Denialism Blog

Category: Politics

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

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

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

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

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

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

  • Three reasons the Supreme Court should uphold ACA

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

    The first proposition is that the health care law is constitutional. The second is that the court could strike it down anyway.
    …
    The law is a completely valid exercise of Congress’ Commerce Clause power, and all the conservative longing for the good old days of the pre-New Deal courts won’t put us back in those days as if by magic. Nor does it amount to much of an argument.

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

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

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

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

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

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

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

    But rather than just knocking down their arguments I think it’s important to remind people of the positive reasons we should support this bill. So I have my own list of 3 reasons this bill should be upheld and we should all support it.
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  • Transvaginal ultrasound now being legislated in Idaho

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

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

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

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

  • Demanding women deliver dead babies is unethical and unsafe

    In a debate on the floor of the Georgia State house over a bill to force women to bring all pregnancies after 20 weeks to term, even in cases of dead or non-viable fetus, this Georgia representative reaches a new low. State Rep Terry England seems to be suggesting pigs and cows do it, why can’t humans?

    Rep. Terry England compares women to cows, pigs and chickens. from Bryan Long on Vimeo.

    Aside from this genius on-the-farm reasoning of Mr England, the failures of reasoning and misrepresentations of scientific knowledge engaged in to pursue this legislation are many.

    The legislation is justified ostensibly because of the ability of the fetus to feel pain after 20 weeks, but there is no data or a legitimate scientific basis for this claim. Our knowledge of neurological development would suggest that conscious perception of pain may not be possible for a fetus at any point and the neural framework for transmission of pain is not even mature before 29-34 weeks.

    Second is the issue that concern for the pain for a nonviable or dead fetus should not outweigh medical risk to the mother. The American College of Obstetricians and Gynecologists recommend dilation and extraction or induction of labor once the diagnosis of stillbirth has been made. The risks of carrying a non-viable fetus are the higher complication rate of delivery versus dilation and extraction, as well as a very high risk to the mother of complications like disseminated intravascular coagulation (DIC) if the amniotic sac is ruptured and she is exposed to the dying tissue. For stillbirth or nonviable pregnancies, dilation and extraction is far safer and more effective with 24% of patients undergoing labor experiencing complications compared to 3% for D&E.

    It has been under-reported that since the 2010 election, the rate of anti-contraception, anti-abortion, and frankly anti-woman legislation has shot through the roof. In 2011 state legislatures have enacted a record number of laws restricting reproductive rights:

    In the 50 states combined, legislators introduced more than 1,100 reproductive health and rights-related provisions, a sharp increase from the 950 introduced in 2010. By year’s end, 135 of these provisions had been enacted in 36 states, an increase from the 89 enacted in 2010 and the 77 enacted in 2009.

    These include everything from preventing physicians from using telemedicine to prescribe medication to requiring ultrasounds prior to abortion despite the fact no association of OB/Gyns supports universal ultrasound prior to abortion. In an effort to legislate their control of women’s reproductive systems, they are interfering more and more with the physician-patient relationship. It has become so extreme that in 11 states they have legislation requiring physicians to perform unnecessary invasive procedures, basically forcing physicians to engage in unethical medical practices. There is no legitimate medical reason for these measures. These exist to shame women, and increase the expense and difficulty of constitutionally-protected medical procedures and medical decisions like birth control and abortion.

    These efforts to ban abortion after 20 weeks, which have succeeded in several states including Nebraska, Idaho, Indiana, Kansas, Oklahoma,Alabama and Utah, are a highly intrusive attack on women’s reproductive freedom. It is once again, an attempt to insert politics in the doctor-patient relationship. Finally it is medically unethical, dangerous, and morally bankrupt to expose women to greater risk by preventing them from having the option of safe termination of pregnancy all for the sake of a dead fetus.

    Via Jezebel

  • What is the cause of excess costs in US healthcare? Take two

    We’ve discussed it before, why are costs so much higher in US healthcare compared to other countries? The Washington Post has a pointless article which seems to answer with the tautology costs are high because healthcare in America costs more. How much more? Well, we spend nearly twice as much per capita as the next nearest country while failing to provide universal coverage:

    i-880005398336c472547ab02e425e6cd0-commonwealthfigureII8.jpg

    In the WaPo article they make a big deal of the costs of individual procedures like MRI being over a thousand in the US compared to $280 in France, but this is a simplistic analysis, and I think it misses the point as most authors do when discussing this issue. The reason things costs more is because in order to subsidize the hidden costs of medical care, providers charge more for imaging and procedures. For instance, Atul Gawande, in his New Yorker piece “The Cost Conundrum” wonders why is it costs are higher to treat the same conditions in rural areas and in a major academic centers like UCLA than at a highly specialized private hospitals like the Mayo Clinic? I think the reason is it’s not nearly as expensive to administer and provide care for a select group of insured midwesterners at the Mayo than it is to provide care to the underserved in the poor areas of inner-cities and in poor rural locations.

    When you are serving a poorer, under-insured population like you get in LA or Baltimore for that matter, the insured are charged more because EMTALA requires hospitals to treat all comers, regardless of insured status. Medical centers like UCLA or University of Maryland are the final common pathway for the sickest and poorest patients who, even if stabilized at smaller local hospitals, are immediately transferred to such centers. These patients are expensive to treat, often have more co-morbidities like HIV or drug use and mental illness, and there is no reimbursement guarantee for taking care of them even though it is our legal and ethical responsibility to do so.

    Further, the cost of defensive medicine, which applies to this patient population as much as any other, ramps the costs of all hospital admissions and medical practice in general. It is also incredibly hard to quantify its contribution to the overall costs of care.

    As a result, to pay for excessive care of the uninsured, all procedures, all tests, all imaging, and all hospitalizations cost more. Caring for inpatients and the uninsured is expensive, so the costs are transferred to the prices of outpatient elective care and procedures which are often administered in a fee-for-service model. Hospitals have an incentive to provide as much outpatient elective care as possible in order to offset these other costs and to generate revenue. The providers that perform procedures or expensive testing then become far more expensive to pay as they are the major revenue generators for the hospital (hence surgeon vs pediatrician pay). Especially because in order to generate more revenue they are paid based on how many procedures they perform. All the incentives are towards more utilization, more procedures, more revenue generation. This is the hidden tax of the uninsured.

    In a way, we have universal healthcare already, but we pay for it in the most irresponsible and costly way possible. We wait for small problems to become emergent, treat them in the most expensive outpatient provider possible (the ER), and then when we can’t pay the bills for the uninsured, we transfer the balance by increasing the costs of the care of insured patients showing up for their cholecystectomies or back surgery. Tack on the costs of defensive medicine and the fear of being sued unless everything is done to cover your ass, and you have a recipe for extremely costly care.

    Other factors figure into higher costs as well, including hugely higher costs of medicare administration since Bush privatized it, higher prescription drug costs since Bush passed medicare part D and prevented bargaining with drug companies, and our incredibly high ICU expenditures at the end of life. the McKinsey report on excess costs demonstrated most of these issues in 2008. This is not news. The US spends far more on medical administration, outpatient/ambulatory care (with hospital-based outpatient care increasing most rapidly in costs), drugs, doctors salaries, and end-of-life care than we should as a percentage of our GDP.

    So what should we do about it? At every step we need dismantle the tendency towards increasing costs. Here are my suggestions:
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  • Virginia Ultrasound Bill Back from Dead

    Turns out I gave Virginia governor McDonnell too much credit after he rejected the VA ultrasound bill on the grounds the state should insert itself into medical decisions. He’s gone and flip-flopped as a slightly revised version of the bill passes through the VA Senate:

    The 21 to 19 vote, mostly along party lines, came a week after Gov. Robert F. McDonnell (R) asked legislators to revise the bill following protests on Capitol Square and repeated mocking on national television. Lawmakers amended the original bill, which mandated that women undergo a transvaginal ultrasound, a procedure that requires a probe be inserted into the vagina.
    …
    The bill will head back to the Republican-led House of Delegates, which already voted for similar measures this year and is widely expected to do so again. McDonnell, who signed legislation last year that imposed new regulations on clinics that perform abortions, told reporters that he will review the legislation but supports the concept.

    “I think women have the right to know all of the medical information before they make a very important choice,” McDonnell said.

    This is nonsense. Women know fully well what an abortion is and what it means. And it’s not the state’s job to legislate what medical information is relevant to the patient. That is a physicians job and there is no legitimate medical reason to perform the maneuvers the state is legislating. The state is legislating unnecessary, and therefore unethical and unlawful medical procedures. This is also from the state that brought us Buck V. Bell, so I guess they’ll never learn.

    It’s a very simple ethical issue. The state has no business dictating medical practice. Worse, dictating physicians perform an unnecessary and invasive procedure is the state legislating unethical medical conduct. No physician should comply with this law, as I believe that forcing doctors to practice unethical medicine is unconstitutional.

    Via Laden at ftb

  • Rick Santorum: usually wrong, never in doubt

    There is a joke expression about surgeons, “sometimes wrong, never in doubt.” Depending on how you feel about surgeons I’ve heard it begin “sometimes right” and “even when wrong.” Applied to Rick Santorum, I think it has to be “usually wrong” if not “always wrong” given the serious of ridiculous distortions, lies, and made up statistics in the last week.

    Starting with his claim that 62% of people that go to college religious graduate without their faith. It seems plausible. College expands peoples experiences and exposes them to new ideas, and such experiences are not going to always mesh with fundamentalist writings of long dead priests. Well, while counterintuitive it actually turns out to be the opposite case. Those who do not attend college may be at higher risk of losing their religion.

    “There is no statistical difference in the dropout rate among those who attended college and those that did not attend college,” said Thom Rainer, president of the Southern Baptists’ LifeWay Christian Resources research firm. “Going to college doesn’t make you a religious dropout.”

    A 2007 LifeWay survey did find seven in 10 Protestants ages 18 to 30 who went to church regularly in high school said they quit attending by age 23.

    The real causes: lack of “a robust faith,” strongly committed parents and an essential church connection, Rainer said.

    “Higher education is not the villain,” said Catholic University sociologist William D’Antonio. Since 1986, D’Antonio’s surveys of American Catholics have asked about Mass attendance, the importance of religion in people’s lives and whether they have considered leaving Catholicism.

    The percentage of Catholics who scored low on all three points hovers between 18 percent in 1993 and 14 percent in 2011. But the percentage of people who are highly committed fell from 27 percent to 19 percent.

    “Blame mortality,” D’Antonio said, “The most highly committed Catholics are seniors, and they’re dying out.”

    Do colleges indoctrinate the young to turn on their parents and reject religion? Salon argues they do a little bit, but the indoctrination that tends to be found on college campuses is on pretty universally accepted issues like rejecting racism and homophobia, both of which a majority of Americans now believe are repellent. But to politicians like Santorum, teaching tolerance is a major drawback to college attendance. The claim that colleges engage in indoctrination against religion is bogus, however, unless one is referring to religious beliefs in discrimination against other races and homosexuals.

    If anything the opposite is the case as studies have shown higher rates of religious “drop out” among the less-educated. Politifact also challenges his statement that Obama wants everyone to go to college cause he’s a snob.

    And how about all his other wacky claims? That prenatal screening causes abortion? Or that JFK believed religious people shouldn’t serve in government?
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  • VA Ultrasound Bill looks Dead

    And good riddance. It sounds like the Governor saw this bill would be more trouble than it’s worth.

    Virginia Gov. Bob McDonnell (R) revoked his support for the original bill just minutes before the House began debate on it, saying that the government did not have the power to require the transvaginal procedure.

    “Mandating an invasive procedure in order to give informed consent is not a proper role for the state,” McDonnell said in a statement. “No person should be directed to undergo an invasive procedure by the state, without their consent, as a precondition to another medical procedure.”

    Now that’s what Republicans should stand for. The state should not legislate which medical procedures are appropriate over physicians expertise and their relationship with their patient. The state should not discriminate against a class of citizens. A state should also not legislate unnecessary and therefore unlawful/unethical medical procedures. While I’m sure this was a purely political decision, he did Virginia a big favor. He’s saved the tax payers money by preventing the inevitable lawsuits in defense of this worthless legislation. He’s also kept the government out of people’s personal lives and doctor’s medical decisions. If Republicans actually stood for such principles consistently I might one day vote for them.

    Update:
    Obama leads Romney by 6% in Virginia, and by 10% (49%-39%) nationally according to Rasmussen polling.

    Hmm. Maybe pissing off women by attacking contraception and reproductive rights isn’t such a good strategy after all?

  • Forcing Doctors to Perform Unnecessary Medical Procedures is Unethical and Unlawful

    Many bloggers and commentators have expressed outrage over the decision by Virginia to require ultrasound examination, possibly transvaginal ultrasound, prior to women obtaining an abortion. From Bill Maher to Dahlia Lithwick people are outraged and have even suggested that it should be considered rape to force women to undergo vaginal examination by ultrasound prior to receiving abortion. Worse, it’s clear from statements like this one by delegate Todd Gilbert, that there isn’t a medical concern related to this intervention. It’s simply designed to humiliate women and interfere with the doctor patient relationship with exclusively anti-abortion motivations:

    “the vast majority of these cases [abortion] are matters of lifestyle convenience.” And, 

”We think in matters of lifestyle convenience and in other matters that it is right and proper for a woman to be fully informed about what she is doing.

    This just reflects how stupid these guys are, because anyone with half a brain could come up superficially plausible defense of the statute from grounds of medical safety. They’re just too brainless to do so and clearly are just trying to interfere with women and their doctors as they try to make a difficult decision.

    There are some indications for ultrasound prior to abortion. Many physicians performing the procedure or especially offering medical abortion might perform a transvaginal ultrasound prior to proceeding. It can serve a few useful purposes. It can help confirm intrauterine pregnancy as well as uterine location. It may be needed to assess patients in their postoperative exam or medical follow up visits to rule out retained products of conception. In cases of uncertain dates, it can give you gestational age of the fetus, which may be critical in determining the appropriateness of the subsequent procedure used. After all, medical abortion is typically limited to the first 9 weeks and uncertainty about gestational age should result in ultrasound prior to use of medical abortifacients.

    However, neither the FDA nor any professional organization of obstetricians and gynecologists indicate ultrasound should be a required component prior to medical or surgical abortion. The procedure is often unnecessary. So, what Virginia has done has legislated a requirement for an unnecessary medical procedure, unsupported by any professional medical association, on a specific subpopulation of women. Given the history of forced sterilization in Virginia, you’d think they’d be more sensitive on this issue. This is the state where Buck v Bell brought the issue of forced medical procedures to light.

    This statute cannot, therefore, stand on either medical ethical or constitutional grounds. The state legislature can not force me or any other physician to perform an unnecessary, and therefore unethical, medical procedure. The state legislature can not pick on a subpopulation of citizens and force them to receive an unnecessary medical procedure.

    I don’t think this law will stand, but it once again will require a legal fight, waste of time and resources, and all of this once again in a effort by governmental busybodies to interfere in women’s health decisions in a punitive fashion. The Republicans need to watch out. This is just another indication of a the size of the assault on women’s reproductive rights, and if they keep pushing, they’re going to see what a mistake it is to piss off 51% of the population.

    **Update: I also noticed from Lithwick’s article Virginia has enacted a personhood law saying life begins at conception. More idiocy. This is like Indiana legislating the value of pi = 3. It is unscientific and illogical. Life does not begin. It is continuous. There is no dead state between parents and offspring. Sperm are alive, eggs are alive, the fusion of the two is alive. Instead they are legislating what constitutes life that is important, or more likely “ensouled”. As a fundamentally philosophic/religious and ultimately arbitrary point, government has no business legislating such a thing. But legislating that life has a “beginning” is biologically ignorant.

  • What Illegal Abortion Looks Like

    Many are linking to this story around the blogosphere and I encourage everyone to read it. In it, a Ob/Gyn describes her emergency care of a woman who arrived in her ED in hemorrhagic shock from a botched illegal abortion. Though clearly it was touch and go and there was some panicky action, our heroine thought fast and saved a life. My mother once worked in a labor and delivery ward to put herself through medschool in the days before Roe v Wade and this type of situation was common.

    This is a great story because it illustrates two points. One, the war on abortion by the right wing is futile. We know abortion is more common where it is illegal and cases like these are more common. Banning abortion does not save lives. It results in more abortions, and more lives lost. Worse, in countries with strict bans even treatment of ectopic pregnancy is forbidden where there is still a beating heart detected by ultrasound. Doctors in these countries can literally go to jail for saving a woman’s life, all for the sake of a non-viable embryo that will kill the mother. The hypocrisy of calling this position pro-life is demonstrated by cold hard data. More women die. More fetuses are aborted.

    Second, it shows how a well-trained doctor can save a life with some quick thinking. Hemorrhagic shock is something I’m pretty familiar with after my second year rotation in Shock Trauma, and in a few spectacular cases of bleeding on the wards. There are many times when as a doctor you think you’ve probably saved a life. Every case of appendicitis, dropped lung, or kid with a gastroschisis technically is a save but situations like those don’t have quite the same visceral terror and immediacy of someone who is bleeding to death right in front of you. It’s hard to keep a cool head when you’re elbow deep in a pool of blood. One case in particular that sticks out in my mind was during a nice calm Saturday in the fall. I had just finished assisting in an open appendectomy and was doing my usual neurotic repetitive rounds through the ICU I always did when I was on call. At this particular hospital, when on call I was responsible for all ED surgical consults, all the surgical floor patients, as well as the surgical ICU (I had to carry 4 pagers). So since I’d been in this case for the last hour or so I decided to check in with the ICU folks. It wasn’t the sickest ICU I’ve ever worked, nothing like the U Maryland Surgical ICU or Cardiac Surgery ICU, but, like the ocean, it’s never a good idea to turn your back on the ICU patients. So, I was passing by one patient’s room and I seen on the monitor a blood pressure of 60/40…
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