Epidemic progression... past Easter

Hospitals are have now been slammed in several cities: Seattle, New York, Los Angeles, San Jose, Atlanta, and New Orleans. Nine states saw significant increases in deaths just today, which is a sign that the we are riding the death curve up to where it could get steeper due to lack of medical resources. This happened in Italy and Spain, and there's no reason to think it won't happen here. The nine states are: New York, New Jersey, California, Michigan, Florida, Louisiana, Georgia, Colorado, and Connecticut.

First-person accounts. In previous posts I linked to accounts from Italy (one, two, three) and New Orleans. This time I have accounts from Washington (older account but good details) and New York City (one, two). Another account from New Orleans. Video from an pulmonary specialist in New York City with practical tips to avoid infection.

We know from all these accounts that about 10-20% of those infected with the virus need hospitalization, so the hospital can jammed up beyond capacity. The virus might have a death rate of 5-10% of those hospitalized in ideal situations, but the death rate goes up to 8% or more in overloaded hospitals. In Italy, many people just stayed home and died there.

The hospitals in northern Italy got slammed about March 8, and the country instituted a quarantine. Eighteen days later and the death toll is still at a peak. There may be some relief after three weeks, which is the average time between exposure and death.

That means for New York City there probably won't see any relief until April 13... if New Yorkers were as blase about contacts as NY mayor DiBlasio was. (DiBlasio didn't close schools until 3/23.) Probably enough New Yorkers started being careful about contact by 3/14 that there might be a noticeable decline in deaths by April 4. But New York has a huge population that is a large reservoir for infection, so the peak may last many more weeks. The example of Italy is that we don't know how long to expect the peak to last.

All these shutdowns are so annoying--to those who want a strong economy going into the elections this fall. It's terribly inconvenient and unfair to have a pandemic spoiling the economy (and election chances). So some, including Trump, are suggesting that we get back to normal as soon as possible, pandemic be damned! Young people should go back to work and elders stay home (one suggestion). The recovered should go back to work. The exposed should go back to work if they aren't having symptoms. Maybe even the older should go to work and the young stay home.

All these ideas ignore some basic facts that can't be fudged. More exposures means more people getting infected, and passing it on. Most jobs are skilled, and absences mean that the workplace will be disrupted. The idea that people can continue working ignores that many will get sick, so soon the workplaces would be closing anyway due to lack of workers and patrons. It's hard to say how soon this would happen. The infection is more concentrated in cities at this point, but it's also inexorably spreading. So will medium sized cities in Ohio have too many sick in 4 weeks or in 8 weeks? We don't know. It's hard to explain why so many GOPers don't understand this--maybe happy-thinking is the mantra and endemic. One contrarian is Liz Cheney, but she doesn't have much of a voice.

So the upshot is that this pandemic, and the way this virus spreads, was always going to be highly disruptive unless it was contained extremely quickly. In the US, we missed that window, so we are taking the huge economic lumps for that. There is no avoiding it.

Image: omfif.org

Corona virus pandemic and the US bungled response

This is the biggest contagion of my lifetime. History is unfolding so it's important to pay attention. I have a lot of links below and I don't want to expend the effort to put them into a narrative. The big narrative is countries that handled the situation well versus those that didn't.

Countries like Singapore, South Korea, and Taiwan have handled the epidemic well, with good public health measures to prevent the wildfire spread. The US had a fairly long warning period, but it didn't have the political leadership to put together a good plan to sharply reduce the effect.

Some countries in Europe are in even rougher shape. Italy has had over 2000 deaths and its hospital system was overwhelmed.Today (3/16/20) it appears Spain is headed that way.

The US might be headed that way too. We were slow to identify carriers, don't have an aggressive testing and followup regime, and we have cases spread widely over the country. Perhaps we started some containment/quarantine efforts early enough to prevent an explosion, but we won't know for a few weeks. On 3/8/20, not many news outlets nor the government were closing down crowded venues to prevent the spread. Just 5 days later, many states had closed schools and banned gathering over 100 people.

The change came about because the situation in Italy exploded starting on 3/8/20. Luckily some people in the US paid attention. However a lot of conservative commenters I saw had reasons or excuses why people shouldn't cut back on their socializing. These included: it's only panic; don't be hysterical; what about the waiters who dependent on tips; this is no worse than the flu; and Obama handled the swine flu (H1N1) much worse. These contrary arguments irk me so much. They are stupid and will hurt or kill people if heeded. And they are based on nothing but partisanship and spiting the other side.

I'm hunkering down, everyone is working from home, we've cancelled our RSVPs to parties, and we're limiting our trips to stores. Luckily I realized the situation with certain supplies, and we have enough toilet paper on hand--bought on 3/8/20 before the hoarding started just one day later.

FINALLY, on Monday 3/16/20, Trump sounds like he gets there is an imminent crisis. The covid task force has a long press conference, and the experts are the people talking the most. Thank God there's an end to the denial. Both the New York Times and New Yorker magazine report that the change is due to a major report out of the UK concerning how high the death toll could be. The New Yorker report is more detailed.

The pandemic will affect so many lives and the entire world economy. Smaller than World War II, but possibly bigger than the 2008 recession or 9-11.

Image: euronews.com

Extras. Trump's misinformation machine. Drezner on Trump's incompetence and predictable consequences. Politico also discusses this with a lot of detail. Some of the failures of the administration. Administration hampered Washington state when they had known cases. Trump makes himself irrelevant. Governors move ahead without him. This might be another reason why Trump changed his tune. The House, Senate and administration can't write a bill. Oh well, they'll get to it eventually. Days later (3/17/20) and still no new bill.

Hong Kong and Singapore handled it much better. South Korea too, which improved after being badly hit by H1N1. The UK had a plan that they dropped. Act now before it's too late.

What China did to slow it down. Readable with plenty of data.

Fast worldwide overview. Hospitals in the west likely to be overwhelmed. Another overview. The dashboard I'm using. It's got daily new cases and new deaths which is info I really want.

Doctors in Italy give accounts. Focus on Italy and why it happened there. Summary of the situation in Italy. By March 7, there were approximately 550 people in ICU beds. The projection for March 20 to April 3 ranged from 900 to 14000. Yikes. More from Italy. More.

Scroll down to see graphic on which ages are dying.

Biogen company meeting that spread the virus. Ohio, with a Republican governor, gets honest and makes a painful guess about its situation. A brief overview of their plans.

Trump Jr. knowingly lies about Dems, again. What a weasel.

Update 3/18/20. A bunch of info from an ICU doctor in Seattle. The course of the disease and some of its quirks. What Fox News said then versus now. Fucking hypocrites. Trump's nonchalance. Trump finally starts to get it... after ignoring experts and the evidence but getting an intervention from Tucker Carlson. Oy vey. We're dependent on Fox News anchors doing the right thing. That's not good. Upon further research, I'm not sure Carlson had that big an effect. His meeting with Trump was 3/7/20. The tone started changing 3/13, with the biggest change coming on 3/16. So perhaps it was the projections from Britain.

A small Italian town stops it by doing 100% testing and lockdown. Not applicable to most of the US. For posterity, a typical daily news update. Will this Lancet report be born out? We shall see.

Update 3/23/20. Straight talk and no whitewash from NIH director. Warning signs that were missed, including those from a pandemic exercise. Trump isn't following through on defense authorization to direct industry to make needed equipment; governors are scrounging as best they can. Florida waited too long to shut down social venues. Trump touted a particular drug as a treatment, incorrectly. Turns out it's rather dangerous, not safe as he claimed. Bad details lead to bad outcomes. Trump and Fox News are already tiring of the lockdown and don't understand why it's important. Short attention span isn't good.

My predictions. There should already be a surge in hospital admissions but information is being held  tightly. On or around 3/26/20, we should have a surge in deaths, which will be reported. By 3/30/20, we should be seeing over 400 deaths per day in the US. This level of deaths will probably last at least 8 weeks. Since the level of deaths will be high, the lockdown won't be cancelled after the initial 15-day period.

Update 3/25/20. Two stories from ProPublica: how covid-19 is different from the usual winter pneumonia by an overworked respiratory therapist in New Orleans. Doctors are writing prescriptions and hoarding chloroquine, the medicine that may fight the virus. A slice of life with the pandemic--a nursing home in New Jersey with 94 patients evacuated. New Jersey is beginning a steep rise in deaths. NIH technical description of covid-19.

Update 4/6/20. I stumbled on an explanation for the run on toilet paper. It started on 2/26 in Hawaii with a message to stock up because of the spread of the virus. This might make sense if Hawaii doesn't have paper mills, and it seems (per a Google search) that maybe they don't. From Hawaii the panic buying migrated to Japan and Australia, then Europe and the US.

July/August links

Don't forget healthcare.  Oops, the GOP did. They are cheering a lawsuit that may end Obamacare even though they haven't considered the chaos if it's struck down. There should be a special word for this beyond 'unbelievable stupid.' Two articles on this: the first features the full-on stupidity of some GOPers; the second features the beginnings of a GOP plan from those that aren't complete morons. And a bit more about the situation.

Walking the high-wire in the Middle East. Qatar is doing this successfully, to the benefit of themselves and the US, and maybe others.

Canadian healthcare. It's very popular with Canadians. We should be taking a look, but most conservatives simply snipe at it.

Lindsay Graham stumbles. He used to be John McCain's best friend. Now he wants to be Trump's sidekick. Sad to find out that he was really just a sidekick with no backbone or moral compass.

Early primary prediction. This article predicts the three frontrunners in the Dem primary based on big donors. It might be a good test of 1) accuracy, and 2) whether only big donors matter.

Predictions about the Iran conflict. Probably no war.

McConnell helps the Russians. McConnell was called out in a big way, and he was mighty angry about it. Nonetheless, he earned it.

Furor over Trump tweets again. What this week? He told 4 Dem congresswomen to (fucking) leave the country.

Bathroom issue ends in a whimper. N. Carolina and their horror at transgender people ends... for now. Related: in Poland, gay pride marchers are attacked.

Armed Iranian speed boats

Image: en.radiofarda.com

October links: even more to catch up with

Writings by Jamal Khashoggi. Collusion and repression in Saudi Arabia, and the Muslim Brotherhood. Khashoggi was murdered and dismembered in a Saudi consulate in Turkey. A fast survey of power balance in the Middle East.

New bombing and terrorism. "Bet it's a Democrat." says a clueless commenter on Breitbart. Some people are either too stupid or too partisan to realize that there are extremists among them. The bomber talked a lot of shit, but complied with the work requirements of his boss, a lesbian. Here are some of the lies that the shooter in a synagogue believed.

Old terrorism. Again, there is some twerp claiming that the driver at Charlottesville isn't a murderer. How many times does this have to be refuted? Some people can't deal with the facts, and have to make up lies that allow them to excuse the actions. The videos taken of the car speeding. The lies about self-defense. White supremacists charged with violence at the rally.

Not a deficit hawk. The GOP doesn't care about deficits, and have increased it greatly in the past year.

How to lower healthcare costs. Focus on the providers. Limit payments to them. What doesn't work: making patients pay a higher share. Sorry, libertarians, but your theory is a bust.

Foreign policy inertia is good. Trump hasn't been able to wreck the foreign policy throughout the world, even though he is president and he's a foreign policy idiot. My comments on the thread: if you're going to scream about how bad the US is, step up and name someone who think would do a better job.

Humorous failed plot to smear Mueller. Try to bribe women to accuse him. Gosh, it fell apart. Who would have guessed. Incidentally, one of the crooks was behind the Seth Rich lies too.

Image: washingtonpost.com

May links: cleaning up from April

Korean peace? Don't be too hopeful yet. North Korea has pattern of reneging, or getting stubborn.

Syrian peacce? The role France may play.

Trump's fixer. Michael Cohen, who handled a payment and non-disclosure agreement for a paramour of Trump, also worked for Sean Hannity. It might be involve real estate, but maybe it's another fix-it situation. Time will tell, and I'm not convinced it is just real estate.

Parties and race. This article chronicles how the Dems signed up with blacks long before the 60's. Contrast this bravery with the craven behavior of most Repubs. Also from Vox: White evangelicals tolerate racism and character flaws in Trump. An explanation about Kanye West and Trump.

Forge and frame, inc. Software now makes it possible to fake someone's words and facial expressions in a video. What a bonanza for computer-capable liars and fake news generators.

What competence looks like. Saving all but one person when a jet engine falls apart, piercing the plane in the passenger compartment. The dive to lower atmosphere for more oxygen, the successful landing. Even calming the passengers. Thank you from the bottom of my heart.

No effect from the weakening dollar. The dollar has been getting weaker, so are we exporting more? Not really. Good explainer for why.

Healthcare cost containment. California may try it. Good!

Russia-related stories: McCabe's wrongdoing at the FBI. I want to hold on to this resource about the Inspector General's report and see what happens. Was he conniving? Was he thrown under the bus? Also this article. Comey notes about Trump. His private memos, written to document the weirdness of Trump's communications with him, are now public. Who's the liar? Trump's legal team. Trump has hired Guiliani for his Russia strategy team. Another Russian tactic. (I almost , typed 'Soviet.') Use international committees to harass emigres in other countries. And to think that my favorite shills think that Russia is good and the US is a war-mongering horror. Russian meddling. A link to the House Intelligence report. A real report, not a Nunes tissue of lies.

Image: gulfnews.com

The state intervenes... too much

The Alfie Evans scandal didn't get a lot of news site attention from the MSM, but it did in the conservative media. A bit of background if you don't know the story (which means that you follow the MSM and thus miss some news stories):

Alfie was born in Britain about 23 months ago. About 6 months after his birth, his health was declining and he was found to have some unknown wasting disease that was shrinking his brain. He's been on life-support since December 2016. The doctors decided treatment was futile, and removed life support. A hospital in Italy offered to take him, which the parents wanted, but this was blocked by the British courts, who also posted guards to prevent his parents from removing him from the hospital. He died at the hospital on 4/28/18 approximately 5 days after being removed from a ventilator.

Superficial review and reaction

Initially I viewed this case of one of people blindly holding on to hope, screaming for everything possible to be done, and ignoring the evidence that it was hopeless. I think most of the news stories played out this way, along with most of the comments. So my initial reaction was to back up the scientific findings and stress the reality of the situation. Alfie was not going to recover. He was not conscious at all, and would never become conscious. He had no prospect in life except being connected to life support and having seizures as they gave him therapy in trying to keep him alive. That was the hard truth that so many people seemed unable to accept.

I agreed that hospital was right to declare treatment futile. I disagreed with the British court preventing the parents from taking Alfie to Italy. There seemed (to me) little chance of significant harm to Alfie. But the judge was overly concerned that he'd die in transit, and that seemed appalling to the judge. I disagree, but at least I understood the rationale, and I didn't think the judge was a monster. Many others did.

The public outrage at the hospital and the British courts was huge, which I didn't understand. Now I do.

When should courts overrule parents?

If you look at the story through the lens of what was good for Alfie and what was medically possible, the parents seem out of touch, and the hospital and courts seem sane, realistic, and reasonably kind.

However, if you look at the story through the eyes of Alfie's parents, it appears very different. They want to do whatever they can for their son. The hospital says they can't do anymore. The parents are distraught, seek other opinions, but are legally and physically blocked from taking their son to another location for treatment.

This is the outrage. They love their son, want to care for him, have never been abusive to him, but their rights as parents were shut down in favor of the court's opinion. I felt this was wrong, but at first I didn't feel the outrage of it.

The mistake of the court was to take away the rights of the parents to decide the child's treatment. Almost all parents will consider carefully, help, nurture, notice how the child responds, comfort, and minimize suffering. Most parents can do this better than a judge can because they are intimately connected to the child.

Not all parents are like this, however. Some are abusive or negligent. For those parents, it makes sense for the courts to intervene. However, Alfie's parents were neither abusive nor negligent. They cared more than anyone else. But at the end, these parents, who dearly loved him, were barred by police from caring for their son in the way they desperately hoped to.

That was the wrong. Not against Alfie, but against his parents. And it was a fairly grievous wrong, to take the decision away from them in such desperate circumstances.

Media focus

Media tended to focus on how it wasn't certain what caused Alfie's decline, and how his last hope relied on getting care elsewhere. Some attacked the British National Health Service (NHS) for its policy to withdraw life support. Some didn't attack the NHS, but faulted the courts for siding with the NHS against the parents and the child's 'last hope.' It became a cause within Britain, but perhaps even more among American conservatives. Their spin, motivated by animus against socialized medicine such as the NHS, regularly contained lies and didn't accurately report the reality of Alfie's condition. The media regularly used words like 'murder' and conservative commenters copied that. Very few gave consideration to the personal, ethical, moral, and financial issues in giving life support for extended periods.

The American Conservative is typically a more thoughtful source of the conservative perspective. But even here, Dreher puts his thumb on the scale. When the NHS wants to end artificial life support, it's described as "forcibly euthanizing the disabled." But should his parents make the decision, it's letting "Alfie die a natural death." Interesting difference in wording considering the actions are the same.

The American Spectator is probably more typical in its invective. The doctors are incompetent and the state is tyrannical. This isn't measured analysis, it's war against tyranny. It's no wonder so many echo these arguments when they're not presented with any counterarguments. Just one side of the story. If you're not practiced in questioning, it's not going to happen.

Luckily, the comments section for the Dreher argument had other thoughtful alternatives. Another columnist for the American Conservative focused more on the parents, and was also fair to the doctors. In the comments section for the American Spectator, anyone dissenting was blasted. Well, that's just another week in the culture war. I wonder what this week will bring?

Alfie on a ventilator, with his dad

Image: dailyrecord.co.uk

Replacing Obamacare is harder than they thought

No surprise about the complexity of the task. The House just barely passed an Obamacare repeal-and-replacement. Now the Senate is trying to do it, and having even more trouble. While the House has some moderate Republicans, every moderate Republican in the Senate has a critical vote. Three defections to 'no' will scuttle the ACA replacement, so the margins in the Senate are even tighter. Also, each senator represents the whole state, not just the more conservative parts of it. It could be that senators need to be more concerned with Medicaid recipients than their colleagues in the House.

It's fascinating to read in this article what different senators want. Rand Paul and Ben Sasse (he of anti-Trump fame) would support a straight repeal. Is that position for real? Don't they worry about the ensuing chaos if there is no replacement plan?

Sen. Bill Cassidy of Louisiana, someone I wouldn't expect to be a moderate, is holding off on supporting the bill if it removes too much money from Medicaid. Louisiana isn't one of the richest states, so it probably has a fair number of people who have gotten their healthcare through the Medicaid expansion. Cassidy seems loathe to throw them back into healthcare limbo. Some senators, like Rand Paul, don't have such quibbles.

These negotiations will be interesting to watch. A pro-Trump PAC already targeted a senator leaning toward 'no' and already had to drop their pressure tactics. Whether the senators will be able to come together, compromise, and satisfy enough of them is an open question. A cool graphic in this article shows that more senators are concerned with the bill not covering enough versus those concerned with that it won't repeal enough. It leads me to expect a more moderate bill passing the Senate. But we shall see. Failure is certainly possible: only three senators need to decide to be stubborn to sink this bill.

Image: cbsnews.com

Links about 'Repeal and Replace'

For seven years the GOP bragged that they could make a better health insurance program than Obamacare. For seven years, they waved their hands, gave us bullets points sprinkled with pixie dust, and didn't deliver.

After winning the presidency, and already having majorities in the House and Senate, the GOP was supposed to be poised to repeal Obamacare on the first day of President Trump's term. Somehow, that didn't happen. BECAUSE REALITY IS A BITCH!

The GOP can't wave their hands anymore and fling pixie dust. They have to seriously crunch numbers, and it hasn't been going well for them. They can drop coverage for millions of people, they can zap the mandate and see cost rise even higher, they can repeal the taxes and blow up the deficit. What they can't do is figure out how to make a program cover more people and cost less. I wonder why not. Maybe not enough pixie dust.

Image: worldwide.chat

Extras. Problems with repeal and replace (with less snark). True believers among Congress just don't understand the delay. Trump makes another promise about the replacement, sprinkled with prodigious amounts of manure-scented pixie dust.

Round-up on US healthcare costs

Today I was contemplating the ever-present problem of healthcare costs in the US. Why does it cost so much here? This article answered that question pretty well. However, it did sugarcoat a big problem:

"... the rest of the system consists, in essence, of a vast number of independent, entrepreneurial providers of health care services and marketers of pharmaceuticals and medical supplies who are free to set their fees and prices as they see fit."

What wasn't said here is that those 'entrepreneurial providers' have a big incentive to gouge as much as they can get away with. That would have been a clearer way to say it.

The next article is much plainer in its explanation, which is great. The comments are also helpful. The highlight here is on how the "I want it now" mentality escalates costs. This is also true.

Neither article dealt much with alternatives, or what a different but still workable system would look like. I would really like a national conference on this. We should look at all the systems in other countries, and pick one out and adopt it. That would mean junking our current system, and I guess I'm ready to do that.

The last article suggests that we adopt the system from Singapore. After reading about it, I have strong doubts that it would work here. Let me know if you share my doubts and why.

Image: 123rf.com

Ebola in Texas, but not worried yet

I wasn't worried about the two Americans being transferred to Atlanta for treatment for Ebola. Am I worried yet with this case in Texas?

No, not yet. But this is of greater concern. The Liberian man exposed a bunch of people before he was quarantined. Now those people may come down with Ebola too, and they could spread it to others. That's what has happened in West Africa.

Handling it right over here

It could happen here, but it won't. We have strong medical systems, not only to treat those with the illness, but to monitor those who may have been exposed. Some are in quarantine to prevent more exposures, and to limit the number of people who have to be monitored.

The personnel directly caring for the Ebola patient are probably limiting their contacts too. They shouldn't be going home to their families and attending church, ball games, and going to shopping malls. It's a big sacrifice to limit contacts, but it's not for a long time, so I think the medical personnel would be willing to make it.

A big problem in West Africa is that the sick weren't separated from the well, and they infected a fair number of people. By the time it was clear that isolation was needed, there were already too many infected people, and the medical system was overwhelmed.

That's unlikely to be repeated here in the US. We have a lot of medical resources to dedicate, and just one case so far. Any contacts who start showing symptoms will go into complete quarantine immediately, not after they've exposed bunches of people. That didn't happen with this first case, but the lesson has been learned. The medical system is on alert and will quarantine, and we will avoid the multiplication effect that occurred in Africa.

The warning sign to watch for is when people are getting sick at home and staying there, denying that they have Ebola. That denial is dangerous because it allows the sick person to infect others. That's when it can snowball. A different warning sign would be medical personnel dying or fleeing hospitals, hospitals refusing to take more patients, or hospitals being attacked. This has happened in West Africa, but there's little chance we'll see it here.

The importance of honesty (again)

This is a lesson in taking the right precautions and being truthful. The man from Liberia lied to get on a flight out of Liberia, lied again by not telling hospital workers that he'd been closely exposed in Libya, and probably lied at other times too. It's important for people not to lie anymore about it. Some people are asking whether we can trust our health officials. From what I've seen, yes, they are telling the truth, and they are taking all the right measures.

In one more month, we won't have a concern about Ebola in Texas. We'll have an all-clear, just like we eventually got in Atlanta. Till then, we have to take the right precautions, and keep this small. That's what we're doing, so it's going to be alright.

Partial view of a well-managed Ebola clinic in Guinea

Image: dailymail.co.uk

Extra. CDC directions on handling the dead. That's more good precautions. 

How big an issue is Obamacare?

Is Obamacare (more properly called ACA) a major issue in this election? Is it a major issue for most folks?

It's hard to tell. The comment boards are still stuffed with vociferous supporters and detractors. Conservatives are still predicting a train wreck, which was supposed to materialize for two years now. Liberals are counting up the successes, and recounting how conservatives' worst predictions haven't panned out.

It's still too early to call ACA a success. We don't know the effect of the health systems or what the costs will be in terms of the federal budget within a few years. The Medicare program costs almost double its projected expense: the program needs a yearly infusion of over 45% of its expenditure beyond the payroll tax that are collected.

IT'S BIG!

ACA really should be a big issue. It's a major piece of legislation affecting a lot of medical care and health insurance, particularly in terms of cost. However, if it's not a big issue, it's because the GOP don't know how to talk rationally about it, and don't know how to criticize it rationally. Most of all, they don't know how to replace it.

The usual conservative meme is that Obamacare is a takeover of the healthcare system, which is about 17% of our economy, maybe higher. This is an exaggeration, of course. You don't have to check in with some government department to see your doctor, as you would have to, say, register a car. The government has a monopoly on car registration, but nothing like that with doctors. Most of the other conservative claims are also wild exaggerations.

This irrational talk can't help too much with swing voters, so I wonder why the GOP does it. Perhaps a party really has to energize the base and the haters in the run-up to an election. Maybe it's just habitual for the GOP, who never stopped hating on the Clintons. But it definitely doesn't help with voters who are trying to make rational choices. On the other hand, that group of voters (the rational swing voters) may be so tiny that it doesn't matter. That's a really sad thought.

Repeal and ... um ... um

I'm not sure which is worse: the irrational critique or that the GOP haven't settled on a replacement. They should have had one for the 2012 election. Maybe they lost partly because of that gap in their agenda. I certainly wasn't going to vote for them with a gaping hole like that.

This vagueness was a problem for them in 2012, and continues to be a problem. Dems can run on the status quo--"don't let the GOP undo what we've accomplished." The GOP can't run on that, but they haven't figured out what they will run on, other than irrational exaggerations about how bad the status quo is. What a stupid party the GOP is, and what a shame for voters who deserve a choice.

Sure, that passes the reality test.

Image: thelastgreatstand.com

Don't worry about Ebola in Atlanta

Two American missionaries who were treating the Ebola outbreak in Africa have contracted the disease. One has already been transported back to the US, and the plan is to transport the other also. They will be treated in a special isolation unit at Emory University Hospital in Atlanta.

How dangerous is it to bring these patients into the US? That's a good question. However, there are some very bad answers to this good question, like these:

"Martial law is what we risk if an epidemic of something like Ebola were to break out here. Far better to prevent its entry to begin with. Not understanding that is moronic."

"This should not and cannot be allowed; that plane should be shot out of the sky; that hospital, burned to the ground; the unelected bureaucrats and plutocrats behind this decision publicly executed as traitors and tyrants; along with and including our President, who could have stopped this and did not due to this personal hatred of the citizens and dedication to the destruction of the United States." --comments here

So, doom predictions from the peanut gallery aside, how worried should we be? Let's think about it.

Ebola hasn't spread worldwide, unlike various forms of flu. Why? Because it doesn't spread as easily as flu. The disease is spreading on the ground in West Africa, but it hasn't gotten into a major city, even with the traveling that people tend to do. Supposedly, people can't pass it on until they're showing symptoms, so you can't pick it up easily or randomly. It doesn't spread via the air. That's very good, and is probably why it hasn't spread throughout the world.

The usual method of infection is from handling the fluids from a person with symptoms, so the visitors and caregivers are the ones who are being infected. Again, it's not random people down the street.

With this limited mode of infection, it won't be hard for a well-prepared hospital to contain the contagion. They will limit the people who have contact. The air from the isolation unit won't be circulated elsewhere. Caregivers will be gowned appropriately and will disinfect appropriately. The staff will be monitored closely, and any sign of illness will be scrutinized, not ignored. Finally, two patients will not overwhelm the resources of the hospital or the special isolation unit.

Am I worried? No. These people are experts in dealing with communicable diseases. This is their expertise, and they practice it a lot. It's the first time they've had an Ebola patient, but hardly the first time they used these procedures. So if you're worried, calm the heck down.

The Ebola patient arrives. No zombies. No martial law.

Image: cnn.com

Extra. Idiot-in-Chief Donald Trump weighed in on the idiot side, of course.

Rant about healthcare spending

I'm fed up with conservatives who complain that Obamacare is going to bankrupt the country but never turn their gaze on Medicare. The message seems to be that other people can spend buckets of government cash on healthcare, but NOT YOU. You are scum because you don't have employer-provided insurance.

There is no acknowledgement of the real problems in the healthcare system. Here's a big example: how many people know that current Medicare taxes aren't covering current Medicare expenses? I heard this mentioned in passing this week, and it was news to me. If we can't even cover our current Medicare expenses, why isn't that information all over the news? It should be a common point when talking about spending, similar to how everyone mentions the yearly deficit and the national debt now being $17 trillion.

Yet it's not mentioned frequently. The fact is that general revenues are paying for more than 45% of our Medicare costs, meaning that other programs are squeezed. And the BABY BOOMERS HAVEN'T EVEN STARTED GETTING OLD YET.

When are we going to start reining in Medicare? I'd cynically say probably not while we have elections and seniors turn out in high numbers, but I don't think we can wait that long. We need some method to force people and doctors to stop this gorging. We've got to start saying "no," but that means saying "no" when life and health are on the line. I don't know if we can do that. We may believe that we have to spend on our healthcare, no matter how much.

Will it be possible to cut back? If so, how? The easiest way is to cut what's ineffective. That means gathering the statistics, and then convincing or forcing doctors not to order the ineffective treatments. We'll probably need to cut barely effective treatments too. I've read of cancer patients being referred for a fourth round of treatment that's known to extend life for only three months. What is the cost? Would you decrease your own bank account $100K per month to extend your life? If not, then you probably shouldn't decrease the country's resources either.

This also means giving comfort care and end-of-life treatment to frail elders instead of hospital care and expensive ICU treatment. Perhaps we shouldn't be trying to save extremely premature babies and people with very severe head trauma. Yes, we will have all these life-saving and life-extended technology that we will purposefully not use because it costs too much.

As I said above, I don't know if we can do that, just let it alone and not jump in with all that. Our track record isn't good.

Image: smh.com.au

What started this rant? The idea that Ben Carson, the neurosurgeon religious black conservative darling can save us. That and finding out that the Medicare payroll tax isn't covering even 55% of our Medicare spending.

Extra. Healthcare costs are growing faster again after a five-year slowdown.

Medical miracle in Maryland

On a radio show this week, I learned that Maryland is the only state with cost controls on hospital charges. The speaker told about how New York once had controls... until a GOP governor put an end to that. Of course I was curious about how cost controls have worked for Maryland, so, as always, I did some research.

Maryland is quite proud of its system. They have their white paper bragging about the results, particularly the lower rate of increase in hospital costs. Their medical system has been more stable too, but perhaps the biggest feature is that there's no cost shifting. That sounds great to me because of the resentment that cost shifting causes. If you're unlucky to work for a small company with a weakling insurance plan, you pay more in the hospital. The government makes this a necessity by being miserly in its Medicare and Medicaid reimbursements--those whales of cost shifting.

In Maryland, all payers pay the same rate, even Medicare and Medicaid. So in one way, the entire nation supports Maryland by paying more there. However, this deal was negotiated decades ago when Maryland's hospital costs were 23% more than the national average. The deal remains in effect because Maryland has done well in lowering its costs and keeping them below average. So it hasn't been a bad deal for the taxpayers either.

Because all payers pay the same rate, the rates are known at hospitals. No insurer wangles a sweet deal at the expense of others. Some hospitals get higher reimbursements, but only due to higher local cost-of-living. That's a consistency I'd love to see. Just imagine, a hospital could easily post its rates in a list, not a complex table accounting for many different classes of insurers or patients.

All this good news was seconded by a (probably) independent review, but what is the bad news? Maryland still has higher than average medical spending than its neighbors. Some costs are displaced from hospitals to outpatient facilities. But I've never heard that Maryland is a hell-hole for medicine, so this cost control approach hasn't ruined life in Maryland.

The Bad News

For a more brutal critique, I had to read a report from the Heritage Foundation. First is a spiel on why cost controls never work. Then the terrible examples from Japan and the Netherlands. Finally, they detail the considerably fewer complaints against Maryland. Cost controls are said to stifle competition and create shortages, yet Johns Hopkins in Maryland has managed to set up surgical centers that allow "the hospitals to circumvent many of the shortages associated with price controls." I read that as saying, well, they don't have the shortages you were warned about. The biggest complaints in the Heritage report are the higher total costs than neighboring states, the waiver from Medicare and Medicaid, and a loss of "care coordination." Weak sauce.

A better critique comes from this healthcare blog. I learn the Maryland has managed to strike a good balance between hospital and taxpayers. Not so with Massachusetts (my state), where "hospitals are so powerful that they ... capture the regulators." The author also tells the history of how other states (all but Maryland) abandoned their cost controls under the illusion of competition between HMOs. Remember how they were supposed to keep medical inflation in check? What went wrong there?

I have to agree--state cost controls sound like a good idea to me. No other method has worked to reduce the inflation in medical spending over the long term. And Maryland provides an example of how to avoid the disadvantages of cost controls. I tend to like market processes, but they haven't worked in healthcare. They may never work in healthcare because it's not your normal market. Let's finally admit that.

Image: northwestern.edu

The Controversy in My Medicine Cabinet

There shouldn't be a controversy in my medicine cabinet. It's my medicine cabinet. It's between me and my doctor what goes in there. There are all these HIPAA regulations that are supposed to protect the privacy of my medical information, presumably including what my doctor prescribes.

So why would anyone care if I have an anti-cholesterol drug in my medicine cabinet? Why should my employer care? Why the hell would my employer go out of his way to complain about me getting this drug, and that some tiny bit might be paid for by him. It's OK if I use my salary to pay for it, but horrible if it's part of my benefits package. Does that make any bloody sense? No, it doesn't.

I am so tired of some people thinking I'm a freeloader because my anti-cholesterol drug is covered in my health plan. Limbaugh thinks I'm some sort of slut because of it, and he demands I upload porno to him.

Now Mike Huckabee is saying something too. He seems to think that I should be offended that my health plan covers my anti-cholesterol drug, because that means they don't think I'm mature enough to handle it on my own, or some such nonsense. Hell, no, I'm glad that they cover the drug, like the rest of my medical needs. Why should I be 'outraged' as Huckabee suggests?

I'm supposed to be outraged at the Democrats for supporting coverage for this medicine, but that doesn't wash either. I don't see how Huckabee can contend that my health plan and the Dems think I'm sort of slut. All they're doing is supporting me when I say "I'm glad my health plan covers this medication."

It seems to me that it's the Republicans who think it's kind of slutty or dirty that I might have anti-cholesterol medication. It's certainly a pretty common med--lots of people use it. Since when did it become slutty?

So to all the Republicans and their dittohead army, would you please shut up about my anti-cholesterol med? You sound very creepy when you get that involved in my medicine cabinet.

Stay out of my medicine cabinet.

Image: laprogressive.com

Extras. Huckabee is raising funds based on this. Some pundit thinks the big problem is that Huckabee is hypocritical about the issue, not how intrusive he is. I disagree. And then there are the idiots who think Huckabee nailed it--that Dems do think I'm a slut. Wrong!

How accurate is brain death?

This post will for those who share my scientific curiosity about the issues involved in the current case of Jahi McMath, the 13-year-old declared brain dead from complications after an operation. The hospital has declared her brain dead, and refuses to fit her with a tracheostomy or feeding tube into her stomach (G-tube). She's currently on a respirator.

These kinds of issues have come up before, including whether Terri Schiavo's G-tube could be disconnected so she would no longer passively receive nutrition and water. Terri Schiavo was in a persistent vegetative state where she could breathe on her own but she didn't have voluntary movement. According to the hospital, Jahi requires a respirator and would cease breathing and all signs of life if detached from it.

Jahi is categorized as "brain dead," a new category that allows someone to be considered dead and have their organs removed by doctors for transplantation. Without this category, all breathing and circulation would have to cease before the organs could be taken and they would be in a degraded condition.

The medical profession has established criteria for brain death including the total absence of response in all cranial nerves. Furthermore, it can be confirmed by studies of blood flow in the brain, which have ceased in a brain dead patient, though this is not 100% accurate in confirming brain death.

It's questionable whether the criteria for declaring brain death are as rigorous as they should be or are followed rigorously. Several supposedly brain dead people have revived, but isn't supposed to be possible. Here's a case from Oklahoma of a man declared brain dead after an accident. His body was being prepared for organ removal when relatives noticed something and subsequent tests showed reflexes indicating greater than expected nerve response. He came out of coma 5 days later (with all his organs) and recovered much of his function. There was a similar case in Britain. This site lists several other cases.

One problem is that doctors are too hasty in declaring brain death after accidents. When there is injury to the head, the brain can swell to the point that most blood flow stops, causing deep coma and looking like brain death. However, in some people the swelling diminishes and the person lives, though with varying degrees of brain damage. Care must also be taken after drowning, exposure to cold, and drug overdose.

Jahi's case doesn't fit into this category, however. She suffered from blood loss, cessation of her heartbeat, and no oxygen to her brain. It doesn't seem to me that swelling was involved. None of the recovery cases occurred to someone in a situation similar to Jahi's.

Of course I don't have inside information about how long Jahi wasn't breathing, test results for brain function, or her response (or lack of response) to trial cessation of her respirator. There's a very good chance that she is indeed brain dead, especially since it's been over three weeks since she had any signs of neural function. However, the eagerness of some doctors to harvest organs for transplant has corrupted the practice of declaring brain death, at least to some extent. It is horrific that doctors should be so eager to take organs that they'd sacrifice lives in the process.

One of many complications

Image: papermasters.com

Update 1/7/14. She will probably die, or finish dying, soon.

Update 5/6/18. Here's a case of a boy with a head injury so severe that he was thought to be brain dead. He regained consciousness and is speaking. The article isn't clear, but it seems that he was in a coma for less than a month. This is quite different from someone in a long-term coma. Jahi is still alive with the support of a ventilator and all the other types of life support. That doesn't mean she isn't brain dead. It could be that our medical systems are excellent at maintaining bodily functions.

One thing I learned: Cultural differences, cancer, and ACA

I'm a strong supporter of ACA. However, I didn't realize until this fall how much my middle-class background contributes to that viewpoint.

Here's the background. Middle-class people are used to living comfortably, with enough money so that running out of money isn't a problem that they've faced. Sure, some get into money trouble by excessive spending or risky investments, but most middle-class people avoid that because they strongly fear poverty--the hand-to-mouth existence is the opposite of middle-class security.

So imagine how a cancer diagnosis affects a middle-class person. He isn't used to the uncertainty, and the treatment of cancer is almost always physically unpleasant. However, it's manageable if there's a good chance that you can return to your old life.

Wrenching choices

Now imagine that cancer diagnosis if you knew you couldn't return to your old life. This is how it feels when a middle-class person faces an extremely expensive, uncovered medical expense. You are almost guaranteed to plunge yourself and your family into a poverty they have never experienced before.

It's little wonder to me that some/many middle-class people in this position might choose to ignore the signs of illness. On one hand, it looks like they (that is, me) value money over life. However, a different way of interpreting the choice is that they choose to maintain their family's comfort and way of life over their own lives. They sacrifice their own lives to maintain the family--something which is easier to understand than why they won't pay what it takes to treat the illness.

This is how I think, and perhaps I'm generalizing too much. But I'm not the only one who feels this way. This also explains the behavior of the woman made famous in the anti-Romney ad. She chose to ignore her symptoms because she didn't have medical insurance, and died because of it. She avoided saddling her family with debt--maybe they even got a life insurance payout. That could well have been preferable to her. I certainly would be to me.

This is why good medical coverage is so important to the comfortable middle class ethos. It's probably one of the first questions families ask when someone gets a job. With more of the middle-class out of work, 2008 was a great time to push for universal coverage, and it finally passed, though more because of the 60 Democrats in the Senate.

Answers from the class divide

If you don't believe there's a class divide in how people view health coverage, read this post giving advice to the uninsured. Look at the range of answers, from which social workers are the best; to how to cash in your insurance to pay for your care; to shopping around for care in other countries. The advice strikes me as coming from solidly middle-class people... until this answer from a commenter named so_so (sorry, no link):

"In August I was diagnosed with a Nice big fat cancerous tumor in My Bladder,,, It Required surgery because I had to have a Catheter .. Could not Pee!!!! [...] I was with a Catheter for almost 1 month and family took up a collection for me to give the Doctor 500.00 Otherwise I was just out of luck.... Needless to say I have not been to the Doctor again... Can not afford it... I do not have money....And do not want Charity... It does not make me feel good at all....( Still not over the Family and X family I had sending 500.00 here... Yes grateful, But taking help from People You know hate you is not a good feeling... ) And that will never let you live it down,,,EVER!!! despite the 500.oo they sent I now owe the Hospital close to 10 thousand.... And it was a day surgery,,,, I talked them into letting me go home....I knew i could not afford the stay.... Glad I did not stay,,,, It will take me a good long while to pay that off..... The Doctor told me 50/50 chance it will come back...."

I don't believe this woman will pay her $10K hospital bill, but it didn't keep her from getting or taking the medical care. I was astonished by this post because it is so different from my attitude. I wouldn't take on medical debt I couldn't pay as this woman did. Though she doesn't admit it, she is a charity case pretending that she isn't one. That option probably isn't open to me, nor should it be necessarily.

Why should my child's college fund, my retirement savings, my additional savings, and the equity in my house be exempt from the bills I run up? Sure, I'd like them to be, but that's not how our personal finance laws work. So I assume charity care is reserved for those who don't have the funds I have.

Self-reliance vs. Outside security

Here's another example of the difference in attitude to how the uninsured should deal with medical expenses:

"I have a good friend...  He is a manual laborer of sorts and has never had health insurance all the time that I have known him.  I am aware of one time that he experienced kidney stones and was in real agony.  He went to the Emergency Room and was treated.  The bill was $4,000.

He depleted his entire savings account and paid the bill in full.  The only thing he owned, which would have been attached had he not paid the bill, was his 12 year old pickup truck which he had to use to work.  I would also add that he has suffered with a bad back for 10 years but still has been able to work, most of the time, in pain.  But work, yes he has continued to do so."

The teller of this story, a conservative I follow named Anson Burlingame, sees this as a story of self-reliance. I see it somewhat differently. Yes, this man was self-reliant. He's been careful and hasn't squandered his money, and toughed it out what he could. But he's also used his entire financial cushion in one day, and he doesn't have any money for the next emergency. What will he do next time? That might also be another reason why he's a hero to conservatives. This man is willing to do what a middle-classer fears so much--pay all the money he has to settle his debt, and go on with his life. Why can't a middle-class family do the same?

There is a cultural difference, not just political differences, in attitudes to ACA. Many approve of charity for the truly poor, but everyone else should be self-reliant. The safety net shouldn't be provided by government, but by the family and community. The Mommy-State takes away this self-reliance and eliminates the need to stay on good terms with your family and community. You can be selfish, lazy, rebellious, or irresponsible, and Mommy will still take care of you. There is some truth to this, but it doesn't capture the whole truth.

Through the filter

The whole truth is that we each have a filter through which we see universal insurance. Some of us see it as a necessity for the financial security we value highly. Others see health insurance as a bonus, but it's wrong for it to creep into the category of a necessity or a birthright. We used to be made of tougher stuff, and not rely on government guarantees for our lives and healthcare choices.

As much as I respect self-reliance, I'm solidly middle-class by birth and education, and I don't want to be uninsured. That happens to be the same sentiment expressed by this Tea Party thirty-something: "This is my only option for employer care and I don't want to be uninsured." We bourgeoisie, we really can't imagine life without our security blankets.

As I said before, possibly I'm overplaying how an uninsured middle-class person would respond to a cancer diagnosis, or I'm generalizing too much from my own personal reaction. I'm not certain, but I see the evidence that others respond the same way.

What we're scared of: expensive and no guarantees

urology.ufl.edu

Extra. Uninsured cancer patients are twice as likely to die.

Short: GOP needs better healthcare lies

I'm not the only one who believes our national dialogue on healthcare is saturated with lying. Josh Barro still identifies as conservative though he's definitely not a cheerleader for the GOP healthcare non-platform. Read how he destroys the current GOP mishmash of healthcare promises lies. Perhaps he explains why I support ACA better than I can.

But to be fair, he ought to focus a bit of that biting critique on ACA too.

The GOP warned us

Image: OBJECTIVEconservative.blogspot.com LOL

Is Obamacare ALREADY a train wreck?

Everyone has heard this. Obamacare is a train wreck. Well, I don't take anyone's word for it. As I frequently tell other internet commenters, your assertion doesn't make it true. So what is the evidence that Obamacare is already a train wreck, even before exchanges crash, subsidy costs balloon, and healthcare providers are so pissed off that they give surly care?

The evidence:

1. In a Gallup poll of small employers, 40% are holding back on hiring because of concerns about the employers mandates in Obamacare. Well, maybe this is true, or maybe it's like the polls showing how many people thought that Obama wasn't born in the US. Some of the respondents will have political reasons for complaining about Obamacare. Refuting data: see the graph below showing trend in full time employment. Or maybe the sluggish job growth is due to a combination of Obamacare and poor sales and demand. On the whole, I think there's some validity to this complaint.
2. People are losing their satisfactory healthcare plans and being dumped into exchanges or forced to pay more for plans they don't want. This is true, but for how many? This tweeter says "After over 5 yrs of no group health ins I finally get a job that offers it and here's the thanks I get [a cancellation notice]. If you think about it for a minute, that tweet isn't a slam-dunk against Obamacare.
3. Here's a rehash of reasons from Heritage Foundation, including job losses due to taxes on medical devices and lower Medicare reimbursements. They mention less than 3000 jobs lost, not a horrifying number considering that the US lost 524,000 jobs in December 2008. 

No, Obamacare isn't a train wreck at this point. It's not as though no one knows how to implement it, what the rules are, or when they will have that information (might describe Dodd-Frank, but not Obamacare). It may turn out to be a train wreck, but it's politically motivated jumping-the-gun to call it a train wreck at this point.

Image: oops, lost the link

Graph above:  theatlantic.com

Extra. Obamacare will explode medical spending, just like Medicare did. I have a few obvious questions about this, including asking about the effect of covering mostly the healthy instead of the elderly. But the kicker in this article is that Medicare didn't positively affect mortality rates. Um, does that means Medicare is an expensive failure? Please defund Medicare immediately and see how that turns out.

Short: Republicans for Obamacare

I hadn't thought of this, but it's true. In many states, some Republicans are working to make health insurance available. I'm not sure how they explain it when asked, maybe something like "... for the good of the people of my state, I'm following the law." These unorthodox Republicans include governors Chris Christie, Susana Martinez, and Jan Brewer.

The next year will be interesting--the implementation of Obamacare might be like the Hindenburg, or it might be ... not so bad. I can hardly wait.

Hat tip: Josh Barro

Image: southdakotapolitics.blogs.com