Tuesday, February 28, 2012

Cross-Over Voting…

Michael Moore indicates all his friends in his native Michigan are voting in the Republican primary today for...Rick Santorum.
Any registered voter, independent, Democrat, or Republican, can vote in the Republican primary in Michigan (though not in AZ).
This has led to “strategic voting.” And Romney is complaining. It’s a close race and Romney doesn’t want to lose because of Santorum’s Democratic “support.” Statistical analyzes indicate as much as 10% of the votes in Michigan’s race might come from Independents and Democrats. Of these votes, as much as one-half would likely be cast for Santorum. In second place, with about one-fifth, is Ron Paul.
While Romney began complaining quite loudly on MI Primary Day about the unfairness of cross-over voting, Santorum correctly noted he didn’t complain in New Hampshire when he was the one benefitting from cross-over votes.
This is very much what upsets a growing number of voters, and Americans generally: the way these candidates for President change principles like they change ties. Sometimes, as with ties, they seem to wear none at all…
Of course, one can also complain of the lack of principle shown by the voters themselves if they engage in “strategic voting.” Michael Moore’s friends are voting for Santorum not because they like Santorum or what he stands for--no doubt they loathe him--but because they think, rightly or wrongly, that Obama can more easily best Santorum than Romney in November.
And here we get to the meat of the issue, overlooked so far by media reports on this topic. There is a MAJOR difference between Democrats and Independents crossing over in Michigan to vote for different GOP candidates.
The vast majority of Democrats voting in the GOP primary for Santorum are voting as a strategy. The vast majority of Democrats and Independents voting in the GOP primary for Paul are voting as a principle.
What’s the difference? The Democrats voting in Michigan on 2/28/12 for Santorum have no intention of voting for him in November. They are strict Obama voters. The Democrats and Independents voting in Michigan on 2/28/12 for Paul mostly want to vote for Paul in November. They are NOT strict Obama voters.
So one sad tale the Michigan primary vote tells is that even as we are burying ourselves under mountains of debt, as we look at Greece and reasonably wonder if we’re next, more people are still willing to vote strategically rather than on principle. And when you think about it, that’s not a very good strategy in the long run...

Saturday, February 25, 2012

Hoist With Their Own Ultrasound Probe…

This is a story about abortion politics, political correctness, and principle, or the lack thereof…
The Virginia legislature recently passed a bill. As with most legislation, the actual history is somewhat complicated. In the House, Republican delegate Mark Cole introduced HB 261. It was subsequently amended by HB 462. Sister legislation in the Senate, SB 484, was simultaneously introduced by Republican Jill Holtzman Vogel. These bills sought to mandate that every woman, prior to undergoing an elective abortion, obtain an ultrasound (US) to determine fetal age.
This kind of Nanny State tinkering, the micromanaging of health care provision, could be opposed on many grounds. For example, it could be opposed by traditional conservatives for involving the State in physician/patient relationships; it could be opposed by fiscal hawks for unnecessarily adding to the cost of medical care. It could be opposed by libertarians on the grounds the State has no role in women’s choices about their own body, to say nothing about doctors’ choices in how they offer services.
But the political Left got their marching orders, it seems, because the widest opposition came from liberals screaming that evil conservative legislators were forcing women to have their intimate parts probed prior to being allowed their right to an abortion.
For example, Democratic Virginia delegate David Englin released the following statement in response the same day the House of Delegates gave preliminary approval to House Bill 462:
“This bill will require many women in Virginia to undergo vaginal penetration with an ultrasound probe against their consent in order to exercise their constitutional right to an abortion...only an invasive transvaginal probe ultrasound can effectively determine gestation age during much of the first trimester, which is when most abortions occur.” It turns out the claim that ONLY a transvaginal US “can effectively determine gestation age during MUCH of the first trimester” is simply false.
This allegation was picked up by both Lizz Winstead of The Guardian and Slate.com’s legal analyst Dahlia Lithwick:
The Guardian: “When this story broke, I had so many questions. The immediate ones seemed so basic. I wondered why [VA GOP Governor] Bob McDonnell is so cruel. I wondered why Bob McDonnell felt he had the legal authority to force doctors to rape their patients.”
Slate.com: “This week, the Virginia state Legislature passed a bill that would require women to have an ultrasound before they may have an abortion. Because the great majority of abortions occur during the first 12 weeks, that means most women will be forced to have a transvaginal procedure, in which a probe is inserted into the vagina, and then moved around until an ultrasound image is produced.” For the whole piece, go here.
So you get the picture, if not the actual US image: ”require vaginal penetration...with an ultrasound probe,” “forced to have a transvaginal procedure,” “legal authority to force doctors to rape their patients.” The Left is never accused of subtlety.
Here’s the actual pertinent excerpt of HB 261:
§ 18.2-76B:  Except in the case of a medical emergency, at least 48 hours before the performance of an abortion, a licensed physician or a qualified medical professional working under the direct supervision of a licensed physician shall perform a limited ultrasound examination on the patient undergoing the abortion to confirm the presence of a viable intrauterine pregnancy
HB 462 amended the above, to add in relevant part: The ultrasound image shall be made pursuant to standard medical practice in the community, contain the dimensions of the fetus, and accurately portray the presence of external members and internal organs of the fetus, if present or viewable. Determination of gestational age shall be based upon measurement of the fetus in a manner consistent with standard medical practice in the community in determining gestational age. When only the gestational sac is visible during ultrasound imaging, gestational age may be based upon measurement of the gestational sac.
Note the word “transvaginal” does not appear. No detail is mandated on how the US must be performed, beyond saying it must be consistent with standard medical practice, something any doctor not wishing malpractice suits does as a matter of course. Meanwhile the legislation DOES use the word “limited” to describe the US procedure. That would tend to speak against including TVS, since fetal US begins with TAS, adding TVS only as needed.

A medical imaging aside: there are two ways to perform a fetal US. 

•By slapping “jelly” and the probe on the patient’s pregnant belly, called a transabdominal sonogram (TAS), or..
•By placing a specially designed condom-covered US probe into the vaginal canal and imaging from the cervix into the uterus--called a transvaginal sonogram (TVS). 

US images are better (have a higher spatial resolution) the closer the probe is to the area of interest, so TVS works better in some circumstances, TAS in others. In mid second-trimester pregnancy, when most women are imaged during routine OB evaluations (and therefore what the Virginia legislators likely, though incorrectly, had in mind), fetal parts are closer to the abdominal wall, and so TAS is often all that is needed. In early pregnancy, TVS is often better. For example, TVS can detect the gestational sac that will house the pregnancy by 4.5 weeks (measured from last menstrual period, or LMP) while TAS may take as long as 6 weeks, a 10 day difference
Here’s the intellectual error: In the context of a fetal US in early pregnancy desired by both patient and doctor, not coerced by the State, a vaginal probe is often helpful, and thus often (not always) used. From that medical fact Winstead, Lithwick, Englin and others leap unwarrantedly to the assumption that a doctor, attempting to comply with the law, with a patient who doesn’t desire a vaginal probe, has no other option than to force compliance on the patient. That’s simply false.

As a matter of routine US imaging protocol, in keeping with the laws against battery, women are of course free at any time to refuse a TVS, even when the doctor advises it may be helpful. For the sole purpose of assessing gestational age (the alleged point of the legislation), this might at most demand a 10 day wait and repeat US. On reading the proposed legislation, nothing is mentioned regarding HOW the US is performed. So the claim the legislation mandates an invasive US is clearly a stretch, albeit a politically savvy one. 
As a practical matter, this legislation doesn’t even require a repeat US in 10 days; for women who know their LMP, and schedule a visit to arrange an abortion, it simply means the first visit will be scheduled 10 days later than would otherwise be the case.
We can say even more. For there is a short period of a week or two in early gestation when TAS shows only the gestational sac, the fluid-containing structure in which the fetus will grow and develop, while the more sensitive TVS will show not only the gestational sac but also, within it, the smaller fetus. One measurement of gestational age is the sac diameter. Another is the fetal length. Note the legislation states: “When only the gestational sac is visible during ultrasound imaging, gestational age may be based upon measurement of the gestational sac.” It doesn’t say, “when only the gestational sac is visible, a more invasive US method is mandated to assess fetal length.” Thus it is clear this proposed legislation is being twisted for reasons of political rhetoric.
Some conservatives, apparently just back from watching a Mad Men marathon, have made the unfortunate claim they find it unusual for a woman to object to an US probe being placed in the same area she desires a suction device be placed in the near future. Englin alleges a “conversation with a GOP lawmaker who told him that women had already made the decision to be ‘vaginally penetrated when they got pregnant.’”  Of course, the Left is right that it is the preference of the woman, or the patient, that distinguishes rape from lovemaking, and battery from a simple and routine imaging procedure.
Nonetheless, there will be a price to pay for the Left’s insistence in painting this story as one of metaphorical Republican rape. Their vitriolic rhetoric makes it sound as if this was the INTENT of the Virginia legislature. A February 22nd Washington Post article quotes the female Senate author of SB 484 explaining “she did not realize that the ultrasound would not be external [and] was shocked to find TVS might be used.” According to the Post article, “McDonnell, Virginia Republicans back off mandatory invasive ultrasounds,” by Anita Kumar and Laura Vozzella, “Many lawmakers did not understand that at the young fetal age abortions usually occur, the invasive vaginal ultrasound would be needed to establish gestational age, as required by the bill.” This is technically wrong in the sense that there are other alternatives, like waiting a week, but, again, makes it clear the legislators were not intent on “raping” their constituents. This shows the lie in the claims on the Left that the legislation MANDATED TVS. And there’s the problem…
For the fact is, if you support abortion rights and oppose State intervention in the doctor-patient relationship, you should be equally opposed to TAS mandates. Laying an US probe on the patient’s abdomen is also battery if the patient doesn’t want it.
More importantly, the article notes the Republicans are now working to modify the legislation so that it will still mandate a fetal US prior to abortion, but will clarify that nothing in the legislation mandates it be done transvaginally. As Kumar and Vozzella put it, “Republican lawmakers on Wednesday in essence said that an abdominal — or ‘jelly-on-the-belly‘ — ultrasound before an abortion would still be required but that vaginal ultrasounds would be voluntary. “
And at that point, the Right will have won. The Left, having protested only the “intimate” nature of the mandate, will have no principled reason for continued opposition...they will have been hoist, so to speak, with their own US probe.

Tuesday, February 21, 2012

Who, Whom? An Investigation into Social Security

Social Security is unsalvageable yet few own up to this fact. A pay-as-you-go system has been sold to the American public as old age insurance. The brute truth is that insurance requires investment; investment requires saving; and no Social Security funds have ever been saved and invested. They have been used instead to pay current recipients, the very definition of a Ponzi scheme. Economist Charlotte Twight refers to it as “forced non-saving.” That it has lasted as long as it has is a testimony to the size and productivity of the American economy, but the demographic truths—a fall off in live births coupled with the coming retirement of the Baby Boom generation—insures its doom. Increased migration--by improving the ratio of workers to retirees--could postpone the inevitable for a few decades, but eventually this system, like all Ponzi schemes, will simply collapse.
The Social Security system unfunded liabilities can be calculated in a variety of ways. By one reasonable estimate, Unfunded Social Security Liabilities are over $15 trillion. This money represents a huge transfer. The interesting question is: a transfer from whom to whom?
It is said “we owe it to ourselves,” but since few us of can cut a check for $15 trillion, this is not the best way to look at the problem. Assuming we don’t “solve” this problem with currency hyperinflation, every dollar owed to a future recipient is now in someone’s hands. What are the details of the transfer?
Money is sent to the elderly to allow them comforts in their senior years. What would happen if we didn’t do that? The elderly, as a group, are already the most affluent in society. This only makes sense: they are the ones who have worked and earned the longest. They are the ones who most often live in homes with paid-off mortgages. Granted, if not for the false promises of Social Security, some (most) elderly would presumably have saved more to take care of their retirement needs. Some might need further help. In wealthy countries like our own, children and extended families would most likely be the first to help. They are after all the ones with the most interest and concern. And in a sense they are also the ones with the most to gain. In the end, as a rough approximation, assets held by the elderly not depleted to care for themselves are repaid to the children who cared for them in the form of a more valuable estate willed to them at death. 
With Social Security, this is all, so to speak, socialized. Money is taken from people in the children’s generation and given to people in the parent’s generation. Money that would have been transmitted for the most part within the family system is spread instead throughout the taxpayers
What is the result? 
There are net winners and net losers. The net losers in the present system are working men and women without parents. Their money goes into the system to benefit strangers. Other working men and women with living parents also pay into the system but their obligations to their parents are thereby reduced, and their parents’ estates maintain value that would otherwise be depleted, value that eventually returns to them. 
The net gainers in the present system are retired people without children. They receive money from the system when otherwise there would be no filial obligations to assist them. Note, though, that the social gain is not that great; if a person has no children, there is less reason, all else being equal, for him to not deplete his estate caring for himself in his dotage.
What happens if we simply end the system…immediately. Although eventually everyone in society would benefit from eliminating a Ponzi scheme, during the early years, there would again be gainers and losers. The net losers in a system that eliminated the Ponzi scheme of Social Security would be older workers and retirees without children. They paid into the current system but have no younger generation to care for them. The net gainers in eliminating the system would be younger workers without parents, benefiting more the younger they are (the less they’ve paid into Social Security.)
In sum, Social Security on net transfers money from workers without parents to the retired without children. Looked at this way, the problem is more tractable than often imagined. “The retired without children” is a much smaller group than “the retired.” Thus the real beneficiaries of Social Security are significantly fewer than normally imagined.  “Workers without parents” is a group that is diminishing over time as medical advances allow more and more people to work to retirement even while their parents are still alive. So the group most mistreated by the current system is also diminishing. 
Thought Experiment
Consider a replacement system: 
  1. Eliminate Social Security, both collections and payments
  2. Provide payments to the elderly without working children from general revenues
  3. Create a tax on workers whose parents have died to fund the above payments
  4. Announce that people have a legal obligation to do what they can to prevent their parents from becoming wards of the state.
Since the group in 2) is much smaller than “all people 65 years and older,” and the group in 3) is smaller than “all working people,” the government intervention into the economy is correspondingly much less. Matters improve further when both groups are means-tested. Then poorer workers are not burdened by an additional tax and wealthy retirees are not unnecessarily put on the dole.
Why tax only those without living parents to pay for elderly strangers? There is no good reason in justice, though perhaps there is in equity. After all, this group isn’t also burdened by caring for an elderly member of the family. And presumably at least some of those without living parents have already received some financial benefit in terms of an estate when their parents died. 
Why treat the elderly without children differently from the elderly with children? In truth, those who did not have children gained financially relative to those who spent assets raising children. Can’t they live off these additional assets? And in fairness this seems appropriate in a generation or two. But at this point large numbers of people had money taken from them via Social Security taxes and were told, in effect, “Don’t bother saving for yourself; the State will care for you in your old age.” So there is SOME moral obligation here. Admittedly, there is also a moral obligation to not take money from some via taxation to benefit others. There is a moral obligation not to use federal power to transfer assets from one private party to another, as was done in the widely reviled Kelo decision. But relative to the current system, this modest suggestion, while not eliminating coercion among the generations, significantly dampens it. It may, in fact, dampen the problem sufficiently that the remaining difficulties could be handled via voluntary charity rather than coercive taxation.
Advantages of the proposed alternative to the current system include:
  • Increases in salary and lowering of the unemployment level as the Social Security tax is removed from both individuals and employers. There is a general consensus among economists that the burden of the portion of the FICA tax putatively paid by the employer in fact falls on the employee. So removing this burden will lead to an overall increase in income for employees. And to the extent that any of the burden does fall on the employer, removing the tax should lead to increases in employment as the cost of hiring is decreased.
  • Improved intergenerational cohesiveness. Families in modern society are too often estranged. While some might like it that way—one wag has said that Social Security allows his parents to be independent of him and is thus worth every cent he pays into it—it has negative social effects. Those without strong family connections are more likely to commit crimes and less likely to optimize socialization skills. A culture in which it was clear that caring for the elderly is the primary responsibility of their adult children would over time improve family, and eventually societal, relations. Knowing one will eventually be dependent on one’s children should ameliorate the child abuse problem. A century ago there were many poor people and many poor families, but the social pathologies we now associate with poverty were largely absent, and without government mechanisms to care for the poor and the elderly, informal but highly effective social mechanisms developed to manage their needs. Government programs crowd out such informal networks, and thereby stultify and coarsen the culture, but there is no reason to think they won’t redevelop when government interventions are removed.
  • Improved retirement options. Now few people save for their retirement, both because Social Security claims they have it handled and because the FICA bite eliminates from their budget funds that might have been used to save/invest for the future. With so little demand, the market is unresponsive to the needs of future retirees. And yet of course it is evident that many investment opportunities now exist to provide for one’s retirement. Imagine how many more options there would be if the market were allowed to flourish in this area by increasing consumer demand in such products.
You might say, and you'd be right, that in today's political climate no one would propose this alternative. Given the quality and moral stature of today's politicians, that is yet one more argument in its favor...

Sunday, February 19, 2012

Will WWII Be the Key Issue in the Upcoming GOP Debate?

Listening to some establishment critics of Ron Paul--on both the Left and the Right--you'd have to conclude his key problem, his major flaw, his demonstrated utter unsuitability for the Presidency, is his position on WWII. (See, for example,  this Weekly Standard piece on the right and this left-wing blog commentary)
Paul’s noted that had we not been attacked, he wouldn’t have sent Americans to fight in Europe, even to save German Jews. Paul’s reluctance to defend the Good War, where 48 million people were killed and the Soviet Union’s grip on Eastern Europe extended, is, to the establishment, clearly a verboten, so to speak, position. Since this is obviously a key issue in 2012. I imagine it will come up in a future GOP debate. Perhaps the transcript will read something like this...
Moderator: Thanks for joining us in this, what seems like, the 252nd 2012 GOP Presidential candidate debate, featuring Mitt Romney, Newt Gingrich, Ron Paul, Rick Santorum, and the decaying corpse of Rick Perry. This debate is sponsored by the History Channel. Welcome gentlemen.
Moderator: First question goes to Congressman Paul. Congressman, as you know, a question of vital and growing interest among the public in this 2012 race to the White House…Would you, if President, have intervened in WWII?
Dr. Paul: Well, after Pearl Harbor and after Germany declared war on us, I would have gone to Congress and asked for declarations of war, as FDR did. But I hope my pre-war policies would have lessened the likelihood of Japanese attack in December, 1941. 
Moderator: Thank you, sir. And now we move to…
Rick Santorum (interrupting): That’s ridiculous! We should have nuked them!
Moderator: Ahh...Senator Santorum, we DID “nuke them.”
Santorum: Hmmm...AND A GOOD THING, TOO! (Riotous applause among his supporters)
Moderator: We move now to the decaying corpse of Rick Perry. Gov. Perry, if you were President instead of Lincoln, would you have fought the Civil War?
Corpse of Perry: ………..
Moderator: Thank you sir for your most cogent answer yet. Now let’s throw the same question to Governor Romney. Sir, would you have fought the Civil War?
Romney: Ah...well, I don’t know that anyone is actually talking about that...we haven’t poll tested it...ah, OK, I’m going to say...ahem…”Yes. Yes I would have fought the Civil War.”
Moderator: Which side?
Romney: We’re allowing follow-ups? [turning to other candidates…"My people said the rules were no followup questions. Wasn’t that your understanding?" Getting no response, he returns to the moderator] OK. Which side, well of course the Southern vote is important...hmmm… Yes. I feel firmly I would have fought the Civil War…
Moderator. I’ll move on. Senator Santorum. Regarding the War of 1812…
Santorum: I’d fight it!! I’d send American troops!!! Nuke ‘em!!!!
Moderator: I haven’t finished the question yet, Senator.
Santorum: Oh, sorry…
Moderator: Where would you send troops? The war was fought on American soil.
Santorum: My point exactly! That was the big mistake. We should have taken the war to the enemy.
Moderator: You would have invaded England? In 1812? 
Santorum: We must support the troops!
Moderator: Speaker Gingrich…
Gingrich: I’m a professional historian, you know. 
Moderator: Yes, I know. 
Gingrich: I have a PhD in history. 
Moderator: War of the Roses. Proper US response?
Gingrich: The Wars of the Roses were a series of dynastic civil wars for the throne of England  fought between supporters of two rival branches of the royal House of Plantagenet: the houses of Lancaster  and York (whose heraldic symbols were the "red" and the "white" rose, respectively). They were fought in several sporadic episodes between 1455 and 1485, although there was related fighting both before and after this period. The final victory went to a relatively remote Lancastrian claimant, Henry Tudor, who defeated the last Yorkist king Richard III and married Edward IV's daughter Elizabeth of York  to unite the two houses. The House of Tudor subsequently ruled England and Wales for 117 years. Obviously, the US government should not have intervened, as it would not yet be created for another 300 years.
Moderator: That’s exactly right!
Gingrich: That will be 1.5 million dollars.
Moderator: Excuse me?
Gingrich: I told you...I’m a professional historian. That’s what I make for offering advice based on my understanding of history.
Moderator: Are you done?
Gingrich: No. I did want to add that, IF the US government HAD existed at that time, we should definitely have intervened.
Moderator: What?
Gingrich: Especially if Israel’s interests were at stake.
Moderator: WHAT?
Gingrich: They are the only true democracy in the Middle East. They are our staunchest allies. I can not suck up to... ahem ...support them strongly enough.
Moderator: OK…
Gingrich: I would also like to add that I am the true heir of Ronald Reagan.
Romney: NO! I am the true heir of Ronald Reagan!!
Santorum: NO!! I am the true heir of Ronald Reagan!!! Nuke Grenada!!
Moderator: Congressman Paul, did you want to add anything here?
Paul: Call me Ron...

Thursday, February 16, 2012

The More Things Change…

How can we explain the mess—the morass—in which we find ourselves today as a society? 
One commentator on the public scene offers this answer: “The demoralization of war. A spirit of gambling adventure, engendered by false systems of public finance. A grasping centralism, absorbing all functions from the local authorities, to control the industries of individuals by largesses to favored classes from the public treasuries of moneys wrung from the body of the people by taxation…”
So this commenter, one Sam Tilden, seems to blame our malaise on the demoralization following the Iraq War; the federal guarantees backing Fannie and Freddie leading to a “gambling adventure” with mortgage-backed securities, as Wall St. functionaries played a game of heads they win, tails the taxpayers picked up the losses; the progressive destruction of Federalism—“absorbing all functions from local authority”—during the Bush and Obama years; the bailouts (“largesses to favored classes from the public treasuries”); the crushing taxes (“wrung from the body of the people.”)
And this may all be true, in which case Sam Tilden was quite prophetic, because Samuel J. Tilden was the liberal Democratic candidate for President in 1876, 134 years ago. He was speaking not of our current predicaments but of the similar corruptions of the post-Civil War Republican Grant administration and their favored business interests.
It gets worse, for Tilden, in the quoted passage, was comparing his time with what he saw as similar growth and corruption towards the conclusion of the first Adams administration at the end of the 18th century, not two decades into the American experiment with limited government, as Hamilton and his cronies moved away from the promise of the Declaration to centralize government power in Washington. 
In Tilden’s time the Federal government spent 3% of GDP, compared to about 20% under Bush II and 24% under Obama. But small as it seems now, that represented a 2-fold (100%) growth in government compared to the antebellum years of less than two decades before. Thomas Paine had noted a century earlier that fighting wars grows government.
At the time Tilden spoke, the Democratic Party was the party of laissez-faire, limited government, and free trade. The Republican Party was the party of high tariffs, government projects for favored businesses interests, and subsidies to the politically powerful; it was a pro-business rather than pro-market party. The Democrats were the party of individual freedom while the Republicans were the party of industrial policy, the mercantilists of their day. 
To paraphrase Nixon, we’re all mercantilists now. 
The French say, “Plus ça change, plus c’est la même chose,” the more things change the more they remain the same. The Democrats are, to say the least, no longer the party of laissez-faire, but the Bush administration was filled with special business interests. Hank Paulson, Bush’s Treasury Secretary, easily—happily—confused an impending bankruptcy of Goldman-Sachs (and the loss of his personal fortune) with societal collapse, to be averted by a taxpayer-funded bailout of his industry, “wrung from the body of the people.”
This battle between Liberty and Power is not new. It is older than the Republic, and people whose idea of a Revolution is raising the federal budget less fast than Obama are not up to the task of reversing Power’s latest advance.
What is to be done? Edwin Lawrence Godkin, a contemporary of Tilden’s and himself a liberal in the 19th century mold, the editor of New York’s Nation, offered this advice: “The remedy is simple. The government must get out of the ‘protective’ business, and the ‘subsidy’ business, and the ‘improvement’ and ‘development’ business. It must let trade, and commerce, and manufactures…alone. It cannot touch them without breeding corruption.” The New York Nation was a respected venue and Godkin a leading voice in his time. But today calls to merely drop the federal budget to 2008 levels are condemned as “extreme” and the idea of the government letting trade, commerce, and manufactures alone is…simply unheard of.
 The Tea Party has a long road ahead of it. As Santayana said, “Those who do not learn from history are doomed to repeat it.” Expanding government’s societal take from 3% to 24% of GDP in a century and a half is extreme. Fighting to reverse the tide is just, as Paine would say, common sense.

Wednesday, February 15, 2012

Is the Mental Illness Epidemic a Medical or Economic Problem?

If you study things long enough, you can anticipate…
For example, if you listen to enough Barack Obama speeches, you can feel pretty confident you will at some point come across the phrase, “Let me be clear…”
I considered this phenomenon on reading the recent excellent two-part article, “The Epidemic of Mental Illness: Why?,” in The New York Review of Books (Part I: 6/23/11; Part II: 7/14/11) by Marcia Angell, MD, a well-known academic physician who is, among other distinctions, a former editor of The New England Journal of Medicine. Angell, reviewing three fresh books on the subject, investigated the putative benefits of psychotherapeutics (neuroleptics, anti-depressants, etc.), and even the reputed reality of psychiatric diagnoses.
And on starting to read, I knew, with a high level of confidence, that at some point in her review, Angell would say something to the effect that “more research has to be done.”  Sure enough, the last sentence of the penultimate paragraph of the second-part of her review starts, “More research is needed to study…”
I knew this would appear because, as I said, Dr. Angell is an academic physician, and this is how academic physicians make money—they get grants, sometimes from businesses but mostly in today’s culture from the tax-payer, to investigate matters they wish to investigate. In Dr. Angell’s ideal world, patients compliantly do what doctors tell them, and tax-payers compliantly pay for what doctors do, be it studies, procedures, surgeries, or (above all) research conducted by academic physicians, often designed to tell other physicians in the trenches how to practice—what is “appropriate care.” It’s a Platonic, hierarchical system with Dr. Angell and her friends at the pinnacle, the physician-kings.
A decade and a half ago, Dr. Angell and the NEJM were among the great champions of “Hillarycare.” More recently, she has supported “Obamacare.” Her view of good medicine includes a single-payer system, with health-care divorced (she might say “released” or “freed”) from banal concerns over cost.
And this is the great irony of her excellent recent review. Because the many problems she points out regarding the growth of mental illness diagnoses and the risk of ineffective psychopharmaceuticals are fundamentally not problems of medicine. They are problems of economics, and they would be magnified, not eliminated, by the single-payer system Dr. Angell herself supports.
The story Angell tells in recounting the recent exposes of modern psychiatry is one where doctors don’t understand the underlying mechanisms of the supposed diseases they allegedly treat, don’t understand how the medications they administer work, and don’t really care as long as symptomatic relief is achieved (which, in the case of psychoses, often means not so much that the patient feels better but that the people around the patient feel better…). She notes, in recounting the work of psychologist/researcher Irving Kirsch (The Emperor’s New Drugs: Exploding the Anti-Depressant Myth) and journalist Robert Whitaker (Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America) that many of these drugs—heavily pushed by the pharmaceutical industry—work no better than placebos. That is to say, these drugs may work no better than (many) herbs.
Which leads one to ask: Herbal medicine is big business. Herbs are now sold not only in herbal medicine stores, but even in Walmarts and regular supermarkets. Tens of millions of people take herbs as a substitute for or in addition to regular medicines. Hundreds of millions of dollars are spent. Yet we don’t see the problems in the selling of Ginkgo biloba and St. John’s Wart that have developed in the selling of Prozac and Chlorpromazine.
As Angell says in her introductory remarks, “It seems that Americans are in the midst of a raging epidemic of mental illness, at least as judged by the increase in the numbers treated for it.” Yet we see no epidemic in the use of St. John’s Wart…no concern need be raised over those choosing to self-medicate with Ginkgo biloba. If both categories—psychopharmaceuticals and herbal remedies—work no better than placebos, why is one category simply rising and falling with market demand while the other is growing as a “raging epidemic?”
Dr. Angell raises two concerns in her review. One is that psychopharmaceuticals, despite being widely prescribed and used, are not really efficacious. The other is that mental illnesses, due to industry and other financial incentives, are multiplying without regard to underlying medical justification. The irony is that both problems, although they sound medical, are really economic in nature. And they apply more broadly than the good doctor is willing to consider.
Why is it a problem if a depressed patient feels better after taking a placebo? Why is it a problem if a depressed patient feels better after going to a comedy club? It’s a problem because of third-party payers. If psychiatrists claimed that depression could be cured by visiting comedy clubs, and patients felt that therefore the expense of attending comedy clubs should be covered by their health insurance carriers, we could expect certain consequences. First, we could expect objections by the carriers. Second, we could expect a marked increase in claims of depression among those Americans who enjoy attending comedy clubs.
This is of course more problematic when we discuss treatments, especially medications, for diseases whose very existence is merely a function of a psychiatrist’s claim, but similar problems exist even for diseases outside of the psychiatrist’s couch, or domain. More and more vaguely defined diseases—from chronic fatigue syndrome to fibromyalgia to restless leg syndrome—are defined without clear pathologic correlates, based solely on presentation and exclusion of more well-defined disease entities. 
Why is it important, today, for all physicians, not just psychiatrists, to make specific diagnoses, even when it requires linguistic creativity more than diagnostic savvy? Why is it important to say to a perplexing patient: “You have chronic fatigue syndrome,” say, rather than reporting, “You seem chronically fatigued; I have no explanation for your symptoms.”? Could it be because third-party payers pay by diagnosis? Could it be that a physician is concerned he won’t be paid without registering, not diagnosis and treatment, but an established ICD10 code? These codes have exploded in number in the last generation [1], as more and more diseases, both inside and outside psychiatry, have been discovered—invented?—to the point where no one is now told, on presenting with complaints, “don’t worry; you have nothing wrong with you.”
Why are there ICD codes in medicine, but not in other businesses, like restauranteuring? It’s because one needs “objective” criteria to bill third-party payers. It’s not enough to merely have, as in a 5-star restaurant, a satisfied clientele. You could practice at the Mayo Clinic or Boston’s Massachusetts General Hospital and yet mere reputation for high quality will not suffice. You still need the codes. And when your payment hinges on the codes, bewildering complaints without clear pathologic basis will no longer do. It’s one thing to repeatedly see a patient who has nothing wrong with them as far as you can tell if they’re paying their bill. It’s quite another if the insurance company is refusing compensation because you can find nothing wrong.
Are there medications that make those diagnosed with fibromyalgia or restless leg syndrome or any other of various infirmities diagnosed without known pathologic correlate feel better? Perhaps. Are they but placebos? And here an interesting question arises: If we allow illnesses, as we always have in psychiatry and are allowing more and more in general medicine…if we allow diseases diagnosed solely on their symptoms, what is the difference between a placebo and a real cure, if both relieve the symptoms?
It doesn’t matter if others call something that makes you feel better a placebo, whether it's chiropractic or cleansing enemas or sugar pills. But it matters greatly who pays for it. Government regulations and tax rules since the 1950s have created an environment where most people don’t pay for their own health care. Over 50% is paid by the government, and most of the rest is paid by nominally private insurance carriers who are highly regulated and restricted by the government. This has a clear effect on incentives, both for patients and practitioners.

The dramatic cost increases associated with third-party payments extend beyond diseases that may not really exist. The Oct 8-9, 2011 Wall St. Journal has a front-page story of a growing problem: doctors gaming the system to maximize their incomes, not constrained by patient cost-concerns. The article discusses spine surgeons who not only do back surgery, but also create their own companies and patent their own fusion devices (each a minor variant of the other), so as to get a double-cut, as it were, in the billing process. Does the patient really need surgery? Will it improve outcomes? Hard to say, but clearly the surgeons marketing their own devices have an interest over and above patient welfare in performing surgery. In a competitive market, this would be handled by second opinions and the patient’s concern that it all is getting too costly. With third-party payers, however, such activity not only persists but thrives. Not surprisingly, failed back surgery (continued, or recurrent, or worsened back pain after surgery for back pain) has become increasingly common… 
Now, if the problem is related to third-party payers, to the need not merely to please the patient but to justify one’s treatment “objectively” to third-parties, is this problem likely to be resolved or to worsen in an environment like Obamacare? The obvious answer is that it will worsen. It would worsen even more under a single-payer system. Yet, ironically, Dr. Angell is a strong proponent of single-payer systems. 
As Thomas Szasz, the iconoclastic psychiatrist whom Angell references obliquely in her review, noted long ago, we live in an age where 'most any complaint is viewed as caused by a disease. Combining the growing list of vague medical diagnoses with the explosion of diseases listed in the latest DSM catalog, it begins to appear as if the entire human condition is one big disease. From stuttering to shaky legs, from bullying to being bullied, from general aches and pains to being a general pain—most any complaint can now get you diagnosed with a disease, and allow a physician to bill for services. These wouldn’t always be services you’d willingly and voluntarily pay for. For some physicians—perhaps Dr. Angell—that’s the whole point.
[1]:  See the Wall St. Journal front page story http://online.wsj.com/article/SB10001424053111904103404576560742746021106.html , and the ensuing letters to the editor.