Minor Thoughts from me to you

Avik Roy, on a very promising development from the AMA.

At the Vice-Presidential debate last week, Joe Biden claimed that the American Medical Association sided with him, and against Paul Ryan, on the merits of the Romney-Ryan plan for Medicare reform. “Who do you believe?” exclaimed Biden. “The AMA [and] me? A guy who has fought his whole life for this? Or somebody [like Paul Ryan]?” Well, it turns out that the AMA’s key policy committee has come out in favor of premium support for Medicare, in a fashion that tracks closely with what Mitt Romney and Paul Ryan are proposing.

... The AMA Council’s report states that it came around to this view not at the behest of Republican operatives or candidates, but after speaking with Bill Clinton’s former budget chief, Alice Rivlin, who along with Paul Ryan proposed a version of this plan. “Dr. Rivlin emphasized that defined contribution amounts should be sufficient to ensure that all beneficiaries could afford to purchase health insurance coverage, and that private health insurance plans should be subject to regulations that protect patients and ensure the availability of coverage for even the sickest patients.”

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Just because you have a piece of paper that says you have “health insurance” doesn’t mean that you can see a doctor when you need to.

There are three major forms of health insurance in America: Medicare, our government-sponsored program for the elderly; Medicaid, our government-sponsored program for the poor; and private insurance for most everyone else. As I have described extensively on this blog, it’s much harder to get a doctor’s appointment if you’re on Medicaid than if you have private insurance, because Medicaid pays doctors so little that doctors can’t afford to see Medicaid patients. This, in turn, leads patients on Medicaid that are at best no different than being uninsured, and in many cases even worse.

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Drone strikes. Obviously, President Obama doesn't want to say anything bad about the gobs of strikes he's authorized. Neither does Mitt Romney; if you're going to spend your whole campaign calling Obama a hyper-apologetic girly boy, you can't turn around and complain that he kills too many people! But American drone strikes--which seem to always target Muslim countries, and sometimes kill civilians--are famously unpopular in the Muslim world.

On this issue, Muslims have a very good reason to be angry. I'm not looking forward to the "foreign policy" debate next week. I think the candidates are very similar (and fairly dreadful) on foreign policy.

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The Asia Times, on the coming disintegration of the Middle East. Should we engage? Or should we withdraw and hope that it melts down in a way that doesn't affect us?

And Iran cannot abandon or even postpone its nuclear ambitions, because the collapse of its currency on the black market during the past two weeks reminds its leaders that a rapidly-aging population and fast-depleting oil reserves will lead to an economic breakdown of a scale that no major country has suffered in the modern era.

When the future irrupts into the present, nations take existential risks. Iran will pursue nuclear ambitions that almost beg for military pre-emption; Egypt will pursue a provocative course of Islamist expansion that cuts off its sources of financial support at a moment of economic desperation; Syria's Alawites, Sunnis, Kurds and Druze will fight to bloody exhaustion; Iraq will veer towards a civil war exacerbated by outside actors; and Turkey will lash out in all directions. And in the West, idealists will be demoralized and realists will be confused, the former by the collapse of interest in deals, the latter by the refusal of all players in those countries to accept reality.

Iran's population is aging faster than any population in the history of the world, its economy is a hydrocarbon monoculture, and its oil is running out.

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More bad news out of the Middle East.

Over the last two years, the Arab uprisings have posed a number of vital questions for Washington and its allies. Where should the United States step in to intervene, and on whose side? What governments and movements should we engage, and which should we isolate or punish? The reality is that there’s little the United States can do at this point to protect one of its most steadfast allies in the region. Perhaps Abdullah will prove creative enough to exploit the weaknesses of the growing protest movement, or broker a new national identity that finally binds the East Bankers and Palestinians together and leaves him on the throne. If not, American policymakers will again be scrambling for answers—and Israeli leaders may find yet another border in trouble.

I'm afraid we're on the verge of a more united, more hostile Middle East.

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For years, Bashar Assad, and Syria, has supported Hezbollah, in Lebanon. Now that Assad is facing serious opposition in Syria, Hezbollah is apparently supporting Assad. And, surprisingly, the Free Syrian Army, is now threatening Hezbollah.

Syrian rebels said they have detained 13 Hezbollah members and threatened to take the fight to Hezbollah’s stronghold in Beirut’s southern suburbs unless the party ends its support for President Bashar Assad’s regime.

“We [vow] to take the battle in Syria to the heart of the [Beirut] southern suburbs if [Hezbollah] does not stop supporting the killer-Syrian regime,” Free Syrian Army spokesman Fahd al-Masri told media outlets Tuesday.

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How do you debate a guy who makes everything up on the fly?

I’d like to discuss the substance of the debate on health care and tax reform, where Joe Biden told one whopper after another in an attempt to help President Obama regain lost campaign momentum.

I was arguing with the TV when VP Biden was making up these facts. The more you know about policy, the more of a buffoon the VP is.

• Contra Biden, Senator Ron Wyden does still support the Wyden-Ryan Medicare reform plan.
• Contra Biden, the CBO determined that Medicare wouldn't save any money by negotiating drug prices .
• Contra Biden, Obamacare did cut $716 billion from Medicare and probably will cause 1 in 6 hospitals to go under and cause 15% of Medicare doctors to stop taking Medicare patients.
• Contra Biden, 7.4 million seniors are expected to lose access to Medicare Advantage once the Obamacare changes are fully phased in, in 2014.

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It's obvious that Obama for America has a high respect for election laws.

The Government Accountability Institute, a Washington watchdog group, says it’s likely a high percentage of Obama online’s donors aren’t Americans. For starters, a full 43 percent of the traffic on the site barackobama.com comes from foreign Internet provider addresses, versus just 11.9 percent at Romney’s equivalent site.

GAI’s 108-page report on online campaign fund-raising at local, state, and national levels shows that many campaigns have inadequate safeguards against foreign donors influencing this election — but Obama’s stands out as a veritable cesspool.

Obama’s campaign refuses to use industry-standard safeguards against online credit-card fraud. For example, some 90 percent of e-commerce companies (and Romney’s site) use Card Verification Value data, which checks those three or four numbers on the back of the credit card to make sure the card user matches the card holder. The Obama site uses it if you want to buy a T-shirt or hat — but not if you make a donation.

Indeed, the moment you sign up at my.barackobama.com, you get numerous solicitations to donate. When you give, you get a thank you e-mail — even if you happen to live in Shanghai.

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Dr. Rob Lamberts isn't going to deal with third party payments anymore.

No, this isn’t my ironic way of saying that I am going to change the way I see my practice; I am really quitting my job. The stresses and pressures of our current health care system become heavier, and heavier, making it increasingly difficult to practice medicine in a way that I feel my patients deserve. The rebellious innovator (who adopted EMR 16 years ago) in me looked for “outside the box” solutions to my problem, and found one that I think is worth the risk. I will be starting a solo practice that does not file insurance, instead taking a monthly “subscription” fee, which gives patients access to me.

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Smitty analyzes the State Department-White House blame game, in terms of the prisoner's dilemma.

Here, we have two public figures who both look negligent over a tragedy. And they hold grudges against each other going back. They can both get hammered together, or can try to minimize their damage by pinning blame on the other.

The most likely scenario, I think, is that Secretary Clinton and President Obama drag each other down, in a downward spiral of escalating recriminations.

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Writing on Wednesday, Michael Walsh foresaw problems for the Obama administration.

I’ll likely have more to say on this down the road, but it seems to me that the Obama administration has made a huge unforced error in trying to lay off blame for the Benghazi fiasco on the intelligence community. Because, wherever the buck stops when we get to end of this debacle, it’s not going to be in Langley, Va. (the CIA), Fort Meade, Md, (the National Security Agency), or any of the other centers of the American IC. It’s not even going to be shouldered by the State Department’s intel service, the Bureau of Intelligence and Research, known as the INR.

... Alienating spookdom, however, is a new order of magnitude stupid. Because spooks fight back — hard and dirty. Bob Woodward and Jake Tapper are only phone calls away. And CIA Director David Petraeus is just one press conference shy of bringing down the whole house of cards.

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Stephen Hayes explains exactly why the Benghazi scandal is a scandal.

There are two possibilities. Either the intelligence community had a detailed picture of what happened in Benghazi that night and failed to share it with other administration officials and the White House. Or the intelligence community provided that detailed intelligence picture to others in the administration, and Obama, Biden, Clinton, Susan Rice, and others ignored and manipulated the intelligence to tell a politically convenient—but highly inaccurate—story.

If it’s the former, DNI James Clapper should be fired. If it’s the latter, what happened in Benghazi—and what happened afterwards—will go down as one of the worst scandals in recent memory.

It seems far more likely that it’s the latter. After all, is it conceivable that White House officials at the highest levels were not actively engaged in interagency meetings to determine what happened in Benghazi? Is it conceivable that intelligence officials, knowing there was no evidence at all of a link between the film and Benghazi, would fail to tell the president and his colleagues that their claims were unfounded? Is it conceivable that somehow the latest intelligence on the 9/11 attacks was left out of Obama’s intelligence briefings in the days after 9/11? It would have been a priority for every professional at the CIA, the State Department, and the National Security Council to discover exactly what happened in Benghazi as soon as possible. Is it conceivable that the information wasn’t passed to the most senior figures in the administration?

No, it’s really not. And therefore, the fact that these senior figures misled us—and still mislead us—is a scandal of the first order.

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From Corker’s standpoint, the explanation for the administration’s public dissembling is plain. He told me, “It is strictly my opinion but the president has gone around the country spiking the football on Osama bin Laden.” Once it became clear that his boast of “vanquishing” al-Qaeda was proven false, the president, according to Corker, “panicked.” He continued, “The president worried it was going to affect the election.”

Corker is known as a workhorse in the Senate and as meticulous on the facts. In this case, he was both irate and insistent: “When four Americans are killed, it’s just not possible that the president didn’t know [it was a terrorist assault].. . . There is not a cell in my body that doesn’t earnestly believe that the administration didn’t know within 24 or 48 hours.”

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The L.A. Times reports from Tripoli.

Face down on a roof inside the besieged American diplomatic compound, gunfire and flames crackling around them, the two young Libyan guards watched as several bearded men crept toward the ambassador's residence with semiautomatic weapons and grenades strapped to their chests.

... They were the "quick reaction force" for a compound that was also protected by about five armed Americans and five Libyan civilians hired through a British firm and equipped only with electric batons and handcuffs.

As if that security wasn't light enough, the Americans didn't take the security concerns seriously.

Bright lights positioned on top of the walls shone into the compound, which the guards say made it difficult to see outside. The lights sometimes left footage from night security cameras either obscured by glare or pitch black, the Libyans say. "It did not seem like a good location for a sensitive building," says Abdelaziz Majbiri, a 29-year-old civilian guard for Blue Mountain, who was shot in the leg in the attack.

The Feb. 17 guards say that when they discussed their concerns with U.S. security officers, they were sometimes told that this was a political mission, not a full-fledged embassy, implying that security requirements were less stringent.

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Ross Levatter offers a vision of what truly free market healthcare might look like. It's radically different from what we have now, but it's the system I, personally, want to have.

... Many healthcare items–from CTs to cholecystectomies–are clearly priced, and people compare prices and shop for quality as well. You can look up surgeons and radiologists on the Internet, for example, and see what prior customers thought of the quality of their services. Other people choose to use a qualified middleman to recommend a local physician of high quality and reasonable price. Such middlemen advertise their services and list many reasons to use them, including the opportunity to take advantage of volume discounts and to have someone knowledgeable to guide you through the various medical options. Yet others make their own decisions, using the Internet and new software programs, just as they use software to help them make the right tax-paying decisions.

Mayo and Kaiser, among others, take strong advantage of their brand name, which signifies quality, but the competition from many other physicians makes it difficult for them to charge too much additional for “value-added.”

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Before the debate, I predicted that Congressman Ryan would wipe the floor with VP Biden. I was wrong. I'd forgotten how good/awful of a debater VP Biden is. He's good because he's always confident and never in doubt. He's awful because he completely makes stuff up and delivers the resulting manure with complete and utter sincerity. How do you fight that without falling into the trap of constantly fact checking your opponent rather than giving your own answers?

How about an example? Last night, they were asked about whether or not the United States should intervene in Syria (given the Libya intervention). And, if not, why not? VP Biden confidently stated that we absolutely should not get involved in Syria. Syria would be a tough intervention because it "is a different country, it is five times as large geographically, it has one fifth the population." Not true. Syria is 185,000 square kilometers, while Libya is 1.7 million square kilometers. Geographically, Libya is ten times larger than Syria. Rather than Syria having one fifth the population of Libya, it actually has 4 times the population that Libya does.

Or, how about VP Biden's confident assertions that we shouldn't worry about Iran's stockpile of fissile material because "they don't have a weapon to put it in"? What kind of argument is that? Building a nuclear weapon is trivial compared to what it takes to acquire fissile material. Pakistan's A.Q. Khan sold nuclear technology to multiple countries, including Iran. If Iran did have problems building a weapon, North Korea would be more than happy to share notes. If Iran doesn't have a weapon now, it's only because they like the plausible deniability of continuing to claim that all of their enrichment is for "energy generation".

In short, VP Biden looks impressive in a debate, unless you know all of the issues well enough to spot all of the times that he's free associating and losing contact with reality. On the appearance of substance, I'd have to rate the debate a tie. Both candidates appeared that they knew what they were talking about.

However, I think VP Biden flubbed horribly on the demeanor side of the debate. He may have forgotten that his job was to persuade undecided voters. As he listened to Congressman Ryan, he spent the entire evening laughing, making faces, or sighing. When he was speaking, VP Biden often sounded angry. He was strident and loud, often shouting, and interrupted Congressman Ryan frequently. It was one of the more unpleasant debates I've ever watched. VP Biden came across as a rude, angry, boor. I know that this fired up the Democrats who already plan to vote for the President and VP. I can't imagine that this will make his ticket attractive to undecided voters. Overall, I don't think this evening was a win for the Obama-Biden ticket.

Jonah Goldberg, talking about the President's incessant Bush blaming, on the 2008 financial mess.

The question of what caused the crisis is obviously still controversial, but a consensus seems to be forming around the following narrative: The federal government, out of an abundance of concern for the plight of the poor and middle class, made it too easy to buy a home. Congress, on a bipartisan basis, set unrealistic affordable-housing goals for Fannie Mae and Freddie Mac.

President Clinton used those goals to expand access to mortgages to low-income borrowers. Then President George W. Bush, with the approval of Congress, expanded the practice, until way too many low-income or otherwise underqualified Americans owned mortgages they couldn’t afford.

A mixture of greed, idealism, cynicism and stupidity led to the practice of bundling those iffy mortgages into financial instruments that Wall Street didn’t know how to handle and regulators didn’t know how to regulate. As Rep. Barney Frank (D-Mass.) put it in 2003, he wanted to “roll the dice a bit” on regulating subprime mortgages.

When the Washington-abetted housing boom went bust, regulators demanded immediate markdowns of mortgage-backed securities, which required financial institutions to sell them, creating a fire-sale atmosphere that fueled the panic even more.

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It appears as though Senator Paul is attempting to flex some political muscle.

Kentucky Republican Sen. Rand Paul is running ads against Democratic senators who voted to continue foreign aid to Egypt, Pakistan and Libya.

The first two targets are Sen. Joe Manchin of West Virginia and Sen. Bill Nelson in Florida. Ads in other battleground states may be forthcoming.

After a September wave of anti-American violence in the region, including the murder of the U.S. ambassador to Libya, Paul forced a vote on a measure that would have suspended foreign aid to the three countries mentioned in the ads.

The bill was defeated 81 to 10, with no Democrats voting in favor.

Senator Paul may not need to defeat either Senator Manchin or Senator Nelson in order to succeed in gaining political power. If he can dent their poll numbers enough, it may gain him some extra cooperation in the next Congress.

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Kate Paulk, an Aussie, talks about her view of Mitt Romney's character.

It’s clear from Mr. Romney’s manner that he steps in whenever needed without complaint because he regards this as just something that needs to be done. And to an Australian, that attitude is admirable. We tend to respect people who do this regardless of whether we agree with their beliefs (with the caveat that those beliefs don’t harm anyone else — the kind of belief that says Person X is less than human tends to get short shrift).

Mr. Romney’s so-called “wooden” manner is also a factor here, and yes, in my view it’s admirable. The thing about MS is you don’t know what it will take next. There’s no way to predict episodes, no way to guess what area of the brain will be attacked. It can’t be pleasant for Mr. Romney to see his wife suffering this kind of deterioration, and since he needs to be strong for her, he’s built up a pleasant, cheerful demeanor so that she doesn’t see how much her pain hurts him. It also protects him to some extent: the masks allow him to defer his suffering while he deals with the more important matter — namely supporting his wife. I’d be willing to guarantee that Mr. Romney’s calm assurance is something he only drops in the presence of those he trusts absolutely and knows he won’t hurt when he drops it. After any length of time, something like this becomes reflex: it takes conscious effort to drop it.

So no, I don’t expect to see any spontaneous reaction from Mr. Romney unless he’s badly shocked, and I certainly hope he never finds himself in that position. This is a good thing. No, he will never be spontaneous in politics, but he is also unlikely to throw unseemly tantrums.

I admit. I come clean. I like Mitt Romney. I've liked him for a while now. I think he's politically awkward in the same way that I'd be awkward if I were to run for political office. But that doesn't make him a bad man. And, the more I read about him, the more I like his character.

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A new paper from Georgetown University researchers suggests a third possible outcome: Absolutely nothing at all will happen. They looked at the three states – Maine, Georgia and Wyoming – that have passed laws allowing insurers from other states to participate in their markets. All have done so within the past two years.

So far, none of the three have seen out-of-state carriers come into their market or express interest in doing so. It seems to have nothing to do with state benefit mandates, and everything to do with the big challenge of setting up a network of providers that new subscribers could see.

Interesting. This is another argument in favor of spending out of pocket instead of purchasing healthcare through health insurance. You can negotiate and shop around immediately. You don't have to wait for an insurance company to set up a network and then pay them.

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