Wednesday, December 12, 2012

An Open Letter to my State Senator

Written in response to a general solicitation for feedback on the Economic Impact Investment Act.

Thank you Senator [] for the opportunity to comment on the Economic Impact Investment Act.  I'm deeply disturbed by the prospect of Oregon being bound for forty years through a law enacted with barely a week of consideration and review.  The process chosen by the governor for bringing forth this legislation guarantees that no one can honestly say they know what they're doing.

With that in mind, some suggestions:
  • This legislation should be a prelude to a law that can receive due and appropriate consideration in the 2013 session.  Emergency legislation should enable the governor to address what is truly an emergency and nothing more.
  • Toward that end, this legislation should include a sunset clause.  If the 2013 session doesn't see these powers as necessary than they are not necessary.
  • I make a living forecasting long term contingent liabilities, and I can tell you with some confidence that no one knows anything about what Oregon's economy will look like in 2050.  That is even more true when considering the fortunes of a single company, even one the size of Nike.  There is no good reason, either for businesses or the state of Oregon, to make promises about their conduct that far into the future.  Any dispensations granted as a result of this legislation should be limited to 20 years at the most.

Finally, a word of caution.  It may be tempting to look at locking in the status quo as a small thing.  But this legislation and the process by which it is enacted will set a precedent.  Who will come calling and what they will demand next Christmas?

Wednesday, October 17, 2012

Romney's Medicare reform and the irony of choice

Presidential candidate Mitt Romney has staked his campaign in part on substantially reforming Medicare.  Under his proposal the insurance plan would switch from providing defined benefits to a defined contribution, based on the 2nd cheapest plan available in a person's area.

There are a lot of gaps and details missing from the proposal, but the Kaiser Family Foundation took a stab at measuring the effect on seniors.  They looked at what would happen if that plan had been in effect in 2010, looking at the plans people actually enrolled in (traditional Medicare or one of the Medicare Advantage plans).  The result:  Overall 59% of all Medicare enrollees (88% of Medicare Advantage enrollees) would have to pay higher premiums to stay in their current plan.  Or to put it more directly, the defined contribution Romney's plan provides would not be adequate to pay for the plans most people are in now. 

The numbers are particularly bad for residents in the Portland area:

County# of Medicare Enrollees not Fully Reimbursed for Current PlanAvg Monthly Funding GapTotal Annual Funding Gap

To put that last number in perspective, $240M is about what the highly contentious income tax increases from measures 66 and 67 will cost this year. Romney's Medicare reform would impose a burden of that magnitude on the elderly just within the tri-county Portland area.

Of course, seniors could always opt for one of the two cheapest plans and avoid any funding gap. But that belies all the justifications for Romney that claim his plan increases choice or involves a free-market. The only people with choices under Romney's plan are those willing and able to pay.  Everyone else gets a pick from the bottom of the litter.

Friday, August 24, 2012

Providence revisited

DCBS has rendered a decision on the 11/1/12 Providence individual rate filing.  They knocked the increase down from 15.7% to 12.2%.  The change is mostly driven by a reduction in annual trend from 7.2% to 5.5%, or as a 23 month factor from 14.3% to 10.8%. 

I wrote before that I thought the Providence trend was high, below is an update of the chart that shows why.  I'm starting it with January of 2010 because that was when the explosive growth in membership tapered off.  Prior to that comparing the book to a point 23 months earlier would be apples and oranges, as the book had more than doubled in that time.  Click for a larger view:

The blue line shows the 12 month change in the rolling 12 month normalized cost per member per month.  It's the same as the figures included in Providence's filing attachment G, column N, except that I'm compounding the changes over 23 months the same way the filing uses them.  So the Feb-2012 value of 7.2% becomes (1 + .072) ^ (23/12) - 1 = 0.143.  That 14.3% figure happens to be what Providence proposed using, it's the actual factor by which the experience claims are marked up for trend as shown in the Rate Projection attachment A.  That pick is shown on the chart as the flat red line.

There are two more lines on the chart.  The flat purple line is what DCBS approved, and the green line is the 23 month change in rolling 12 month normalized cost pmpm.  That is, instead of looking at a 12 month change and extrapolating it over a 23 month period I'm looking at the actual change over 23 months. 

People can decide for themselves how reasonable the proposed and approved trends are.

Wednesday, August 8, 2012

Tweets that make me laugh

First this:

A few items later in my stream was this:

The latter references a new RWJF synthesis on the effects of hospital competition.  The key points:

  • Hospital consolidation generally results in higher prices. This is true across geographic markets and different data sources. When hospitals merge in already concentrated markets, the price increase can be dramatic, often exceeding 20 percent.
  • Hospital competition improves quality of care. This is true under both administered price systems, such as Medicare and the English National Health Service, and market determined pricing such as the private health insurance market. The evidence is more mixed from studies of market determined systems, however.
  • Physician-hospital consolidation has not led to either improved quality or reduced costs. Studies find that consolidation was primarily for the purpose of enhanced bargaining power with payers, and hence did not lead to true integration. Consolidation without integration does not lead to enhanced performance.

For background, Providence was one of the higher cost providers Regence tried to cut out of their network, while Tuality was one of two low cost providers the insurer wanted to keep.  Despite providers being mostly successful in pushing back against that move, it looks like it still struck a nerve...

Wednesday, July 18, 2012

Republicans and ineffective medicine: The saga continues

The love affair between Republicans and ineffective medicine grows ever more torrid.  Last week it was seeking to undermine the US Preventative Services Task Force, this week it's eliminating health services research.

These attacks on effectiveness research are bizarre.  Republicans claim to support market solutions to health care, but one of the biggest obstacles to that is that people have no idea what they are buying.  Are they buying a Cadillac treatment that delivers 100% satisfaction with no side effects or a 1979 Pinto that will blow up in their face?  When people can't tell the difference between shit and shinola there is no market and you can't have market solutions.   If Republicans are in any way serious about markets they should be advocating for more effectiveness research, not less.

So what explains the attraction?  Why do Republicans seek to protect treatment that doesn't work, like widespread PSA screening?  It's almost like they're afraid of the paradigm of using evidence to guide decisions.  Probably because in the real world so much evidence goes against them...

Thursday, July 12, 2012

Providence Rate Filing

I'm normally sympathetic to insurers, but something about this filing rubs me wrong.  Maybe it's because someone thought it was important that everyone know that we're paying an extra 1.1% for women's preventative health services through the ACA, so important that they included it as a line item in the summary.

Or maybe it's because of this:

Instead of estimating an annual factor and blowing it out over 23 months I'm looking at the actual 23 month changes.  I'm comparing that to Providence's selected 7.2% annual factor, which compounds out to 14.3%.  Even against the worst point in 2011 the factor used in the proposed rates is almost double.  Putting it in comparative terms,

Monday, July 9, 2012

Why CCO's may not fail like HMO's

In response to @ChargerJeff, who asked why CCO's would fare any better than HMO's:

HMO's did succeed at cost control, which is a primary purpose of CCO's.  Where HMO's failed was in working cooperatively with doctors and patients, CCO's if they are to last will have to do better.

Reasons to think they will:
  • We already have managed care, particularly in OHP.  The distance between where we are and where CCO's are going is shorter than the distance between indemnity plans and HMO's.
  • The distance between doctor patient interactions and financial authority is shorter, you're less likely to see the kinds of coverage conflicts for which HMO's were notorious. 
  • There is more cost awareness among providers now than there used to be.  Concepts like variation and evidence-based medicine are gaining growing acceptance, even if they are not entirely mainstream.
  • Maybe most important, providers have no choice.  CCO's are an attempt to control costs by empowering providers, if they fail the alternative is to control costs by disempowering providers and stripping them of authority over treatment.  Think about the ER restrictions that Washington considered (and that for-profit hospitals have implemented), or more direct interventions in provider pricing.

None of this is to say that CCO's are a sure thing, there's a reason the feds made their funding contingent on results.  But the cost of trying in my view is much smaller than the cost of doing nothing and hoping that a 40 year history of medical inflation will somehow reverse on its own.

Sunday, June 17, 2012

Why Evidence Based Medicine is hard

Grrr…  I see the Lund Report carried a press release from a device manufacturer lamenting Medicare's decision to drop coverage of their product for treating chronic lower back pain.  In a different universe that article would have been written by a third party without a direct financial interest and it would have been called, "Clinical studies show that TENS units offer no benefit in treating chronic lower back pain, Medicare to stop wasting tax payer money on them."  But that would be a universe in which health care wasn't eating the economy, not ours.  Why did Lund Report run this?  I'll speculate:
  • It was there, and free.  The manufacturer had a financial interest in getting its message out that was not matched by any organization on the other side of the decision.  Nothing from EBM promoters, nothing from those supposedly concerned with Medicare solvency, nothing at all.
  •  There is a community with a strong interest in seeing coverage continued:  current and prospective patients.  Which narrative would those people rather see:  That what they've been doing is a waste of time and money, or that government is corrupt and denying them what is rightfully theirs?  Take a guess.
Whatever the reasons, thinking about why this article was run sheds light on why the public has a hard time accepting evidence based medicine.  And no, it has nothing to do with government vs. private insurance.

ps yes, this is another example of Republicans defending ineffective medicine.

Thursday, May 31, 2012

Followup on Hollywood

Last year I shot some photos around the Hollywood Theater, trying to understand why people were concerned about the aesthetics of putting an apartment building next door.  The new building isn’t finished, but it’s far enough along to get a sense of the visual impact. Below are side by side comparisons, with the first shot from July of 2011 and the second from May 2012 while construction is in progress.

I still don't get what the fuss was about. The only view negatively impacted was the middle shot from the east side of Sandy around 41st street. I think the apartment building actually improves the view from the west side.

Saturday, May 12, 2012


How Effective is Arthroscopic Knee Surgery?
Something to file away for the next time I try to convince someone doctors are no more trustworthy than plumbers.

Thursday, March 29, 2012

Why Burial Insurance is not the same as Health Insurance

The right wing of the Supreme Court tried to make the case that a mandate for health insurance is no more necessary than a mandate for burial insurance.  There are a lot of ways of tackling that claim, but a key issue I haven't seen acknowledged is the skewed cost distribution of health care.  With health care the most expensive 5% of individuals account for almost 50% of total spending.  What would happen if burials had the same cost distribution?

As of 2007 the average death cost $6,310 in funeral expenses*. If the same distribution that we see in health care applied to burials we'd have 5% of the population getting $63,000 funerals while everyone else's cost $3,300.  And neither you, your next of kin nor the state would have any say in who got which funeral, it would be as random and arbitrary as people's health needs.  Think about how that would impact families, think about how it would screw up government budgets as they had to fund funerals for the poor or uninsured.

In effect burial spending is nothing like health care spending, and if it was alike we'd have the same conversations about how to pay for it.

*Total revenue for Funeral Services (NAICS Code 8122) divided by number of deaths.

Saturday, March 24, 2012

Hip Implants on NPR

via Maggie Mahar's twitter feed, an NPR story covering the consequences of metal on metal hip implants in grisly detail. We're going to spend billions in direct medical costs putting these implants into people and then taking them out after they've shredded their insides, and probably billions more in legal costs as the manufacturer, surgeons, and hospitals try to stick each other with the blame.  All that money for this:
The first implant also became loose. "At one point, the doctor said, 'OK, I'll hold your hands ... now stand on that leg.' And I stood and it went kuh-CHINK, like that, and he said, 'What the hell was that?' "
I think the story of how this product came to the market and why surgeons chose to use it will say a lot about health care in America.  I look forward to someone writing it.

Saturday, March 17, 2012

The cost of scapegoating

A good quote from "Since Yesterday" (emphasis mine),
A good deal of the bitter anti-Roosevelt talk could not, of course, be taken at its face value.  Often it was a form of conscious self-indulgence in the emotional satisfaction of blaming a personal scapegoat for everything that went wrong.  When, as in a New Yorker cartoon, a group of ladies and gentlemen sallied forth to the trans-lux theatre "to hiss Roosevelt," they enjoyed the sort of release that many liberals had enjoyed when they blamed all the ills of the economic system on the personal wickedness of bankers, or that Nazis enjoyed when they blamed all the ills of Germany on the Jews.  To find a scapegoat is to be spared, for the moment, any necessity for further examination of the facts or for further thought.

Yet to the extent that it stopped factual inquiry and thought, the Roosevelt-hating was costly, not only to the recovery, but to the haters themselves.  Because as a group (there were many exceptions) the well-to-do regarded the presence of Roosevelt in the White House as a sufficient explanation for all that was amiss and as sufficient excuse for not taking a more active part in new investment, they inevitably lost prestige among the less fortunate.  For the rich and powerful could maintain their prestige only by giving the general public what it wanted.  It wanted prosperity, economic expansion.  It had always been ready to forgive all manner of deficiencies in the Henry Fords who actually produced the goods, whether or not they made millions in the process.  But it was not disposed to sympathize unduly with people who failed to produce goods, no matter how heart-rending their explanations for their failure.  Roosevelt-hating thrust the owners and managers of business into inaction--into trying to resist the tide of affairs, to set back the clock.  It made them conservatives in the sense that they were trying to hold on to old things, whereas before 1929 they had been, in their own way, innovators, bringers of new things.  It made them, as a group, sterile.  And they were soon to learn that sterility does not stir public applause.
I think this says a lot about right wing politics today...  especially the word "sterile."

Saturday, March 10, 2012

Practical Health Care Reforms from NY

Via Kaiser, the State of New York's Department of Financial Services issued a report on 'surprise' medical bills affecting people who have insurance.  The consequences of such bills can be profound.  There is too much good material in the DFS study to pass on through quotes so I urge you to read it yourself.

 What struck me about the study is that it's the first one I've seen that tries to get into the nitty gritty interactions between patients, insurers, and providers that actually determine what people pay.  The description of doctor "run-ins", where an out of network physician gets involved in a procedure without the patient's knowledge or consent really hit home, in a personal, "hey I got f$@#$! by a doctor just like that!" kind of way.  The same goes for the inadequate notice on what providers are in or out of network.  For my family and I suspect lots of people, seeing an out of network physician amounts to going uninsured.  We try pretty hard to avoid that, but neither providers nor insurers make it easy. 

Health care reformers tend to blow past this stuff because it doesn't offer that much in savings in the big picture, and it is a problem for people with insurance who by virtue of that alone are already a lot better off than those without.  But addressing these problems, problems that people will recognize and react to, is a great way to build political support for reform.  I hope those working on the state exchanges are paying attention because I think this will be a pass/fail test.  Address problems that bother people and you get the laurels, ignore them and all the rocks people now throw at insurance are going to be heading your way.

Tuesday, March 6, 2012

Putting numbers on Provider Price Increases

I thought this story out of Boston was pretty striking:  A state house leader putting a number on what the average provider price increase should be.  It is impossible to imagine an Oregon politician (much less one in a leadership position) making such a statement today.  Heck, I can't even see a mainstream reform advocate saying that out loud.  And yeah, prices matter.
It shows that while Oregon in some ways is ahead of the game in promoting health care reform it still has a long, long way to go.

Sunday, March 4, 2012

Maine vs. Anthem Decision

The Maine Supreme Court released its decision in the Anthem case last week, where the insurer had challenged the adequacy of the Superintendent of Insurance's approved rate.  I'm glad the court found in favor of the Superintendent, states should have flexibility in regulating and a judicially imposed profit load would just be a mess.  But I'm a little amused at the court's dismissal of the subsidization argument, where Anthem argued that the low profitability of the individual and small group lines would drive up large group pricing.

Here is the key section addressing this on page 18, emphasis mine.
There is no evidence in the record to suggest that the approved rate increases will inexorably result in higher rates being charged to Anthem’s unregulated group insurance consumers. To say that Anthem might occasionally need to use its substantial company-wide surplus, which we agree is funded in large part by the financial success of its unregulated group insurance products, to pay for intermittent losses sustained by the individual lines, is both in form and substance a different statement than saying that its group consumers are in fact being charged higher rates in order to subsidize the regulated lines. Without some discernable proof that cross-subsidization is occurring as a result of the rate approved by the Superintendent that included a 1% risk and profit margin, Anthem’s argument falls short of persuading us that the Superintendent overstepped the bounds of her statutory authority by using her concept of the “inadequate” standard as a vehicle to consider the financial health of the company as a whole.
The judges acknowledge that the surplus is largely derived from the unregulated lines, and that regulated lines will occasionally take money from that surplus.  They don't say it explicitly, but clearly they understand that the lower the margin on the regulated lines the more it will take from surplus and the less it will contribute back to it.  So where is the money supposed to come from?  How is this not requiring subsidization?

 What the judges are really saying is that to make this claim stick you need clear evidence of subsidization, such as attaching a "you are now subsidizing the regulated lines" fee onto all the unregulated business.  That works for utilities, just look at all the line items broken out on your bills.  Utilities can throw whatever they want on there without consequence because customers have no choice, it's a monopoly.  That isn't the case with large group health insurance.  Businesses have plenty of options if they don't want to effectively help out all the employees of companies that don't bother offering health coverage.  I think that kind of subsidization is unsustainable even when it is under the table, eventually people would figure out that insurers that didn't write any regulated business would be cheaper than those who did.  But how much quicker will that happen when you slap businesses in the face with an overt penalty fee?  The judges made a lot out of the lack of evidence submitted by Anthem, but what could Anthem say without sabotaging the lines where they actually make money?

Grist for the mill for those thinking about how to effectively regulate health insurance.

Saturday, March 3, 2012

Judgment and Technology

Via Health Care Renewal, an interesting quote on the interaction between human skill and technology.  The quote comes from a paper on nursing, but I think it applies much more broadly:
Skill is the ability, drawn from education and experience, to do something expertly. It can also be defined as the effective exercise of professional judgment in non-routine situations.

Following prescribed rules, as a machine would, makes an employee competent to perform tasks, but it doesn’t make the employee skilled. They can do their job as long as there are no surprises. But when something unexpected happens, the rules break down, and caring for patients means facing the unexpected every day. Only skilled health professionals can cope with the unexpected. To know what to do, they have to rely on their own judgment. The exercise of judgment is the essence of skill.
The realm of the unexpected isn't limited to health care!

Tuesday, February 28, 2012

Horace Mann describes "White Flight"... in 1842

From a text on the social underpinnings of education (picked up on whim), a selection from Horace Mann.
I have met many individuals, who, having failed to obtain any improvement in the means of education in their respective places of residence, have removed to towns whose schools were good, believing the sacrifice of a hundred, or even of several hundred dollars, to be nothing, in comparison with the value of the school privileges secured for their children by such removal.  Still more frequently, when other circumstances have rendered a change of domicile expedient, has this principle of selection governed in choosing a residence.
-  Fifth Annual Report to the Board of Education of Massachusetts, 1842
I don't think I can understand that without understanding more about public education in MA at that time.  How many towns had schools?  What percentage of the child population attended them, and what were their economic characteristics?  Were they a trendy municipal feature like highways in the fifties or streetcars today, or did they have deeper community roots?  It's an interesting quote either way.

Monday, February 27, 2012

Emergency Rooms

Last week Kaiser ran a Phil Galewitz story on for-profit hospitals that were screening emergency room patients.  Patients deemed to have non-emergency conditions were required to make a pre-payment, as much as $150 in HCA's case.

This week Kaiser noted a Wall Street Journal article on a Washington state Medicaid plan to stop reimbursing emergency rooms for providing non-emergency treatment.

Is there a meaningful difference between these policies?  For-profit corporation and state program alike, they both utilize financial incentives to prevent emergency rooms from being used for non-emergency care.  They demonstrate the point that rationing care isn't really optional, it is already happening.

What is optional is how much discretion and transparency we allow in the process of rationing.  The for-profits and Washington are opting for rote standards where care givers have no flexibility in distinguishing what care is necessary (and reimbursable) from what is not.  Contrast that with Oregon's CCO plan, which goes the opposite way in trying to find savings by empowering providers.  I don't know which approach will prove the better, but I know which one I'm rooting for.

Sunday, February 26, 2012

A question for Representative Conger

The CCO bill was finally passed, but the Exchange bill is still in a holding pattern.  The Lund Report caught a powerful statement by Representative Jason Conger (R-Bend), talking about the CCO bill (emphasis mine):
After listing many of those complaints about the legislation, Rep. Jason Conger (R-Bend) said “to do nothing is simply unacceptable,” adding that “it required leadership” to get the bill to the House floor for a vote.
“I don’t mean the twisted, pathetic concept of leadership that values political positioning and partisan gain over good policy,” he said. “I mean real leadership, to do the hard work that is required to address big issues that matter to Oregonians who are not in this building, to the rest of the state besides us. There is risk involved in passing this bill. But I believe that I know I was sent here to address those kinds of problems—like jobs, and yes, healthcare…despite the risk in the bill, I will be voting yes.”
 I'm impressed to see someone buck party for conscience in the way Conger did, especially because passage of the CCO bill was a near certainty once it came to a vote.  He could have just voted for it and held his peace, as 22 (of 30) other Republicans did.  Saying what he did took guts...  So why tolerate the stonewalling on the Exchange bill?  If Conger thinks people sent him to the legislature to work on the problem of health care, how is spiking the Exchange bill part of the solution?

Wednesday, February 22, 2012

Gender and Transit continued

I've been searching for any materials discussing gender issues and transit.  I haven't found anything Portland specific yet, but this post from a Seattle blogger pointed me to this study, part of a project called "Gendered Innvoations".

The GI study was mostly about how traditional metrics don't capture the full usage of transit by women because they are more likely than men to "chain" their trips, making multiple stops on the same excursion.  Because of the mismeasurement, transit agencies risked over emphasizing commuter service in ways harmful to women.  That's interesting, but not what I'm after.

The GI study also Included a chart showing women consistently utilizing public transit at higher rates than men, across ethnicity, I wonder how it looks when you break it down by income or age.  People who have no choice will use public transit, that isn't saying anything interesting.  What I'd like to know is, are there gender differences in how people who have a choice decide between driving and alternate transportation?

The most helpful part of the paper was a footnote describing safety improvements at stops and stations, referencing Schulz et al., 1996.  That reference is to this paper, Women and Transit Security: A New Look at an Old Issue.  It includes a history of efforts to safeguard women on public transit, beginning with attempts (that failed) to reserve the last car on New York Subway trains for women only, and other more successful ventures:
Those familiar with Progressive Era concerns about white slavery know that creation of such groups as the Traveller’s Aid Society were directly related to demands that women be present in train stations to protect young women, often runaways or working-class immigrants, from the clutches of those perceived as ready to lure them into lives of prostitution. Early policewomen, too, spent much of their time patrolling train stations, with the expressed aim of saving women from the perils believed awaiting them there. Thus concern about women and their safety in and around transit systems has a long history and plays an important role in women’s demands for public positions in both the social service and criminal justice fields.
The description of the Traveller's Aid Society strikes me as very relevant to Portland today, and the concept that women's entry into law enforcement and public transit are connected is interesting in a different way, but neither is what I'm after right now.  What I'm after is this reference included in the Schulz paper,
S. Rosenbloom and E. Burns, Do Environmental Measures and Travel Reduction Programs Hurt Working Women? (Tucson, AZ: Roy P. Drachman Institute for Land and Regional Development Studies, 1993)
 Sadly, that paper appears to be really, really hard to get.  But I found a review of it, which helps (emphasis mine):
Rosenbloom and Burns looked at surveys of workers conducted as part of employers' efforts to reduce solo driving by their employees in Phoenix and Tucson, Arizona in 1990 and 1991. They discovered that women, especially women with children, are more or as likely as men to be solo drivers and that women take longer to get to work despite their shorter commute distances.
The authors hypothesize that women with children and domestic duties use cars more because they find alternatives such as buses unsafe and impractical. The surveys did not ask respondents about "linked trips" (stopping at daycare on the way home from work), but the authors suggest that linked trips explain women's more time-consuming travel and their preference for solo driving. They offer the anecdote of the woman who worked across the street from her home but reported that it took her 15 minutes to get to work, because she had to first drive her children to daycare.
Rosenbloom and Bums assert that working mothers (about one third of women surveyed) will be hard hit by trip reduction programs aimed at reducing solo driving. "Many women will continue to drive," the authors suggest "accepting new expenses [financial penalties for solo driving], because driving still costs less than the additional child or eldercare needs created by longer commutes, or because they cannot obtain the needed care, or because they must use the time to conduct their domestic responsibilities, or because they cannot find or do not feel safe taking public transit Other women will change modes, but at some cost to the well-being of their families."
So they observe the same phenom noted in the GI paper about chaining trips, but connect it to what I think is a very logical preference for auto transport even without the safety issues.  The review concludes with this summation, again with my own emphasis:
While this report suffers from its authors' biases--they believe that the car is the best all around transport mode, that transit is unlikely to conquer the suburbs, and that "bicycling is largely a male mode," apparently not for women--their basic point needs to taken seriously by the environmental community. If working mothers' concerns are ignored, the road/auto lobby can claim that environmentalists care more about the earth than about women and children. Let's prove them wrong.
 Are we proving them wrong, Portland? 

Also, are there any more recent studies that follow up on this issue?

Tuesday, February 21, 2012

Gender and the City

Two recent posts in the O highlight the absence of gender in the Portland urbanization discourse.  A story on the increase in biking revealed the fact that men outnumbered women 2 to 1 among bicyclists.  And a letter to the op-ed page lamenting the absence of free parking included this passage:
By removing four blocks of free, albeit unsafe, parking, the number of available spaces within walking distance of my apartment has been cut in half. Think about the implications for safety and work schedule: For a woman who returns from work after dark, it does not appeal to abandon a car under the I-405 bridge.
That the cost of parking should be increased is an axiom among urbanists, but how often do you see an acknowledgement that walking, biking, or taking public transit as opposed to driving poses different trade-offs for different genders?  Do urbanists have anything more to say to women concerned with the safety implications of abandoning the car beyond, "Grin and bear it"?

OSPIRG and ineffective medicine

I was struck by an op-ed relating OSPIRG's efforts to open up the rate review process in Oregon.  OSPIRG working in concert with DCBS brought rate review before the public in a big way.  That is certainly a good thing.  But how good?  The trouble is, the individual and small group markets were already pretty well regulated:
Notice the horizontal axis crosses the vertical at 80%.  To be clear, the medical loss ratio is the portion of premium going to medical bills.  The portion above the medical loss ratio is production expense, admin and profit.  That insurance portion of premium is what OSPRIG is gunning for, they've said nary a word about the money on the medical side, where the vast bulk of the dollars go.

OSPIRG's efforts are further limited in that the review process they're promoting is limited to individual and small group markets.  In the latest Health Insurance in Oregon report those two groups total 36% of the private market.  Which is to say, among Oregonians who have private insurance for every one who might be helped by these efforts there are almost two who will not.

Combining the market distribution with a lowball MLR pick of 80% and you get this:
Not as ineffective as Republicans when it comes to health care reform, but it sure does leave room for improvement.

Saturday, February 18, 2012

Real Tort Reform

I don't have time now to do a full write-up of what I think tort reform should look like and why, and to my surprise I discovered I don't need to.  I guess I'm not the first person to think that a workers comp style process is applicable to Medical Malpractice.  Closer to home, I found that Jack Roberts had written about this very concept back in 2009 in the O (emphasis mine):
Other proposals are more specific to medical malpractice, such as specialized health care courts and safe-harbor practices to protect doctors from liability even if something goes wrong. But maybe it's time to consider a more radical reform, such as a system of no-fault insurance for medical malpractice similar to the workers' compensation system.

Since the adoption of workers' comp laws early in the last century, workers injured on the job are covered without regard to whether the injury was caused by the negligence of the employer, a co-worker, the worker himself or simply bad luck. Injured workers have their medical bills and other out-of-pocket costs covered as well as receiving compensation for loss of income and certain general damages in accordance with an established schedule. In return, they give up the right to bring an individual lawsuit against their employer and with it the hope of winning a lottery-size award or settlement.

Applied to medical malpractice, such a system would compensate any patient whose surgery or other treatment (or lack of treatment) resulted in an adverse result, whether or not the doctor, hospital or nurse was at fault. It could redirect resources currently spent finding fault to compensating patients who have been harmed. And it would recognize that even where medical providers have performed their jobs badly, large jury verdicts are not paid by the wrongdoers but shared by everyone through the insurance system.
 To get a sense of how much more efficient workers comp is at delivering benefits than med mal, let's look at Oregon state wide experience:
ALAE are expenses that can be directly attributed to a specific claim.  So the cost of a court filing for instance is particular to a claim while the cost of a claims department generally is not.  In practice, for these lines ALAE is mainly defense counsel.

What these figures show is that from 2003 to 2010 only half of the med mal premium dollars went to indemnity payments to claimants.  The rest was chewed up by defense costs, overhead and profit.  In contrast only 13% of the Workers Comp premiums were diverted in this way.  The difference is even more striking when you realize med mal claims are much more likely to have a plaintiff's attorney involved than workers comp, and they are paid from indemnity proceeds.  So not even half of the med mal premium money actually reaches patients suffering harm.

A lot of ink has been spilled on the extension of a tort cap, but I think all of the above shows that we need to ask a deeper question.  Does the way we've structured Medical Malpractice liability make sense?  As our experience with Workers Compensation shows, alternate structures exist that have far less costly processes for adjudication.

Thursday, February 16, 2012

What Opt-In Does

Nick Christensen does a write-up on how Metro councilors view Opt-In, a registration-required online survey tool.  I think this gets at what this service really does, and what it replaces:
Metro spent $76,000 on Opt In in 2011, generating  more than 20,000 responses – about $4.50 per completed survey.
By comparison, said a staff report for Tuesday's work session, Metro spent about $400 per open house attendee during the 2010 roll-out of then-Metro chief operating officer Michael Jordan's growth and policy recommendations; those numbers soar to $2,800 per completed survey at each of those open houses. The agency also spent $35 per attendee at the dozens of stakeholder meetings Jordan attended.
Opt-in is a new way of connecting with citizens, in a way that allows two way communication- both Metro and citizens learn from the interaction.  And look at the number of people reached, a recent survey had 4,000 respondents.  How many public meetings or open houses have you seen that attracted 4,000 people?  How about a meeting where 4,000 people got to get up individually and express their view?

Some councilors expressed concern that their hands would be tied by the surveys.  How could they justify a vote that went against "majority opinion?"   Even aside from concerns about the opt-in demographics, councilors have a pretty solid excuse:  Voters elected them, not a survey.

The people who should be nervous are the interest groups who make up most of the participants at conventional public meetings.  They are the people most motivated to attend, and most likely through pooling and coordination to have a representative available to attend a meeting at 9am on a weekday.  Most individuals don't have the time or interest for that.  That dynamic gives interest groups a dominant role in reflecting "the public", quite independent of how much popular support their positions actually have.  As Metro President Tom Hughes said,
"Public hearings are an avenue for getting public input, but they're imperfect at best," Hughes said. "They're usually repetitive, not very helpful and usually the people who show up are the people who are absolutely directly involved – you don't get a sense of what the public wants."
Opt-in offers a potential check on interest groups, it creates an opportunity for a truer test of the popular will.  Whether it fulfills that potential depends on participation.  If the only people who sign up are the same people who would otherwise be represented by interest groups, nothing changes.  So if you're a Metro resident not already signed up, please consider it.  Especially if you disagree with me.

Monday, February 13, 2012

Oregon Republicans disappoint

Right after I write about why Democrats should compromise on the CCO bill, Republicans prove me wrong.
A coalition of 30 Republicans and 1 Democrat in the state House of Representatives blocked approval of Oregon's health insurance exchange this morning, prompting concern that bills are being taken hostage to leverage other votes in the month-long 2012 Legislature...

[A Republican house leader] said questions had arisen in a recent caucus meeting of House Republicans over what commitments existed over federal funding of the program, as well as the potential for a change to the legal status of federal health care reforms, currently under consideration by the U.S Supreme Court.
In contrast to tort reform and the CCO bill, this looks like a straight forward attempt to spike the Health Insurance Exchange.  That would put Oregon in league with the other red states that are standing around waiting for a federal exchange to be dropped on them.  Thing is, only in the most sheltered, isolated, reality deprived imagination could today's Oregon be conceived of as a red state.  Efforts like this ensure it never will be.

Sunday, February 12, 2012

CCO Bill and Tort Cap

The Oregon Legislature is trying to figure out whether or not to include a tort cap in the CCO bill.  The stakes are high, as legislators are expecting up to $2.5 billion in federal aid if the CCO bill passes.  I don't know the politics well enough to guess what would happen if a CCO bill doesn't pass in this session.  Maybe the federal money will still be there next year, maybe not.  But since the state already banked savings resulting from CCO's in the current biennium budget, it doesn't really matter.  The bill needs to pass.

For that reason I think Democrats need to hold their noses and pass the bill with the tort cap included.  While it is true that Republicans are engaging in hostage taking and you risk encouraging such behavior by giving in, there are some mitigating factors.
  • One of the central purposes of CCO's is to save money by reducing unnecessary or ineffective care.  The tort cap may be politically undesirable and only marginally effective, but however slightly it still promotes the goals of the CCO.  Tacking this on isn't as irresponsible as would be say, a demand for PERS reform or tax cuts.
  • Passing the CCO bill with a tort cap does not forestall pursuing more effective tort reform in the next session.  Passage of a more comprehensive reform which affected all providers state wide would render the CCO compromise moot.  And make no mistake, there is ample reason to pursue tort reform quite apart from CCO's.
 Given the money at stake and the relatively small compromise needed, legislators would be grossly negligent if they fail to pass this bill.  Jawbone and posture all you want.  Call out the fine 15 for committing to the proposition that $20M in annual savings is worth more than $2.5B, a trade that takes 125 years to pay off.  But at the end of the day, we need this bill.  Get it done.

Wednesday, February 8, 2012

Honesty in Medicine

Incidental Economist is another great blog I wholeheartedly recommend.  Aaron Carroll calls attention to a study of physician attitudes towards honesty.  The punchline, emphasis mine:
They[sic] survey also asked specifically about things subjects had actually done in the last year. That’s where it gets even more depressing. More than 10% of docs had told an adult patient or guardian something that wasn’t true. Almost 20% had – in the last year – not fully disclosed a mistake because they were afraid of being sued. And more than a quarter of physicians had revealed, either intentionally or unintentionally, personal health information of one of their patients to an unauthorized person.
Bear in mind those are physicians voluntarily self-identifying their behavior, in the wild it's probably even more common.  I've said it before, but doctors really are not angels.

Monday, February 6, 2012

Hospitals and Data mining

More reporting from Phil Galewitz.  Back in December he described how hospitals were using former drug reps to target physicians to get referrals for "profitable, well-insured patients".  The suggestion that doctors could and would prompt patients to get particular procedures at a particular facility at the whim of a sales rep is pretty grotesque, even to someone who has read a lot about health care finance.  But at least there is a possibility of responsibility, doctors after all do take an oath to do no harm.  What happens when hospitals cut them out and go straight to the patients?  And not just ad buys on TV, but specific procedures marketed directly to individuals:
[Provena St. Joseph Medical Center] is one of a growing number of hospitals using their patients' health and financial records to help pitch their most lucrative services, such as cancer, heart and orthopedic care. As part of these direct mail campaigns, they are also buying detailed information about local residents compiled by consumer marketing firms — everything from age, income and marital status to shopping habits and whether they have children or pets at home.
While hospitals may profit from offering cholesterol tests and mammograms, the big payoff is in what those screenings may lead to – additional tests and procedures, including surgery.
"It's all about downstream revenue," says Patrick Kane, senior vice president of marketing at Cape Cod Healthcare in Massachusetts who used such approaches at Wellmont Health System in Kingsport, Tenn. "The old adage in business is that it’s easier to sell an existing customer new services, rather than find a new customer."
One of the biggest pluses for hospital executives is that they can track a campaign's financial success by comparing the amount of services used by targeted consumers against those in a control group with the same demographic and economic characteristics, but who are not sent mailings.
When the Henry Ford Health System promoted mammograms last year in mailings to 30,000 women aged 40 or older, more than 5,700 responded -- 304 more than in the control group. The mailings generated $268,000 more in profit than the control group -- a return of more than four to one on the cost of the campaign, says Denise Beaudoin, vice president of customer engagement.
"Some doctors used to be leery about the effectiveness of these marketing campaigns, but not when we can show them data like this," she says.
It's nice to know that while we don't know much about whether one treatment works better than another, we have randomized controlled trials on the effectiveness of their marketing.  Great job folks!

Saturday, February 4, 2012

Passages I like

From Cringely:
My kids go to the best public school in Sonoma County. I know that because I chose my house based on that research. But when Cole finishes his math problems in a quarter the time it takes anyone else in the class, his teacher has him insert a wait state by putting his head down on his desk.  Conversely, when some other kid never quite gets the problem set finished, ever, well he/she never gets a rest and never masters the material, either.

The current system is unfair to both kids.

The only solution I can see is one teacher per student. And the only way something close to that is going to happen is through technology.  And it’s coming.
 A followup passage that I don't like but agree with:
My conclusion, then, is that schools serve a limited social and cultural function but our kids mainly learn despite them. My own experience is that I learned a lot about learning from half a dozen teachers in my life, so those relationships are both rare and essential. But are they reliable enough to even justify modern schools?  I don’t know. What I do know is that if I want to improve the educational environment for my children in the next year or two, I’ll probably have to come up with my own solutions.

Republicans and Medicare Cuts

I don't mind saying, John McDonough's blog is worth following.

The claim that Democrats voted to cut Medicare through the ACA has gotten a lot of play.  Here in Oregon it came up a lot in the Bonamici-Cornilles race, with Cornilles claiming Bonamici wanted to restrict choices for seniors.  Via McDonough, here is an aspect that didn't get a lot of press (emphasis mine):
In the new Republican-controlled House of Representative in 2011, House Budget Chair Paul Ryan (R-WI) advanced a controversial federal budget plan which included a major restructuring of the Medicare program to change the program from largely fee-for-service to premium support/vouchers. This proposal drew widespread praise and condemnation, and mountains of attention.
Less noticed was the part of the Ryan budget plan which repealed most of the ACA, with one huge and unnoticed exception -- the $449 billion in Medicare reductions, documented in the CBO report on the Ryan plan. The Ryan plan was put before the entire House, and nearly every Republican member voted for it; the plan was also put before the Senate and endorsed by all Republican members minus four (one of those four was MA Senator Scott Brown).
So the one part of the ACA that congressional Republicans are on record as supporting are those same Medicare cuts that Republican candidates use to bash Democrats.  And Rob Cornilles was as culpable as Bonamici (neither served in Congress for the ACA or its repeal vote) of everything he accused her of.  Gee, I wonder how Politifact missed that.

Thursday, February 2, 2012

Health Insurance is not Auto Insurance

John McDonough reviews Mitt Romney's concept of cost control: co-insurance and high deductibles (emphasis mine)
...Mitt Romney's approach to controlling private sector health spending growth is to continue and to accelerate the shift to insurance policies that expose patients to higher and higher levels of cost sharing. This reflects a view, popular among conservative health economists, that health insurance should, as much as possible, resemble auto insurance, where you only get help for catastrophic events.
 There is a big problem with equating health insurance and auto insurance.  With auto insurance underlying costs tend to correlate with income.  Someone working minimum wage probably drives a beater with no collision and minimal liability limits.  That policy costs much less than the one for a one-percenter driving a porsche with $1M limits.  Cost, and thus premiums correlate with income.

In contrast with health insurance there is no correlation, poorer people do not need less expensive care than richer people.  There is no equivalent to a "beater" surgeon, cutting people open in a dirty basement.  At least not today...

Monday, January 30, 2012

Senior Tax Deferrals

There is an op-ed in today's O that demonstrates the difference between a government program and private insurance.  The state of Oregon has long had a property tax deferral program to help seniors stay in their homes.  Taxes are deferred until a home is sold, with annual interest charges accruing.  The program is equivalent to a reverse mortgage with the annual payment fixed at the property tax level.  The state acts as the insurer, fronting the deferred taxes to counties and taking risk on the level of repayments.

Unsurprisingly, the program has gotten screwed up because of the recession.  Tax repayments are no longer adequate to front the money to counties, and the state has to either find a way to reduce fronted expenses or get into the business of subsidizing senior property taxes.

The legislature opted for the former (emphasis mine),
The Revenue Committee's response to this temporary downturn was to eliminate 5,000 people from program rolls -- by capping enrollment, raising interest rates, changing eligibility rules and excluding anyone with a reverse mortgage. The cruelest response was to apply these changes retroactively to existing program participants.

The result was to disqualify nearly half of the 10,500 families in the program, including many lower-income homeowners -- the very people it was designed to help. Most participants had assumed that once certified for assistance, they could be reasonably secure in their retirement years and safe from the threat of tax defaults.
 I don't fault the legislature for refusing to create a subsidy, that money doesn't come out of the air.  It comes out of budgets for other priorities like education, healthcare, and social services which have already been slashed.  Prioritizing public spending, deciding what should be paid for and what should not is pretty much the legislature's job.

And that shows the difference between public and private insurance:  A public insurance program has no guaranty, it exists at the whim of lawmakers.  As a program it necessarily competes with other public spending for priority and its benefits and costs can be changed unilaterally with the stroke of a pen.  In contrast, private insurance is spelled out by contract and can be changed only with mutual consent.  People who buy private insurance don't have to justify its benefit against money for schools or Medicaid or whatever the public thinks is more important.

As participants in the tax deferral program are discovering, that is no small thing.

Thursday, January 26, 2012

Reading Now: Since Yesterday

An op-ed from a few months ago was interesting enough to land Since Yesterday on my reading list.  To my surprise the local library branch had a copy, which is now in my hands.

I'm reading it to get a sense of how we've changed since then, and how we have not.

I liked this passage, on FDR's inauguration speech:
You can turn off the radio now.  You have heard what you wanted to hear.  This man sounds no longer cautious, evasive.  For he has seen that a tortured and bewildered people want to throw overboard the old and welcome something new; that they are sick of waiting, they want somebody who will fight this Depression for them and with them;  they want leadership, the thrill of bold decisions.  And not only in his words but in the challenge of the very accents of his voice he has promised them what they want.
I feel the appeal of these sentiments, but I could also see them leading a nation to a really bad place.  Magnificent and terrifying...

Wednesday, January 18, 2012

Dancing around a problem

WonkBlog notes a CBO writeup on the failure of some Medicare demonstration projects to reduce spending.  The summation (emphasis mine):
Why didn’t the demonstrations reduce costs? Largely because they didn’t reduce the quantity of care delivered. Some programs actually correlated with increased hospital admissions. A few saw reductions. On balance, it was pretty much a wash — and a troublesome sign for the health reform law’s soon-to-launch attempts to curb Medicare spending.
That rang a bell, which led me to dig up this passage from Money-Driven Medicine (emphasis mine):
Critics [of pay for performance] point out that very few of the performance targets address the problems of overtreatment.  While CMS is rewarding health care providers to do "more" in the form of tests and procedures that they might overlook, there are few obvious incentives to do less.  "Counting how many patients survived bypass surgery is one thing," says one New York City hospital executive.  "But how many survived a surgery that they didn't need?  That's the important number that you'll never see."

Dr. Stephen Jencks, Medicare's director of quality coordination, concedes that the critics have a point:  "I would say we are moving much more slowly on trying to prevent overuse than in trying to fix underuse," he acknowledged at the end of 2004.  "If I tell a physician he shouldn't do a surgery he wants to do, I personally would anticipate a lot more resistance than if I told him he should give a medicine he wasn't thinking of giving."  Yet if Medicare and other payers don't find ways to locate and discourage unnecessary treatment, pay for performance will only add another layer to health care inflation.
Telling doctors what to do is hard, but it's even harder telling them what not to do.  We're going to have to grapple with that in a serious way if we want affordable health care.

Tuesday, January 17, 2012

Finished Money-Driven Medicine

Wow, this was good. 
Incorporating journal research, literature and original interviews, Mahar describes the myriad conflicts within the health care industry that drive up spending, and why that spending buys so little.  The chapters on for-profit hospitals and ineffective treatment are particularly good, the latter should be required reading for anyone who utters the phrase "death panel".  I like that the book is rich in sources, most of the articles are as relevant today as they were in 2006.  Here is one favorite:
There is no formal rationing system in the U.S., with its complex mix of private insurance and Medicare and Medicaid coverage, plus 41 million uninsured people who pay for their own care or get treated as charity cases. But in fact, health-care rationing occurs every day in the U.S., in thousands of big and small decisions, made mostly out of sight of patients, according to rules that often aren't consistently applied.

The people who make these decisions are harried doctors, Medicaid functionaries, hospital administrators, insurance workers and nurses. These are the gatekeepers of the American health-care system, the ones forced to say "no" to certain demands for treatment.
"The Big Secret in Health Care: Rationing is Here"  Wall Street Journal, 9/12/2003
This book is an excellent place to start for those interested in understanding health care costs, I strongly recommend.

Disclosing Drug Payments

The ACA was derided in part because of its length and complexity.  Funny thing is, the more we see of the health care reform the better it looks.  Here is one small measure packed into it that means a lot:  mandatory disclosure of payments to doctors from drug companies regardless of how it is accounted for.  Sales, research, kickbacks, whatever.  All of it will be subject to public review, so you can judge for yourself how closely your doctor's interests coincide with your own (at least when it comes to prescription drugs).  That might not seem like a lot until you realize you can't do that now, efforts of ProPublica not withstanding.

One of many ways the ACA reforms healthcare in America.

Monday, January 16, 2012

Great Quote on leadership

A great quote from Don Berwick, cited in Money-Driven Medicine (it can also be found here):
"The leader who thinks it is enough to create report cards and contingent rewards misses the biggest and hardest opportunity of leadership itself- to help people discover and celebrate the meaning in their work."

That rings true on so many levels it makes my head dizzy.

Friday, January 13, 2012

More on property tax dilemma

Portland Tribune has a story covering the mayor of Tigard's annual address.  He lays out the situation plainly (emphasis mine),

Many cities and counties across the state are in financial trouble, Dirksen said, and the problem isn’t because of the still struggling economy.
“The problem is caused by a fundamental problem with the way tax revenue is collected in Oregon,” Dirksen said. “Not the overall tax rate, but the process.”
Part of the problem, Dirksen said, is Measure 50, the Oregon law passed in 1997 that limits the rise of a property’s maximum assessed value to no more than 3 percent per year.
But while the state is taxing homes at the same rate each year, the cost of doing business continues to rise.
Though the assessed value only rises by 3 percent, the municipal costs increase in Tigard by about 4 to 5 percent in order to provide the same level of service as we did the year before,” Dirksen said.
This is the same problem ECONorthwest wrote about, it is why every municipal budget discussion in Oregon amounts to a question of "what will we cut this year".  The only way to grow revenue faster then 3% is to either impose new use-based fees or allow development to reset property values to a higher (much higher) value.  Remember this when someone tosses around the idea of another historic preservation district.

Retainer Medicine

I was surprised to see this press release from DCBS, I don't recall any public discussion of how retainer services would be regulated during the last legislative session.  The registration asks for a business plan with specifics on how and when prepaid fees would be subject to refund, and a filter-type question on bankruptcy.  Some thoughts:
  • What is to stop doctors from offering contracts that bar refunds under any condition?  Conceivably people could be paying up to a year's worth of fees up front.
  • Who is buying these contracts?  Are they well-to-do people who are buying luxury, or is it low income people with cat coverage?  The lack of regulatory specifics suggest this is aimed at the former group, but some material suggests the latter.  If so the regulations are way too weak, see "predatory lending" for how that story ends.
  • What protection is there against a doctor blowing all the money up front, or conversely taking on an arbitrarily large number of patients and never being available for appointments?
One could argue that consumers need no more protection from retainer medicine then they do from plumbers or electricians, but there is a big difference.  Society teaches us to be skeptical of contractors, from the adage about getting multiple quotes to fear stories about scams and rip-offs.  We don't have the same skepticism of doctors, quite the opposite.  People are taught they should listen to their doctors and do what they say.  That can lead to all kinds of conflict of interest situations even when the financing is at arms length via insurance, how does this work when the money is front and center?

Thursday, January 12, 2012

What life looks like without effectiveness research

Via healthcare economist, a gooznews post on why patient advocacy groups are unlikely to promote comparative effectiveness research even though such concerns are of central interest to patients.

Compare the crying need that gooz describes with the mission of PCORI as described by its Chief Operating Officer:
Q: Can you give an example of how you envision people using the kind of research that PCORI will fund?
A: Let’s say someone is trying to decide if they should have Procedure A versus Procedure B. You give them all this information, but what the patient is saying is, "Well, what’s really important for me is that I’m very afraid of pain. What procedure is going to be the lowest pain option that still gives me the benefits that I need?" Somebody else is going to be very interested in what will give them the longest life. Somebody else may say, "Well, what’s really important to me is whatever procedures I have, I am a working parent and I can’t really afford a lot of time off from work, so what procedure is really going to take care of this condition, but get me back to work as quickly as I can?"
So, then we [at PCORI] are trying to think of the different options that are available to us, not only looking at research that says, "If you do this cardiac procedure versus this cardiac procedure, here's what the outcome is." But now: here’s what the outcome is in terms of pain, here’s what the outcome is in terms of days off from work, here’s what the outcome is in terms of longevity. So then you, as the patient, have the information to make that comparison and make really a tailored decision that meets your needs.
There are a lot of problems in health care, but it isn't like we can't solve them.  We just have to learn how to ignore yahoos who get in the way.

Monday, January 9, 2012

Good Quote on legal challenges to Health Care Reform

The Times ran an op-ed refuting some common arguments against the legality of the individual mandate.  I thought this quote was particularly good (emphasis mine).
Opponents of the new mandate complain that if Congress can force us to buy health insurance, it can force us to buy anything. They frequently raise the specter that Congress might require us to buy broccoli in order to make us healthier [...]
That certainly sounds like a stupid law. But our Constitution has no provision banning stupid laws. The protection against stupid laws that our Constitution provides is the political process, which allows us to toss out of office elected officials who enact them. This is better than having unelected judges decide such policy questions, because we cannot toss the judges out if we disagree with them.
Nor are all required purchases stupid. It is not stupid to require us to buy air bags for our cars and pensions for our retirements. Nor would it be stupid to require us to buy life and disability insurance to make sure we have provided for our children. Whether the law should is up to our political process, not judicial second-guessing. 
 This gets at one of the reasons I find the conduct of congressional Republicans so inexcusable.  They claim to be serious about reducing the deficit and managing long term liabilities, but they are utter cowards when it comes to building actual legislation.  Their preferred approach is to find a bomb (payroll tax cut, debt limit, federal budget) and threaten to set it off unless Democrats pass their legislation for them.  Republicans do none of the hard work of gaining support through compromise, they consign that to "not my problem" status.  The thing is, making political choices is exactly their problem, that is what they are supposed to do.  If they want deficit reduction then come up with a deficit reduction package that can get the needed votes and pass it.  It may or may not be popular, but casting such votes and living with the consequences is the core definition of their job.

I've criticized Occupy protesters for not understanding civics, but at least they have the excuse of being joe-schmoe citizens.  What excuse do Republicans in Congress have for not understanding their job description?

H/T White Coat Notes

Thursday, January 5, 2012

Green Castle Wins

Green Castle won their land use appeal against BDS over the zoning decision that shut down the cart pod.  Some notable points:

-  The Hearing Officer rejected the 1987 neighborhood action plan as mostly irrelevant:
[what should be considered is] the character of the neighborhood as it exists today, not how it may be envisioned in the future by an adopted area plan. For this reason, the Hearings Officer disagrees that the Kerns Neighborhood Action Plan can be a criterion for approval in analyzing whether the proposed food court fits into the residential character of the surrounding neighborhood. Such area plans, however, can constitute some evidence of the existing character of the neighborhood and provide an indication of whether an adjacent residential area will remain residentially zoned over time. Here~ the 1987 Kerns Neighborhood Action Plan, which is admittedly outdated, indicates that the residentially zoned lands near the subject property are likely to remain residentially zoned at least into the near future. Other than that, the area plan is not very helpful in this analysis.
Do you know what your neighborhood action plan is?  Do you know who wrote it?  Are you comfortable with someone making any decision of consequence based on it?  Score one for common sense!

-  The officer then goes back to Websters Dictionary(!) to get a working definition of "residential character".  Based on that,
it is reasonable to read the concept of"residential character" as used in 33.25S.0S0.B.2 to mean the distinctive quality of the place where people dwell and live. For this reason, the Hearings Officer concludes that for the purposes of complying with 33.25S.0S0.B.2, the "residential character of the * * * R zoned area" cannot be determined solely by looking to the zoned use of the residentially designated buildings in the vicinity of the nonconforming situation. As described more fully below, it is reasonable to examine the residential area's  proximity to other uses such as existing commercial uses to determine the "character" of the residential area, and to determine whether the appearance of the proposed change in the nonconforming situation conflicts with that character. 
Score TWO for common sense!  You can't understand the character of a neighborhood without actually looking at... the neighborhood.  The whole neighborhood, warts and arterial traffic and other zoning uses and all.

- Finally, the officer acknowledges that neighborhood opinion should matter:
...the analysis is not as dependent on definitional limits as BDS Staff seems to conclude, but is determined primarily by substantial evidence. Here, the preponderance of substantial evidence strongly supports the Appellant. At the hearing, several parties submitted uncontroverted testimony that the "appearance" of the commercial parking lot before the food carts arrived was very undesirable. Those parties stated that illegal camping, litter, and illegal dumping were occurring and that the parking lot had an unkempt look. In contrast, the parties described the food court, while it was in operation, as clean, well kept and well lit. Their testimony indicated that illegal dumping and camping had ceased, and that the food court generally had a pleasant appearance.  The Hearings Officer views this testimony as substantial evidence that the appearance of the food court is considered a benefit or amenity to the surrounding residential area.
And he hits the trifecta!

The appeal finding pretty much refutes everything that made the initial BDS decision so bad.  Voices of today should count while those from 1987 should not.  Boundary lines that exist only on zoning maps shouldn't be taken to arbitrarily limit what constitutes a neighborhood.  Cheers to the Hearings Office and Green Castle!