• Adult docs may not ask about guns, but pediatricians do

    Kevin Drum dissents on my earlier NYT piece today:

    I don’t often disagree with Carroll, but I think I might here. Not about Florida’s law: that really is ridiculous. The state may have an interest in making sure doctors don’t give demonstrably bad advice, but it certainly doesn’t have a legitimate interest in preventing them from asking simple, fact-oriented question. This represents prior restraint on non-commercial speech, and as such it’s beyond the pale.

    That said, should physicians ask about gun ownership? I’m not so sure. Carroll says he only wants to discuss “health risks,” and that’s appropriate. Doctors have expertise in the area of human health: that is, the biology and physiology of the human body. But that’s not the same thing as the safety of the human body.

    Not only do doctors have no special professional expertise in this area, but it’s simply too wide open. Does your car have air bags? Do you ever jaywalk? Have you checked your electrical outlets lately? Is your house built to withstand an earthquake? Do you know how to work safely on your roof? Do you make sure to watch your kids in the pool? Are you planning any trips to eastern Ukraine?

    I replied by email, which he posted to his blog (with permission!):

    I think you ask legitimate questions, but these are consensus things that pediatricians ask about. You’re thinking like an adult, and not as a parent.

    I don’t know if internists ask adults about guns. I doubt they do. But pediatricians do ask parents. They also ask if parents have talked about street safety. They ask if they keep chemicals out of reach of their children. They ask if they’ve checked the temperature of the hot water heater. They ask about water safety, bathtubs, and talk about drowning. Fire safety. Bike safety. Car safety (including airbags). I could go on and on and on.

    This is what pediatricians do. You may be too far removed from that to remember, but it is! Read Bright Futures. It’s hundreds of pages long.

    Pediatricians like to say that kids are NOT little adults. I think it’s also safe to say that pediatricians are NOT little adult doctors. Your doctors likely don’t feel the need to warn you about the many dangers you face in everyday life, but parents often need to be reminded that their kids don’t know better. We talk about lots of things you might not talk about with your adult doctor.


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  • Asking about stuff is only the first step

    Today I wrote about how docs ask about guns in the home because that’s how prevention works. Asking about sensitive topics is important. Here’s a great example – “An Electronic Screen for Triaging Adolescent Substance Use by Risk Levels“:

    Importance: Screening adolescents for substance use and intervening immediately can reduce the burden of addiction and substance-related morbidity. Several screening tools have been developed to identify problem substance use for adolescents, but none have been calibrated to triage adolescents into clinically relevant risk categories to guide interventions.

    Objective: To describe the psychometric properties of an electronic screen and brief assessment tool that triages adolescents into 4 actionable categories regarding their experience with nontobacco substance use.

    Design, Setting, and Participants: Adolescent patients (age range, 12-17 years) arriving for routine medical care at 2 outpatient primary care centers and 1 outpatient center for substance use treatment at a pediatric hospital completed an electronic screening tool from June 1, 2012, through March 31, 2013, that consisted of a question on the frequency of using 8 types of drugs in the past year (Screening to Brief Intervention). Additional questions assessed severity of any past-year substance use. Patients completed a structured diagnostic interview (Composite International Diagnostic Interview–Substance Abuse Module), yielding Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) substance use diagnoses.

    Main Outcomes and Measures: For the entire screen and the Screening to Brief Intervention, sensitivity and specificity for identifying nontobacco substance use, substance use disorders, severe substance use disorders, and tobacco dependence were calculated using the Composite International Diagnostic Interview–Substance Abuse Module as the criterion standard.

    Results: Of 340 patients invited to participate, 216 (63.5%) enrolled in the study. Sensitivity and specificity were 100% and 84% (95% CI, 76%-89%) for identifying nontobacco substance use, 90% (95% CI, 77%-96%) and 94% (95% CI, 89%-96%) for substance use disorders, 100% and 94% (95% CI, 90%-96%) for severe substance use disorders, and 75% (95% CI, 52%-89%) and 98% (95% CI, 95%-100%) for nicotine dependence. No significant differences were found in sensitivity or specificity between the full tool and the Screening to Brief Intervention.

    Conclusions and Relevance: A single screening question assessing past-year frequency use for 8 commonly misused categories of substances appears to be a valid method for discriminating among clinically relevant risk categories of adolescent substance use.

    The gist of this study is that asking adolescents a single question about substance use uncovers a ton of disorders, including severe disorders. That’s why we ask the question, even when it’s uncomfortable.

    But an accompanying editorial is equally important. It makes the following point:

    To date, no clinical trials have reported the efficacy of brief (or extended) interventions for alcohol, cannabis, or other prescription medication misuse in pediatric settings. As a result, the US Preventive Services Task Force has issued an “I” (for insufficient) recommendation for screening and interventions for adolescents with illicit drug use, alcohol misuse, or nonmedical pharmaceutical use.

    It’s great that we can find the problem. We also need to do something about it. Too often, we lack research in those areas. That’s because such research is time consuming and expensive. We still need to do such work, though. Recent pushes to focus on more “patient-centered” outcomes are a step in the right direction.

    I feel this way about obesity, too. It’s also true for guns. I’m sure one of the complaints that people will level at my NYT piece is that there’s no evidence that finding out that guns are in the home and encouraging parents to store them more safely actually prevents injuries. That’s true. It’s because almost no research gets done with respect to guns and injuries at all. Please fund it. I know tons of health services researchers who would love to do that work.

    It’s not fair to cause ignorance, or refuse to combat it, and then use it as excuse to do nothing.


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  • The D.C. Circuit says (again) that the ACA isn’t unconstitutional

    Forget about the exchange litigation for the moment. Last month, I wrote about the other pending existential challenge to the ACA: the lawsuit claiming that it is unconstitutional because its enactment violated the Origination Clause. I said that nothing was likely to come of the challenge, and that nothing should. Today, a unanimous D.C. Circuit panel released an opinion saying pretty much the same thing.

    The controversy turns on the procedure that Congress used to enact the ACA. The bill that became the ACA was first passed in the House as the “Service Members Home Ownership Tax Act of 2009.” It had nothing to do with health care. When the bill came to the Senate for consideration, its language was stripped out and replaced with what became the ACA.

    The plaintiff here—an Iowa artist and part-time National Guard employee named Matt Sissel—argued that this “shell bill” procedure violated the Origination Clause, which says that “[a]ll Bills for raising Revenue shall originate in the House of Representatives.” The ACA raised revenue and didn’t really originate in the House. So Sissel thinks it’s unconstitutional.

    The D.C. Circuit, in an opinion by Judge Rogers, disagreed. Rogers’s analysis hinges on whether the ACA is a “Bill for raising Revenue.” She notes—correctly—that “the Supreme Court has held from the early days of this Nation that ‘revenue bills are those that levy taxes in the strict sense of the word, and are not bills for other purposes which may incidentally create revenue.’”

    The distinction, Rogers explains, turns on the statute’s purpose. Is it mainly about raising revenue? If so, the statute had to originate in the House. But if it’s about something else, it doesn’t matter where the bill came from. Judged under that “purposive approach,” Rogers reasoned that the ACA isn’t mainly about raising revenue. It’s about extending insurance to the uninsured. As such, the Origination Clause just doesn’t apply to the ACA.

    That should be the end of this litigation. Yes, Sissel will probably ask the Supreme Court to hear his case. Yes, it’s remotely possible the Court will be more sympathetic to his Origination Clause claim, much as it proved more sympathetic to the constitutional arguments over the individual mandate than many predicted. But I doubt the Court will have any interest in hearing the case. As I explained earlier:

    The litigation over the individual mandate mobilized a broad social movement around widely shared and deeply personal objections to a purchase mandate that, to many, epitomized government overreach. The avid support of the Republican Party, as Jack Balkin has emphasized, gave an institutional imprimatur to that movement and made constitutional innovation at the Supreme Court much more likely.

    In contrast, the Origination Clause challenge hasn’t mobilized the public at all. Maybe that’s because the purported constitutional violation seems like a technicality. Maybe it’s because the Seventeenth Amendment, which provides for the direct election of senators, makes both houses of Congress directly accountable to the public. Or maybe it’s because people are tired of the incessant wrangling over the supposed unconstitutionality of Obamacare.

    Whatever the case may be, the Supreme Court isn’t likely to craft a novel constitutional holding to invalidate a statute that, just two years ago, it upheld against a more substantial constitutional challenge.

    This case is over, and it should be over. Now we can all get back to worrying about the exchange litigation.


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  • Healthcare Triage: Germany

    We continue our international romp through healthcare systems with Germany:

    The last international health care system we covered – Singapore – got a great response from all of you. This week. We head back to Europe. Specifically, we’re going to Germany. Their universal health care system is based on the principles of Bismark, which say that the state should provide only for those unable to provide for themselves. It’s a private insurance system, and it’s the topic of this week’s Healthcare Triage.

    For those of you who came here for references, here are some:


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  • On attributions of bad faith in policy debate

    Last week’s Halbig decision elicited a lot of anger between left and right intellectuals. Brian Beutler called the decision:

    a fundamentally dishonest solicitation of right-wing judicial activism

    In the first sentence of his dissent, Judge Edwards accused the appellants and, by implication, his colleague Judge Griffith, of bad faith :

    This case is about Appellants’ not-so-veiled attempt to gut the Patient Protection and Affordable Care Act (“ACA”).

    Conversely, conservatives had their eyeballs popping out of their heads in response to what they viewed as the feckless bad faith of liberal responses to Halbig. Liberals are just indifferent to what their own law actually said, because the text is absurd? The absurdity of the text reveals the infeasibility of the enterprise — and you’re calling that a typo?

    I’ve nothing to say on the merits of these arguments (for that, read Nick!). But I don’t think attributions of bad faith should have much role in policy debates.

    It’s not because I want people to be nice. Great scholars have done an immense service by cutting down preposterous fools and letting them bleed out on the floor. Chomsky’s review of B. F. Skinner’s Verbal Behavior is a classic.

    Similarly, I’m not questioning the importance of a sincere motivation to be truthful. There are charlatans and liars. Look around.

    My point is rather that it is in your interest to focus on intellectual opponents whom you have reason to take seriously and to then actually take them seriously. This is your best chance of getting near the truth.

    Humanity’s natural mode of thought is self-serving misrepresentation of facts and inconsistency of argument. Read Dan Kahan on the distortions of ideologically-motivated cognition. But don’t read him to comfort yourself that others are knaves. Read him to get clear that you and I are likely the victims of our own intellectual self-deceptions.

    How do we get outside of our ideological bubbles? Here is J. S. Mill:

    In the case of any person whose judgment is really deserving of confidence, how has it become so? Because he has kept his mind open to criticism of his opinions and conduct. Because it has been his practice to listen to all that could be said against him; to profit by as much of it as was just, and expound to himself, and upon occasion to others, the fallacy of what was fallacious. Because he has felt, that the only way in which a human being can make some approach to knowing the whole of a subject, is by hearing what can be said about it by persons of every variety of opinion, and studying all modes in which it can be looked at by every character of mind… The steady habit of correcting and completing his own opinion by collating it with those of others, so far from causing doubt and hesitation in carrying it into practice, is the only stable foundation for a just reliance on it. (emphasis added)

    I find that my primary motivation for attributing bad faith is to escape the responsibility of answering a strong argument.

    If you are in politics, you have to answer arguments by frauds. But if you are trying to get at the truth, that’s not your best move. If you believe that someone is arguing in bad faith, just stop reading them. We’ll all be forgotten, soon enough.


    Thanks to Paul Kelleher for the pointer to Mill.

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  • ARGH! – ACA renewal edition

    One of the nicer aspects of the ACA was that it allowed “automatic renewal” of your health insurance if you got it from an exchange. This allowed you to avoid the yearly “open enrollment” madness if you so desired. But now there’s a problem:

    If you have health insurance on your job, you probably don’t give much thought to each year’s renewal. But make the same assumption in one of the new health law plans, and it could lead to costly surprises.

    Insurance exchange customers who opt for convenience by automatically renewing their coverage for 2015 are likely to receive dated and inaccurate financial aid amounts from the government, say industry officials, advocates and other experts.

    The problem comes from the fact that since both subsidies and premiums change from year to year, the amount that people might have to pay can go up quite a bit. Those who want a “cheap” plan might find that the choice they made this year isn’t the same one they’d make next year. Assuming that you just want to continue is a potential costly mistake.

    The bottom line is that while automatic renewal sounds great in theory, it might not be for many of the people who are getting insurance through the exchanges. Just one more “benefit” the administration may need to backtrack on as November nears.


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  • Vacation

    Starting now, I’ll be off the internet and without screens for a week. I do this annually and love it. (Yeah, I had a bonus week last month, but normally this is a once-per-year event.)

    As I’ve said before, you should try this too. I find that when I come back, I get about 7-10 days during which almost nothing irritates me. I more accurately (in my view) recognize most of the chatter designed to play on my emotions as noise (yes, I’m looking at you social media and you traditional media). It’s a great way to live!

    When I return, I expect you all to have fully sorted out all Halbig-related issues. Talk amongst yourselves.


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  • The regions of Australia

    Via tastefullyoffensive:

    austrailia dog cat


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  • What does the Gruber video tell us about Halbig?

    When it comes to the exchange litigation, what should we make of the Jonathan Gruber video that just came to light? In 2012, Gruber, who was heavily involved in debates over the ACA, responded to a question from the audience after a speaking engagement:

    [T]hese health-insurance Exchanges … will be these new shopping places and they’ll be the place that people go to get their subsidies for health insurance. In the law, it says if the states don’t provide them, the federal backstop will. The federal government has been sort of slow in putting out its backstop, I think partly because they want to sort of squeeze the states to do it. I think what’s important to remember politically about this, is if you’re a state and you don’t set up an Exchange, that means your citizens don’t get their tax credits. But your citizens still pay the taxes that support this bill. So you’re essentially saying to your citizens, you’re going to pay all the taxes to help all the other states in the country. I hope that’s a blatant enough political reality that states will get their act together and realize there are billions of dollars at stake here in setting up these Exchanges, and that they’ll do it. But you know, once again, the politics can get ugly around this.

    He apparently said something similar earlier that year. Gruber has since clarified that what he said “was just a mistake. People make mistakes. Congress made a mistake drafting the law and I made a mistake talking about it.”

    Clarification notwithstanding, does Gruber’s statement tell us something about what the ACA means? For their part, the courts probably won’t care all that much. One person’s (disavowed) view offered two years after the ACA was enacted can’t substitute for a careful analysis of the statute.

    Still, I don’t think Gruber’s statement can be written off altogether. As I’ve explained, I’m skeptical of the challengers’ claim in part because they’ve got no remotely credible evidence that Congress meant to use the loss of tax credits as a threat to get states to set up their own exchanges. To date, this Gruber video is the best they’ve found. It ain’t nothing.

    But if you think what Gruber said is some evidence about what the ACA means, you can’t ignore other, similar evidence. That’s cherry-picking. So go ask John McDonough, who was intimately involved in drafting the ACA and is as straight a shooter as there is: “There is not a scintilla of evidence that the Democratic lawmakers who designed the law intended to deny subsidies to any state, regardless of exchange status.” Or ask Senator Max Baucus’s chief health adviser, Liz Fowler. She says the same thing. Or ask Doug Elmendorf, the current CBO Director: “To the best of our recollection, the possibility that those subsidies would only be available in states that created their own exchanges did not arise during the discussions CBO staff had with a wide range of Congressional staff when the legislation was being considered.” Or ask Peter Orszag, then-OMB Director: “[A]s someone who was there, [there is] zero chance this was the intent (as opposed to typo/poor drafting).”

    Or ask Jonathan Cohn or Ezra Klein, both of whom followed the deliberations over the ACA closely. Neither heard a whisper about any supposed threat. Or ask Abbe Gluck, a law professor at Yale who details how “a basic understanding of the ACA’s legislative process makes clear that Congress intended for the subsidies to be available on the federal exchanges.” Or ask Aaron, who wonders, if this threat was so clear, why TIE never mentioned it. “Do you think we would have ignored this? We wouldn’t have been concerned?”

    Better still, ask the states, which were on the receiving end of the supposed threat. According to a report from the Georgetown University Health Policy Institute, there’s no contemporaneous evidence that the states feared that declining to set up an exchange might lead to a loss of tax credits. How can it be that Congress unambiguously threatened the states with the possible loss of tax credits if the states never understood that threat?

    In that vein, it’s telling that Gruber’s statement was made long after the ACA was passed. If Congress really meant to level a threat at the states to force them to establish exchanges, surely someone—anyone!—during the extended debate over the ACA would have said something—anything!—that made the point with comparable directness. The absence of any such statement still speaks volumes to me, whatever Gruber said in 2012.


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  • Stand Up! – July 25, 2014

    I was a guest this morning on Stand Up! with Pete Dominick, which airs on Sirius/XM radio, channel 104 from 6-9AM Eastern. The show immediately replays on the channel, so those on the West Coast can listen at the same times.

    We talked about—you guessed it—Halbig and the exchange litigation. It was a hoot. It wouldn’t have happened without Aaron’s much-too-kind introduction, so I owe him thanks for that.

    You can play the audio right here, after the jump…

    Read the rest of this entry »

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