The Hail Mary

by Dave Schuler on October 20, 2014

When I was an undergraduate my alma mater’s football team’s biggest yard-gaining play was the quick kick. You read that right. It’s a play of desperation, one that’s rarely seen in modern football. Another play of desperation is the “Hail Mary pass”, a long forward pass with little likelihood of successful execution.

That’s pretty much analogous to what Scott Gottlieb and Tevi Troy propose as our response to the Ebola epidemic in West Africa:

Mr. Obama has stated repeatedly that the U.S. has helped to snuff out every other outbreak of Ebola and that the country will do the same with this one. However, past outbreaks occurred almost exclusively in remote villages, and entire locales would be cordoned off while the virus burned itself out. Liberia, a country of 4.4 million people, can’t be encircled. Nor can Dallas be quarantined.

Instead, medical countermeasures are critical. Despite early swagger by public-health officials at the National Institutes of Health and CDC that this crisis will be solved with public-health tools alone, and that a vaccine or treatment won’t be available in time, smart medical experts are recognizing the need for a therapeutic drug or vaccine.

One leading plan is for a 30,000-person clinical trial to begin as early as December with two experimental vaccines. Two groups of 10,000 West Africans will each receive one of the two novel vaccines. A third group of 10,000 West Africans will serve as a control group and receive a hepatitis B vaccine. The plan is dependent on completing early-stage trials under way now and having vaccine supply on schedule.

While a vaccine is needed to help stop the epidemic in West Africa, it is equally important to develop a drug to treat the disease in those who have been infected. This is especially so for the U.S., where a drug or drugs can combat containable outbreaks.

The problem with this strategy is that it ignores downside risk. It could take two years or twenty years to develop an effective vaccine. Or it may prove impossible to develop one. We just don’t know. Meanwhile, the number of cases in West Africa will continue to grow, people will continue to die, and, in all likelihood, the probability that Ebola will become endemic in West Africa or even in sub-Saharan Africa more generally will grow.

The only way we can avoid the worst case scenarios of the Ebola epidemic is by serious attention now, not merely from the United States but from the entire developed world. There’s a lot riding on it.


Premature Burial

by Dave Schuler on October 20, 2014

The editors of the Chicago Tribune pronounce cost control under the PPACA dead:

In year one, spending increased at 14 sites and only 13 of the 32 qualified for a bonus. In year two, spending increased at six of the remaining 23 and 11 received a bonus. Spending did fall somewhat overall, driven by a few high-performance successes. After netting out the bonuses and penalties, the Pioneer ACOs saved taxpayers a grand total of $17.89 million in 2012 and $43.36 million in 2013. All in, per capita spending was a mere 0.45% lower compared to ordinary fee for service Medicare.

Yet the upfront start-up investments for the pioneers (in administration, compliance and information technology) ran to $64 million, so at best the program is a wash. More to the point, the Medicare budget for 2013 was about $583 billion and these are supposed to be the most experienced providers. If most of them can’t succeed, what about the community hospitals that need the most improvement?

HHS runs a second ACO pilot for everybody else, with rewards but no penalties, called the Shared Savings program. Among those 114 ACOs, only 29 hit HHS’s financial targets in 2012. They saved $128 million and were paid $126 million in bonuses. In 2013, only 64 of 243 participants hit the targets.

The WSJ editors continue to cling bitterly to the illusion that market forces can bring down healthcare costs in the U. S.:

A better alternative would give patients the incentive and usable information about prices and value a la Paul Ryan’s defined-contribution Medicare reform. Doctors and hospitals will quickly adapt to compete for their business. That might mean ACOs or something else.

That might be true except that providers control both the supply and demand for healthcare. Revenues can be increased either by increasing the prices of individual services or by increasing the number of services prescribed. That’s no market.

The reality is that the fee-for-services model has fallen and it can’t get up. Under the model as it exists now almost all of the economic surplus is captured by producers while far too many patients can’t afford care. The PPACA with its healthcare exchanges has not improved on this. It has merely provided an illusion of improvement. For many people deductibles are unaffordably high.

Reform can no longer just nibble around the edges. It’s got to be a lot more basic than that.


Tribune Endorses Durbin

by Dave Schuler on October 20, 2014

The editors of the Chicago Tribune explain how they had to struggle with their consciences to endorse the re-election of Dick Durbin to the Senate:

We often disagree with Durbin on issues. But we would rather have Illinois represented by a highly capable partisan than by a less capable partisan.

My misgivings about Durbin extend farther than those of the Trib editors. I don’t think that he’s been a particularly effective senator for Illinois. Even when they’ve risen to leadership roles in the Senate, senators aren’t elected to represent the whole country. They’re elected to represent their states and I do not see that Illinois has prospered through Sen. Durbin’s tenure or Senate leadership. Just look around you at the statistics. We lead the country in lost jobs, lost companies, and net outmigration. Although Illinois didn’t share in the huge run-up in home prices seen in California or Nevada, we haven’t shared in the housing price recovery, either.

In the final analysis a candidate for the Senate does not need to be the best of all possible candidates. Merely better than his or her opponent. This epitomizes the problem with the Republican Party ion Illinois:

In their primary, Republicans did have a promising candidate, political newcomer Doug Truax: West Point grad, former Army Ranger, owner of an Oak Brook firm helping employers address the costs of health care and retirement benefits. He had smart ideas for rescuing entitlement programs and reforming the tax code.

Republicans instead nominated Jim Oberweis, a business executive who in 2012 won an Illinois Senate seat after five unsuccessful runs for higher offices.

During that candidate debate with Durbin, Oberweis was every bit as partisan, but more evasive and not as prepared to delve into difficult issues such as immigration and federal finances. Oberweis’ campaign rests on stock GOP themes — less government, lower taxation — and that’s fine. But we have no faith he’d be a change agent in the Senate. When he finally got elected to something — the state Senate — he could have served a term and built a record. Instead, he quickly jumped into the next campaign, for the U.S. Senate.

They have an unerring instinct for snatching defeat from the jaws of victory. In a year in which events are breaking in favor of the Republicans they fail to nominate a decent candidate. I am thoroughly unimpressed with Jim Oberweis. Love his milk but hate his politics.


Thinking About Ebola

by Dave Schuler on October 20, 2014

At this stage in what may be a series of events of worldwide importance, I think it’s appropriate to consider a few alternative scenarios dispassionately. Before I begin it might be helpful to define a few terms: epidemic, endemic, and pandemic. If you know Greek, their meanings are obvious but classical educations have become rare.

We characterize a disease as “epidemic”, literally “among the people”, when there is a outbreak of an infectious disease in a large number of people over a short period of time. A disease is “endemic”, literally “in the people”, when it is maintained within a population at a more or less stable rate permanently. For example, chickenpox is endemic in the United States. A disease is said to be “pandemic”, literally “all of the people”, when there is global outbreak of a disease affecting a significant number of people.

Here are some scenarios I think are worth thinking about:

  • Worldwide Ebola pandemic
  • Ebola becomes endemic outside Africa
  • Ebola becomes endemic in sub-Saharan Africa
  • Ebola becomes endemic in West Africa
  • Ebola epidemic outside West Africa
  • Ebola epidemic in West Africa
  • Ebola outbreak outside West Africa

There are other possibilities that could be considered but that list hits the high spots. Now let’s put a little flesh on these scenarios and do a bit of speculating about their likelihoods.

Worldwide Ebola pandemic

I think this is extremely unlikely. I have no way of calculating the costs of this taking place but they would be vast. Half of the world’s population would die.

Ebola becomes endemic outside Africa

I think this is unlikely.

Ebola becomes endemic in sub-Saharan Africa

I think this is somewhat unlikely. If it takes place it will be a consequence of inaction in stemming the epidemic in West Africa, the weak economies and institutions in sub-Saharan Africa, and indifference on the part of the developed world. The costs of this scenario both in human and economic terms would be large.

Ebola becomes endemic in West Africa

This is a substantial and significant fear and the longer the epidemic in West Africa continues the more likely it becoming endemic will become. I think this is slightly likely.

Ebola epidemic outside West Africa

I think this is somewhat unlikely. If it does take place, it will be a consequence of allowing the epidemic in West Africa to continue and is most likely to take place in countries with weak economies and institutions.

Ebola epidemic in West Africa

Since there is already an ongoing epidemic in Guinea, Liberia, and Sierra Leone, this is now a certainty.

Ebola outbreak outside West Africa

Sadly, since there are has already been a small outbreak in the United States, this, too, is now a certainty. It should debunk the notion that an outbreak in the United States is impossible but interested parties are already trying to spin the truth away, a practice that I think increases the likelihood of future outbreaks rather than reducing their likelihood. IMO the outbreak was caused by reckless behavior on the part of professionals. We can only hope that the professionals will be chastened by the experience but I see no signs of that yet.

Note that these scenarios operate along several different planes, i.e. geographic extent, duration, number of cases, and cost. Also note that as the last-mentioned scenarios increase in likelihood the scenarios mentioned earlier become more likely, too. So, for example, if Ebola becomes endemic in West Africa, it will become harder (and more expensive) to prevent it from becoming endemic in sub-Saharan Africa more generally.

That’s why I think that we need to undertake a somewhat more muscular effort in Guinea, Liberia, and Sierra Leone that we presently have. As of this writing we have fewer than 1,000 troops there and they are insufficiently trained to deal with Ebola cases themselves.

They are better prepared to build hospitals but hospitals won’t staff and equip themselves. Not only the United States but France, the United Kingdom, Germany, and China should be making significant commitments of money, materiel, and people in West Africa.

The United States Navy has two hospital ships capable of treating 1,000 patients each and eight Wasp class amphibious assault vehicles capable of treating 600 patients each. These are, in effect, large mobile modern hospitals, fully staffed and equipt. Should some of these existing resources be deployed there? That’s a question. I’m not in the Navy and I don’t know the complications or issues involved.


The Council Has Spoken!

by Dave Schuler on October 20, 2014

The Watcher’s Council has announced its winners for last week.

Council Winners

Non-Council Winners

The link at the Watcher’s site is here.


Images of the Past

by Dave Schuler on October 19, 2014

Have you ever wondered about how a French aristocrat lived 70 years ago? Voici!

The auctioneer who walked into that was one lucky chap.


There Are Other Choices Than Black or White

by Dave Schuler on October 18, 2014

While I’m on the subject, can someone please explain to me why the only alternatives being presented are complete freedom of movement from West African countries and completely banning all travel between the United States and West African countries? I mean other than it’s a lot easier to beat a straw man than have a fully-fleshed legitimate discussion?

If we’re going to take the position as we appear to be now that the way to deal with Ebola within the United States is by flying a squad of experts into wherever a case springs up and then airlifting the patient to one of the handful of places in the country equipt to deal with it, doesn’t putting some effort into managing the number of cases likely to travel to this country from West Africa sound prudent? Not completely eliminate, reduce to zero, etc. but control?


The Puzzle

by Dave Schuler on October 18, 2014

If there’s one thing that baffles me about the present discourse on Ebola, it’s the effort to paint it as a partisan issue. Democrats are complaining that Republicans are turning Ebola into a partisan political issue even as they mendaciously claim that were it not for Republicans we’d be in a much better position for dealing with it.

In that light I’d appreciate an explanation of President Obama’s appointment of Democratic Party apparatchik Ron Klain as matrix manager for Ebola. I think that the complaints of some, including the editors of the Wall Street Journal, that he doesn’t have medical expertise is completely nonsensical. However, I think complaints that he’s neither a general nor even a manager are legitimate.

To the best of my ability to determine Mr. Klain is a lawyer and Democratic party apparatchik full stop. Should we interpret that as the president’s believing that the problems posed by Ebola are purely political?


Ron Fournier’s take bolsters mine:

The choice makes sense if Obama’s main concern is a) the incompetence of his team, or; b) midterm politics. My strong hunch is it’s “b”. The Obama White House is not self-aware. It is nakedly political. The uneven response to Ebola threatens to be a toxic issue for Democrats, and the president is under pressure from his party’s desperate candidates to do something.

The problem with the White House strategy in my view is that the situation is not purely political, especially now that we’re talking about having 4,000 soldiers in the Ebola “hot zone”.


Matrix Management

October 18, 2014

Matrix management is an organizational structure in which many of the workers have more than one direct manager. For example, if all engineers report to a director of engineering but also report to a project manager who does not report to the director of engineering, it’s an example of matrix management. If all accountants within […]

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The Sweeney

October 17, 2014

By the way how practical does the president’s plan for Ebola sweeneys (Cockney rhyming slang: “flying squad” = “Sweeney Todd”, shortened to sweeney) to deal with the cases that will occur here in the United States sound to you? To me it sounds as though he’s been advised of the time and expense of training […]

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