Cosgrove also said the health care law, which was recently upheld by the U.S. Supreme Court, doesn't control costs or contain many incentives for people to take care of themselves.
WSJ: How does the health overhaul affect you?
Dr. Cosgrove: We knew that we had to reduce costs and we had to drive a more efficient health-care delivery system. [The law] just gave additional impetus to get that done.
"Impetus" for major groups of hospitals and doctors to cut costs yes, "control costs" no.
One in eight jobs saved by the auto rescue. Cops', firefighters', and teachers' jobs saved by the stimulus' aid to state governments. Small businesses saved by the avoidance of Great Depression II and the unfreezing of credit.
Today's Ohio's unemployment rate is below the national average. It's small exaggeration to point out that the Obama administration saved our state from calamity. His opponent is on the record as saying he wouldn't have done any of that. One man decided to let Ohio live, the other would've condemned it to die.
The choice is easy, Ohio.
Let's go for two posts in one day; it's been dead around here lately.
Last night I finally watched Recount, HBO's 2008 film recounting (pardon the pun) the events in Florida in the 36 days following the 2000 presidential election. None of it was new to me, as I was already painfully familiar with the events of that historic 6 weeks. I just hadn't thought about them in years.
In some ways, watching the movie brought back some personal memories. Election Year 2000 is the moment I pinpoint as the time when I became politically aware. It was the first election in which I had a horse in the race and the first election in which I had determined which political party aligned with my understanding of the world. Recount opens with some real footage from Election Night 2000: Tim Russert with his whiteboard stressing the importance of Florida, Dan Rather and his barrage of bizarre but amazingly entertaining aphorisms, Tom Brokaw sheepishly walking back his network's early call of Florida for Al Gore.
I remember all of it. The exhilaration, watching the early coverage that night, of watching my preferred candidate (the first real political preference of my young life) seemingly headed for victory giving way to the excitement and confusion of that night. Florida goes for Gore, then Florida goes for Bush, then Florida is too close to call. Al Gore's concession call to George W. Bush, followed by his call to retract his concession (and the resulting popularization of "snippy"), and the cancellation of his late night concession speech. I can't recall for sure if my obsession with news coverage and my love affair with C-Span began that night but I suspect it may have. I was up all that night, glued to the coverage of that memorable night, not wanting to risk missing its resolution while I slept. Of course, as we know, there was no danger of that.
But watching the movie--as well as reading the comments in this post about the media coverage of Gore in 2000 over at The Monkey Cage--also reminded me of some of the 2000 campaign itself. The triviality of much of it, the relentless attempts to paint Gore as boring and, worse, some sort of pathological liar over willful distortions of his words (given the sheer volume of whoppers we're being subjected to this cycle about real policy issues of import, not dissections of the precise role one candidate played in securing support for the research that led to the development of the Internet, the more bitterly laughable it seems).
But even more than that, the remembrance of the palpable sense in some quarters that the country was on autopilot and who it put at the helm didn't matter. The false exuberance at the tail end of the Clinton years that lulled many into thinking peace and prosperity are easy. The conviction that, as Ralph Nader suggested, there wasn't "a dime's worth of difference" between Bush and Gore or the Republicans and Democrats.
I didn't believe that then and I don't believe it now.
But we don't get do-overs. We can't get back the lost decade that saw zero net job creation and declining median incomes and ended with us trying to claw our way out of the worst recession since the Great Depression. We can't get back the blood and treasure lost in the deserts of Iraq. We can't erase the torture conducted in our names. Nor can we forget the mistakes and failures of the Democrats in their minority role as the loyal opposition. We can't get back the lost opportunities.
But despite all this, watching Recount wasn't nearly as painful as I thought it might be (not that I didn't expect it to be entertaining and well-done, which it is). That was a long time ago and there's not much use in dwelling too much on what might've been. I find my mind wandering to Obama's '12 campaign theme: "Forward." We can't do 2000 over. But we can do 2012 and beyond right.
So I suppose the moral is: elections matter. Make sure you're registered to vote.
I'm in a mildly reflective mood this afternoon, thinking on the great changes this country has seen since its founding. One window on these changes--the coming of the Industrial Revolution, the steady evolution of our work force (including the coming and going of unions), etc--is where people choose, or are compelled, to live. It should come as no surprise that since the founding days we've seen a massive shift from living in sparsely populated rural areas to the collecting of folks in close proximity to their neighbors in urbanized areas. The ideal in America shifted from the solitary plot of land to the small, fenced in enclosure mere steps from our neighbors (look to the right for the ideal American relationship and proximity to his neighbor in the late 20th century).
I took a look at Census data (and here for the most recent decades) to see just how much and how quickly that transition has happened:
Jefferson's veneration of the yeoman farmer in the vision of agrarian egalitarianism that came to characterize his philosophy took place in a nation that was more than 90% rural. Decades later, when the visceral, visual manifestation of Manifest Destiny, the driving of the Golden Spike into the ground, took place in a nation shifting its attention from war to industry, and when the first great waves of labor unrest swept through the land, the nation was still nearly three-quarters rural. When the American frontier officially closed and William Jennings Bryan took his brand of prairie populism up against the best financed, most Big Moneyed presidential campaign in history (up to that point and since), the nation was still more than 60% rural.
Even as late as the Great War, which saw future president Harry Truman leave behind his plow for the lure of an overseas adventure, the country was still split roughly 50-50 between urban and rural living. By the time our cities burned in the midst of the massive social unrest of the 1960s, the nation was over 70% urbanized. Today we're over the 80% mark.
Where do we go from here? Do these trends reflect changing economic and social realities or shape them (or both)? How do these changes affect our politics and our polity today (e.g. public awareness of and reaction to the fact that the U.S. is now experiencing the largest drought in a half century, or the unusual inability of the current Congress to pass the Farm Bill). No answers, just questions from me this Sunday afternoon.
After a thoroughly enjoyable three-day Democratic convention, it's time to put up a few notable moments chosen because 1) they're worth watching, and 2) they're currently available as short clips on YouTube. There are many more notable moments but not notable enough to be clipped off and uploaded to YouTube yet, it seems.
If you didn't watch much of the convention here are, in no particular order, a few clips worth watching.
1) Gabby Giffords leading the Pledge of Allegiance.
In an emotional moment, the former Congresswoman who was shot in the head last year came out to lead the convention in the Pledge. The reaction of the crowd and her obvious joy make this one very enjoyable.
2) John Lewis reminiscing about his incredible past.
He gave the campaign slogan (and frequent thematic device at the convention) "Forward" deeper meaning with powerful reflections on the past and how far we've come.
3) Obama on foreign policy.
In 2008, Obama (though then a member of the Senate Committee on Foreign Relations) was the relative neophyte on foreign policy, a subject that was at least theoretically one of John McCain's strengths. The student is now the master. In this clip from Thursday night, he points out his administration's remarkable foreign policy successes and gets in a few jabs and the complete lack of foreign policy experience on the Romney-Ryan ticket. Given that Romney completed neglected to mention our troops currently in harm's way or Afghanistan in his own acceptance speech, this bit stands in sharp contrast to his speech last week.
4) John Kerry (currently Chairman of the Senate Committee on Foreign Relations) making the foreign policy case for Obama.
Kerry gave a surprisingly entertaining speech to push the foreign policy argument, working in both self-deprecating humor ("talk about being for it before you were against it," he said with a half-smile as he attacked Romney's ever-shifting opinions on Afghanistan) and even a reference to Rocky IV! But at a convention where, to put it mildly, Osama bin Laden's death did not pass without notice, Kerry had probably the line of the convention about bin Laden: 5) Clinton makes the economic argument for Obama.
In an extraordinarily policy-oriented and delightfully engaging (even folksy) speech that's rightly been described as a tour de force, Bill Clinton forcefully rebutted Republican criticisms and made the case for a second Obama term. In this short clip, he succinctly lays out the Republican and Democratic arguments and, with a playful grin, recycles a famous line from the Republicans' patron saint.
6) Ted Strickland gets rowdy.
In a speech some felt was too loud or too populist, Ted Strickland reminds us what the auto bailout meant for Ohio. An earnest speech from an earnest Rust Belter and I don't think he could've delivered his final line any better. Plus the strange little chuckle he does occasionally is pretty entertaining.
7) Barack Obama's closing argument.
I'll have more to say about his speech sometime this weekend. But in this short clip, he ends his acceptance speech and officially begins the fall campaign.
Throughout the presidential campaign, Mitt Romney has had an oddly reactive approach to putting out policy proposals, seemingly flying by the seat of his pants and offering almost spur-of-the-moment, invariably ill-thought out policy ideas and usually defining himself by what he's not (i.e. Obama). Who can forget his tax plan, developed during the Republican primaries, which turns out to raise the tax burden on the middle class (whoops!)? He's done it again now that Paul Ryan is his running mate.
He seems to have impulsively decided to move up the date at which the Medicare trust fund becomes insolvent.
As Rick Perry might say: oops.
But first some perfunctory background. Broadly speaking, Medicare pays for hospitals services, services from doctors (e.g. like your family doc), and prescription drugs. In table form:
Medicare Component
Pays For
Financed Primarily Through
Finances Go Into...
Part A
Hospital services
Payroll taxes
Hospital Insurance (HI) trust fund
Part B
Physician Services
General revenue/Monthly premiums from beneficiaries
Supplementary Medical Insurance (SMI) trust fund
Part D
Prescription drugs
General revenue/Monthly premiums on beneficiares
Supplementary Medical Insurance (SMI) trust fund
(Part C is the privatized portion of Medicare--Medicare Advantage--that generally combines these three benefits in a single private health insurance plan for the 23% or so of Medicare beneficiaries who choose to go that route: and at only ~114% of the price of traditional Medicare!)
As the table should make clear, there are two trust funds to think about: one funded primarily by payroll taxes that covers hospital services and another funded primarily by general tax revenue (with another significant component coming from insurance premiums on seniors enrolled in Medicare) that pays for doctors' services and prescription drugs. This excellent Kaiser Family Foundation primer on Medicare financing identifies a difference between these two trust funds that's worth noting:
A key difference in the structure of the HI and SMI Trust Funds affects their financial status. In the case of the HI Trust Fund, dedicated revenue may be greater or less than expenditures in any given year, so that in some years HI expenditures may exceed income, while in other years, reserve funds may be generated. By contrast, SMI Trust Fund financing does not produce excess revenue or shortfalls due to the way it is structured, with premiums and general revenue contributions adjusted each year in order to cover projected expenditures for that year. When
excess HI Trust Fund revenue is collected, the excess amounts are loaned to the federal government and used to pay for other federal obligations. Interest on the loans is credited to the Trust Fund as income.
So theoretically there is some money collected in the HI trust fund for spending on Medicare hospital services. Or rather, that money was loaned out to the rest of the government at interest to help pay for other things but it can be reclaimed when needed. But now that Medicare is paying out more than it takes in, at some point the money in that trust fund--or owed to it--will be exhausted. At that point, Medicare won't be able to fully pay for its obligations to cover hospital services, though it can still pay out whatever the Medicare payroll tax is bringing in. But the coming insolvency of the HI trust fund is a serious concern, particularly since the shortfall the trust fund experiences will just continue to grow with time.
In 2009, before health reform (or the Affordable Care Act or ACA or Obamacare--whatever the kids are calling it these days) passed, the Medicare Trustees forecast that the HI trust fund would be exhausted in 2016/2017. Then the ACA passed and the next year that number receded to 2029. The continuing stumbling of the economy put a little damper on that and for the next two years (including this year), the Trustees' report put the date of insolvency at 2024.
The point is that the ACA pushed the HI trust fund's insolvency date back from being a few years from now to being in the middle of the next decade. The catalyst for this change is the controversial savings (or cuts, as the GOP prefers to put it) that got so much airtime and ad time during the midterm elections two years ago. These Medicare savings showed up primarily in three forms:
1. As I intimated above, the privatized portion of Medicare (known as Medicare Advantage) costs more per enrollee than traditional public Medicare. The reason is essentially that the process by which the federal government's payments to these private insurers on behalf of Medicare beneficiaries are determined is currently rigged in the private insurers' favor, allowing them to pick up outsized federal subsidies. The ACA dials these back, reducing the government subsidy to these private insurers over time to largely bring them in line with traditional Medicare.
2. Traditional (public) Medicare pays for hospital services according to a fee schedule. The ACA, assuming certain "productivity improvements," requires that those reimbursements increase more slowly over the next decade than they were otherwise scheduled to. These assumptions aren't baseless, as the ACA also contains some mechanisms to help hospitals (and other providers) achieve them. But it's going to be a challenge to make it all work.
3. A hodgepodge of other savings/cuts (though not to physicians; their payments are governed by a different law). For instance, Medicare pays certain hospitals extra to cover some of the costs of the uninsured; the theory is if there are less uninsured people under the ACA, those payments can start going down.
Together those savings push back the date of the HI trust fund's insolvency by several years because the trust fund is paying out less over the next decade thanks to them.
When House GOP Budget Chairman Paul Ryan (now Mitt Romney's running mate) was putting forth his budget proposals this year and last, he sought to include a plan to transform Medicare into a voucher program. The merits of that plan aside, people tend not to like change, particularly when they've been expecting or experiencing something else. The bigger the change you're proposing, the more important it becomes to make the change's implementation minimally disruptive. So Ryan delayed implementation of his proposed Medicare reforms for a decade, stipulating that they wouldn't start until 2022. That allowed Ryan to claim that no one currently receiving benefits would be affected by the changes, nor would anyone 55 or older, i.e. folks within 10 years of Medicare eligibility. It was only folks who were 11 years away from hitting Medicare eligibility at 65, the 54-year-olds and younger, who would be given a voucher.
But there's a problem here. If the HI trust fund is exhausted in 2016--assuming the ACA is repealed--then how does Ryan wait until 2022 to implement any kind of Medicare reforms? The answer is that he can't. So in writing his budgets, he retained the ACA's Medicare savings (while calling for the repeal of the rest of the health reform law). The fact that Ryan tacitly endorsed them and virtually every federally elected Republican--in the House and Senate--voted for them didn't stop Ryan's party from shamelessly continuing to attack the President for his Medicare "cuts." (Now that he's in the national spotlight, Ryan has recently been called upon to explain why the cuts that his running mate routinely denounces were included in his budgets. His rather lame answer: "First of all, those are in the baseline, he [Obama] put those cuts in...It gets a little wonky but it was already in the baseline. We would never have done it in the first place.")
But running on Obama's Medicare cuts at the same time he was demonizing them on the campaign trail proved too much even for Multiple Choice Mitt. After being unable to describe any difference between his plan for Medicare and Ryan's (the plans are, after all, virtually the same), by mid-week Romney had found a major difference between his approach and his running mate's: “My campaign has made it very clear: The president’s cuts of $716 billion to Medicare — those cuts are to be restored if I become president and Paul Ryan becomes vice president,” Romney said on “CBS This Morning.”
Nice! Jettison Ryan's baggage by not following his lead in adopting Obama's Medicare savings/cuts. Why did Ryan even embrace those in the first place? Oh, right...
It turns out this creates a problem for Mitt. He too has pledged that under his Medicare plan "Nothing changes for current seniors or those nearing retirement," meaning that none of his reforms begin until 2023 (i.e. the year in which a current 54-year-old would hit 65 and become eligible for Medicare). But by "restoring" Obama's savings/cuts, Romney moves the date of the HI trust fund's insolvency up to 2016 from 2024. Whereas Ryan had retained the hated cuts to keep the trust fund solvent until his reforms could kick in in the early 2020s, Romney is explicitly saying he won't do that.
Meaning that the trust fund will be exhausted in 2016, but Romney's reforms (a voucherization of Mediare similar to Ryan's proposal) won't kick in until 2023.
That makes for seven lean years in which Medicare can't meet the entirety of its hospital care obligations to current beneficiaries. Indeed, the magnitude of the shortfall and thus the degree to which current beneficiaries' services are cut into grows each year. Again, ignoring the merits of Romney's proposed reforms, under his plan there will be a seven year gap between the HI trust found becoming insolvent and any reforms beginning.
To date he hasn't explained how Medicare beneficiaries are supposed to get by during their seven lean years and what, if anything, his administration is prepared to do to fix the problem. The Obama campaign seems to have noticed, mentioning at 1:38 of their latest video explaining Romney and Obama's differences on Medicare that "If Mitt Romney and Paul Ryan are elected, Medicare will be bankrupt by the end of their first term."
Good of them to reference it but this strikes me as a huge issue requiring more attention: Mitt Romney is pledging to accelerate Medicare's spending, depleting the HI trust fund more quickly, to the point that it will be exhausted within four years. And he's also promising not to reform Medicare in any way for a decade. That's huge. And I doubt it was intentional. More likely, it was an unintended (and unforeseen) consequence of Romney's constant ill-thought-out Not-Obamaism. But now is the time for the Obama camp to make him pay for it.
I'm genuinely surprised. Portman was the obvious "don't rock the boat" pick with a potential marginal upside in Ohio. But that choice is appropriate for a campaign that's more or less in a dead heat with its opponent.
Apparently Romney concluded that thus far he's been on track to lose. Granted, he hasn't had a good week since the first half of June, he's the first candidate in recent memory to have a higher unfavorable rating than favorable, and three polls that came out at the end of last week showed him down between 7 and 9 points.
But I still wasn't expecting a risky choice like Paul Ryan, the GOP Budget Chairman best known for his draconian budget that would replace Medicare with a voucher for private health insurance. This strikes me a sign of mild panic (or at least resignation) in the Romney camp. Which surprises me.
Sorry Rob, maybe next time.
Thirty-five years ago (the anniversary is on September 5), Voyager 1 began a historic journey across the universe. During the 1970s, a rare alignment of all the Solar System's outer planets--Jupiter, Saturn, Uranus, Neptune, and then-planet Pluto--offered a once-in-several-lifetimes opportunity to get tremendous bang for one's space exploration buck. NASA scientists, long on ambition and imagination but short on budgetary politics sense, envisioned a Planetary Grand Tour of a fleet of space probes continuously hopping from one of those distant worlds to the next. Fiscal reality reduced that fleet to a duo, the Voyagers, intended to study Jupiter and Saturn.
It was at Saturn that the twins' destinies diverged. Voyager 2 was given the go-ahead for an extended mission following its successful flyby of the planet: it was to salvage the majestic concept of the Planetary Grand Tour. It would go on to give us our first (and to date, only) close-up looks at Uranus and Neptune. It then continued on into deep space.
Meanwhile, mission scientists made a different decision about Voyager 1's post-Saturn destination. A proposal to send it on a Pluto flyby was rejected (Pluto remains unvisited; the arrival of the New Horizons probe in 2015 will mark mankind's first exploration of that world). Instead, it was diverted to take a closer look at Saturn's enigmatic moon, Titan. The probe's instruments had difficulty penetrating Titan's thick, hazy atmosphere but produced tantalizing hints that conditions on the moon might allow for the existence of seas--this was confirmed in 2006, when the Cassini-Huygens mission found lakes of ethane and methane, the only standing liquid known to exist in the universe off of the Earth.
Voyager 1's flyby of Titan was the end of its own planetary tour, as the process jettisoned it out of the plane of the planets' orbits. It now headed off to deep space. Aided by its interactions with Saturn and Titan, Voyager 1 was receding from the Sun faster than any other probe. Today, Voyager 1 is the farthest piece of humanity in the universe, a whopping 11.1 billion miles from home. Wiki has a sobering simulation of what its view would be were it gazing homeward:
I bring up this remarkable spacecraft not just because it's as far as anything's ever been, but because it's back in the news this week for yet another first (and yet another reminder of its remoteness):
Evidence suggesting that NASA's venerable Voyager 1 probe is about to leave the solar system is piling up, scientists say.
Researchers are eyeing three key parameters for signs that Voyager 1, which launched in 1977, has escaped into interstellar space. The spacecraft's measurements show that two of these three parameters are now changing faster than at any other time in the last seven years, scientists said.
If it hasn't already, it's on the verge of leaving our solar system and marking mankind's first venture into interstellar space. So begins its last great adventure, one that presumably will never end (though by 2025 we will probably lose contact with it as its power sources die). A drink to the universe, to our amazing little emissary, and to the men who built her!
Sherrod is in trouble.
It's not time to panic. But it is time to wake up.
I'll admit, I've been complacent. With his early double digit lead, his skill at connecting with Ohio families, and his long history of service to the state, I didn't imagine he could be unseated. Certainly not by an opponent as lacking in substance, political experience, and integrity as Ohio's 34-year-old State Treasurer.
But I've ignored the new reality: thanks to recent rulings from the nine robed demigods who channel the Spirit of the Founders, this year's election isn't like those held even just four or six years ago. Our public offices are now for sale in a way they've never been before.
Andrew Romano, writing in Newsweek, has proclaimed Sherrod "The Hunted Democrat" in an eye-opening piece. Please read it.
Still, Ohio is the starkest example of the dystopian havoc that outside groups can now wreak on a race. In theory, the contest shouldn’t be close. Brown has outraised Mandel by $5.1 million. His approval and disapproval ratings are roughly equal; Mandel’s unfavorables outstrip his favorables by a perilous 15 percentage points. This is part of the reason why Brown was drubbing Mandel by an average of more than 13 points as recently as January—even though the populist, pro-Obama senator is far more progressive than the swing state he represents.
But then the super PACs and 501(c)(4)s began to spend on Mandel’s behalf: nearly $12 million so far, or more than Brown dropped on his entire 2006 campaign, with another $7 million reserved for the fall. The number on Brown’s side of the ledger is much smaller: about $3 million from unions, liberal interest groups, and Democratic super PACs. All told, Mandel’s third-party allies have outspent and outreserved Brown’s 6 to 1, and nearly twice as much money has been spent and set aside by or for Mandel than Brown. No other competitive Senate race is this lopsided. In response, the polling gap between Mandel and Brown has shrunk to 7.7 percent, and strategists are beginning to talk of the race as a possible tossup.
Sherrod has become Public Enemy Number One to the outside billionaires who are now free to try and buy a Senate seat. Our Senate seat.
It was 100 years ago this year that a Constitutional amendment went to the states after receiving the requisite 2/3 vote in each chamber of Congress. The writers of this amendment, mindful of the corruption and Senate seat-selling that had come to mar Congress's upper chamber, sought to return ownership of Senate seats directly to the people.
And here we are again, with the well-connected and the wealthy seeking to write a check for a shiny new Senate seat. But it's not their seat to buy. It's ours.
I stand with Sherrod.
The band Mumford and Sons is a doing a series of Gentlemen of the Road stopovers in four U.S. cities. The idea of these stopovers is that they're more extended, intimate (though extremely crowded) events--not just a concert, it's a daylong festival, followed up by a series of after-parties around the town after the show. Yesterday was their first American stopover, in Portland.
The concert is just one of four "Gentlemen of the Road Stopover" festivals that Mumford & Sons has planned for this summer (in addition to a regular tour). This has drawn national attention to Portland -- not only is the event expected to bring in fans from all over the country, band members have praised the city's art scene and historic, creative vibe in explaining why they picked it as a venue.
"It's got the ocean, a lively music scene, and it's an old town. We're very interested in history," said Mumford multi-instrumentalist and vocalist Winston Marshall, 24, in a phone interview. "It's exactly the vibe and character we were looking for in picking these sites."
Marshall will get to see more of Portland than just the Eastern Promenade -- after the show, he's scheduled to be at one of the five after-parties, at The Big Easy in Portland's Old Port.
But it's their philosophy that I dig:
The band's other "Stopover" festival events this summer are all in relatively small places: Bristol, Va.; Dixon, Ill.; and Monterey, Calif. Portland is the first city on the U.S. leg of the tour. (The festival debuted in June with one show each in the U.K. and Ireland.)
Marshall said the idea of the "Stopovers" was to have a daylong festival that celebrates an entire community.
"We want to be learning about the towns we're in, going into the bars and pubs," said Marshall. "We're not particularly well-informed or well-educated, so this is good for us."
I love the idea of the tour. Instead of the band having to run to the airport after the show, they hang out in the community following the festival (indeed, they were apparently already in town hanging out on Friday night during the First Friday Art Walk). But it was the venue that really sealed the deal. The festival was set up in a spot that I don't believe has been used for that purpose before, though it is the spot where the annual Fourth of July fireworks are held. The main part of Portland is a peninsula, jutting out into the Atlantic (Casco Bay). The festival was held in the public park that makes up the very eastern edge of that peninsula. You can see it marked on the handy map to the right that the band provided on their website.
More than that, most of it was on a hill, with the main stage set up down at the bottom (and the second stage set up a little to the right). So as you're sitting out in the bright sunshine of a beautiful August day, what you're seeing is the band and behind them the blue waters and green islands of Casco Bay, dotted with boats going to and fro. I don't have a wide-angle lens on my iPhone but I think this captures a bit of what it looked like:
I think I've only been to concerts in indoor/theater venues before so I was blown away by this. Factor in amazing sound quality and an amazing performance (they ended with a fireworks performance after 9pm) from all involved and I'd be hardpressed to say that wasn't the best concert--ahem, festival--I've ever been to.
This post was a bit bloggy-er than what we usually do here but I was really impressed with Mumford and Son's approach to this tour and I wanted to share their philosophy (and the amazingness of the location).
I can't vote there anymore but I'm fascinated by the political earthquake that took place in the district this week. After not only serving 9 terms in the House, but actually winning this year's primary and being a shoo-in for yet another term, Steve Latourette announced this week he's going to retire after this term. It's hard out there for a moderate. Apparently if you're not completely insane, your future in the Republican party isn't very bright these days.
Both parties scrambled Tuesday to assess their prospects in the 14th district in the wake of Rep. Steven LaTourette’s surprise retirement.
With the GOP Congressman’s decision to delay his retirement long enough to avoid a special primary, Republicans were confident that they could choose a successor capable of holding the moderately GOP-leaning district in November.
But Ohio Democrats are moving to replace their nominee, Dale Blanchard, with a top-tier contender, and whether they’re successful could determine their ability to put this winnable seat in play. [...]
“These are some of our best organized counties,” Ohio Republican consultant Barry Bennett said. “These guys fight for their lives, so they get it.”
Neither the Democratic Congressional Campaign Committee nor the Ohio Democratic Party could comment specifically on any effort to persuade Blanchard to drop his candidacy so that he could be replaced in similar fashion with a viable candidate. If Blanchard does drop out, expect Democrats to invest in this seat, which is considered a perfect fit for the moderate LaTourette but highly competitive without him.
Why replace perennial candidate Dale Blanchard? Well, the guy isn't a pro, he's a sacrificial lamb. Take a look at his campaign website: it's horrific.
But despite Democratic hopes that he can be replaced, he doesn't appear to be going anywhere:
Solon Democrat Dale Virgil Blanchard said Thursday morning that he has no intention of dropping out as the Democratic Party’s nominee for Ohio’s 14th Congressional District.
Blanchard, an accountant, who has run for the position every two years since 2000, has felt energized since U.S. Rep. Steven C. LaTourette, R-Bainbridge Township, announced he would not seek re-election.
“Under no circumstances am I going to drop out,” Blanchard said. “I have no reason to do it. I’m the one who wants it.” [...]
Making predictions about politics is usually a dumb idea. And in a week or two when Mitt Romney announces his VP pick, I'll probably have egg on my face.
But I'm going to make a prediction anyway: Romney's vice presidential pick will be Ohio's very own senator, Rob Portman.
This isn't a particularly novel prediction, as it's well-known that he is on Romney's short list and the folks over at Larry Sabato's Crystal Ball are also betting that it'll be Portman. I've leaned in this direction for some time now--through the Marco Rubio and Chris Christie fads--but in recent weeks this pick has started to seem more likely.
Despite Portman being from the uber-swing state, it's generally accepted that candidates generally don't choose a running mate with the intent of swinging a specific state, though they may seek some sort of regional "balance" to avoid the perception of having only sectional appeal. Off the top of my head, the last election I can think of where the ability of a VP candidate to swing a state or region played an important role in his selection was in 1960.
However, there's something peculiar happening in the polling right now: the curious phenomenon that Obama is outperforming his national numbers in key swing states, most noticeably in Ohio. As Nate Silver noted at the end of last week: Ohio Polls Show Trouble for Romney.
Nowhere was this more apparent than in Ohio, where there were two new polls out on Friday. One of them, from the firm We Ask America, gave Mr. Obama an eight-point lead there. Another, from Magellan Strategies, put Mr. Obama up by two points.
Our model “thinks” the Magellan Strategies poll is a more realistic estimate of the state of play in Ohio. The model now forecasts a three-point victory for Mr. Obama there, which it translates to about a two-in-three chance of his winning the state given the uncertainty in the forecast.
Mr. Obama’s projected three-point lead in Ohio is important for the following reason, however: it’s slightly larger than the 2.4-point advantage that the model now gives Mr. Obama in the national popular vote.
In other words, based on the data so far this year, Ohio has been slightly Democratic-leaning relative to the country as a whole. That reflects a reversal from the usual circumstances. Normally, Ohio — though very close to the national averages — leans Republican by two points or so.
That was followed up by another new Quinnipiac University/New York Times/CBS News poll of three battleground states this week:
A snapshot of the race, taken during a burst of summer campaigning, found that Mr. Obama holds an advantage of 6 percentage points over Mr. Romney in Florida and Ohio. The president is stronger in Pennsylvania, leading by 11 percentage points. The margin of sampling of error is plus or minus three percentage points in each state.
As of this moment, the RealClearPolitics average of state polls of Ohio has Obama up 4.8 points in Ohio.
Republicans do not win the presidency without winning Ohio. I invite you to play with 270towin and find realistic winning scenarios for Mitt Romney that don't involve Ohio. It's very, very tough. And while it's still overwhelmingly likely that whoever wins the popular vote will also win the electoral vote and become President, there is a small chance that Obama will lose the popular vote but win the electoral college (Nate Silver's models currently show that outcome 5.4% of the time, vs. only 0.8% for the reverse scenario). If that occurs, Ohio will likely be the reason.
Of course, the candidate winning the popular vote has only lost the election three times in races where two candidates earned all the electoral votes (in the election of 1824, electoral votes were split between four different candidates). In the late 19th century, during a period of intense polarization this happened twice in 12 years: in the election of 1876 (the only time a candidate won an outright majority, not plurality, of the popular vote and still lost the election) and the election of 1888. In our own time, of course, the relevant example is the election of 2000. Which happens to have been 12 years ago.*
Yes, the polls in Ohio may well tighten up (maybe even reverse themselves) over the next three months. But Romney needs to make his choice now, not after waiting a few months to watch how Ohio plays out. Hoping that Ohio will swing his way requires making a number of assumptions: that Romney's opposition to the auto bailout ultimately won't have much impact, that Obama's characterizations of Romney in his latest ad blitzes won't stick, that the lower unemployment rate in Ohio will be trumped by continued tepid national numbers, and so on.
One thing that held me back a bit regarding Portman, however, was that his lengthy record of public service includes a stint as George W. Bush's budget director. George W. Bush's fiscal credentials, you may recall, are suspect among a base that's rhetorically devoted to fiscal discipline. And memories of his dismal economic record are unlikely to have faded among the broader public.
Indeed, we've seen lately that the Obama campaign is framing the election as something of a matchup of the policies of Bill Clinton vs. the policies of George W. Bush. A Portman pick would seemingly play into that narrative. In addition to the recent announcement that Bill Clinton will be getting a primetime speaking slot at the Democratic convention next month (taking the slot that normally would go to Joe Biden, who gets bumped to performing as Obama's warmup act the following night), Obama has used some lines on the campaign trail that compare Romney's Bush-esque agenda of tax cuts for the wealthy and deregulation with his own Clintonesque tax agenda:
I'm running because I believe you can’t reduce the deficit -- which is a serious problem, we’ve got to deal with it -- but we can’t reduce it without asking folks like me who have been incredibly blessed to give up the tax cuts that we’ve been getting for a decade. (Applause.) I'll cut out government spending that’s not working, that we can’t afford, but I’m also going to ask anybody making over $250,000 a year to go back to the tax rates they were paying under Bill Clinton, back when our economy created 23 million new jobs -- (applause) -- the biggest budget surplus in history and everybody did well.
Just like we’ve tried their plan, we tried our plan -- and it worked. That’s the difference. (Applause.) That’s the choice in this election. That’s why I’m running for a second term.
(Perhaps predictably, Mitt Romney's campaign has continued its habit of using out-of-context quotes to make attack ads. They have at least one of Obama saying "we tried our plan--and it worked" to imply he's speaking about the stimulus which, Trunk's excellent post aside, is much easier to demonize among average Americans than is Clinton's economic policy).
But Portman is trying this week to get out in front of attempts to link him to the Bush administration's failures. See this article out of The Hill today: Possible VP pick Rob Portman was ‘frustrated’ at Bush budget office
.
Sen. Rob Portman (R-Ohio), who served as former President George W. Bush’s budget director, sought this week to distance himself from his former boss by saying he was “frustrated” in the high-profile post.
Pressed on his record with Bush, Portman — a leading GOP vice presidential contender — agreed to an exclusive interview with The Hill in his Senate office.
Portman was careful to not criticize Bush while detailing the challenges he faced from other administration officials, whom he declined to name. The comments indicate that Portman is seeking to keep Bush at arm’s length while also not appearing to be disloyal.
Self-serving attempt to overcome his greatest weakness as Romney closes in on a final VP decision? Or perhaps the word has come down to start the messaging process because he's very likely to be the VP nominee? I have no idea, of course, but it's interesting. Perhaps Romney will ultimately choose a different incredibly boring white guy as his Number Two (e.g. Tim Pawlenty) but right now Portman has to be the favorite.
Fun fact: this ticket would be the reverse of the winning ticket in 1920. In that election, a Republican Senator from Ohio (Harding) topped the ticket, pulling along a Massachusetts Governor (Coolidge) as his VP. Now we'd have a Massachusetts Governor enlisting an Ohio Senator.
* This is just a bit of political numerology. Presidential elections in the 1880s were more polarized than those today: the two intervening elections between the 1876/88 popular-plurality-loser elections were decided in the popular vote by 0.1% and 0.3%. Meanwhile, in our time the 2004 and 2008 elections were decided by 2.4% and 7.2%, respectively (though the latter had some shades of 1932 to it, which disrupted what otherwise looked like a potentially close election).
I've been seeing this ad a lot lately here in Ohio and I can't help but think that the person who wrote this moon-lights as a crazy guy screaming on the street corner. But it got me to thinking, how exactly did the Stimulus effect the economy, namely the jobs data, as that was its purpose. Especially since the Obama administration has been touting the now ubiquitous job creation graph.
While I'm not an economist, I do like to think that I'm able to read graphs, so while I might not know exactly what all of this terms mean, there does seem to be some sort of correlation between the Stimulus (which was passed February 2009) and positive economic data.
Now, we all know that correlation does not imply causation (as it would be silly to think that there is a causation between a decline in pirates and an increase in the global temperature). However, there does seem to be a great positive trend in the unemployment rate, GDP growth, and total private-sector payrolls (amongst other things) immediately following, or in the near term after, the passing of the American Recovery and Reinvestment Act.
So, Mr. Romney, where did this money go? It seems like it went where it was supposed to, perhaps not to the extent that was expected, but it sure looks like it worked to me (as I sit, cradling a beer, filling out job applications).
In some departments of our daily life, in which we imagine ourselves free agents, we are ruled by dictators exercising great power.
--Edward Bernays, Propaganda (1928)
Centuries ago, when the details of the natural universe were first being worked out with mathematical precision, a mental picture began to emerge in some quarters. Some philosopher-physicists began to believe the universe worked like a fabulously large and complex clock: given knowledge of conditions at any instant, one could take a set of deterministic physical equations and do a little lot of math and end up with perfect knowledge of any future state of the universe. Gradually, better understanding of the emergence of chaos from certain non-linear (but deterministic) systems and the 20th century revelation that an (apparently) indeterminate event lies at the heart of quantum mechanics disabused the world of this notion. But the clockwork universe idea was a subject of interest for centuries.
So, too, in the late 19th century and into the early 20th century, did some loosely analogous ideas about the social universe come into vogue. Social structures and organizations became laboratories for a new kind of scientist, but one with every bit as much expectation of complete mastery of his craft as the clockwork physicists of earlier centuries. Thus arose enthusiastic new philosophies like “scientific management” and sober analyses like the rigid Weberian account of bureaucracy. To some degree this dream of a clockwork social universe also manifested itself in politics, as optimistic reformers took on the messy patronage systems undergirding urban political machines and sought more scientific, merit-based civil service structures.
At the tail end of this intellectual movement a remarkable little book emerged. The book can be traced to another intellectual history (which we’ll talk about another time) but its appearance at a time of such confidence in the nascent science of shaping society is impossible to ignore given its thesis. It was produced by a nephew of Sigmund Freud, Edward Bernays, a man who became involved in the U.S. government’s successful propaganda efforts during the First World War. Bernays recognized that propaganda, such a potent tool in wartime, could become a powerful force in peacetime.
Thus he set out on a successful course in the postwar world to develop what we might lovingly call “public relations,” though Bernays himself was able to see through the negative connotations that came to surround the word “propaganda” and embrace that term. In 1928, he developed a piece of propaganda for propaganda itself, a book entitled Propaganda. Pretty meta.
Bernays asks “If we understand the mechanism and motives of the group mind, is it not possible to control and regiment the masses according to our will without their knowing it?” Propaganda, understood by Bernays as a not-quite-scientific set of principles for mental manipulation of the masses, is, in his words, a “practice of creating circumstances and of creating pictures in the minds of millions of persons.” This notion of “creating circumstances” is one that recurs throughout the book. Propagandists are not pulling strings on marionettes or unconsciously fully assuming agency for the masses. Rather, they are manipulating the background in which impressions, conceptions, and decisions are formed. By creating the right circumstances, the successful propagandist configures the dominos; a little push here and they begin to fall, with the vagaries of human nature and psychology inexorably leading individuals en masse to the desired endpoint. Like clockwork.
Of course, Bernays recognized limits to propaganda’s powers. Used skillfully it could be a tremendous tool for smoothing out humanity’s rough edges and overcoming our cognitive deficiencies—even turning them to our, collective, advantage. But it can’t lead the mind where it won’t go. Some products just can’t be sold.
(Despite some interesting attention paid to political uses of his craft, it’s clear that more than anything Bernays understands propaganda to be lucrative. One of my favorite passages:
Under the old salesmanship the manufacturer said to the prospective purchaser, “Please buy a piano.” The new salesmanship has reversed the process and caused the prospective purchaser to say to the manufacturer, “Please sell me a piano.”
The book is, after all, in many ways an advertisement to potential private sector employers of Bernays' skills in the arts of the “new salesmanship.”)
Whatever else can be said about his ideas, clearly Bernays’ insight in pinpointing “creating circumstances” as the key to shaping outcomes is critical. It’s an insight that would be echoed in a big way nearly a century later by Richard Thaler and Cass Sunstein (two UChicago scholars, though Sunstein fled for the greener pastures of Harvard a few years ago and currently resides in the Obama administration as Administrator of the Office of Information and Regulatory Affairs), most notably in their 2008 book Nudge.
Thaler and Sunstein rebrand Bernays’ essential concept as “choice architecture” and its implementers as “choice architects.” In a very real way, these architects are one important incarnation of the “dictators” Bernays referenced; as he wrote, “We are governed, our minds molded, our tastes formed, our ideas suggested, largely by men we have never heard of.” In Thaler and Sunstein’s telling—in their paper “Choice Architecture”, which is an awesome and highly recommended read if you have a few minutes--“A choice architect has the responsibility for organizing the context in which people make decisions.”These are the circumstance-creators of Bernays’ invisible intellectual dictatorship. If acting deliberately, these architects have enormous power to shape decision-making on a large scale. As Thaler and Sunstein write in that paper:
Norman’s basic lesson is that designers need to keep in mind that the users of their objects are Humans who are confronted every day with myriad choices and cues. The goal of this essay is to develop the same idea for people who create the environments in which we make decisions: choice architects. If you indirectly influence the choices other people make, you have earned the title. Consider the person who designs the menu in a restaurant. The chef will have decided what food will be served, but it is someone else’s job to put those offerings on paper (or blackboard) and there are lots of ways to do this. Should hot starters be in a different category from cold ones? Are pasta dishes a separate category? Within categories, how should dishes be listed? Where should prices be listed? In a world of Econs [T&C’s word for imaginary beings that “reason brilliantly, catalogue huge amounts of information that they can access instantly from their memories, and exercise extraordinary will power”], these details would not matter, but for Humans, nearly everything matters, so choice architects can have considerable power to influence choices. Or to use our preferred language, they can nudge.
Of course, choice architects do not always have the best interests of the people they are influencing in mind. The menu designer may want to push profitable items or those about to spoil by printing them in bold print. Wily but malevolent nudgers like pushy mortgage brokers can have devastating effects on the people who are influenced by them. Conscientious choice architects, however, do have capability to self‐consciously construct nudges in an attempt to move people in directions that will make their lives better. And since the choices these choice architects are influencing are going to be made by Humans, they will want their architecture to reflect a good understanding of how humans behave.
The importance of “environments in which we make decisions,” the circumstances in which decision-making takes place if you will, is hugely important to the choices people make, utopian conceptions of human beings as enlightened rational calculators aside. The concept of bounded rationality--that men are not calculators, but rather frequently use mental shortcuts and emotional or borderline irrational techniques to aid in decision-making--was introduced by Herbert Simon in the 1950s and is relevant to this picture of how our minds work.
But, as it tends to do, my mind strays to a current health policy issue. Earlier this month Consumers Union released a report they developed in conjunction with a communications firm: “Choice Architecture: Design Decisions that Affect Consumers’ Health Plan Choices.” In 2014, under the Affordable Care Act, residents of every state who don’t have health insurance through their job are supposed to have access to new markets called exchanges (technically, customers are supposed to be able to begin shopping for insurance plans on October 1st of next year). Health plans in the exchanges will compete in “tiers” of coverage, based on a calculation of how generous they are—bronze, silver, gold, and platinum are the four levels of coverage that will exist. These standardized levels are intended to make decision-making easier by allowing apples-to-applies comparisons of insurance plans within a given tier of coverage. This, along with new standardized product descriptions, should help to overcome some of the cognitive limitations that become apparent when a person is shopping for a complex financial product like insurance—limitations that insurance companies can and (I assume) do use to their advantage in the current marketplace.
But this report on choice architecture is focused on a particular aspect of the exchanges: what the web-based health plan chooser tools will look like. When you log onto your state’s exchange website (once it exists), you’ll be guided through a smooth, user-friendly process that will help you find a health plan that suits you. But, as the report’s authors note, “Given the number of attributes associated with health plan choices (premium, covered services, provider quality, etc), no website can emphasize all elements of a health plan equally. Tool designers make decisions about what to emphasize and how to frame the elements that they feel are important to consumers, such as health plan cost or quality.” In short, the choice architecture of the chooser tool is going to be very important.
In particular, the authors are concerned about the initial set of plan options that will be displayed to the customer shopping for a plan on the exchange website. The importance of default options is something Thaler and Sunstein emphasize in their work because, more often than not, folks gravitate towards the defaults when they make a choice (“For reasons of laziness, fear, and distraction, many people will take whatever option requires the least effort, or the path of least resistance,” T & S write.) From the exchange choice architecture paper:
The study emphasized the choice architecture used to display the initial set of health plan options. The default choice set radically affects consumers’ shopping experiences because once they see the default, they use it as an anchor or baseline for the rest of their selection process. What consumers see first will frame their understanding of the rest of information – in effect, creating a mental model for them. Consumers won’t always know what they aren’t seeing, and the choice architecture conveys implicit and explicit decisions about what is important. Research conducted by PBGH/CalPERS [an existing exchange in California] shows that 93% of the time the default display of information is accepted by consumers with no customization on their part. More than 60% of users of the Checkbook site make their decisions without leaving the initial summary screen.
The authors of the Consumers Union report looked at how existing exchange-like tools work (including the existing exchange in Massachusetts) to consider the options available to states as they think about how to display plan choices to customers. The report and the considerations it presents are interesting in and of themselves, but the underlying moral is one laid out by Bernays 80-odd years ago: when folks shop for insurance plans on their state’s exchange website, imagining themselves free agents, they are in fact going to be ruled by dictators whose design decisions greatly affect consumer decisions.
If you’re slightly unnerved by the power afforded these invisible, web design dictators, perhaps Bernays’ parting thought—reminding us that propaganda, and thus choice architecture, can be a tool for achieving good and noble aims—is worth noting:
Intelligent men must realize that propaganda is the modern instrument by which they can fight for productive ends and help to bring order out of chaos.
About a week ago, George Zimmerman spoke to Fox News in an interview regarding the Trayvon Martin shooting, where he expressed having no regrets. When pressed further by interviewer Sean Hannity, he stated "I feel it was all God's plan."
Interestingly, I happen to be researching Charles Julius Guiteau at the moment. Guiteau was the assassin who shot President Garfield and during his trial used the following defense:
I thought the Deity and I had done it, sir. I want it distinctly
understood that I did not do that act in my own personality. I unite
myself with the Deity, and I want you gentlemen to so understand it. I
never should have shot the President on my own personal account. I want
that distinctly understood. (Source).
Guiteau's defense tried to use the insanity plea (Guiteau himself claimed he was perfectly sane, but was insane when God told him to shoot the President; his lawyers did not make the distinction). Nearly everyone at the time, including religious leaders, agreed that Guiteau had no divine inspiration for such a pointless act and the debate centered around whether he was either insane or a self-obsessed, evil assassin. I have not seen the reactions to Zimmerman's statement, but I wonder if the number of people who believe him is comparatively higher or lower than those who believed Guiteau? That could be a depressing statistic.
Charles Rosenberg, author of The Trial of the Assassin Guiteau, argued that had Guiteau shot any other man (or had he simply wounded the President), he would have been committed to an asylum and not executed. I'm not 100% convinced that Zimmerman isn't slightly "out there" anyway, but I wonder if his defense will change if it begins to appear he can't get out of this one using the "Stand Your Ground" law? I'm not really trying to compare the two trials other than to point out a similarity in statements, but at least you could say that in both cases
they ended up being not as open-and-shut as you would think. And as you guys are well aware I'm always looking for excuses to talk about history.
Anyway, here's some general interest facts/quotes I've found regarding Guiteau. I'm of the opinion he was insane but still sane enough to know what he was doing. There's some though who still think it was all an act or that he was completely sane if admittedly a little odd.
Charles Guiteau: "It was transitory mania that I had; that is all the insanity that I claim."
Guiteau, in response to why he bought the particular pistol he did: "I do not claim that I was to do the specific act; but I claim that
the Deity inspired me to remove the President, and I had to use my
ordinary judgment as to ways and means to accomplish the Deity's will." He later hinted that he believed the ivory-handled pistol he bought would look better in a museum one day.
Guiteau: "The Deity uses certain men to serve Him. He is using this honorable
court, and this jury, and all these policemen, and these troops to
serve Him and to protect me."
Guiteau, in response to whether he killed the President: "The doctors killed him; I did not kill him."
Guiteau: "I presume the President was a Christian, and that he will be happier in Paradise than here."
Mr. Porter [prosecution]: "Was one of your purposes in removing the President to
create a demand for your book?"
Guiteau: "Yes, sir; with the modification that I have
previously stated--to preach the gospel as set forth in the book."
In his autobiography that he sent to the New York Herald while in prison awaiting trial, Guiteau added the footnote: "I am looking for a wife. I want an elegant Christian lady of wealth, under thirty, belonging to a first class family... I am fond of female society, and I judge the ladies are of me, and I should be delighted to find my mate."
George M. Beard, neurologist for the defense, regarding Guiteau's mental state: "All the links of the chain are there, but they are not joined, but rather tossed about hither and thither, singly, like quoits."
In response to Guiteau's self-written defense, one asylum superintendent described it as "...bearing the same relation to ordinary reasoning that the scenery and incidents of a nightmare bear to ordinary life."
Before and after the assassination, Guiteau claimed that his ideas in a speech entitled "Garfield vs. Hancock" were what allowed the Republican Party to win the presidency. During the trial, it was discovered that the speech was originally for Ulysses S. Grant, who was seeking a third term but had been defeated by Garfield in the Republican convention. When Garfield got the nomination, Guiteau simply crossed out Grant's name and wrote Garfield's above it. He only gave the speech once, to a handful of citizens in New York.
Sources: The Trial of the Assassin Guiteau by Charles E. Rosenberg Garfield by Allan Peskin
Harbors up and down the coast of Maine are filled with idle fishing boats, as lobster haulers decide that pulling in their lobster pots has become a fruitless pursuit.
Prices at the dock have fallen to as low as $1.25 a pound in some areas—roughly 70% below normal and a nearly 30-year-low for this time of year, according to fishermen, researchers and officials. The reason: an unseasonably warm winter created a supply glut throughout the Atlantic lobster fishery. [...]
Retail lobster prices in Maine have started to fall along with the glut, and Mr. Bayer said that some fishermen have begun selling lobsters out of their trucks for as low as $4 a pound. But consumers elsewhere in the U.S. aren't likely to see bargains. The Maine lobsters that currently are in season can't be shipped long distances due to their soft shells, and retailers have other fixed costs that limit big price drops.
"There could be a small effect, but I wouldn't expect much," Mr. Bayer said.
A total of 17 Viacom channels, including MTV, Comedy Central and Nickelodeon, went off the air for DirecTV customers on Wednesday as the companies were unable to agree to a new contract.
DirecTV and Viacom were quick to pin the blame for the blackout on each other.
In a statement, DirecTV claimed that Viacom was demanding a 30 percent increase on the price to carry its channels — which would amount to an extra $1 billion.
"We have absolutely no problem compensating Viacom fairly, but they have now knowingly put our customers in the unreasonable position of either accepting their extravagant financial demands or losing some of their favorite TV shows," said Derek Chang, a DirecTV vice president.
Normally, I wouldn't care, since I'm not a DirecTV subscriber. Indeed, since I dropped Time Warner a few months ago, I'm nothing. I subsist on Netflix, HuluPlus, and the mercy of the Internet at large.
But what took me aback was this:
Viacom even took popular programs, such as "The Daily Show," off the Internet to prevent DirecTV subscribers from watching the shows online.
It's true. If you go to thedailyshow.com or colbertnation.com you're treated to an anti-DirecTV propaganda ad from Viacom. If you then try to watch episodes of the shows, you discover that "full episodes are currently unavailable."
Of course, TDS and TCR aren't new this week and even if they were they still seem to be accessible in full via Hulu (at least episodes aired within the last 30 days). But man, how fucking obnoxious.
How convenient! In the latest issue of the New England Journal of Medicine, there is a follow up study on the new resident work hour restrictions, last updated in June of 2011. The researchers decided to send a survey out to current resident physicians, asking how they liked the new 80 hour work week and how their medical training and lifestyles have been altered due to these restrictions. I thought there were quite a few interesting results of the survey, and I'll talk a little about what I've noticed in the hospital as a result of all these changes.
In 2003, the 80-hour work week restrictions were put into place, stating that residents could not work more than 80 hours per week, averaged over a month. Shifts were limited to 24 hours + 4 hours for educational purposes (i.e. lectures), and call was limited to every third night. In 2011, shifts were cut for interns to 16 hours + 4 hours, but higher level residents were still held to the 24 + 4 limitation. (Here is a table comparing the 2003 and 2011 regulations) As would be expected, there was a slight outcry in the medical community that duty would be shifted from interns to higher level residents, since they worked longer shifts. People complained that continuity of care would be lost for interns and that they wouldn't be as prepared for subsequent years in residency. People on the other side of the argument said that more medical mistakes were being made because residents were so tired and overworked.
Let's see how the residents felt about all of this.
First off, 123 of the 682 ACGME-accredited residency programs participated in the survey, and the researchers received a 23.3% response rate from residents at these programs (6202 individuals). All specialties and subspecialties seemed to be well-represented, with internal medicine the largest group, composing 28% of the total responses. The responses to the questions were based on a simple, 3 point scale: worse, unchanged, or better. If you take a look at table 2 in the article, you can see what the doctors thought of the new changes. In summary, it seems that residents thought that the safety of patient care, the amount of rest they get, the availability of supervision, and the total number of hours worked this year as compared to last year remained unchanged after the new 2011 regulations. The only thing that was remarkably better, according to the survey, were the quality of life for interns. About 30% of those polled felt that they get more rest after the restrictions, and about 30% feel that their work schedules are better. The things that were remarkably worse after the new restrictions were quality of life for senior residents, work schedules (43% felt they got worse), and preparation for a more senior resident role. The quality of resident education overall was either unchanged or worse after the 2011 restrictions. As feared, the number or frequency of handoffs in patient care was thought to have increased, as was the frequency of senior residents taking on work of more junior residents. I would have liked to see a better breakdown of the responses, especially by specialty and by year of residency. I'm sure they have this data, it just wasn't presented in the article.
In conclusion, 48.4% of residents disapprove of the 2011 regulations, 28.8% are neutral, and 22.9% approve of them.
Wow! I bet the ACGME isn't too happy about the results of this study. Unfortunately, I haven't been working in hospitals enough to really confirm for myself whether these 2011 changes, coupled with the 2003 restrictions, have or haven't been beneficial. I do see a lot of work getting dumped on senior residents because the interns have to go home, so as not to go over their hours. I have also noticed a TON of handoffs occurring, and I have noticed that many things often get lost in the mix. Imagine the "telephone game," where one person whispers something into someone's ear, then they whisper something to the next person, and so on until the original message returns very distorted from how it started. In a milder sense, this is what is happening with increasing handoffs in medicine. The more whispers, the more can get distorted or misunderstood. I actually have seen some pretty important information missed during a handoff that made for a poorer outcome for a patient. If residents were at the hospital for longer periods of time, the argument would be made that they retain the continuity of care, know the patient's story, and are less likely to miss a small detail as compared to a resident who just acquired the patient 2 hours ago during a handoff. The resident who has known the patient for 2 hours is obviously less invested in the patient, as opposed to someone who was paying close attention to that patient for a continuous 20 hours.
I have also seen work hours being violated in certain departments, especially surgery. One of the main problems with how this system is set up revolves around the reporting of work hour violations. Residents who want to file a work hour violation complaint are NOT protected by whistleblower laws. This isn't anonymous reporting. Also, why would any resident want to report work hour violations, when the penalty to their program is loss of accreditation if these violations pile up? If the program dissolves because of the violations, residents are left out of a job, and it becomes infinitely harder to get licensed. Anyone with common sense sees that you're just shooting yourself in the foot by reporting work hour violations. That's why resident work hours are believed to be vastly understated, especially in specialties such as surgery and OB where very long days are the norm. We clearly need a better reporting system.
There are a few studies out there that disagree whether morbidity and mortality is actually increased or not when residents stay up for long periods of time. It really seems like these arguments for or against work hour restrictions are based more on anecdotal and theoretical evidence than hard facts. One thing is clear from this study, however...residents aren't too happy with the 2011 regulations. It seems to me that, if there really isn't a difference in patient outcomes with longer hours and residents aren't a fan of the current system, maybe some further adjustments have to be made with these regulations. As it stands, I find myself leaning more towards having longer hours for residents. I like continuity of care, and I personally hate handing off patients every 12 hours or so. I feel less responsible for my patients, less connected to them, and ultimately less interested if I know that the next team will be handling the brunt of my patients' problems during their shift.
I'd be interested in seeing if Stanek has run into anything regarding this stuff during policy-making discussions. I don't know much about the financial aspect of these regulations, or the implications on federal/state/hospital policy.
I'd also be interested to hear whether nurses and other staff have noticed a difference in patient care now that the new regulations are in place, or if things have remained about the same for the past 10 years. What does everyone think?
So it's 5 am and I'm on my 2 week internal medicine night rotation, sitting here in the resident's lounge on the top floor of a huge hospital. We haven't seen a patient in 7 hours because the day team already "capped", meaning we can't accept any more patients tonight unless they are bouncebacks to our team. My two residents went to the call rooms to sleep (I certainly don't blame them!), leaving me to watch old reruns of sportscenter and the history channel. It's actually a nice time to reflect on topics that I haven't thought about in a long time, just because I've been so busy studying. One of the things I've been meaning to discuss on the Speakeasy pertains to residents, the docs that actually take care of you when you're an inpatient at the hospital.
Let me preface this by saying what I'm going to talk about applies mostly to large teaching hospitals, not the smaller community hospitals that do not accept resident physicians. A lot of people don't realize that, when they are admitted to a large hospital, most of their care is not managed by seasoned physicians like House. Usually a team of doctors, who aren't that far out from med school, are the ones really taking care of you. This team includes interns (first-year residents right out of med school) all the way to 5th year senior residents in some specialties. It's a hierarchy of power and decision-making capacity, designed to deliver the best care while providing the most education for these new doctors.
I want to run through what usually happens if you come into the ER at 2pm with a simple complaint like a skin infection (I'm going to pretend you're one of the patients that we saw tonight). You'll probably spend a few hours in the waiting room, depending how busy the day/night is. Unfortunately for you, your ailment isn't nearly as urgent as the 40 pack-year smoker having chest pain, that guy on a motorcycle who was just hit by a semi, or the little old lady with dementia who fell on her hip. You could be waiting for a couple hours just for an ER room. Once you get one, you'll probably spend another hour answering questions from a nurse, having vitals taken, and answering questions from another nurse. Then, if there haven't been a ton of other admissions to the ER more urgent than you, you'll get to be seen by an ER intern. He/she will ask you a bunch of questions, going over all of your past medical history and the history of your current illness. Then you'll wait as the intern eventually meets up with the chief resident or attending (depending on who is at the hospital at the time and how serious your complaint is) to present your case. The attending will eventually get to see you, popping his or her head into your room to eyeball you. They make a decision on whether to consult with the intention to admit or "treat and street", meaning they take care of you in the ER and send you home right from there. If they suspect that you will be admitted, the whole cycle starts again. In your case, they consult internal medicine, and the intern (with a medical student) comes down to the ER to see you. They ask you all of the same questions that the other resident asked, but because they're a different service, they have to ask you everything again so they can put it in their history and physical on the Electronic Medical Record (EMR). Once they are done, the intern presents you to their chief, and the chief comes down to see you (and often asks the same questions again, filling in any gaps the intern missed). The chief resident decides whether to admit you or not, in most instances. Not the attending. The attending is probably asleep, because by the time that decision has to be made, it's 11:30pm. regardless, it takes about a half hour to put in orders into the computer to admit you, and you find yourself in a room around midnight, finally ready to sleep.
Not many people actually know how much is decided for you by the resident when you go to the hospital. Let's start with your skin infection. They have to decide whether it looks bad enough to get surgery involved in your case, or whether it can be managed medically. You'll need IV antibiotics, labs, and an x-ray if a bone infection is possible. You also need IV fluids, depending on the labs drawn in the ER. If you were taking medications at home, those have to be reviewed and either continued or discontinued in the hospital. You have to be put on a diet, you have to be given bathroom privileges, and orders for tomorrow morning have to be put in (especially for labs). Contact precautions, because the last time you were in the hospital you had a MRSA infection, have to be initiated. You will need cultures of your skin infection, as well as nasal cultures, to prove that you are a MRSA carrier during this hospitalization. These are just some of the dozens of decisions and orders that have to be made for you, the easy patient with a simple skin infection. Imagine a patient with 12 current medical problems, with crazy abnormal labs, needing a slurry of decisions and orders to be made for each of these problems. Even though only one of those problems may have brought them to the hospital, they all have to be managed appropriately for the duration of their stay. The point of this is that residents do a shitload of decision-making and are really in control of over 95% of your treatment while in the hospital.
Ok, back to your skin infection. In the morning, you'll be bombarded by questions from the new nursing staff, medical students, and a whole new day team of residents. They will all have a meeting with the attending during or before morning rounds, talking about you and how to manage your problem. The attending will probably make only a few adjustments with the orders, everything else being taken care of by the night intern who admitted you or the day intern that you saw very early in the morning. Around 11am, the entire student/resident/attending team will show up in your room, the attending will say a few words to you and wish you luck in your recovery. Depending on their schedule, the attending will probably leave in the early afternoon to take care of other business, or more complicated patients. But to bill for the entire hospital stay, the attending must "lay eyes on you" at least once per day. That's it! He or she really needs to only see you for ten seconds. The attending will sign off on the resident's progress note, and the next time you will see the attending will be around 11am on the next day. Every question that the nurses have about you will go to the intern first, the up the food chain of residents until it gets to the chief, if it needs to go that far. Usually everything is taken care of by the intern. Unless something very serious happens, the attending will only find out about the previous day during the next morning rounds. Things can get much more complicated if multiple consults are made, or if you have procedures done to treat your illness. But for the sake of argument, we'll say that you didn't need any consults and you didn't need to have that skin infection drained.
Because you're such a healthy patient otherwise, your IV antibiotics do a good job taking care of that skin infection, and in a few days you're ready to go home. Before you can go, the attending must again "lay eyes" on you that day...then you're free to go! The residents handle most of the paperwork, including the discharge summary that goes to your primary care doc (and any other pertinent healthcare providers) summarizing your hospital visit. Oh, and they are most likely handling about 7 more patients more complicated than you at the same time they are taking care of you and your skin infection.
So the point of all this, if you made it this far in the post, is to demonstrate how much residents actually do for you while you're in the hospital. A lot of people immediately ask for the attending when they get here, not understanding how the system really works. In fact, consider yourself lucky that you're in a hospital with residents in the first place. A lot of smaller hospitals don't have this resident backbone, and in my opinion this can cause your healthcare to suffer. A lot of double-checks and discussion about your case takes place in these larger hospitals, both between residents and students, residents and residents, and residents and attendings. All this communication can only help when it comes to improving a treatment plan...the more minds, the better. However, you'll be sacrificing in time what you gain in brainpower, a concept that many patients don't understand when they come to very large hospitals. They assume that care will be faster because there are more resources, more staff, and more collective experience in the bigger hospitals. That's definitely not the case, and you may be waiting a very long time if you have a relatively minor complaint (minor in the eyes of the healthcare providers--I understand that even minor things can seem really scary and bad to patients).
One moral of this post is that everyone should get a primary care doc and go to them when they have smaller issues (or call them when you're not sure). I should practice what I preach, since I don't have a primary care doc while in med school, as don't many med students and residents--a topic for another post!
The real moral of this post is to be nice to your residents when you go to the hosptial. I'll try to talk a little more about resident work hours in yet another post, because this is one of the hottest topics when it comes to resident education in the US. Just remember that you are lucky to have them, as they are also lucky to have you as their patients and to learn from you. Consider that extra time you spend in large teaching hospitals to be a good investment in your health, since so many problems and mistakes get caught by people other than the lone attending watching over you from a distance, especially by residents and students (and nurses--another post topic!)
I'm really setting myself up for failure by suggesting all these future post topics...but hopefully I'll have some time on nights to address all these things. Let me know if there's something that strikes your fancy that I might be able to talk about more in depth. I want to get some quality stuff on here in the next two weeks.
