Saideman's Semi-Spew

Thus far, the Senate Democrats have done ok in a difficult time--how to slow or stop Trump when they have a minority.  Not easy and burning down the government is something that a party that believes in governance cannot do.  But selling out Americans on health care to get a bipartisan effort on Russian sanctions is going way too far.

The deal is this: the Senate agrees to keep sanctions on Russia and the Dems agree not to obstruct too much on health care.  This seems to be exactly backwards for both moral and political reasons.

First, AHCA will get Americans killed.  Sorry, but there is no way to avoid this basic truth--people losing access to health care will lead to needless deaths.  The lives of millions of Americans will be hurt, one way or another, by gutting ACA.  More money for premiums, more people losing insurance because of pre-existing conditions, less medicaid money so that kids and poor folks get bounced.  Just awful.  So, the toll of not fighting AHCA is going to be huge.

Second, will Americans vote in 2018 and 2020 based on how much we sanction Russia?  Or will they vote on health care?  Yeah. 

So, this is both bad and dumb.  I really don't know what the Dems are thinking--maybe they just suck at obstruction and this is the way to turn lemon in lemonade.  Maybe they want AHCA to pass so that the GOP loses in 2018/20.  Maybe so, but the point of being in office is not just to win the next election but to protect your voters and those who didn't vote for you now.  I am easily outraged this days, but this is really epitome of outrageousness.

Brian McFadden pulls no punches today on how one can react if the Supreme Court shoots down Obamacare:

I am now a big believer in physical therapy.  Growing up and playing ultimate for years meant many ankle sprains and other injuries, and I never got any help.  I would just eventually heal, maybe wear a brace from a sporting goods store.  Eventually, I just got in the habit of wearing ankle braces when playing ultimate. 

When I hurt my knee skiing a few years ago (I was trying to slide fast near but not into my daughter to spray her with snow), I got some "physio" as they call it Canada (is that what it is called in the US?), and within a short period of time, I felt better.  This August, I hurt my achilles pretty severely the last week of the ultimate season and did not seek help, thinking it was going to get better.  It did a bit, but kept hurting.  Within a couple weeks of getting some physio, I felt better quickly.  So, I have learned my lesson.

So, if you get hurt, get to a good physical therapist.  It seems to be a booming industry in Ottawa with heaps of outlets nearby.  With their help, I have probably another few years of ultimate left. 

And other kinds of advice as well!

William Watson argues today that evidence-based policy-making can produce bad policy.  Maybe, but ideology-based or evidence-less based policy might just be far worse, right?  This reminds me of certain political scientists pushing against hypothesis testing.  The advice at the end is correct--that we should be mindful of the reality that experts will disagree, that the evidence is not always clear, and that choices have consequences.

The funny thing is that Watson uses pretty selective evidence to illustrate (not test) his argument--his ability to get a doctor.  Now, to be clear, I had pretty much the same experience .... in Quebec.  One thing this article does (perhaps it was written for Quebec audiences first and foremost), and a common mistake it is, is to conflate a provincial policy with a Canadian experience.  It may be the case that provinces besides Quebec also messed up the sizing of the medical community, but one thing that all folks who compare Canada to the US or anywhere is must ALWAYS keep in mind is that the administration and thus the quality of medical service varies by province because the provinces run them.


When I moved to Ontario (using my experience to generalize) from Quebec, it took us a few weeks to find a clinic and a doctor.  Both the clinic and doctor are wonderful--the service is quite fast--appointments within a day or three, the facility is clean and modern, the doctor is responsive, and so on.  The emergency rooms can be a bit slow, like Quebec, but they are not beaten to crap so that they look like a 2nd or 3rd world facility (that would be Lakeshore General in Montreal).  It really is night and day.  It is not utopia, but anyone making arguments about health care in Canada must be wary of generalizing from their province's experience especially if their province happens to be Quebec. I have long argued that anything that Quebec's government touches turns to crap, that Quebec could not administer a lemonade stand (see here for how opposition politicians are of little help).

The argument Watson is addressing is the notion that doctors were creating more business for other doctors, so if one cuts the number of doctors, there might be less spun up health care expenses.  This seems like an incredibly stupid theory, and I have no clue as to what evidence was used to test it (I am not a health economist nor was I around at the time).   It seems real convenient to a government that might be interested in cutting costs and being not so accountable for good government (because elections based on nationalist issues tended to distract SQUIRREL! the public from issues of good governance).  So, was it really that experts advocated cuts in doctors or was it that the government of the day listened to the advice that matched their preferences?  Oh, and where did the doctors go?  Ontario and elsewhere, right?


So, I would argue that we need to be careful about the evidence that we use (perhaps my experience in Ottawa is an outlier), that we need to keep in mind the source of policy-making (province or federal), and that we need good theory and good evidence AND we need to keep in mind that there are always tradeoffs and second/third order consequences. 

I saw this piece last night at Jezebel and went on a twitter tear.  Why? Because of searing memories from nearly seventeen years ago.  So little has changed in this area, compared to pretty much everything else. The Jezebel story asserts pretty convincingly that doctors know diddly about lactation despite the past few decades of increasingly pressuring women to breastfeed their babies.  Yes, yes, yes, breastfeeding is better for babies, but it does not always work out very well.  When people insist that breastfeeding is natural, I retort: so is infant mortality.  Why?  My tale from long ago:

When Teen Spew was just a few days old (Baby Spew), the timing/connection for breastfeeding to work didn't synch up well.  A sleep-deprived Mrs. Spew and I were averse to trying anything other than nursing because we were told that using bottles even just a little bit would mean that the kid would not be able to return to the breast.  Yes, my wife got some help from the lactation experts at the hospital, but not before we had to go back to the hospital a couple of days after my daughter was born--she was dehydrated, which amped up her slight jaundice.  Which led to a little game I like to call "Pin the IV on the Dehydrated Newborn."  Watching a nurse or two try to put the IV needle into my daughter and failing again and again was pretty painful for me to watch probably painful for her.  They had to get a nurse from the neo-natal intensive care unit to find a spot to insert the IV and where did she choose?  See below:
The red thing is a pacifier, the white stuff over her eyes were to shade her from the lights used to deal with the jaundice and that thing on the back of her head is the IV.  Lovely.  Just freakin' lovely.

My wife and baby Spew finally got the connection going and managed to do the nursing thing quite well for quite a while, but the first week was hell and damn near killed the kid.  So, I have a great deal of sympathy for women who cannot get the breastfeeding going, and a great deal of animus towards the medical community for failing to research lactation with even a bit of the enthusiasm erectile dysfunction has received.  One area involves life, death and the health of babies; the other involves men's sex lives mostly in the second half of our lives.

 Good to know where our priorities are.

People wonder why I moved from Montreal with its hip and lively folks and from the Harvard of the North, McGill, to the squarest city, Ottawa, and to Carleton which is far less famous.

The answer of the day would appear to be death from above:


No, we did not move because of the threat of eagles grabbing my kid (teenagers are probably a bit too big).  One of the major drivers was a dissatisfaction with everything the Quebec government touched, which is quite a lot.  One of these things is health care.  When people lauded the Canadian health care system and compare it to the American one, I always scoffed, saying that health care is not national but provincial.  And today I had my first encounter with the Ontario health care system (well, besides the Children's ER), and I have to say, damn, I am glad I moved to Ontario.  I might have to start admiring the Canadian health care system....

I didn't have to wait past my appointment time to be seen, the doctor met with me while the blood pressure machine was still cycling, the clinic was clean, the doctor was friendly and engaged.  The pharmacy next door was super-helpful.&  It was like I was in fantasy medical treatment land.  Sure, this is just one encounter, and perhaps it will suck in the future.  But the juxtaposition between my old health care in Montreal (free in price and free in quality as in quality-free) and my new setup here is night and day. 

*  Next door to the pharmacy?  The Beer Store!

So, keep in mind that when you hear "Canadian health care", it really does vary by province.  If your kid gets picked up and dropped by an eagle, I hope it happens in some place other than Quebec. 

Francois Legault, the leader of the CAQ, the new party that proclaims to be different from Quebec's older parties, seems to be cut from the same cloth. Why do I say this?  Because he is promising to restrict the exodus of doctors produced by Quebec's medical schools (mostly aimed at McGill).  The funny thing is that Charest of the Liberals has been accusing Legault of being a closet separatist, when the real concern should be that Legault would run the province like any other PQ government--into the ground with over-reaction and coercion and one size-fits all solutions.

Is there a Doctor exodus from Quebec? Probably.  Do I know of McGill-produced doctors who have moved out of Quebec?  Certainly.  One might ask why some leave.  It might be about pay, but it also might be about how poorly administrated the health care system is in Quebec.  I remember early in my time in Quebec lots of discussion of doctors being compelled, rather than persuaded, to serve outside of Montreal and especially in the less populated parts of the province.  Again, coercion, not incentives.  The Soviet style decision-making about how many pediatric oncologists a hospital needs can be a bit of a turn off.

The thing that is most annoying and most typical is that this kind of policy assumes that people do not have choices and will not react.  Certainly, they will do so.  How so?  Well, the most obvious thing is that McGill (and others, I guess) would receive fewer applications as students anticipate and choose to go elsewhere rather than McGill.  Why is that a problem if people intend to leave?  Well, this selects out people who may not intend to leave but want the freedom to do so if they change their minds or get a good offer.  Perhaps the CAQ would argue that we don't need those people.  Well, if you reduce the pool of applications, you will almost certainly reduce the quality, causing a lowering of standards.  This is problematic because advocates of educational reforms almost always forget a key reality--students learn from each other.  So, if you reduce the size of the pool of applicants, you will probably reduce the quality of the educational experience.  I don't know about you, but I prefer that folks doing the doctoring to be not only really smart but also really well educated.  And the quality of the education depends critically on those who are school with the doctors that stick around.

There are other dynamics as well.  Students may come to McGill intending to leave but then fall in love with Montreal and Quebec and stay.  But you will not get those students if they know ahead of time that they cannot leave.  Further, McGill and similar schools, while public schools, do not just exist to help Quebec.  They produce public goods--a better educated medical community in Quebec AND beyond.  They also may help produce research while they are in Quebec or even after they leave that helps out Quebec.  If Quebec punishes those who try to leave and work in the rest of Canada, perhaps Canada might react by considering whether to fund McGill's medical schools.  Ah, yes, some of the med school funding is federal, not provincial.  Ooops. 

Lastly, McGill should be a point of pride in Quebec despite is Anglophone-ness as it has a reputation around the world as one of the finest schools.  Quebec politicians should keep in mind that when they come up with policies that would diminish McGill, they are also diminishing Quebec in the world.

But, of course, it is far easier for Quebec politicians to come up with coercive policies--to threaten doctors, to restrict choice--than it is to develop policies that require some imagination, some creativity, ways to appeal to aspiring doctors to keep them around so that they can help fix a broken health care system.  So, the CAQ, as the "new" party in town seems a lot like the old ones.  The quick reference to the "Notwithstanding Clause" should set off alarm bells.

Talk about restricting choice--this election gives Quebeckers a lousy set of alternatives.

Ignorance is just bliss--for those who can mock the ignorant.  Given how busy I was yesterday with movers and technicians and such, I did catch the big health care ruling, but I did not really see the stream of tweets about "moving to Canada" until late at night.

I thought it had to be just a joke, right?  [Insert SNL bit: really?  Really?  REALLY?  Really?!] I mean, Canada has public health care that dwarfs what Obama put into motion.  I hesitate to call it a national health care system since it is distributed by province, but it is definitely government-provided.  Indeed, my move will help me test my beliefs on this score--will my family have better access in Ottawa than it did in Montreal?

But while reading these tweets, I realized that the folks who are probably most upset about the ruling are the same folks who would say that they support many of its elements if asked one by one and Obama's name is taken off of it.  The funny thing about these folks saying this (even if only a portion of them are not joking) is that the two countries' health care debates have always obsessed about the other.  In Canada, they tend to accept the flaws in the system since they only compare themselves to the tragedies in the American system--people going bankrupt and losing their house as they pay extraordinary bills.  So, they wait and wait and wait, and, at least in Montreal, sit in hospitals that are beaten to crap.  In the US, people focus on the waiting times in Canada and forget how unequal the American experience is.  In neither country do people think that hard about models outside of North America. 

All I can say is that I am glad that the Canadian media has not caught up to me on this one--I really don't want to be answering questions about whether Americans will genuinely seek to move up here because of this ruling.  They didn't flood north to escape Bush.  If anything, folks might try to move up here because the job market is better.  But that may be temporary as government austerity seems to be contagious.  As the drop in government spending in the US seems to be responsible for a significant hunk of the current employment, it seems to be the case that this is the one thing that Canada (at least Harper) wants to imitate--starving the government.

This post, about how doctors treat their own serious medical challenges, is most instructive.  It makes sense to look at how the experts treat themselves (although considering how political scientists do politics within their departments or within political systems might cause us to think otherwise).

Doctors, at least anecdotally, are not enthusiastic about prolonging their own lives with extensive treatment.  I am not sure how mainstream this guy's views really are; is CPR really that bad?

Still, doctors seem to accept death when the time comes.  I hope I am that brave since I do not believe in an afterlife.  It is all or nothing, but I think prolonging the all is probably worse than the nothing.  I do know that we spend far more money on medical care on the last couple of years rather than we should, that more $$ should go to prevention and early medical intervention.  As long as old people vote more than kids, that probably will not change much.  But, if we educate people better about their choices and ignore the idiots who talk about death panels, we might get less painful processes for some.

The Democrats could have been this clear earlier:


As soon as health care passes, the American people will see immediate benefits. The legislation will:

• Prohibit pre-existing condition exclusions for children in all new plans;
• Spew take: Amazing this didn't happen earlier.  Could have been achieved without this reform but this loophole's existence suggests that might not have been easy.
• Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;
• Spew: Huge.  Previous efforts to address this seem to have failed.
• Prohibit dropping people from coverage when they get sick in all individual plans;
• Spew:  This gets to the heart of the problem with the current system.  This reform by itself is worth all of the trouble.
• Lower seniors prescription drug prices by beginning to close the donut hole;
•  Spew: The prescription drug law of a few years ago remains a disaster.
• Offer tax credits to small businesses to purchase coverage;
• Spew: Sure.  Anything to get more folks covered.
• Eliminate lifetime limits and restrictive annual limits on benefits in all plans;
•  Spew:  This might, just might, mean that sickness does not become bankruptcy.
• Require plans to cover an enrollee's dependent children until age 26;
• Spew: With this job market?
• Require new plans to cover preventive services and immunizations without cost-sharing;
• Spew: About time.  We really need to do more on prevention.  Spending here is very cost-efficient.
• Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions;
•  Spew: Some accountability is way overdue.
• Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs.
• Spew:  Now if they could only apply that to administrative costs in other fields, like academic?

I had breast cancer back in 2000, and I am trying to come up with a way that I can use that experience to shed some light on these new findings. I have never believed that everything happens for a reason. But I do feel very strongly that everything happens so that it can be turned into a column.

Gail Collins has a particularly punchy column today about the mammogram controversy, and she speaks from a direct cancer experience.  Mostly, she is poking at the medical community and at the Republicans.  Always good fun. 

Anyhow, it is a good read as it puts some of the current news in context.

Seems to be a critical tipping point on mammograms lately.   Gladwell has one essay on the difficulties of reading mammograms in his new book of old essays, that reading of them is as much art as science.  Plenty of newspaper articles on the controversy plus one spiffy Slate post that takes the Belichick 4 and 2 decision and turns it into a decision about the probabilities of breast cancer and detection.

How does mammography improve these stats? Researchers generally agree that mammograms save lives, but—this is critical—catching breast cancer early changes the outcome in only 15 percent of cases. So consider the actual numbers: For the average 40-year-old woman, annual mammography for a decade increases one's overall chance of breast cancer survival from roughly 99.7 percent to 99.8 percent. That is, it increases the final batting average by only 0.001. According to the National Cancer Institute, there's also a downside. During this time, half of all screened women will have at least one suspicious mammogram, and one-quarter of them will end up getting a biopsy. Mammograms in women from 40 to 50 years old cause a huge number of false positives, resulting in about 100 biopsies for every life saved. Even more worrisome: It's possible the radiation from those mammograms may end up causing more cancers than they prevent.

The false positives discussed here and in the Gladwell piece seem to be the real key--that mammograms before 50 do a very slight bit of good in detecting some cancer but the false positives may create a great deal of unnecessary havoc.  The Slate piece recommends approaches that focus on a less blunt indicator than age but other risk factors instead.  Would seem to be obvious, but after years of preaching one set of recommendations, it is hard to turn the ship around.