Tuesday, December 26, 2006

It's Kidneys, Doc, Kidneys!

I really did get emails from one reader who lost her brother to kidney disease and who claimed she didn't know that ESRD is covered by Medicare. She thought it was the wonders of the market. I wonder if she's tried to purchase health insurance lately. I figure it can't hurt to confront these libertarians with reality every now and then.

Most of the statistics in this column came, directly or indirectly, from Medicare’s End Stage Renal Disease Program, by Paul W. Eggers, Ph.D. of the National Institute of Diabetes, Digestive, and Kidney Diseases at NIH, published in Health Care Financing Review (Fall 2000). Additional background on the political origins (and need for) the ESRD diagnosis can be found in Daniel M. Fox, Power and Illness: The Failure and Future of American Health Policy (University of California Press, 1993), at 76-77.

Bonus points if you know the setup to the punchline above, provided you're no longer in elementary school.

East Valley Tribune, Dec. 24, 2006

Some Bush-supporting dead-enders, upset at criticism of the Iraq war, have demanded the name of one government program that actually works. So let’s consider the Medicare end stage renal disease (ESRD) program. It’s not perfect, but since 1973, over 1 million people have had their lives extended or saved -- by socialized medicine.

Even people who should know better don’t understand how dialysis and kidney transplants became widely available. One reader lost her brother to kidney disease forty years ago; she thought market forces made dialysis cheaper, just too late for her brother. She simply didn’t know -- or her ideology wouldn’t let her know -- that it was government’s doing.

Today’s dialysis machines date back to 1960, and successful kidney transplants from cadavers became common a few years later -- early enough that her brother might have been saved. But until 1973, treatment was extremely costly; dialysis machines were rare, and most health insurance didn’t cover such "experimental" treatments. Physicians rationed care, deciding whether the mother of young children, or the older business executive, or the teenager should get the last dialysis slot. If you didn’t win, you died.

Not surprisingly given a subjective rationing system, patients getting dialysis didn’t quite reflect the population with kidney disease. In 1967, patients were overwhelmingly male (75 percent), white (91 percent), and young (only 7 percent 55 or older). By 1978, after the government became involved, patients were evenly balanced between men and women, blacks represented 35 percent, and 46 percent were 55 or older.

It took about a decade for the political system to make kidney care widely available. A Johnson administration advisory committee concluded that the benefits of dialysis and kidney transplantation far exceeded the disease’s costs. Five years later, Congress amended Medicare to cover ESRD -- a political diagnosis essentially invented to convert a chronic disease into an acute condition so it Medicare could cover it.

The ESRD program kept expanding, both in terms of coverage and patient numbers. Part of the latter increase comes from the dramatic increase in diabetes incidence; in 1978, 10 percent of patients in ESRD program had kidney failure from diabetes, but by 1998, 45 percent did. Additional advances also have allowed more medically fragile patients, and especially patients over age 65, to receive dialysis. Finally, Congress has expanded the program several times, although per capita and inflation-adjusted reimbursement rates are considerably lower than twenty years ago.

Not everybody qualifies for ESRD treatment under Medicare; it’s an entitlement only for those fully or currently insured for Social Security benefits, or a spouse or dependent. But those are not exacting requirements, so approximately 92 percent of persons with ESRD qualify for Medicare coverage. Thus, we have nearly, but not quite, universal coverage for nephritis under a socialized system, where every wage earner’s Social Security taxes help fund medical care for everybody, regardless of means, suffering from end-stage renal disease.

Yes, people who should know better don’t understand the role that government played in making dialysis and transplants widely available, so that losing kidney function wouldn’t mean death unless you won the rationing lottery. You’ll see ‘wingers complain about restrictions on dialysis in New Zealand, without acknowledgement that dialysis is widely available in the U.S., especially to elderly patients, only because Medicare covers it.

Ask anybody with kidney disease if they want to go back to the way life was in 1972, before big, bad government got involved. Start with those 1 million people who had their lives extended by Medicare; ask if they want to return to having doctors decide who shall live and who shall die.

Medicare ESRD is a government program of socialized medicine. It’s not perfect; lots of advocates want better reimbursement, especially for home dialysis, and there have been lots of not-nearly-as-successful government programs. But the next time you mindlessly parrot that government’s the problem, remember Medicare ESRD and those 1 million people.

As Matthew Holt once put it, remember that government spending led to the creation of the Internet and biotechnology; the market created reality TV.

Monday, December 18, 2006

War Isn't Like Poker (and Life Isn't Like a River)

For this week's column, I'm not sure the headline is right. My suggestion wasn't much better, but isn't the Bush administration's belief that you play for victory--unless it jeopardizes (not requires) tax cuts? That if raising taxes would guarantee victory in Iraq, well, we'd take our chances in Iraq? Well, it's weird either way. My original suggestion was "Iraq is the most important thing -- except for tax cuts" but this is how it got translated into newsprint.

You can click on links to some of the "double down" neocon articles, if you want to see the poker analogy in its natural habitat. It doesn't make any more sense in context.

East Valley Tribune, Dec. 17, 2006

By hiring a new football coach, Arizona State University has let the terrorists win.

That’s a pretty stupid theory, but it’s being pushed by the neoconservatives and other Bush administration enablers about Iraq. They claim that our enemies are banking on the American public’s weakness of will. Victory depends on the enemy knowing that we’ll do whatever it takes to win, that our capacity to inflict and absorb pain is so much greater than theirs.

The terrorists are supposedly media-savvy, designing their activities mainly based on how they’ll play in the U.S. press. We’re allegedly too susceptible to fretting over bad news and too fearful of casualties. We don’t understand that it’s absolutely vital that once the Bush administration decides on a course of action, no matter how seriously wrong-headed, the nation simply cannot turn back. Under their military theories, you don’t ever dare stop throwing good money after bad; instead, you keep increasing the bet. War, they say, is like poker; if you raise the stakes enough, you can win.


Did I say this theory was stupid? The poker analogy is particularly pathetic, because winning by raising the stakes depends on the other players not throwing good money after bad, to save their chips for the next hand. It’s also, as Matthew Yglesias notes, bad poker strategy because of the difference between the U.S. military -- which can leave Iraq -- and the Iraqis, who can’t. How do you bluff a player who’s already "all in"?

It’s also stupid because who, exactly, in Iraq is the enemy we’re trying to impress with our strength of will? Is it al Qaeda in Iraq, a marginal foreign presence? Former Ba’ath party officials? The Sunnis? Muqtada al-Sadr? The Iranian-backed Shi’a political parties, like the Supreme Council for the Islamic Revolution in Iraq, or SCIRI -- whose leader, Abdul Aziz al-Hakim, met with President Bush earlier this month? It’s hard to know which group upon which we must train our superior mental powers to make sure they understand the firmness of our resolve.

But the usual analogy isn’t that war is like poker (now there’s a slogan for McCain 2008: "Iraq -- a good bet at the time!") Instead, it’s football that’s like war. And if you win wars not by having the right leadership, strategy, and personnel, but rather by having enough willpower and resolve, then why did ASU bother hiring a new coach?

Shouldn’t ASU instead have demonstrated its superior strength of will by keeping Dirk Koetter, thus proving to our enemies that we simply won’t admit defeat, that our ability to absorb punishment far exceeded their ability to dish it out, and that our resources are inexhaustible and our resolve implacable? Isn’t replacing an underperforming coaching staff simply a distraction from demonstrating the willpower needed to triumph over our opponents? If wars are won and lost over the other side’s perceptions of our strengths and weaknesses, why not football games?

You’d never send a football team, at any level, out on the field armed solely with a bizarre theory that victory depends solely on "will." You also don’t tell them we want "victory" without first giving them a scoreboard and a game plan, two subtleties still eluding President Bush. You’d want some recruiting, preparation, and execution, then you’d try to pump everybody up at game time with pep talks about wanting it more than the other guys. Otherwise, we’d choose coaches based on oratory, not recruiting skill.


The most laughable part of the "willpower" theory is that even the most dead-end Republicans don’t really believe that the war in Iraq is the absolutely most important issue our country faces. Just ask what they’d do if winning the Iraq war depended on (gasp!) raising taxes.

With more money, we could pay more soldiers and reservists and reconstruct Iraq. We even could bribe more Iraqis. But if winning in Iraq wouldn’t make Republicans willing to reinstate the tax rates on the wealthiest we had during the 1990’s boom, then why, oh why, would we consider sending even more troops on this undefined mission, with no good ending possible?

Monday, December 11, 2006

Get Your Fresh ISG Backlash Here!

It's time for across-ideological-boundaries backlash for the Iraq Study Group! Obscure headline, but it's all my creation, I hope you get it.

East Valley Tribune, Dec. 10, 2006

It was "hooray for bipartisanship" week in Washington, as the wise men and woman of the Iraq Study Group finally issued their long-awaited report. The report is quite definite about our serious, and increasing, problems in Iraq. On solutions, it’s backside-covering mush, but it’s not like anybody else has a better plan.

The report is quite stark on the problems with Bush administration’s policy and the grimness of the current situation. Forget all the happy talk and Bush’s plan-of-the-month club. Whether it’s stay the course or stay the course-light or even barbeque-flavored-stay-the-course, the situation in Iraq is "grave" and "deteriorating." And, you’ll note, this occurred before Nancy Pelosi becomes Speaker of the House, so don’t blame her.

All you people who insisted that the media was exaggerating the problems in Iraq, that the reality was better than the "if-it-bleeds-it-leads" reporting, and that the day of glorious victory is just around the corner? You’re wrong.

The wise guys and gal, on page 94, said that the Bush administration has engaged in "significant under-reporting of the violence in Iraq" due to a tracking system designed to minimize Iraqi deaths. The reporting standards excluded attacks on Iraqis where the source could not be readily determined; attacks not resulting in U.S. casualties also weren’t counted. The ISG’s conclusion: "Good policy is difficult to make when information is systematically collected in a way that minimizes its discrepancy with policy goals."

That may be a bit opaque for lay readers, so let me translate into plainer English: In the Bush administration, when reality differs from ideology, it’s reality that’s biased.

The ISG report’s recommendations, however, are easily picked apart, mainly because there really aren’t any good options left. Conservatives demand that we try harder to win, but except in comic books, strength of will doesn’t win wars; I’d rather depend on technical expertise, sufficient forces and firepower, and having a competent strategy. Next time, try having the basics covered before starting a war, and let willpower take care of itself.

It’s not particularly troublesome that the ISG recommendations don’t seem militarily realistic, and are sufficiently vague that they could be used to justify immediately withdrawing combat troops or increasing the U.S. commitment. It’s also not practical to imagine the FBI and Justice and State Departments suddenly placing thousands of career bureaucrats into body armor and Arabic-language courses to help create a functioning Iraqi civil society. It’s also plainly foreseeable that President Bush won’t adopt many of these recommendations, even when they called it a "diplomatic offensive" hoping that sounds more macho than asking the administration to talk to other countries for their help.

No, what bothers me is all this folderol about wise men, bipartisanship, and comity. David Broder went over the edge when he described the members of the ISG as having undergone "an exhilarating experience, a demonstration of genuine bipartisanship that they hope will serve as an example to the broader political world."

Yes, isn’t it wonderful? We created an evenly-balanced (5 Republicans and 5 Democrats, 9 men and 1 woman, 9 whites and 1 black -- that’s balance for you!) commission and let them solve all our problems in a bipartisan, polite, unanimous way. Apparently, the only thing more important than democracy is civility.

Yes, bipartisanship is such a wonderful thing. Just think how useful this structure could have been only a few years ago. Instead of that nasty, partisan, and contentious impeachment, we could have convened a similar group, evenly balanced between Republicans and Democrats. They could have investigated President Clinton in secret then, with great fanfare, issued a report that would have been a model of civility and unanimity, coming up with a way to disapprove of his behavior without, well, making an unseemly fuss.

Now that Bush has thoroughly messed up Iraq far beyond the powers of even James Baker to fix, now you want bipartisan civility? Kids, you should have thought of that during the last president’s term.
Obscure Political Sports Analogies

You don't expect the Jewish kid to use a boxing analogy, do you? Well, maybe you should.

I also gave Paul Davenport a different sport analogy, noting that last spring conservatives opposed to gay marriage were upset with the GOP-controlled legislature for only having the votes to put on the ballot a constitutional referendum that would have banned gay marriage. Outraged that it wouldn't also prohibit domestic partnership arrangements, they instead gathered signatures for the combo initiative-- which gave opponents their message and means to defeat the initiative. So here's a perfect example of Republicans who not only were out of the mainstream; they were aground on the right bank and left to wonder why the canoe wasn't moving.

Monday, December 04, 2006

Fife and Me -- A History

Here's some ancient Arizona political history, triggered by the unsuccessful candidacy of former Gov. Fife Symington for chair of the GOP committee in Legislative District 11. It's internal political party politics, a topic about which I unfortunately know something. Being chair of a state party, as many of you have heard me say, is like taking small children to a fancy restaurant. You always want people to say when you leave, "I wish you could have stayed longer."

My editor enjoyed the local color and gave me more space than usual. Everyone's still in a bit of shock that the D's picked up one of the seats in this district in the state house.

East Valley Tribune, Dec. 3, 2006

Fife Symington, I feel your pain.

Which feels pretty odd, especially knowing our history. I once was on Fife’s holiday gift list (Cookies from Home -- nice choice). I represented the permanent lender for Symington’s Mercado project. When the loan closed, we were friends. Once he had to repay it, no more.

Trying to stave off bankruptcy, he sued me personally. I was a witness in his bankruptcy trial, and both of us testified in the lawsuit between the Mercado’s permanent and construction lenders. The jury returned a verdict for my former client, convincing me of the accuracy of a poll of 12 registered voters.

Politically, we similarly moved farther apart. Fife started as a moderate, back when moderation was cool. As governor, he appointed good people, like Chris Herstam as chief of staff, Ed Fox at environmental quality, and Betsy Rieke at water resources. He campaigned as the alternative to the failed ideology of Evan Mecham, then as governor started channeling Evan Mecham. Now he’s the most anti-abortion, anti-gay marriage Harvard College grad around.


After my defeat in the 1994 GOP wave, I got elected chairman of the state Democratic Party, where much of my role consisted of Fife Symington jokes -- after his bankruptcy filing, political comedy gold. Assisted by Symington’s continuing ethical and political troubles, Bill Clinton carried Arizona in the 1996 election, the first for a Democrat since 1948. But Symington couldn’t squawk much about Clinton, not after getting one of Clinton’s last-minute pardons.

I now also share with Fife, besides residing in Legislative District 11, an unsuccessful political party election. Last month, Symington ran for chair of the District 11 GOP committee, and lost 215-166 to incumbent chair Rob Haney.

Haney is reportedly (permalinks don't work; scroll down to "Fife's Running") a tireless grassroots organizer who recruited most of the district’s precinct committeepeople, who elect the chair. He also detests Sen. John McCain, another District 11 resident. Haney won approval of resolutions censuring McCain from both District 11 and the Maricopa County GOP committee, embarrassing a potential presidential candidate.

Besides Symington, an entire slate ran for District 11 GOP office to try to limit some of the intra-GOP squabbling, with endorsements from Sen. Jon Kyl and Reps. John Shadegg, Jeff Flake, and Rick Renzi. (McCain stayed out of the fray, but notable by her absence was state Sen. Barbara Leff, who is now officially as right-wing as they come.) Despite the endorsements, Fife’s entire slate lost -- big.

In my case, eight years ago, after being a congressman and State Chair, I ran from my district for the state Democratic Party committee. Like Fife, I wanted to unseat the incumbent state chair, a buffoon with a knack for shooting other Democrats in the foot. Unfortunately, his true-believer supporters thought actually winning elections was for sissies, so I lost.

The Haney faction is only following the advice of Matthew Dowd, President Bush’s former pollster, who believes most independent voters almost always vote with one party. Using Dowd’s research, Karl Rove instructed Bush not to govern from the center, but rather by rallying the base and dragging along rightward-leaning independents.

But Dowd’s analysis may not hold up, because the base can devour endless red meat and only clamor for more. A twice-elected former governor and the most hawkish GOP senator were insufficiently conservative for District 11 true believers, who wanted their carrion even more right-wing -- potentially too right-wing for many independents.

There are few things less worthwhile than internal political party elections and bickering. Like faculty politics, it’s so vicious because the stakes are so low. And one of your greatest burdens as a candidate or public official is the vitriol from those exhausting true believers theoretically on your side. They proclaim loudly that they stand on principle, but it sure seems like petty squabbling over personalities.

In Congress, I was tormented, with a viciousness that even Rob Haney might admire, by people who thought the most important issue facing our country was The School of the Americas. (Go Google it, and see that on the Internet, nobody knows your issue is a dog.) And don’t get me started about the 2000 Nader campaign. Thanks again, Ralph.


A major accomplishment of the long, dark night of the Bush administration is convincing Democrats we have more important battles than intramural ones. It’s bad for the state, but as a Democrat, I’m delighted that Republicans want to mimic our worst mistakes -- and even more delighted if the GOP wants to convert “independent in name only” voters into actual independents.

While District 11 has an 18-point GOP registration edge, there also are over 20,000 registered independents -- 21 percent. If you can only be a Republican if you’re a real true believer, then Democrats may keep finding common cause with those independents and “soft” Republicans.

District 11 independents may be becoming more independent than Republicans would like. They certainly had no problem voting for both Democratic Gov. Janet Napolitano and Republican Sen. Kyl -- and Democratic state Rep.-elect Mark DeSimone thanks them, too.
Yet Another Race Update

Sunday was the Fiesta Bowl-Runner's Den half marathon in Scottsdale, and while I was 31 seconds--31 seconds!--short of my goal of breaking 1:50, I did improve my time from last year by over 8-and-a-half minutes, and it's a new PR for the distance at 1:50:31 (gun time, not chip time, too). Maybe next time I'll do better if I haven't donated blood 4 days before the race. It's a pretty fast crowd; the third fastest male in my age group finished in 1:32, and there's no way that's happening for me. If I make it to age 80, only then would I have a chance. Nice T-shirt, though.