Bittman changes his tune on Sugar Study, while Mother Jones Doubles Down

There’s been an interesting edit in Marc Bittman’s sugar post, as he has now changed his tune on the PLoS one sugar study, now Bittman acknowledges obesity too is important. That was big of him, it is after all, the most important factor. Maybe my angry letter to the editor had an effect, but he’s grudgingly changed this statement:

In other words, according to this study, obesity doesn’t cause diabetes: sugar does.


In other words, according to this study, it’s not just obesity that can cause diabetes: sugar can cause it, too, irrespective of obesity. And obesity does not always lead to diabetes.

The second sentence is totally unnecessary. Of course obesity doesn’t always cause diabetes, or heart attack or whatever. Nor do cigarettes always cause lung cancer. Nor does sugar intake always lead to obesity or diabetes. But obesity is the primary cause of type two diabetes, just as cigarettes are the primary cause of lung cancer, and who knows what sugar is doing.

Mother Jones, sadly, has decided to double down, calling the PLoS One study the “Best. Diet. Study. Ever.” It’s not, of course. It’s merely interesting and suggestive of an effect. It is not nearly proof of causation. They also laud the Mediterranean diet study (maybe it was supposed to be the Best. Study. Ever.?), however, they again show they’re not actually reading these papers because if you read our coverage of the study you’d know they didn’t actually study the Mediterranean diet! In a case of the blind leading the blind, they quote Bittman’s misinformed piece on the Mediterranean diet study

Let’s cut to the chase: The diet that seems so valuable is our old friend the “Mediterranean” diet (not that many Mediterraneans actually eat this way). It’s as straightforward as it is un-American: low in red meat, low in sugar and hyperprocessed carbs, low in junk. High in just about everything else — healthful fat (especially olive oil), vegetables, fruits, legumes and what the people who designed the diet determined to be beneficial, or at least less-harmful, animal products; in this case fish, eggs and low-fat dairy.

This is real food, delicious food, mostly easy-to-make food. You can eat this way without guilt and be happy and healthy. Unless you’re committed to a diet big on junk and red meat, or you don’t like to cook, there is little downside

Except for one critical fact. The subjects assigned to the Mediterranean diet did not have lower consumption of red meat, sugar and hyperprocessed carbs, or other junk! If you look at the supplementary data, you see that the subjects took the positive recommendations of the diet (olive oil, nuts, fish), and more or less ignored the negative recommendations (less meat, less spreadable fats/butter, less baked goods). If you look at figures like supplementary S6, the study groups did not change their diets in these categories relative to the controls, so the effects on their cardiovascular events relative to controls aren’t likely to be from the diet recommendations. When there were changes relative to baseline, even when statistically significant, the changes were tiny.

The participants in this study actually had a very high fat intake, about 35-40% of calories across all groups. And while there was a statistically-significant decrease in cardiovascular events like stroke and heart attack in both study groups (Med + olive oil, Med + nuts), only one arm of the so-called Mediterranean diet (Med + Olive oil) had a non-significant decrease in mortality, while the other arm (Med + Nuts) had a similar curve compared to the “do nothing” control. My interpretation of this, and it’s fine to be critical of it, is that this isn’t that meaningful. If anything, the only variable correlating with decrease in mortality was excess olive oil consumption (> 4 tbsp/day), not the Mediterranean diet. Either that, or eating nuts cancels out the beneficial effects of the diet on mortality.

This is why people always dump on nutrition science when it appears to change every 10 years. Results get overblown, and when the inevitable regression towards the mean occurs, we get blamed for it. The reality is, the press coverage of science is extremely poor, and there is not adequate critical analysis and presentation of results to their audience.

Don't Switch to the Mediterranean Diet Just Yet

The New York Times made big news with reports that the New England Journal of Medicine study on the beneficial effects of the Mediterranean diet showed it could dramatically reduce the rates of heart attack and stroke. But this study has major issues that bear directly on whether or not physicians should make new recommendations about dietary intake of fats like olive oil, or whether patients should adopt the diet as a whole. Let’s talk about the trial.

First of all, this is a randomized, controlled trial, in which 7447 men and women between 55 and 80 years of age who had major risk factors for cardiovascular disease such as diabetes, obesity, smoking, hyperlipidemia etc., were divided evenly between 3 groups, one which received recommendations on a “low fat” diet, and two in which there was extensive counseling on the Mediterranean combined with either a ready free supply of extra-virgin olive oil, or alternatively a variety of nuts.

The primary end points being studied was the combined number of heart attacks, strokes, and death, and over the course of about 5 years of study about 288 such events occurred. If you combine all three of these end points together, and evaluate their frequency between the groups you find 96 of these end points occurred in the “Mediterranean diet with extra-virgin olive oil” or 3.8% of the group, 83 occurred in the Mediterranean diet with nuts for 3.4% of that population, and 109 in the control group for 4.4% of the controls.

But before anyone takes these results to heart, we have to recognize major flaws with the study design, and the populations that comprised these three groups. First, the rate of primary events was surprisingly low for such a high risk group, and because the study was stopped early, absurdly for “ethical reasons”, the number of events is quite low. For the life of me I can’t think of what that ethics committee was thinking. These results are not that dramatic. Further, the “low fat” diet was very ineffectually enforced or counseled, to the point that midway through the study the authors revised the protocol to include more counseling sessions. Evaluating the supplementary data, specifically table S7, you see this control group was in no way on a low fat diet. They still were consuming 37-39% of their calories from fat! “Low fat” should have 10-15% of calories from fats, so basically, everyone ignored the diet. Further, all of the groups consumed a similar amount of total fat, mono and poly-unsaturated fats, and even a used olive oil as their main culinary fat. All groups consumed (see table S5) a similar amount of red meat (forbidden from all diets), butter, soda, baked goods, etc. The places where there seemed to be more dramatic differences were in olive oil consumption (about 50% of controls had > 4 tbsp a day, vs 80% of the “nuts” group and about 90% of the “extra-virgin olive oil group), wine consumption (modest at about 30% in diet groups vs 25% in “low fat” control), nuts (crazy high at 90% in nuts group, vs 40% and 20% in “olive oil” and “low fat”, as well as modest elevation of the amount of fish, fruits and vegetables in the Mediterranean groups. Further, some of these differences, such as the consumption of alcohol, fruits and vegetables, was higher in the Mediterranean groups at baseline (notice no mean change in table S6) so the groups may have started out in a different place.

What does this mean? First of all, we have to reject the notion that this study compared Mediterranean diet to “low fat” diet. This was a study of basically no diet intervention versus increasing your intake of fish, nuts and/or olive oil. Otherwise, there didn’t appear to be compliance with the negative suggestions of the Mediterranean diet, to decrease red mean intake, baked goods, dairy, etc. The participants basically took the recommended items and increased them in their diets, but didn’t exclude any of the “discouraged” items. This is very interesting, but to call it the “Mediterranean diet” is misleading. In reality, it’s diet supplementation with olive oil, nuts and fish.

Second, the final results, while they sound impressive (30% reduction in combined primary end points!) are actually not as important as some of the less-emphasized findings. For this we have to evaluate the secondary endpoint, which happens to be the one we really care about – all cause mortality. They could not show a difference in mortality! So while you might be less likely to have a heart attack or stroke, you’re no less likely to die. This is why I’m so confused they ended the study early. This is really the only end point that matters, and it was unchanged at the interval at which the ethics committee decided this study had to be stopped for efficacy. Why did they do this? The evidence is suggestive that with more participants, the Mediterranean diet + olive oil might have diverged a bit and shown a benefit compared to the do nothing “low fat” control, but this didn’t reach significance.

What have we learned? Compared to other Spanish folks between the ages of 55 and 80, all with cardiovascular risk factors, those that added olive oil, nuts, and fish to their diet had fewer cardiovascular events, but no difference in their mortality compared with people that did nothing to change their diet.

Why did this make the front page of the New York Times? Let’s show a little bit more critical analysis of findings, and not just swallow the PR.

No, It's Not the Sugar – Bittman and MotherJones have overinterpreted another study

Diet seems to be all over the New York Times this week, with an oversell of the benefits of the Mediterranean diet, and now Mark Bittman, everyone’s favorite food scold, declaring sugar is the culprit for rising diabetes. His article is based on this interesting new article in PLoS One and begins with this wildly-inaccurate summary:

Sugar is indeed toxic. It may not be the only problem with the Standard American Diet, but it’s fast becoming clear that it’s the major one.

A study published in the Feb. 27 issue of the journal PLoS One links increased consumption of sugar with increased rates of diabetes by examining the data on sugar availability and the rate of diabetes in 175 countries over the past decade. And after accounting for many other factors, the researchers found that increased sugar in a population’s food supply was linked to higher diabetes rates independent of rates of obesity.

In other words, according to this study, obesity doesn’t cause diabetes: sugar does.

No! Not even close. I hate to repeat his misstatement, because I’d hate to reinforce this as a new myth, but it’s critical to see his full mistake here. This is a wildly inaccurate summary of the authors’ findings, and one they don’t even endorse in their discussion. Bittman has actually just said “obesity doesn’t cause diabetes”, and now has proven himself a deluded fool.

Let’s talk about this paper. This is what is called an “ecological study”, which means it studies populations as a whole, rather than individual patients. Using data from the United Nations Food and Agricultural Organization, the International Diabetes Federation, and various economic indicators from the World Bank, the authors compared populations of whole countries, in particular the prevalence of diabetes correlated to other factors such as GDP, urbanization, age, obesity, and availability of certain varieties of food like sugar, meat, fibers, cereals and oil. Using the rise, or fall, of diabetes prevalence over the last decade in various countries, they correlated this increase with increasing availability of sugar, obesity, urbanization, aging populations etc., and found a few interesting things. For one, increases in GDP, overweight and obesity, tracked significantly with increasing diabetes prevalence. But interestingly, when those factors were controlled for, increasing availability of sugar also tracked linearly with increasing diabetes prevalence, and the longer the duration of the exposure, the worse it got.

However, this does not mean that “obesity doesn’t cause” diabetes, if anything, it’s further support for the exact opposite. While a correlative study can’t be a “smoking gun” for anything, the data in this paper supports increasing modernization/GDP, obesity, and sugar availability are all correlated with higher diabetes prevalence. Even if the sugar relationship is causal, which is no guarantee, the increase in sugar availability could only explain 1/4 of the increase in diabetes prevalence. Obesity is still the main cause of diabetes, which can be demonstrated on an individual level by increases in weight resulting in loss of glycemic control, and subsequent weight loss results in return of euglycemia. In particular, the results of studies of bariatric surgery, in both restrictive and bypass procedures, weight loss is accompanied by improvement in diabetes. The attempts of toxin paranoids like Bittman to reclassify sugar as a diabetes-causing agent, and to dismiss obesity as a cause, are highly premature.

Mother Jones, has a slightly more balanced read, but it still oversells the results.

This is a correlation, of course, and correlation does not always equal causation. On the other hand, it’s an exceptionally strong correlation.

Well, that’s another overstatement. Want to see a picture?

Article Source: The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data

Basu S, Yoffe P, Hills N, Lustig RH (2013) The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data. PLoS ONE 8(2): e57873. doi:10.1371/journal.pone.0057873

Figure 2. Adjusted association of sugar availability (kcal/person/day) with diabetes prevalence (% adults 20–79 years old).

I wonder what the R-squared is on that line fit. Now, consider a comparison with obesity rates by diabetes prevalence:

Figure 1. Relationship between obesity and diabetes prevalence rates worldwide.

Obesity prevalence is defined as the percentage of the population aged 15 to 100 years old with body mass index greater than or equal to 30 kg/meters squared, from the World Health Organization Global Infobase 2012 edition. Diabetes prevalence is defined as the percentage of the population aged 20 to 79 years old with diabetes, from the International Diabetes Federation Diabetes Atlas 2011 edition. Three-letter codes are ISO standard codes for country names.

Hmm, they didn’t fit a line here, but I can bet the fit would be better. Diabetes strongly correlates with BMI, this has been shown time and again using national survey data like NHANES or SHIELD. And before people start whining about BMI as an imperfect measure of obesity, it is perfectly appropriate for studies at a population level, and other metrics such as waist size, hip/waist ratios etc., all show the same thing. Diabetes risk increases linearly with BMI, with as many as 30% of people with BMI > 40 having diabetes, and further, we know from cohort and interventional studies that weight loss results in decreased diabetes. Much of this data is correlative as well (with the exception of the weight-loss studies), and the study that would prove this for certain – dividing people into diets providing excess fat, vs sugar, vs mixed calories, vs controls, with resultant measurement of diabetes rates, would be unethical. Either way, declaring sugar the enemy is both incomplete, and premature. While this paper provides interesting correlative evidence for increased sugar availability increasing diabetes prevalence, it is still subject to risk of confounding errors, it is correlative, and the link does not explain away other known causes of type II diabetes such as obesity. It is a warning however, and we should dedicate more study towards determining if sugar consumption (rather than mere availability) is an independent risk factor for type II diabetes.

Bittman has wildly overstated the case made by this article. He should retract his claims, and the title and false claims should be corrected by the editors. This is a terrible misrepresentation of what this study shows.

What happens when you study conspiracy theories? The conspiracy theorists make up conspiracy theories about you!

I’ve known about this effect for a while as I’ve been variously accused of being in the pocket of big pharma, big ag, big science, democrats and republicans etc. Now Stephan Lewandowsky, in follow up to his “NASA Faked the Moon Landings – Therefore (Climate) Science is a Hoax.” paper, has used these conspiratorial responses to study how conspiracy theorists respond to being studied! It’s called “Recursive fury: Conspiracist ideation in the blogosphere in response to research on conspiracist ideation“.

Here’s the abstract:

Conspiracist ideation has been repeatedly implicated in the rejection of scientific propositions, although empirical evidence to date has been sparse. A recent study involving visitors to climate blogs found that conspiracist ideation was associated with the rejection of climate science and the rejection of other scienti c propositions such as the link between lung cancer and smoking, and between HIV and AIDS (Lewandowsky, Oberauer, & Gignac, in press; LOG12 from here on). This article analyzes the response of the climate blogosphere to the publication of LOG12. We identify and trace the hypotheses that emerged in response to LOG12 and that questioned the validity of the paper’s conclusions. Using established criteria to identify conspiracist ideation, we show that many of the hypotheses exhibited conspiratorial content and counterfactual thinking. For example, whereas hypotheses were initially narrowly focused on LOG12, some ultimately grew in scope to include actors beyond the authors of LOG12, such as university executives, a media organization, and the Australian government. The overall pattern of the blogosphere’s response to LOG12 illustrates the possible role of conspiracist ideation in the rejection of science, although alternative scholarly interpretations may be advanced in the future.

Awesome. It’s actually a great paper, from the introduction discussing Diethelm and Mckee’s work on conspiratorial ideation (who cited us in their original paper), to the comparisons between censorship accusations by diverse anti-science movements from the tobacco/cancer denial to HIV/AIDS denial, Lewandowsky et al., lay the groundwork for understanding this problem as a fundamental characteristic of all anti-science. They even cite a book chapter in which the authors make the link that conspiracies are specifically used to rhetorically challenge science when one lacks adequate data (Lahsen, M. (1999). The detection and attribution of conspiracies: the controversy over Chapter 8. In G. Marcus (Ed.), Paranoia within reason: a casebook on conspiracy as explanation (pp. 111{136). Chicago: University of Chicago Press.) I’ll have to look that one up, as that was our primary conclusion about denialism when we started writing about it in 2007.

The authors then go on to the conspiracist reaction to their original paper:

When the article by Lewandowsky et al. became available for download in July-August 2012, the climate denialist blogosphere responded with considerable intensity along several prongs: Complaints were made to the rst author’s university alleging academic misconduct; several freedom-of-information requests were submitted to the author’s university for emails and documents relating to LOG12; multiple re-analyses of the LOG12 data were posted on blogs which purported to show that the e ects reported Recursive fury 8 by LOG12 did not exist; and a number of hypotheses were disseminated on the internet with arguably conspiracist content. This response is not altogether surprising in light of research which has shown that threats – in particular to people’s sense of control – can trigger targeted small-scale conspiracy theories (Whitson & Galinsky, 2008), especially those involving a speci c opponent (Sullivan, Landau, & Rothschild, 2010).

So what does any good scientist who is interested in the empirical study of conspiracy theories do in such a situation? Mine it for data!

The remainder of this article reports a content analysis of the hypotheses generated by the blogosphere to counter LOG12. The extent and vehemence of contrarian activity provided a particularly informative testbed for an analysis of how conspiracist ideation contributes to the rejection of science among web denizens. Unlike previous analyses of web content, the present project was conducted in real time” as the response to LOG12 unfolded, thus permitting a fi ne-grained temporal analysis of the emerging global conversation.

Using google alerts and other strategies they tracked the response to their paper throughout the denialsphere, then evaluated them using 6 criteria to judge whether the author used conspiracist tendencies independent of actual content. These criteria were great, and as I read them I couldn’t help thinking it is really a beautiful summary of the aberrant thought processes of the conspiracist. They were (1) assuming nefarious intent (NI) on the part of their opponent, (2) delusions of persecution including Galileo comparisons (persecution/victimization or PV) -awesome-, (3) a “nihilistic degree of skepticism”/paranoid ideation (NS), (4) an inability to believe in coincidence or “not an accident” (NoA) thinking, (5) toleration of inconsistencies and contradictions in their own counter-hypotheses as long as they challenge the “official” version (or Must-Be-Wrong MbW), and (6) the incorporation of contrary evidence as further evidence of a conspiracy thus “self-sealing” their hypothesis (SS). This is a really brilliant break down of the behavior if you ask me in particular number 6 which they even provide the perfect example of:

Concerning climate denial, a case in point is the response to events surrounding the illegal hacking of personal emails by climate scientists, mainly at the University of East Anglia, in 2009. Selected content of those emails was used to support the theory that climate scientists conspired to conceal evidence against climate change or manipulated the data (see, e.g., Montford, 2010; Sussman, 2010). After the scientists in question were exonerated by 9 investigations in 2 countries, including various parliamentary and government committees in the U.S. and U. K., those exonerations were re-branded as a whitewash” (see, e.g., U.S. Representative Rohrabacher’s speech in Congress on 8 December 2011), thereby broadening the presumed involvement of people and institutions in the alleged conspiracy. We refer to this “self-sealing” criterion by the short label SS.

At denialism blog we’ve been describing these tactics for years, in particular I feel like the Crank Howto seems to incorporate most of these denialist tactics. In particular, that the authors recognized the persecution complex of the conspiracist is heart warming.

For the meat of the study, the authors then go through the evolution of reactions to their paper, and it’s fascinating. Starting with lots of allegations of “scamming” (must be wrong) and a smear to make them look like nutters (persecution victimization) the conspiracy theories then evolved about everything to whether or not the authors didn’t actually contact skeptic blogs (amazingly the blogs they did contact came out and appear to have lied about not being contacted), persecutorial delusions about the authors blocking individual skeptics IP addresses from accessing the paper (and further conspiracies that when they are being unblocked it’s just to make them look paranoid), conspiracies about it being a ploy by the Australian government (nefarious intent), and it gets crazier and crazier from there. One of the most fascinating aspects of the evolution of the response was how, predictably, as more information was made available, rather than quashing conspiracies, the conspiracy theorists would just broaden the nefarious actors to larger and larger circles of foes:

Second, self-sealing reasoning also became apparent in the broadening of the scope of presumed malfeasance on several occasions. When ethics approvals became public in response to an FOI request, the presumption of malfeasance was broadened from the authors of LOG12 to include university executives and the university’s ethics committee. Similarly, the response of the blogosphere evolved from an initial tight focus on LOG12 into an increasingly broader scope. Ultimately, the LOG12 authors were associated with global activism, a $6 million media initiative, and government censorship of dissent, thereby arguably connecting the response to LOG12 to the grand over-arching theory that “climate change is a hoax.” Notably, even that grand “hoax” theory is occasionally thought to be subordinate to an even grander theory: one of the bloggers involved in the response to LOG12 (cf. Table 1) considers climate change to be only the second biggest scam in history. The top-ranking scam is seen to be modern currency, dismissed as “government money” because it is not linked to the gold standard

And doesn’t that bring this back beautifully, full-circle, to the author’s original hypothesis in the first paper that free-market extremism is behind global warming denialism?

Finally the authors discuss implications for science communication, and, unlike most people, I think they actually understand the problem. That is, you can’t fix this problem with more communication, and more data. The nature of the conspiracy theorist is that all additional data and all contradictory data will only be used to demonstrate further evidence of conspiracy, that the conspiracy is even larger, or that the data are fraudulent. The “self-sealing” nature of the conspiracy theory, as the authors describe it, makes it fundamentally immune to penetration by logic, reason, or additional information.

Implications for science communication. A de fining attribute of conspiracist ideation is its resistance to contrary evidence (e.g., Bale, 2007; Keeley, 1999; Sunstein & Vermeule, 2009). This attribute is particularly troubling for science communicators, because providing additional scientifi c information may only serve to reinforce the rejection of the evidence, rather than foster its acceptance. A number of such “back fire” e ffects have been identi fied, and they are beginning to be reasonably well understood (Lewandowsky, Ecker, Recursive fury 37 et al., 2012). Although suggestions exist about how to rebut conspiracist ideations|e.g., by indirect means, such as affirmation of the competence and character of proponents of conspiracy theories, or affirmation of their other beliefs (e.g., Sunstein & Vermeule, 2009) we argue against direct engagement for two principal reasons.
First, much of science denial takes place in an epistemically closed system that is immune to falsifying evidence and counterarguments (Boudry & Braeckman, 2012; Kalichman, 2009). We therefore consider it highly unlikely that outreach e fforts to those groups could be met with success. Second, and more important, despite the amount of attention and scrutiny directed towards LOG12 over several months, the publication of recursive hypotheses was limited to posts on only 24 websites, with only 13 blogs featuring more than one post (see Table 1). This indicates that the recursive theories, while intensely promoted by certain bloggers and commenters, were largely contained to the “echo chamber” of climate denial. Although LOG12 received considerable media coverage when it first appeared, the response by the blogosphere was ignored by the mainstream media. This confinement of recursive hypotheses to a small “echo chamber” reflects the wider phenomenon of radical climate denial, whose ability to generate the appearance of a widely held opinion on the internet is disproportionate to the smaller number of people who actually hold those views (e.g., Leviston, Walker, & Morwinski, 2012). This discrepancy is greatest for the small group of people who deny that the climate is changing (around 6% of respondents; Leviston et al., 2012). Members of this small group believe that their denial is shared by roughly half the population. Thus, although an understanding of science denial is essential given the importance of climate change and the demonstrable role of the blogosphere in delaying mitigative action, it is arguably best met by underscoring the breadth of consensus among scientists (Ding, Maibach, Zhao, Roser-Renouf, & Leiserowitz, 2011; Lewandowsky, Gignac, & Vaughan, 2012) rather than by direct engagement.

Don’t argue with cranks. I can’t agree more. And historically this is what has worked with denialist groups. You don’t debate them as if they’re honest brokers, you treat them as the defective brains that they are, and eventually, their influence dwindles, and they’ll be reduced to a small community of losers sharing their delusions of grandeur and righteous indignation in some tiny corner of the internet.

The key to preventing denialism isn’t in arguing with those that have already formed fixed, irrational ideas. It can only happen with prevention – early education that emphasizes logic, scientific methods, rational thought and non-ideological, pragmatic approaches to problem solving.

What is the cause of excess costs in health care Part 4 – Time's "Bitter Pill", CEO compensation and the Kafkaesque chargemaster

Steven Brill’s extensive piece in Time has generated a good discussion once again on why Americans pay so much more for health care than other countries, and while I agree with most of his critiques, he seems to have gotten overly hung-up on the hospital chargemaster.

Readers of this blog know I’ve also discussed reform in health care, the diverse sources of excess cost including price gouging on pharmaceuticals, defensive medicine, expensive end-of-life care, the high cost of primary care in the ER etc, and both Brill and I appear to have relied on the same sources of data in the McKinsey report. We’ve also discussed the “hidden tax” of the uninsured, as well as some signs of reform (although of note, my belief that and EMR would reduce waste has proven wrong as the software designers have designed their programs to gouge medicare on behalf of the doctor – increasing costs!).

Brill has written a piece for Time that takes a different tactic, however. Rather than starting from the data on sources of excess costs (although he does reference them), he starts with the patients’ bills and then tries to figure out where all these expenses come from. This is a creative and innovative approach to the problem, except I cringed when I read it because I knew what he was going to find before the end of the first page. Medical bills are insane.

The total cost, in advance, for Sean to get his treatment plan and initial doses of chemotherapy was $83,900.


The first of the 344 lines printed out across eight pages of his hospital bill — filled with indecipherable numerical codes and acronyms — seemed innocuous. But it set the tone for all that followed. It read, “1 ACETAMINOPHE TABS 325 MG.” The charge was only $1.50, but it was for a generic version of a Tylenol pill. You can buy 100 of them on Amazon for $1.49 even without a hospital’s purchasing power.

Dozens of midpriced items were embedded with similarly aggressive markups, like $283.00 for a “CHEST, PA AND LAT 71020.” That’s a simple chest X-ray, for which MD Anderson is routinely paid $20.44 when it treats a patient on Medicare, the government health care program for the elderly.

Every time a nurse drew blood, a “ROUTINE VENIPUNCTURE” charge of $36.00 appeared, accompanied by charges of $23 to $78 for each of a dozen or more lab analyses performed on the blood sample. In all, the charges for blood and other lab tests done on Recchi amounted to more than $15,000. Had Recchi been old enough for Medicare, MD Anderson would have been paid a few hundred dollars for all those tests. By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries.

This is the fascinating aspect of his article but also the tragedy. Because Brill becomes so highly focused on what hospitals charge, and the apparent horrifying mark-up of medicine, I worry that people will come away thinking that this is the cause of excess costs.

The problem Brill is describing is that the costs itemized by hospitals on their bills come from a mysterious document called the “chargemaster”. I’m pretty sure no one knows how the costs are calculated, and I know there is no rational basis for the prices on it. But as shocking as the bills that are generated by these documents are, they are largely irrelevant to the excess costs of healthcare. The chargemaster is a red herring, and despite Brill’s protestations that it is some central evil in health care expenditure, it really isn’t.

The tragic circumstances Brill describes, repeatedly, are what happens when someone who is uninsured, underinsured, or paying out of pocket for medical care experiences when they receive their bill. It is covered with charges that seem insane – because they are – and lacking the knowledge and tools to deal with these ridiculous charges, the uninsured, understandably, believe they need to pay this full, ridiculous bill. But they don’t, and shouldn’t. An uninsured person receiving one of these bills is a little like a tourist who has just been dropped in a foreign bazaar, with no understanding of the rules of the market, discounts, haggling, gouging, or any idea of what other actors in the same market are paying. The reality is that hospital bills, and many other bills in medical care are little more than an opening gambit in an irrational, and largely incomprehensible, cost war between providers and payers. Hospitals, knowing that insurers never pay a full hospital bill, and will haggle and discount charges away or pay a percentage of “chargemaster” costs, push back by artificially inflating costs – as demonstrated throughout Brill’s article. When someone who doesn’t have the power or expertise of the insurance company receives their bill (hospitals of course can’t send different bills to different kinds of customers right?) they end up paying more, or worse, think they have to actually pay the full bill, because they have fallen into this market without the tools or knowledge to navigate it.

The proof of this are the medical bill advocates Brill interviews for the article. For a fee, you can hire someone who has similar expertise as the payers to fight back, and often reduce these bills to a tiny fraction of their original amount.

Shocked by her bill from Stamford hospital and unable to pay it, Janice S. found a local woman on the Internet who is part of a growing cottage industry of people who call themselves medical-billing advocates. They help people read and understand their bills and try to reduce them. “The hospitals all know the bills are fiction, or at least only a place to start the discussion, so you bargain with them,” says Katalin Goencz, a former appeals coordinator in a hospital billing department who negotiated Janice S.’s bills from a home office in Stamford.

Goencz is part of a trade group called the Alliance of Claim Assistant Professionals, which has about 40 members across the country. Another group, Medical Billing Advocates of America, has about 50 members. Each advocate seems to handle 40 to 70 cases a year for the uninsured and those disputing insurance claims. That would be about 5,000 patients a year out of what must be tens of millions of Americans facing these issues — which may help explain why 60% of the personal bankruptcy filings each year are related to medical bills.

“I can pretty much always get it down 30% to 50% simply by saying the patient is ready to pay but will not pay $300 for a blood test or an X-ray,” says Goencz. “They hand out blood tests and X-rays in hospitals like bottled water, and they know it.”

After weeks of back-and-forth phone calls, for which Goencz charged Janice S. $97 an hour, Stamford Hospital cut its bill in half. Most of the doctors did about the same, reducing Janice S.’s overall tab from $21,000 to about $11,000.

Brill also seems very disturbed by two consistently capitalistic elements of hospitals, high compensation of hospital CEOs and non-physician administrators, and the ability of “non-profit” hospitals to actually make a profit. The difference, is, of course, “profits” in this case go back into the hospital, hiring staff, into equipment, buildings, etc., rather than shareholders pockets so one could argue the money largely goes back into the community (disclosure – I work for a non-profit hospital). But what about CEO pay? Brill seems largely offended that they make so much, even making the suggestion at the end of the article that hospital profits be taxed at 75% (insuring no one will ever invest in them again) and that CEO pay be limited to some multiple of a lower-level employee’s salary. Sounds wonderful, except it will only work if that model is applied to CEOs across the board. Brill cites hospital CEO compensations of between 1-4 million dollars. But the average CEO salary is about 13 million dollars as of 2011. Yes CEOs are paid too much, but it’s a global problem, not just in healthcare. If anything, healthcare CEOs are payed a great deal less than their counterparts in other industries, it seems strange to single out healthcare as the one service where CEO pay is somehow more sinful than in others, especially if you want hospitals and medical centers to be able to attract talented management. So am I bothered by CEO pay? Sure, but not as much in my industry as in say, finance, where CEOs who aren’t making profit, and are hurting shareholders get rewarded with bonuses and golden parachutes. Brill seems to be upset that the industry is profitable and are CEOs are well-compensated. But this isn’t so much a source of excess costs in healthcare as it is a source of excess costs in capitalism, and I don’t anticipate that changing any time soon, nor do I think it’s ultimately a good idea to nationalize or socialize the industry to make no profit.

This is too bad, because in an extensive, lengthy documentation of the absurdity of the hospital billing scheme, and anger at CEO pay, Brill’s final recommendations hit many of the true sources of excess cost.

So how can we fix it?

Changing Our Choices
We should tighten antitrust laws related to hospitals to keep them from becoming so dominant in a region that insurance companies are helpless in negotiating prices with them. The hospitals’ continuing consolidation of both lab work and doctors’ practices is one reason that trying to cut the deficit by simply lowering the fees Medicare and Medicaid pay to hospitals will not work. It will only cause the hospitals to shift the costs to non-Medicare patients in order to maintain profits — which they will be able to do because of their increasing leverage in their markets over insurers. Insurance premiums will therefore go up — which in turn will drive the deficit back up, because the subsidies on insurance premiums that Obamacare will soon offer to those who cannot afford them will have to go up.

Agreed. In particular I find the financial conflict of doctors owning labs and radiology equipment, that they then can profit from ordering tests on, is very disturbing. It’s been shown in the literature that this arrangement results in the physicians ordering more unnecessary tests, and demonstrates that it’s an unacceptable conflict of interest that only increases costs.

Similarly, we should tax hospital profits at 75% and have a tax surcharge on all nondoctor hospital salaries that exceed, say, $750,000. Why are high profits at hospitals regarded as a given that we have to work around? Why shouldn’t those who are profiting the most from a market whose costs are victimizing everyone else chip in to help? If we recouped 75% of all hospital profits (from nonprofit as well as for-profit institutions), that would save over $80 billion a year before counting what we would save on tests that hospitals might not perform if their profit incentives were shaved.

We could save lots of money if we forbade various industries from making profit and taxed their incomes at 75%. But I don’t think this is a viable suggestion in a capitalist society, and I believe that if we did increase competition in insurance, pharmaceutical, and other healthcare markets we could decrease costs. Socialism is not the answer, although Brill makes a compelling argument for a public-option as medicare’s administration and pricing is highlighted in the article as a model of efficiency compared to the private insurers. I’d have no problem with expanding medicare as a payer. Next:

We should outlaw the chargemaster. Everyone involved, except a patient who gets a bill based on one (or worse, gets sued on the basis of one), shrugs off chargemasters as a fiction. So why not require that they be rewritten to reflect a process that considers actual and thoroughly transparent costs? After all, hospitals are supposed to be government-sanctioned institutions accountable to the public. Hospitals love the chargemaster because it gives them a big number to put in front of rich uninsured patients (typically from outside the U.S.) or, as is more likely, to attach to lawsuits or give to bill collectors, establishing a place from which they can negotiate settlements. It’s also a great place from which to start negotiations with insurance companies, which also love the chargemaster because they can then make their customers feel good when they get an Explanation of Benefits that shows the terrific discounts their insurance company won for them.

While I agree outlawing the chargemaster should be considered, I’m not really sure it will work. For one, yes, it is a fiction, it’s not an actual source of excess costs like so many other problems described in the McKinsey report. And hospitals are in a bind. They can’t charge what things actually cost, because insurance companies will still try to pay less. Hospitals know what their costs are, but it’s nearly impossible to truly itemize a patient’s stay, and take into account the exact time every physician doctor and nurse spent with them versus another patient, exactly how many disposable materials were used, as well as factor in all the other costs hospitals need to balance such as covering uninsured patients (most of whom never pay their bills), profit-losing divisions of hospitals and “mission” costs, as well as having a adequate nest egg at the end of the year to ensure adequate capital to expand as needed to meet demand, buy new equipment, and hire new staff. My guess as to what the chargemaster is accomplishing (and it is just a guess), is that it’s a strategy that reliably returns a certain amount of profit on each hospitalization relative to patient utilization of specific services, while providing plausible deniability for what is ultimately overcharging the insured to subsidize the total costs of running their operation. It has to be inflated to cover all the costs of overhead, supplies, etc., that just can’t be reliably quantified, and the fact that insurance companies will only pay a fraction of the final bill. The alternative would be to “bundle” costs so that hospitalizations for specific services cost a set amount, and hospitals then have an incentive to come in under that reasonable fixed price for the service. But then, you run into the problem of penalizing the hospitals that treat needier, poorer, sicker, older populations that cost more to treat, and will have poorer outcomes, readmissions, and complications.

It’s a pickle. You want hospitals to have some measure of profitability – they provide a necessary service, employment, and pride to the community. But if you create profit incentives that put them in conflict with the community – like avoiding poorer, sicker, older patients, they won’t provide the very service for which they exist.

I don’t have a good solution to this problem. We need to own up to the costs of treating the difficult populations, rather than continuing to play the insurance shell-game. Hospitals have to treat people who are sick no matter what because of laws like EMTALA. EMTALA is an unfunded mandate, passed during the Reagan years, that doesn’t specify how hospitals shall recoup their losses when someone can’t pay, just that they have to provide care for sick people no matter what. The unwillingness to pay for the poor and the uninsured pushes even their primary care into the ER, and they present with more acute problems that earlier access to primary care could have managed more cheaply, raising the costs of their care, and foisting it on the hospitals – especially the non-profit, inner-city hospitals providing care to the most at-risk. They then have to figure out some way of spreading these costs back onto medicare and the insured and paying patients without attaching a rider to the bill that simply says, “paying for the sick and uninsured in your community — $1200” (then you actually only have to pay only $200 for this service in reality because everything is inflated). I suspect the chargemaster, in its irrational and frightening way, is accomplishing this task. It’s not pretty, but I’d love to hear suggestions to address the need of hospitals to provide universal health care without a funding source to do so.

Then Brill gets to the things which I agree the McKinsey report shows are our real sources of excess costs:

We should amend patent laws so that makers of wonder drugs would be limited in how they can exploit the monopoly our patent laws give them. Or we could simply set price limits or profit-margin caps on these drugs. Why are the drug profit margins treated as another given that we have to work around to get out of the $750 billion annual overspend, rather than a problem to be solved?

Just bringing these overall profits down to those of the software industry would save billions of dollars. Reducing drugmakers’ prices to what they get in other developed countries would save over $90 billion a year. It could save Medicare — meaning the taxpayers — more than $25 billion a year, or $250 billion over 10 years. Depending on whether that $250 billion is compared with the Republican or Democratic deficit-cutting proposals, that’s a third or a half of the Medicare cuts now being talked about.

We pay twice as much for our drugs as any other country, R&D is a BS excuse, and the inability of medicare to collectively bargain is anti-capitalistic and anti-market. How is it possible that in a capitalistic society a buyer isn’t allowed to bargain for bulk purchase? It’s just a wealth-redistribution scheme! And the proof is systems like the Veterans Administration, which is allowed to negotiate for lower prices, and does, typically paying about half as much for the same drugs.

Similarly, we should tighten what Medicare pays for CT or MRI tests a lot more and even cap what insurance companies can pay for them. This is a huge contributor to our massive overspending on outpatient costs. And we should cap profits on lab tests done in-house by hospitals or doctors.

I think that particular conflict of interest should be banned, but one must remember again that differing CT and MRI costs are largely a reflection of which hospitals have higher “mission” costs. It’s not the CT in the suburb that costs medicare more, it’s the CT in the inner-city.

Finally, we should embarrass Democrats into stopping their fight against medical-malpractice reform and instead provide safe-harbor defenses for doctors so they don’t have to order a CT scan whenever, as one hospital administrator put it, someone in the emergency room says the word head. Trial lawyers who make their bread and butter from civil suits have been the Democrats’ biggest financial backer for decades. Republicans are right when they argue that tort reform is overdue. Eliminating the rationale or excuse for all the extra doctor exams, lab tests and use of CT scans and MRIs could cut tens of billions of dollars a year while drastically cutting what hospitals and doctors spend on malpractice insurance and pass along to patients.

Tort reform may benefit but it’s effects will take decades to see. It’s almost impossible to adequately quantitate the cost of “defensive” medicine, and how it has inculcated generations of physicians to overtest, overtreat, and overspend on patients. Even if such changes were made, the paranoia runs deep within us. I agree it’s costly, but it will take more than just removing the threat of lawsuits to generate more responsible cost-practices for physicians.

Over the past few decades, we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.

We’ve created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract.

And we’ve allowed those on the island and their lobbyists and allies to control the debate, diverting us from what Gerard Anderson, a health care economist at the Johns Hopkins Bloomberg School of Public Health, says is the obvious and only issue: “All the prices are too damn high.”

If you throw in a ban on Direct To Consumer Advertising on Drugs, implementation of CPRS or a universal record standard for the EMR (not these medicare-gauging EMRs that for-profit companies are designing), and better end-of-life planning, data, and management, I think we’d go a long way to reducing costs. Brill’s final recommendations hit the mark, but I’m concerned his obsession with the admittedly Kafkaesque chargemaster is a distraction. That’s not the true source of the excess costs. Rather I suspect it’s a way for hospitals to try to rationalize the redistribution of resources from medicare and the insured to cover their broader mission.

And one final petty complaint which as a surgeon I couldn’t resist:

Steve H.’s bill for his day at Mercy contained all the usual and customary overcharges. One item was “MARKER SKIN REG TIP RULER” for $3. That’s the marking pen, presumably reusable, that marked the place on Steve H.’s back where the incision was to go.

No! The pen is sterile! We have to mark the skin after prep – the alcohol based preps we use will wash away most markings placed before sterile preparation, and iodine preps hide them pretty well too. Complaining about a lot of potentially “reusable” items is also just not going to fly in this modern world of MRSA and nosocomial infections.

Denialism From Forbes Courtesy of Heartland Hack James Taylor

It’s fascinating when you catch the start of a new bogus claim enter the denialsphere, bounce from site to site, and echo about without any evidence of critical analysis or intelligence on the part of the denialists. A good example of this was an article by Heartland Institute’s contributor to Forbes, James Taylor, falsely claiming only a minority of scientists endorse the IPCC position on the causes of global warming. This new nonsense meme gets repeated by crank extraordinaire Steve Milloy, bounces the next day to Morano’s denialist aggregation site, and before long I’m sure we’ll be seeing it on Watt’s site, Fox news, and in a couple more weeks, in an argument with our conservative uncles.

The claim is, of course, a deception (or possibly total incompetence) on the part of Heartland’s “senior fellow for environment policy” (I wonder if there is significance to the use of “environment” as opposed to “environmental”). Linking this paper in the journal Organization studies, Taylor makes a false claim that a mere 36% of scientists, when surveyed, hold the consensus view. Anyone want to guess at the deception? Cherry-picking! It was a survey of largely industry engineers and geoloscientists in Alberta, home of the tar sands. In the study authors’ words:

To address this, we reconstruct the frames of one group of experts who have not received much attention in previous research and yet play a central role in understanding industry responses – professional experts in petroleum and related industries. Not only are we interested in the positions they take towards climate change and in the recommendations for policy development and organizational decision-making that they derive from their framings, but also in how they construct and attempt to safeguard their expert status against others. To gain an understanding of the competing expert claims and to link them to issues of professional resistance and defensive institutional work, we combine insights from various disciplines and approaches: framing, professions literature, and institutional theory.

This is pretty classic denialist cherry-picking and and is one of the most common deceptive practices of denialists like Taylor. By suggesting a survey of industry geoscientists can be generalized to scientists as whole, Taylor has demonstrated the intellectual dishonesty inherent in denialist argumentation. You might as well make claims about the consensus that tobacco causes lung cancer by surveying scientists in the Altria corporation headquarters.

The paper is actually quite interesting, and I’m glad I read it, as it is consistent with our thesis that ideological conflicts result in refusal to accept science that contradicts one’s overvalued ideas or personal interests. The authors surveyed a professional association of geoscientists in Alberta Canada (APEGGA), most of whom are working for the petroleum industry, and then performed a detailed analysis of their free-text responses on why they accept or reject climate science. What they found was there are 5 general “frames” used by respondents that their answers conformed to. The most common response was that global warming is real, and we need to act with regulation to address the problem (at 36%, the number quoted by Taylor to suggest there is no consensus), another 5% expressed doubt at the cause but agreed green house gases needed to be regulated. The second most common responses were “it’s nature” or “it’s a eco-regulatory conspiracy” and these responses showed a great deal of hostility in language towards environmentalism, proponents of global warming, liberalism etc. These came in at about 34% of responses and were more common from older white males in the higher tiers of the oil industry corporate structure. The most common remaining frame was a “fatalist” frame (17%) which could take or leave the science because hey, we’re screwed no matter what we do.

The authors weren’t attempting to validate the consensus with this study, but rather were trying to understand how scientists working in industry justify their position on global warming, as they often reject the consensus view of climate science. When a true cross-section of climate scientists is sampled, agreement with consensus is found among about 90% of scientists and 97% of those publishing in the field. A more appropriate summary of what these authors showed was that oil industry geoscientists and engineers most frequently express a view consistent with the consensus IPCC view and a need for regulation of green house gases. A similar but slightly smaller number express hostility to the consensus view and about half as many as that think we’re screwed no matter what we do.

It all would have been short-circuited if Forbes had exercised any kind of appropriate editorial control over this crank James Taylor. Or, if the echo chamber had read some of the comments on the initial post before rebroadcasting a false claim far and wide, but then, that would require intellectual honesty and a desire to promote factual information. Does Forbes have any interest that one of their bloggers is misrepresenting the literature in this way? Is this acceptable practice among their contributors? Is this the kind of publication they wish to be?

Finally, I see the authors of the paper (who I alerted to the Forbes article’s presence – they clearly were not contacted by Taylor for comment) have response. From their comment:

First and foremost, our study is not a representative survey. Although our data set is large and diverse enough for our research questions, it cannot be used for generalizations such as “respondents believe …” or “scientists don’t believe …” Our research reconstructs the frames the members of a professional association hold about the issue and the argumentative patterns and legitimation strategies these professionals use when articulating their assumptions. Our research does not investigate the distribution of these frames and, thus, does not allow for any conclusions in this direction. We do point this out several times in the paper, and it is important to highlight it again.

In addition, even within the confines of our non-representative data set, the interpretation that a majority of the respondents believe that nature is the primary cause of global warming is simply not correct. To the contrary: the majority believes that humans do have their hands in climate change, even if many of them believe that humans are not the only cause. What is striking is how little support that the Kyoto Protocol had among our respondents. However, it is also not the case that all frames except “Support Kyoto” are against regulation – the “Regulation Activists” mobilize for a more encompassing and more strongly enforced regulation. Correct interpretations would be, for instance, that – among our respondents – more geoscientists are critical towards regulation (and especially the Kyoto Protocol) than non-geoscientists, or that more people in higher hierarchical positions in the industry oppose regulation than people in lower hierarchical positions.

Incompetence or deception by Taylor? You tell me. Either way, this is the kind of shoddy, non-academic discourse we get from bogus ideological think tanks like Heartland. They should be embarrassed.

Article Cited:
Lianne M. Lefsrud and Renate E. Meyer
Science or Science Fiction? Professionals’ Discursive Construction of Climate Change Organization Studies November 2012 33: 1477-1506, doi:10.1177/0170840612463317

Gun control Part III – Some final questions for Matt and closing remarks

Go by and check out Matt’s second response on gun control.

I think this response is a good argument. After all, my arguments are correlative. It is impossible to do randomized controlled trials on whole countries after all.

I would ask a few questions in response to this rebuttal, however. Matt, what do you think about about data that demonstrates, within our own country, higher gun prevalence correlates with higher homicide, independent of other risk factors? Can we really dismiss the potential impact of federal gun laws using local gun laws as an example? Its pretty clear from places like New York and Chicago, that any local law is undermined by whatever nearest state (or county) has the softest laws.

The issue of whether or not increasing or decreasing gun ownership is also a bit besides the point. After all, that was not the major thrust of my suggestions. Repeatedly, it seems, I am arguing against a straw man that I am advocating gun bans. Matt acknowledges this problem:

This is true, and fair enough as it goes. We gun-rights types are justifiably a bit jumpy about this sort of thing. It would be nice if Mark were the one writing the various laws being proposed in congress and various state legislatures. Unfortunately it’s people like Dianne “Turn ‘em all in” Feinstein and Carolyn “Shoulder thing that goes up” McCarthy and Andrew “Confiscation could be an option” Cuomo. It’s great for the two of us to discuss our Platonic ideals of the way things ought to be, but we also have to remember that we’re dealing with members of the world’s second oldest (and least reputable) profession. Since their stated intent is to take a mile, I’m not very willing to give them any free inches without an airtight case as to effectiveness and respect for the rights of the law-abiding.

I have emphasized in the past, I despise the stupidity and futility of the cosmetic Assault Weapons Ban as advocated by Feinstein for the twin sins of demagoguery and uselessness. But pretend for a moment I am an honest broker in this debate, and I’m not trying to land you on the slippery-slope towards gun confiscation. Do you really believe there is nothing that can be done on the supply-side to decrease either mass violence or, separately, gun homicide in this country? Or that there is nothing that can be done to prevent these guns from falling in the wrong hands in the first place? I believe we can prevent on the supply-side by preventing these guns from getting into the wrong hands, and this can be accomplished without bans.

As a closing statement on this debate, I’d reiterate the laws I advocate do not ban guns. You hear that commenters? During the entire debate, I haven’t suggested a single gun ban, so I don’t need to have this nonsense showing up in the comments. No. I believe there should be two major regulatory efforts: (1) there should me more scrutiny on gun purchasers who want to buy weapons that make mass violence easy, and (2) secondary markets need to be subjected to the same minimal level of scrutiny as the primary markets for all guns (background checks for shotguns, revolvers, bolt-action rifles etc., my higher level of scrutiny and responsibilities for purchasers of semi-automatic weapons).

I’m not talking about any kind of ban, but scrutiny on purchase of magazine-fed semi-automatics. This means people have to do some paperwork, have a check to make sure they’re not a crook (these two already exist), find a couple people to vouch they’re not nuts, demonstrate they can use and store the weapon safely, and they understand simple things like high powered semi-automatic rifles shouldn’t be used with metal-jacketed ammunition in a dense metropolis. Scrutiny, training, safety. These should be relatively noncontroversial measures.

We’ve all done this before after all, or don’t you remember the first time you showed up to the DMV to get a driver’s license? Similar theory, a car is a very dangerous machine, before you start driving you show up, they make sure you haven’t been arrested for joy-riding, you go for a little ride with an instructor to make sure you aren’t completely incompetent at operating the very dangerous machine, and you pass a little test to make sure you know the rules for safe use of the machine. Not a big deal. And how about using technology to make unauthorized use of the machine more difficult? Make it hard for the “dead-eyed killer”, as Matt calls them, to get their hands on the weapon, either from the store, or from someone’s home. Even more ideal, start working on technology to prevent unauthorized use, like the humble car key, that makes it harder for the unauthorized user to jump into your very dangerous machine, and run over a bunch of kids on the playground. Sure they can always hotwire it, but that’s hard, it takes special knowledge, and unauthorized use of the very dangerous machine shouldn’t be easy. It will invariably be argued ad nauseum that such measures can be defeated. Sure! I agree, they can be defeated. Almost any preventative measure can be defeated by a motivated, intelligent and skilled individual, but that doesn’t mean tomorrow banks will stop using vaults, or that we should give up on restricting access to grenades and C4. Barriers are just that, barriers, not perfect preventatives. All human efforts are imperfect, but these barriers may be effective strategies to decrease the likelihood or frequency of such attacks. There’s an expression, low fences keep in big animals.

And what’s so scary about such regulations for an item that kills as many as 30,000 of us a year? For years, we’ve recognized we need to regulate cars, they’re one of the single most dangerous objects in our daily existence. Automobile accidents are the most likely thing to kill you for a good chunk of your life. That’s why we make sure before people can drive, they know how. That’s why we require safety features. For years, the NRA has resisted any equivalent regulation to make gun ownership safer, they’ve resisted any attempt to incorporate safety features into weapons, they’ve resisted any scrutiny before gun purchase, and they’ve resisted scrutiny of secondary gun markets. Why is it so controversial to treat dangerous machines as something that need to be respected? Guns are machines that require training to use, they should have safety features that prevent improper use, they require safe storage when not in use, and there should be barriers and strategies in place to prevent possession by criminals and the mentally ill.

The second major thrust, and I’m not sure Matt really disagrees with me here, addresses the fact guns in the hands of criminals are coming from secondary markets. I discussed extensively in part II guns used in crime are usually fairly new guns. The generally-agreed upon sources are secondary gun markets – straw purchases, trafficking, and stolen guns – only about 10% are used in crime by the original purchaser. If we acknowledge that gun crime is a problem in this country and actually want to do something about it, we have to extend criminal background checks to all transfers of firearms. We have to make secondary markets subject to the same scrutiny as primary markets, and when guns end up in a criminal’s hands, we have to be able to track down the source of the weapon and punish them.

This is how guns get to the street. If we don’t arm law enforcement with the tools to punish gun traffickers and straw purchasers, we’re not going to be able to stop the steady flow of weapons to the streets, and into the hands of criminals. I know, 300 million guns are already out there that couldn’t be tracked by a newly-implemented system, but I’m assuming the overwhelming majority of gun owners are decent citizens who aren’t interested in selling their guns to criminals either, will gladly use the NICS system, and won’t sell their guns to criminals once the existing secondary markets are tightened. Straw purchasers, gun traffickers, and anyone else who sells guns or makes guns available to criminals should be put in jail, and treated like the accessories to crime that they are.

In these debates I’ve suggested these two overarching strategies, one to prevent mass shootings and one to decrease firearm use in crimes. For the first I admit, as does Matt, the data on viable preventative strategies is poor. The events are rare. One of the few examples of a specific response to the problem of mass violence, Australia, is consistent with a benefit to reducing mass violence by restricting magazine-fed semi-automatic weapons, but is questionable in its reduction on gun violence as a whole. I agree with Matt, making these weapons harder to obtain isn’t going to make a huge dent in gun violence as a whole, but I reiterate, increasing scrutiny of purchases of magazine-fed semiautomatics is specifically my suggestion to decrease mass violence. It is possible however, my storage and training portion of that strategy might decrease gun homicide rates modestly by decreasing the frequency of accidents and gun thefts. My second strategy, that of subjecting all gun transfers and purchases to this type of scrutiny, is specifically meant to address gun crime, based on the clear data that guns on the street are (1) usually new guns, and (2) coming from secondary gun markets 90% of the time. If we dry up the flow of guns to the street we are likely to accomplish two goals. We may decrease gun homicides, and we will arm law enforcement with the tools to track down and punish those that supply weapons to criminals.

Neither of these strategies should prevent any law-abiding citizen from obtaining any weapon that is available to them today, at the same time, they obstruct the flow of guns to criminals and erect barriers to those that might commit mass violence.

Anti-Gay Marriage Argument makes no sense

I was bewildered by this LA times article over the weekend describing the latest tactic of the DOMA defenders planning to argue before the Supreme Court, that is, that marriage is necessary for heterosexuals only because of the possibility of accidental child bearing.

Marriage should be limited to unions of a man and a woman because they alone can “produce unplanned and unintended offspring,” opponents of gay marriage have told the Supreme Court.

By contrast, when same-sex couples decide to have children, “substantial advance planning is required,” said Paul D. Clement, a lawyer for House Republicans.

This unusual defense of traditional marriage was set out last week in a pair of opening legal briefs in the two gay marriage cases to be decided by the Supreme Court this spring.

Am I taking crazy pills or does this make absolutely no sense? At the same time, I had just read (via Gawker)
this marriage announcement:

Ada Laurie Bryant and Robert Mitchell Haire were married Saturday in Hockessin, Del. Robert L. Bryant, a Universal Life minister and a son of the bride, officiated at his home.

The bride, 97, is keeping her name. She graduated from Lesley College in Cambridge, Mass.

She is the daughter of the late Ada Lee Laurie and the late Richard Laurie, who lived in Hingham, Mass.

The bride was a widow and the groom a widower.

The couple met in 2007, when Mr. Haire and his first wife, Jean, moved into Country House, a retirement community in Wilmington, Del. Mrs. Bryant had lived there since 2001 with her first husband, Leonard, who died shortly after they moved in. Mrs. Bryant and Mrs. Haire became close friends.

On Jan. 25, 2012, Mr. Haire, a hobbyist poet, slipped a sonnet vowing “friendship and affection” beneath Mrs. Bryant’s apartment door with a note that said “this represents how I feel in our relationship as a couple.” He was afraid to give it to her in person.

“I was desperately trying to strike a balance between too timid or bold. I didn’t want to mess things up,” he said about the courtship. “I can attest that it doesn’t get easier even in advanced age.”

Mrs. Bryant finally accepted his proposal on Aug. 6, and they will move into her apartment (“It’s slightly bigger,” he said) after the wedding.

She explained why she first turned him down. “There’s a great difference in our ages, as you can see,” she said. “I didn’t think it was the thing to do because I don’t have that many years ahead of me, but he said, ‘That’s all the more reason.’ I like him very much. I love him. So we’re going to be married.”

It’s all very sweet, finding love and getting married at even such an advanced age. But by the logic of the DOMA advocates, these two shouldn’t be allowed to marry because there is no chance of offspring.

Can we really defend this law by saying marriage is only for procreation when so many examples abound of how it clearly is not?

Gun Control Part II: My response to Matt Springer

I was curious to see what kind of defense Matt would put on against my suggestion of additional regulations to address the problem of gun violence and homicide in the US, and I was a bit disappointed to see that the response is largely a “no problem” argument. I had actually come into this debate thinking that both of us at least acknowledge that the US has a problem with gun homicide, but it appears as though I’ll have to backtrack a bit. So, starting with the “no problem” argument, I will describe why it is bogus, why the US does have a problem with firearm homicides (I can’t believe that’s an area of contention), and restate with some additional data why I believe my original proposals might make a dent in the two separate issues of mass violence and gun homicide.

The no problem argument usually takes a few different forms. First, describe other things we encounter in our daily lives that are responsible for as many deaths, like automobiles, or in the case of mass shootings, Springer choose lightning strikes.

In the 32 years since 1980, there have been some 513 people killed in 62 incidents of mass shootings under the Mother Jones definition (perpetrators generally included). This amounts to an average of 16 per year. Over the 12 years for which the CDC has available data, the average death rate due to lightning strikes has been 45 per year.

Some of my commentariat chose to talk about household falls, second-hand smoke, and a diet rich in bacon. These arguments almost always arise when you make an argument to do something about almost anything, and the do-nothings come out of the woodwork to concern-troll you about how there is some more important issue that should be addressed. The problem with these “no-problem” arguments is that (1) they often rely on poor analogies, and (2) they assume that almost no problem, other than maybe cancer or malaria in the third world, should be absorbing all of our attention. Nothing preventative can be done about lightning strikes. Automobiles are not only highly-regulated, titled by government, restricted from use by the under-aged and untrained etc., but also necessary to function for most people in their daily lives (also guns are almost as deadly – I’ll get to it). As are ladders, stairs, other household implements, and as far as second-hand smoke, I’m pretty sure I haven’t been exposed to that since I was last in a casino thanks to extensive government anti-smoking efforts. As far as a diet rich in bacon, sure, I’ve had more than a few patients die from heart attacks or strokes in their 60s and 70s after decades of self-inflicted harm, but the patient I think about more is the 24-year-old paralyzed from the neck down after catching a stray while standing on the wrong street corner at 5 pm. Lightning is one thing, but a 6 or 7-year-old killed by a gun, due to no action or risk they took upon themselves other than living in the same community as a mentally-defective monster with access to firearms, is a different kind of tragedy. We can’t stop lightning, but I think there are preventatives to gun violence, and we must be careful not to compare risks that one assumes for oneself, versus actions that create risk for those around us.

Springer is also concerned that a response, just for the sake of response, will create government excess similar to our excessive government overreach post-9/11. But while some anti-gun advocates may be talking in extremes, I don’t think my suggestions, or basically identical ones from the Obama administration were so over-the-top. I didn’t call for a ban on any type of weapon (although I favor a ban on large-capacity magazines), confiscation, or any other of the major bugaboos that usually terrify the pro-gun crowd. Briefly, I suggested increased scrutiny on purchases of what I consider military hardware – magazine fed semi-automatic weapons – and required safety precautions for storage and access to such weapons. To address the approximate 10,000 gun homicides in any given year, I suggested relatively minor barriers, now being advocated by the Obama administration, on private sale of firearms. This is because currently law enforcement has some ability to address trafficking by licensed gun dealers, but the paper trail ends at the first retail sale. To stop gun crime we have to get the guns out of the hands of criminals. As I’ll discuss below, some 90% of these guns come from the secondary gun market.

The second form the “no-problem” argument usually takes is minimization:

Now it’s worth taking a look at violent crime generally. While an uncommon cause of death in percentage terms, murder is a significant source of mortality in the United States. Of murders in the United States in 2011, 8,583 (about two thirds) were committed with firearms. Of firearms murders, the overwhelming majority were committed with handguns (6,220 with certainty, and likely most of the 1,587 “type not specified”). The rate of homicides (by all methods) is about 4.8 per 100,000, which is high compared to Australia (1.0) the UK (1.2), or Canada (1.6). On the other hand, it’s low when compared to most nations outside the highly developed first world, such as Russia (10.2) and Mexico (22.7). The highest, Honduras, is a staggering 91.6.

Mark dismisses any comparison to Mexico, but the comparison is more instructive than it first appears. The population of the Texas border city of El Paso is some 75% Mexican (and more than 80% Hispanic), but its homicide rate is a relatively bucolic 0.8 per 100,000. Its adjoining Mexican neighbor of Juarez is one of the most violent places on the planet, peaking at a hideous 130 per 100,000 in 2009. Do El Paso’s gun-friendly Texas laws make it so much more peaceful than Juarez? I doubt it. But it does put to bed the idea that gun laws are the primary or even a significant driver of the crime rates.

As I’ve mentioned in comments multiple times, I totally reject comparisons of the US to Mexico, or even Russia, as highly absurd given synergy of corruption and ineffectual governments present in both of those examples. Not to mention, the drug war in Mexico is practically an internecine war and is responsible for as many as 50,000 deaths since 2006. I reject the comparison to Mexico as totally meaningless just as I would reject the comparison of our country to any other war zone like Afghanistan or Iraq.

The Institute of Medicine in comparing the US to similar industrialized countries in terms of life expectancy found that our homicide rate is far in excess of comparable OECD countries, and significantly affects our life expectancy. The IOM study found our homicide rate to be 6.9 times higher than the other OECD countries, our gun homicide rate 19.5 times higher, and of the 23 countries in the study, the US was responsible for 80% of all firearm deaths. It is also useful to narrow down the problem by age. One of the worst aspects of this type of mortality is that it disproportionately affects the young. If you convert it from a mere cause of death, to a calculation of years of life lost, gun homicide is a much more striking phenomenon. In the end, our mortality rate is 100%. A comparison of the relative mortality of different mechanisms of death is not meaningful in itself unless we also consider the age at which the mechanism strikes. Firearm homicide kills at a mean age in the 30s for males, and in when years of life lost is used for comparison firearm homicide is only exceeded unintentional injuries (car accidents, falls etc), cancer, and heart attacks. Sorry if that’s old data, that’s what happens when the gun lobby prevents the CDC from studying the problem. A more recent analysis puts firearms just behind automobile accidents for decreasing our life expectancy.

We have a problem.

Finally, the “no problem” argument, especially in regards to guns, seems to fall back on these damn cat-skinning arguments. Yes, there is more than one way to skin a cat. I get it. It’s irrelevant:

The Bath School bombing in 1927 killed more than Sandy Hill and Columbine combined. Julio González killed 87 in the Bronx in 1990 with a match and some gasoline. The most lethal female mass killer in America used a Lincoln Continental. The unknown perpetrators of the Black Saturday fires in Australia killed many times more people than the Port Arthur massacre that touched off that nation’s much stricter gun laws. Now a list of anecdotes is not dispositive, but it is surprisingly hard to find comprehensive academic lists of rampage killings for the purpose of comparing across borders and between gun and non-gun attacks. At any rate the Wikipedia compendium of rampage killings internationally is striking (if not rigorous) reading – it lists 119 mass killings in the Americas and 100 in Europe.

This is not a relevant argument to making firearms more difficult to obtain. As I’ve pointed out repeatedly, the ability of killers to use more than one kind of weapon does not have anything to do with whether or not weapons ideal for commission of mass homicide should be easy to obtain. Yes, it is possible for many to create bombs from relatively common materials, after all the Columbine killers also attempted to blow up their school – which demonstrates another point, these things require expertise, much more planning, and have a fail rate more significant than a manufactured, ready-to-shoot rifle. Just because there is more than one way to skin a cat doesn’t mean you should sell industrial grade cat-skinning machines that skin 1000 cats a minute to anyone with a driver’s license and 500 bucks.

And while the list of mass killings is very hard to interpret, when sorted by year you see the European list has about 20 incidents in the last 20 years, whereas the US alone has had 31 in that time period. The list also does not include school shootings which gives the US another 12 mass incidents and Europe an additional 7. I think we’re sadly still winning in this competition at 43 to 27 (and the US has 3/7 the population of Europe).

We do have a problem (sigh).

Onto the criticisms of my proposals. This is how Matt characterized my argument:

Mark has penned his own contribution, in which he argues along four lines. First, that gun control will reduce acts of mass violence. Second, that gun control will reduce violent crime generally. Third, that specific gun control methods he enumerates ought to be put in place in view of the previous two points.

I disagree. Saying that I believe gun control will reduce acts of mass violence is a simplification, because “gun control” usually is a stand in for bans. This is not quite correct. I made the argument that since magazine-fed semi-automatic weapons are the weapons of choice in the last few dozen of these shootings that before sale the purchaser should get a bit more eyeball by authorities. Specifically in regards to the VT shooter, the Aurora Shooter, or the Giffords shooter, I suggested increased scrutiny for these purchases, law-enforcement taught training and competence testing for their use, and I also suggested the Canadian voucher system (as did Kristof immediately after Sandy Hook), which would require two other people to stand up for you and say you are responsible enough to possess such a machine. Part of the profile for a significant portion of these shooters has been they have set themselves apart from society. They are not “plugged-in” to their community, and are frankly weird. These proposals serve two purposes. They expose the purchaser to additional scrutiny to demonstrate they are competent and safe users of potentially very dangerous equipment, and they demonstrate the purchaser is not a loner weirdo who doesn’t even have two people in the world that think they’re capable of owning such equipment without turning it on the neighborhood. If you think the second restriction is too much, well, that’s kind of pathetic. If you can’t find two other people in your town that don’t think you’re too psycho to own a weapon, you probably shouldn’t have a weapon. Sure, these systems can be foiled. They won’t prevent all instances of mass violence. They are imperfect, and similar high levels of restriction have been foiled in other nations, but that doesn’t mean that obstacles to ownership for those matching the mass-murder profile won’t have any effect. We shouldn’t let the perfect ruin the good.

The second suggestion I made for mass shooting prevention is requiring owners of such weapons to store them in a safe manner, and require manufacturers of such weapons to incorporate built-in fire-locks, or user specific locks to prevent unauthorized use. The shooter in Newtown was, by accounts to date, a very mentally-disturbed individual, who accessed his mother’s own weapons to first kill her, then 20 school children. Could this have been prevented by something as simple as a gun-safe? Or could it have been prevented by an integral fire-lock mechanisms that require key or smart guns that prevent use by anyone other than the owner? We have not adequately addressed the possibility that technology can do a great deal to prevent unauthorized use, not to mention render theft of firearms, and subsequent trafficking, much more difficult or completely non-profitable. Most guns confiscated from criminals are actually relatively new guns, and the illegal gun market requires continuous inputs of new weapons either stolen from homes or straw-purchased from legitimate owners or dealers.

Which brings me to my third point, to deal with gun homicide generally, I did not describe “gun control” per se, but rather adequate record keeping and background checks for private sales. Again, “gun control” suggests bans or limits. I would not ban private sale or forbid it at all, but simply require such sales to undergo the same type of background checks as at an FFL, and require owners to keep records of such sales. The issue of gun trafficking is actually quite difficult to address, as the data on it is quite poor (of course). However, the evidence from gun-traces conducted by the ATF is intriguing:

ATF trace data

More recent data (usually not cited by gun control advocates-likely since it shows more guns coming from NYC):
2011 trace data

This data is suggestive, but by no means conclusive, that the lax gun laws of other states have a detrimental impact on New York’s ability to prevent gun crime in the city, as a significant portion of guns confiscated are coming from out-of-state sales. Problems with this data are that not all guns confiscated are traced (or traceable), and determining if a gun is purchased for trafficking, or was stolen and subsequently trafficked (without a report) can not be determined with current tools available to the police. This data is also not going to contain untraceable weapons that have had serials defaced – an important and illegal step for traffickers to take to ensure their activity isn’t easily tracked.

Sadly, more recent data on trafficking is hard to come by, and atf publications in their “historical” section contain some of the most comprehensive data on the types of guns being used by criminals. Data from these reports that suggest that trafficking from private buyers are a major input into the illegal market likely have not changed in the last 10 years however, as, if anything, congress made it more difficult to trace weapons via the Tiahrt amendments which have hampered the ability of law enforcement to prevent trafficking.

Interesting facts from the most recent publication include (1) 77% of guns used in crime are handguns and 50% of all guns used in crime are semi-automatic pistols (2) the quality of records is so poor that fully a third of the time traces failed due to inaccurate records or absent records kept by the dealers, and 10% of the time from “problems” with the serial numbers (alteration or defacement likely) (3) fully a third of crime guns are under 3 years old, and half less than 6 years old – time to crime being an correlate of trafficking (4) 88% of the time the crime gun was not originally purchased by the criminal – that is 88% of guns in crime have entered a secondary market.

This is the problem as described by the ATF:

Tracing from Purchaser to Possessor. Transfers of a firearm beyond the initial purchase by a retail customer usually cannot be followed to the criminal possessor using serial numbers and transfer documentation alone. Federal law does not require unlicensed sellers to perform Brady background checks or maintain transfer records for tracing, and firearm owners are not required to keep a record of the serial number of their firearms or to report lost or stolen firearms. Therefore, it is generally impossible for a National Tracing Center (NTC) crime gun trace alone to identify purchasers beyond the initial retail purchaser. If a crime gun is not recovered from its original purchaser, it has been transferred at least once in the secondary market, that is, by someone other than an FFL. These transfers may be lawful or unlawful. The crime gun may have been illegally transferred by a straw purchaser; resold by an unlicensed seller or as a used gun by an FFL; borrowed, traded, or given as a gift; stolen by its criminal possessor; or stolen and trafficked, among other possibilities.

As described in my original post, the major source of guns for criminals is the secondary markets – either straw purchased, gun show purchased, or privately-sold firearms which require no background check, and no records (not that the licensed dealers are doing that great a job of it). Some criminologists, such as Gary Kreck have criticized the idea there is a large source of trafficked guns in this country and that most crime guns are stolen weapons. However, while criticizing over-interpretation of trace data, I think Kreck under-interprets it. He arrives at the bizarre number of only about 1.6% of guns originating from some kind of organized trafficking. However, he does this by dismissing any trafficker that does not have a large (> 100/year) operation, and by suggesting the only real valid indicator of a trafficked weapon is evidence of a defaced serial number. Considering not all guns collected in crime are traced, and there isn’t much point even trying to trace a gun without a serial number (an exercise in futility – correct me if I’m wrong), I believe the trace databases are going to be subject to an under-reporting bias. Not to mention, in the report I’m working from, 10% of the weapons had serial number issues, and only a very small minority correlated to a report of a stolen gun. Likely the problem is the serial numbers in crime guns aren’t destroyed as much as altered, to prevent accurate tracing by creating an incorrect number. We can discuss Kreck more if needed (he’s often the goto-guy for those trying to suggest guns make us safer), but I don’t think his analyses have held up against other criminologists’ criticisms (please read this paper, and this paper before defending Kleck’s survey studies).

Given these data however, I think a powerful case can be made that tighter control of the secondary markets, as well as safety controls like integrated gun locks, will make trafficking more difficult, more costly, more risky, and in the case of stolen guns, potentially impossible. If we want to impact gun crime, these are the steps to address the overwhelming majority of guns found in the hands of criminals. This also negates the common critique of such measures that there already 300 million guns in circulation. Most gun owners are not interested in selling their guns into the criminal market, and the preponderance of new guns in crime shows there is a need or demand for a continual supply of new weapons into the criminal market.

Now let’s address some of Matt’s specific points:

We could begin by looking at whether or not semi-automatic rifles are actually a particularly heinous implement of death (we will discuss handguns in the “crime generally” section). In 2011, the United States experienced a total of 2,437,163 deaths. Of these, 12,664 were victims of murder. So for every 192 people who died in the United States, one was a victim of murder. Of those 12,664 murder victims, 323 were killed by a rifle. Thus for every 40 people who were victims of murder, one was shot by a rifle. This comes in well behind knives or blunt objects or even bare hands. In terms of death toll, rifles are roughly on par with falling off ladders (which killed 404 in the year 2010). And this category comprises all rifles, from bolt-action deer rifles to AR-15s to .50-caliber Barretts.

It should be noted from my original article that I was not suggesting the control of magazine-fed semi-automatics as necessarily being effective against gun homicide in general, but as a tool of mass homicide. Although, it should be noted, I included handguns in my suggestion and they represent more than 50% of crime guns. To prevent gun homicide I suggested regulation of secondary markets, not bans.

Fortunately Matt cites one of the best examples of a gun control policy that appears to have worked, and addresses it:

The best example on the pro-gun-control side is that of Australia, in which guns are regulated under a regime which has been a near ban since the Port Arthur massacre in 1996. There has nonetheless been at least one school shooting since then, though fortunately it only resulted in two deaths. A mass shooting of 4 or more victims has not occurred since 1996. The total rate of mass killings by arbitrary methods did not change significantly, and overall homicide rates were unaffected[1]. It is a matter of conjecture as to what extent this quite modest success in a island nation of a very different culture and just 10% of the US population can be extrapolated to the US. (Here’s a data point for the difference in firearms culture: the Australian buyback program after Port Arthur brought in 631,000 firearms. US citizens bought almost three million last month alone.) In summary, mass violence, despite its considerable press, is exceptionally rare, not particularly reliant on guns, and not particularly preventable by gun control.

I however, come to different conclusions, and not just about Australia being a continent. For one, in yesterday’s NYT, John Howard, the PM that passed their gun control legislation, describes the effect of the laws and the difficulties we might face replicating their effort. For one, Howard notes, “Almost 700,000 guns were bought back and destroyed — the equivalent of 40 million guns in the United States.” It seems like a smaller number, but for a smaller population, that’s a big dent. Also his interpretation of the post-gun control homicide rate appears different:

In the end, we won the battle to change gun laws because there was majority support across Australia for banning certain weapons. And today, there is a wide consensus that our 1996 reforms not only reduced the gun-related homicide rate, but also the suicide rate. The Australian Institute of Criminology found that gun-related murders and suicides fell sharply after 1996. The American Law and Economics Review found that our gun buyback scheme cut firearm suicides by 74 percent. In the 18 years before the 1996 reforms, Australia suffered 13 gun massacres — each with more than four victims — causing a total of 102 deaths. There has not been a single massacre in that category since 1996.

Further, in reading the source material cited (Evaluating Gun Policy: Effects on Crime and Violence, P 121-156, 2003, Philip J. Cook and Jens Ludwig) I found the authors reached a different conclusion than what Matt stated. Rather than being “unaffected” the rates were decidedly lower, however, the significance given the already low numbers of gun homicides is questionable. It should also be noted that Australia already had significant control of handguns. Here’s a snippet from Google books:

Additional research, readily available suggests a significant drop in the rate of gun violence after the ban. This suggests to me, both in the specific intervention, and overall given their tight regulation of handguns, that Australia is quite a strong example of gun control working. Although, for some of the same reasons Howard cites, the Australian method is not easily ported to the United States. The idea that gun control in general can never work is also prima facie absurd, just look at Japan. Yes, I know, we could not ban guns here, but it goes to show when guns are truly, effectively banned, even the criminals don’t have guns.

Matt also suggests my proposals, “come close to banning civilian handgun ownership”, which is amazing since I think I’ve beat that horse to death. Every time you talk gun regulation at all it seems to become a ban in the pro-gun side’s mind. However, at no point, for any currently available weapon, have I suggested a ban. Just paperwork. It’s not the end of the world people. It should be noted one suggestion I had, that owners should provide a legitimate need for ownership, is actually untenable. It was tried in Maryland and subsequently overturned by a federal judge. I will drop that suggestion, and it strengthens the “non-banning” aspect of my proposal as it was the only subjective criteria that government could use to prevent ownership. The proposals I have left result in a ban on nothing, just some hoops, just some paperwork. I think we can grow up on this issue and realize that reasonable measures to monitor secondary gun markets, and additional scrutiny for purchase of these weapons is nowhere near a “ban”.

I do have to take issue with Matt dismissing owner responsibility for misuse of guns:

Criminal penalties for having your guns misused more generally are not reasonable. Locks and safes are breakable, often with something as simple as a sledgehammer (of course locks and safes are still a good idea, but far from infallible), and it is unacceptable to put people in jail for being the victim of a crime.

This is, of course, nonsense. I never suggested a gun owner should be responsible for the criminal use of their gun if someone breaks into their gun safe and takes their weapons. On the other hand, if you leave your gun on the dashboard of your car and it’s stolen, you should be jailed for criminal stupidity and negligence. We require people to put up fences around their swimming pools because we know they are dangerous and an attractive nuisance. Minimal barriers to gun access in the home, like gun locks, should be expected for anyone with children, or reasonable expectation of the unauthorized having access to their firearms. This should be common sense, but also we need to increase barriers to access at guns in the home to prevent accidental gun death, and gun theft – a major source of trafficked guns. Maybe we should show Stray Dog in schools. That’s how you should feel if you lose your gun.

Finally I will take exception with Matt’s defense of the “good guys with guns” argument:

In vast majority of cases, mass shootings are stopped when the perpetrator is shot, either by suicide or police. But we have almost no data on the possibility of concealed carry permit holders stopping mass shootings. This is not surprising. Mass shootings are extremely rare, concealed carry is rare in percentage terms (around 2% have a permit in Texas), and mass shootings almost exclusively occur in places where concealed carry is prohibited by statute or the property owner. On the other hand, in terms of raw numbers millions of permit holders rack up billions of man-hours carrying every year. Permit holders outnumber police 7 to 1 in Texas, for instance. It is unreasonable to expect that extension of concealed carry to schools will result in catastrophic movie shootouts when it has not done so anywhere else – including many college campuses. I would not suggest concealed carry in schools as a panacea in view of its lack of a track record and the small percentage who would actually do it, but I would also not suggest we automatically discount it.

In the vast majority of cases, mass shootings are stopped when the perpetrator is shot…by themselves. Do we have evidence of police or armed citizens interrupting even one of the mass shootings in the last 20 years? Do we have any evidence of good guys with guns making a dent except after the shooting is done? Nope. We do have the example of Columbine, with a good guy with a gun, on the scene, in the school, exchanging fire with the shooters and…not preventing anything. Then there is this joke of a case of the Portland Mall shooting where apparently the presence of citizen with a concealed piece hiding behind cover made the shooter kill himself. And the cases Mother Jones cites where the armed citizen made things worse. Or how about the cops responding to a shooter at the empire state building and successfully stopped the shooting by shooting a bunch of civilians? The idea that your average schmuck is going to stand up to rapid fire from a lunatic with a semi-automatic is still just a fantasy, it’s hard for cops to respond to these incidents without shooting a handful of innocents. You’re not going to do it unless you’re a cop or ex-military, and even then, it’s questionable if you’ll do anything more than create a deadlier crossfire. Sorry, this strikes me as one of the stupidest arguments in the pro-gun portfolio. It’s not as easy as it looks in the movies, and the usual creepy fantasist gun lover who buys into this myth is not John McClane, he’s Walter Mitty.

The way to stop this problem is prevention, not escalation. If guns were the solution the country with the most guns wouldn’t be having this problem.