This is a joint post by Austin, Aaron, and Adrianna (the TIE admins and comment moderators).
All TIE admins are in agreement that we need a break from comment moderation. It’s a lot of work and the benefits relative to costs have dwindled. We’d rather use our time in other ways. So, at least until the end of January, comments will be disabled on all TIE posts by default. We may open up comments now and then to solicit input on specific issues. We might invite comments on an occasional open thread, but we haven’t decided.
This is an experiment, and we’ll revisit this decision at the end of January.
This brief post doesn’t convey how much time and effort we’ve devoted over the past year or so in trying to find ways to make comment moderation less taxing on us. Our latest approach didn’t increase the burden,* but also wasn’t of substantial help in reducing it. The idea of shutting comments down altogether goes back at least a year; we would have done it long ago, but we recognize the value of comments to some readers, so we wanted to try other things first.
Those other things are not working well enough. And so, after lengthy deliberation, we’ll try going (mostly) comment free.
You are, of course, welcome to email us. Or, if you prefer a more public forum, you can tweet at us. And, you always have the option to start your own blog, start a comment thread on Reddit or similar sites, etc. We value feedback. We just need a break from the moderation duties. (And, no, we can’t run an unmoderated site. You would not believe the spam, even with a good spam filter running.)
* As of this writing, Austin has received a grand total of zero inquiries about unpublished comments.
As yesterday’s post on ADHD highlighted, it’s not been the best year for “medical” treatments in the US. I gathered my thoughts on this in an end-of-year column for CNN.com.
I spent last week in Disneyworld with my family. I love Disney, so it was awesome. It wasn’t even the rides. Any week I get to spend the majority of the time holding my kids’ hands is a win.
But I found that I didn’t check the news at all. Not once. They could have repealed the Affordable Care Act and I would have had no idea. When I got back, I just deleted the entire RSS news feed that had built up and started anew. You know what? Nothing had changed at all.
I saw the exact same stories finding examples of people who had lost their insurance. I saw the exact same stories about people who had gotten new insurance. I saw the same (albeit updated) horse race stories about how many people had signed up for Obamacare. I saw the same predictions of doom from the same exact people over and over and over again.
It’s all a bit tiresome, no? It is for me at least. I’ve talked with Austin more and more lately about how I’m feeling a bit over this. Maybe it’s end of the year rush, or maybe it’s just that I needed a break, but the feeling is there nonetheless. I do think, though, that part of the problem is that I’ve been feeling boxed in by the media narrative right now.
That storyline is dominated by screaming over whether the ACA is a success or a failure. It’s overwhelmed by a need from partisans to own the landscape and the megaphone as to whether Obamacare will hurt or help America. The problem is that it’s not evidence based. At least, not at this time. How could it be? The law doesn’t even go into full effect until tomorrow. Even then, it will likely take years (yes, that long) to know whether it’s actually doing more good or bad.
That’s how we do things over here in empirical land. After the years it takes to land a grant, and the years it takes to do a study, you spend a lot of time analyzing the results and trying to get them published. It’s a long, hard slog, and it takes a fair amount of patience. But you don’t write about the results until you have them, and you don’t scream predictions at the top of your lungs to drown out people who think otherwise.
I love research. I love science. That’s why I got into this gig. I wanted to use data and evidence to help change the health care system for the better. The activities that take advantage of that are the ones that bring me the most reward at the moment. I think part of the problem is that I’ve allowed myself to be pulled from that wheelhouse into the more traditional noisiness of health care media. In the new year, I’m going to make an effort to pull back. I don’t want to cover the horse race. I don’t want to make baseless predictions (for which I’ll never be held accountable nor admit I’m even the slightest bit wrong). I don’t want to discuss the politics. I don’t want to focus on laws over policies.
Most of all, I don’t want to get into fights.
I’m going to make a serious effort to make my stuff better next year, even if that means there’s less of it. Three and a half years in, I could not be more proud of this blog, or the people who contribute to it. As always, I’m grateful that you come to read what I (and the others here) write. We really do appreciate your support.
I hope your new year is everything you hope it to be.
Twenty years ago, more than a dozen leaders in child psychiatry received $11 million from the National Institute of Mental Health to study an important question facing families with children with attention deficit hyperactivity disorder: Is the best long-term treatment medication, behavioral therapy or both?
The widely publicized result was not only that medication like Ritalin or Adderall trounced behavioral therapy, but also that combining the two did little beyond what medication could do alone. The finding has become a pillar of pharmaceutical companies’ campaigns to market A.D.H.D. drugs, and is used by insurance companies and school systems to argue against therapies that are usually more expensive than pills.
But in retrospect, even some authors of the study — widely considered the most influential study ever on A.D.H.D. — worry that the results oversold the benefits of drugs, discouraging important home- and school-focused therapy and ultimately distorting the debate over the most effective (and cost-effective) treatments. [Emphasis added]
The study is the Multimodal Treatment of Attention Deficit Hyperactivity Disorder (MTA) study. It is among the best studies ever conducted in child psychiatry. Large samples of children diagnosed with ADHD were randomized into groups that received (a) the usual treatment offered in their community (‘Community Care’), (b) high-quality behavioral treatment, (c) medication following evidence-based guidelines, or (d) behavioral treatment and medication (‘Combined Treatment’). Community Care (a) might have included medication or behavioral treatment, but not the carefully-managed, evidence-based therapies delivered in conditions (b)-(d). Children were followed for 14 months. The Figure below presents the key results.
Statistical analyses showed that for most of these outcomes, behavioral treatment, medication, and combined treatment showed better results than community care. But although combined treatment was somewhat more successful than medication alone for some outcomes, those differences were not statistically reliable. The researchers concluded that
Combined behavioral intervention and stimulant medication—multimodal treatment, the current criterion standard for ADHD interventions—yielded no significantly greater benefits than medication management for core ADHD symptoms; this parallels findings reported by others.
The implication for practice was to medicate, medicate, and medicate. Medication is a much easier health service to deliver than behavioral treatment. Primary care physicians rarely have skills in behavioral treatment and even if they do they do not have the time that behavioral treatment requires. Similarly, it is much easier for a parent to give a child a pill than to change your behavior and your child’s. (Trust me on this: I raised five children.)
Yet several of the MTA authors are concerned that the study’s apparent validation of a “medication-only” strategy may have harmed children. They — and I — believe that even if there is a short term role for medication, children with ADHD symptoms need training to build the cognitive and social skills to function successfully without medication. Co-author Dr. Lily Hechtman:
I hope [the MTA] didn’t do irreparable damage. The people who pay the price in the end is the kids. That’s the biggest tragedy in all of this.
What went wrong?
It’s not that the MTA researchers were compromised by the pharmaceutical corporations. The study was conducted without drug company support. The constant promotion of medication by Big Pharma created a receptive environment for the message that “drugs are all you need,” but that’s not the authors’ fault.
The most important problem with the reception of the MTA findings was that we didn’t take a sufficiently developmental perspective in thinking about the problem. Learning to regulate your behavior and focus your attention are among the most important developmental tasks in childhood. A lot of this learning requires training by adults: This is much of what parenting and primary education are about. Some children need more help in this than others. Medication may be part of that help, but it is not a substitute for training. These developmental processes continue throughout childhood. This means that a 14-month study was not a sufficiently long period to draw definitive conclusions about the value of behavioral treatment or combined therapy.
Disclosure: Like Aaron, I’ve published on ADHD. I am the statistician for a group seeking to developed an improved method to treat ADHD and I receive funding for this work. Several of the MTA investigators are my friends.
If you don’t know already how much I love this episode, then you’re not a fan of the blog:
Pundits, media types, and curmudgeons like to claim that things were so much better in the “good old days”. They bemoan how kids are all sexed up and ruining everything now. They especially like to make these kinds of claims around the new year. They’re wrong. Things are pretty much better than they’ve ever been, and we’ve got data to prove it. The sky isn’t falling.
Please watch and share! We need support in terms of subscribers and viewers to keep this going!
My two daughters each received a 3x3x3 and a 2x2x2 Rubk’s Cube. As smart as they are, they’re both a bit young to have any reasonable chance of solving either on their own. I will confess, I never did so as a child either … or even as an adult. Fortunately, there are tons of resources to help me learn how to do so now: videos and countless websites, all of which anyone can find with the obvious search.
After stumbling around those, I finally found two I thought were the most helpful for the 3x3x3 cube:
In both cases, I found solving the first layer simple enough to do without instruction. Even the 2x2x2 bottom layer is tricky for my brain to intuit. That I don’t have a head for this surprises some people, but not me. I appear not to be a gifted 3D thinker. Two-dimensions is a different story. I wonder if this relates to my affinity for Go but not chess. Yes, both are nominally 2D, but chess pieces move so irregularly it feels like a third dimension of complexity to me. That never appealed to me, whereas I find Go as beautiful a game as could possibly exist.
Given the rate at which my kids mess up their Rubik’s Cubes, I’m sure to be able to solve them without help soon. Then I’ll have more patience to teach them, unless they figure them out on their own. That would be a thrill!
A friend, who’s a teaching assistant for an undergraduate political science class, invited me to chat with his discussion sections a few weeks ago; the Affordable Care Act is their last topic of the term. The students had just received an essay prompt on the law, and this was their final discussion (complete with donuts and eggnog to celebrate). We let the sessions take a relatively free-form Q&A structure. Two questions came up in both sections; I figured I share those here, in case you’re curious what—an admittedly very small, specific cross-section of—young adults worry about when it comes to health reform.
What’s up with states refusing to expand Medicaid? Considering the relative dearth of media coverage, it surprised me that this was the first topic brought up, and it seemed to bother them most. More than the website problems. More than long-run political implications.
Bracketing the politics for a second—though, with Obamacare, it seems politics can never be sidelined for long—I explained the economic concerns that states have about expanding their Medicaid rolls and taking on the eventual economic burden of paying for 10% of the expansion population. To that, I’d point to a recent report out of the Commonwealth Fund that puts those costs in perspective; Austin blogged on it here. There is also fear of the federal government walking back their commitment to a 90% match after 2020, but extant match levels have remained steady since the program’s inception, even during economic contractions (the federal government actually upped contributions during the most recent recession).
The political critiques come in two general flavors, though they’re not mutually exclusive: a belief that we oughtn’t subsidize health insurance for low-income but able-bodied adults, and a belief that Medicaid is a broken program that we shouldn’t invest in further. As I’ve written before, the Arkansas model is one answer to the latter point—but conservatives have to grapple with the reality that a “private” expansion will be more expensive than a traditional one.
I anticipate that the states will eventually all expand; the program took several years to initiate nationwide, as did the CHIP expansion. The recent budget deal delays reductions to DSH payments by two years, though. That was one of the biggest incentives for states to expand, so I expect take-up to lag.
What’s the worst-case scenario that could unfold over the next year? The one thing that could still be a huge blow to the law is a full delay of the individual mandate, which HHS could maneuver by expanding the recent “hardship exemption” to include those who were uninsured. I’m not confident that’s off the table yet—especially considering that some state exchanges are still struggling—but if the administration does offer a blanket delay, I don’t think we’ll see it until the end of open enrollment. The reasons are both pragmatic and strategic: we can’t know the extent of “hardship” until enrollment wraps, but we also know that people tend to sign up just under the wire. Massachusetts illustrated this, and so did enrollments before the “soft deadline” this week, if the limited data we have so far is any indication.
A one-year mandate delay is also something the exchanges could probably recover from. I’m more bullish on this than others, but that possibility was the original context of my “risk corridors” post; the risk adjustment mechanisms are in place for three years. Moreover, the penalty is weak enough in the first year ($95 or 1% taxable income, whichever’s higher) that I’m not sure that enrollment will be meaningfully different with or without a mandate in the first year. This is doubly true if a mandate delay were to be announced late in the game, when most of the people who would have signed up will have signed up.
Republicans are considering several ideas for how to proceed. [Republican Senator Ron] Johnson argued that Congress should do away with the mandate that most people obtain insurance, but not the online exchanges at the heart of the law. Instead, he said, the options in the marketplaces should be augmented by other choices that fall short of the law’s coverage standards, such as catastrophic health plans. […]
Senator Kelly Ayotte, Republican of New Hampshire, said she was teaming up with Democrats on a host of incremental changes to the law, such as expanding health savings accounts and repealing a tax on medical devices. And other Republicans are wondering aloud how long they can keep up the single-minded tactic of highlighting what is wrong with the law without saying what they would do about the problems it was supposed to address.
Representative Tom Price, Republican of Georgia, a physician and a prominent conservative voice on health care, is pushing what he calls the Empowering Patients First Act, which would repeal the health care law but keep its prohibition on exclusions for pre-existing conditions in private health insurance.
The bill would allow for insurance to be sold across state lines, push small businesses to pool together to buy insurance for their employees, expand tax-free health savings accounts, cap malpractice lawsuits, and offer tax credits of $2,163 for individuals and $5,799 for families to buy health plans.
The American Action Forum, a conservative advocacy group run by Douglas Holtz Eakin, a former director of the Congressional Budget Office, analyzed the Price plan this month. The group concluded that it would lower insurance premiums by as much as 19 percent by 2023, while leaving the ranks of the uninsured about five percentage points higher than the Affordable Care Act would by then.
Representative Paul D. Ryan of Wisconsin, the Republican vice-presidential nominee in 2012 and a possible 2016 presidential hopeful, is preparing his own health insurance plan for release early next year.
Mr. Ryan’s plan will build on one that he and Senator Tom Coburn, Republican of Oklahoma, introduced in 2009, according to aides familiar with it. The proposal, called the Patients’ Choice Act, would have eliminated the tax break for employer-provided health care to finance a tax credit of about $5,700 for families and $2,300 for individuals. States would have been asked to create insurance marketplaces like the ones many have created under the Affordable Care Act.
As with the Obama health care law, the Ryan proposal demanded that insurers meet minimum standards of coverage and be prevented from excluding the sick. But instead of mandating penalties for failing to buy insurance, the approach would have automatically enrolled people unless they opted out.
It being an election year, the safe money is that nothing of significance becomes law. The caveat would be if the ACA clearly and badly fails in more than a few states and for reasons beyond the control of those states (refusing to expand Medicaid hardly counts). Frankly, I don’t think that we’ll be able to make that assessment until next year.
I know it is difficult to get anything meaningful through this Congress, but I expected more from The Drug Quality and Security Act. See my Perspective at NEJM.
Austin and Aaron are participants in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to amazon.com.
12/31/2013
multiple authors
