And no free pass for President Obama either. As you know if you've been reading -- because I mentioned it a few days ago -- Obama's health care proposals include requiring insurers to cover preventive services, which he claims will reduce health care costs. Hillary Clinton makes some vaguer claims along the same lines, to the effect that universal coverage will end up saving money because people will get timely preventive care.

Joshua Cohen and colleagues in NEJM consider this proposition. (And you'll be pleased to know that this is one of those articles of broad public interest that the editors have made available to the rabble, so go ahead and read it.)

Alas, as a general proposition it isn't so. Screening and prevention may be worthwhile, but that isn't the same as saving money. Very few procedures actually produce a net cost saving. Cohen et al don't point it out, because it isn't really the focus of their analysis, but the really bad news is that extending people's lives actually costs money. If somebody drops dead of a heart attack, you only have to pay for the funeral. But if they live for 20 years taking beta blockers and ACE inhibitors and statins and getting angioplasties etc., you've prevented a heart attack, but spent a helluva lot of money.

This morning we heard from Dr. Kelly Kelleher about how it's a great idea for primary care doctors to screen for alcohol and other drug abuse problems. There are, however, some difficulties.

Every disease advocacy organization in the world wants primary care doctors to be screening -- for asthma, diabetes risk, cancer, depression, domestic violence, you name it. In fact there are something like 700 questions that primary care docs are supposed to be asking their patients. However, they generally see 4 or 5 patients an hour. Since the patients are presumably there for some reason other than to be asked the first 30 or so of 700 questions, it's unlikely we're going to get very far with that.

On the one hand I'm happy to see a presidential campaign focus on policy instead of who you'd like to have a beer with or how severe John Kerry's war injuries really were. (A lot more serious than George W. Bush's that's for sure.) But the debate last night just demonstrated, once again, the great frustration of my adult life. There is no way to talk about health care policy without getting deep into the weeds of wonkery and boring and confusing people to death.

Congrats to Hillary for getting the idea out there that you need to get everybody into the insurance pool in order to spread the cost, that a voluntary system has to mean higher premiums because young and healthy people won't be in it -- until they are hit by a bus, at which point they will be expensive too. But a) it was not possible for her to spell out all of the implications and ramifications in the available time; b) if she did spend the time, it would have resulted in a massive epidemic of narcolepsy; and c) the whole discussion came close to creating condition (b) as it was. I doubt most people really got it and it certainly didn't inspire any voters.

Like you, I really don't have a clue what exactly TF Hillary Clinton thinks she's been doing for the past couple of months, or why she's been doing whatever it is, but in any event, no matter what she says tonight, starting right now Barack Obama and the Democratic Party -- with the possible exception of Hillary and 182 fervent supporters who will continue to hold out in caves on some remote Pacific islands -- will start to run against John McCain for the office of prezneh unigh stay, as Sen. McCain pronounces it. That means that if we are very lucky, we just might hvae some conversations about public policy.

So here's my list of public health priorities. It's difficult to put them in order, and I might change my mind five minutes from now, but as of 1:42 pm eastern time they are:

But they do try to predict health care costs ten years out. You may have seen a news brief about the new prediction that health care spending will be 19.5% of GDP by 2017. Health Affairs has made this open access, so go for it if you are turned on by wonkery.

Now, there are a lot of assumptions that go into any such prediction, and it's pretty obvious that unless the McCain campaign succeeds in its increasingly transparent plan to make voters believe that Barack Obama is a secret muslim extremist who has been planted by al Qaeda to turn the country over to Islamofascist infiltrators and give Tomahawk cruise missiles to Hamas,* some of those assumptions will be overturned somehow some way, and they probably won't all work out anyway. But, for what it's worth, the broad outlines of what these perpetrators of deep wonkery expect assuming that nothing major changes are as follows.

This was unbelievable. To see this kind of frankness in a public report just made my jaw drop. Virtually all of the diabetes- and health-related material I've laid my hands on over the years has skirted these issues. Most of those publications, however, were either produced by drug companies directly, or indirectly influenced by them. My non-profit is.

Digby, (who has turned off commenting apparently because it bugs her when people figuratively yell at each other by hurling photons down fiber optic cables) gives this account of the battle for California's Democratic voters -- Obama reaching past the cerebral cortex to forge a mystic connection with the lizard brain, Clinton's generals meticulously marshalling the troops. Note that in neither case is the election about public policy.

And of course it cannot be. Elections are about very expensive theater, as edited and repackaged by a corporate media with its own bizarre obssessions that have no discernible relationship to any definition of the national interest or the interests of any definable group within society except for their own self adoring selves; and as transmitted directly by the campaigns to the extent they can pay for advertising. Secondarily, once sufficient brains have been rewired by the dramaturgy, the zombies have to be marched to the polls, which is where the military-style organization comes in.

All of this costs immense amounts of money, so that's where it all begins. And that's our form of government -- a moneyocracy.

Jeffrey K. Tulis

Whether Senator Obama has a well worked out domestic policy agenda and a detailed understanding of foreign policy is a lingering concern of democrats who find his inspirational rhetoric short on specific analyses, proposals, and plans. This concern has provided occasion for Senator Clinton and others to revive Walter Mondale’s famous question to Gary Hart, taken from a then popular TV commercial for a hamburger, “where’s the beef?” Obama may be tempted respond to the question by offering detailed counter-proposals to Senator Clinton’s plans for health care, immigration, the economy, campaign finance and any other issue she chooses to highlight. This would be a mistake both as tactical choice in the primaries, and in light of his impressive understanding of the place of the presidency in the constitutional order.

John Kenneth Galbraith's popular economic history of the first part of the 20th Century is called The Age of Uncertainty. My history of the present era -- once I get done with the other three books I keep meaning to write -- will be called The Age of Denial.

The presidential campaign we are now enduring is utterly surreal. Barack Obama, rightly, has gotten a major wacking for talking about a Social Security crisis, when there actually isn't one. But helloooooooooo Barack, Hillary, John, Chris, all you characters -- there really are crises out there, major problems that we need to acknowledge and get to work on. I don't expect the Republican candidates to be connected in any way to reality, but somebody has to be.

Okay, since the NYT decided to hire Bill Kristol over me, I'll have to restrict my punditication to this space.

You may have noticed that I've had basically squat to say about the presidential campaign. I did point out that of the three Dem contenders, Edwards has the best health care plan, and Obama has the worst, but who cares, really? It's not as if an Edwards presidency -- which seems unlikely at this point anyway -- will result in the legislation he has posted on his web site becoming reality. In the best case, a Democratic president and a somewhat more Democratic congress in 2009 will result in some marginal changes around the edges. Big Pharma and Big Insurance aren't going to get rolled no matter who is elected.

Suppose you knew you had a terminal illness, and the doctor told you there was a drug that cost almost $100,000 a year, that had not been shown to help people with your condition live any longer; had potentially serious side effects; and might even kill you itself. However, it did seem to slow the progression of signs of your disease such as the appearance of x-rays. Would you take it? As a taxpayer or a payer of insurance premiums, would you want the government or your insurance company to use your money to pay for it?

The FDA says yes, and yes. Avastin, a so-called angiogenesis inhibitor, was just approved for use in metastatic breast cancer, even though all of the above applies, and the relevant advisory council had voted against approval. Avastin has been shown to slow the growth of tumors, but not to confer any significant survival advantage. Again, the FDA has approved a drug on the basis of a so-called "surrogate" end point, some element of a disease process or a presumed risk factor that it affects, without any evidence that the drug actually benefits patients in any subjectively meaningful way.

Talk about polarizing issues. While campaigning in South Carolina yesterday, presidential candidate Fred Thompson said:"I don’t think that it’s the primary responsibility of the federal government to tell you what to eat."Thompson: Don't Let The Government Tell You What To Eat

Hillary Clinton is evidently running for the Republican nomination for president. Monday, she met with Richard Mellon Scaife -- yes, the very architect and financier of the Vast Rightwing Conspiracy, the man behind the Whitewater hoax, the man who spent millions of dollars promoting the story that Hillary Rodham Clinton had Vince Foster murdered -- now the publisher of a commercially non-viable far right-wing vanity newspaper, and used the occasion to denounce Barack Obama for being a member of Jermiah Wright's church.

Today, I read this in the Washington Post: "[Like John McCain] Sen. Hillary Rodham Clinton's campaign has also started slapping the L-word on Obama, warning that his appeal among moderate voters will diminish as they become more aware of liberal positions he has taken in the past, such as calling for single-payer health care . . . ."

It's not very surprising that a recent poll finds that 28% of Clinton supporters would vote for John McCain if Obama is the nominee, since it has been the Clinton strategy for several weeks now to endorse John McCain over Obama.

Got a tip from reader Kathy about a little business as usual at a health insurer in Cal that ducked $35.5 million in expenses by dumping sick people. Yeah, that's what the God-given Free Market does folks. The scandal, as far as the LA times is concerned, is that their head hit-woman was given the assignment of wacking 15 sick people a month, and paid a bonus for exceeding the goal. That's not a scandal, that's how insurance companies work. The scandal is that she only got 20 grand for screwing over 301 people and saving the company $6 million bucks. Come on, Health Net, have a heart.

This letter was submitted anonymously by a working reality writer. He/She requires anonymity, because otherwise, he/she fears being fired for writing this.

Dear AMPTP,

Today, I read on your website, “thousands of people in reality and animation have chosen not to join the WGA.”
This statement is false.

As a writer (aka "Supervising Producer", the name I'm given to get around having to give me a WGA contract) who has worked in reality television for over three years and who knows many people on the reality circuit, I can tell you that reality writers desperately want to be part of the WGA.

A couple of recent reports in the popular press on academic exercises offer considerable food for thought. First, I'll offer my own well-fed cogitations on this effort by a task force of physicians in various powerful positions to decide who gets triaged to the scrap heap in the event of an influenza pandemic or a comparable mass casualty event. Unfortunately, the issue of Chest in which this report appears hasn't made it onto my library's on-line subscription service yet, so I can only go by the news report. Hence I don't know the full composition of the task force. It includes representation from the military and the Department for the Impregnable Defense of the Glorious FatherlandHomeland Security, among other federal agencies, as well as medical societies and prominent academic physicians. I'm sure many will see this as vaguely sinister but I'll give them the benefit of the doubt as to motive.

My thanks to the commenters on my post about my father -- and thank you particularly for sharing some of your own stories. I try to let my personal life intrude minimally here, but as a disciple of the late Irving Kenneth Zola I take very much to heart his insistence that sociology can only be called objective when we disclose ourselves. It may seem paradoxical but only if you haven't thought about it very hard. Obviously, I have a personal stake in the issues I write about here. You should only conisder me credible to the extent I reveal it.

Yes, another political post. Tomorrow is the Super Tuesday to end all Super Tuesdays, so I don't feel too bad about it. For a political junkie, this has been the most fascinating 6 weeks I've ever seen. Results wildly out of line with the polls, huge lead changes, the death of "momentum" as a meaningful gauge of a candidate's chances, debates more wonkish than I've ever seen, and two candidates I'm super enthusiastic about...

And that's just on the Democratic side. With the Republicans we've got Giuliani's 50 million dollar delegate, Huckabee's shock win in Iowa and all-too-predictable collapse, Romney remembering too late that he had a far better case as a smart business guy than he ever did as the cultural warrior, and the resurgence of McCain (which I'm not enthusiastic about in a strategic sense, but which does make me feel smart for predicting that he would win the nomination way back in November when he looked DOA).

Anyways, I got an e-mail today from a friend in California leaning toward Hillary asking me to make the case for Obama. I ended up with a fairly lengthy response and figured it wouldn't hurt to post it here. Yesterday I made the emotional case. This is the strategic one:

So okay, I could wallow around in wishy-washy sophomoric philosophy for a few more days, but let's put the key issue on the table. What do we mean by good health? Sure, that's technically just a semantic question, but it's actually substantive because the word "health" tends to stand in for whatever the ultimate goal is supposed to be of the blob that ate the economy -- or at least one of the blobs, the Department of Imperial Hegemony Defense being the other.

The Randomized Controlled Trial (RCT) is the so-called gold standard for determining what is and is not evidenced based therapy. When we talk about the clinical trials submitted to the FDA in new drug applications, that's what we're talking about. When people call for Evidence Based Medicine, they mostly want doctors to use interventions that have been "proven" through RCTs.

So it was refreshing to day to hear Malcolm Gordon, who is an official of the Center for Mental Health Services, tell us about many of the reasons why RCTs don't necessarily tell us what does and does not work when it comes to mental health services. For example, they are very expensive to do, so they seldom go on long enough or have large enough sample sizes to support adequate subgroup analysis. An intervention that works for some people might not work for others, but we just don't get the information we need from RCTs to understand that. Attrition is a big problem in trials, particularly of mental health treatments, and it can seriously mess up the statistics. A truly major problem is that interventions are developed, implemented and tested in highly specialized settings and circumstances that just don't correspond to anything that is likely to happen in the real world of the mental health system.

I'm like, scratching my head. Barack Obama won the Democratic nomination for president, correct? The nomination will be awarded officially by delegates to the Democratic National Convention, the delegate selection process is over, and the majority of the delegate votes at the convention belong to people who will vote for Obama. Ergo, QED, therefore, ipso facto, a fortiori and you can take it to the bank, Senator Obama will be the nominee.

So Hillary Clinton takes the occasion to announce:

She is the candidate who will be the best president;
She is asking people to continue to donate to her campaign;
She will decide on the future of her campaign in the coming days, based on what the people who voted for her want her to do;
That the voters of South Dakota have had the last word in the primaries, even though the polls in Montana were still open at that very moment;
That more people voted for her than had ever voted for a candidate in a primary -- even though more people voted for Obama than for Hillary Clinton.

I haven't ranted very much lately about the democratization of science, and mea culpa. So the theme for today is that we can't have a more democratic scientific institution if most people lack the basic knowledge they need to participate.

This is the story of my professional life, actually. My day job is with a community based public health agency, and my academic half is concerned with people's control -- or usually lack thereof -- over their own health and health care. (As I often say, I am a community-academic partnership.) My work concerns all sorts of issues -- mental health, addiction, environmental justice, diabetes, heart disease, you name it -- but HIV is a particularly big piece of it, in part because it has paradigmatic qualities that make it particularly instructive for many of the principal concerns of medical sociology.

From KCRA: Homeowners may see a new fee to cover firefighting costs under a proposal in the new state budget...Homeowners would each see an increase of about $10 to $12 in insurance each year.
...
Even though it's a small fee, some are opposed to another fee for something people are already taxed on. "I don't think increasing any fees in a declining market is a good idea," homeowner Karin Libbee said. "People are struggling to pay their mortgages."From Fortune: With the national foreclosure rate zooming and the real estate market in a two-year funk, the insurance industry fears more homeowners will see arson as a way out of their financial woes.
...

I'm not a clinician, I'm here as a project evaluator with the intention of getting sense of the what the field of mental health care for traumatized children is like these days -- at least for those community based agencies and academic experts who are fortunate enough to have support from SAMHSA as part of the National Child Traumatic Stress Network.

There's plenty of good news here -- then I'll give you the bad news.

Good news bulletin #1: I have heard scarcely a word about psych meds. The only way pills have come up is as a peripheral note that somebody who is part of a case scenario had been prescribed something. The NCTSN is not about drugging kids.

Bulletin #2: The DSM-IV is equally conspicuous by its absence. There is absolutely no interest in classifying kids' problems as diseases, tossing around disease categories, or using diagnostic labels to guide treatment.

Much of the time, when people are furiously debating some question, it turns out they don't have any substantive disagreement after all -- they are arguing over the meaning of a word. On the other hand, it may not be quite that simple, because the words in question may be embedded in larger constructs, so that disagreements about their meaning can reflect differences in substance after all.

I am sure you have all seen the headlines – the big Democratic turn out, the big Obama win, the big Clinton loss, and the religious right’s single-handed miracle of a Huckabee win – but what happened in Iowa last night holds far more secrets about what is to come than those headlines.

I caucused with the Democrats so I will have to limit my comments to what I saw there, although from my understanding, the Republicans go, pledge, pray, vote, and go again -- home to watch the Orange Bowl (Kansas was playing after all). The Democratic caucus procedure is much more involved, but more on that later.

Few Americans remember the Great Depression. For my grandparents, it was an essential formative experience, but for people of my parents' age, it's a childhood memory, with little impact on their understanding of the world. Since World War II, Americans grew accustomed to a steadily rising material standard of living and eventually came to take it for granted that the average person would always be wealthier than people of a decade before. However their own dreams had fallen short, people invested not merely optimism, but faith, in the greater well-being and achievements of their children.

This is the first of what we hope will be a number of "calls to action."

As of last week, the AMPTP retained the powerhouse "crisis management" firm of Fabiani and Lehane (known in political circles as "the Masters of Disaster." )They also have "a reputation for hardball tactics in damage control and inflicting damage on opponents."