kottke.org posts about USA
Can you put a dollar value on a human life? Peter Singer writes that the US needs to do just that if we’re serious about making our healthcare system work.
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man - and everyone else like him - with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.
In an attempt to answer that question, Elizabeth Kolbert reviews a gaggle of books in this week’s New Yorker. (This is only part of the answer.)
According to what’s known as the Expensive Tissue Hypothesis, early humans compensated for the energy used in their heads by cutting back on the energy used in their guts; as man’s cranium grew, his digestive tract shrank. This forced him to obtain more energy-dense foods than his fellow-primates were subsisting on, which put a premium on adding further brain power. The result of this self-reinforcing process was a strong taste for foods that are high in calories and easy to digest; just as it is natural for gorillas to love leaves, it is natural for people to love funnel cakes.
Kolbert’s article is a good overview of the current popular views on obesity. Related: Scientists Discover Gene Responsible For Eating Whole Goddamn Bag Of Chips.
I’ve got two follow-ups to share with you regarding Atul Gawande’s New Yorker piece about healthcare costs in the US (kottke.org post). In the Wall Street Journal, Abraham Verghese argues that in order for a healthcare reform plan to be successful, it has to include cost cutting.
I recently came on a phrase in an article in the journal “Annals of Internal Medicine” about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since. It may be the single most important fact about health care in America that you or I need to know. It means that all of us — doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others — are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? — it’s hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman’s plan and scuttled Hillary Clinton’s proposal.
In Gawande’s example, what Verghese is saying is that you can’t just make McAllen’s healthcare system adopt an El Paso type of system without a whole lot of pain.
Gawande addressed some of the criticisms of his article on the New Yorker site. One of the major criticisms was that McAllen’s higher costs were associated with higher levels of poverty and unhealthiness:
As I noted in the piece, McAllen is indeed in the poorest county in the country, with a relatively unhealthy population and the problems of being a border city. They have a very low physician supply. The struggles the people and medical community face there are huge. But they are just as huge in El Paso — its residents are barely less poor or unhealthy or under-supplied with physicians than McAllen, and certainly not enough so to account for the enormous cost differences. The population in McAllen also has more hospital beds than four out of five American cities.
Atul Gawande discovered that McAllen, Texas spends more per person on healthcare than El Paso (which is demographically similar to McAllen) and set out to find out why. Along the way, he encounters a curious relationship between the amount spent on healthcare and the quality of that care: higher spending does not correlate with better care.
When you look across the spectrum from Grand Junction to McAllen — and the almost threefold difference in the costs of care — you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Obama, you’re reading this guy’s stuff, yes? Get him on the team.
Update: Dr. Peter Orszag is the Director of the Office of Management and Budget for the White House and is working on some of the problems that Gawande talks about in this article. Here’s a 40-minute video of Orszag speaking on “Health Care - Capturing the Opportunity in the Nation’s Core Fiscal Challenge”. (thx, todd)
I changed the bit in the first paragraph about El Paso and McAllen being “nearby”. Funny, I thought 800 miles in Texas *was* nearby. (thx, stephen)
I also changed “lower spending correlates with better care” to “higher spending does not correlate with better care”…those two statements are not the same. I misread the results of one of the studies that Gawande mentions. (thx, patrick)
Richard Smith is hosting the Dollar Redesign Project, which is starting to attract some interesting redesigns of American paper currency.
Ministry of Type has some further analysis, including a comparison to European bills.
Georg Jensen aruges that the USPS has, in effect, turned into a huge mail spamming operation (among other problematic aspects of the organization).
Just as General Motors has in effect subsidized Big Oil by continuing to build gas-guzzlers in recent years, so has the USPS continued to subsidize Big Mail by shaping its operations to encourage what it now calls, revealingly, “standard mail” — that is, advertising junk mail. Most American citizens are blissfully unaware of the degree to which USPS subsidizes U.S. businesses by means of the fees it collects from ordinary postal customers. For example, if you wish to mail someone a large envelope weighing three ounces, you’ll pay $1.17 in postage. A business can bulk-mail a three-ounce catalog of the same size for as little as $0.14.
Atul Gawande branches out from his usual excellent writing on medicine and turns his attention to solitary confinement in America’s prison system. Gawande likens extended solitary time to torture.
This is the dark side of American exceptionalism. With little concern or demurral, we have consigned tens of thousands of our own citizens to conditions that horrified our highest court a century ago. Our willingness to discard these standards for American prisoners made it easy to discard the Geneva Conventions prohibiting similar treatment of foreign prisoners of war, to the detriment of America’s moral stature in the world. In much the same way that a previous generation of Americans countenanced legalized segregation, ours has countenanced legalized torture. And there is no clearer manifestation of this than our routine use of solitary confinement-on our own people, in our own communities, in a supermax prison, for example, that is a thirty-minute drive from my door.
This likely will not change until Americans start to believe that rehabilitation and not punishment is the primary goal of prisons. So, probably never.
The results of a survey commissioned by the California Academy of Sciences reveals that Americans don’t know a whole lot about science.
- Only 53% of adults know how long it takes for the Earth to revolve around the Sun.
- Only 59% of adults know that the earliest humans and dinosaurs did not live at the same time.
- Only 47% of adults can roughly approximate the percent of the Earth’s surface that is covered with water.*
- Only 21% of adults answered all three questions correctly.
I bet this got cumulatively 10 seconds of coverage on the major “news” networks, if that. Compare with the endless airtime given to this AIG business and then pull your hair out until you resemble Bruce Willis. (via clusterflock)
Pew Research Center’s interactive maps of migration flows in the US are pretty interesting. The region map makes it seem as though the Northeast is rapidly losing population to the South but the states map clarifies the picture…the flow looks to be hundreds of thousands of retirees moving to Florida and Georgia.
Some think it’s unfair that the former president of Countrywide Financial, a mortgage company that played a big (and negative) role in the subprime mortgage debacle, is now the head of a company making big money buying troubled mortgages from the US government for cheap and then refinancing with the owner, making big money in the process.
But as a Baltimorean explains to McNutty in the very first scene of the first episode of The Wire, that’s how America works.
McNulty: Let me understand. Every Friday night, you and your boys are shootin’ craps, right? And every Friday night, your pal Snot Boogie… he’d wait til there’s cash on the ground and he’d grab it and run away? You let him do that?
Suspect: We’d catch him and beat his ass but ain’t nobody ever go past that.
McNulty: I’ve gotta ask you: if every time Snot Boogie would grab the money and run away… why’d you even let him in the game?
(thx, aaron)
Right or wrong, How the Crash Will Reshape America, Richard Florida’s analysis of how different areas of the United States are going to be affected by the current financial crisis, is full of fascinating bits.
The University of Chicago economist and Nobel laureate Robert Lucas declared that the spillovers in knowledge that result from talent-clustering are the main cause of economic growth. Well-educated professionals and creative workers who live together in dense ecosystems, interacting directly, generate ideas and turn them into products and services faster than talented people in other places can. There is no evidence that globalization or the Internet has changed that. Indeed, as globalization has increased the financial return on innovation by widening the consumer market, the pull of innovative places, already dense with highly talented workers, has only grown stronger, creating a snowball effect. Talent-rich ecosystems are not easy to replicate, and to realize their full economic value, talented and ambitious people increasingly need to live within them.
And:
But another crucial aspect of the crisis has been largely overlooked, and it might ultimately prove more important. Because America’s tendency to overconsume and under-save has been intimately intertwined with our postwar spatial fix — that is, with housing and suburbanization — the shape of the economy has been badly distorted, from where people live, to where investment flows, to what’s produced. Unless we make fundamental policy changes to eliminate these distortions, the economy is likely to face worsening handicaps in the years ahead.
Others have written about it elsewhere, but the few paragraphs Florida devotes to Detroit are stunning. (thx, peter)
America was discovered accidentally by a great seaman who was looking for something else; when discovered it was not wanted; and most of the exploration for the next fifty years was done in the hope of getting through or around it. America was named after a man who discovered no part of the New World. History is like that, very chancy.
That’s Samuel Eliot Morison, author of several books of history, including The European Discovery of America, Admiral of the Ocean Sea, and The Oxford History of the American People.
From the New Yorker last week, Atul Gawande on how the US should nationalize healthcare. His answer: nationalize slowly, use what’s already in place, and don’t rebuild the whole system from scratch.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
As usual, Gawande makes a lot of sense. Whatever the solution, we should be doing all we can to avoid something like this from ever happening again:
“When I heard that I was losing my insurance, I was scared,” Darling told the Times. Her husband had been laid off from his job, too. “I remember that the bill for my son’s delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself.” So she prevailed on her midwife to induce labor while she still had insurance coverage. During labor, Darling began bleeding profusely, and needed a Cesarean section. Mother and baby pulled through. But the insurer denied Darling’s claim for coverage. The couple ended up owing more than seventeen thousand dollars.
Here’s a small and nerdy measure of the huge change in the executive branch of the US government today. Here’s the robots.txt file from whitehouse.gov yesterday:
User-agent: *
Disallow: /cgi-bin
Disallow: /search
Disallow: /query.html
Disallow: /omb/search
Disallow: /omb/query.html
Disallow: /expectmore/search
Disallow: /expectmore/query.html
Disallow: /results/search
Disallow: /results/query.html
Disallow: /earmarks/search
Disallow: /earmarks/query.html
Disallow: /help
Disallow: /360pics/text
Disallow: /911/911day/text
Disallow: /911/heroes/text
And it goes on like that for almost 2400 lines! Here’s the new Obamafied robots.txt file:
User-agent: *
Disallow: /includes/
That’s it! BTW, the robots.txt file tells search engines what to include and not include in their indexes. (thx, ian)
Update: Nearly four months later, the White House’s robots.txt file is still short…only four lines.
User-agent: *
Disallow: /includes/
Disallow: /search/
Disallow: /omb/search/
Obama made a small error in the first part of his inaugural speech. He said:
Forty-four Americans have now taken the presidential oath.
Because of Grover Cleveland’s two non-consecutive terms, there have been 44 Presidents but only 43 people have held the office and taken the oath. I’m surprised his speechwriters didn’t catch that little detail. Of course, I think of Al Gore as an ex-President so maybe that’s where it came from.
Slate has a slideshow of the most gerrymandered Congressional districts in the US. Gerrymandering is the practice of redistributing electoral boundaries in order to achieve a political advantage, often without regard to geography.
From The Last Traffic Jam in The Atlantic.
Unless we exercise foresight and devise growth-limits policies for the auto industry, events will thrust us into a crisis that will lead to a substantial erosion of our domestic oil supply as well as the independence it provides us with, and a level of petroleum imports that could cost as much as $20 to $30 billion per year. (This in turn would produce a staggering balance-of-payments problem for the United States, and give the Middle Eastern suppliers a dangerous leverage over our transportation system as well.) Moreover, we would still be depleting our remaining oil reserves at an unacceptable rate, and scrambling for petroleum substitutes, with enormous potential damage to the environment.
And:
In short, common sense dictates that we begin a transition to policies designed to avoid an energy impasse that could cripple out transportation system and imperil our economy. We must set growth limits that will allow the automobile and oil industries to maintain economic stability while conserving our resources and preserving our environment. Of course, such a reorientation will require statesmanship as well as public pressure. It will not happen unless corporate self-interest yields to a responsible outlook that serves the broader interests of the nation as a whole. Above all, this shift requires a thorough redirection of the aims of these two industries.
Believe it or not, those words appeared in the magazine in 1972. These views would have seemed out-of-date and old fashioned just a year or two ago but now all those chickens are coming home to roost.
Aired a few weeks before the 2008 election, The President’s Guide to Science is a 50-minute video featuring several prominent scientists — Richard Dawkins, Michio Kaku, etc. — offering their advice for the incoming US President, basically what they would teach the President about science. (via smashing telly)
StateStats is hours of fun. It tracks the popularity of Google searches per state and then correlates the results to a variety of metrics. For instance:
Mittens - big in Vermont, Maine, and Minnesota, moderate positive correlation with life expectancy, and moderate negative correlation with violent crime. (Difficult to commit crimes while wearing mittens?)
Nascar - popular in North and South Carolinas, strong positive correlation with obesity, and and moderate negative correlation with same sex couples and income.
Sushi - big in NY and CA, moderate positive correlation with votes for Obama, and moderate negative correlation with votes for Bush.
Gun - moderate positive correlation with suicide and moderate negative correlation with votes for Obama. (Obama is gonna take away your guns but, hey, you’ll live.)
Calender (misspelled) - moderate positive correlation with illiteracy and rainfall and moderate negative correlation with suicide.
Diet - moderate positive correlation with obesity and infant mortality and moderate negative correlation with high school graduation rates.
Kottke - popular in WI and MN, moderate positive correlation with votes for Obama, and moderate negative correlation with votes for Bush.
Cuisine - This was my best attempt at a word with strong correlations but wasn’t overly clustered in an obvious way (e.g. blue/red states, urban/rural, etc.). Strong positive correlation with same sex couples and votes for Obama and strong negative correlation with energy consumption and votes for Bush.
I could do this all day. A note on the site about correlation vs. causality:
Be careful drawing conclusions from this data. For example, the fact that walmart shows a moderate correlation with “Obesity” does not imply that people who search for “walmart” are obese! It only means that states with a high obesity rate tend to have a high rate of users searching for walmart, and vice versa. You should not infer causality from this tool: In the walmart example, the high correlation is driven partly by the fact that both obesity and Walmart stores are prevalent in the southeastern U.S., and these two facts may have independent explanations.
Can you find any searches that show some interesting results? Strong correlations are not that easy to find (although foie gras is a good one). (thx, ben)
Alex Tabarrok proposes that now is a good time for the US government to form the Buffalo Commons, a huge nature preserve in the western US.
The western Great Plains are emptying of people. Some 322 of the 443 Plains counties have lost population since 1930 and a majority have lost population since 1990. Now is the time for the Federal government to sell high-priced land in the West, use some of the proceeds to deal with current problems and use some of the proceeds to buy low-priced land in the Plains creating the world’s largest nature park, The Buffalo Commons.
According to this map, the US government owns more than 50% of the land in some western states (Nevada 84.5%, Utah 57.4%, Oregon 53.1%, Arizona 48.1%, California 45.3%).
There are likely many benefits of an electoral college voting system, but I would still like to see it dead. Because this is just crazy:
The presidency could be won with just 22 percent of the electorate’s support, only 16 percent of the entire population’s.
That is, you could lose 78% of the popular vote and still gain The White House! Is that even correct? This seems insane to me. (via jake)
Michael Pollan, who I have spoken of previously, wrote an open letter in a recent issue of the NY Times magazine to the whoever prevails in the November presidential election. Pollan is concerned with contemporary American food policy.
There are many moving parts to the new food agenda I’m urging you to adopt, but the core idea could not be simpler: we need to wean the American food system off its heavy 20th-century diet of fossil fuel and put it back on a diet of contemporary sunshine. True, this is easier said than done — fossil fuel is deeply implicated in everything about the way we currently grow food and feed ourselves. To put the food system back on sunlight will require policies to change how things work at every link in the food chain: in the farm field, in the way food is processed and sold and even in the American kitchen and at the American dinner table. Yet the sun still shines down on our land every day, and photosynthesis can still work its wonders wherever it does. If any part of the modern economy can be freed from its dependence on oil and successfully resolarized, surely it is food.
This is a really long piece but essential, important reading dripping with great stuff. If you don’t have time to read it, Michael Ruhlman summed up Pollan’s main points in a more bite-sized form. An even more abridged version of Pollan’s recent food advice would be:
For people: “Eat food. Not too much. Mostly plants.”
For the United States: “We need to wean the American food system off its heavy 20th-century diet of fossil fuel and put it back on a diet of contemporary sunshine.”
The more I read of Pollan’s writing, the more I wish he were the Secretary of Agriculture or the head of the USDA or something. Paging Mr. Obama…
HBO is developing a series set 25-40 years in the future when Americans are fleeing the country en masse and settling elsewhere in the world.
In his research for “Americatown,” Winters had explored possible nightmare scenarios that could bring the U.S. to a collapse decades down the road, like the price of oil skyrocketing and natural disasters reaching catastrophic proportions. Then suddenly oil hovered near $150 a barrel this summer, floods hit the Midwest and the South and Wall Street crashed under the weight of the mortgage crisis.
(via bygone bureau)
More new work from the busy Phillip Toledano: America the Gift Shop.
If American foreign policy had a gift show, what would it sell?
I like the Cheney shredding secret documents snow globe.
The New Republic on the demographic inversion of the American city.
In the past three decades, Chicago has undergone changes that are routinely described as gentrification, but are in fact more complicated and more profound than the process that term suggests. A better description would be “demographic inversion.” Chicago is gradually coming to resemble a traditional European city — Vienna or Paris in the nineteenth century, or, for that matter, Paris today. The poor and the newcomers are living on the outskirts. The people who live near the center — some of them black or Hispanic but most of them white — are those who can afford to do so.
Update: The WSJ wrote about this issue a couple of weeks ago.
‘Mericans today are eating 1.8 pounds more food per week than in 1970, including an extra 1/2 pound of fat. Check out the chart for more info on how we’ve changed our diet. (thx, meg)
A very interesting graph of the estimated ideological positions of US voters, senators, and representatives shows that members of Congress are much more liberal and conservative than are US voters, who fall somewhere in the middle. (via 3qd)
After the launch of Sputnik by the Soviet Union in late 1957 awoke the US to the possibility of a developing outer space “gap” with the Russkies, President Eisenhower signed the National Aeronautics and Space Act into law on July 29, 1958, thereby creating NASA. Only 11 years later, NASA landed men on the moon. Happy birthday, NASA.
Population densities in the United States vary over nine orders of magnitude.
In case you’re wondering, the most densely populated block group is one in New York County, New York — 3,240 people in 0.0097 square miles, for about 330,000 per square mile. The least dense is in the North Slope Borough of Alaska — 3 people in 3,246 square miles, or one per 1,082 square miles. The Manhattan block group I mention here is 360 million times more dense than the Alaska one; population densities vary over a huge range.
That’s approximately the same range from the height of an iPod to the diameter of the Earth. (via fakeisthenewreal)
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