Sunday, June 2, 2013

Sunday Question for Conservatives

Barack Obama's Gallup approval today is at 47%, which is toward the lower end of the range it's been in during May. Where do you expect it to be by January 1?

(Yes, yes, averages are better...but Gallup has the advantage of easy comparison with other presidents, even though all of it should be used with caution).


  1. Whenever I read posts like this, I first think "what a distraction" then I remind myself that this is the main event; it's the science of the horserace.

    Considering that most journolists have already made up with Opapa over the recent messiness, I expect business to return to normal.


  2. My wife was chatting with a fellow parent, a physician, at a school event the other day. They were talking about the changes to come with Medicaid, the exchanges, etc. The physician noted that a lot of the stuff people fear happens already and then related that Big Insurance already penalizes physicians for "unnecessary" procedures such as the demerit points the physician received for ordering an x-ray for a stage II cancer patient. We've all heard some variant of this story a thousand times in the managed care era.

    Setting up: supporters of Obamacare believe the following to be true as of Jan 1, 2014 -

    1) Health insurance will be extended to a large number of previously uninsurable (expensive) Americans,
    2) At lower per patient cost, due to
    3) "Efficiencies" relative to the inefficient, costly, denying-radiology-to-cancer-patients world of private insurance.

    Says here that, as the clock ticks closer to midnight Jan 1 2014, more folks will come to terms with what exactly is meant by those "efficiencies". Given the fact that Obama's name is on the thing, marginally attached voters will sour on him in the process.


    1. This addresses the lower patient cost idiocy in detail:

    2. @CSH -- Given the fact that Obama's name is on the thing, marginally attached voters will sour on him in the process

      His name is on "the thing," but Obamacare is a complete abstraction to people and I expect it will remain so. Rising premiums or worse coverage, preference for particular procedures and more transparently comparable procedure prices, otoh, won't have Obama's name (literally) on them. They'll have insurers' and doctors' and hospitals' names on them. I'm pretty sure it will continue to feel like the intermediaries we have the most direct contact with are the ones responsible. I mean, I have never once thought: "The authors of the DSM-IV (or whatever, pick your specialty) are amazing. Their broad, unclear guidelines really gave my doctor the resources to diagnose and treat me," even though I've read a bit about how thoroughly the manual shapes diagnosing, treating, and prescribing therapists' and physicians' choices. Things happening at that level of abstraction and distance simply don't affect our perceptions in that way. Considering that the class of "marginally attached voters" probably overlaps heavily with the shockingly, or say -- clarifyingly high proportion of the population that will tell pollsters that ACA is repealed, overturned, or perhaps already implemented -- I have a really hard time thinking it'll have any direct impact on Presidential approval ratings.

      In fact, I'm not sure that what the ratings of the ACA itself will be then, and what they'll be after it's been fully in place for ten years -- will reflect the actual content or (scholarly or even partisan assessment of the) consequences of the bill.

    3. What's interesting, though, is that it appears that the administration is gambling that, by the time supporters come to terms with these issues, ACA/the exchanges will be settled policy and resistance will be futile. FWIW, this is not a bad strategy on the part of the administration, it seems to me.

      I envision a column from one such as Krugman, maybe in October, arguing that ObamaCare is a good thing since private insurers are assholes, denying coverage to the previously ill and care to the already enrolled. A few days later we'll get the ObamaCare is a good thing because of the cost efficiencies vs. the status quo bit.

      At least in October, that will float with the true believers. Indeed, those opposed will mostly do so because they dislike either Krugman or liberals; the population that reacts negatively to the internal inconsistency of those arguments will be quite small. In October.

      People won't really start catching on until the guy down the street has to wait way longer for his angioplasty in the exchange than he did a few years back in Humana. That process will be slow and occur in fits and starts. By the time it reaches critical mass, the ACA may indeed be settled policy.

      Actually, not a terrible plan, assuming indeed the WH is pursuing it.

    4. CSH, I'm afraid I don't follow that. The angioplasty doesn't come through the exchange. The exchange merely makes it easier for some people to find and acquire insurance from a private insurance company. Most people will probably never deal with an exchange.

    5. Scott, (from one of backyard's links), I'm drawing an inference from the experience of Massachusetts writ large. (See page 17 for average 2009 wait times in Boston v. other metro areas).

      Of course, this data point hasn't in any respect 'ruined' hc in Massachusetts; depending on how it plays out, it might not ruin hc in the US either.

    6. correction - page 14.

    7. I see. Yes, if you add more patients to the same system, I suppose wait times will increase, at least until the system adjusts through greater efficiencies and/or more doctors. That will take time. I'd still like to think that the best solution is to adjust the system rather than to suppress access to it.

    8. I'd still like to think that the best solution is to adjust the system rather than to suppress access to it.

      Well, see, that's what makes you a communist.

  3. Obama's approval range, except for his honeymoon period in early 2009, is fairly narrow; he is a partisan and polarizing leader, and so I expect him to stay in the 40s or very low 50s, as most Democrats very much like him and most Republicans very much do not. There is a mild tendency for approval ratings to drift a bit lower during second terms (Bill Clinton very much the exception to this mild trend), so I will say 44%.

  4. Aside to the classicist, here's the wikipedia page for criticisms of the DSM series. A sentence from the section headlined "Medicalization and Financial Conflicts of Interest":

    Of the authors who selected and defined the DSM-IV psychiatric disorders, roughly half had had financial relationships with the pharmaceutical industry at one time, raising the prospect of a direct conflict of interest

    You argued above that the DSM-IV (or policy making board for the ACA) exist at a level of abstraction making it impossible for private citizens to question the underlying frameworks. That is certainly a legitimate point of view for a DSM-IV, ACA, or any similar broad policy-making entity.

    Just curious, though...after you read that sentence in italics, do you still feel the same reflexive confidence in the DSM series?

    1. O, evidently I've totally miscommunicated, or else just forgot to write what I was thinking, which is a thing that happens. I meant to say, or was thinking, that I actually have read a fair bit about how the DSM is produced and therefore have an uncommonly clear sense BOTH of how influential it is in generating the options available to doctors AND of how contentious, how arbitrary, how unscientific the process can be and how dubious, how vague, how unscientific the resulting concrete product can be. (and yet I still don't reflexively attribute decisions about my health care to the system it makes but to individual and corporate actors within that system, blah blah blah)

      I'm not especially familiar with but am utterly unsurprised by the pervasive commercialization of the DSM -- unsurprised because of how commercialized prescription is within individual practices and the medical community writ large. (Do you know the pharmaceutical companies hire lots and lots of fresh-faced young women, using sororities (or was it cheerleading teams) as feeders, to give doctors free samples and innocently push them to prescribe the name brands that are many times more expensive than the relevantly chemically identical generics?) My window in is just reading anout some of the actual debates that have taken place. For instance, the terrific and accessible Canadian philosopher of science Ian Hacking wrote a whole book, Rewriting the Soul, about the history and sociology (and philosophy) of what was in DSM-III called multiple personality disorder, and in DSM-IV reexplained as a spectrum of dissociative disorders. And the psychologist Kay Redfield Jamison has also discussed the shifting boundaries of schizophrenia and what she calls "manic-depressive illness" but I think DSM is still calling bipolar disorder.

      Don't get me started on how impossible the history and sociology of IQ testing makes it to take the term seriously. Or I mean, get me started. I want to teach some of this stuff in the winter, so I need to go back to the literature at some point anyway ...

    2. I probably mentioned that, a thousand years ago, I was an intern in a neuropsych clinic, doing psychometric tests on youths taking adderall, ritalin and the like. Though I was an exceedingly dense youth, I quickly realized what everyone in that environment does: that ADD (and less so, ADHD) is a real and at times terrible condition, but one afflicting maybe 10 or 20 percent of the children through the clinic. Even a stupid kid like me could easily tell the difference between the clinical cases and those not: put pressure on the kids to stay on task and the ones without the disease would always comply, while the ones with the disease never could.

      I thought about that skimming Hacking on the multiples. There's a similar issue there as with attention diagnoses, it seems to me. Multiples (separate personalities unaware of each other) are exceedingly rare; the lesser form is dissociation, which describes, to some extent, just about all of us. I cop to it: I come back here and think, damn, you're smart CSH, I bet everyone thinks that last comment was teh awesome, and maybe Jeff or Scott or the classicist or even Jonathan himself will say so, and if they don't say so, they must be thinking it...and it isn't, technically, multiple personality disorder because "I'm" aware of the whole thing...

      ...but if I show up at the reception window, with a really intense look and unwillingness to take no for an answer, and I swear six ways to the weekend and all day Sunday that the "teh awesome" me and the real me - never the twain shall meet - can I get my drugs? Whose gonna stop me?

      Coming full circle, I think this illustrates why the great hope for efficiency from the ACA (in particular) or universal health care (in general) will vastly overpromise and underdeliver. The theory is that, if you take the profit motive out of health care, the incentive for Novartis to push ritalin on unsuspecting kids and families will decrease. That's part of the problem.

      The bigger problem, as per the anecdote above, is me. Socialized medicine doesn't help in that regard, unfortunately.

    3. @CSH -- oy, you sound like Chesterton ("the problem is me" ... I'm sure you know that story). I would add though that, if profit motive plus you (!), if those are the problems that lead to overdiagnosis and overmedication, and universal health insurance weakens the first and leaves the latter be -- if that's so, nevertheless underdiagnosis and undermedication are huge simultaneous problems. And I support universal health insurance because from my perspective those are the most important of the relevant problems.

      Yeah, abuse of ritalin and adderall (sp?) is ridiculously widespread (in certain sets). I read a whole article in the Times (I think) just about ritalin and adderall abuse among professional classical musicians. But prescriptions are cheaper than a doctor's time ...

      And -- in case you were fishing -- it is indeed the case that I appreciate many more of your comments than I respond to!

    4. Out of pocket all day...and you're too kind, I actually wasn't fishing, there is an element of dissociation to participation here (mine at least), though hopefully not always...or even often...


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