PAYGO Is Killing Us

In the ongoing saga in the U.S. to try to limit drug prices, we come across this little vignette about how our obsession with good Congressional Budget Office scores is killing us (boldface mine):

Perhaps the strangest odyssey about the bill involves an amendment from Representative Pramila Jayapal (D-WA), the co-chair of the House Progressive Caucus. Jayapal’s amendment expands a section of the bill that mirrors the Grassley-Wyden legislation in the Senate. It would generate rebates to Medicare on excessively priced drugs that rise above the rate of inflation. Jayapal wanted those rebates extended to group health plans. That way everyone would benefit from the rebates, and drug companies would have incentives to keep cost increases below the rate if inflation, since they would lose any profits above that threshold.

House leadership came down on Jayapal for seeking this change. Speaker Pelosi’s staff, particularly Wendell Primus, didn’t want the amendment to pass, and this trickled down to the staffs of the Ways and Means and Energy and Commerce Committees, two of the three with jurisdiction over the bill. Jayapal got the third, the Education and Labor Committee, on board, and the amendment passed there. Even then, it had to be watered down, forcing the Secretary of Labor to conduct a feasibility study for extending the rebates to group plans, and then regulations coming subsequently on the expansion.

The leadership resisted keeping the amendment in the final bill, even after passage. The reason why is one of those around-the-bend, up-is-down consequences of a broken legislative apparatus in Washington. Pelosi’s staff has been obsessed with getting a good score on the legislation from the Congressional Budget Office (CBO). They accomplished that, with just the negotiation provisions saving the government $345 billion over a ten-year period. The more money that the bill saves, the more that can be plowed into improvements in Medicare, another priority of the bill.

However, if the rebates were extended to group plans, drug companies would have incentives to lower costs. That means less money in rebates going to Medicare, and less for Medicare to spend on other matters. So, insanely, Wendell Primus would rather keep drug costs higher outside of Medicare, so Medicare can get more rebates and use the money. The bill is called the Lower Drug Costs Now Act, but this provision, if the Jayapal amendment is removed, would incentivize higher drug costs.

“What you’ve hit on is one of the many perverse incentives in the U.S. system,” says Annette Gaudino of Treatment Action Group. “We’re robbing Peter to pay Paul to have health infrastructure in this country.”

In case you got lost trying to follow this (wouldn’t blame you as it makes no sense), Medicare gets paid the difference by drug companies between the approved Medicare price and the non-Medicare price–this is essentially a 100% tax on the difference, with the tax receipts being counted as additional assets for Medicare. For example, if group health plans were charged $200 for insulin, but Medicare only pays $100 for the same insulin, every time Medicare purchases insulin the Medicare budget receives $100 (the group health plans still have to pay $200).

However, if these rebates were expanded to programs outside of Medicare (e.g., private insurers), the private price would decline: if a drug company ends up losing that $100 of additional profit from the group health plans anyway, they’ll just lower the group health plan price to $100, so they avoid paying the Medicare ‘tax.’ This means that the ‘tax’ would generate less revenue and Medicare’s budget would shrink, the result being that other Medicare services would have to be cut (unless, of course, Congress were willing to tell its own budget office not to count this against the spending cap, which the PAYGO Austerians will never do).

If you still don’t get it, don’t feel bad: this is nonsensical.

Austerioeroticism in the form of CBO scores is killing us.

Also, best healthcare system in the world something something.

Posted in Fucking Morons, Healthcare | 1 Comment

Links 12/10/19

Trump_wevegottheforms
Links for you. Science:

New research investigates intriguing approach to Alzheimer’s—and potential that it can be reversed
Why the huge surge in EEE cases? Federal rules requiring quick sample disposal mean we may never know
For sea turtles, Cape Cod Bay can be a deadly trap in the fall. These volunteers are rescuing them.
Progress in predictions: With over 40 years of snow forecasting, he wrote the book on East Coast storms
A Reporter Took DNA Tests in the U.S. and China. The Results Left Her Worried

Other:

Baseball Will Probably Turn Its Back on Marvin Miller—Again
A city with two political swamps and two political scandals
When exciting education results are in the news, be skeptical (wrote about this here)
Doubts about teacher value added
The genealogy boom has hit a roadblock. The Trump administration plans huge fee hikes for immigration records.
We’ve seen enough. Trump should be impeached
Administrative assistant jobs helped propel many women into the middle class. Now they’re disappearing.
Why Are Democratic Candidates So Obsessed With This Phrase?
Nikki Haley gets the history of the Confederate flag very wrong
How the Schiff Report Deals with Disinformation
Pete Buttigieg Won’t Talk About His Secret Work At McKinsey
We can afford Medicare for All… and it could even deliver a huge pay raise to the middle class.
Neo-Nazi Terror Group Harbouring Missing Ex-Soldier
The Great American Eye-Exam Scam
The list is long of the “things” #MayorPete didn’t know while mayor of #SouthBend. It would be an #SNL skit IF he wasn’t a front runner for POTUS
Impeach the president
Oh, dear. I wake up to see that my colleague Bret Stephens is bashing France. The French do have problems. But their biggest economic disease is hypochondria.
Finland Is a Capitalist Paradise. Can high taxes be good for business? You bet.
Mainstream journalists need to stop falling for bad faith nonsense like conservatives’ feigned outraged over the mention of Barron Trump
Kansas City becomes first major American city with universal fare-free public transit
The Fascism to Come (excellent)

Posted in Lotsa Links | Leave a comment

Voters Often Do Not Behave Linearly, and They View National Elections Like Local Elections

Having done canvassing in the old days when we had to canvass neighborhoods both ways uphill identifying voters wasn’t very sophisticated, I learned that many voters don’t really organize candidates along a left-right axis–they don’t think linearly. One corollary of this is that voters’ second choices often don’t appear to follow from their first choices, with the following consequence for the 2020 primary:

Despite what the internecine snipers on the leftward side of the party would have you believe, Sanders and Warren are each pulling away significant votes from Biden. If one of them drops, Biden moves up in absolute terms, and this race suddenly becomes the centrist versus the leftist, with Biden the centrist having the advantage. That won’t play out well, as the political press corps will begin to marginalize the left-ish candidate, and Biden could pull away.

Likewise, if there isn’t a clear winner by the time the convention rolls around, both Sanders and Warren will have turned a significant portion of willing Biden supporters into lefty delegates–which is a good thing. Because the leftward side of things needs to remember that Biden isn’t a good candidate, and he likely would be a mediocre president, setting up someone like Tom Cotton for 2024.

We need both of them in the race right now, unless you want a Biden candidacy.

Or even worse, a Buttigieg candidacy–and he’s more conservative than Biden*.

But don’t believe me about second choices, listen to political scientists (boldface mine):

In a large-scale project called Nationscape that we’re conducting with our colleague Chris Tausanovitch at the University of California at Los Angeles, we have queried more than 6,000 voters weekly since July. Using these data, we find a surprising amount of agreement among Democrats on major policy issues. Contradicting the conventional wisdom, clearly defined ideological “lanes” don’t seem to exist in the minds of most voters.

This general agreement is reflected in how voters rank candidates. Despite all the talk about the moderate-progressive split, for instance, the most popular second choice of Biden voters is Sen. Bernie Sanders (I-Vt.) — followed by Warren. Many supporters of the “progressives” also rank a moderate as a second choice.

More specifically, in surveys from Oct. 17 to Nov. 13, 35 percent of Biden supporters list Sanders as their No. 2 choice, and 29 percent list Warren. Only 9 percent list Buttigieg. Meanwhile, Sanders supporters are nearly evenly divided in their second-choice candidate: 36 percent say Warren, while 32 percent say Biden.

Warren supporters also show considerable willingness to embrace a “moderate”: 32 percent of them say Sanders is their second choice, 26 percent say Biden and 15 percent say Buttigieg. And to whom would Buttigieg supporters turn as a fallback? Thirty percent say Biden, and 28 percent say Warren.

Perhaps people’s preferences will change when the prospect of voting for someone other than their first choice is more than hypothetical. But there is little indication that voters are ranking the candidates primarily in terms of ideological affinity.

The reason may be that, right now, the ideological differences among the Democratic candidates, while noticeable to professional observers of politics, may not necessarily be large enough to register with Democratic voters paying only intermittent attention to the race… And some voters, of course, also don’t have the kinds of strong and coherent ideologies that commentators assume.

This is one reason why the clusterfuck over HOW DO WE PAY FOR IT? was so stupid: most people aren’t drilling down into the weeds on this stuff at all.

Most people, even those who claim they are paying attention, really aren’t into the particulars. They follow politics the way many mavens follow local politics–that is, very intermittently and not in great detail. They use rules of thumb, which can be flawed as well as based on flawed information. But they aren’t reading policy papers–at best, most are reading second or third-hand discussions of those policies.

Something to keep in mind when thinking about electability and so on.

*A year ago, Buttigieg strongly supported Medicare for All, now he doesn’t. The man is a stone cold opportunist.

Posted in Democrats, Voting | Leave a comment

Links 12/9/19

Trump_fivemoreyears
Links for you. Science:

Samoa shuts down in unprecedented battle against measles crisis (anti-vaccinationism is self-correcting, though the promulgators of this idiocy rarely pay the price)
What’s behind the spike in death rates among young adults in Minnesota?
China’s Genetic Research on Ethnic Minorities Sets Off Science Backlash
The Deep Sea
WHO Calls Measles Outbreaks Cases Across The Globe A ‘Collective Failure’

Other:

The Republicans’ Star Impeachment Scholar Is a Shameless Hack
Pete Buttigieg is bad news
This Republican Impeachment Argument Is a Catch-22 of Stupid
Pelosi Will Impeach, and John Roberts’ Role Will Loom Large
Mayor Pete Just Broke Charles P. Pierce’s First Law of Economics
Almost half of Fox News viewers believe baseless Russian claim that Ukraine meddled in 2016
3.5%
California Bans Insurers From Dropping Policies Made Riskier by Climate Change
To make himself look good, Buttigieg bashes Democrats with GOP talking point on national deficit
Metro shows six “fantasy maps” for the Blue and Silver lines
The Pro-Choice Movement Has Won the Culture War
This Highly Organized Right-Wing Militia Is an Ominous Portent
We need to hold the Kremlin responsible for its 2018 cyberattack on the Olympics
High School Football Players Took a Knee Before a Game, and Opposing ‘Fans’ Threw Trash at Them
The Disappearance of John M. Ford
Revolution & #Resistance: The Life and Times of Lauren Duca
Why Political Pundits Are Obsessed with Hidden Moderates
Why Racists (and Liberals!) Keep Writing for Quillette
Propaganda, Anti-propaganda
How I Won a Florida Swing Seat as a Proud Abortion-Rights Supporter
Dynamic pricing for the Expressway

Posted in Lotsa Links | Leave a comment

Pharmacies Need to Be Part of Fighting Influenza

And right now, they aren’t (boldface mine):

When adults want a flu shot, they have two choices: go to the doctor or go to a pharmacy.

But in most states, laws prevent parents from just walking into a pharmacy and getting their children vaccinated for the flu. Public health experts say that’s costing children’s lives.

“Parents should have no barriers whatsoever to getting a flu shot,” said Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University. “It’s what we’d call a no-brainer.”

Currently, 40% of children don’t get a flu vaccine, and public health authorities are keen to change that. Flu kills children every year; last year, 143 children lost their lives to the flu.

Another reason to get children vaccinated: With their less than ideal hygiene, they’re powerful at spreading the flu to others.

Pharmacies are an attractive alternative for many busy parents, since they have evening and weekend hours, and there’s no need for an appointment.

But three states — Florida, Connecticut and Vermont — don’t allow children to be vaccinated in pharmacies, and another 30 states have restrictions based on the child’s age.

“We’re relinquishing our responsibilities as a society if we don’t really aggressively try to get as many children vaccinated with the flu vaccine as possible,” added Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. “I just want to see more children get vaccinated. I don’t really care how you do it.”

It’s unclear why so many states restrict children from getting the flu vaccine at pharmacies. The American Academy of Pediatrics doesn’t object to children getting vaccinated at pharmacies, according to the group’s position paper on preventing flu.

“It’s the same vaccine. Pharmacists are trained to give it. I had my own flu shot at a pharmacy and my grandchildren have, too,” said Redlener, who lives in New York, where children over age 2 can get a flu vaccine at a pharmacy.

And some doctors really need to get on board with this:

She was told that if children get their flu shots in pharmacies, the pediatrician’s office wouldn’t know how many to order for the following year.

Nabers understood the bureaucratic predicament, but it still didn’t seem like a good enough reason for her or her husband to miss work, or for her children to miss school. She even considered finding a new pediatrician.

“I didn’t threaten to leave, but I told them while I loved their practice, I was very unhappy with this and would have to consider it moving forward,” she said.

Only then did the office call in a prescription to the pharmacy — and the nurse made it clear that it was a one-time exception.

While much of the discussion around healthcare is about Bending Cost Curves Like Beckham, a national system would make administering things like vaccines much easier–and, if the anecdote is correct, would remove incentives to make getting shots harder.

It’s critical for kids, not just for their health, but for everyone else’s: the grandchildren are killing their parents, since kids are an important vector of influenza. Even without healthcare reform, we need to let kids get flu shots at the pharamacy.

Posted in Healthcare, Influenza, Public Health | 1 Comment

Links 12/8/19

Trump_bathroomelements
Links for you. Science:

China Uses DNA to Map Faces, With Help From the West
Tainted Data Can Teach Algorithms the Wrong Lessons
How Peru’s potato museum could stave off world food crisis
OK SO let’s say it’s 1962 and you’re lucky enough to be a programmer working somewhere that has an IBM 7090. This is a top of the line transistorized revision of the IBM 709, capable of 100,000 floating point operations per second. But how do you code for it?
Dunno if this will pass review but here’s the most parsimonious phylogeny of baked goods I made for some reason.

Other:

We scorned addicts when they were black. It is different now that they are white.
HAHA FURRINERS LAUGH AT OUR PREZNIT
The Ohio abortion bill is a terrifying sign of things to come
Many Americans are ready for a black woman president. Just not Kamala Harris (I think we are overestimating the role misogyny and bigotry played and underestimating how her campaign’s lack of a theme or focus hurt her)
‘The Best Thing You Can Do Is Not Buy More Stuff,’ Says ‘Secondhand’ Expert
What the C.I.A.’s Torture Program Looked Like to the Tortured
Republican Complaints about Phone Records Back Democratic Impeachment Case
Park It, Trucks: Here Come New York’s Cargo Bikes
Wall-to-wall impeachment coverage is not changing any minds. Here’s how journalists can reach the undecided.
The French Fries Are Doing Just Fine
What the Gentrification of Baltimore’s Chinatown Means
Inside The World of Interiors, Condé Nast’s Secret Weapon
Bernie Sanders isn’t polling in first place. His caucus organization may mean that doesn’t matter
What Is Voters’ Highest Priority? There’s a Way to Find Out (interesting method, though I’m not entirely convinced this is exactly right)
State legislators, stop being cowards. Mandate state funerals for all spermatozoa.
All of Jack Evans’ Colleagues Recommend Expelling Him from the Council
How Red States Are Steamrolling Blue Cities
What the U.K. Election Tells Us About Universal Health Care
San Francisco has nearly five empty homes per homeless resident
Joe Biden’s “No Malarkey” bus is smarter than you think
Life Under the Algorithm: How a relentless speedup is reshaping the working class

Posted in Lotsa Links | Leave a comment

‘Coding’, Coding, and Biologists

Saturday, I reupped a piece about coding and biologists, which seemed to make a lot of people upset. I’ll attribute that to ‘instructor error’ on my part, since I obviously wasn’t clear what I meant (people still might disagree, of course, even if I’m clearer). If there’s one thing I learned from the reaction, it’s what coding means very different things to different people.

I primarily work with computational scientists and software engineers, so my definition of coding is very different from what I think many commenters meant.

I’ll return to coding in a bit, but consider this: I imagine many people reading this have, at some point in their careers, performed a 2×2 contingency table test, or a simple 2-way ANOVA (I don’t want to get into arguments about statistical methods, but suffice it to say, I think these tools do have their uses, even if it’s just to say, “I should probably explore that result further tomorrow because it might not be random”). No one would say, solely on the basis of having performed these tests, however, that they are statisticians (I hope). Yes, you did a statistical test, and if you’re trying to, let’s say, encourage young students in science, there’s nothing wrong with saying that they know some statistics. But you’re not going to apply for that job opening in the applied math department or that consultant position that requires, well, a trained statistician based on the qualification of using a 2×2 contingency table.

Many biologists (depending on the discipline) were told in days of yore they needed to learn statistics: not the simple techniques, or a basic understanding of methods, but be really well-trained in stats–perhaps not to the level of an Ph.D., but enough that, were you to apply for a job requiring statistical training, you really did have the chops. Now, we don’t hear that so much.

There was also a period where learning math (that is, theoretical biology), not just what you need for your non-mathematics major requirements (usually calculus or a semester of linear algebra), but enough math, to the point where you were in the same league as math majors was prized. Not so much anymore either. That isn’t to say either statistics or mathematics aren’t good now (I’ve worked in both of those areas). But is having a high level of expertise essential?

So to return to what I meant by coding. It’s useful to use awk and sed to pull data from tables, to write a short bash or python script to munge data around from one format to another, to use existing packages in R, or to run an software tool on a batch of data files. I do this! But I really don’t consider this coding. Yes, you put something in a file with .sh or .pl at the end and executed it. If I were trying to convince students to get excited about science and so on, I would probably call it coding (good job guys!). But that level of skill isn’t the level I would call a coder/programmer, anymore than performing a chi-square test means you’re a statistician. It’s useful, it’s ‘coding’, but that’s not what I meant in my posts–which is why I referred to having a backup plan (for coding to be a backup plan, you have to have significant skills–you will be competing against trained and/or experienced programmers).

There are opportunity costs to gain expertise in anything (arguably, life itself is one big sunk opportunity cost), and when I saw the discussion about coding, I interpreted it as meaning someone has spent a significant amount of time, both training and experience, comparable to being trained as a statistician. I still don’t think many biologists need that level of expertise in coding, even in The Tech Era. Obviously, if you need to solve your scientific problem of interest by building a new software tool, then you need to learn how to do so. But that’s no different than saying if you need to figure out your scientific problem of interest using crystal structure, then you need to learn crystallography. Crystallography is good and useful, but no one is saying ‘biologists need to learn crystallography.’* (and as I noted, people aren’t emphasizing advanced math or statistics as universal skills much these days either–and they’re good to know too!).

From where I sit, ‘coding’ probably will become less important to many biologists as analyses will become more routine and self-contained and as ‘wrapper’ tools that allow converting among formats and tools are better developed. More importantly, we will have failed if we aren’t in that position. People on the bleeding edge will always do the bespoke stuff that might require serious programming (i.e., both coding and ‘coding’), but most biologists won’t be doing that–and when they need to, that’s when you collaborate with an expert.

If we think about all of the things biologists were supposed to know very well (not just a few basic things in each of these areas), including molecular biological techniques, stats, advanced math, and now coding, I don’t see how it’s possible to be an expert in all of these things (even as we do need experts in these areas, along with other areas I haven’t listed). That doesn’t mean you should learn new things–I still learn new things, but having expertise is very difficult to come by. There are opportunity costs.

Finally, there’s one other tangential thing: the learning to think argument, the precision thinking arguments and so on. I call bullshit. I’ve never heard an intellectual discipline that doesn’t claim it teaches its trainees ‘how to think.’ Philosophers, lawyers, physicists, statisticians, scholars in the humanities, all argue that their discipline teaches rigor (No one says, “Actually, we don’t teach our students how to think, we just cram data up their asses. We’re fine with them being dumber than a sack of hammers.”) If you went through college, and are in a PhD program or completed one and it took coding to teach you how to think, then you have received a shitty education and should be disappointed in your teachers.

*Nor is anyone claiming crystallography ‘teaches you how to think’, though one could probably argue that it could.

Posted in Education | 3 Comments