Denialism Blog

  • Keep Akin in the race!

    Everyone has heard about Akin’s comments about “legitimate rape” and the push now coming from the GOP to get him out of the race. But is this really fair or ideal? The problem with removing Akin from the race over this is that his gaffe was not just one exposing his scientific ignorance, but because it was a Kinsley gaffe. That is, it’s a gaffe because it unintentionally revealed the truth.

    I’m not saying that his medieval medical hypothesis has any scientific validity, he is after all just parroting pro-life misinformation spread to attack scientific data about the frequency of pregnancy after rape. The Kinsley gaffe in this case is that he revealed the truth about what he, and other pro-life politicians who support no-exception abortion bans, believe.

    Why should we punish this truth-telling with removal of Akin from the race? All that will happen is that the GOP will replace Akin with another pro-life fanatic who is simply better at hiding what he actually believes about women, reproduction, sexual assault, and their autonomy over their own bodies.

    I’m thankful for Akin’s honesty, because he has dropped the facade that the radical right cares about women, respects their autonomy, understands sexual assault or has any place in this century. He has pulled back the curtain and shown what they really believe. Other examples of this attitude abound, from the abusive ultrasound bills, to this comment from Idaho Republican Chuck Winder in March wondering if women even know what rape is, to American Vision’s comparison of the blowback against Akin as “like gang-rape”. He has only further exposed the misogyny of the pro-life movement and brought some of their more despicable lies front and center for all to see. We should be thanking him for his honesty.

  • Is Lynda Resnick's Admiration Good or Bad for Fareed Zakaria?

    Earnest reporting or catty criticism? Fareed Zakaria, according to the Times, is on the short list of Lynda Resnick’s dinner parties, along with “Queen Noor of Jordan, George Soros, the financier, and Senator Dianne Feinstein, Democrat of California.”

    Is the Times’ Christine Haughney critiquing Zakaria or not? Resnick is well known for being a marketing personality, one that makes broad, unsubstantiated health claims about “POM,” her silly juice that you should not waste your money on. Nor should you ever buy anything from her former business, the Franklin Mint, or Fiji, her overpriced water (see a theme here?).

    Is a Resnick endorsement a thumbs up or down?

  • App.net and the Free Problem

    Have you heard of App.net? If not, check it out. The basic premise is to create a social media platform that is aligned with users’ interest. And so, gasp, it costs money! The CEO, Dalton Caldwell, has a neat video explaining the inception of the project and the philosophy of the venture. Critics have said Caldwell’s proposal is misunderstood, and that users are projecting their own ideals onto the platform. They have said that there are too many men on App.net. They have said that it’s just another gated community, and segmenting away users is a bad thing.

    I joined and still think it is a good idea to join, based upon arguments started in a series of posts concerning Chris Anderson’s book, “Free.”

    There are two reasons to avoid free products and start paying for things. First, free is a force for mediocrity, both online and off. It displaces better products, because no one can compete with free things, and because free things are usually just good enough to do the job we need them to do.

    Second, as Jan Whittington and I explain in our work on social network services that are advertised as free, “free” services have costs. A sample of food at a mall’s food court is free to the recipient. You get it and walk away. Online services are different, because you do not walk away whole. The service keeps personal information about you and you forever have to monitor how it deals with that data. In our first paper, we describe the depredations of C Everett Koop’s dr.koop.com, a free social network for medical issues. Drkoop.com went bankrupt, and its member database was sold to a Florida-based “nutritional supplement” company. The best part of the story was the reaction of the buyer. He said, “Three years ago, Drkoop.com would not have given us the time of day…Now we own them.” Shifting policies represent a monitoring cost, a real investment of your time and a risk to your privacy.

    At the end of the day, services like Facebook and Twitter must adhere to what advertisers want, and so paeans to “making the world more open” and real identity requirements are masks for serving advertisers’ wishes. If we want to escape that trap, we’re going to have to actually start paying for things with money.

  • The Privacy Competition Myth

    In his non-book-review of Garret Keizer’s new book, Privacy, “Reason” Magazine correspondent includes this ill-informed quip on privacy:

    With regard to modern commerce, Mr. Keizer grumps: “We would do well to ask if the capitalist economy and its obsessions with smart marketing and technological innovation cannot become as intrusive as any authoritarian state.” Actually, no. If consumers become sufficiently annoyed with mercantile snooping and excessive marketing, they can take their business to competitors who are more respectful of privacy. Not so with the citizens of an intrusive state.

    There is almost no market for privacy among merchants. Companies learned long ago that raising privacy as an issue backfires–it causes consumers to worry about it rather than feel safe about an alternative product. Whether online or offline, going to a competitor doesn’t increase your privacy, in real or perceived terms. It’s simply too easy to hide invasive practices from consumers.

    Our work at Berkeley shows the folly of simply going to a different site in order to have more privacy. Here’s just one example, in our Web Privacy Census, we did a large-scale survey of popular websites in order to assess mercantile snooping and excessive tracking. Of the most popular 1,000 websites, Google trackers are present on 712 of them. Good luck finding a competitor who is more respectful of your privacy.

  • Hark! A New Trade Group is Born

    BNA reports on the formation of the Internet Association, a new trade group that will represent Google, Facebook, eBay, and Amazon. The group introduces itself as, “the unified voice of the Internet economy, representing the interests of America’s leading Internet companies and their global community of users. The Internet Association is dedicated to advancing public policy solutions to strengthen and protect an open, innovative and free Internet. ”

    I do not know what the Internet Association will do nor do I discuss its merits here (as it has no track record yet). I wish to use this as an opportunity to discuss some of the issues in trade group lobbying. Consumer groups have problems too, but unlike companies, consumers have no direct representation in most regulatory matters, and consumer groups are completely outgunned in money, influence, and manpower in DC.

    The creation of a new lobbying group for tech interests is a notable thing. These organizations are always created for some strategic reason. It could be that the many existing trade organizations are too closely aligned with other tech companies with dissimilar interests. Here, the Internet Association makes a big deal about being the first group to explicitly represent the interests of the Internet, whatever that means. Or perhaps it was created because other organizations have become too discredited to be believed anymore. When firms’ sock puppets are discredited, they can simply be abandoned, and rise again (sometimes with the exact same employees) in new form. This is a lot like Unbranding.

    There are already tons of tech lobby groups. Companies find them useful because they can launder policy through them. The groups can say controversial things, or engage in sock puppetry with reasonable deniability. So when you read a news article about some controversy, and see a trade organization quoted instead of a company directly involved in the tussle, chances are that the company decided to participate in the fray through its proxy and avoid the risk of direct exposure to critical reporting. Reporters do not kick the tires too hard on these groups to see who is actually behind them.

    The Lobbying Clone Wars

    Generally speaking, we too easily recognize these groups as legitimate. Federal agencies, for instance, recognize them and take them as seriously as ordinary principals in debates. This is problematic, because firms use these groups to amplify their interests. So, for instance, on Congressional hearings or FTC events, sometimes you’ll see company representatives appearing on a panel along with witnesses from trade organizations that the company underwrites. Similarly, in the current debate at the Department of Commerce over privacy, the agency is going to try to develop a “consensus.” Those wanting to influence that consensus will be far more effective if they multiply their presence in the room with additional lobbyists who appear to be independent but really are fully backed by specific companies.

    “The Internet must have a voice in Washington.”

    Turning back to the Internet Association, a few things to note for future reference. First, their PR firm is HDMK. That’s important to know because closely related groups often share the same PR firm. If you see two groups with the same PR firm, chances are they have coordinated their messages, or they are really just the same interest broadcasting through two different speakers.

    Second, the Internet Association is interesting because it explicitly claims to represent users. It will represent, “the interests of America’s leading Internet companies and their global community of users.”

    This could be a great source of legitimacy problems for this group, because user interests so often diverge from the interests of Google, Facebook, Amazon, eBay, and the like. These companies tend to think that user interests align with their own because consumers would simply choose other services if they were in misalignment. It’s a form of circular reasoning that many businesses suffer from.

    Of course, consumers use what is available to them, and the market often obscures or blocks options that users are likely to take. For instance, in Douglas Edwards’ recent book [FN1] about working at Google, he discussed the company’s first-party cookie policy:

    What if we [Google] let users opt out of accepting our cookies altogether? I liked that idea, but Marissa [Mayer] raised an interesting point. We would clearly want to set the default as “accept Google’s cookies.” If we fully explained what that meant to most users, however, they would probably prefer not to accept our cookie. So our default setting would go against users’ wishes. Some people might call that evil, and evil made Marissa uncomfortable. She was disturbed that our current cookie-setting practices made the argument a reasonable one. She agreed that at the very least we should have a page telling users how they could delete their cookies, whether set by Google or by some other website.

    Even when companies know that consumers want more privacy, firms can have incentives to code in privacy-invasive options by default. Firms may also have incentives to hide the tussle among these options. Google could have implemented compromise approaches that preserved some privacy, by using session cookies or by choosing cookies that expired after some short amount of time, but it did not.

    A similar theme appears in Katherine Losse’s tale of employment at Facebook. According to Losse, when Facebook made major changes to users’ privacy settings, there was no internal debate at the company about how users would feel about the changes. Losse was charged to write blog posts on behalf of Zuckerberg explaining the need of users to become more open.

    It will be interesting to see how the Internet Association will represent user interests and the interests of companies such as Google and Facebook, when we know that these companies themselves make strategic decisions to shape, deny, or flat out commandeer users’ choices.

    FN1: Douglas Edwards, I’m Feeling Lucky: The Confessions of Google Employee Number 59, at 341 (HMH 2011).

  • Disinformation about Disinformation: L. Gordon Crovitz's Information Age

    When one spouts disinformation about disinformation, does it make it information? No, it’s L. Gordon Crovitz’s “Information Age,” the weekly poorly informed and poorly reasoned blather about information policy in the Wall Street Journal.

    Recall that Crovitz recently wrote about the invention of the Internet and online privacy. I wrote about these last two columns, and this week in the Journal Crovitz tries to backpedal, with the standard trope that his “Who Really Invented the Internet?” article was controversial—”It [became] for a time the most read, emailed and commented upon article on the Journal’s website, with more than 1,000 comments.” It was popular in the same way that reality stars enjoy popularity.

    Crovitz tries to explain that he was reacting to President Obama’s recent speech about government and business. Crovitz responds that:

    • Government alone didn’t create the Internet.

    • Government didn’t help build the Internet in order to create commercial opportunities.

    • Companies that succeed on the Internet do not succeed because of government.

    Of course, this is not what Crovitz said last week. He said:

    If the government didn’t invent the Internet, who did? Vinton Cerf developed the TCP/IP protocol, the Internet’s backbone, and Tim Berners-Lee gets credit for hyperlinks.

    But full credit goes to the company where Mr. Taylor worked after leaving ARPA: Xerox.

    Full credit. Not shared credit.

    To Crovitz’s second point, government builds a lot of things that have secondary uses in the commercial market. The many inventions of NASA, for instance, were first developed to execute space travel, and these technologies find their way into the commercial sector.

    To Crovitz’s third point, companies do succeed on the Internet because of government. There is plenty of interaction and cooperation between high tech companies and government, and that is why high tech companies are not libertarian. If high tech companies were severed from the government gravy train, innovation would suffer. We’d have fewer drones and other wonderful technologies.

    More fundamentally, so many internet entrepreneurs came from America’s college and university system, where big government funding helps develop leaders like Sergey Brin, Larry Page, Steve Wozniak and others.

    This tech libertarian “I am an island” meme is fully debunked by Paulina Borsook’s Cyberselfish. In that book, Borsook lampoons arguments of Crovitz’s sort: “The most virulent form of philosophical technolibertarianism is a kind of scary, psychologically brittle, prepolitical autism. It bespeaks a lack of human connection and a discomfort with the core of what many of us consider it means to be human. It’s an inability to reconcile the demands of being individual with the demands of participating in society, which coincides beautifully with a preference for, and glorification of, being the solo commander of one’s computer in lieu of any other economically viable behavior…”

    But back to Crovitz:

    Supporters of big government don’t want to hear about the private-sector contributions to the Internet…

    What is Crovitz’s basis for this crazy talk? This is an unhinged straw man argument. Any sensible person recognizes that private-sector contributions are critical to all sorts of ventures.

    …but today the Internet is defined by individuals using it for their own purposes—communicating, accessing social media—and critiquing opinion columns. Many innovations are via free, open-source software. Perhaps we can all at least agree that the Internet boom began in the mid-1990s when the government shut down its remaining role, leaving the Internet to the power of the people.

    The government never shut down its role in the internet. Has this guy ever heard of the Department of Commerce and ICANN? Or the NSF?

    How did this guy get this column and is there no one at the Journal that recognizes it for what it is, or is this a case of crank magnetism?

  • Louis Gordon Crovitz’s Disinformation Age

    Imagine a newspaper oped with half a dozen fallacies. Such a thing could appear in any newspaper in the US. But now imagine that the author is a Rhodes Scholar and you’re left with the Wall Street Journal’s L. Gordon Crovitz.

    For years I’ve followed the bizarre arguments of L. Gordon Crovitz, who has a weekly column on information policy in the Wall Street Journal. It’s part of my daily routine of reading the Journal, which is great for business news but something else for everything else.

    Last week, Crovitz wrote a real howler, arguing that the Internet was really created by Xerox, not the government, because among Xerox’s many great inventions was Ethernet. Of course, the Internet is the world’s biggest copying machine, but Xerox itself doesn’t claim to have invented the Internet. A chorus of more well informed people attempted to correct Crovitz, including the author of the book Crovitz relied upon to support his argument, but the damage is already done. The libertarian claque is parroting Crovitz as part of its mission to undermine any of the good deeds done by the government.

    Perhaps Crovitz was attempting to cure the largest source of cognitive dissonance for the libertarians: that the libertarians’ favorite invention, the Internet, was funded by the source of all evil, our federal government. This single unfortunate fact may be enough to cure the Manichean mind of the libertarian, and thus it must be attacked.

    One column does not completely undermine one’s claim to be an expert in information issues. But Crovitz has a track record of reactionary, inaccurate, and incoherent essays on issues of importance. For example, just the week before, Crovitz made a series of disconnected arguments and inaccurate observations about privacy. Dear reader, let me guide you through the sad times of the Disinformation Age.

    The Way the Digital Cookie Crumbles
    If regulators and lawyers limit the use of data, advertising online will become less efficient.

    Typically, editors write headlines, so we have to give Gordon a pass on this assertion.

    For a measure of how technology is changing human expectations, consider the “cookies” on your computers. These invisible text files are how websites track activity, delivering to marketers detailed information about individual behavior and preferences. In exchange for data, we get highly personalized online services.

    I’m not sure what an “invisible” text file is. One that is empty? One that your operating system does not allow you to see? In any case, cookies are not invisible to marketers, who are attempting to track our every move online. This fact has been detailed by Crovitz’s own paper in the What They Know series.

    Crovitz also engages in a false analogy here, which is more fully developed later. Yes, cookies enable tracking, but what websites choose to do with that data is different based the business model of the site. Some tracking, such as when one shops on Amazon and receives product recommendations, are an example of a personalized service that individuals can choose to enjoy. Most tracking does not deliver personalized services—it attempts to deliver advertising of all sorts. My work shows that when asked, Internet users overwhelmingly reject the value proposition that Crovitz lionizes.

    Crovitz goes on to describe an example of differential pricing on the web, where for instance, certain consumers were presented with more expensive products or services because they were Apple users.

    […]

    When Orbitz used these data to feature higher-priced hotels more prominently in Apple users’ search results, privacy lobbyists claimed outrage. But even in the analog era, readers of this newspaper saw advertisements for different products and services than readers of less high-end papers.

    Of course the analog and digital eras are completely different. Contextual advertising (the idea that one places ads consistent with the publication, such as ads for golf balls in a golf magazine) is not privacy invasive at all. In fact, in the analog era, the Journal could not tell whether you even read the newspaper at all—only that you were a subscriber or not. In the digital era, newspapers are designed specifically to encourage the user to click more, so that precise interests can be mapped and advertising dollars maximized. A change to a more information-rich medium may justify a change in privacy rules.

    These uses of personal data can seem a bit creepy, but the evidence also shows how quickly consumers have gotten used to being tracked. When given the choice, few consumers opt out of cookies. People accept the benefits of more relevant ads and more personalized websites in exchange for letting marketers track their interests.

    This single paragraph demonstrates a complete lack of familiarity with the research that has been done in privacy and is descriptively inaccurate. Marketers complain bitterly about consumers deleting cookies, and research has shown that even popular websites have resorted to hidden and nearly-impossible to avoid tracking to address this consumer rejection.

    Crovitz’s larger point, that people do not opt out, is backwards as well. Consumers can get used to a lot of things if those things are hidden from them, and they are offered no real choice about the matter. In reality, consumers think that they are protected by strong privacy laws. My research has shown that consumers mistakenly believe that privacy policies impose strong, legally-enforceable limits on the use of data.

    …Consumers are loyal to Amazon in part because of its recommendation tools—if you liked that book, you may like this one—which mine user data to determine relevancy…

    Here again, Crovitz does not present an important wrinkle in the privacy debate: first party tracking may be a “feature” that consumers desire. Consumers may use Amazon.com specifically for its recommendations. Research shows that most cookies on popular websites are delivered by third parties, typically companies that track individuals for advertising purposes.

    Left alone, people would continue to make their own evolving judgments about how much data to share. Instead, regulators issue edicts. The Federal Trade Commission has extracted 20-year consent decrees from Google, Facebook, Twitter and Myspace, giving regulators broad review over their privacy and data practices. This would be fine if the purpose were to ensure that companies comply with disclosures about how they use data, but the FTC wants to define privacy standards.

    And here, the libertarian paranoia emerges in full–regulators have nothing better to do but issue edicts, which are fully untethered from consumers’ desires. Here again the Manichean nature of the libertarian is exposed—regulation is so evil that it has to be spawned by evil people with evil motives.

    In reality, American consumers strongly support some definition of privacy standards. No Congressperson has ever lost office for passing a privacy law. The FTC, under Republican leadership, was in fact the progenitor of the most successful privacy edict of all—the Telemarketing Do-Not-Call Registry. The FTC predicted that only about 60 million numbers would be enrolled. Last I checked, over 200 million numbers were enrolled.

    The FTC’s consent decrees all flowed from situations where companies made promises that were false or reneged upon. And in each case, the company agreed to the decree—making it a “consent decree.” If these were real edicts, these companies could have litigated them. They don’t litigate them because in the course of a typical investigation triggered by a misrepresentation, the FTC finds lots of other privacy problems.

    One result of FTC meddling is that plaintiff lawyers have open invitations to file nuisance suits on behalf of supposed privacy victims. A federal judge is considering a $20 million settlement offer by Facebook, which has agreed to make its disclosures clearer that when users click “Like” to promote a product on Facebook, their names and photos can be used.

    The paranoia continues. Plaintiff lawyers file suits regardless of what the government does or doesn’t do. And these cases often result in cy pres remedies, given to organizations (such as Berkeley Law) that work on privacy and information policy.

    If regulators and lawyers push too hard to limit the use of cookie data, advertising online will become less efficient. This in turn will reduce the amount of free, advertising-supported services enjoyed by consumers, such as social media, entertainment and email.

    I think this argument hints at a core problem in the cookie debate—a false dilemma between a completely unregulated and fully tracked world, and regulation, any of which would kill the golden goose. Of course, there are middle-way approaches.

    Crovitz’s argument assumes that online advertising in its current form is the most efficient, but in fact, more privacy-friendly systems may be more efficient. For instance, the DMA claims that telemarketing is now more efficient, perhaps this is because those who didn’t want to buy can opt out.

    Crovitz’s false dilemma also shows that he is committed to a certain business model. There are alternative methods for highly-tailored advertising that could be completely private. But these alternatives require more work, and the industry has settled on a lazy approach that prioritizes tracking everyone (even those who opt out) all the time.

    …Each consumer should be able to decide how to make this trade-off between sharing data and getting advertising-supported services.

    I wonder if Crovitz really means this, because the FTC is considering “Do-Not-Track,” a method that would allow each individual consumer to decide whether or not to be tracked online. So perhaps the FTC is good after all. The industry currently offers no way to take this decision (even if you opt out, they track you).

    The privacy debate shows how naive Silicon Valley firms were to sign 20-year agreements granting Washington regulators broad authority over how they operate. Digital entrepreneurs should be allowed to innovate freely, with consumers also free to choose their individual trade-off between how their data are used and the benefits they get in return. Overregulation is the way the digital cookie crumbles.

    In other words, Silicon Valley firms were naïve to agree to consent decrees on the advice of the most sophisticated, well-trained lawyers in the world. If they only had Louis Gordon Crovitz, they would have decided differently, and the market would be free at last.

  • 2 of Hearts in the WSJ: Bad Apples are Spoiling the Otherwise Pristine Barrell of For Profit Education

    As an educator, I realize that much of education is…well…a scam. And some scams are much bigger than others. We’ve all read about the graduates with six-figure debt loads from obscure colleges. But the for-profit college world operates on another level. Gawker has had excellent commentary on the issue, and has pointed out that the only way the people at the Washington Post make money anymore is through Kaplan “education.”

    But in a setback for justice in this arena, a judge recently invalidated some regulations of the for-profit field. This gave the Association of Private Sector Colleges and Universities an opportunity to whip out a pretty-low-value argument straight out of the Denialists’ Deck of Cards:

    “No one is suggesting that anyone ought to have a free pass, but there are appropriate standards in place already,” said Steve Gunderson, president and chief executive of the Association of Private Sector Colleges and Universities, which was the plaintiff in the case. “If there’s a particular school that has a problem, then deal with that school but don’t [come down] on the entire sector.”

    Yes, this is the old “bad apples” argument…and maybe “no problem” too.

    Attention, Association of Private Sector Colleges and Universities, I expect for you to cite to us going forward if you are going to continue these bogus arguments!

  • Atul Gawande on Resisting Health Care Reform – He Misses a Tactic, Lying!

    Atul Gawande, thoughtful as always, writes about the “wicked problem” of healthcare reform and the historical similarity between this battle and previous battles to expand fairness to all of our citizens. Opening with the kind of experiences all physicians have had with tragically-uninsured patients, he emphasizes why this was a needed change:

    A few days ago, while awaiting the Supreme Court ruling on the Obama health-care law, I called a few doctor friends around the country. I asked them if they could tell me about current patients whose health had been affected by a lack of insurance.

    “This falls under the ‘too numerous to count’ section,” a New Jersey internist said. A vascular surgeon in Indianapolis told me about a man in his fifties who’d had a large abdominal aortic aneurysm. Doctors knew for months that it was in danger of rupturing, but, since he wasn’t insured, his local private hospital wouldn’t fix it. Finally, it indeed began to rupture. Rupture is an often fatal development, but the man—in pain, with the blood flow to his legs gone— made it to an emergency room. Then the hospital put him in an ambulance to Indiana University, arguing the patient’s condition was “too complex.” My friend got him through, but he’s very lucky to be alive.

    Another friend, an oncologist in Marietta, Ohio, told me about three women in their forties and fifties he was treating for advanced cervical cancer. A pap smear would have caught their cancers far sooner. But since they didn’t have insurance, their cancers were only recognized when they caused profuse bleeding. Now they required radiation and chemotherapy if they were to have a chance of surviving.

    Even inexperienced physicians like me, still in my residency, have these kinds of stories to tell. They’re tragic. But worse, they’re just so stupid. Notice how, in each instance, the problem still ends up being taken care of, only now it’s emergent, farther along, more risky, and of course, more expensive to treat. This is part of the ludicrous nature of the opposition to health care reform. There is no way to get out of paying for these things. All we do by denying people coverage for necessary medical treatment is guarantee that in a few days, months, or years, they’ll be in the emergency room, only now it will cost ten times as much to fix, at greater risk to the patient. This is also backed up by the international experience of health care. Every other industrialized country has universal coverage, many have far superior care, not to mention superior service (France anyone?) to the United States. Yet every one of the countries pays far less per capita (most less than half) than we do on health care. Data from studies within our own country show it’s cheaper for the state to cover the uninsured than to let them stay uninsured. Because of EMTALA, passed by that notorious socialist Ronald Reagan, everybody gets emergency care whether they are insured or not, and fully 50% of emergency care is uncompensated, costs which get transferred to the insured and the tax payers.

    For most of us in the healthcare system we see that universal coverage is necessary (unless you reverse EMTALA which will never happen), although we may disagree on how to accomplish it. If anything, the ACA/Obamacare is more of a free-market reform than many physicians would like. Many in my generation (though certainly not in the older generation) would have preferred single-payer, but for reasons I discussed yesterday this is actually not as important as merely guaranteeing universality. Mixed private/public and government payer/private insurance schemes are, if anything, the norm around the world and they work well while still costing less than 50% of what we pay per capita.

    So why so much resistance to what should be obvious? There is no way to avoid paying for this stuff, so why don’t we do it more sensibly? Why don’t we move primary care out of the ER? Why not pay for problems when they’re cheap and not emergent?

    Gawande suggests the problem is that healthcare is a “wicked problem” and such problems that don’t have simple, crisp answers generate more controversy and resistance to change.

    In 1973, two social scientists, Horst Rittel and Melvin Webber, defined a class of problems they called “wicked problems.” Wicked problems are messy, ill-defined, more complex than we fully grasp, and open to multiple interpretations based on one’s point of view. They are problems such as poverty, obesity, where to put a new highway—or how to make sure that people have adequate health care.

    Solutions to wicked problems, by contrast, are only better or worse. Trade-offs are unavoidable. Unanticipated complications and benefits are both common. And opportunities to learn by trial and error are limited. You can’t try a new highway over here and over there; you put it where you put it. But new issues will arise. Adjustments will be required. No solution to a wicked problem is ever permanent or wholly satisfying, which leaves every solution open to easy polemical attack.

    This sounds awfully familiar, and I think it’s a good explanation for much of the controversy. I’ve been emphasizing from the beginning, there is more than one answer to the problem of the uninsured. The only really wrong answer is, “doing nothing”. We’ve been doing that for long enough and it actually costs us more to do nothing than to expand coverage! Gawande then discusses Albert O. Hirschman’s studies of the polemical forms of resistance to solving these wicked problems, and how they rely on arguments of perversity, jeopardy and futility. However, I find that a critique of these debates isn’t particularly satisfying. Just because one argues that a reform is perverse, or risky, or futile, doesn’t necessarily make one wrong, even if it is a frequent pattern of obstinance. Gawande also leaves out the 4th tactic of the current opponents of reform. That is, of course, mendacity.

    In order to oppose a reform so obviously needed, so completely supported by the data from international experience and studies from within our own country, and in the face of the obvious gob-smacking experience of every physician in the country, one ultimately must rely on just lying. Politifact, both before and after the Supreme Court decision, has demonstrated this phenomenon. Many of the claims against the ACA have been so rabidly false as to deserve their “pants-on-fire” designation, including the fully debunked death panels nonsense (2009 lie of the year!), that it’s the largest tax increase ever, it’s rationing, or that it is some kind of Obama socialist plot. See the top five lies here. Immediately after the ruling Romney was apparently tripping over his own feet in order to be the first to lie about his own reform package saying it would increase the deficit by trillions, another lie, and Limbaugh reiterated the lie that it was the largest tax increase ever.

    I think that’s what’s most disappointing to me about this current debate, but these days it is no surprise. The outrageous mendacity of the opponents of reform, and the unwillingness of the right to engage in honest debate on this topic, are beyond anything I’ve seen in my lifetime. But a few facts are undeniable. We spend more on health care than any other country. For that cost we can’t even cover all of our citizens. Universal healthcare systems are also universally less expensive than ours. When we refuse to cover people, and allow them to be uninsured, they still receive care, it just costs us more to deliver. Why do people oppose universality when these are the facts?

    The simple, sad answer, is they’re being lied to.

  • Healthcare Upheld!

    It’s good news that the Supreme Court split 5-4 with Roberts (and not Kennedy?!?) as the deciding vote, to uphold the affordable care act. It’s interesting that this was controversial, and certainly Roberts led the court to a very safe middle ground making the issue about taxation and saying the commerce clause could not apply. If anything, I wonder if this weakens the previous commerce powers of Congress as defined by Wickard v. Filburn, I’d love to hear what a lawyer thinks.

    What does this mean?

    Well in the short term not a whole lot, this healthcare bill requires a very slow roll-out of provisions. This was never a revolutionary law, which is why it was so surprising that people treated what was essentially a free-market giveaway as if it were some act of revolutionary socialism. But it will mean that states will have to go ahead and start implementing exchanges, it means that lots of other cost-control provisions are going ahead, coverage for pre-existing conditions will remain (victory!), and most importantly, we can start a great cultural shift from using emergency rooms or just plain avoidance to deal with necessary health maintenance and primary care needs.

    Now, I know many that think single payer is the only way that healthcare can be provided might have been hoping this hodgepodge mix of free-market and social reforms would fail in favor of a truly government-administered system. I would say to them, don’t worry! It’s possible to have highly efficacious universal healthcare based on insurance for all and subsidization for those who can not afford it. Most systems not inherited from the Soviets came to universal healthcare from different angles, and only really the UK, Canada, and New Zealand represent totally government-administered healthcare systems in such countries. In between would be Sweden, Japan, France, or Australia with government-administered payment or mixtures of public and private hospitals with government sponsored insurance options. Even Russia now has a mixture of public and private healthcare spending. Then there are the systems which look a bit more like what the ACA will be. For instance Germany, which has had universal health care since Otto von Bismarck, has health coverage through employer-subsidized sickness funds, a mixture of public and private hospitals and clinics. Finally, the Netherlands system probably is most like the system proposed by the ACA. They describe it as “private insurance with social conscience”, and the Netherlands enjoys metrics of patient satisfaction, short wait times, and access to procedures far superior to that of other systems including ours (which performs quite poorly on almost all metrics including access). On the extreme free-market side of universal health care is Singapore, which relies on universal governmental catastrophic insurance coverage, but an individual mandate on citizens to contribute to personal health savings funds which cover primary care and most expenditures until you go over a yearly limit. The only thing all of these systems have in common is that they spend half of what we spend yearly per capita on healthcare.

    So, to those who oppose it because you either don’t want healthcare or because you don’t think it was enough, don’t despair! For those who think it’s the worst thing ever to pay for other’s health insurance, don’t worry! You already are! You have been since Reagan passed EMTALA. That won’t change, the cost might actually get cheaper (or at least stop increasing at such a violent pace). For those who think that anything but single-payer is awful, don’t complain! What’s most important is that we have universal coverage that encourages primary care usage, getting patients out of the ER and subsidization for the poorest among us. The international experience shows that truly single-payer systems are the minority, and most systems are a mixture of public and private hospitals, insurance and personal expenditure. Further, one of the best systems in the world, the Netherlands system closely resembles what the ACA will accomplish and has resulted in excellent outcomes and patient satisfaction in that country. In fact, most single-payer systems perform worse in terms of access, wait times, and satisfaction than the mixed systems, with the possible exception of Sweden (probably because they put so much money into it).

    This is a victory for healthcare and the country. Even if it’s not “perfect”, or even if you think people being treated for their medical problems is some kind of sin against capitalism, too bad. It will accomplish a great deal, there is international precedent that such systems work (and may work better than single-payer), and there is no escape from the fact that we have to pay for people’s healthcare. We can do it expensively, wastefully, and emergently in the ER, or we can do it like thoughtful, decent citizens who care about each other’s welfare and provide a baseline of access for all.