What Kind of Medicine Do We Want?

In an op-ed in the Wall Street Journal, a physician laments the direction his profession has taken:

For me and many of my colleagues, the real practice of medicine is supposed to involve an intimate encounter with each patient and a diagnosis of illness leading to a potential cure. In the future, however, a diagnosis of Lyme disease or the severity of a patient’s depression may be missed because showing the photo or taking an extensive mental-health history doesn’t fit squarely into the 10-minute visit authorized by insurance, along with mandatory computer documentation, insurance verifications and appointment scheduling.

The PPACA didn’t cause that. Sadly, it doesn’t remedy it, either, but rather pushes the practice of medicine even farther into the wrong direction. He continues:

Unfortunately, the kind of insurance that is growing under ObamaCare’s fertilizer is the exact kind that was jeopardizing the quality of health care in the first place: the kind that pays for seeing a doctor when you are well, but where guidelines and regulations predominate and choice is restricted when you are seriously ill.

What we’ve got is an unholy alliance between Big Business and Big Government, a development none of us should relish.

Someday, perhaps, we can start thinking about the kind of practice of medicine we’d like to see. I think it’s one in which physicians don’t worry about starving but don’t live like Renaissance princes, either, and, more importantly, don’t expect to. Patients can receive the care they need but maybe not as much care as they want and that decision is made by professionals rather than by administrative guideline. Something that more closely approximates the “old country doctor”, a physician who maintains a longitudinal relationship with his patients rather than a medical retailer. What we’re getting is the worst of all worlds: standardized care at high prices.

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Nativity Scenes

The first instance of a nativity scene being used in devotion at Christmastime was in 1223 in Greccio, Italy. It was erected by Francis of Assisi, the greatest of Christians other than Jesus himself. In his “Life of Francis”, Bonaventure reported:

Now three years before his death it befell that he was minded, at the town of Greccio, to celebrate the memory of the Birth of the Child Jesus, with all the added solemnity that he might, for the kindling of devotion. That this might not seem an innovation, he sought and obtained license from the Supreme Pontiff, and then made ready a manger, and bade hay, together with an ox and an ass, be brought unto the spot. The Brethren were called together, the folk assembled, the wood echoed with their voices, and that august night was made radiant and solemn with many bright lights, and with tuneful and sonorous praises. The man of God, filled with tender love, stood before the manger, bathed m tears, and overflowing with joy. Solemn Masses were celebrated over the manger, Francis, the Levite of Christ, chanting the Holy Gospel. Then he preached unto the folk standing round of the Birth of the King in poverty, calling Him, when he wished to name Him, the Child of Bethlehem, by reason of his tender love for Him.

My wife and I both grew up with crèches, nativity scenes, as part of our Christmas celebration. After our first Christmas together we realized we wanted one but it took quite a while to find one that suited us. After a number of years we finally stumbled upon the crèche above. The figures are small—roughly 3 inches tall—it is made of majolica, and I believe it was made by American artists.

The Samoyed guarding the infant Jesus was a later addition and, to the best of my knowledge, it is distinctive to us.

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Tourtière

On Sunday evening I made something that I believe is a Québécois Christmas tradition, a tourtière, a pork pie.

I used about as simple a recipe as I could manage. I put about a pound and a half of coarsely-chopped pork and beef, two potatoes, mashed, in a pie crust, seasoned with mace, allspice, black pepper, and a bit of garlic. Bake for about an hour.

The original recipe called for grinding the meat but I decided that chopping the meat into approximately eighth inch dice would provide a nicer texture. And the original recipe called for a teaspoon of nutmeg. I substituted mace and allspice to give it a bit of a medieval quality. I also reduced the quantity of spice a trifle. A teaspoon of nutmeg (or mace) can be pretty overpowering.

It was quite tasty and, as you might imagine, filling. Good cold the next day and especially good with mustard and pickles.

The pie could serve eight gourmets with, say, a salad and cheese course or four gourmands.

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Notate Bene

While the words “duck” and “dynasty” may appear in this blog from time to time, I don’t envision their ever appearing together here. Similarly, although “honey” and “boo” may be used in one post or another, that’s about it.

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To Preserve Disorder

To re-purpose an immortal remark from the late Mayor Daley, it is not the intention of the Administration to create disorder by its repeated tweaks of the PPACA in reaction to political pressure. It is the intention of the Administration to preserve disorder:

The biggest danger is that the Obama administration is encouraging politicians to meddle in the health-care system every time a few vocal constituents get upset about its requirements. Ms. Sebelius’s Thursday announcement was a response to six Democratic senators from competitive states who are concerned about people getting insurance cancellation notices. Not everyone was going to win under health-care reform, and not everyone can if the system is to work. The threat is that, in seeing to the concerns of those who might have to pay more in 2014 or in future years or some other group that feels put upon at some time, politicians will poke so many holes and add so many exceptions that the law is seriously undermined.

No fear. Any law that requires as much attention as the PPACA has to date is self-undermining.

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It’s the Policies, Stupid

Dean Baker and I are on the same page on this. Globalization doesn’t mean that you must protect (and subsidize) the wages of physicians while hammering down the wages of factory workers:

There is nothing about the globalization process that necessitated this result. Doctors work for much less money in Mexico and elsewhere in the developing world than in the United States. In fact, they work for much less money in Europe and Canada than in the United States. If we had structured the trade deals to facilitate the entry of qualified foreign doctors into the country it would have placed downward pressure on the wages of doctors (many of whom are in the top one percent of the income distribution), while saving consumers tens of billions a year in health care costs.

In other words, the government quite deliberately structured our trade to put downward pressure on the wages of much of the labor force, while protecting doctors and other highly paid professionals from similar competition.

Preserving the financial system doesn’t require that bankers’ incomes be preserved:

The subsidy for too big to fail banks, which makes the Wall Street crew incredibly rich, is another way that the government redistributes money to the top. Bloomberg estimated the size of this annual subsidy for the Wall Street gang at $80 billion a year, more than the government spends on food stamps.

And there is neither anything natural or necessary about the strength and duration of our system of protection of intellectual property:

The longer and stronger patent protection the government has given pharmaceutical companies is another way that money goes from the rest of us to the rich. The annual size of patent rents in the drug industry is currently in the neighborhood of $270 billion, more than three times as much as the government spends on food stamps.

Don’t like the income inequality? Don’t like the slow growth of the economy? It’s the policies, stupid:

And the macroeconomic policy run by the government has also worsened inequality. Budgets are crafted by politicians, not the gods or nature.

Now, I suspect that Dr. Baker and I differ on what the best remedies are. But there’s no disagreement between us that policies have consequences and we’ve arrived at the results we’ve accomplished as a result of policies rather than despite them.

There’s a broad consensus in Washington over the general direction of policy. The political conflicts there have been described as a game of football fought between the forty yard lines.

And yet, somehow, year after year and despite Congress’s 18% approval rating and a majority of voters disapproving of their own Congresscritters in opinion polls, we elect the same people again and again and will no doubt do so in November 2014. 72% of Americans see the government as the biggest problem facing the country. What’s the solution?

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The President’s Anniversary

Today marks the anniversary of the beginning of the long slide in President Obama’s approval rating, illustrated by the chart above from RealClearPolitics. Since December 22 of last year the president’s approval rating has fallen from 54% to 42.2% and the difference between approval and disapproval rating has dropped a full 22 points. One of the ironies of the RealClearPolitics average of polls the graph illustrates is that without progressives’ least favorite polls, Rasmussen and Reason’s, the average of polls would be signficantly worse for the president than it is.

The Huffington Post’s poll looks even worse:

The president’s approval is far lower than Bill Clinton’s or Ronald Reagan’s were at this point in their presidencies, roughly comparable to George W. Bush’s.

Supporters of the president might take some solace in the small uptick in the president’s popularity that has occurred over the last couple of weeks. Time will tell whether that holds and is the harbinger of a recovery or just noise in an otherwise persistent downward trend.

Whether President Obama recovers from the year-long slump or resumes his slide in popularity in the coming year, I think his supporters are going to need to resign themselves to the reality that Barack Obama’s term in office will not mark the beginning of an “Obama coalition” that will result in Democratic domination of the national political scene as was the case for Franklin Roosevelt nearly 80 years ago. By this time in FDR’s presidency he was receiving enthusiastic support from the popular Republican mayor of New York, Fiorello La Guardia. There have been no comparable crossovers in Obama’s presidency and I think that the president’s election is more an indicator that a realignment along demographic lines has occurred rather than one of a future realignment. The alignment we have now can probably be expected to endure for the foreseeable future.

As I remarked in a post at OTB today, the big news of the midterm elections of 2014, whether Republicans hold the House or take the Senate or any other combination, is how many incumbents will be re-elected and how few seats ultimately change from Democratic to Republican or vice versa.

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Jacqueline Leo on the Impact of the PPACA on the Economy

Writing at Fiscal Times Jacqueline Leo reports on the prospective economic impact of the PPACA. At this point it strongly appears that it will help a very few people and hurt a lot more, particularly those who are healthy and under age 40, categories with substantial overlap. She concludes:

If even a fraction of the middle class and upper middle income earners divert some of their discretionary dollars to pay for health care, it will have a significant impact on consumer spending. What will that mean for the economy? Consumer spending accounts for about 70 percent of the nation’s GDP, although experts say that number is likely to decline.The top 20 percent of income earners account for about 40 percent of all spending in the U.S. When you increase the costs of health care and the new taxes associated with Obamacare, you can hear the wallets closing.

Not all of the effects will be adverse. For example, it may result in more entrepeneurs starting their own businesses than might otherwise be the case. Contrary to what you might think they’re not all Young Turks. More are over 40 than under and the increased availability of healthcare for individuals through the exchanges could potentially be an inducement to take a flyer.

But many of the effects will. Rather than thinking in terms of “consumer spending”, think more concretely. The dollar that is spent on healthcare insurance is a dollar that won’t be spent on cars, houses, or iPhones. Our economy is very dependent on consumer spending by people who are under 40 and one consequence of the PPACA is there is likely to be less of that than there otherwise might be.

And again, contrary to what you might think, the PPACA will not result in a transfer of income from rich to poor but from young to old and, more precisely, from all other sectors of the economy to the financial and healthcare sectors, both sectors that create fewer jobs per dollar of GDP.

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Walking the Walk

West Virginia Democratic Sen. Joe Manchin says something I’ve been saying for some time now:

(CNN) – The President’s failure to build friendships with lawmakers has damaged his chances of finding bipartisan support for legislation, a senator from his own party said Sunday.

“It’s just hard to say no to a friend,” Sen. Joe Manchin, D-West Virginia, said on CNN’s “State of the Union.”

“When you build that relationship and that friendship, you’re looking for ways to try to work things out and find a compromise and, you know, that friendship means an awful lot. When you don’t build those personal relationships, it’s pretty easy for a person to say, well, let me talk about it, you know, and not really make, you know, that extra effort.”

To be president you need to win elections but to be an effective president takes more than winning elections. It’s reassuring to me that I’m not the only person pointing this stuff out.

Not all of that is the president’s fault—there’s plenty of animosity from the Republican side. But that doesn’t absolve the president. It just means he should be working twice as hard to cultivate the relationships that are a necessary part of doing the job of president.

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Anywhere But Here

The concluding quote in this post at the Huffington Post on the tough year the president has had in 2013 took me aback:

“I would argue that if he didn’t have the website collapse, he wouldn’t be subjected to the five-year curse as much,” said Dean [ed. former DNC chairman Howard Dean]. “All the other five-year curses were of the sitting president’s own making. This one you may argue that three people down the line screwed up the website, not Obama. … I do not think that he has been personally stained the way the other presidents were.”

I realize that Dr. Dean is a party functionary and as such can be expected to put things in the best possible light but that remark strikes me as detached from reality. Just look at the graph of declining presidential approval in the linked post or the analogous one at RealClearPolitics.com. The president’s approval rating has been declining for a solid year, since long before October 1 when the unready condition of Healthcare.gov was exposed to the light. You could argue that some of the decline in the president’s approval rating since October 1 was due to the failure and the attendant press coverage that included revelations that would have come to light years ago with a press corps less eager to show the Administration in a good light. But all of it?

And who’s responsible for the “three people down the line”? Especially when even the president refers to the PPACA as “Obamacare”. Does the president have no responsibility at all for the lack of attention to the portal for the signal legislative accomplishment of his first term? We’ve come a long way since Harry Truman. Apparently, the buck now stops anywhere but here.s approval rating has been declining for a solid year, since long before October 1 when the unready condition of Healthcare.gov was exposed to the light. You could argue that some of the decline in the president

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