Pete Hoekstra Cannot Keep a Secret

I’ve previously expressed my happiness that my Congressman will not be running for reelection when his current term ends. Pete Hoekstra is in the news once again, this time for revealing secret information on Twitter. Congressional Quarterly reports:

A congressional trip to Iraq this weekend was supposed to be a secret.

But the cat’s out of the bag now, thanks to a member of the House Intelligence Committee who broke an embargo via Twitter.

A delegation led by House Minority Leader John A. Boehner , R-Ohio, arrived in Iraq earlier today, and because of Rep. Peter Hoekstra, R-Mich., the entire world — or at least readers—now know they’re there.

“Just landed in Baghdad,” messaged Hoekstra, a former chairman of the Intelligence panel and now the ranking member, who is routinely entrusted to keep some of the nation’s most closely guarded secrets.

Before the delegation left Washington, they were advised to keep the trip to themselves for security reasons. A few media outlets, including Congressional Quarterly, learned about it, but agreed not to disclose anything until the delegation had left Iraq.

Nobody expected, though, that a lawmaker with such an extensive national security background would be the first to break the silence. And in such a big way.

Not only did Hoekstra reveal the existence of the lawmakers’ trip, but included details about their itinerary in updates posted every few hours on his Twitter page, until he suddenly stopped, for some reason, on Friday morning.

Think Progress points out an op-ed which Hoekstra wrote in The Los Angeles Times in 2006 on the importance of keeping secrets safe.

But every time classified national security information is leaked, our ability to gather information on those who would do us harm is eroded. … I regret that I see little sign of intolerance for unauthorized disclosures of intelligence to the media from some of my Democratic colleagues today. … We are a nation at war. Unauthorized disclosures of classified information only help terrorists and our enemies – and put American lives at risk.

Rather than worrying so much about whether Obama would have a BlackBerry, they should have been keeping an eye on Pete Hoekstra’s Twitter account.

American College of Physicians Backs Health Spending in Stimulus Bill

Bob Doherty at the American College of Physician’s Advocate Blog comments on the Republican attempts to remove health care spending from the stimulus bill:

Let’s think about this. Health care costs are, in the words of the Congressional Budget Office (CBO), the “greatest fiscal challenge” facing the United States.

Spending money on health IT will likely produce jobs in the short-term (someone has to design, sell, install, update, maintain the systems, and provide support to practices on implementation and use). But the benefits of spending money on health IT can’t just be measured by the numbers of jobs produced. Health IT has the potential to lower health care expenses by billions of dollars, reduce medical errors, and improve quality (CBO).

Other programs in the stimulus bill, like funding for comparative effectiveness research and training more primary care physicians, can bring enormous benefit to the economy by creating the infrastructure needed to improve health care outcomes and reduce the costs of care. Yet they are also vulnerable to being struck.

On this issue, the president has it right, and his critics, wrong. In a letter sent this afternoon to all U.S. Senators, ACP urged that programs to fund health IT, comparative effectiveness research, and primary care be kept in the bill.

Today’s question: If you had $800 billion to spend, would you spend it: (1) only on programs that may create jobs in the short-term, but may produce little long-term economic gain for the economy or (2) programs that can create jobs now and help the economy over the longer haul by lowering health care costs?

Conservatives might take a knee-jerk position against spending, but in their attempts at playing politics they are also pushing many constituencies, which in the past might have backed Republicans, towards support for Obama. In the past physician organizations typically sided with Republicans against Democratic measures to bring about expansion of health care coverage. With a growing number of physicians witnessing the increasing problems with our current system, Republicans can no longer count on the support of physicians or physician organizations.

The Potentially Fatal Consequences of Allowing Insurance Companies To Direct Health Care

One danger of health care turning into a political issue is that we are seeing people who have little understanding of health care making recommendations for how medicine should be practiced. Two such examples can be seen from Dave Snow, benefits manager of Medco, and Arnold Kling.

Snow believes that “the time has come for doctors to follow set protocols on how to treat patients, and to be paid based on whether they do it.” 

On the surface, to those who know little about the practice of medicine, this view might make sense. Doctors should definitely base their treatment decisions upon what has been proven scientifically and should consider the treatment protocols of specialty organizations for the treatment of their patients’ problems. What people like Snow fail to understand is that the practice of medicine goes far beyond this.

The Covert Rationing Blog takes this argument to its logical conclusion that there would be no need for primary care doctors if heath care consisted of merely following evidence-based treatment protocols. For those who do have not figured out the problems with this approach from this mockery, others have more explicitly criticized this belief.

Richard Dolinar recently presented a strong argument against over-reliance on treatment protocols imposed by third parties back in December, concluding:

It is absurd to think that a third party, operating at a distance in time and space from the patient being treated, is able to make a better medical decision than the treating physician and therefore should be allowed to preempt the treating physician’s decisions.

Arnold Kling disagreed, arguing without any real basis that  “a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.” The Covert Rationing Blog debunked his views in further detail here.

DB’s Medical Rants provided a quick summary of the problems in allowing  insurance companies or other third parties to dictate medical care as Kling believes is possible:

I see three major flaws in all these arguments. First, these arguments always assume correct diagnoses. Correct diagnosis is a major problem in medicine. Second, these arguments focus on treating a disease, while many patients have multiple diseases. We have no evidence base on the management of multiple diseases. Third, these arguments discount the healing relationship which great physicians provide. Patients respond to reassurance, encouragement and empathy. The physician really can help improve quality of life independent of the specific prescriptions.

The first two points can be seen in a recent experience I had with an insurance companies which thinks it can dictate medical care based upon evidence based medicine alone. I had a patient who had multiple problems, but the most significant were advanced Chronic Obstructive Pulmonary Disease (COPD), with the patient spending a considerable amount of time on a ventilator, and end-stage renal failure. During the course of treatment the patient ocassionally had elevated blood sugars due to the use of high dose steroids which were sometimes used to treat the COPD. He also was had a low blood pressure and therefore had testing for heart disease, with this being trivial compared to his more serious lung and kidney problems.

Somehow Humana picked up on the elevated blood sugar and cardiac tests and this remote third party reviewed his care based upon treatment protocols for diabetes and heart disease. The protocols were perfectly valid when applied to the right patient, but they did not apply at all to this patient. Since Humana believed he had heart disease, they complained that I was not treating him with beta-blockers. Beta-blockers are excellent medications for those with heart disease, but are contra-indicated for those with COPD and could have precipated respiratory failure on those days when he wasn’t already on a ventilator.

Believing the patient had diabetes, Humana also argued that he should have been on ACE inhibitors, basically claiming that all diabetic patients should be on these medications. The vast majority of my diabetic patients are on ACE inhibitors or medications with equivalent benefits, but there is no evidence that they are beneficial for all diabetics (even ignoring the fact that this particular patient did not have diabetes). ACE inhibitors have multiple benefits, including slowing the progression of renal failure. They are indicated when there are very early signs of renal failure, but not when there is zero evidence. While ACE inhibitors are beneficial in those with early renal failure to prevent progression, they can also impair renal function in those who do have renal failure. In the case of this patient the ACE inhibitors likely would have done more harm than good, reducing his already impaired renal function.

Both ACE inhibitors and beta-blockers lower blood pressure, and are commonly used in the treatment of hypertension. However, as this patient’s primary cardiac problem was hypotension, the use of both of these medications could have been catastrophic for the patient.

If the patient really had both diabetes and coronary artery disease then beta-blockers would have been strongly considered. However beta-blockers cannot be used in some diabetic patients as they reduce the symptoms of hypoglycemia, placing some diabetics at risk of having serious hypoglycemic reactions without having advanced warning. The use of beta-blockers in diabetic patients must be decided by a physician who knows the individual patient, not by third parties in some distant place.

Humana thought they were following good medical practices in telling me this patient should be on ACE inhibitors and beta-blockers. Following their advice could have been fatal for the patient. Regardless of what insurance executives like Dave Snow and economists like Arnold Kling believe, treatment decisions must ultimately be made by physicians who have examined the patient and are monitoring the course of treatment.

Ideology and Pragmatism

In 2005 Jonathan Chait wrote at article about ideology versus pragmatism at The New Republic,  comparing left versus right:

We’re accustomed to thinking of liberalism and conservatism as parallel ideologies, with conservatives preferring less government and liberals preferring more. The equivalency breaks down, though, when you consider that liberals never claim that increasing the size of government is an end in itself. Liberals only support larger government if they have some reason to believe that it will lead to material improvement in people’s lives. Conservatives also want material improvement in people’s lives, of course, but proving that their policies can produce such an outcome is a luxury, not a necessity.

The contrast between economic liberalism and economic conservatism, then, ultimately lies not only in different values or preferences but in different epistemologies. Liberalism is a more deeply pragmatic governing philosophy–more open to change, more receptive to empiricism, and ultimately better at producing policies that improve the human condition–than conservatism…

Bush’s administration gives primacy to political advisers over policy wonks in large part because they have no need to debate their ends, only the means of achieving them … The next liberal administration, whenever it happens, will not be nearly so certain. Aside from rolling back conservative excesses, its economic agenda will take its cue from external events, and the decisions it arrives at could, in time, be cast aside through experimentation. Ultimately, those policies, whether they move left or right, will be measured against their effect on people’s lives, not the degree to which they bring the government closer to some long-ago agreed-upon vision. In time, those policies will be altered yet again to suit a changing world. This is known as progress.

Ross Douthat responds by using the massive spending in the stimulus bill as an example of the “next liberal administration” following liberal economic ideology. He concludes:

This is not to say that there aren’t degrees of ideology and degrees of pragmatism, or that some thinkers and some politicians aren’t more empirical than others. And it’s certainly possible to imagine – and hope for, from this administration – a liberalism that’s more pragmatic and evidence-based than was George W. Bush’s conservatism. But the debates that have dominated the first two weeks of the Obama Presidency ought to be an object lesson in why ideological preconceptions always matter, no matter how empirically-minded you aspire to be.

Ross is partially correct, but also makes a mistake in using the response to the current economic crisis to compare the reliance on ideology of the Bush administration to the Democratic stimulus package. Jonathan Chait responds:

Is he saying that Democrats would deem the stimulus a success even if they discover that it fails to stimulate economic growth, merely because it has enlarged the size of government and that is a liberal end in and of itself? Does he further believe that the Obama economic team would have implemented something like a $900 billion stimulus plan even if the economy was humming along rather than facing its worst crisis since the Depression?

Brian Beutlers adds:

Imagine an alternate reality in which the economy is in fine shape and Barack Obama’s just been elected president. Perhaps he’d go hog wild and propose a trillion dollars in unfunded spending just to sneak a bunch of liberal wish list items on to the government debt ledger. But I don’t really think so. And I don’t think Ross does either. Maybe I’m crazy, but I think it’s much more likely that under kinder circumstances Obama would carry forward with the plan he campaigned on–to let the Bush tax cuts expire, tackle the energy, climate and health crises and, maybe, give the middle class a tax cut. That, of course, was before the economy started shedding 600,000 jobs a month, but it made some sense at the time. Just as Jon’s analysis suggested it would.

Now imagine Barack Obama is a Republican. He’s just been elected and the economy is in the toilet. What’s his answer? Tax cuts for the rich! What if the economy’s in decent shape? Tax cuts for the rich! What if we’d just been invaded by China, Canada, and Mexico, and alien space craft were hovering over Manhattan, Los Angeles, and Washington, D.C.? Tax cuts for the rich!

This contrast carries across the board. If burning fossil fuels was harmless, for instance, would Democrats stand behind a politically fraught plan to price carbon just for the fun of it? If the private insurance industry had somehow contained costs and covered 98 percent of the people in the country, would Democrats be demanding major, complicated reforms to the health care system? Obviously not.

As I said, Ross is partially correct, especially in concluding that “ideological preconceptions always matter.” Ideology matters, but liberals realize that facts must be considered when adopting policies while conservatives ignore facts which do not fit into their ideology.

Response to the economic crisis on the part of both the left and right is primarily influenced by ideology. It might be true that large government spending on the infrastructure will create more jobs and strengthen the economy. It is also possible that, as we got into this mess at least partially by overspending and not saving as a society, the best response might actually be decreasing government spending and tax cuts (of course not limited to the rich). There is really no evidence to argue this on pragmatic grounds and I do not believe writers on either the left or right who are convinced that their answer is the right one. We can’t even come to an agreement as to whether the New Deal worked.  Lacking facts it does make sense to consider ideology, as long as one is willing to change the policy if facts prove them wrong.

While Ross is correct in pointing out that ideology affects many decisions, he is incorrect in using this to create an equivalency between the left and right. Obama is responding to a bad situation based upon what his economic advisers, right or wrong, have advised is the best pragmatic course. If he took office during different economic conditions, the influence of his Chicago school economic advisers would likely be more significant and we would probably see more fiscally conservative policies. Obama might be right or wrong, but he is attempting to respond to the economic crisis pragmatically. This is not changed by the fact that many liberals are supporting his policies based upon ideology. Regardless of who is ultimately right, the Republicans are certainly coming out of this looking like they are more interested in playing politics (and are perhaps even crazy as Steve Benen writes).

One major difference between liberals and conservatives is that many (although certainly not all) liberals would abandon the idea of responding to the economic crisis with massive spending if there were to be evidence that this did not work. As Jon wrote in  his 2005 article, “Contemporary economic liberalism is less of an ideology than the absence of one–a rejection both of dogmatic fealty and hostility to the free market.”

Liberals (with some exceptions) generally support the free market and realize that most things are better done by the free market than by government. Liberals, not being blinded by ideology, also realize that there are certain things which the free market does not handle well. Liberals realize that such decisions must be made based upon objective facts, not based upon ideology. Chait used Bill Clinton as an example:

Bill Clinton came to office planning to spur the economy with a Keynesian stimulus, but abandoned those plans after fierce debate among his staff economists. Instead he embraced the novel goal of sparking recovery by slashing the deficit in the hopes that lower interest rates would enable sustainable growth. As that policy seemed to work, moderate liberals continued to embrace the credo of fiscal restraint. But, after the economy slid toward a recession in 2001, liberal economists abandoned short-term restraint in favor of temporary tax cuts to encourage spending.

He also noted how the Republicans have both moved further to the right, and become more ideological, in recent years. He  looked back at Eisenhower, Nixon, and Ford:

Eisenhower used the federal government, rather than states and localities, to build the Federal Highway System, and he made no effort to reduce a top tax rate that stood at an absurdly high 91 percent. Nixon declared, “We are all Keynesians now.” He raised Social Security benefits and proposed an ambitious national health care plan. Conservatives have since renounced Nixon’s economic record, and no wonder. Today it would place him on the left edge of the Democratic Party.

It’s not a coincidence that the two most economically liberal Republican presidents–Nixon and his successor, Gerald Ford–also displayed the most serious interest in empiricism. Both required their assistants to produce detailed “Brandeis briefs” outlining the essential arguments on both sides of any policy debate. Ford invited Milton Friedman and John Kenneth Galbraith into the Oval Office for a free-ranging debate on economic policy.

Since the mid-’70s, the GOP has grown steadily more conservative, and therefore less pragmatic.

Taking advice from both Milton Friedman and John Kenneth Galbraith is essentially what Barack Obama is doing. His economic advisers include both Chicago school economists who have been influenced by Milton Friedman and more liberal economics who would fall closer to Galbraith.

While conservatives might attack it as “flip-flopping,” liberals realize that when the facts show that a policy has not worked, or when conditions change, it is necessary to change the policy. In contrast we have repeatedly seen Republicans stick to the same principles based upon ideology regardless of how much evidence there is that their policies have failed. Conservatives have even build extensive defenses against objective evidence, with the most extreme classifying any information source which does not share their ideology as being liberally biased.

Ideological preconceptions do matter. Often there is more than one pragmatic course of action and basing policies based upon one’s principles may be justified. Other times ideology must be set aside to make the best decision. The difference between liberals and conservatives is that liberals can look beyond their ideological preconceptions and consider the facts to develop pragmatic policies. Conservatives in recent years have demonstrated an inability to do this.

Guide to Progressive News and Politics on the Web

Paul Evans has posted a Guide to Progressive News and Politics on the Web which links to many of the major liberal web sites. Thanks to Paul for looking beyond the big, well known blogs as he also writes:

There are plenty of other unsung blogs out there. Check out Liberal Values, for example; this is a really good blog!