies will gain millions of new customers. So everyone is happy? I guess the real trick is how to pay for it, since unions fought the Dems to remove the "Cadillac plan tax". Maybe there will still be a tax on the rich? But I think the administration and CBO think that the savings from not having to treat the uninsured will pay for expanded coverage for all?

I just don't think there is much in this legislation to control the costs of premiums and fee-for-service doctors. I thought in big bills like this, everyone has to give back a little, and then get a little. Insurers won't be able to turn away sick people any longer, but in return they get more customers. I don't know if they will still maintain their regional monopolies or not. But what have doctors had to give up? Maybe with a cap on lawsuits, they can pledge to charge less for services, and not turn away Medicaid/Medicare people because reimbursements are lower than private customers. As a legal professional, how do you feel about the medical malpractice situation?

Yes as you said, the voting is so close that just one senator can derail it all - might be Lieberman. But I also think the Dems and the administration should not just throw all sorts of proposals and amendments out there and hope they get their 60 votes. As you said, a good bill needs to stand the test of time and be well researched to have a meaningful positive impact, and can't just be an exercise in throwing darts until you get a passage. The Medicare plan seemed to come out of thin air, and I don't think it was publicly discussed in the fall. I worry about these last-minute desperation ideas. If the negotiations aren't public, that leaves even more room for industry lobbyists and the like to tamper. And when you're in a hurry, you make mistakes of course, like the rushed TARP plan and Wall Street bailout. They were necessary (I suppose), but obviously flawed.

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All I can say is the details are not all public and we don't know what the final version will look like. As for me, I'm disgusted with the thought that we have a for-profit health insurance industry. I'd like to simplify this with single-payer and extend medicare to everyone. I agree with you completely as to last-minute, ill-conceived deals and the influence of lobbyists. But I voted for Obama because I had confidence in his judgment and so for now I have to assume he will not sign off on any legislation unless he believes it will indeed benefit the vast majority of Americans and not turn out to be a debacle which will hurt the country (and the Democratic Party).

As to the medical malpractice situation, in my opinion at least, the tort system is what keeps the powerful in check, and having financial incentives for lawyers to take cases for plaintiffs is important to justice in our country. "Tort reform" is code for the insurance industry (again!) wanting to maximize its profits. The fact is that insurance companies and major U.S. corporations have armies of lawyers working for them at very high hourly rates. And these armies of lawyers at the top corporate firms are typically the top legal minds coming out of law school (law students usually go for the gold upon graduation, and those who get it are usually the top 10% of the graduates from the top law schools in the country. (Obama, by the way, was one such graduate, but he resisted the temptation and became a community organizer -- talk about taking the long view, 'out of the box' thinking' and deferred gratification.) The average person cannot afford to pay a lawyer in anything resembling a major case. He/she must find a lawyer willing and able to take cases on a contingent fee basis and have pockets deep enough to advance costs and expenses. A big case is usually hard fought by the companies being sued. It's not uncommon for a lawyer to take a case and put in a thousand hours and have many thousands of dollars in expenses paying for depositions and expert witnesses. Since the plaintiff can't pay for this, the incentive has to be there for the lawyer to take the case and take the risk of coming up with nothing in the end. Thus you have the typical contingent fee of 33 or 40% of the recovery. If you cap damages, say in a medical malpractice case, it means lawyers don't take them unless they're potentially huge cases, and they pass on cases that may in fact be meritorious but where the potential damage recovery will not justify the expenditure of the attorney's time and expenses to be incurred. Take a look at this link for an example of the injustice of capping pain and suffering damages in medical malpractice cases in California: http://www.lectlaw.com/files/lit13.htm. I had a professor once who was adjunct faculty and took a plaintiff's antitrust case on a contingent fee basis. He was up against many corporate lawyers. He came in one morning after being up all night working on a brief in the case, and said he'd like a rule that limits the number of hours any side can put into a legal brief, but without it he had to just work harder to be able to meet the arguments of 3 or 4 lawyers on the other side working against him. The insurance companies may want tort reform by limiting damages, but I can guarantee you they would oppose a rule limiting the number of lawyers, their pay, or the hours they invest or in working on a case for them.

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Thanks for writing. I think even if McCain won, there would be some sort of health reform now because the status quo is just so unsustainable (16% GDP on health spending and rising). He might have some crazy GOP ideas about health spending accounts (can be more efficient than Medicare if regulated properly and used wisely, though I doubt Americans are up to the challenge), but they would pass something. So I don't think it's a great accomplishment if Obama just passes some watered-down token bill, as any American president now should be able to do at the minimum (a lot of urgency and political momentum). I think if health reform was a heavyweight boxing match, it's Round 7 and the Dems are down 64-68. Though as you said, a lot of details remain unresolved so it is possible to turn things around. But sad to say that the GOP hate and misinformation campaign seems to be working, as usual. Public option would have changed the playing field in the people's favor, but I guess for now that looks doubtful. Lieberman said he wouldn't support the P.O. or the Medicare-to-55 plans, and without him the Dems don't have the 60 votes. Though maybe he can still be bribed?

But after so much media coverage, fighting, and PR blitzes, each party needs to leave the health care issue claiming that they won. The Dems will pass some version of health reform by February or so, and they can claim a victory for the people. It will cover more of the uninsured poor and make private plans more accessible to people, so I don't want to make light of those gains. But the bill won't likely contain any sweeping reforms, so the GOP can claim victory that they didn't let America go socialist, and all the while the insurance, physician, and drug industries are fat and happy as always.

As you said, for-profit health is borderline immoral, if not completely obscene. I know medical workers should be paid fair compensation for their services, but insurance companies reap huge profits while not really providing us with any service at all (just headaches mostly). But like the prison system, now these behemoth bureaucracies are "too big to get rid of" (or even regulate it seems), and they have billion-dollar legal and PR teams to lobby Washington and fight any challenges to their earnings. Actually working for a large biotech/pharma (even one rated highly in the field), I am tired of seeing the mismanagement, propaganda, and decisions based on profits rather than patients. I plan to switch careers this year and am applying for a "green MBA" program to work on business development for biofuels or green engineering in the future. I hope it works out better, but I am sure there will be plenty of hypocrisy and BS there too.

I agree with what you said about tort reform. It's pure lies how the doctors & HMOs claim they need to keep raising fees because of the "rising" threat of malpractice. As the attachment shows, malpractice payouts per capita have remained flat in the last decade, while medical costs have gone up sharply, so they're uncorrelated. But aren't most malpractice cases settled without ever going to court? Like the MD's malprac. insurance basically tells him to settle, and he has little choice since fighting a court battle will take him away from his practice for months, thereby costing even more money (even if he is innocent). I guess in the single-payer health care nations, malpractice suits are much less common and for less money? Maybe that is due to better quality of care, but probably also fewer ambulance chasers? Lawyers should have financial incentive to take on these cases, but if the incentives are too great, they will over-pursue cases, like fee-for-service doctors over-prescribing procedures. Obviously doctors need to be held accountable for mistakes, but they can't be "practicing scared" and prescribing care based on lawsuit paranoia. It's not good for the doctor or the patient. Medicine is not exact and some people will die even if the doctor goes by the book perfectly. Angry patients and grieving families have a right to be upset, but of course we can differentiate between honest mistakes and negligence. Though if the industry favors settling out of court, then the truth will never be able to come out.

Wow, I didn't realize CA had a cap that was so low and enacted so long ago. It's just a tough situation because obviously HMOs, MDs, and hospitals pass on the costs of malpractice protection onto the government and customers. Yes as you said, maybe it would be more fair to not have lawsuit caps, but instead a cap on legal hours per side. Not just in malpractice, but I think it's terrible if one side can afford an "OJ-sized" legal defense All-Star squad, while the other has an overworked rookie public defender. It would be hard to regulate and enforce of course. Or maybe doctors shouldn't just fear the financial repercussions of malpractice, but fear losing their license instead. Too many repeat-offender doctors still practice and make lots of money. If an independent agency can evaluate malpractice cases, like the Trustee's Office for debt cases, and bar guilty doctors from practicing medicine (either a fixed time period or permanently), then doctors will be more careful for their own career's sake. And then they won't have the excuse of needing to charge more to cover their malpractice insurance, because they won't be financially liable for any damages. Maybe the agency can make payments to victims, funded by a tax or modest penalties to offending doctors. I don't know, just brainstorming. It's a frustrating situation for everyone I think.

Obama's Nobel speech

From Obama's Nobel acceptance speech in Norway this week:
http://www.mcclatchydc.com/homepage/story/80410.html
http://www.npr.org/templates/story/story.php?storyId=121304855

First of all, it's probably a really bad sign when Sarah Palin praises your speech on war, peace, and realism vs. idealism.
http://www.twincities.com/politics/ci_13970425?source=rss

Commentary from Newsweek's chief political correspondent, Howard Fineman:

Well, I said in many ways that's true. Yes, the tone [of Obama's speech] was humble. Yes, it was philosophical. Yes, it was complex. He talked about negotiations and banning torture and so forth, the importance of diplomacy. But I was struck, as somebody who covered the Bush administration, by how fundamentally he accepted some of the premises of George W. Bush's view of the world - the existence of evil. The president used the word terrorism several times. That's a word he's avoided in some recent speeches. He said no jihad could ever be a just war. No holy war could ever be just, but he said that in essence the war in Afghanistan was. Those are all notes I think that George W. Bush might well have struck.

In his very long speech, Obama once again showed that he is really gifted in articulating what every high school freshman should vaguely and abstractly know about war, humanity, and morality. He never really communicated how America's current wars (that he is continuing instead of ending) will lead to more peace in the future, vs. other less violent security precautions. He spoke in absolutes like Bush - a pacifist world where dictators can push us around because they know we will appease, vs. the "real world" with ugly war. But of course America only fights when it's just and necessary (even though he and everyone else have already admitted that Iraq didn't qualify). The problem with his and Bush's "just war" argument is that even if a war's cause is just, its prosecution is always messy and fraught with abuses. War is too confusing and humans are too flawed to conduct a just war justly. That's why we must seriously try (and try harder than we are!) to avoid any war, no matter the moral spin. Sure even Palin would say that America hates when it must march to war, but our track record suggests otherwise.

Obama said that no holy war can ever be just, which is true. We already know about the crazy Crusaders and the crazy Muslim terrorists, but what about America's holy war of Manifest Destiny that helped the US become a world power? Wasn't it our divine right or White Man's Burden to put blacks to work for no pay and conquer the lands between the two oceans, by displacing, raping, or killing any natives or Spaniards in our way? Or how about the Monroe Doctrine that basically compels our government to militarily intervene in small conflicts in the Western Hemisphere any time foreign "colonialism" is suspected? How hypocritical to claim to combat colonialism with colonialism. What about "Remember the Maine" when we declared a vengeful war against Spain (just like Afghanistan) that was actually a territory grab (we got the Phillipines and Gitmo). We had to attack Spain to prevent them from attacking us again, right? And it wasn't even proven that Spain sank the Maine, just as we have very sketchy evidence linking the Taliban to 9/11.

Even the most just war of them all, WWII, ended with American bombs massacring over a million defenseless Japanese civilians who were not at Pearl Harbor and who meant us no future harm. Japan was already on its knees and possibly ready to capitulate, but we had to nuke them twice anyway, just to flex our muscles to the Soviets that East Asia is ours. Obama also claimed that the fall of the USSR signaled a great victory for freedom and self-determination, and of course our side won. No one misses the USSR, but how exactly did freedom win the day when American forces slaughtered millions (or backed dictators who did) in Korea, Southeast Asia, and Latin America in the process? How did those "just wars" lead to the Soviet collapse and help people win their freedom? And if the Cold War was all about freedom and human rights, then why after the wall came down did American businessmen penetrate the former Soviet satellites faster than US aid and diplomats?

To me, the worst war is not the horrible Jihadi actions of Osama, Zarqawi, and his kind (they are bad but not the worst), but instead the much bloodier and deceptive large-scale Western-perpetrated war wrapped in the flag of freedom and peacekeeping. If Obama understands this, he didn't articulate it during his many war-themed speeches this year, which is moral cowardice on his part. And no coward deserves the Nobel. As one of only 3 US presidents who have received this prize, I think Obama not only missed a precious chance, but also shirked his moral duty (and better judgment as a thinking man), to cut the crap about America always being the noble world savior, and come clean about our past abuses and ulterior/selfish motives for war that relate more to power than security. We're in the 21st Century now, and many world polls show that people think America is a bigger threat to world security than Russia or Iran. Obviously, the rhetoric only goes so far and even slick Obama won't be able to persuade others who can see the writing on the wall, even if we refuse to out of "patriotism". I think we would make more friends and marginalize our enemies better by coming clean rather than perpetuating the status quo. We are America, and we do err and sin too.

Obama gave token credit to peace figureheads MLK (Obama would not be president if it wasn't for MLK) and Gandhi, and excused himself from their tenets because he is a head of state and commander-in-chief, so he doesn't have the luxury of idealistic pacifism. Maybe that is true, but Gandhi was also a political leader in the newly-formed India (albeit not a very good politician - not a profession for a decent man). When Hindu-Muslim tension turned to street violence after independence, did Gandhi crack down on them in the name of national security? And did he side with his fellow Hindus against the outsider Muslims? No, he staged a hunger strike and prayed for both sides. That sent such a powerful message, and because of his great reputation, the warring groups took just 5 days to broker a ceasefire, because they loved Gandhi and his life meant more than their conflict. Gandhi didn't have to make a single threat or send a single young soldier to kill or be killed to restore peace. That is what leadership is all about. Plus, Gandhi was eventually killed by a Hindu radical, not a Muslim. He was betrayed by his own people, like Rabin. That should remind us that the greatest threats to the state are usually internal (like the lobbyist-Congress revolving door, and right wing radio nuts), not Taliban bogeymen hiding in caves. I know Obama fasting will not stop Al Qaeda from fighting us, but maybe if America acted more like Gandhi in the last 100 years, Al Qaeda would have never been created.

"America's commitment to global security will never waver," Obama said. I guess that's why we have done or continue to do next to nothing positive for the tense, unjust, and/or atrocious situations in Burma, Kampuchea, Rwanda, Congo, Korea, Iraq (when Saddam was killing Kurds), Sudan, Georgia, Israel/Palestine, and such? In fact, our pro-Israel actions in the UN have prolonged wars and suffering there. We fight when we want to increase our influence, and when our economic interests are at risk. Sure that may coincide with humanitarian concerns, but that is obviously not our chief priority. We're just like any other army or state (actually worse than most), and not anointed with some higher moral status. So cut the crap Obama, or you really are the foreign policy infant that the GOP and Hillary labeled you as during the campaign.

We're stuck with Afghanistan now because we can't change the past. But our role is really janitor instead of policeman. We are obligated to try to fix the mess we've caused (huge poppy production, Taliban resurgence, spillover to Pakistan, etc.), and then get the hell out.

More Afghanistan concerns (some already mentioned in the last email):

http://www.salon.com/opinion/feature/2009/12/01/afghanistan_surge/index.html

Top Ten things that Could Derail Obama's Afghanistan Plan
1. Obama's plan depends heavily on training 100,000 new soldiers and 100,000 new policemen over the next three years. It has taken 8 years to train the first 100,000 soldiers fairly well, and the same period for the Europeans to train a similar number of police badly. Can the pace really be more than doubled and quality results still obtained?

2. Obama's plan assumes that there can be a truly national Afghan army. But the current one is disproportionately Tajik and signally lacks troops from the troubled Helmand and Qandahar provinces. Unless the ethnic tensions are eased, training a big army could well provoke an anti-Tajik backlash in Pashtun regions that feel occupied.

3. Obama's goal to "break the Taliban's momentum" may well fail. Only 20 percent of insurgencies in modern times are defeated in a decisive military manner.

4. The US counter-insurgency plan assumes that Pashtun villagers dislike and fear the Taliban, and just need to be protected from them so as to stop the politics of intimidation. But what if the villagers are cousins of the Taliban and would rather support their clansmen than white Christian foreigners?

5. Obama is demanding that Pakistan help destroy the Taliban movement, a historical ally of Pakistan in Afghanistan. While Pakistan now has good reason to attempt to wipe out the Pakistani Taliban Movement, which has committed a good deal of terrorism against the country, Islamabad has no reason to attack the Afghan guerrilla groups fighting Karzai. They are fellow Muslims, and are Pashtuns (as are 12 percent of Pakistanis), and dislike India. The Northern Alliance elements in the Karzai government, which have recently grown stronger, are pro-India. Obama is asking Pakistan to betray its national interests, which is not realistic in the absence of some much bigger carrot than a few billion dollars in foreign aid.

6. Obama asserts that although the Afghan presidential election was marked by fraud, the results (the victory of Hamid Karzai) are legitimate within the constitutional framework. But isn't it possible that Karzai has decisively lost legitimacy among broad sections of the Afghan public, wounding him as a partner in working for a recognition of the legitimacy of a greatly expanded foreign occupation army in the country?

7. Obama is demanding accountability from cabinet members in Afghanistan and offering agricultural and economic aid. But 15 present and former cabinet members are under investigation for massive embezzlement, and 7 key ministries were only able to spend 40% of their budget allocation last year. Isn't Obama counting on a culture of official probity and a governmental capacity that simply does not exist in Kabul? What happens when there is more cabinet-level corruption and when the Ministry of Agriculture once again just can't spend the money Obama gives it?

8. Obama assumes that the US is not fighting a broadbased insurgency in Afghanistan. This assumption is true in the sense that there is zero support for Taliban or Sunni extremists among Tajiks, Hazaras, Uzbeks, and a majority of Pashtuns. But if we looked at the equivalent of counties in Helmand, Qandahar and some other Pashtun provinces, we might find substantial swathes of territory where the insurgency is in fact broadly based. Moreover, Pashtun guerrillas can count on a certain amount of sympathy from other Pashtuns in their struggle against foreign forces-- including the 20-some million Pashtuns of Pakistan. If the issue is not the "cancer" of extremist ideology, but a form of religious Pashtun anti-imperialism, then that could be the basis for a broadly based movement.

9. Obama maintains that the "Taliban" have in recent years made common cause with "al-Qaeda" in seeking to overturn the Karzai government. But although the Taliban control 10-15% of Afghanistan, there are no al-Qaeda operatives to speak of in Afghanistan. That does not sound like much of a common cause. By confusing the Taliban with al-Qaeda, and by confusing the Taliban with other Pashtun guerrilla groups such as Hikmatyar's Hizb-i Islami, Obama risks making the struggle a black and white one, whereas it has strong regional, ethnic and nationalist overtones (see 8 above). Black and white struggles are much more difficult to negotiate to a settlement.

10. The biggest threat of derailment comes from an American public facing 17 percent true unemployment and a collapsing economy who are being told we need to spend an extra $30 billion to fight less than 100 al-Qaeda guys in the mountains of Afghanistan, even after the National Security Adviser admitted that they are not a security threat to the US.

Top climate scientist slams Copenhagen and cap/trade

http://www.guardian.co.uk/environment/2009/dec/02/copenhagen-climate-change-james-hansen
http://www.kqed.org/epArchive/R912070900
http://www.columbia.edu/~jeh1/

NASA and Columbia's Dr. James Hansen, the preeminent American global warming scientist since the 1980s (Al Gore is the figurehead but Hansen is the brains), has really come out against the Copenhagen summit (boycotting it in fact), the big nation's emissions reductions targets, and the whole concept of "cap and trade". While heads of state seek to reduce carbon emissions to 1990's levels by 2020 or so, Hansen thinks we need doubly aggressive reductions to even have a chance of averting climate disasters. Like we can live with the inevitable 1 meter sea level rise as a consequence of our past pollution and climate trends, but a 10 meter rise (if we do nothing) will be thoroughly disruptive to human kind. And despite the cheerleading and positive spin, it doesn't look like China and India will be of much help. They have agreed to reduce their "carbon intensity" by 20-40% by 2020, but not actual emissions. Intensity only refers to carbon emitted per unit of energy/commerce, so intensity goes down as GDP grows anyway (which India's and China's will obviously do). Therefore nations can reduce their intensities without ever doing anything about carbon. So while the US and China are the top carbon polluters (42% of total CO2), their carbon intensities are far below those of Congo or Kampuchea (<1% of global pollution), so obviously something is amiss.

Cap and trade (establishing total emissions limits and allowing low-polluting businesses to sell their carbon credits to high-polluting ones, or back to the government, which is in effect in Western Europe as we speak) is also inherently flawed according to him (though not for the reasons that Glen Beck believes). He even goes further to say that it is just a smoke screen to conceal, or at least prolong, business as usual (quite plausible considering the Washington-business relationship). We capitalists stubbornly believe that the "miracle of the market" will save us every time. A "carbon exchange" will incent less pollution while funding innovation. But is it the fairest and most efficient way of doing so? For a potential cap and trade industry, imagine the bureaucracy and costs associated with establishing such a complex, dynamic, lawsuit-fraught commodity exchange.

Just as investment houses nickel and dime us year after year for "managing" our 401(k) accounts, cap and trade will be run (or at least manipulated) by big Wall Street banks, who will also take their "service fee" cut of the pool. We've seen what happened with savings & loan, energy trading, telecoms, mortgage derivatives, and credit-default swaps, so can you just imagine the tricks that Goldman Sachs and others are scheming up for this nascent market that gov't is not equipped to properly regulate? The big banks have hundreds of people working on this already, and no bills have even reached the Senate floor yet (but they smell blood in the water with a carbon exchange expected to be worth a cool $1T). Already big polluters like energy companies and factories are threatening that they will have to pass costs onto the consumer due to the carbon fines from their business operations, and more than likely the banks' service fees for maintaining the carbon exchange will also get passed onto us. Yes some of the money will funnel into green research (mostly "clean coal" that will never be as clean as nuclear), but rest assured that Wall Street will extract its pound of flesh first.

In addition, "carbon offsets" will grant polluters more room to pollute, while not truly offsetting their actions, so it's really cheating the cap. Like Exxon could earn x more carbon credits for paying to protect y acres of forest from deforestation. That sounds very kind of them, but really what has it done? Since all forests are not protected, loggers and ranchers will just level another tract of land instead. And all the while Exxon gets to spew more carbon for pocket change (which will obviously benefit Exxon financially, or their bean-counters wouldn't have approved it). Another concern is "grandfathering". When sulfur limits were imposed by Congress to address acid rain pollution in the 1980s, coal power companies persuaded regulators to exempt older plants constructed before 1970. Maybe that explains why so few new power plants have been constructed, while demand has steadily grown. So despite the cap, it was business as usual, and the same might occur with carbon (you can imagine the companies whining about the huge costs of retrofitting old plants).

Hansen suggests that on the other hand, why not just impose a fee on carbon for a fixed amount, like we do for air travel and cigarettes? Like water, energy is artificially cheap in America, so that the social and environmental costs of wasting those resources are not directly felt by the waster. The reasons for this are varied, but clearly due to gov't policy. But just as the cost of used motor oil or car battery disposal is factored into the garage fees you pay, the costs of carbon pollution to the environment should be included in the carbon-emitting products we buy and the carbon-emitting business practices of most or all companies. But of course industry lobbies hate this idea because it will make their operating expenses rise while reducing revenues/productivity. A carbon fee would fund green projects and research, just as part of the cigarette tax funds gov't health programs like S-CHIP. If we were to tax $115 for every ton of carbon (or $1 for every gallon of gas, 8 cents per KWH electricity), we would net $670B each year for public use. Imagine what good that would do - we could even bail out Wall Street again during the next bust. Some of that money could even be paid back to the public to offset the higher costs of carbon-based goods or subsidize green retrofits/products (up to $250 per legal US resident per month). So instead of cap and trade (where the public gets nothing, and could even be shafted), we should implement "fee and dividend".

Obama's Afghanistan escalation

For the first time since 2001, according to polls, a majority of Americans believe that the war in Afghanistan is "not worth fighting." Fifty-seven percent of independents and nearly three-quarters of Democrats oppose the war — and overall, only 26 percent of Americans support the idea of adding more troops. Indeed, if Obama were to escalate the war, his only allies would be the Pentagon, Congressional Republicans, an ultraconservative think tank called the Foreign Policy Initiative, whose supporters include Karl Rove, Sarah Palin and a passel of neoconservatives and former aides to George W. Bush.
- R Dreyfuss, Rolling Stone Oct. 28

I was disappointed with our Nobel Peace Prize laureate's rhetoric during this week's Afghanistan speech (he plans to send in 30,000 more Marines for ~18 months, many straight from Iraq, which must be demoralizing for their families). NATO may add 5-10,000 troops too, but I am skeptical. He can argue that this course of action is the best choice of dismal options, and remind us that he inherited this conflict, but don't feed us the same tired War on Terror crap. Public opinion is majority against a troops surge, partially because Americans feel that Afghanistan is not "winnable", nor critical to our security anyway, and they're probably right. Even the worst-case scenario of a Talibanized Afghanistan is not like North Korea or Iran. The country is mostly illiterate, dirt poor, internally divided, and geographically isolated, like Somalia with poppies instead of pirates. They may export some petty criminals and terrorists from time to time, but their ability to do harm is greatly diminished vs. 2001.

Obama did not heed the protests of Congressional Dems, VP Biden, and Karl Eikenberry (US ambassador to Afghanistan and a retired general who served in Afghanistan from 2005-2007) in this decision. He caved to our rock star generals instead (McChrystal and Petraeus, the latter rumored to seek a run for political office, assuming we are successful in Afghanistan?). Eikenberry's protest is especially noteworthy since he was part of the McChrystal/Petraeus/Odierno clique from West Point, and Army chums place a premium on loyalty. But his experiences in-country have soured him to the possibility of working with the Karzai regime towards victory. I hope President Obama hasn't forgotten the man he was as Candidate Obama. I understand that he must represent the Office of the President now, respect the conservative mainstream, and placate Pentagon interests. But if JFK deferred to the hawks during the Cuban Missile Crisis, probably none of us would be here. Sometimes the bravest thing to do is not to fight.

Biden warned that the world will test a young, idealistic Obama the minute he assumes office, and maybe Obama wants to show the world that he is a tough war president too. Maybe he fears that weakness on Afghanistan will create an opening for the GOP in the 2010 midterms. But after 8 years of fumbling and violence in the Middle East, it's disrespectful to the American people and the people of the world for him to re-hash the same tired Bush arguments for prolonging and even escalating a frustrating war. Ironically, many of the arguments he made on the campaign trail against Bush's Iraq Surge could equally apply against him here. Change we can believe in?

First of all, we were NOT attacked on 9/11 from Afghanistan, and not a single hijacker was Afghan (or Iraqi). Osama and other Jihadists did receive sanctuary in Afghanistan from their days as fighters in the Mujahadeen against the Soviets. But the Taliban government under Mullah Omar had little inkling Al Qaeda was planning 9/11, and probably would have tried to stop them if they found out (because obviously it would trigger a Western invasion and the toppling of their fragile regime). Why do you think Sudan expelled Osama and even offered him gift-wrapped to Clinton? The old Taliban was more interested in retaining power than attacking America. Where did the 9/11 attacks come from then? First, it came from our oil rich "buddies" in the Persian Gulf - suicidal fanatics and rich financiers in Saudia Arabia, Yemen, etc. Second, it came from within. The 9/11 hijackers were granted entry into the US months prior to the attack, and learned to fly, evade authorities, and infiltrate airport security. You can't really get that training in the remote terrorist camps that Clinton bombed. Maybe at best the 9/11 terrorists learned basic combat tactics, explosives, and weapons training in Afghanistan - skills that were not pivotal in accomplishing the 9/11 attacks. But the panic and mania immediately following 9/11 allowed NATO to justify an Afghanistan invasion and Taliban coup to the UN, and the rest is history. So just because the war is sanctioned by the UN and 43 nations have contributed to the effort doesn't make it a righteous or necessary war (see Kosovo conflict).

And then Obama claimed that we can't allow the "same people" who perpetrated 9/11 to regain a foothold in Afghanistan to launch new attacks against us. The same people are not in Afghanistan now! Our initial special forces operations in Afghanistan in 2001 decimated much of Al Qaeda (some estimate up to 85%), and improved international surveillance has greatly reduced Al Qaeda's ability to travel, communicate, and obtain resources. By our Nat. Sec. Advisor's own admission, there are fewer than 100 "real Al Qaeda" inside Afghanistan (meaning Arabs directly connected to Osama's network and acting as his agents). Mullah Omar's Taliban no longer exists, and he is probably not even in country (same with Osama, who is quite ill by some accounts and only serves as a symbolic figure for terrorism). The "new Taliban" (or so we call them) are groups of Pashtuns, Uzbeks, Tajiks, or other dissident minority groups who are conducting an insurgency against foreign occupation and the Karzai regime, which is widely and accurately viewed as illegitimate and corrupt. Taliban means "students", as in those who have attended fundamentalist madrasas and subscribe to that form of Islamic doctrine. Most of the current "Taliban" have not even attended such schools (and are illiterate in fact), and they are definitely not unified and cohesive. Just as we lumped all communists together during the Cold War to our peril, we can't label everyone who is not friendly to the NATO presence as Taliban. At least Obama offered the olive branch to any Afghans willing to lay down their arms, but I am not sure how that offer will be received by the insurgents and Karzai.

Pakistan is a different and more delicate situation, so I will limit this discussion to Afghanistan. Clearly those nations' fates are intertwined, but does anyone really think that the Pakistani Taliban would be so belligerent today if we were not across the border in Afghanistan and killing Pakistanis with our drones (thereby undermining the Pakistani government that is supposedly critical to winning the War on Terror)? Whereas Al Qaeda ostensibly fight us because of who we are, the Taliban fight us because we are there. They have little interest in a global caliphate or the destruction of the West. They may not complain if those things happen, but they are not dedicated to achieving those goals. They fight because a foreign force is occupying their country (and a force with a history of imperialism, hostility, or at least disrespect to the Muslim world). So if we boost our military presence there, shouldn't we expect the insurgents to do the same? And let's remember that Bush/Obama already sent 21,000 new troops earlier this year to launch new offensives, and since then violence has only gotten worse and the Taliban have made shocking gains (they now "control" or roam freely in 15-25% of the country).

What will 30,000 more troops do for a rugged nation that is bigger than Iraq (both acreage and population, and a more diffuse rural population at that)? South Vietnam was a much smaller state, and the US had nearly 1M troops there, as well as 0.5-1M better trained and better equipped South Vietnamese forces. McChrystal's people want to copy as many successful Iraq techniques as possible, but the two wars are not interchangeable. As part of the "clear, hold, build" strategy, US forces will embed themselves with the local population to better protect them from insurgents. But many villages (especially in the volatile Helmand Province and Pashtun areas) do not want more Marines in their lives. They may not love the Taliban, but that doesn't mean they'll welcome us with open arms and offer aid (especially when collaboration with foreigners may provoke Taliban reprisals). It's not like the Iraqi Sunnis who were sometimes happy to have a US presence to prevent Shia takeover.

The hope is that we can train enough Afghan security personnel to assume ISAF's duties, so we can start our "victory withdrawal". Obama's plan is to train 400,000 more Afghans in the near future, which is a pipe dream. We probably couldn't even train 400,000 new American cops in a year. And as we've seen in Iraq, rapid recruitment of armed forces leaves us vulnerable to infiltration. Another problem is most Afghans don't trust the security forces, who often shake people down like thugs and are not trustworthy (or even participatory) in difficult combat situations. Plus it is quite challenging to develop a unified national army and police there, built from the remnants of the brutal Northern Alliance and local warlords. We have very little expertise in nation-building and peacekeeping in tribal/communal societies (see our great record in the Balkans and Africa). Afghanistan's forces are comprised of a dozen distinct ethnic groups, each of which is chiefly concerned with protecting its own population and probably won't risk themselves for anyone else (or may even be rivals with each other).

Obama is a young president and I'm sure a little awed or intimidated by the dashing senior brass at the Pentagon. He is not a pushover, but I think he is also very conflict and risk averse. He doesn't want the wars to overwhelm his other foreign and domestic policy initiatives. Generals always say they need more men/resources, and always believe that victory is not only possible, but assured, if they get what they need and we get out of their way. Heck, what manager doesn't ask for those things at work? In other words, the Pentagon's advice will always be biased, even if chickenhawks like Feith and Wolfowitz aren't directing traffic anymore. Our military leadership loves America and wants to keep us safe, but they are also arrogant and career-minded. Insurance companies resist health reform, so it should be expected that our generals resist withdrawal plans. Some hypothesize that McChrystal's force request was deliberately leaked early to the press to make it even harder for Obama to reject it. If Obama spurns the generals' request and Afghanistan continues to deteriorate, things will be very bad for him and his party. But the generals aren't car salesmen, and Obama and the American people shouldn't be shmoozed or pressured into buying an extended warranty and DVD entertainment system that we don't need.

I know we can't just pack up and abandon Afghanistan tomorrow, but after 8 years of spinning our wheels (at best), we really need to act with caution. If our objective is to stabilize and modernize Afghan society (the humanitarian mission that our NATO allies are more concerned with), as well as containing or hunting down those committed to international terrorism (the military mission that the US is more concerned with), then our actions should not destabilize the region or create new terrorists. I know I was pessimistic about the Iraq Surge and my fears did not really materialize, but most experts agree that Afghanistan is a much more difficult challenge. What is wrong with Biden's strategy of de-escalation? He believes that a surge would be counter-productive and we should actually reduce our footprint, shifting to surgical strikes against Al Qaeda and obvious Taliban targets. If we can't trust Karzai and we don't have the troops to really execute the Counterinsurgency Manual (and we don't), then what is the point of taking the McChrystal/Petraeus approach that will probably require a decade of more commitment to Afghanistan? Just because we're too ashamed of possible defeat?

To conclude, I was hoping Obama would declare a plan something like this (which also has a chance for success):

"My fellow Americans, fighting is not the only way, nor the preferred way, to defeat Al Qaeda and international terrorism. With UN backing, we invaded Afghanistan to bring to justice the perpetrators of 9/11 and those who protect them. While that objective still remains partially unresolved, we have gravely wounded Al Qaeda since then, and their ability to threaten our homeland, or even wire money to each other, is much reduced. For that, we all owe thanks to the Bush administration, our allies, and those in the armed forces and intelligence. It is true that Osama's inner circle roams fairly freely in the border region with Pakistan, and I am not happy about that. I pledge to constructively and respectfully work with the Pakistani government to address this problem. But as long as we maintain diligent surveillance, take good opportunities for surgical strikes with minimal civilian casualties, and support friendly military, economic, and democratic development in the region, I am confident that Bin Laden and his network pose minimal danger to us.

It is true that Taliban-like insurgents in Afghanistan threaten our allies in the Karzai government and our interests in the region. But unless we have a clear, quantifiable, plausible strategy and milestones for assessing and containing that threat, then it is not worth more American lives and resources to police a nation the size of Texas and as rugged as Alaska. Our armed forces are the toughest in the world, but they are stretched thin and not being used efficiently. By gradually and rationally drawing down US forces in Iraq and Afghanistan during my presidency, our men and women in uniform will be able to spend more time with their loved ones, receive improved training back home, and focus on small-scale counter-terrorism rather than state-scale counter-insurgency, which are two distinct missions. Withdrawing from a fight can also increase our security, because it will permit us to recuperate and be ready when the next serious fight emerges. We will still maintain a lean presence in Afghanistan to assist in the training of Afghan security forces, execute counter-terrorism operations, and aid the Karzai government to improve transparency, prosperity, the rule of law, and basic services to the Afghan people.

America is a great nation, but we have our limits and must respect the other peoples who share the planet with us. We cannot and probably should not intervene every time there is civil strife, and we should be aware that our extended military presence overseas may cause resentment and play into the hateful rhetoric of our enemies. Sometimes we must be humble and let other nations take the lead in attending to their affairs. Yes there will be delays and failures, but America did not become a global power overnight either. Let me be clear that we are not retreating like cowards or throwing our friends in the Middle East to the wolves. America will always be there when we are called upon and there is critical need, to friend and foe alike. While we may not be surging troops to Afghanistan, we will make a diplomatic and development surge. Under military protection and rigorous standards of accountability, we will greatly increase our aid projects. We will listen to our allies, deliver what they need, and offer our input while respecting their wishes. But our assistance is not unconditional and open-ended, and I will ensure that every taxpayer dollar spent on Afghanistan is an investment in real progress for the future, or it won't leave our shores. We can also defeat terror and extremism by being good global citizens and peacefully improving life in needy countries, so that the conditions which spawn hatred and violence never materialize. Thank you and good night."

http://www.kqed.org/epArchive/R912020900
http://news.yahoo.com/s/ap/us_fact_check_obama_afghanistan
http://www.rollingstone.com/politics/story/30493567/the_generals_revolt
http://worldaffairs-manwnoname.blogspot.com/2009/08/problems-with-our-afghanistan-approach.html
http://www.npr.org/templates/transcript/transcript.php?storyId=120346497

The Family

"Jesus didn't come to take sides, he came to take over." - member of the Family and US congressman

"We desire to see a leadership led by God," reads a confidential mission statement. "Leaders of all levels of society who direct projects as they are led by the spirit." Another principle expanded upon is stealthiness; members are instructed to pursue political jujitsu by making use of secular leaders "in the work of advancing His kingdom," and to avoid whenever possible the label Christian itself, lest they alert enemies to that advance.

--------

No, this is not about the mafia, but it's not that far off either. There is a secretive fundamentalist Christian group headed by Doug Coe named "The Fellowship" or "The Family", founded in the 1935, which makes Scientology or the K Street Gang look like Boy Scouts. Members of the Family include US senators, cabinet members, and state governors, and they seek to use their business/political connections to advance their views. They help organize the Congressional National Prayer Breakfast in Washington that sitting presidents also attend.

Their agenda is quite bizarre and hard to even call Christian. They believe that the New Testament's emphasis on helping the poor, humility, love, and compassion is all wrong. In fact, the Bible's secret message is all about worldly power, and they use free market capitalism, anti-gay, and anti-abortion issues to rally support. Yes, I know, Dan Brown is taking notes as we speak. Ironically for US lawmakers, they believe that American democracy is doomed to fail and totalitarianism is the way to go - the way Christ intended for us. Like many US elites, they were enamored with the European fascists (rising from nothing, their manipulation of the masses, uniformity of thought, and rapid industrialization/militarization), but after WWII they had to tone it down of course. Though even today, their leaders including Coe have used the examples of Hitler, Mao, Stalin, and Pol Pot to instruct and describe how the Family seeks to embody and propagate total fanatical commitment to absolute power for Christ and his "true message".

They could be described as "elite fundamentalism". They also believe that Jesus has a special message for the chosen few, and his parables for the masses were just Spam, because we can't really handle the truth of his grand plan. Of course the high-ranking members of the family are the chosen. Strangely, the Family has both Catholic and Evangelical members. I suppose they put their dogmatic differences aside to join forces for the Culture War.

Their prominent members:
- Congressmen (some potential 2012 GOP presidential nominees, and some Dems too): Coburn, Prior, Grassley, Pitts, Stupak, Wolf, Ensign, Shuler, Nelson, Enzi, Thune, Inhofe, Wamp, McIntyre, Clinton (while she may not be an official member, Family head Doug Coe is an intimate spiritual advisor to her since her husband was president).
- Governor: Mark Sanford (yes, the guy who was caught using state resources to go to Argentina for a booty call).
- Other notable alums: Strom Thurmond, Charles Colson (Nixon's hatchet-man who went to jail for Watergate but after became CEO of big defense contractor Raytheon), Pat Robinson's father, David Kuo (Dubya's head of Faith-Based Initiatives).

Maybe leftist journalists are just trying to tar these conservative politicians with shady, unproven connections to a religious cult (like how douchebag Glen Beck tries to connect Obama to ACORN to the end of the world). But many of the Congressmen listed above live at C Street residences while in Washington owned by the Family, and rented to them at below-market rates. Probably the only reason the mainstream knows of the Family is some of their members were caught in embarrassing affairs (Ensign, Sanford, Pickering). I guess sometimes God wants you to break one of his commandments in service to the greater good.

Maybe you think that this is just tabloid and doesn't really affect our lives, but look at some of the Family politicians' recent actions. The last-minute abortion amendment to the House health bill was called the Pitts-Stupak amendment. Mother Teresa was not an outspoken critic of abortion until she met Pitts in the 1970s. Family members have used government funds to go on overseas missions in support of cruel dictators and corrupt regimes who happen to endorse pro-Family policies. They helped get weapons and money to Indonesian dictator Suharto, supported Christian militias in Lebanon, and currently back Yoweri Museveni, the despotic leader of post-Idi Amin Uganda (a nation with some of the most draconian anti-gay laws in the world). Before Museveni, they also armed Somali strongman Siad Barre during the Reagan-Bush years, who contributed to thousands of deaths. I have no idea how those Third World, war-torn nations and their pathetic leaders factor into God's plan for the world, but apparently the Family does. But what's the big deal, since other politicians take trips sponsored by companies or special-interest groups all the time? Well, it undermines US foreign policy and credibility when US legislators travel to speak with foreign leaders, advancing a private agenda that may or may not be aligned with official Washington policy (I would hope it isn't). One thing we have to thank Abramoff for are 2007 Congressional reforms that allow these trips and their funding to become public knowledge.

So to close, I know the Family is probably less of a risk to global stability than Al Qaeda or H1N1, but the fact that they are out there, that they believe what they do, and occupy very high positions of US power is cause for concern. If they are doing God's work and mean no harm as they say, then why be so secretive? Level with us and lead the masses on the path of righteousness, like the dictators they admire. Hopefully government transparency and accountability will grow, and constituents may find out if their leaders are affiliated with and executing the agenda of private groups that don't have the people's or America's best interests in mind.

http://www.npr.org/templates/story/story.php?storyId=120746516
http://www.youtube.com/watch?v=LVrQkunIZXo&feature=related
http://en.wikipedia.org/wiki/The_Family_(Christian_political_organization)
http://www.worldmag.com/articles/15778 (a criticism of the Family from a Christian right source)
http://www.democracynow.org/2009/8/12/sharlet

A consequence of China's social engineering

http://video.nytimes.com/video/2009/04/04/world/1194839161724/china-s-kidnapped-children.html

With the "one child" policy now a generation old, many unforeseen
consequences affect the most populous nation. Sons are obviously
preferable in a Confucian society, so the family line can continue,
and girls are often expected to live with and serve the husband's
family after marriage (especially in rural/poorer communities),
leaving the parents of the girl without a caretaker in their old age.
Therefore many of the boys in China are referred to as "little
princes" because they are spoiled and the focus of the family, with so
much riding on their existence.

So even though prenatal gender screening is illegal in China, some 40M
girls have been aborted since 1979 according to this documentary:
http://www.hbo.com/docs/docuseries/chinasstolenchildren/index.html.
That creates a terrible gender imbalance, which will render millions
of (mostly poor) Chinese males unable to find a mate when they mature,
which defeats the whole purpose of their parents having a son in the
first place.

The policy and culture have created an environment where children are
a very precious commodity, and a black market has emerged. In China's
growing economy, more mothers have joined the workforce, and migrating
labor creates transient communities where neighbors do not know each
other, so children are more vulnerable. Human traffickers abduct young
children and sell them to a new family. Obviously the child has to be
young enough so it can't escape and find its way back home, and cuter
males are more expensive. Babies are cheaper because they are more
labor-intensive. People are willing to pay 10,000 RMB ($4,000) for a
child.

Besides kidnappings, some poor parents have no choice but sell their
kids. Even if you have no children, you must obtain a birthing license
with the state (pre-labor) to be able to officially register your
child. Otherwise authorities will charge large penalties (8-20k RMB)
if a couple has a child without a license. Some laborers many only
earn 2-5k RMB per year, so such a fee is impossible to meet, and they
may decide to not register their child and sell them to traffickers
for 3-8k RMB. Then I suppose the new parents will falsely register the
child under their name.

Girls are kidnapped for another reason. Due to the gender imbalance,
poorer males will have a harder time getting married. Black market
wives can be more expensive (~20,000 RMB) and less reliable, so why
not buy a girl younger, cheaper, and then groom her to become your
little prince's spouse?

Officially, there are about 3,000 official kidnapping cases under
investigation each year, but some estimate the actual number to be
70,000. Law enforcement is either too busy or unwilling to investigate
many cases, maybe due to lack of evidence. But local authorities are
also concerned about angry parents traveling to Beijing to petition
the government and make a stink about their case. So instead of
helping the grief-stricken parents, they will intimidate them into
silence. Injustices and discontent make the state look bad, and the
government is more concerned with preserving stability and the
appearance of harmony versus solving crimes. For the greater good I
suppose.

Some committed parents have set up web networks for kidnapping victims
to share information, and this has resulted in a few rescues. But
generally, cases will never be solved and families are forced to live
with the shame and despair of their predicament. But since this
tragedy mostly affects the poor, much of China is turning a blind eye.
Growth and progress always come at a price, with a huge abyss
separating those who profit and those who pay. Just as the Great Wall
was supposedly built upon the corpses of slave laborers and conquered
foes, modern superpower China is only able to exist because of the
suffering of the poor masses (as an example, over 4,000 Chinese coal
workers officially die each year to keep their factories humming, but
the actual number is probably double). Marx and Mao may not have
expected that curve ball, but to be fair, this is the case for every
strong nation.

Newsweek's "How we could have won in Vietnam"

http://www.newsweek.com/id/221632

To Newsweek,

In response to your Nov. 16 cover story about how we could have won in Vietnam, your writers failed to mention that (a) the fact that we lost in Vietnam did not greatly imperil America as the hawks predicted, and (b) we could have recognized an independent Vietnam in 1945, and worked diplomatically to sway them from communism, thereby averting the deaths of over two million people.

a) After the US withdrew and South Vietnam fell, a pan-communist Asian axis never materialized to threaten Western interests in the region. In fact, those nations were at times hostile to each other. China briefly invaded Vietnam in response to their toppling of the Pol Pot regime in Kampuchea - all three being communist nations at the time. Since the 1990s, the US and Vietnam have been cordial trading partners, though of course political differences persist. But there was no "domino effect" or hateful Vietnamese fanatics plotting revenge against America, which is often speculatively associated with radical Islam today. Defeat is never palatable, but it's not the end of the world either, even in Afghanistan.

b) Abraham Lincoln said, "Am I not destroying my enemies when I make friends of them?" A war with Vietnamese communists was not inevitable. The OSS helped Ho Chi Minh and the Viet Minh (precursors to the Viet Cong) fight an insurgency against the occupying Japanese during WWII, with the hopes of earning independence later. As a vision for the postwar world, the US and UK signed the "Atlantic Charter" proclaiming that all peoples have the right to self-determination, and Ho called Truman on it. But after the war, Washington ignored Vietnam as France attempted to reclaim its former colonies. If we upheld our principles of freedom and liberty, instead of succumbing to Cold War fears and bygone colonialism, we could have made an independent Vietnam our ally. Ho lived in the West and was inspired by the American Revolution, but the US decided to make him an enemy.

Health bill narrowly passes House

http://news.yahoo.com/s/ap/20091108/ap_on_bi_ge/us_health_care_overhaul
http://www.npr.org/templates/story/story.php?storyId=120220977

"The House bill drew the votes of 219 Democrats and Rep. Joseph Cao, a first-term Republican who holds an overwhelmingly Democratic seat in New Orleans. Opposed were 176 Republicans and 39 Democrats."

I called in a favor to my cousin there! You can thank me later, Obama. Well I guess Cao was in a tough spot, getting fluke elected in a mostly Dem district just because the FBI found blocks of cash in his opponent's freezer. He voted yes to hopefully get re-elected (doubtful) by his liberal constituents, but pissed off the GOP in the process. So even if he does get another term, no one will want to work with him (as if anyone wants to work with a guy named Cao to begin with).

The bill narrowly passed the House, which has a much bigger Dem majority than the Senate. So if 39/258 Dems opposed the bill (15%), and the same percentage holds in the Senate, then they can't get the 60 votes needed (even with Snowe). Lieberman said that he feels "morally obligated" to filibuster any bill with a public option in it. So I guess anything that passes the Senate probably won't have a public option.

And Blue Dog Dems even had to inject a sneaky abortion proposal into the House bill for it to pass. These conservative Dems (they should just register Republicans and stop trying to have it both ways) are so worried about their re-election if they endorse the health bill, that they supported an amendment essentially making the ban on federal assistance for abortions permanent. And Pelosi caved. Apparently the ban is currently yearly and needs to be renewed (but it always is), stemming back from Clinton times when he needed a big bill passed and the GOP stuck that provision in there, so he had no choice but accept it to move his bigger policy priorities forward.

Of course it's not like DC is handing out free abortions all the time to piss off Jesus, but that's what conservatives fear I guess. They think that federal subsidies to help the poor afford health insurance will allow them to get abortions covered by their health plans (and currently many health plans do cover abortions), so I guess in a convoluted way that could be seen as gov't assisted abortion. But abortion rights groups worry that with this ban in place, that will encourage private insurers to drop coverage of abortion, because why should they when their gov't-subsidized competitors aren't? So I guess abortions will still be legal, but you will pay out of pocket (assuming the bill passes in current form).

And it's not like Obama would veto this huge bill (and the main mission of his presidency) over a polarizing issue like abortion.

Don't believe the hype

1) Cash for clunkers

http://news.yahoo.com/s/ap/20091104/ap_on_bi_ge/us_cash_for_clunkers

Of the $3B in federal subsidies for vehicle trade-ins, almost 1/3 went to old truck/SUV to new truck/SUV swaps (that not only guzzle more gas, but also have dirtier emissions than compact cars). There were 677,000 trade-ins in total, and 1/7 of those were for new vehicles getting less than 20 mpg. Preliminary data show that the average trade-in mpg was 16 and the average new vehicle mpg was 25. So there were 137M registered passenger cars in the US in 2005, and let's say the number is the same today. If 677K vehicles were traded in, at an average mpg improvement of 56%, the CARS program improved the American auto fleet's fuel economy by 0.28%.

The most common trade was an older Ford F-150 pickup for a new model (at a whopping 1-3 mpg savings to the planet), which happened 8,200 times. There were even $500M in deals where the new vehicle got the same or WORSE mileage than the traded in "clunker", supposedly in violation of the program rules, but nevertheless still happened. The gov't is currently investigating. But hey, Ford and GM posted improved profits recently, and the recovery underway! On the green side of things, GOP senators on the Environment Committee boycotted discussions on the climate change bill, but Chairwoman Boxer passed it anyway.

2) Bill Clinton honored with statue in Kosovo

http://news.yahoo.com/s/nm/20091102/wl_nm/us_kosovo_clinton_statue_2

The recently independent Kosovar Albanians honored their "savior" and champion Bill Clinton with a bronze statue and boulevard in his name at their capitol. First off, it was highly dubious for the US/EU/UN to grant autonomy and recognize breakaway regions at risk of ethnic cleansing such as Kosovo and East Timor, yet ignore the Ossetians, Chechens, Palestinians, Kurds, and others in similar predicaments elsewhere. But I suppose Indonesia has 17,000 islands, so losing one won't hurt too much (and Timor doesn't have much oil), and we just wanted to punish Serbia for its actions in the 1990s. Secondly, what was the deal with the mostly-forgotten Kosovo war anyway? In 1999, The ethnic-Albanian Kosovo Liberation Army (KLA, freedom fighters or terrorists, depending on who you ask) revolted against the Serb government. Albanians attacked gov't buildings and the Serb minority in Kosovo, and of course the Serb military and paramilitary gangs retaliated harshly (but not much worse than Sherman in Atlanta). Clinton and his defense secretary William Cohen made the media rounds to justify NATO intervention, claiming that "hundreds of thousands" died in genocidal attacks, akin to Rwanda or the Holocaust. Of course than number came out of thin air, and later investigations of human remains in the region uncovered ~2,000 corpses, and not all were Albanian or victims of genocide. But despite some protests, Congress gave the green light. NATO dropped the hammer on Serbia with 78 days of air strikes, including cluster bombs (weapons now rejected by most of the civilized world besides Israel, the US, and Russia), until the Milosevic government finally capitulated (at the behest of Russia). 10 years later and billions of dollars spent, Kosovo is still a dirt-poor near-failed state, there are still 14,000 Smurf peacekeepers there (including 1,000 Americans), organized crime has flourished, and Yugoslavian refugees have flooded Western Europe, so hardly a success story of American nation building. But better than Afghanistan and Iraq I suppose.

But what you may not know, and most mainstream media ignore, is that the NATO bombing campaign also killed hundreds of civilians and barely diminished Serbia's military capabilities. In fact, the bombing angered Serbs and accelerated ethnic cleansing against Albanians in some instances (the NYT estimated 4,600 Albanians killed AFTER the NATO bombing commenced). And after the Serb withdrawal from Kosovo, the "hands off" UN forces were unable to stop the vengeful KLA from brutalizing the Kosovar Serbs. It's quite possible that as many Serbs were killed/raped/displaced in the war as Albanians. But we sided with the Albanians because we didn't like Serbia for causing all those problems in Bosnia some years back, and Milosevic was a grotesque strongman. Serbia was misbehaving and challenging the credibility of the US and NATO in post-Cold War Europe, so we had to respond with violence, even if it upset our wary ally Russia (historically a supporter of Serbs) and destabilized Eastern Europe with a humanitarian crisis. The attached reports from the libertarian Cato Institute (yes I know, consider the source, but at least they had the courage to tackle the subject) give more details.

After the Serb surrender, Clinton said that we "did the right thing in the right way". But now we are indefinitely responsible for Kosovo stability (a gloomy prospect), which gives the people and their leaders little incentive for reconciliation and development for a better, truly autonomous future (the same quandary exists in Iraq). Maybe doing nothing was unacceptable, but war and bombing usually kill all hope of a diplomatic solution and increase hatred, not decrease it. And let's be honest, we bombed because we didn't think the Yugos were worth American blood, but attrition bombing can't stop non-uniformed thugs from killing innocents. If the UN left today, probably nationalistic/ethic violence would resume, so we have really painted ourselves into a corner. So yeah, Clinton was all smiles in Pristina at the statue unveiling, like Bush on the aircraft carrier. Why do they always seem to erect more statues of short-sigted, self-righteous warlords than true peacemakers?

GDP can't really tell us when a recession is over

http://www.businessweek.com/magazine/content/09_45/b4154034724383.htm?chan=magazine+channel_top+stories

So Washington is jumping for joy that the 3rd quarter GDP growth numbers were POSITIVE (3.5%) after 4 straight negative quarters. The stock market has surged from its low in March (Dow 6,000s) to now (Dow 9,700). Auto and home sales are up too (mostly due to gov't incentives, and are expected to decline as rebates expire, so really it was just a loan from the future). Consumer spending has risen in some months, and of course the US personal savings rate has grown. Though unemployment is around 10% (those jobs may not return for years), and recent college grads are having a harder time getting hired than ever before. The White House says its spring stimulus package created or saved 1.2M new jobs (then reduced the figure to 0.65M when errors were exposed). But many of those jobs are temporary (highway projects) or non-white-collar, and 0.65M is less than 10% of the ~7M jobs lost since last fall. The stimulus did have some benefits, and gov't spending will always create jobs. But is it worth it? Nearly $1T in stimulus spending saved/created jobs for 0.43% of the American workforce, at the cost of $153K/job (triple the average household income). I know that is an unfair calculation since the stimulus was not 100% geared for job creation, but you get my point.

So what is going on? Are we out of the woods yet? GDP doesn't take into account R&D or other business investments that pay off big for the future economy. Of course those things are challenging to quantify, but it is possible. "Intangible business investments" were 40% smaller than tangible assets (equipment, buildings, etc. that the GDP can capture) in 1985, then the two were equal by 1995, and now intangibles are actually higher. America's wealth, innovation, and productivity have grown tremendously since 1985, and intangibles played a big part. The Bureau of Economic Analysis (the overworked and underfunded agency that calculates the GDP) plans to include some measure of intangibles into the GDP by 2013, so it is clearly important. Based on the author's rough calculations, drops in intangibles could make the real GDP 1-1.5% lower than the published figure.

While the GDP was supposedly rising, more and more professionals got pink slips (especially R&D scientists and engineers) in order to cut costs. In fact, techies are getting laid off at 150% the rate of the overall workforce, so it's not just the assembly line workers in the Rust Belt suffering this year. Companies want to do this to inflate their profit margins and please Wall Street (hence gains in the Dow), but they're sacrificing their future for short-term fiscal savings. Venture capital investments are half of what they were in 2008 (much of that money goes to hiring smart people to develop cool stuff), and big names like Texas Instruments and J&J have cut their R&D budgets by over 10%. Expenditures on worker training is also down (it was already down 4% in 2008, so 2009 is probably higher - though the data is not available yet), which is contrary to one of the stimulus package's goals of retraining workers for the 21st Century economy.

So what is the point of an economic recovery that threatens future development and productivity? We're just kicking the can down the road, like the Band-Aid patches for California's debt. I don't have brilliant ideas to truly end the recession, but it seems that declaring a recovery is premature.

Tim Donaghy book on NBA corruption

http://deadspin.com/5392067/excerpts-from-the-book-the-nba-doesnt-want-you-to-read

Disgraced and incarcerated former NBA referee Tim Donaghy just finished a tell-all book about NBA corruption that was supposed to be published by Random House, but strangely the company changed their mind after investing thousands of dollars on the venture (maybe Stern made a few calls). So it was taken off Amazon pre-order, but this website managed to transcribe some excerpts, and maybe a smaller publishing house will give it a try. Of course we have to consider the source and his motives, like Canseco's tell-all about steroids in baseball. But we should also remember that Canseco turned out to be right with several of his allegations.

We all know that refs influence (deliberately or not) NBA games probably more than officials in all the other pro sports, maybe apart from the goof-riddled MLB playoffs this year. But it's just the nature of the big-money, big-media modern NBA and ref culture that controversies are likely, especially due to the subjective, inconsistent, and vague nature of personal foul rules and enforcement in basketball. Literally millions of dollars are at stake from a whistle at a critical moment. NFL and soccer refs believe that they do a great job if no one notices they're even there. But NBA refs have big egos and want to be noticed. They're a sideshow like the cheerleaders, even at the expense of fairness and correctness.

So Donaghy says what we all suspect: the NBA front office wants to promote big stars, keep games close and interesting, extend playoff series, help the home teams win, and maybe have more interesting/profitable teams succeed. This will make the NBA and its sponsors richer. And officiating can help that. Stars walk all over and rarely get in foul trouble (except clumsy big men), yet defensive specialists get whistles just for breathing on a star. Often home teams or teams down in a game get more calls and go to the foul line more (give the people what they want!). But fans have all the data available for foul calls and which teams/ref crews were participating, so someone should crunch the numbers and see if there is measurable bias (if all else fails, I will take a week off work and try). That doesn't prove intent, but at least could expose a problem.

Donaghy talks crap about several refs, but alleges that Dick Bavetta is the league's "cleaner". He makes sure the proper result plays out in critical games, and even brags about how good he is at it. Coincidentally, he was on the floor during several controversial playoff games, such as game 6 between LAL-SAC in 2002 with SAC up 3-2 against the Juggernaut Lakers (yeah, I'm still bitter). It's also strange that the NBA picks the officiating crew a few days before the game. Why wouldn't they have ref schedules randomized and pre-set even before the playoffs began, in order to reduce the chance of tampering?

http://www.youtube.com/watch?v=b0KJvlSUB-w

Well some might say that the NBA already is very popular and makes a ton of loot, so why would they risk it all to squeeze a few more millions out? An exposed scandal would ruin everything. Pete Rose was rich, successful, and still broke the rules; same with A-Rod. Success can't stop greed and corruption. In fact in may be a strong motivator; enough is never enough and Stern has to keep growing the NBA's success or he'll be fired. And maybe scandals won't deep-six a pro sport anyway, so it's worth the risk. Although MLB attendance was severely down this year (probably due to the recession), fans still keep coming after the unpopular players' strike and steroids scandals.

But what about ugly, small-market teams doing well in recent times, like SA, DET, NO, and SAC? There are a lot of series sweeps in the playoffs too. And Bron/Nash still haven't won rings. Shouldn't Stern have pulled enough strings so those things didn't happen? Well the NBA can't be blatantly obvious. Some teams are way better than others and should get a sweep. And SA, DET, and SAC did have good, championship-worthy squads for a while. Even with tampering, they still could have overcame and won. It's not like Stern could hire a sniper to take out Duncan with a rifle during a time out. They are clever and they pick their spots, like the DAL-MIA Finals or the LAL-SAC 2002 series. I wish the refs did strike this season so we could see what a properly-officiated pro game looks like.

Rethinking the SF Bay Bridge

http://www.insidebayarea.com/sanmateocountytimes/localnews/ci_13658982?source=rss
http://baybridgeinfo.org/faqs
http://www.dot.ca.gov/hq/esc/tollbridge/SFOBB/Sfobbfacts.html

After yet another near-lethal accident and emergency bridge closure for repairs that costs the region millions in economic productivity loss, maybe we should rethink the entire bridge concept anyway. We know the eastern span of the bridge is a piece of crap and won't withstand a 7.0 quake, which is why a new bridge is under construction.

The bridge's construction began in 1933 at a cost of $77M ($1.2B in 2009 dollars; a cool website to calculate: http://www.dollartimes.com/calculators/inflation.htm). Another $49M was spent in 1958 ($362M in 2009 dollars). In CA bill AB 1171 in 2001, $3.3B was allocated for bridge seismic retrofitting. $20B in new transportation bonds were issued in 2006 to address cost over-runs, which now total $6.2B and counting.

So instead of wasting ~$8B on building/maintaining the bridge, why not destroy it and dredge a land bridge instead? A Google search didn't find any proposals in circulation. You could have a small high-rise section for ships to pass underneath. We know the tourism snobs would say that a land bridge wouldn't be as picturesque, but we still have the Golden Gate don't we? Obviously a land bridge would be safer in a quake or storm (assuming the dredged Earth was stabilized properly and won't liquify from tremors). It will ease pressure on traffic, emergency responders, and Caltrans as well.

So the big question remains - would this idea be more or less economical? Under the bridge, nautical charts show an average water depth of ~55 feet. The bridge spans 3.68 miles of water. So assuming the land bridge would be 500 feet wide (very generous), that is 0.35 square miles. Well how much did a similar project cost? Dubai had Van Oord company (and the Dutch know their stuff when it comes to land reclaimation) build its famous "Palm Jumeirah" islands. They needed 90M cubic meters of sand and 7M tons of rock to dredge water that was 11 meters deep (28 feet). The archipelago extends 5 miles offshore and totals 700 hectares of land, which is 2.73 square miles - 8X the size of my proposed land bridge project. So it's a much larger project than the Bay Bridge span would need, albeit constructed with the help of dirt-cheap South Asian laborers. The whole Jumeirah cost $12B, but not sure what fraction was dredging. Maybe to get a sense, Van Oord won a new $4B contract to build an even bigger Palm (the Deira) in Dubai. This one is 4,000 hectares or 5.7X bigger than the Jumeirah, or 45X bigger than the land bridge. But since the Bay is 2X deeper than the Dubai coast, lets quadruple the cost to be fair. I am sure dredging jobs don't scale linearly, but just for argument's sake, that's a cost of only $360M. $6B just to retrofit the bridge vs. $0.36B to make a land bridge, hmmmm.

http://en.wikipedia.org/wiki/Palm_Jumeirah
http://www.sandandgravel.com/news/article.asp?v1=8727

But ~270,000 vehicles use the bridge every day, which at $4 per car is over $1M in revenues each day (and there are proposals to raise the toll to $5-6). So I guess it's a cash cow and a "pretty landmark" for the area, so we'll continue to sacrifice time, resources, and safety to maintain the bridge, when cheaper and safer alternatives exist.

More on prescription drugs

Yeah, for a culture that's so gung-ho about wars on drugs, just saying no to drugs, etc. there sure is a lot of accommodation of prescription drugs; yet another mystery of American life, eh?

BTW, I did want to add one thing to the discussion (top-posted per request, cross-posted with T's Blogger Blog, & duplicated to Google Groups for posterity): it could be that the real villain with respect to over-prescription of drugs is actually the privacy policies which make data collection regarding drug interaction as well as long-term efficacy something of a question rather than a no-brainer... I know that there are plenty of systems (and algorithms) which are capable of automatic collection and anonymization of such data so the technology definitely exists; as far as I'm know the only reason such systems haven't been deployed (or federated) is a lack of will and/or legal framework to allow the needful to be done.

PS: DTC marketing is obnoxious and more existential than hanging out at a gym; it's reason enough to turn off the TV for good and/or abandon network television for good.

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Thanks for writing. Yeah Rx painkillers are I think in the top 5 for illicit drug abuse in America. But instead of brown people smuggling blow across the Rio Grande to poison our kids, American drug pushers just have to raid grandma's medicine cabinet or obtain a bogus Rx. I am sure most of you have heard stories of even teens selling their leftover vicodin to classmates after a wisdom teeth removal or whatnot. Customer service is generally pretty poor at most retirement homes and hospice care centers for the sub-rich, but one thing they're great at is medicating the elderly. Then they have to deal with fewer complaints and whining.

Another problem is how to dispose of all the surplus drugs. It's fairly well documented that doctors overprescribe antibiotics for even viral illnesses or patients whose symptoms are not severe (and would probably recover on their own, but the doc wants to be careful and not upset the patient/get sued). This selective pressure gives an evolutionary advantage to drug-resistant bacteria strains. Discarded antibiotics and other drugs are winding up in our water supply. Our water purity tools are now more sensitive, so maybe drugs were always there and now we can finally detect them, but still - it's quite likely that we're ingesting trace amounts of all sorts of drug cocktails when we drink tap water (or even cheap bottled water).

http://www.staphaseptic.com/news.cfm?id=18FE4C5D-C6C9-0EF9-9F1678797221DAA9
http://www.usatoday.com/news/nation/2008-03-10-drugs-tap-water_N.htm

As you said, there isn't much data on long-term drug effects, drug interaction, or even acute side effects. With pressure from drug companies and even overzealous patient advocacy groups to get products to market ASAP, the FDA is unable to be totally thorough. There is a new prostate cancer vaccine (Provenge) being reviewed by the FDA. 4/17 docs on the advisory panel have concerns about the drug's efficacy, and two published their findings. The authors now need 24/7 bodyguards because crazy people are making death threats to them, because they think the docs' obstruction is threatening theirs. Even though the docs are doing this out of concerns for potential patients and have no financial incentive, unlike other docs who praise drugs from companies that do them favors. This is the state of medicine today.

http://www.psa-rising.com/blog/2007/06/prostate-cancer-doctor-receives-death-threat-over-provenge/

As we know, haste causes mistakes, like in the cases of Vioxx, Raplon, Palladone, Trasylol, Baycol, Raptiva, or other drugs that were initially approved and pulled after drug-related deaths/complications were reported. Just do a Google search for "drugs pulled from market" and you will find a huge list. The FDA, NIH, and other gov't entities are underfunded and understaffed. In fact, most drug testing is funded and conducted by the company itself, and the FDA just reviews their paperwork. Or resources are poorly allocated: breast cancer research gets the most funding (30% of all NCI grant funding), even though it is not the most common nor lethal cancer, probably due to America's Oedipal fixation with mammaries and maternal guilt issues. But long-term studies are expensive and time-consuming, and it's hard to follow patients for years. We hope academics will conduct these critical studies for us, but they have their own constraints and there's still so much we don't know. Maybe with more electronic records, information sharing, and sophisticated computational methods, we can learn more about the pharmacokinetics/dynamics of various drugs, but as you would expect, the medical field is not at the cutting edge with respect to computing. As you said, without the gov't will and legal mandate to obtain these data, it will never happen on its own.

http://www.cancer.gov/cancertopics/factsheet/NCI/research-funding

Attitude-wise, I think patients should stop expecting new miracle drugs to keep curing them of illnesses and improving/extending their lives. Practically everything out there is a carcinogen or pathogen. Maybe diseases evolve faster than science (and bureaucracy) can combat them anyway. The "George Bush approach" that technology will always save us from ourselves is not valid in most cases, and probably foolhardy. Yes we should rationally and ethically continue research and try to help the sick get better, and yes drug companies and doctors deserve reasonable compensation for the products/services they provide, but let's remember that we are all mortal and fragile. Death is part of life, and let's face it with some zen and humility. Why are you so important that society needs to spend half a million dollars so you can see your 86th birthday? Research isn't really the problem either. The top killers in the world are respiratory complications (from flu, pneumonia, etc.), tuberculosis, and malaria. All those are easily and CHEAPLY preventable/treatable. But of course the people who die from them are from the Third World, and we don't give a shit about them. The top killers in the West are probably heart disease and cancer. So we pour billions of dollars into research and care for those diseases. Probably one infusion of chemotherapy ($10k in some cases) could pay for an entire village's anti-malarials for a year.

Doctors prescribing drugs

In my experience, primary care physicians are very responsible in providing their patients with the correct medications and education. Being a news article, it is easy to cite a few examples of patients that are unaware to skew towards a general opinion rather than an official study supported by lots of data from a balanced group of subjects. The majority of my patients that are taking medications are mostly aware of their drug names and why they are taking them, and some also know the exact dosages. It is true that the majority are for high cholesterol, blood pressure, anti-coagulants, diabetic medication, etc. There are many drugs that can be prescribed, however there are fine differences in the mechanisms of the drugs, so the physicians may prescribe a drug, but then change the prescription due to the medication's effects of that patient's blood chemistry, exam, etc to titrate them for the best effect on their patient. I feel that they are putting the patient's best interest first, especially since there is no tort reform. The rise in pharm sales can be attributed to patients asking for a specific drug by name, but it will not be prescribed unless it is the right drug for them. In the case where many drugs can work, if a patient feels more satisfaction for a certain drug name, it will probably be prescribed. Otherwise, it is just new technological advancements that are helping patients live longer than the had in the past and a new generation in which Prevention is the mode of operation.

It used to be that a patient would have a heart attack before medication was prescribed. Now, we have many indicators to help prevent heart attacks. So instead of a patient having a heart attack/stroke and living 10 years longer the previous generation after the attack and dealing with the repercussions of that heart attack, we are moving towards a generation of patients living 20 years longer than the previous generation, but not having that heart attack and living a normal life. With the baby boomer generation taking bp/cholesterol/anticoagulants/diabetic meds younger than the current older generation, we can expect them to live even longer with less ailments. When patients live longer than they are supposed to, new ailments arise however, that never had before been seen because they would be dead in the past. So, new medications will need to be prescribed/developed.

It's true that American's are also not healthy and they do rely are on multiple drugs to live longer, but not because they are hypochondriacs (its malpractice to prescribe drugs that pts don't need, plus insurance won't cover it without a diagnosis backed with exam information), but because they would be dead otherwise or living miserably having survived a medical emergency.
In general, most doctors do try to prescribe generics when they can. On prescription forms you check a box that says "Generic Substitute" which is checked 99% of the time unless the patient feels better with a prescription name, i.e Hydrocodone 5/500 vs. Vicodin.

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Plenty of drugs are prescribed that have nothing to do with extending life, yet are quite expensive: antihistamines or other immunomodulators, digestive medications, sleeping pills, penis pills, PMS pills, behavioral drugs, and anti-depressants (unless for severe suicide risk, though teens taking anti-depressants may actually increase their risk of suicide, but of course patients who are prescribed anti-depressants are more likely to attempt suicide anyway: http://www.redorbit.com/news/health/731343/new_look_at_antidepressant_suicide_risk/index.html). Yes those drugs may improve a patient's quality of life (either marginally or significantly), but they are not a matter of life and death.

Drugs are one of several factors contributing to the huge drop in cardiovascular-related mortality. Fewer Americans smoke (I also believe alcohol consumption is down) and there is more education about healthful living and eating vs. the previous generation. Our diagnostic technologies have improved, so hypertension can be detected and addressed earlier. It's not just these wonder drugs that are making Americans live into their 80s. And if the drugs were so great, why is it that America is the most pill-popping nation per capita, yet our overall life expectancy is ranked 24th worldwide (see my previous email "Health care overhaul potpourri")?

It's naive to think that drugs are only prescribed out of critical medical necessity. Plenty of doctors prescribe drugs off-label (as in, for indications not officially approved by the FDA), because some data shows the drug could help, but in that case the prescribing doc is responsible for any adverse effects (since thorough safety/efficacy tests have not been conducted). Maybe they help the patients by doing so, and maybe it's excessive. Not all doctors are greedy con men, and not all doctors are saints. There's a mix of the two and plenty in between. Insurance and Medicare don't have the time and resources to scrutinize every Rx. The CDC said that 14M Americans misused their Rx's in 2004, resulting in 20,000 deaths. So obviously they were using the wrong drug, or not taking it properly, so either they are junkies or their physicians/pharmacists did not properly Rx or educate them on the risks.

The Centers for Medicare & Medicaid Services reported that 30% of the nursing home population is receiving an antipsychotic, yet 21% of those cases do not suffer from psychosis. In 2007 doctors filled more than 45 million prescriptions for an antipsychotic, according to IMS Health. Yet there are only 2.4 million schizophrenic patients (for whom the drugs were originally intended), according to the National Institute of Mental Health.

http://www.businessweek.com/debateroom/archives/2008/06/stop_casual_rx.html

Yes it is malpractice to Rx a drug that the patient doesn't need, and guess what - malpractice occurs a lot in America (~14K settlements paid out each year, either valid or frivolous, though few are drug-related). The attached report (I can't vouch for the data since I haven't read it all and am unfamiliar with the org, but just food for thought) suggests that malpractice settlements are not the bogeyman that physicians make them out to be. Before federal anti-kickback laws were enacted in 1972 & 1989 (42 CFR Part 1001), pharma companies were routinely paying for doctor's gifts, posh meals, and junkets to conferences in Hawaii (and some of it persists today). Why would they do that? They have a business to run and can't afford to throw money away as goodwill. They are investing in quid pro quo obviously. This is from the New England Journal of Medicine (scary stuff actually), written by doctors:

Interactions between drug companies and doctors are pervasive. Relationships begin in medical school, continue during residency training, and persist throughout physicians' careers. The pervasiveness of these interactions results in part from a huge investment by the pharmaceutical industry in marketing. In 2002, the industry expended 33 percent of its revenues on "selling and administration."12 In 2001, one company, Novartis, reported spending 36 percent of its revenues on marketing alone.2 The marketing expenditures of the drug industry have been estimated variously at $12 billion to $15 billion yearly, or $8,000 to $15,000 per physician.7,8,13 In 2001, the industry's sales force of drug detailers, whose job is to meet individually with physicians and promote company products, numbered nearly 90,000 in the United States2,8 — 1 salesperson for every 4.7 office-based physicians.8

Moynihan14 catalogued 16 different ways in which drug companies relate directly or indirectly with doctors. These range from the seemingly trivial (e.g., the ubiquitous dispensing of gifts such as pens and pads with drug names inscribed) to the much more troubling (e.g., the ghostwriting of articles for academic physicians, the payment of large honoraria and consulting fees to prominent physicians who extol the virtues of company products, and the support of lavish trips and entertainment for physicians who commonly prescribe company products).
Surveys of residents indicate that they receive an average of six gifts from pharmaceutical companies annually.15 In a survey of 106 directors of emergency-department programs in 2002, 41 percent responded that their programs allowed residents to be taught by representatives of drug companies, 35 percent reported that residents received free industry samples at work, and 29 percent said that residents' travel to meetings was sometimes dependent on the availability of company support.16 According to another report, residents in a psychiatry program in Toronto attended up to 70 lunches that had been sponsored by drug companies and received 75 promotional items over the course of one year.17

... As many as 59 percent of the authors of clinical guidelines endorsed by many professional associations have had financial relationships with companies whose drugs might be affected by those guidelines.23

... In a very thorough review of the literature on the effects of interactions with drug companies on physician behavior, Wazana15 identified 16 relevant studies. These studies found that a wide variety of interactions — meetings with company representatives; the receipt of gifts, free drug samples, and free meals; company support for travel to and lodging at educational events; attendance at lectures by representatives of pharmaceutical companies; acceptance of honoraria; and other relationships — were associated with changes in physicians' use of medications. Involved physicians were more likely to request the inclusion of the company's drugs on hospital or health maintenance organization formularies, more likely to prescribe the company's products, and less likely to prescribe generic medications. The resulting changes in the use of medication were often costly and "nonrational" in that the newly prescribed or requested drugs had no therapeutic advantage over the alternatives. Interestingly, several studies have found that the larger the number of gifts that physicians received, the more likely they were to believe that gifts did not affect their prescribing behavior.15,28

http://content.nejm.org/cgi/content/full/351/18/1885?ijkey=8tzMb5l1u.Np2&keytype=ref&siteid=nejm

So if doctors can enjoy millions of dollars of gifts/assistance/what-have-you from pharma companies and still prescribe their products ethically and scientifically, then medical school is really worth the $40k/year.

Baucus health bill passing: historic progress but unimpressive impact

http://www.kqed.org/epArchive/R910140900

An interesting panel discussion of the recent Baucus health bill passage and challenges ahead. Some points to consider:

- This bill will increase the number of Americans covered by health insurance from ~85% now to 94% by 2014. Is that much to celebrate? And there is very little in the bill that would control costs, increase competition, or help under-insured individuals (some studies have shown that "health care cooperatives" would do little and may not even get off the ground). At least new rules would prohibit companies from rejecting customers based on pre-existing health conditions, but that would probably increase costs.

- Did Senator Snowe incur GOP ire by endorsing the Baucus bill (the only version without a public option currently in circulation) in order to actually help the GOP and pre-empt more liberal provisions such as the possibility of a public option?

- The Republicans have no health reform alternative, absolutely ZERO. They just want to impede action, but by doing so are missing a key opportunity to advance conservative changes. The GOP have spoken for years about reforming and trimming down Medicare/Medicaid, and now they could achieve it by playing ball and gaining concessions from the Dems for yes votes. But instead they are just the "Party of No".

- In order to get the 60 Senate votes to send the bill to the president's desk, all Dems, 2 Independents, and 1 Republican need to vote yes. It could be very close, because Senator Lieberman was not thrilled with the bill (many health insurance companies are based in CT).

- It will be very difficult to reconcile the arch-liberal and arch-conservative wings of the Dem Party, who are both against this middle-of-the-road bill for different reasons. House Dems are irate with the lack of a public option (which they see as integral to "real reform", and they are probably right).

- In order to keep this bill deficit-neutral (or positive), the "Cadillac" health plan tax (taxing the most generous health plans) and/or a tax on millionaire Americans seems inevitable. But unions are against the former (some union members enjoy Cadillac coverage), and the House is against the latter (no one wants to be labeled as a tax raiser prior to the 2010 midterms).

- By mandating that more Americans get coverage, it would help if coverage was more affordable, but that looks doubtful. And if families who can't afford coverage (even with more gov't subsidies) remain uncovered, they will be fined. On the flipside, the penalty is meager, so this may encourage more affluent people to game the system. While healthy, they will remain uninsured (since that will save them money overall, even after paying the fee), and then only purchase coverage when seriously ill (since they know they won't be rejected). This will of course increase costs to insurers, who will pass that along to us.

- The plan taxes comprehensive, low-cost, long-term delivery health systems such as Mayo Clinic, InterMountain Health Care, and Kaiser Permanente, even though Obama and others have touted those companies as models for reform. Why penalize the companies who are doing it well, and give their more wasteful competitors a pass?

- The financing for this bill is hardly transparent, and relies on many short-term gimmicks to balance costs. So even if it passes to law, it is likely that we will be doing this all over again in the near future. Also, the bill expands Medicaid eligibility (covering 11M more Americans, which in theory is good), which will be supposedly 90% covered by the feds. But states would still be on the hook for 5-22% of their own costs (which would range in the billions, depending on numerous factors). As we know, most states are in terrible financial shape, and the bipartisan National Governor's Association came out against the Baucus bill. The bills in the House would cover Medicaid expansions 100% by Washington.

- There is nothing in the bill to address Medicare/Medicaid physicians' reimbursement modernization. So as Congress is trying to cover more people under Medicaid, more and more doctors are turning away those patients because they make less money from them.

http://www.ama-assn.org/amednews/2009/09/28/gvsb0928.htm