Legalized Bribery

Ever wonder why health care costs so much in this country, and why we get such poor outcomes in return? Here's a small piece of the puzzle.

The New York Times reports that an obscure paragraph in the recent “fiscal cliff” bill extends a delay in implementation of Medicare price controls on Sensipar, a drug used by kidney dialysis patients, for two years. The drug is manufactured by Amgen. The delay will cost Medicare—and ultimately taxpayers—$500 million. The section of the bill (Section 762) is not tranparent and does not mention Amgen by name. It's one of many examples of pork that are buried in a bill that was supposed to reduce the deficit.

Here are the details. Currently, Medicare pays for dialysis drugs individually. They determined that this created an incentive to overprescribe medication that was useless and possibly harmful. The change, now postponed, was that Medicare would pay a single, bundled rate for dialysis treatment.  That was a threat to Amgen's profits.

According to the Times, this decision was made by Senator Max Baucus (D-MT), chair of the Senate Finance Committee, and Senator Orrin Hatch (R-UT), the ranking Republican on the committee. It was subsequently approved by Senate Minority Leader Mitch McConnell (R-KY) and Vice President Joe Biden, who negotiated the “fiscal cliff” agreement. Amgen has made over $5 million in political contributions since 2007, including $67,750 to Senator Baucus, $59,000 to Senator Hatch, $73,000 to Senator McConnell, and $141,000 to President Obama's two presidential campaigns.

Sen. Mitch McConnell
(or possibly a turtle)

The Times quotes aides to Senators Baucus and Hatch and an Amgen spokesperson as saying that the delay was justified because it would “give Medicare and health care providers the time they need to accommodate complicated changes in federal reimbursement for kidney care.” The price restraints were originally scheduled to begin in 2012. Congress granted Amgen a two year delay until 2014. The “fiscal cliff” bill extends that delay until 2016. How much time do they need?

An aide to Senator Baucus added that, “What is the best policy for Montanans and people across the country is at the heart of every decision Chairman Baucus makes.” But none of the people contacted attempted to justify the decision on medical grounds.

Amgen is the world's largest biotech corporation, with $15.6 billion in revenue in 2011. It has 74 lobbyists in Washington, including former chiefs of staff of both Senators Baucus and McConnell. Senator Hatch's leading staff member on health care policy is a former Amgen employee.

On December 19, Amgen pleaded guilty to illegally marketing Aranesp, an anti-anemia drug, for purposes the FDA had explicitly not approved. The $762 million settlement was a new record for a biotech company.

I think incidents like this pose a serious threat for single-payer advocates. One of the major arguments against single payer, which resonates strongly with the general public, is that the federal government can't be trusted to run a health care system that will provide quality medical care at a reasonable price. We usually try to counter that argument by pointing out that all other countries with single-payer systems achieve better health outcomes than we do at lower cost.

However, the United States is not like other industrialized countries. It's possible that our level of political corruption is so much higher than other countries as to make us not comparable to them. If so, it's impossible to predict how single payer would fare in this country. Of course, despite our corruption, Medicare is still cheaper than private insurance. However, if Congress ever passes a single payer bill, it is important that it contain safeguards that insulate the system from corporate and political interference.

Update (1/31/13)

The liberal organization Progressives United has latched onto this story and is asking people to sign a petition to the CEO of Amgen asking him to give back the $500 million. (Good luck on that!) The petition can be found here.

Coursera

You should be aware of a valuable resource that you can take advantage of free of charge on the internet. Coursera describes itself as a “social entrepreneurship company,” which makes college courses available online. They are offering 214 courses (so far) in virtually all academic fields, taught by professors at 33 universities.

Right now, I'm in my ninth week of a 12-week course, “Think Again: How to Reason and Argue,” taught by two philosophy professors, Walter Sinott-Armstrong of Duke University and Ram Neta of the University of North Carolina. There are three to nine video lectures each week. Each lecture is followed by an ungraded quiz. There are four graded tests, which determine whether you pass the course and get a certificate. If you flunk a test, you can retake an alternate version. There are discussion forums with other students. The textbook is optional, and I seem to be doing fine without it. Other courses are structured differently. Some require papers. The difficulty level seems to be comparable to a typical undergraduate course. I'm spending about an hour a day on average in this course.

There are several courses about health care policy. I'm planning to take “Health Policy and the Affordable Care Act,” taught by Ezekial Emanuel of the University of Pennsylvania. I'm also looking forward to “Introduction to Sustainability,” with Jonathan Tomkin of the University of Illinois.

Is anyone interested in social psychology? You could take “Social Psychology” with Scott Plous of Wesleyan University, or you could take “A Beginner's Guide to Irrational Behavior,” taught by social psychologist Dan Ariely of Duke. I recommend both instructors. As a jazz fan, I'm intrigued by “Introduction to Improvisation,” by vibraphonist Gary Burton. Unfortunately, I don't play an instrument.

Lurking in the background is the question of how these “entrepreneurs” plan to make money out of this website. According to the New York Times, two possibilities are to charge colleges and universities for allowing their students to take these courses for credit, or to charge students whose universities will accept these courses as transfer credits. Of course, its also possible that they will start to charge their internet consumers directly. In the meantime, this is one of the greatest bargains on the web.

Once Upon a Time in the South

Quentin Tarantino's films are not just about characters and events. They are movies about other movies, drawing on Tarantino's broad familiarity with films of various genres, countries and time periods. Django Unchained is, among other things, a tribute to “spaghetti westerns,” and I love it in part because I'm a fan of that genre. (The Django Unchained entry on the Internet Movie Data Base contains a list of “connections” between it and previous films. It is incomplete.)

There were over 600 westerns made in Europe in the '60s and '70s, with mostly Italian casts and crews and Spanish locations. They differ fundamentally from American westerns in style and ideology. Stylistic differences include self-consciously artistic photography, crisp editing used to expand or compress time, and the stirring musical scores of Ennio Morricone and his imitators. Ideological differences include a greater willingness to address political themes, usually from a socialist perspective. (Some critics mistakenly claim that European westerns are more violent than the American variety. It's true that they usually have a higher body count, but the geysers of blood in Django Unchained are actually copied from American films such as Sam Peckinpah's The Wild Bunch (1969).)

One of the most internationally successful Italian westerns was Sergio Corbucci's Django (1966). Because the name was not copyrighted, it spawned over 30 “sequels,” the best being Django, Kill! and Django the Bastard, which was remade (without attribution) by Clint Eastwood as High Plains Drifter. Here's the Django Unchained trailer. The man who asks Django (Jamie Foxx) his name is the Italian actor Franco Nero, star of the original Django.

The opening title of Django Unchained says “1858—Two years before the Civil War.” Some people have assumed this was a blooper, but my interpretation is that Tarantino was warning us not to expect what follows to be literally true. But fiction can sometimes come closer to the abstract truth than an accurate presentation of historical events. I believe Django Unchained is a more accurate retelling of the end of slavery than Lincoln. Lincoln portrays African-Americans as passive beneficiaries of the actions of a white saviors. While Django clearly benefits from the help of “Dr. King” Schultz (Christoph Waltz), Tarantino's hero is a black gunslinger whose goal is to free his wife, and who frees other slaves along the way.

A major part of the appeal of Django Unchained is that Django takes violent revenge on his oppressors, which is why it is claimed that only a white director could have made this film. (Black director Spike Lee's most radical film was Bamboozled, which is about media portrayal of blacks. You haven't seen it? Surprise! It was buried by the studio that produced it.) We could argue about whether Tarantino was able to make this film because he is white or because he has a proven track record of success. It is clear that the Weinstein Company thought they could raise their middle finger to the South and still make money on this film. They were right.

There is one thing that makes me uncomfortable about Django Unchained—its relentlessly negative depiction of white Southerners of all social classes as outrageously prejudiced scumbags who treat black people with sadistic cruelty. Don't get me wrong. I believe this portrayal is basically true. I don't question Tarantino's claim that he could have filmed even more graphic real incidents of torture. It's also true that regional differences in racial attitudes still exist, and that they are the basis of the Republicans' Southern strategy that has poisoned our political culture for the last 50 years.

However, this portrayal of Southern whites not-so-subtly suggests that slavery was a result of white people hating black people. This is a compositional fallacy, and is no more true than it would be to claim that the United States invaded Iraq in March 2003 because Americans hated Iraqis. It is misleading in two important ways.

• As implied by the theory of cognitive dissonance, dislike of African-Americans is more likely to be an effect of slavery than its cause. If you are going to treat human beings as property, you have to convince yourself that they deserve to suffer. You have to dehumanize them.

• It obscures the fact that the primary motive for slavery was economic. Slavery was as important part of the U. S. economy. It made the South the richest and most powerful region in the country. The brutality and torture portrayed in Django Unchained were intended primarily to ensure that production was not disrupted, which would have been bad for business.

Can Tarantino be blamed for not delivering an economic history lesson? Probably not. Interpersonal conflict is easier to portray in films than structural inequality, and audiences can be counted on to find it more interesting. In fact, it's hard to think of many films that have convincingly educated us about the deeper social and economic structures that automatically influence our behavior.

Enjoy!

Appendix

Like all film genres, spaghetti westerns include a few great films, many good ones, a majority that are mediocre, and some that are really bad. (Some of them were made so cheaply and quickly that they lack even the most basic continuity.) Most of the 600+ spaghetti westerns are not available on DVD in this country. Here are a dozen of them (actually 14) that you can probably find and should check out if you get a chance.

1. The Big Gundown (1966)--director, Sergio Sollima; actors, Lee Van Cleef, Tomas Milian.
2. A Bullet For the General (1966)--d. Damiano Damiani; Gian Maria Volonte, Lou Castel, Martine Beswick, Klaus Kinski.
3. Companeros (1970)--d. Sergio Corbucci; Franco Nero, Tomas Milian, Jack Palance.
4. Django (1966)--d. Sergio Corbucci; Franco Nero.
5. Django, Kill! (If You Live, Shoot) (1967)--d. Giulio Questi; Tomas Milian.
6. The Dollars Trilogy—d. Sergio Leone [A Fistful of Dollars (1964)--Clint Eastwood, Gian Maria Volonte; For a Few Dollars More (1965)--Clint Eastwood, Lee Van Cleef, Gian Maria Volonte; The Good, the Bad and the Ugly (1966)--Clint Eastwood, Lee Van Cleef, Eli Wallach.]
7. Face to Face (1967)--d. Sergio Sollima—Gian Maria Volonte, Tomas Milian.
8. The Great Silence (1968)--d. Sergio Corbucci; Jean-Louis Trintignant, Klaus Kinski.
9. The Mercenary [aka, A Professsional Gun] (1968)--d. Sergio Corbucci; Franco Nero, Tony Musante, Jack Palance.
10. Once Upon a Time in the West (1968)--d. Sergio Leone; Charles Bronson, Henry Fonda, Claudia Cardinale, Jason Robards.
11. The Price of Power (1969)--d. Tonino Valerii; Giuliano Gemma.
12. Requiescant [aka, Kill and Pray] (1967)--d. Carlo Lizzani; Lou Castel, Mark Damon, Pier Paolo Pasolini.

For what it's worth, probably nothing, Once Upon a Time in the West is my all-time favorite film.

Get the Lead Out, Part 2

Part 1 of this post concerns the relationship between lead in the environment and the rate of violent crime. Please read it before continuing.

The lead hypothesis helps us to understand additional facts about violent crime. For example, the crime rate has been higher in urban areas, probably due to the greater concentration of motor vehicles in large cities. Now that lead has been removed from gasoline, the crime rates in big and small cities have converged. The lead hypothesis also sheds light on black-white differences in crime. Black children have blood lead levels that are on average 50% higher than white children, since African-Americans typically live in inner-city locations where traffic is dense and there is less pressure on slumlords to clean up the lead in their buildings.

Of course, there will be resistance to the lead hypothesis from the criminologists, who think of crime as a sociological rather than an ecological problem. The law enforcement establishment would like to claim that police procedures, such as those that follow from the broken windows hypothesis, or the fact that we are putting more people in jail for longer times are responsible for the change.

Although the amount of lead in the environment has dropped, we are far from rid of this toxic element. Lead paint can still be found around the windows of older homes. Where it is highly concentrated in the soil, it must be removed. Prevention is always superior to remediation, especially when the behavior in question causes significant human suffering. However, lead abatement is worth doing on economic grounds alone. Drum cites estimates that replacing old windows and cleaning up lead saturated soil would cost $20 billion per year for 20 years. He assumes that this would reduce crime an additional 10%, which would save $150 billion per year. He also adds $60 billion per year for the higher income children would have had their intelligence not been reduced by lead. These figures are speculative, but if correct, that's a net savings of almost $200 billion per year. To put that in perspective, President Obama's proposal to increase the Medicare eligibility age from 65 to 67 would save the government $24 billion per year—although it would cost seniors at lot more, since they would have to buy private insurance.

As David Roberts has pointed out, the history of lead abatement is typical of how we deal with many other environmental pollutants. In this country, corporations are permitted to introduce potentially toxic substances into the environment without first proving that they are safe. In other words, we ignore the precautionary principle. Once the substance is in use, it is up to the public to prove that it is harmful in order to have it banned. The university scientists and public interest groups that might do the necessary research are typically underfunded, and the burden of proof that they must meet is extraordinarily high. Corporate polluters generate as much confusion as they can about the scientific evidence in order to forestall regulation, and exaggerate the economic costs of making necessary changes. Meanwhile, people are getting sick and dying. If the corporations are finally forced to remove the pollutant, the costs almost always turn out to be much lower than predicted, and the benefits much greater. As a final step, the corporations responsible for the pollution take out television ads congratulating themselves for making the changes that they so strongly resisted.

Hope and Change

I am in this race to tell the corporate lobbyists that their days of setting the agenda in Washington are over. I have done more than any other candidate in this race to take on the lobbyists—and won. They have not funded my campaign, they will not fund my White House, and they will not drown out the voices of the American people when I am President.

                                                                                       Barack Obama (2007)

Four years ago, President Obama talked about changing business as usual in Washington. Consistent with this pledge, he banned corporate and union contributions to his inauguration. He also published the names of individual donors and the amounts of their contributions. Individual gifts were limited to $50,000.

Change has come to the Obama administration. This year, the fundraising goal was $50 million, and the ban on corporate and union contributions was lifted. The upper limits for "sponsorship" are $250,000 for individuals and $1 million for institutions.  Corporations such as Exxon-Mobil, Microsoft, AT&T, Bank of America, and unions such as the American Federation of Government Employees, are paying to play. Many of them are federal contractors, or have immediate business pending with government agencies, i.e., United Therapeutics, which has a new drug awaiting FDA approval "within the next four years.". How much are they paying?  This year the donors are listed, but not the amounts of their gifts. 

Now there's a change you can believe in!

Get the Lead Out, Part 1

The rate of violent crime in this country has been declining for decades, and although there several plausible hypotheses, no one really knows why. Kevin Drum argues in the January Mother Jones that changes in lead emissions from automobiles have been the primary influence on violent crime in this country. Why didn't I think of that?

Here's the argument, in brief. Violent crime began to increase in the '60s, peaked in the early '90s, and has been declining ever since. Neither demographic changes, i.e., increases and decreases in the number of young men, nor changes in the economy can fully explain this pattern. Lead in the environment comes from two major sources: lead paint, which was gradually phased out during the last century, and gasoline. Following World War II, Americans began driving a lot more, and the oil companies added lead to gasoline, allegedly to improve engine performance. In the mid-'70s, due to evidence that lead exposure reduced I. Q., government forced the oil companies to switch to lead-free gasoline. Lead has its greatest influence on the developing brains of children. The results of lead on violent behavior becomes apparent when people are in their early twenties. Here are the data (originally compiled by by Rick Nevin) showing the relationship between the concentration of lead in the environment and the rate of violent crime 23 years later.

It's obvious that there is a correlation. But like many social scientists, I've spent my career telling students that “correlation does not mean causation.” Whenever a variable, A (lead), is correlated with another variable, B (violent crime), there are three possibilities: A causes B, B causes A, or some third variable, C, is responsible for the apparent relationship between them. Since no one is arguing that violent crime causes lead to be deposited in the environment, the real issue is whether confounding variables (Cs) have been ruled out.

Correlational arguments can be strong or weak. They are relatively strong if they have been replicated using several different data sets and research methods, and if alternative explanations can be ruled out. The two primary methods of determining whether a social policy, such as lead abatement, influences a behavioral variable are time series and comparison group designs. In a time series design, you look at whether a change in the policy is followed, at an appropriate interval, by a change in the behavior. Those are the data in the above graph.

In a comparison group design, you compare different spatial locations that have different levels of the presumed cause to see whether they also have different incidences of the presumed effect. The switch to unleaded gasoline was not uniform among the 50 states. Reyes found that states that switched to unleaded sooner saw their violent crime rate drop sooner. Nevin has examined the relationship between lead and crime in several countries, and has found that lead predicts differences in crime rates both within and between nations. Mielke has compared lead concentrations in various U. S. cities with the same results. Mielke has also measured lead concentration in New Orleans soil samples—which is quite unevenly distributed. He finds that it predicts crime rates at the neighborhood level. There are also data relating the crime rate to the distance one lives from a major highway.

Turning to alternative explanations, all these studies do a reasonable job of statistically controlling for confounding variables such as race, gender, socioeconomic status, family demographics, and unemployment rates. Of course, the number of possible alternative explanations is theoretically infinite, so you can never anticipate all of them. It is important to note that these researchers are not suggesting that lead is the only variable that influences violent crime, only that it is much more important than has been generally realized.

The relationship between lead and violent crime has been confirmed at the individual level in longitudinal studies. Researchers at the University of Cincinnati have followed a cohort of children for 30 years. Those with higher levels of lead in their bloodstreams as children are more likely to be arrested for violent crimes as adults. Lead exposure is also related to lower I. Q., attention deficit disorder, and higher rates of teen pregnancy.

Furthermore, plausible physiological mechanisms to explain the lead hypothesis have been proposed. The Cincinnati group compared the MRI brain scans of adults who had high or low lead exposure as children. Those exposed to more lead had less gray matter in the prefrontal cortex, the area of the brain associated with “executive function”—attention, verbal reasoning and impulse control. They also have a thinner myelin sheath around the synapses which connect adjacent neurons, suggesting that their communication channels within the brain are slower and less reliable.

Tomorrow:  Part 2

I'm Back

In August, I broke my hip—an injury I recommend that you all avoid, if possible. While the forced inactivity of recuperating from a broken hip might seem like an ideal time to blog, the injury had an unfortunate effect on my morale.

The experience hasn't been a total loss. I learned how unpleasant it is to be partially helpless. Being an invalid is at least a part-time job. My physical therapy routine takes a couple of hours each day, and routine tasks like showering and dressing were originally a chore. Most importantly, you need a lot of help and support. Thank you, Tina.

I also learned a few things about our health care system. I'm finding out how much everything costs. (Fortunately, it will almost all be covered.) I received a fair amount of overtreatment. Some of it can be attributed to an excess of caution, i.e., my hip was X-rayed far too many times. Other charges are simply bill-padding, i.e., the general practitioner who sticks his head in your hospital room for 15 seconds each morning to ask how you're feeling. Cost: $115 per day, $68.39 of which was actually paid ($54.71 by Medicare and $13.68 by me).

Finally, this was my first sustained experience with opiates and their side effects. While it's unrealistic to think I could have gotten through this injury without painkillers, at some point you have to stop taking the medication. I finally broke the habit due to a misunderstanding with my doctor. He implied that after I stopped taking the pills, he would allow me to drive. He didn't, but being able to feel my pain—and when it was going away—was a good thing at the time.

I've been driving for quite a while now, and I'm getting around pretty well with the aid of a cane, but when I go without it, I still walk with a limp. Full recovery is supposed to take 6 to 8 months, so I'll be seeing some of you in the Spring.

In addition to resuming Thinking Slowly, I'm also hoping to realize my intention of starting a blog about jazz and blues music. I call it Blues and the Abstract Truth, and  here's where you can find it. My posts may be intermittent for a while, but I hope to eventually get both blogs up to speed. Please bear with me.