Liberal Values

I’m heading out to the Liberal Values summer office for a long weekend (ie returning to Grand Hotel on Mackinac Island) so posting will probably be lighter. Hopefully the recent problems with moderation picking up far more than it should have been fixed so comments should continue to provide weekend entertainment. As long as the WiFi is working ok I should be posting intermittently.

I can’t resist a note on the June traffic numbers. Last year there was a huge increase in traffice as the primary campaign heated up. This calmed down by May when it appeared that Obama was going to win (plus blog  traffic always tends to decrease as the weather gets warmer). Traffic picked up again September through January for the general election campaign and inauguration. (Interest at the end of football season in posts with pictures of girls rumored to be dating Tim Tebow also picked up traffic.) While down from the election, traffic began to pick up again later in the spring. June turned out to be the fourth heaviest month ever (and wasn’t very far behind November 2008). June traffice was also up 35% from last year.

One of the problems with the Republican effort to distort health care reform is that they don’t have a Ronald Reagan to deliver the misinformation. While still untrue, the conservative claims about Medicare sounded more convincing coming from Ronald Reagan than current claims from Rush Limbaugh and Sean Hannity. There are many similarities between Ronald Reagan’s scare tactics about Medicare and the scare tactics being used today about health care reform. (Hat tip to Digby).

My name is Ronald Reagan. I have been asked to talk on the several subjects that have to do with the problems of the day. . . .

Now back in 1927 an American socialist, Norman Thomas, six times candidate for president on the Socialist Party ticket, said the American people would never vote for socialism. But he said under the name of liberalism the American people would adopt every fragment of the socialist program. . . .

But at the moment I’d like to talk about another way because this threat is with us and at the moment is more imminent. One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project. . . . Now, the American people, if you put it to them about socialized medicine and gave them a chance to choose, would unhesitatingly vote against it. We have an example of this.

While some on the far right still claim that Medicare is leading us down the path to socialism, if put to a vote there is no doubt that an overwhelming majority would vote to keep the program. Among the scare stories told:

The doctor begins to lose freedom. . . . First you decide that the doctor can have so many patients. They are equally divided among the various doctors by the government. But then doctors aren’t equally di­vided geographically. So a doctor decides he wants to practice in one town and the government has to say to him, you can’t live in that town. They already have enough doctors. You have to go someplace else. And from here it’s only a short step to dictating where he will go. . . . All of us can see what happens once you establish the precedent that the government can determine a man’s working place and his working methods, determine his employment. From here it’s a short step to all the rest of socialism, to determining his pay. And pretty soon your son won’t decide, when he’s in school, where he will go or what he will do for a living. He will wait for the government to tell him where he will go to work and what he will do.

This prediction didn’t come true, just like the predictions from those proclaiming health care reform must inevitably lead to doom are unlikely to come true.  Of course the details are important. We can have bad outcomes if the health care reform is done the wrong way, but the opponents on the right are opposing any efforts at meaningful health care reform.

Reagan completed his attack on Medicare by concluding:

And if you don’t do this and if I don’t do it, one of these days you and I are going to spend our sunset years telling our children, and our children’s children, what it once was like in America when men were free.

Another prediction which has not come true. Other than a handful of people on the extreme right, few would claim that formation of Medicare marks the end of freedom in America. Some conservatives would make the same claims about health care reform now, but the lies sound even less convincing when coming from someone without the skill of Ronald Reagan.

Despite the claims from the right, Medicare provides health care coverage more economically than private plans. Despite all the scare stories of government taking control of health care, Medicare also tends to intervene in medical decisions far less than many private plans. The scare stories about “socialized medicine” were greatly exaggerated while nobody predicted all the problems under corporate-controlled medicine.

While it seems like the Democrats have won pretty much everywhere, The New York Times describes how the Supreme Court is tipping more to the right:

Chief Justice John G. Roberts Jr. emerged as a canny strategist at the Supreme Court this term, laying the groundwork for bold changes that could take the court to the right even as the recent elections moved the nation to the left.

The court took mainly incremental steps in major cases concerning voting rights, employment discrimination, criminal procedure and campaign finance. But the chief justice’s fingerprints were on all of them, and he left clues that the court is only one decision away from fundamental change in many areas of the law.

Whether he will succeed depends on Justice Anthony M. Kennedy, the court’s swing vote. And there is reason to think that the chief justice has found a reliable ally when it counts.

“In the important cases, Kennedy ends up on the right,” said Thomas C. Goldstein, a student of the court and the founder of Scotusblog, which has compiled comprehensive statistics on the current term. The two justices agreed 86 percent of the time.

If Judge Sonia Sotomayor is confirmed by the Senate, she will succeed Justice David H. Souter, a liberal who spent almost two decades on the court. Her record on the federal appeals court in New York suggests that her views are largely in sync with those of Justice Souter, though there is some evidence that she will turn out to be more conservative in criminal cases.

SCOTUS Blog believes that it won’t be until after the 2016 elections that the court can change direction:

Later in his term, President Obama will likely replace Justice Stevens with someone else on the left. If he is reelected in 2012, he will replace Justice Ginsburg with someone on the left. Nothing changes.

It isn’t until the election of 2016 at the earliest that there is a real prospect for a significant shift to the left in the Court’s ideology. Actuarially, that election is likely to decide which President appoints the successors to Justices Scalia and Kennedy (both on the right, and both 73 now) and Justice Breyer (on the left, and 70 now). Absent an unfortunate turn of health, between now and the summer of 2017 there is no realistic prospect that the Court will turn back to the left.

A Quinnipiac poll continues to show considerable public support for a public option to attempt to keep the insurance companies honest:

Sixty-nine percent of Americans support creation of a government-run health plan to compete with private insurance companies, a new poll found. In addition, 52 percent of those surveyed by Hamden, Connecticut-based Quinnipiac University said such a plan would keep the private insurance companies honest. Thirty-two percent disagreed. Twenty-six percent said they opposed a government-run insurance program.

A CNN/Opinion Research Corporation survey shows that there is room for Republicans to increase opposition by using fears of increased costs:

Fifty-one percent of people questioned in the poll say they favor the president’s health care plan, with 45 percent opposed. Obama aims to bring down health care costs and provide medical insurance to many of the more than 45 million Americans currently without coverage. His proposals, which are making their way through five different congressional committees in the Senate and the House, also call for a government-run health insurance program to compete with private insurers.

“Women and younger Americans are slightly more likely to support Obama’s approach to health care,” says CNN Polling Director Keating Holland. “Those are usually the groups that are more concerned about health care and health insurance.”

The poll suggests that 55 percent think the U.S. health care system is in need of a great deal of reform, with four in ten saying only some reform is needed. Nearly half of those questioned have more trust in the President rather than Republicans in Congress to handle health care form, with 38 percent backing the congressional Republicans over Obama.

A government run health insurance program is one of the most controversial parts of the Obama health reform proposals, with Republicans suggesting that such a plan could force current health care providers out of business, forcing Americans to switch doctors. The poll indicates such arguments may not be working.

“Two-thirds believe that the president’s plan would allow them to see the same doctors they currently receive care from, and most say that their health insurance provider would not go out of business if Obama’s plan is passed,” says Holland.

But the poll does provide some ammunition for Republicans opposed to the president’s proposals. Fifty-four percent say their medical insurance costs will increase if the Obama plan becomes law, with 17 percent feeling their costs will decrease. Around one in four say their costs will remain the same. And only one in five say their family will be better off if the president’s plan becomes law, with 35 percent feeling they would be worse off, and 44 percent saying they would be about the same.

There is a considerable amount of misunderstanding about what is being proposed (with this largely being caused by a considerable amount of misinformation being spread by the right wing noise machine). It looks like this is having some effect with many believing insurance reform will increase insurance costs while less are buying the argument that they will be forced to change doctors. Providing more options will greatly decrease the current problem of people being forced to change doctors due to employers changing plans which the employees must join.

“Conceptually, insurance means normal people should not go bankrupt from serious medical conditions.”–Len Nichols, a health economist for the New America Foundation

Unfortunately the reality is that insurance does not work that way, as is discussed in this article in The New York Times.

Al Franken, who can finally take the Senate seat he narrowly won, began in politics by writing the book, Rush Limbaugh Is A Big Fat Idiot. This seems like a good time to provide today’s example (via Mark Halperin) which shows how big an idiot Limbaugh is:

You have to wonder if Obama is just trying to lay a foundation for not being a hypocrite when he tries to serve beyond 2016. I wouldn’t be at all surprised if in the next number of years there is a move on the 22nd Amendment, which term limits the President of the United States. He may not do it that way, he may not openly try to change the Constitution. But there might be this movement in the country from his cult-like followers to support the notion that a democratically-elected leader who is loved and adored has carte blanc once elected. Just serve as long as he wants because the people demand it, because the people want it, because the people love it.

And I wouldn’t put it past Obama to be plotting right now how to serve beyond 2016 and I think the way he’s reacting to what’s happening in Honduras – Look, they’ve got a constitution, they’re a democratically-elected set of officials down there and you had a guy running the country, Mel Zelaya, who was just going to basically rip that country’s democracy to shreds and the country moved in to stop in him from doing it and Obama sides with the guy who wanted to rip up the constitution. He sides with other dictators in the region. Regardless, I mean, one thing is clear here: Obama is nothing if not a hardcore liberal. Always, always more sympathetic, appearing to side with the bad guys on the world stage.

And I’ll tell you folks, this business about running beyond 2016, you know, the thing that when you look at Obama’s followers – and we’ve discussed it here – they are a cult-like bunch and their attachment to him is not political, it’s not ideological, it is not issue-wise, it is cultish. It includes a wide percentage of minorities, by the way, who for different reasons, who will come to think that he simply cannot be replaced. Let him succeed with amnesty, for example, and all the illegal aliens who are instantly made citizens. He’ll be too important. Just like right now he’s too big to fail as far as the drive-bys are concerned, he’s too important to be replaced. No one else can lead the nation,  they will say. And they won’t care a whit about the legalities that might be trampled. Half of the legalities if they don’t even know about them because they haven’t been properly educated. I think this situation in Honduras is very instructive. Anybody who thinks that he intends to just constitutionally go away in 2016 is nuts … These are people who seek power for reasons other than to serve. They seek to rule.

While his ideas for beyond 2016 are absurd, it is interesting that Limbaugh assumes that Obama will be reelected in 2012.  Robert Gibbs did respond to a question with regards to repealing the 22nd amendment:

I think the President is firmly in support of an amendment that would limit his time in the presidency to eight years if he’s given that awesome responsibility by the American people.

The 2000 presidential election seemed to go on forever, but it was a short affair compared to the Minnesota Senate race this year. Like in 2000, the end came with a court decision–except this time the state’s Supreme Court’s decision prevailed, and the result was much fairer. Eight months after the election, the Minnesota Supreme Court ruled in Franken’s favor and declared he was entitled to an election certificate. While some Republicans wanted him to fight on, Norm Coleman conceded.

Todd Purdhum has an article in Vanity Fair which summarizes all that went wrong with the McCain campaign after he made the mistake of choosing Sarah Palin to be his running mate. He raises the question of how such a huge mistake could have been made and how someone like Palin could have even been considered for the position:

What does it say about the nature of modern American politics that a public official who often seems proud of what she does not know is not only accepted but applauded? What does her prominence say about the importance of having (or lacking) a record of achievement in public life? Why did so many skilled veterans of the Republican Party—long regarded as the more adroit team in presidential politics—keep loyally working for her election even after they privately realized she was casual about the truth and totally unfit for the vice-presidency? Perhaps most painful, how could John McCain, one of the cagiest survivors in contemporary politics—with a fine appreciation of life’s injustices and absurdities, a love for the sweep of history, and an overdeveloped sense of his own integrity and honor—ever have picked a person whose utter shortage of qualification for her proposed job all but disqualified him for his?

McCain picked Palin as a gamble without knowing much about her. Among her problems, Sarah Palin plays loosely with the truth, and didn’t even bother to study the actual facts that mattered outside of Alaska:

…no serious vetting had been done before the selection (by either the McCain or the Obama team), and there was trouble in nailing down basic facts about Palin’s life. After she was picked, the campaign belatedly sent a dozen lawyers and researchers, led by a veteran Bush aide, Taylor Griffin, to Alaska, in a desperate race against the national reporters descending on the state. At one point, trying out a debating point that she believed showed she could empathize with uninsured Americans, Palin told McCain aides that she and Todd in the early years of their marriage had been unable to afford health insurance of any kind, and had gone without it until he got his union card and went to work for British Petroleum on the North Slope of Alaska. Checking with Todd Palin himself revealed that, no, they had had catastrophic coverage all along. She insisted that catastrophic insurance didn’t really count and need not be revealed. This sort of slipperiness—about both what the truth was and whether the truth even mattered—persisted on questions great and small. By late September, when the time came to coach Palin for her second major interview, this time with Katie Couric, there were severe tensions between Palin and the campaign.

By all accounts, Palin was either unwilling, or simply unable, to prepare. In the run-up to the Couric interview, Palin had become preoccupied with a far more parochial concern: answering a humdrum written questionnaire from her hometown newspaper, the Frontiersman. McCain aides saw it as easy stuff, the usual boilerplate, the work of 20 minutes or so, but Palin worried intently.

As time went on, members of McCain’s campaign realized they made a huge mistake:

As Palin has piled misstep on top of misstep, the senior members of McCain’s campaign team have undergone a painful odyssey of their own. In recent rounds of long conversations, most made it clear that they suffer a kind of survivor’s guilt: they can’t quite believe that for two frantic months last fall, caught in a Bermuda Triangle of a campaign, they worked their tails off to try to elect as vice president of the United States someone who, by mid-October, they believed for certain was nowhere near ready for the job, and might never be. They quietly ponder the nightmare they lived through. Do they ever ask, What were we thinking? “Oh, yeah, oh, yeah,” one longtime McCain friend told me with a rueful chuckle. “You nailed it.” Another key McCain aide summed up his attitude this way: “I guess it’s sort of shifted,” he said. “I always wanted to tell myself the best-case story about her.” Even now, he said, “I don’t want to get too negative.” Then he added, “I think, as I’ve evaluated it, I think some of my worst fears … the after-election events have confirmed that her more negative aspects may have been there … ” His voice trailed off. “I saw her as a raw talent. Raw, but a talent. I hoped she could become better.”

They had hopes but also understood the ramifications of this mistake:

They all know that if their candidate—a 72-year-old cancer survivor—had won the presidency, the vice-presidency would be in the hands of a woman who lacked the knowledge, the preparation, the aptitude, and the temperament for the job.

Sometimes I tell my daughter about the olden days when computers filled an entire room and we had no method of recording any of the four television channels we received. Then there’s the difference in portable music. Years before the iPod, the Walkman seemed like a tremendous technological advance. We could carry around music by listening to cassettes through a box which is many times the size of even the largest mp3 player. The BBC tried giving a Walkman to a 13-year-old. Besides being laughed at on the school bus, he had some difficulty understanding such old technology:

It took me three days to figure out that there was another side to the tape. That was not the only naive mistake that I made; I mistook the metal/normal switch on the Walkman for a genre-specific equaliser, but later I discovered that it was in fact used to switch between two different types of cassette.

Another notable feature that the iPod has and the Walkman doesn’t is “shuffle”, where the player selects random tracks to play. Its a function that, on the face of it, the Walkman lacks. But I managed to create an impromptu shuffle feature simply by holding down “rewind” and releasing it randomly – effective, if a little laboured.

I told my dad about my clever idea. His words of warning brought home the difference between the portable music players of today, which don’t have moving parts, and the mechanical playback of old. In his words, “Walkmans eat tapes”. So my clumsy clicking could have ended up ruining my favourite tape, leaving me music-less for the rest of the day.

His misunderstanding of the tapes reminds me of the scene in Star Trek IV: The Voyage Home where Scotty tried to use a 20th century computer. Seeing the mouse he figured out that it is an input device–and tried speaking into it. With everyone now getting DVR’s it won’t be long until few can figure out how to program an old fashioned VCR (which, come to think of it, might not be all that different from how things used to be).

Thomas Sowell provides this nonsensical warning:

Perhaps people who are busy gushing over the Obama cult today might do well to stop and think about what it would mean for their granddaughters to live under sharia law.

Don’t conservatives realize that such statements might fire up the base, but make virtually everyone else question both their fitness to govern and their sanity?

Consider how many people are calling themselves libertarians while supporting the Iraq war, the Patriot Act, and often the full agenda of the GOP, it is good to see some  “crazy libertarian talk” such as this. Jason Kuznicki attacks traffic lights.

Actually this isn’t all that crazy, and not necessarily even a libertarian argument as opposed to a question of the best way for the government to handle traffic. He points to this article from 2006 showing that roundabouts are safer and handle traffic better than traffic lights. This is not the only source arguing this, and many cities are turning more to roundabouts. I’ve personally noted them from coast to coast (in Michigan that is, from suburban Detroit to Muskegon on the coast of Lake Michigan). He also notes some government action regarding traffic which is counterproductive.

We knew that  John Edwards brought Rielle Hunter into his campaign as a film maker but it turns out that she made a a film that was previously kept secret. An upcoming book  by Andrew Young, an aide to John Edwards, includes information on a sex tape made by Edwards and Rielle Hunter:

Former Edwards aide Andrew Young says the ex-senator and his former mistress, Rielle Hunter, once made a sex tape, according to someone who has seen Young’s book proposal.

St. Martin’s Press just inked a deal with Young, who also says in his proposal that, contrary to his public statement last year, he is not the father of Hunter’s infant daughter — Edwards is. Edwards has denied that.

Young says that his belief in Edwards ran so deep that he agreed to take the fall for the candidate, inviting the pregnant Hunter to live with him, his wife, Cheri, and their three children. Later, after Hunter delivered the baby, Young and his family moved to a different home in California.

While he was unpacking, Young discovered a videocassette, according to the book pitch. Hunter had been hired by the Edwards campaign to videotape the candidate’s movements, but this one is said to have shown him taking positions that weren’t on his official platform.

The purported sex tape confirmed to Hunter that Edwards was even more reckless than he thought.

According to our source, Hunter confided to Young that she and Edwards talked about getting married should the candidate’s cancer-stricken wife, Elizabeth, pass away, even discussing what music they’d play at their wedding.

Ron Moore’s Virtuality was shown on Friday night and, after viewing, I can see why Fox left it to die by airing it on a Friday night in June. Moore just tries to throw too much into this, which perhaps would have left him with many avenues for future television series but it leaves the pilot looking like a mess.

The premise is that a ship is on a ten year mission to another solar system and, to keep the crew from going nuts or killing each other, virtual reality is used. This is to keep the crew from feeling claustrophobic and to allow them to interact with other people, even if only computer generated. The claim is that this is not a series of holodeck stories because each crew member uses their own goggles (like the virtual reality in Caprica) as opposed to being in a specific room as in Star Trek. That hardly matters.

Of course something goes wrong  in the simulations (as in Life on Mars). As this was intended to be a pilot we have a lot of mysteries and no answers. We don’t know if it is a computer glitch, a crew member messing with the programs, or perhaps Cylons influencing the ship. Crew members are attacked in their simulations, and one is even raped.  One good aspect of the show was to treat the virtual rape as meaningful to the woman involved as it had the same psychological impact as if real.

The virtual reality simulations aren’t the only place where something goes wrong. Perhaps 2001: A Space Odyssey’s HAL is involved as there is even a murder involving the air lock.

If this already seems to be throwing ideas from many sources together, it gets worse. The crew is also being filmed as the cast of a reality television series. It was amusing when Doctor Who used reality series for one episode (Bad Wolf), but this was too much for a pilot. The idea is that the company running the mission might also be playing mind games with the crew to affect their behavior and improve ratings.

If they haven’t already thrown in enough, there is yet another crisis. After they left it was suddenly found that global warming is real and life on earth is doomed (especially if you live around London or Florida).

With all this, the show still managed to deal briefly with events of the space mission. A lot of time was spent creating false drama as to whether the mission would go on or return to earth as they approached their last moment  to decide this. Of course viewers realized they would go on. Even when the captain announced this to the crew there was still false drama when they complained that the captain made the decision to go without consulting the crew. There was more time wasted as everyone got a chance to vote, and all voted to go.

This was intended to be largely a show about people in space but with twelve crew members it was difficult to really get interested in any of them. Perhaps if the show made it as a series this would have provided for more potential stories.

BBC America aired the first of this year’s Doctor Who specials. I previously reviewed The Next Doctor here when it originally aired on the BBC.

It is far from certain at this point whether health care reform will succeed. Most insiders believe that Congress will enact some form of comprehensive health care reform but it is easy to envision scenarios where they are not successful. The opposition comes mainly from the right, but there is also the view (perhaps as this is more of a man bites dog storyline) that it is the left which will cause health care reform to fail. Cici Connolly of The Washington Post examines how some activists are targeting Democrats:

In recent days — and during this week’s congressional recess — left-leaning bloggers and grass-roots organizations such as MoveOn.org, Health Care for America Now and the Service Employees International Union have singled out Democratic Sens. Ben Nelson (Neb.), Mary Landrieu (La.), Ron Wyden (Ore.), Arlen Specter (Pa.) and Dianne Feinstein (Calif.) for the criticism more often reserved for opposition party members…

Much of the sparring centers around whether to create a government-managed health insurance program that would compete with private insurers. Obama supports the concept, dubbed the “public option,” but he has been vague on details. Left-of-center activists want a powerful entity with the ability to set prices for doctors and hospitals.

But in the Senate, where the Democrats do not have the 60 votes needed to stop a filibuster, members are weighing alternatives such as a nonprofit cooperative or a “fallback” provision that would kick in only if market reforms fail.

Pushing for the public plan does have popular support but Connolly notes that this does not mean that a majority supports the entire agenda of those on the left who see a public plan as a means of transitioning to a single payer plan. She notes that, “While recent polls show high initial support for a government option, the number declines if told the insurance industry could fold as a result.” Many who support providing the option of a public plan also desire to continue with their current insurance.

There are signs that this pressure is influencing some Democrats but others fear this is counterproductive:

One Democratic strategist who is working full-time on health reform was apoplectic over what he called wasted time, energy and resources by the organizations.

The strategist, who asked for anonymity because he was criticizing colleagues, said: “These are friends of ours. I would much rather see a quiet call placed by [Obama chief of staff] Rahm Emanuel saying this isn’t helpful. Instead, we try to decimate them?”

If this effort is based upon pushing Democrats to support the public plan there should not necessarily be adverse consequences on the success of health care reform. Of greater concern is talk among some progressives of voting against a health care reform bill which does not contain a public plan. I can envision scenarios where Republicans have enough votes to filibuster a bill which contains a public plan, but a bill without a public plan could also fail if both Republicans and some progressives vote against it.

The goals should be to reduce the number of people who lack insurance and to reduce insurance problems such as people being cut off when they develop a serious illness. These are serious problems which need to be addressed and there are multiple possible solutions. Ideological battles such as over whether to have a single payer plan should not be used to prevent meaningful reform, even if the reform will inevitably fall short of what some desire.

Last year the talk was whether Hillary Clinton could manage to win the Democratic nomination due to having a greater number of superdelegates. That turned out not to be a factor as superdelegates shifted towards Obama along with the primary and caucus voters, and now its Obama’s party. The Democratic National Committee is looking at how to change the process and one idea is to reduce the number or outright eliminate the superdelegates.

Touching on what may prove to be one of the more contentious issues considered by the DNC, one presenter, Democratic Party activist and Harvard University lecturer and former superdelegate Elaine Kamarck, suggested that it may be time to completely eliminate superdelegates since most of those party leaders clearly determined their role in 2008 to be one of ratifying the decision made by voters in primaries and caucuses.

“We can probably let go of the superdelegates,” said Kamarck.

“Their deliberative role,” she added, “has in fact been supplanted by a very very public process.”

Other matters under discussion include starting the process later in the winter and the always controversial question of who gets to go first.

There’s been a lot of talk lately about changing how physicians are paid as a part of health care reform. Many have recommended that pay for primary care physicians be increased, arguing that this will increase the number of doctors practicing primary care, leading to higher quality care along with lower costs. As a primary care physician I totally agree with this. There have also been bad ideas raised, such as returning to capitation despite how badly this idea has failed in the past. Today The New York Times has a round table on physician reimbursement.

Elliott S. Fisher, a professor of medicine and director of the Center for Health Policy Research at Dartmouth Medical School, recommends:

One approach that has shown some early promise is to combine the fee-for-service with “quality bonuses” and “shared savings” payments when they reduce spending growth for all of their patients. Doctors, hospitals and society should realize that slowing spending growth would not require dramatic cuts in income under a system where providers would be rewarded for better care, not just more care.

In general that is what some are now trying, but so far such ideas have been poorly implemented. One major problem is that it is hard to measure quality and tell what is really going on in all the offices around the country. At present incentive payments are so low that it often isn’t worth the administrative expenses to submit the data to qualify. General measures of quality often do not apply in specific cases. While practice guidelines are often written for a specific disease, in the real world patients have multiple problems and sometimes the recommended care for any specific condition is not the appropriate care for the individual patient.

Sometimes insurance companies will try to analyze whether a patient is receiving all the appropriate medications based upon diagnoses submitted. The entire concept is flawed as often diagnosis codes are used for suspected ailments to justify testing, and sometimes one person seeing a patient enters a diagnosis into the system which is simply incorrect. Even if they have the correct diagnosis, particular medications might be not be tolerated by certain patients, or a patient might simply refuse to take them. Sometimes the actions of doctors to help patients turns out to be counterproductive with regards to quality measurements. We might give a patient samples, or switch the patient to a generic medication they can receive for less than their insurance co-pay at certain pharmacies. To the insurance company it appears that the patient is not receiving a needed medication.

Steffie Woolhandler and David Himmelstein, associate professors of medicine at Harvard Medical, note that every system has its flaws:

There are a variety of bad ways of paying doctors, but no particularly good ones. Fee-for-service health care rewards the overprovision of care; capitation (a set monthly fee per patient) rewards underprovision; and salaries reward just showing up. The minority of physicians (and hospital administrators) who are motivated mostly by money will find a way to game an incentive system rather than do the hard work of providing excellent care.

Even paying doctors based on quality measures (using data from medical records that the doctors themselves create) can be fudged.

They support a single payer system, noting the tremendous cost savings on administrative expenses, but that still leaves the question of how to pay doctors unanswered.

Liam Yore, an emergency room physician, points out a serious problem with the current system:

The underlying cause, however, is a bias within the physician compensation system that extravagantly rewards surgical procedures performed compared to “cognitive” services like diagnosis and medical management. In the E.R., for example, sewing a facial laceration pays far better than accurately diagnosing a heart attack. The same principle applies to any procedure — from angiograms to colonoscopies.

The predictable consequence is that physicians gravitate toward lucrative procedural specialties. They perform more and more procedures, using expensive new technologies, driving costs ever higher.

Meanwhile, office-based primary care doctors struggle. The compensation for an office visit is a tiny fraction of that for the simplest procedures. The family physician must rush from patient to patient just to keep pace with static or diminishing reimbursement. Fewer and fewer medical students are going into primary care.

What we need to do is rebalance physician compensation away from procedures and toward primary care. Surgeons can easily earn three to five times the average salary of a family doctor. The compensation for surgical procedures should be reduced, and the savings realized should be applied toward increasing pay for primary care physicians.

Better-compensated primary care specialties would attract more doctors who would be able to spend more time with their patients. They would require fewer expensive diagnostic tests like M.R.I.’s and rely less on specialists. Accordingly, the use of expensive and invasive procedures would decline. Prevention, wellness and chronic disease management would be encouraged: enhancing quality and patient satisfaction, but at a far lower cost.

Primary care is the linchpin to successful health care reform. Ignore it, and reform will fail. Make it an appealing career choice, and the odds of success increase greatly.

We often see cases of poorly handled damage control which makes the situation worse. Mark Sanford provides just the latest example. On the other hand, his wife Jenny Sanford is doing an excellent job of enhancing her own reputation despite all the publicity. Perhaps that’s why some say she was “the real brains behind the operation.”

Whenever I’ve seen a television news report on her she has been quoted talking about caring for her children. Presumably this is sincere, but regardless it is the perfect answer under the circumstances. Otherwise she avoids getting into the dirt. She did manage to get out one piece of information which protects her from any potential criticism that she should be standing behind her man:

Through a spokeswoman, Mrs. Sanford declined requests to be interviewed for this article, but told The Associated Press she learned of her husband’s affair early this year when she found a letter he had written. She told him to end the relationship, but he repeatedly asked permission to visit the woman in Argentina in the months that followed.

“I said absolutely not,” Mrs. Sanford told The A.P. “It’s one thing to forgive adultery. It’s another to condone it.”

Then, last week, when the governor told her he needed time alone to write, she had specifically warned him not to see his mistress. She said she was devastated when he went to meet her in Argentina.

It might just be a trial balloon, or perhaps unsubstantiated rumor, but Obama needs to reconsider the idea of issuing an executive order regarding preventive detention.

I realize that he was left a mess by Bush. Now that the people have been held without due process it is hard to try them at this point and there are some who should not be released. Still we cannot risk setting a precedent which seems to legitimize the actions of George Bush.

I really like John Kerry and think he would have made an excellent president, but he really needs to stop trying to tell jokes.

Lawrence Krauss has an op-ed in The Wall Street Journal explaining why God and Science Don’t Mix. The article came from his participation in a panel discussion at the World Science Festival in New York City on Science, Faith and Religion. Krauss argues that “A scientist can be a believer. But professionally, at least, he can’t act like one.”

There are difficulties  in questioning whether science and religion are compatible. There are many scientists who are also religious, while there are also many religious conservatives who see science as a threat. Krauss wrote:

These scientists have been castigated by believers for claiming that science is incompatible with a belief in God. On the one hand, this is a claim that appears manifestly false — witness the two Catholic scientists on my panel. And on the other hand, the argument that science suggests God is a delusion only bolsters the view of the of the fundamentalist religious right that science is an atheist enemy that must either be vanquished or assimilated into religion.

Coincidentally, I have appeared numerous times alongside Ken Miller to defend evolutionary biology from the efforts of those on various state school boards who view evolution as the poster child for “science as the enemy.” These fundamentalists are unwilling to risk the possibility that science might undermine their faith, and so they work to shield children from this knowledge at all costs. To these audiences I have argued that one does not have to be an atheist to accept evolutionary biology as a reality. And I have pointed to my friend Ken as an example.

The views of fundamentalists are inconsistent with science and what we know of the real world as they reject scientific findings which conflict with religious teachings.  Religious fundamentalists develop a wide variety of arguments to contradict scientific findings where science conflicts with their views on subjects such as evolution and the age of the earth. Some will argue that any evidence that the earth is older than 6000 years was planted by God to test our faith. The Discovery Institute has published numerous claims to oppose evolution which fail to hold up to scrutiny.

Science, in contrast, is constantly tested and theories must be abandoned if they are found to be inconsistent with the evidence. P.Z. Myers describes the difference between obtaining knowledge of the universe with the scientific method versus explaining the universe based upon religious dogma:

We have to look at what they do to see why. In order to probe the nature of the universe around us, science is a process, a body of tools, that has a long history of success in giving us robust, consistent answers. We use observation, experiment, critical analysis, and repeated reevaluation and confirmation of events in the natural world. It works. We use frequent internal cross-checking of results to get an answer, and we never entirely trust our answers, so we keep pushing harder at them. We also evaluate our success by whether the end results work: it’s how we end up with lasers and microwave ovens, and antibiotics and cancer therapies.

Religion, on the other hand, uses a different body of techniques to explain the nature of the universe. It uses tradition and dogma and authority and revelation, and a detailed legalistic analysis of source texts, to dictate what the nature of reality should be. It’s always wrong, from an empirical perspective, although I do have to credit theologians with some of the most amazingly intricate logical exercises as they try to justify their conclusions. The end result of all of this kind of clever wankery, though, is that some people say the world is 6000 years old, that it was inundated with a global flood 4000 years ago, and other people say something completely different, and there is no way within the body of theology to resolve which answers are right. They have to step outside their narrow domain to get an independent confirmation — that is, they rely on science to give them the answers to the Big Questions in which they purport to have expertise.

Krauss quotes J.B.S. Haldane, an evolutionary biologist and a founder of population genetics, on the those who “extrapolate the atheism of science to a more general atheism.”

My practice as a scientist is atheistic. That is to say, when I set up an experiment I assume that no god, angel or devil is going to interfere with its course; and this assumption has been justified by such success as I have achieved in my professional career. I should therefore be intellectually dishonest if I were not also atheistic in the affairs of the world.

It is not necessary for scientists to totally reject religion but scientists must be willing to abandon religious dogma when it conflicts with information established with the scientific method.  Krauss  found that, at least among those in this panel discussion, religious scientists were certainly not fundamentalists and were willing to accept views on religion which do not take religious teachings literally:

When I confronted my two Catholic colleagues on the panel with the apparent miracle of the virgin birth and asked how they could reconcile this with basic biology, I was ultimately told that perhaps this biblical claim merely meant to emphasize what an important event the birth was. Neither came to the explicit defense of what is undeniably one of the central tenets of Catholic theology.

Krauss concludes with noting that this conflict between science and religion is relevant to real world issues:

Finally, it is worth pointing out that these issues are not purely academic. The current crisis in Iran has laid bare the striking inconsistency between a world built on reason and a world built on religious dogma.

These issues can also be seen far closer to home than in Iran. The differences between the modern conservative movement and liberals, moderates, and the few remaining rational conservatives also come down to whether one has a view of the universe based upon religious dogma or based upon science and reason. Fortunately, while countries such as Iran are dominated by religious fundamentalists, since the Republican Party became dominated by fundamentalists it is quickly turning into a minor regional party of the deep south and Mormon belt of the west. As the Founding Fathers realized when they established a secular government with separation of church and state, religion and politics do not mix any better than religion and science.