Tuesday, June 24, 2014

Will Obama Qualify as a Profile in Courage?

This from the NYT:

Disapproval of Obama’s Foreign Policy Rises

OK, yesterday I opined that Obama was pursuing a very brave path in risking the unknown and defying a repellant "ally" in whom we had invested tons of money and people and prestige and you name it.  Now we see even more headwinds, political unpopularity.  In politics, popularity is power, so losing it is not nothing, especially as midterm elections loom.  I don't know whether or not they foresaw this, but here it is.

Let's get it straight -- we remember FDR's statement about Somoza, "He's a son of a bitch, but he's our son of a bitch."  Part of what Obama is saying is, "No more Somozas."  That's quite a statement, quite a change, a very important departure from short term to long term, an enlightened view of garnering soft power.  With change comes risk and sometimes opprobrium.

Let's also remember that Obama is doing a lot on the environment on his own, and pushing very hard for public recognition and acceptance of the necessity to lead on climate change.  They say you can't do too much at once, and that as you progress in second terms you get less and less done. But he's trying, and trying hard.  He's picking up the pace.

"Profiles in Courage" was a terrific book that emphasized the heroic individual.  Is Obama possibly becoming a new candidate for the ongoing list?

budd shenkin

Sunday, June 22, 2014

Obama's Foreign Policy: The Tail Shouldn't Wag The Dog

I have been quite critical of Obama through the years, mostly about his performance rather than his ideas. He spent the whole first term domestically negotiating with himself, trying to figure out what proposals would have a chance of acceptance from the Republicans, and then being surprised when they upped the ante as he proposed what he thought they might accept. Or that's the way it seemed.

So it is with some sense of ruminative perplexity that I see I am agreeing with him pretty much across the board these days. Of course, now that he has screwed up the public relations and perceptions for so long, his chances are diminished, but maybe he's at his best coming from behind. Who knows.

Strangely, since he is taking his time and making sure he thinks clearly and doesn't just react, I think he is acting very bravely on Iraq. I also think he is acting in a way that my policy ideal at the Goldman School of Public Policy, Aaron Wildavsky, would approve, if he were still alive.

First, bravery in action and negotiation. Obama is getting pilloried for not keeping forces in Iraq. “They say” that if he had done that, somehow the ISIS forces would not be sweeping in from the northeast. Somehow the divisions of troops in the Iraq Army would not be melting away, abandoning their equipment and their uniforms. “They” are various, amazingly including the should-be discredited voices of the past – Cheney for God's sake, Wolfowitz, Bolton, everyone except Rumsfeld. But even the sober voices somehow allege that Obama was ball-less, and should have insisted on keeping troops there, although they don't say how he could have left troops there given the poor deal Maliki was offering for status of forces.

Now, maybe it's true that there was nothing Obama could have done to leave some forces in place, that Iran dictated that end result. Maybe that's the truth. But the way I look at it, the question is, how much is the US willing to give up in order to keep forces in place, which costs the US a lot, but which is nominally for the benefit of the host country? Are we begging to be of help to them? Certainly to ourselves as well, blocs not having been abolished in the world, and terrorism being exportable, but most directly, isn't it being helpful to them, the recipient countries? Are they children that we care for so much that we are begging to let us do something for them? Isn't this the tail wagging the US dog??

So, it's a negotiation. Obama says, this is our last, best offer. They say no. What should we do, revise the offer? Or should we say, OK, we both lose by not doing things together, but so be it. We'll see what happens. We think it will hurt both of us, but we can't accept your terms. What is wrong with that?

“Stay the course” was heard in Vietnam, and it has been heard here in Iraq, too. “They” say that if we don't stay the course, America will not be trusted in the future. What will it do to our “credibility?” Well, I think that's crap. It's more important for our credibility that we be seen as a country that has a decent negotiating position, a country that will help ourselves by helping others, but up to a point. That is the kind of credibility Obama is forging for us. He is being politically brave to do so, and being canny in not announcing it publicly. And he is being very brave in risking “failure.”

Now, about that “policy” business. There are the “planners,” and there are others, perhaps called those who “muddle through” (Lindblom's term.) “Planners” have to have everything set from the start. If this, then that; if something else, then another “that.” It is in some ways a very defensive strategy that seeks to eliminate risk by thinking of every contingency beforehand. “Muddlers,” on the other hand, take it one step at a time. They realize that the world is complex and that everything cannot be foreseen. So they take a step that seems to provide a good prospect for the future, understanding that assessments and decisions will have to be made. They have confidence in their future intelligence and capacity.

In a way, the “invade with overwhelming force” crowd is like the planners. In seeking to dominate, they are seeking to get their way, whatever it is, and not let the voice of others be heard, not let the choices of others intrude, and have it set up from the start. I think it was Crash Davis who said, “Strikeouts are fascist.” Our neocons are quite fascistic, in case no one noticed.

So I think Obama is being brave in saying, OK, the negotiation fell through, I think we're still in a good position, let's see what happens. I have confidence that we will find good options to take in the future, and that the wrongheadedness of Maliki will run its course, and we will find a way to ally with more enlightened forces. We'll find allies willing to make sure terrorists don't find a haven. It's brave.

I think Obama is pissed he's getting such a bad rap, and I think he's great at coming from behind. So I am belatedly rallying to him. I think he is pretty admirable right now.

Budd Shenkin

Friday, June 13, 2014

Medicare, Hospital Readmissions, and LUC

The reader might remember how my step-daughter's father was sorely neglected when he had to return to UCSF after an operation for esophageal cancer. (see http://buddshenkin.blogspot.com/2014/04/a-sad-tale-in-teaching-hospital.html). He was poorly treated in the ER where he was delayed for hours and then poorly treated by the resident team on the floor. The attending was in Hong Kong where he responded admirably by telephone to an email from Sara, who is a physician, who was advocating for better care and attention for her father.

I didn't think much more about it, other than to blog about the faults of teaching hospitals. But Sara has brought up another interesting view about the Law Of Unintended Consequences (LUC).

Medicare has tried to incentivize hospitals to do a good job with patients the first time around. In particular, Medicare has wanted them not to neglect patient discharge instructions and coordination, which hospitals have traditionally neglected partially because there has been no money to be made in doing so, and partially because there is no dramatic consequence, either, for the staff and doctors involved. “Out the door and off my plate” has been the traditional attitude. If the patient bounced back, why then, it was another admission that could be charged to Medicare.

The solution Medicare came up with was to inform hospitals that it would refuse payment for a patient readmission within 30 days after discharge. It seems like a simple enough solution, one that would incentivize good and definitive hospital care with an appropriate coda. But Sara observes that while hospitals might save themselves money by doing good discharge planning, if the patient does bounce back to the hospital, the hospital has no incentive to bill for the services delivered, because they won't be paid for. Yes, minimizing the extent of services and discharging the patient as fast as possible is still in the hospital's financial interest, but – importantly in this case where the residents were overloaded with work and Sara's father was neglected – it doesn't matter to the hospital if a staff physician sends in a bill or not, because the hospital won't get paid. It can just be a “resident case.”

Background – for many years teaching hospitals billed for attending physician services whether or not the attending physician actually saw the patient, which was illegal – but if you're a teaching hospital, who cares? Who could or should challenge an institution with such prestige? Well, the US government did so, fined Penn many millions of dollars, and from then on, all the teaching hospitals made sure they had the signature and a note from an attending physician on every patient every day.

But now, with readmissions, all bets are off. They're not going to get paid anyway! So if the attending is in Hong Kong, why get a substitute attending to look at the patient, and to actually care that his sodium is at 128 and plunging? The hospital doesn't really care since payment is not involved. And residents? Ah, residents, our future stars. For now, they're just trying to get through the day, their hours are curtailed by law, and they probably operate in a blame culture, which means that the ultimate bureaucratic virtue is not to be blamed for anything, and the ultimate blame would be to ask an attending to actually help out with patient care, when the attending's priorities are in research and travel, not patient care.

LUC, you are everywhere. Good catch, Sara. She is getting real smart.

budd shenkin

Thursday, June 12, 2014

Fear of Health Care Rationing

A quick note on something that the reader will have understood from the start, but which has just become apparent to me. Sometimes I'm slow.

Rationing of health care has long been a huge bugaboo. I remember that my father said, “Why are people so stupid to talk about the evils of rationing? We already have rationing, we have to!” He thought people were just being stupid.

Well, they weren't being stupid, just a bit disingenuous. Yes, of course we have rationing. My Dad was thinking about what doctors do in guiding patients to one path or another. They ration. But much more importantly, as long as there is any element of the market in health care, we ration care as we do any other good or service, by price. It's clear that the poor get less than the rich, and the in-between – the working poor, those just above the Medicaid eligibility line – get less than anyone.

So, when someone says, “We don't want rationing!” (think, Sarah Palin), what are they really saying? What they are saying is that they don't want to get less than they are already getting. Don't take something away from me and give it to the poor or anyone else – that's the real message. They can't say that directly most of the time, but “don't ration” is code for “don't take it away from me.” And don't give it away to my most feared competitor, those right under me.

As always, those most threatened are those just above the poor, or those just above the working poor. They are the most conservative elements, usually, except for the superrich. (And what is it with them? Are they really just selfish pigs, or do they unconsciously believe that they have no right to what they have, and so are all the more and very insistent on their right to have what they have and more, in a kind of reaction formation?) “What's the Matter with Kansas” investigated why that group of working class voted against their own economic interests, and found that they were diverted toward social conservative ideas by the class above them that really stood to benefit from the conservative economic policies pursued by conservative politicians. But I think the key is, don't take away from me what I already have and give it to those below.

I remember a staff member at Bayside who came from a labor union family. We asked her why she wasn't for the Clinton health plan. She said that everyone having the same plan would mean that she, and everyone else, would have the equivalent of Medicaid. In other words, her take would be downgraded. We were amazed she didn't have our optimistic outlook, but in looking back, I can't blame her. Maybe she actually had it right. After all, even strictly socialistic health care systems have parallel private systems. So, even if you even things up, the upper wealth sectors will have private systems available. It will be the currently strongly insured who have their resources diluted, because they will have to share strictly with the newly enfranchised, while they upper crust won't.

So, as I said, I bet 90% of people understand this, but I didn't really, and now I think I do.

budd shenkin

Monday, June 9, 2014

Bookstores in England; The NHS

In a flash of brilliance in packing, I stowed a scrunched up gym bag as a packing safety valve in my suitcase for our recent one month European trip.  Thus it is that we traveled back home with thirteen paperback books checked in baggage in said gym bag. In addition to the books that did in fact fit into the regular suitcases.

It's not that we don't have paperbacks in the US, but according to my high-reading wife, not all the books available in Europe can be bought at home. Which ones she is referring to I'm not sure, but I'm certain she is correct. And in fact, let me admit that three or four of the books are indeed mine. In Portugal I picked up a book translated from the German by a Swiss professor of philosophy in Berlin called “Night Train to Lisbon” – I'm enjoying it very much, despite its tepid review a few years ago in the NYT. And I just finished a book called “God Bless the NHS,” by Roger Taylor, a journalist, about the English National Health Service, that I bought three days ago at Blackwell's in Oxford where we were visiting son Allie. I saw that book and wanted it, then I saw another book, Emerald Planet, that Allie had read with his newly-formed book club in Oxford that meets in the pub where C. S. Lewis and others used to meet, so I had to buy that. But both were in the 2 for 3 sale, so I could get another one for free. I had two candidates, one on human evolution and the other called “How Much is Enough,” about money and the good life. Ann said, “Get them both!” and ran off to buy two more in the 2 for 3 category, because then it had become 2 for 1, irresistible. So we walked out with 6 – after she had already bought a couple.

What is it with English book stores? My brother-in-law Ralph can't believe that Berkeley – Berkeley, of all places – can't seem to support a big, interesting, independent bookstore like Blackwell's, and indeed Blackwell's seems even bigger than the Coop in Cambridge, Mass. Then we went to a big, great one in London (where we bought a couple more and I got the names of two more I intend to buy), and a great little neighborhood bookstore in the Primrose Hill community, where on my recommendation Emily bought “My Native Land” by Ari Shevit, which is a great book, I think. Why has the Amazon virus killed off the Berkeley hosts but not the English ones? Dunno. But it was great to wander around the English bookstores and contemplate the carrying capacity of my gym bag.

So, this book on the NHS is interesting. Health care organization is my specialty, and I should know about the NHS, and I do to some extent, but this book really helped me understand it. The author, Paul Taylor, is a journalist by training who used to work for Which?, the English equivalent of Consumer's Reports. Now he does outside evaluation of the English hospitals for a guide called Dr. Foster's, using criteria that the NHS itself doesn't use for self-evaluation. So this is a journalist who can be trusted to know his subject. (My sister Emily's former boyfriend, David Shortino, married Mary, then he died, Mary remarried and had a kid who worked intimately for Obama from the start. He says he will never believe anything he reads in the press. Depressing to hear this so many times again and again. OK, another digression in a blog post full of such.)

Some points about the NHS. One, it is a religious object. It was formed from socialism as an avatar of common purpose, and woe be to anyone who doesn't realize that. Criticize with caution; it is still revered. The NHS is the embodiment of non-aristocratic feeling (he doesn't say this, I do, but he does make the basic point.)

Two, it is a bureaucratic institution. The bureaucrats are unusually capable, but they are English bureaucrats. My son Allie has run into the English bureaucracy already and says he has experienced bureaucracies around the world, and this is the champion so far in silo-vision. Of course, he hasn't been to India. This bureaucracy doesn't like surprises, and it likes to have strong management control. Everyone in it looks up at the next in power, not down, and the one at the bottom is, of course, the patient. Thus, patient complaints can be discomfiting to those in power, so the best patient-complaint-takers bury their reports in the deepest drawers of the farthest reaches. The bureaucracy is blame-oriented, so avoiding blame is the watchword. Check all boxes, make sure all procedures are followed, evaluate only by preexisting and agreed upon procedures and criteria – above all, don't think. So when the Mid-Sheffordshire scandal of poor care erupted, and a capable legal politician made the inquiries, seeking the cause of poor end results, it all came as a shock to the bureaucracy, which as far as they were concerned, had a good opinion of the hospitals there, until they didn't. Bureaucratic criteria blinded the to the reality of killing patients, because all the check marks checked out. The inquirer was smart and independent, which was a novelty to those inquired of.

There are three basic questions the NHS confronts: how to get doctors involved in managing the NHS (Taylor thinks they shouldn't be, but he's wrong); how to set up centers of excellence (COE); and how to get the private world involved with the NHS operations.

His point about COE is quite interesting. A centralized system like the NHS can do COE very well, as opposed to our decentralized US system. But it does involve sometimes shutting down some services that are geographically closer to people, so it seems like a loss to them. Sometimes, it's clearly not – in London, centralizing the A&E (accidents and emergencies) services means maybe 3 or 4 minutes more to the heart attack center, but the care is so much better there it is clearly worth it. But what about rural areas? What the NHS doesn't do is measure the results after they make the changes. Is it really better for the locals, or not? No one knows. It is a centralized, elite country, and this is what they can do – just do it and let the peons complain. But since the NHS is a religious object, excessive criticism is condemned. Taylor says, measure it! (But they won't.) What a great point about organizational behavior and complex situations.

He says you can tell what is going to happen when a reform is proposed and the British Medical Association opposes it, as they do most any reform. It will pass, inevitably. And as the price for passing it, the politicians will grant the BMA favors. British doctors are thus among the best-paid in the world.

As to privatization, there is a lot of ideology involved. The profit motive is suspect in Britain, even if the non-NHS institutions involved are not-for-profit. Don't fiddle with our NHS! But in fact there is more privatization, and it's probably good that there is.

Another thing: the politics of the NHS are in one aspect the opposite of the environmental problems. In the environment, people understand and support energy change, but the politicians and those in power have been slow to the mark. For the NHS, it's the opposite: the elite see a great need for change, but the people say, leave it alone, it's OK. The elite says that costs will go out of control, and to keep giving the best to everyone, more efficiency and hard choices are needed. They're right. But they have to push the general populace.

Anyway, I'd have to say that Ann's right, I doubt I could get this book at home, and it would certainly not come to my attention. But there it was at Blackwell's, right on the 3 for 2 table. And all those other books, too. There is just no replacing a bookstore, and yet Berkeley has a few little ones here and there, a Barnes and Noble, but that's it. Progress happens, but not all is for the good. Allie told us that when he was in Bolivia he had a rental car and part of it got scraped. In the US they would have ordered a new part. There in Santa Cruz a 60 year old guy fashioned a tool to smooth and straighten, mixed the colors himself by eye, and by the end you couldn't tell it was an injured vehicle. What a genius! In the USA? A lost art. And no bookstores, either.

Budd Shenkin