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Al Smith on Democracy

In 1925, a handful of extremely wealthy Long Island residents tried to thwart state plans to run highways from New York City through Long Island to beaches that the masses could enjoy. These wealthy people were understandably upset, that part of their property would be taken away to make room for highways and the like. But they resisted to the point of inflexibility, and the millions of lower and middle class New York City residents who hoped to find weekend refuge from summer heat looked like they would be shut down by a few dozen multimillionaires. But Gov. Al Smith was not happy with this arrangement. And in a speech arguing in favor of these parks and beaches, he also made some pretty profound statements about democracy:

The cure for the evils of democracy is more democracy. Let us battle it out right in the shadow of the capitol itself and let us have a decision, and let us not permit the impression to go abroad that wealth and the power that wealth can command can palsy the arm of the state.

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Dramatic Primary Care Changes in Ontario

Healthcare systems are big and complex beasts, that are very hard to transform overnight. In the United States, for example, we have long had a system of care dominated by fee-for-service payment. In this kind of system, the more tests and procedures and office visits that a physician orders, the more that physician gets paid.

A little over 10 years ago, fee-for-service also dominated primary care practice in Ontario, Canada. You can see that with the light blue area in the circle on the left. But look what is happened in the past 10 years! System has dramatically shifted away from fee-for-service. And guess what? Primary care physicians in Ontario have greater job satisfaction than they had a decade ago.

If you want to read more about this transformation, check out the article by Brian Hutchison in the April edition of Health Affairs.

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On Repetition and Good Writing

In high school, I was taught not to repeat words too often in the same paragraph, or even within a relatively short essay. I know I am not alone in having been taught that way, because many of the people I’ve mentored over the years present me drafts of their writing which show that they have been working hard to give a different name to the main topics of their writings, each time those topics occur. A person writing about congestive heart failure, for example, may call it congestive heart failure one time, CHF another time, systolic dysfunction yet another time, etc., leaving the reader to wonder whether these are different but related concepts or simply the same idea put forward in a variety of guises. But often, repetition is a mark of good writing, not only because it is easier to understand, but because repeating the same word over the course of a paragraph, or even a longer chunk of writing, can give the writing rhythm.

Consider this paragraph from The Power Broker, by Robert Caro. In the paragraph he is writing about the main character of the book, Robert Moses – a behind the scenes politician, to most eyes, who nevertheless had an enormous impact on New York State and New York City, from its highways and parks to many other aspects of urban design. Moses had a brilliant legal mind, and was famous for throwing language into obscure sections of bills that would sneakily enable him, in whatever government position he held at the time, to garner more power.

Quoted below, Caro writes about the way he slipped concepts of “entry and appropriation” into the law in a way that clearly circumvented what anyone else wanted the law to accomplish, thereby accomplishing exactly what Moses wanted to:

To realize a dream of unprecedented scope, Robert Moses, by use of the law, had armed himself with unprecedented powers – and then, finding that these powers were still inadequate, he had deliberately gone beyond them, beyond the law. “Entry and appropriation” was, even as defined in law, of questionable constitutionality in its negation of the individual’s rights when his property was coveted by the state. And Moses had gone beyond the definition to use the power of the state with even less restraint than the law allowed. But both courts and Legislature understood the situation; before both courts and Legislature, Moses stood stripped of all defenses and, it seemed in February 1925, both courts and Legislature would now step in and rectify the situation, the courts by affording redress to the individuals injured by his actions, the Legislature by ensuring that he never again have the opportunity similarly to injure any other individual.

But the ultimate court in which the fate of Moses and his dream was to be resolved would be the court of public opinion. And in this court, Robert Moses had close to hand three formidable weapons…

Like a drumbeat, the words courts and Legislature recur throughout the paragraphs. And the closely related concepts of law and court do too. But rather than make the writing boring and repetitive, they propel the writing along. Beautiful stuff. Expect to see more over the next few weeks.

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On the Importance of Getting Things Done in Politics

I’m currently in the middle of reading Robert Caro’s first book, The Power Broker: Robert Moses and the Fall of New York. I’ll be blogging intermittently about this wonderful book over the next few weeks. Expect a few of those posts to be focused on drawing writing lessons from this wonderful author.

But a relatively early in the book, only 129 pages into it in other words, a paragraph jumped out at me that struck me as very relevant today: on the importance of finding the right balance between ideals in politics and accomplishing something in politics. The paragraph occurs in a chapter about Al Smith, the longtime governor of New York. He was not an intellectual, didn’t like to read it all, but was nevertheless very intelligent and shrewd. And what he understood most of all how to get things done. And that meant he sometimes lost patience with people who fought so hard for their ideals that they missed opportunities to implement policies that improve upon existing policies.

He has no patience for reformers who, unlike Belle Moskowitz, didn’t understand the importance of practical politics and getting things done, who refused to compromise, who insisted on having the bill as it is written, who raged loudly at injustice, who fought single-mindedly for an unattainable ideal. Their pigheadedness had the effect of dragging to political destruction politicians who listened to them, of ruining careers men had taken years to build. He had seen it happen. And more important, what was the inevitable result of their efforts? Since they refused to compromise and operate within the political framework – the only framework within which their proposals could become reality – the laws they proposed were never enacted, and therefore at the end of their efforts the people they had wanted to help, the people he knew so well needed help, hadn’t been helped at all. If anything, they had been hurt; the stirring up of hard feelings and bitterness delayed less dramatic but still useful reforms that might have been enacted. When the reformers were finished with all their hollering and were back in their comfortable homes, the widows of the Fourth Ward would still be forced to give up their children before they could get charity. What good was courage if it’s only effect was to hurt those you are trying to help?

I do love the writing of this paragraph – the back and forth between long and short sentences, for example. The rather than dwell on the writing per se, it’s the idea here worth noting right now: political courage doesn’t mean being unwilling to compromise. It means doing what you can, within the political realities you inherit, to make the world a better place.

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Will Obamacare Reduce the Crazy Variation in Hospital Prices?

If you have been paying attention to US healthcare policy debates lately, you know that hospitals have a price problem. Walk across the street from one hospital to a competitor hospital, and you could easily find yourself facing a $30,000 increase in your medical bills. At one extreme for instance recent information shows that replacing your hip with a surgical implant might cost anywhere from $5000 to more than $200,000, depending upon which hospital you go to for your procedure.

The good news is this: Obamacare will largely eliminate these price variations, by increasing the proportion of Americans with health insurance, thereby leading our insurance providers to negotiate more reasonable prices from hospitals.

Not sure that anything good can come out of Obamacare? Let’s look a bit more closely at the recent hoo-hah about hospital pricing… (Read more and view comments at Forbes)

 

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Great Writing from Charles C. Mann in the Atlantic Monthly

Followers of this blog, and I mean both of you, know by now that I am a fan of getting the word out about good writing. Here’s a nice example from the May issue of the Atlantic Monthly. It is from the cover article, titled “We Will Never Run Out Of Oil.” The whole article is fascinating, and I suggest you check it out. But there are also some nice little gems. Consider these two sentences:

Going about Bakersfield one night, I got hopelessly lost and ended up at a chain-link fence. Behind the fence were thousands of oil pumps, nodding up and down like so many giant plastic drinking birds.

This kind of sentence makes me realize how rarely I make use of such visual imagery in my own writing. That is something for me to work on.

 

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What Does It Mean to Be an Organism?

In a tremendous article in The Smithsonian Magazine, Richard Conniff writes about the largely unexplored oodles of microorganisms that make us what we are. The article overflows with wonderful facts: for instance, that there are 150 microbial species, on average, behind your ear, and 440 on the inside of your forearm. Not to mention the several thousand in your intestines, which of course I just mentioned.

“We tend to think that we are exclusively a product of our own cells, upwards of 10 trillion of them. But the microbes we harbor add another 100 trillion cells into the mix. The creature we admire in the mirror every morning is thus about 10 percent human by cell count.”

This is amazing stuff to think about. Philosophically speaking, it forces us to wonder what it means to be human. It’s not just about that bit of human DNA we have, that causes us to make our human cells. If we didn’t share space with all these other microorganisms, we would not exist.

But this is incredibly important stuff for medical experts to understand, too. Every time we give someone an antibiotic, we kill hundreds of thousands or even millions of microorganisms that make that person part of what they are. We are messing with a very complex group of organisms. Keep your eyes out for what scientists learn about this topic over the next couple decades.

 

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What Countries Are Successfully Controlling Healthcare Costs, and How Are They Doing That?

In the April issue of Health Affairs, a group of authors explored the cost-containment strategies and four high income countries, and try to see what they were doing that we are currently not doing in the United States. The first picture below, shows all five countries and reveals that, over the last 10 years, only two of them have done significantly better than the United States at controlling the rise of healthcare expenses. Keep in mind, however, that the United Kingdom has historically spent way less than these other countries, and over the past 10 years has been under pressure to increase health care spending.

All these countries, though, have a long track record of trying to keep health care costs under control. And given that they spend half or less, per capita, than what we do in United States, they must be doing something that we are doing. The authors have a nice table summarizing these approaches:

You should check out the article if you want to see more details. Because one way or another, the United States is going to have to begin adopting more of these strategies, if we hope to control the rise of healthcare costs and avoid bankrupting ourselves with unaffordable medical care.

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Healthcare Spending and Life Expectancy

I am not a fan of judging the quality of a nation’s healthcare system by examining life expectancy. Many, many factors influence life expectancy that have nothing to do with healthcare. When examining life expectancy in developed countries, for example, all of which have decent healthcare systems, your best bets at predicting differences across countries are to look at things like violence, income inequality and the like. You probably aren’t going to find differences based on aggressiveness hypertension treatment or the skill of local oncologists.

But this picture, from an article in Health Affairs in April, shows just how important healthcare spending can be in poorer developing countries.

At very low levels of spending, life expectancy dramatically plummets. The relationship between spending and life expectancy is pretty darn flat above about $2000 per person per year. Of course, no health care system should be judged upon life expectancy alone. Often quality of life looms just as large as length of life. But nevertheless I thought this was a pretty fascinating picture. Curious to hear your thoughts.

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Offensive Statements about Progressives from David Brooks of the New York Times

David Brooks is a pretty solidly moderate conservative, and one who is a big fan of behavioral science. But that doesn’t mean he can see beyond his own biases, especially when describing the differences between conservatives and liberals. He was particularly offensive on May 7, in an article titled “Beyond the Fence,” in which he discusses immigration reform. In the op-ed, he’s actually trying to promote a sensible middle ground, and it is clear that he thinks conservatives are off base in many of their ideas about immigration. But nevertheless, the first thing he says conservatives should know about immigration reform is the following:

First, immigration opponents are effectively trying to restrict the flow of conservatives into this country. In survey after survey, immigrants are found to have more traditional ideas about family structure and community than comparable Americans. They have lower incarceration rates. They place higher emphasis on career success. They have stronger work ethics.

By this logic, if you can call it that, one of the things that characterizes Progressives and liberals is that they end up in jail. Perhaps because they don’t care about careers? Because they have no work ethic?

I live in a neighborhood populated largely by Progressives, none of whom, to my knowledge, have spent any time in prison, and most of whom are workaholics. Hard work and following the law are not conservative values. They are moral values. And it is offensive to suggest that conservatives have better moral values than Progressives. If David Brooks really knew his social science, he would not have made this ridiculous statement.

 

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