Ron Paul & Clicktivism

The point raised by yesterday’s Times article on Ron Paul was that while Paul attracts big crowds, these crowds do not translate into voter turnout.

Perhaps the problem is that Paul has appeal within his fervent base, but that base is unable to influence people outside the circle. If Paul can attract thousands to a rally, many more should actually vote for him. Paul himself discusses the problem in the article:

“I don’t have a full answer for that,” says Mr. Paul, who says he believes ballot irregularities have chipped into his numbers in some places. He adds, “I think there’s some problem with always making sure this energy is translated into getting to the polls.”

Perhaps the answer is clicktivism. Paul’s fervent base is all over the internets, commenting on this blog for instance, but clicks and comments do not create voter turnout. Nor are they part of anything resembling a dialogue. Libertarian movements are something akin to PR firms, all transmit and no receive. Able to create the appearance of broad appeal, but with a actual following that is quite shallow.

And that honestmistake video is not very compelling. So news organizations, particularly television, omits Paul from a bunch of infographics. If that is your beef, you are not ready for the national stage, where many unfair things happen. You cannot blame the media for not taking Paul more seriously. He’s not even a serious member of Congress–introducing dozens of bills on crackpot topics that are all languishing in subcommittee land. He appears to have accomplished next to nothing in his many years there.

There is no There There — Ron Paul's Loud, Thin Base

Writing in today’s Times, Richard A. Oppel asks, “Whatever happened to Ron Paul?”

Ron Paul has fans, in the traditional sense of the word–fanatics. They foam over this small and strange man, whose career in Congress has largely been ineffectual. Thousands go to his rallies, but as Oppel observes, “A Feb. 27 event at Michigan State University drew 4,000 people. But at polling places the next day, Mr. Paul finished third — with 3,128 votes — in Ingham County, where the campus is. Mr. Romney got more than three times as many votes.” Paul’s supporters attribute this to a failure in conveying the urgency to vote.

Paul is emblematic of the larger libertarian movement, if it can even be called that. Paul’s supporters are loud and able to manipulate the levers of public spectacle and the media. They seem omnipresent in Washington, DC, on policy panels and the like, but support for their ideas is not widely shared. In general elections, libertarian candidates routinely capture less than 1 percent of the vote. Perhaps that is a reflection of the power of our two political parties. But Ralph Nader, representing the complete opposite of the libertarian canon, captured over 2% in 2000.

The Ron Paul people remind me of the Lyndon LaRouche supporters who used to plague the Berkeley campus. They typically were good looking young people who would accost others with a message that might be popular on the campus: “Impeach Dick Cheney.” That might be a conversation starter. But once one looks at the spectrum of where that conversation goes–in both LaRouche’s case and in the case of the libertarians–one might be turned off. All sorts of crazy is on parade, from years-long campaigns against global warming, bluster about the stimulus, and hysterical attacks on Obama’s healthcare plan.

One cannot just cause a spectacle and win an election. It takes people, investment, and time. Once one takes the time, invests in people, and actually organizes, one sees that the world is a complex place and perhaps is less likely to vote for the likes of Ron Paul.

Bad news for the Affordable Care Act

The NYTimes reporting suggests a 5-4 split against ACA is likely:

Justice Kennedy, along with Justices Samuel A. Alito Jr. and Antonin Scalia and Chief Justice John G. Roberts Jr. all asked questions suggesting that they had a problem with the constitutionality of the mandate requiring most Americans to buy insurance. Justice Clarence Thomas, as usual, did not ask any questions, but he is widely expected to vote to overturn the mandate.

As does CNN’s Toobin’s analysis:

This is interesting. Part of the issue is how much of the law would fall if they turn against it? Would we still be able to prevent insurers from dumping patients and refusing to cover chronic conditions if the mandate falls? Will both provisions be struck down? All provisions?

I think a strategic error was made in not describing the penalty as a tax. Because no one doubts congress’ power to tax, and after all, it made sense to tax the uninsured considering as a group they cost the taxpayers $43 billion a year in unpaid medical bills.

The other interesting outcome may be political. Without Obamacare to rile up the base, what issue will Republicans have left come next fall? This was their touchstone, and if the Supreme Court pulls the rug out from under them, they’re going to have to come up with a new form of librul fascism to rail against for November.

In the end this may be an opportunity or a catastrophe for medical care depending on how we are led into the future. The failure of this law may result in a tax-supported single payer system. It may result in expansion of health exchanges to cover the uninsured. It may result in a new national flat tax, like Japan’s, that results in income-based subsidization of healthcare costs. All of these things are clearly constitutional based on the congressional ability to tax.

The worst outcome would be if we saw another 15 year delay in addressing the crisis of rising health care expenditures and coverage for the uninsured. Or, if it became delegated to the states to create individual universal systems as, sadly, most red states have no financial capacity to afford it. Already the southern and para-Mississippi states have higher obesity rates, poorer objective measures of health, worse infant mortality, and higher bankruptcy rates etc., this will likely worsen these disparities. California, New York, Massachusetts (will they lose their mandate?), Maryland and other states which are the major federal revenue generators could probably manage it if they could convince their population to support universal healthcare legislation with additional taxes, but a patchwork approach will create unnecessary complexity. What if a Pennsylvanian gets a surgery in Maryland? What if someone wants to chose an out-of-state hospital, which they very frequently do? What about emergency care for out-of-staters? Will this just further increase disparities between the states until the we see an ever worsening downward slope in quality of life as you approach the Mississippi river? Will states like Texas that can probably afford reform refuse to enact any out of cold-hearted laissez-faire libertarianism?

It’s sad, but oh well. America gets the government it elects.

Mooney now agrees with us – Denialists deserve ridicule, not debate

He had to realize Nisbett’s framing was worthless and write a whole book on defective Republican reasoning to realize it but it sounds like Chris Mooney has come around to the right way to confront denialism:

The only solution, then, is to make organized climate denial simply beyond the pale. It has to be the case that taking such a stand is tantamount to asserting that smoking is completely safe, no big deal, go ahead and have two packs a day.

Sounds a little bit like what I wrote in 2007 when I pointed out denialists should not even be debated:

The goal instead must be to enforce standards of scientific debate, to delimit sharply what kind of evidence and argument is worthy of being listened to, to educate people about the form of pseudoscientific arguments, and when these arguments are proffered, to refuse to engage on the grounds they aren’t even worthy of consideration.

Don’t mistake denialism for debate…

The whole goal of denialists is to create the appearance of a legitimate debate when there is in fact no legitimate scientific debate to be had. What is the point of arguing with someone who denies the moon landing? Or evolution? Or that HIV causes AIDS? Or the holocaust? They get real angry when you mention that one as they feel it creates a moral equivalence between the types of denial. But the operative word is “denial” which is totally unrelated to whatever specific topic one denies. It’s just another helpful distracting strategy, to try to prevent critics from using the legitimate word to describe their pathology – denial – by suggesting it’s a wrongful comparison to one specific type of denial.

The solution to these problems is not in confrontations or debates or even necessarily careful fisking of their arguments every time they appear in the blogosphere. For one, it’s somewhat futile. They’re cranks. They will just go on and on, immune to any new data, scientific findings, or any evidence the real world can present. Worse, evidence suggests that repetition of false claims reinforces them even if you are debunking the claim. So debating them to supposedly educate those around you is not a legitimate reason because it’s probably making things worse, not to mention legitimizing the denialist. It’s a constant struggle I have to try to write about things in such a way as to reinforce positive true claims rather than repeat false claims with correction. It’s natural, but it doesn’t work.

Chris is right, the only way to address denialism is to call it what it is and ridicule it. People have to understand the difference between denialism and debate, and when they encounter denialism expose and attack the tactics. Denialism is an established strategy, likely ancient, honed to a science by tobacco companies, and now used by those attacking everything from global warming to evolution. Some of the same fake experts for the tobacco companies are now working for the global warming denialists. The way to win is to remember the way tobacco science was eventually beaten, and that was with exposure of their deceptive techniques, and public ridicule for denial of the obvious reality.

Three reasons the Supreme Court should uphold ACA

With the Supreme Court hearing arguments for the next three days on the Affordable Care Act, many commentators, including Dahlia Lithwick appear to have so much contempt for the Roberts court that they believe the issue will likely be settled on politics rather than law.

The first proposition is that the health care law is constitutional. The second is that the court could strike it down anyway.

The law is a completely valid exercise of Congress’ Commerce Clause power, and all the conservative longing for the good old days of the pre-New Deal courts won’t put us back in those days as if by magic. Nor does it amount to much of an argument.

Despite the fact that reading the entrails of those opinions suggest that they’d contribute to an easy fifth, sixth, and seventh vote to uphold the individual mandate as a legitimate exercise of Congressional power, the real question isn’t whether those Justices will be bound by 70 years of precedent or their own prior writings on federal power. The only question is whether they will ignore it all to deprive the Obama of one of his signature accomplishments.

Professor Randy Barnett, the intellectual power behind the entire health care challenge, wrote recently that Justice Scalia could break from his previous opinions–freeing him to strike down the Affordable Care Act–“without breaking a sweat.” I suspect that’s right.

If that’s true, we should stop fussing about old precedents. These old milestones of jurisprudence aren’t what will give Scalia pause. What matters is whether the five conservative justices are so intent in striking down Obama’shealthcare law that they would risk a chilly and divisive 5-4 dip back into the waters of Bush v. Gore and Citizens United.

It disturbs me when legal commentators as experienced and knowledgeable as Lithwick have essentially given up on the notion that the court is non-partisan or above the political fray. Instead, they seem to think it’s just another political body, making decisions based on partisan point-scoring over legitimate constitutional analysis. With the tea party rallying to keep us uninsured under the false notion that the bill will increase costs (it will actually reduce the deficit according to the CBO) and impinge their freedoms. These are the false arguments that people like Nick Gillespie (or libertarian Fonzie) are using, quite successfully, to convince the American people to oppose their own interest. Gillespie argues in his three point essay that (1) it’s unconstitutionally intrusive legislation (2) it’s price tag is ballooning, and (3) it won’t make us healthier. The first claim is debatable since it’s ultimately up to the courts. However good arguments suggest congress does have the power to pass such regulation.

For one previous case like Wickard and Raich suggest extensive powers for congress to regulate commerce. Second, if one of every seven dollars is spent on healthcare, it represents a significant portion of the economy. Third, and most importantly, the uninsured inflict an economic penalty on taxpayers and the insured, so rather than claiming they have a right not to buy, I would argue we have a right to address the cost the uninsured inflict on society. The penalty for not carrying insurance I believe makes complete sense in this regard.

The second claim is blatantly false and his description of the costs as “ballooning” is unsupportable based on the CBO reports. This talking point is an outright lie being spread far and wide by right wingers. The CBO director had to issue a comment to correct this widespread deception.

The third claim is a bit of a red herring. The health benefits of people being insured may eventually result in a healthier population but probably not by much and it’s besides the point. We’re not arguing the law will make us healthier. We’re arguing that the reform law will reduce healthcare expenditures, and protect people economically from the often devastating costs of illness.

But rather than just knocking down their arguments I think it’s important to remind people of the positive reasons we should support this bill. So I have my own list of 3 reasons this bill should be upheld and we should all support it.
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What is the cause of excess costs in US healthcare? Take three – signs of reform

We’ve already extensively discussed why it costs twice as much for the US to provide healthcare for it’s citizens all the while failing to cover health care for all. Most recently, we discussed the hidden tax of the uninsured and the perverse incentive structure of US healthcare which encourage costlier care, more utilization, and more procedures.

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To summarize, the US spends more on healthcare compared to other industrialized nations because

  1. We deliver it inefficiently
  2. Without universality problems present when critical and in the ER
  3. Fee-for-service incentives in the form of excessive reimbursement for procedures and hospitals ramp up costs by encouraging doctors to overuse expensive tests and perform more procedures
  4. Direct-to-consumer advertising (we are one of two countries that allow advertisement of prescription drugs) and medicare part D encourage overuse of pharmaceuticals while tying providers hands when it comes to bargaining for lower drug prices
  5. Defensive medicine
  6. Poor management of end-of-life decisions and excessive and futile overuse of resources at the end of life
  7. Absence of a universal electronic medical record (or record format) to prevent redundancy and waste.

Now, what about the new Affordable Care Act? Are there going to be measures to address these sources of excess cost while creating universal coverage? The WaPo has an article outlining reforms addressing many of these specific problems.

First off, fee-for-service is going to be discouraged with increased use of “bundling” of costs:
Continue reading “What is the cause of excess costs in US healthcare? Take three – signs of reform”

Huffpo Science – already slipping into anti-science

Our initial optimism over Huffpo science being a haven for reason in a den of disease-promotion and quackery appears now to be misplaced. It appears the animal rights cranks have made inroads with Bruce Friedrich, a member of PETA and advocate of animal liberation, who has jumped from Huffpo “green” to Huffpo “science”. The science gatekeepers at Huffpo have clearly failed.

Writing about “Speciesism: The Movie”, he exposes the anti-science ideology of the animal rights movement, and Huffpo science doesn’t seem to have noticed:

Every now and then, a movie comes along that is capable of fundamentally changing the worldview of its audience. Speciesism: The Movie, a new documentary by Mark Devries, is that kind of film.

The word “speciesism,” which has been popularized by Princeton bioethicist Peter Singer, refers to the assumption that a vast gulf exists between the ethical value of human interests and the ethical value of the interests of other animals. At its extreme, we may see ourselves as the only species that matters morally, and view other animals as existing merely for our use: to eat, to make into clothing, to perform experiments on, to be entertained by in circuses and zoos. Like those who grew up having overt racist beliefs assimilated into their worldview, some degree of speciesism has been so well-assimilated into the worldview of most of us that it does not even appear to be worth questioning.

Devries goes to great lengths to put together a thoughtful and entertaining film–whether commissioning an airplane to fly over factory farms’ giant “manure lagoons” with an anti-CAFO Republican from North Carolina, or (somehow) scheming his way into receiving a guided tour of a factory farm.

Along the way, he meets and questions a remarkably broad range of people, including Peter Singer (whom the New Yorker has named “one of the most influential philosophers alive”), Richard Dawkins (the most influential evolutionary biologist of the past century), and Temple Grandin (designer of the animal handling systems used by over half of the slaughterhouses in the United States).

He also speaks with anti-factory farming activists, a man who is dying next to a huge hog farm, a current member of the American Nazi Party, a disability rights activist, a vivisector, quite a few people on the street, and more–all in his quest to thoroughly consider the philosophy that says that bias on the basis of species is unjustifiable. Disclaimer: He also spoke with me.

Above all, Devries confronts some very difficult and uncomfortable questions head-on. For example: How strong are the grounds for believing that humans have special moral worth? How valid are the comparisons between our use of other animals and the slavery of other humans?

My emphasis added. So here we have it on Huffpo science. Believing that our species should be valued over other species is a sin equivalent to racism. Use of other animals is like slavery. Biologists aren’t scientists we’re “vivisectors”. We’re all going to hell.

To be clear, biological science without use of animals is impossible. It’s not just toxicity testing of drugs either, and we are fully aware of the limitations of our animal models, thankyouverymuch. But from the ground up, the study of life depends on the use of living things. From the cells we harvest for culture (we can’t all study wacky immortalized cancer cells you know), to the serum we grow them in, to the antibodies we generate by exposing animals to antigens, to the transgenic animals we use to study genes in vivo, to the model animals that modern surgical techniques and technologies are refined in, biological science is intimately tied to living things. The face transplant I wrote about yesterday? Impossible without prior animal modeling, practice with surgical technique and molecular investigation of immunosuppression. Transplant in general? The earliest investigations of skin grafting and surgical techniques for transplant were honed in animals – with some hefty human experimentation as well. Every major surgical advance, medical advance, and plain basic biological science knowledge comes from our manipulation of the living things around us. But are we in any way noble for our pursuit of knowledge, for yes, explicitly human benefit? No, we’re speciesist, we’re vivisectors.

Well fine, I admit it. I value human life over that of other species. I’ve devoted my life to saving human lives, and as a scientist, I’ve sacrificed animal lives to do so every time I’ve ordered a polyclonal antibody or bottle of FBS. According to radicals like Friedrich that makes me “vivisector”. I’m therefore a monster, like a slaver or murderer.

This is the unexamined ethics and thoughtless smug moral superiority of the animal rights activist. I doubt, when push came to shove they would sacrifice a human for an animal. Or even a large number of animals. Who, after all, swerves to avoid the squirrel and instead hits the kid on the sidewalk? No one. Human life is more valuable to us because we’re human and that’s OK. It’s not wrong to be self-interested or interested in our survival over that of other species. Survival requires a certain amount of self-interest, human survival requires the ingestion of other living things, and agriculture is never going to be cruelty free.

The vegan militia have forgotten that to get their cruelty free vegetables, the land has already been cleared, all competing species have been killed or driven out, those that remain are poisoned (even by organic farmers – they just use “certified organic” methods of pest control or even other animals like ladybugs). We put humans first every time we clear a field, dig a foundation, fence and spray our crops, and burn diesel to harvest and bring them to market. We have said, these resources are ours, we own the land, and all the beetles, voles and deer can go right to hell. Survival is cruel, and will always involve putting ourselves before other species.

The health benefits and technology they enjoy everyday has already been tested and worked out thanks to comparative medicine. It’s easy to feel morally superior about eating greens, and denigrating scientists, now that all that messy stuff has been done and the last time you were on a farm it was to pick a pumpkin in 3rd grade so you don’t know what actually goes into agriculture, even organic agriculture.

This is not to say I agree with CAFOs, food monoculture, the slimey tactics of Monsanto, or any of the extremes of poor infrastructure, corporate malfeasance and environmental stupidity of our food supply. But lets stop pretending that you become morally superior for eating tofu, all the while you happily ignore the habitat destruction, mass removal of unwanted species, and outright extinctions we’ve caused in order to create our agricultural dominance.

So let’s stop calling the people who are trying to understand, preserve and extend human lives speciesist (read racist) and vivisectors. Life is complicated. Living it without cruelty to something either requires you to be oblivious to our constant impact on the living things around us, or to retreat into some Jainist agrarian fantasy world that will never exist. Isn’t it better to have a healthy understanding that human beings survive in competition for limited resources with the species around us? We evolved to the point where we’ve become adapt at manipulating and controlling the natural world, and rather than being ashamed of it, we should accept it as a gift from our ancestors after eons of struggle.

Supreme Court to Debate Affordable Care Act Next week – and plaintiff's case has imploded

With the impending, and unprecedented, 3 days of arguments over the Affordable Care Act occurring early next week, it’s interesting to see that the test case being used to challenge the law has now become a test case demonstrating the necessity of the law.

Mary Brown, the woman who asserts no one has the authority to make her buy health care is now bankrupt, at least in part due to medical bills. From theLA Times article:

Mary Brown, a 56-year-old Florida woman who owned a small auto repair shop but had no health insurance, became the lead plaintiff challenging President Obama’s healthcare law because she was passionate about the issue.

Brown “doesn’t have insurance. She doesn’t want to pay for it. And she doesn’t want the government to tell her she has to have it,” said Karen Harned, a lawyer for the National Federation of Independent Business. Brown is a plaintiff in the federation’s case, which the Supreme Court plans to hear later this month.

But court records reveal that Brown and her husband filed for bankruptcy last fall with $4,500 in unpaid medical bills. Those bills could change Brown from a symbol of proud independence into an example of exactly the problem the healthcare law was intended to address.

I think at this point the solicitor general just has to point at the plaintiff and say “See! See!”.

People without health insurance are still covered by the ethical obligations of EMTALA. They can still see doctors and get treatment and not pay their bills. Then who pays for it? All of the rest of us.

The “individual mandate” should be called a “personal responsibility” provision, because the fact is all these rugged individualists are parasites. They are refusing to pay into the system then benefiting when they, inevitably, need to use it.

And how about the argument that the commerce clause can’t for such an individual responsibility provision?

The couple owed $2,140 to Bay Medical Center in Panama City, $610 to Bay Medical Physicians, $835 to an eye doctor in Alabama and $900 to a specialist in Mississippi.

“This is a very common problem. We cover $30 million in charity and uncompensated care every year,” said Christa Hild, a spokeswoman for the hospital center. “If it’s a bad debt, we have to absorb it.”

So, this couple has generated bills in three different states that they now will not be able to pay and the rest of us have to eat the bill for them. It’s amazing how the plaintiff’s own actions have justified nearly every argument for the bill. When healthcare now represents something like 1 in 7 dollars spent in this country, how can we argue that the commerce clause does not allow congress to regulate it?

2nd US Hospital to do full face transplant – today at University of Maryland

The news was just publicly announced that the University of Maryland is now the 2nd hospital to perform full face transplant in the US. Just a handful of these procedures have been performed around the world, and they are enormously complex ethically, surgically and medically.

To begin with, long before the surgery even became a possibility, there have been years of work put into setting up such a novel transplant program. Besides obtaining approval for what is still an experimental procedure from an IRB, it is necessary to very carefully screen a population of potential recipients. A face transplant is still quite high risk, especially if the surgery fails because it has the potential to cause serious morbidity and mortality. So, patients selected for transplant have to be vetted very carefully. In the case of the first Chinese transplant, the patient stopped taking immunosuppressive drugs in favor of traditional Chinese remedies, and died soon after. This emphasizes the importance of choosing potential recipients that will reliably take their medications as rejection can be catastrophic.

This surgery took approximately 32 hours from start to finish, and involved a huge multidisciplinary team including multiple transplant and plastic surgeons to perform the procedure. These procedures involve very complex microsurgery to reattach the vascular supply, muscles and nerves to the graft, and, since the jaw and tongue were also transplanted, bones as well.

The surgery is also just the beginning. A life-long course of immunosuppression is required, at least until we can reliably determine how to induce immune tolerance to transplanted organs (this is an exciting field which has also been in the news). And since the jaw contains marrow, there is a risk of graft versus host disease from the transplanted bone.

Then there are the complex ethical issues with facial transplant.

More below the fold…
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Transvaginal ultrasound now being legislated in Idaho

In the continual spread of assaults on women’s reproductive freedom in the wake of the 2010 tea party movement, another state, Idaho, is legislating women receive unnecessary and invasive medical procedures prior to obtaining abortion.

This is part of an unprecedented effort at the state level to restrict reproductive rights, and in 2011 a record number of these measures have passed.

And it won’t stop here, as we’ve seen in Georgia, they are trying to pass a law to force women to carry all 20 week gestations to term, even if the fetus is dead. And if you think that’s creepy, Georgia isn’t the first to do it, such laws have succeeded in Nebraska, Idaho, Indiana, Kansas, Oklahoma,Alabama and Utah.

John Scalzi has a guest post from a physician asking “where’s the outrage?”. Well it’s right here. Scalzi’s poster is suggesting that civil disobedience should follow, but I’m worried that that might be the excuse these states are looking for to shut down clinics and effectively ban all abortion within a state. While I agree the situation is untenable, and is requiring physicians to engage in unethical practice I worry that violating the law is just what the zealots are waiting for. But maybe this needs to happen. We need a test case in front of the courts that asks the question, “can legislatures dictate medical practice in conflict with medical ethics, and without medical justification?” I think the answer would be no, and should be no. Physicians shouldn’t be taking orders from the state on what they do in the examining room. Physician autonomy, ethical practice, reproductive freedoms, and the whole doctor-patient relationship are on the line here. Physicians are here to treat patients, not to serve as tools of the state, against our patients’ interests, to score political points for zealots.