2017 Politics open thread, May 14-20

Let’s talk politics!

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370 thoughts on “2017 Politics open thread, May 14-20

  1. What has surprised me about recent events is how unpatriotic Republican leaders (if that term is still apt) are.

  2. Like the Dearmans, Mr. Belanger canceled a plan that complies with the Affordable Care Act and bought a short-term policy that does not meet the law’s standards, paying $580 a month for his family of four compared with the nearly $1,200 a month he paid last year. Policies like theirs usually have high deductibles and primarily offer catastrophic coverage for major injuries. Once the policies expire, policyholders must reapply and may be rejected if they are sick.

    What’s the plan if they get sick? They’ll have to reapply and premiums could hit $14k a month depending on their prognosis.

    https://mobile.nytimes.com/2017/05/12/health/affordable-care-act-repeal.html

    I have noticed that many on the right view medical expenses as episodic. A friend’s mom had breast cancer a few years ago and it was $70k after all was said and done. Another friend’s mom had the same, but it came back, again and again. She ended up fighting it for five years before she passed away.

  3. Continued: In my personal experience a fair number of people who get sick don’t end up needing a one and done procedures they end up with reoccurring cancer, premature babies without ongoing health problems, heart disease, lupus, neurological problems, etc. that are chronic and expensive.

    Is it cognitive bias that has some folks focused exclusively on the one and done or is that just their personal experience?

  4. I don’t think that is the issue. People want to be able to buy in advance at a reasonable price a good catastrophic policy without ridiculously low limits, preferably one that can’t be cancelled on renewal date when they get sick, but see below. They are willing to buy one that excludes a lot of stuff that they believe they won’t need. Period. Most people, other than those who have become accustomed to cadillac plans with low deductibles or live in metro areas where there are top notch kaiser type plans, don’t want a prepaid health plan allowing for constant cheap visits to the doctor and lots of tests. They are willing to pay for services when they absolutely need them, and testing and routine visits far less often than the norms of the full service plans. Most people don’t need a yearly checkup, but doctors won’t renew your prescriptions without one. I don’t ever need a bone density test again in my life. I don’t need a yearly mammogram. But I get little reminders all the time.

    But in reading Rhett’s link, it appears that the interviewees also think that anyone with a chronic disease should not be left to die or be unable to get treatment. One had family members who can’t buy insurance. They just think that taxpayers in general via the government should provide a base level of care (a level of care that they themselves would generally consider sub optimal, but beggars can’t be choosers) via some mechanism – high risk pools, buy into medicaid, not healthy regular hardworking people paying more for private insurance. Something like WCE’s argument that MA health care worked because we have more well off people to pay more taxes, but on a national scale (so even more fed tax money going from MA to MS). I guess the wishful thinking is that they fail to recognize that they might fall into that situation quickly and that an episode, even a trivial one – everyone has seen the long list of disqualifying preexisting conditions, not only a recurring disease, can make them one of the uninsurables in a private market.

  5. They just think that taxpayers in general via the government should provide a base level of care

    1. Six of one half dozen of another. Either they pay $500/month and we run it through the insurance system or pay $250/month insurance and $250/month in taxes. The only way you can prefer the tax option is you believe the government can administer the plan more cheaply.

    don’t want a prepaid health plan

    I haven’t see any breakdown that shows the checkups and tests are a significant driver of cost.

    people want to be able to buy in advance at a reasonable price a good catastrophic policy without ridiculously low limits, preferably one that can’t be cancelled on renewal date when they get sick.

    With the possibly naive assumption that they will have a one and done medical expense, not on that draws out for years.

    The other issue is the 1:3 limit on the premium older folks can be charged under the ACA to old people compared to the 1:5 or more limit under the AHCA. There is a logic behind that change but also the assumption that people will be saving extra toward an unplanned 58 year retirement. The average person’s long term planning track record is pretty poor in that regard.

  6. Meme said “Most people, other than those who have become accustomed to cadillac plans with low deductibles or live in metro areas where there are top notch kaiser type plans, don’t want a prepaid health plan allowing for constant cheap visits to the doctor and lots of tests.”
    Is that really true? The complaints people were making against the high deductible plans that are in the ACA was that they couldn’t afford to go to the doctor when they thought, for example, they had strep. People do seem to want to run to the doctor for things like that, and they want it to be covered. That is why they were hating the high deductible plans so much.

  7. For example, read the complaints in this article. People are complaining that their insurance is only good for emergencies, and that they can’t afford to go to the doctor. They don’t want high deductible plans that mainly cover catastrophic stuff

  8. The problem I see with Americans is that they think their health is going to stay static. So they conceive of health insurance not as insurance against a future risk, but instead, a kind of prepayment card tailored to their exact healthcare needs at this moment. But life doesn’t work this way, and just because you only go to the doctor twice a year, for say allergies, doesn’t mean that next year you might develop MS or lupus or heart disease. That is why I cannot understand those advice columns that tell people to purchase insurance based on their current expenses. Generally, most people become less healthy over time, rather than staying the same.

  9. Most people don’t want costs for routine/current care built into their premiums or their budgets. One aspect of the healthcare debate is that people will want care if other people pay for it that they might not choose if they had to pay for it out of pocket at current cost levels. (I’m limiting my examples to care that to my knowledge doesn’t affect public health or healthcare statistics between countries.)

    One example is epidurals during childbirth. It’s expensive to have an anesthesiologist/anesthetist available for a mother in labor at a smallish hospital. Another example from my own experience is mastitis treatment. I commented last year about suffering from ~10 bouts of untreated mastitis before I had a 3 week bout that I finally got treated. I am unwilling to pay ~$150 for a visit with a primary care provider for something I know is probably not going to kill me and that I’ll probably get over soon. Presumably working/lower middle class women are even more price conscious than I am.

  10. WCE, then why were people complaining so much about their ACA plans? They were upset that they would have to pay out of pocket for doctor visits

  11. There are two sorts of complaints. One is from people who truly want a basic long term catastrophic policy, while paying for occasional doctor visits out of pocket and can’t get one in their state anymore because of the essential services and covered tests and routine visits reqirements. The other is from people who haven’t had insurance for a while and were looking forward to a policy like their old one from an employer 15 years ago. They wanted high coverage at a low price, and high deductible plans on the exchange were a shock. Both groups feel that they are getting a raw deal because they are paying through the nose fir what they don’t use and one way or another are disadvantaged versus either Medicaid recipients who don’t have deductibles or really sick folks who blow through the dedutible quickly.

  12. These complaints seem to stem, at least in part, from a disconnect between what people believe health insurance to be and what it actually is. The first group is seeking true insurance (i.e., financial protection against unpredictable catastrophic events) and can’t find it at affordable rates. The second group is seeking low-cost prepaid health care and can’t find it either.

    Just wondering how people in the first group came to accept the concept of paying out of pocket for routine or occasional medical care, and how others still believe that insurance should cover such expenses. Is this, as Meme suggests, a legacy from generous employer-provided health care plans from BITD? Should we be nudging more people from the second group into the first group? How do you encourage people to regard routine health care costs in the same way as food, housing, utilities, transportation, and other life necessities for which adults are expected to budget?

    That last question hit home as working DS has been dealing with an annoying but not life-threatening health issue but has been reluctant to return to see a doctor because he has to pay for it. He earns a good income and has health insurance (both from his employer and as a free rider on DH’s policy) but visits and tests aren’t “free” so he doesn’t go. When he was living at home, it never occurred to me to discuss the finances of medical care, as we did with food and housing and cellphone plans. Clearly, that was a mistake, but who knew? It was also a challenge to nudge him to find a dentist and schedule regular appointments. For at least a year after his departure from the nest, I still got reminders from our dental office that he was due for a cleaning.

  13. The people I know who have had to buy their own healthcare insurance resent how high the monthly premiums are for what you get. These are people that can well afford the premiums, but when you’re paying $1500 per month for a family plan and then you take your kid to the ER because he’s having an allergic reaction to milk, you can expect an additional $3000 bill. We’re covered under my husband’s work but it is terrible compared to my old state employee HMO which had low premiums (because the state was kicking in so much) and then maybe there was a $15 co-pay (no deductible). Our premiums are double now and anything beyond annual care is out of pocket until you meet the deductible. We are not big healthcare users anyway but I would probably avoid going to the dr. if I was sick so I wouldn’t have a $300 bill to get a prescription in addition to the $12K per year we pay for premiums. You always compare with what you used to have.

  14. How do you encourage people to regard routine health care costs in the same way as food, housing, utilities, transportation, and other life necessities for which adults are expected to budget?

    Why would we want to encourage that? It’s certainly not the main driver of healthcare costs. I’m curious why you keep bringing it up – do you have some data on how much it would save if people did that?

  15. As far as I can tell, many people want to pay very little, get everything covered for themselves at the exact moment that they want it (including new and cutting edge stuff) and not have to pay for anyone else’s care. So, basically magic.

  16. Epidurals at a small hospital is a perfect example of the weird market of health care. However, I don’t think it proves that we overuse when others are paying. Hospitals that deliver babies need on call anesthesia. No exceptions. Even with my crunchy birth philosophy I think the unplanned, emergency c-section rate should be above 0% in a well-screened population.

    The actual cost of putting in the epidural is likely less that $100 (there is a specialized catheter). The doc, the nurse were going to be there anyway. In a single payer system the cost of labor might reflect that every patient needs to cover the cost of the anesthesiologist. Instead we charge gigantic procedure and equipment costs to recover the cost of providing a necessary service.

    In any case, individuals may save money by declining an epidural. The system, as it currently exists, does not. That seems perverse.

  17. When I was paying through the nose (avg monthly cost over that time 500 per mo) for the high deductible plan – PPO, not HMO – (6 years before Medicare kicked in last fall) I was able to deduct the cost against 1099 income for fed and state income tax (but not against the base subject to self employment tax at 15%) and also funding to the max the health savings account (about 5K a year), and using those tax favored dollars to pay for prescription copays, deductibles, dentist, eyeglasses. Vaccinations, yearly physical, mammogram, colonoscopy were fully covered. The negotiated insurance rate brought the cost of lab tests and doctor visits well down from list price.

    The effect of never meeting the deductible was to make me not go to the doctor for a lingering cold for an insurance negotiated cost of say, 120 dollars. But I did go if there was something I felt needed attention (not much). I haven’t had dental insurance for years – I can buy an exam, xrays and 2 cleanings for 200 a year on the prepaid plan, and dental ins is 60 dollars a month or some such. Now that I am on the lowest level of Medicare advantage (no extra premium above my Medicare assessment) which is HMO style, I have a free annual physical, the same free tests and vaccinations, and a 30 dollar copay for PCP visits and 40 dollar for specialist visits and flat rate for ER visits. No more ability to contribute to HSA, but I have a balance that I am using slowly. The 40 dollars is perfect price point for me to choose 6 visits to the occupational therapist for my thumb instead of the authorized 10, and to decide that if I really feel the need for a shrink, I’ll just find a good one and pay out of pocket (few non clinic mental health providers who have openings take any form of insurance any more – they are not just refusing medicaid/medicare) instead of throwing the copays away.

  18. “Why would we want to encourage that?”

    Why *don’t* you want to encourage that?

  19. Why *don’t* you want to encourage that?

    For all the hassle involved it won’t save a meaning full amount of money.

  20. The examples above remind me of the system challenges I observed with the twin pregnancy. As far as I could tell, NICU charges at least double actual costs, because Medicaid reimbursement is so low, so the private insurance pays ~160% of the actual costs and privately insured parents pay 40%. The implicit subsidy of private insurance appeared to be part of what the system work. The hospital I went to also overbilled and billed above the contracted level of care, and it took a year of phone calls to fight that battle. There is no recourse against such a hospital, I am told, even though they make no effort to fix the “errors” in their systems.

  21. The Singapore system forces people to contribute to a lifelong HSA and to a retirement fund, and caps how much of the HSA they can use during the early years on each procedure and overall each year, but allows family pooling up to the limits. They also have to use HSA dollars for the catastrophic insurance premiums, also mandatory, and for the modest copays – nothing is free. The covered care is pretty much all in the public hospital system, and 25% of the population uses the private non covered system (covered by multinational corp insurance or personal wealth or private insurance). So you have government mandate, government health care, “death panel” type limitations on what is covered, and an opt out for the well off and the medical professionals who don’t choose to work for the State. All within 300 sq miles for 6 M people who live under a benevolent authoritarian regime established to ensure ethnic/racial dominance of one group.

  22. so the private insurance pays ~160% of the actual costs and privately (publicly) insured parents pay 40%.

    I can certainly see the rational for raising taxes to increase the Medicaid rate and reducing the degree to which we fund indigent care by over-billing private insurance. But that would require a tax increase and many would object to that even if it meant the average person’s take home pay would stay the same.

  23. Rhett keeps making a good point – stuff like visits to the doctor for a strep test are not big drivers of costs in our system. I think high deductible plans will end up just nibbling at the edges, while at the same time making a lot of people mad. What makes healthcare costs so difficult for many people is that they are both very unpredictable and at the same time, often can’t be deferred. If your kid is sick with what may be strep and can’t go to daycare or school, you need to do something about it asap. The only thing remotely similar are emergency car repairs – and that is another thing that makes people boiling mad. I do not think high deductible plans are going to save our broken healthcare system, and I don’t think the fury and finanical instability that they cause is really worthwhile.

    I still cannot understand why, if so many other countries are able to cover healthcare costs so that people feel secure, for lower costs and quite often better outcomes, why we continue to throw our hands in the air in despair and say “We can’t do it!”.

  24. “For all the hassle involved it won’t save a meaning full amount of money.”

    Theoretically, there should be far less “hassle” in a system in which insurance coverage is reserved for catastrophic care. And a quick Google search found this (old) article* estimating the significant administrative costs associated with health insurance coverage. http://www.nejm.org/doi/full/10.1056/NEJMsa022033#t=article

    *as an aside, the first author of this study has the easiest name to Google — Woolhandler. Love it.

  25. “The only thing remotely similar are emergency car repairs – and that is another thing that makes people boiling mad.”

    But they pay for them, and don’t expect their auto insurance policy to pick up the tab. Just as they don’t expect insurance to pay for new tires or windshield wipers.

  26. This isn’t political, just argumentative. Antibiotics for strep pharyngitis does not decrease duration of symptoms. Tune into this space in 3-7 weeks where I’ll be saying the same thing again. Some day I’ll win the in the internet.

  27. Scarlett,

    OK, fine let’s say administrative costs are 50% of the cost. To get my yearly prescriptions refilled is $120 for the appointment and another $50 for tests so $170. 50% of that is $85 for a total savings of $7.08/month. I don’t see how that’s going to result in huge cost savings.

    Theoretically, there should be far less “hassle” in a system in which insurance coverage is reserved for catastrophic care.

    So we’ll utilize the great untapped font of cognitive ability and executive function and have the public take over the administrative burden of some portion of the health care industry. Personally, I don’t know that the font has anything in it.

  28. The difference is that you can often hold off a bit, or do at least some of the work yourself. People who are economically most vulnerable to auto repair costs also often have the skills to keep their car running. People also will hitch rides with friends for a while or in many areas, take the bus. You can’t do that when the school nurse is telling you your kid can’t be back in school until they have a note from the doctor, or when you have injured your wrist and it is all swollen and may be broken but you aren’t sure.

  29. But they pay for them, and don’t expect their auto insurance policy to pick up the tab.

    Many people don’t. Why do you think Hyundai and Carmax offer 10 year 100,000 mile warranties and auto insurers have deductible and accident forgiveness plans?

  30. “Antibiotics for strep pharyngitis does not decrease duration of symptoms”
    Please, please, communicate that to the school nurses and daycare directors. A very common school policy is that kids with symptoms can come back in when they have been on antibiotics for 24 hours. I really wish that doctors did more outreach to the schools, because I swear that school/daycare policies are one of the big drivers of unnecessary doctor visits.

  31. Scarlett,

    How much do you personally is left in the font of cognitive ability and executive function? Given how many people can’t come up with $400 if you held a gun to their head and have no retirement savings, I’d say we’re pretty much at the limit now.

  32. “they fail to recognize that they might fall into that situation quickly ”

    The neighbor kid, 19 or 20, had a job as a pizza deliverer. He crashed his car into a telephone pole Saturday night. Don’t know the specific circumstances/cause. His sister, same age as my middle, said he had spine surgery yesterday and it looks like he is paralyzed from the waist down.
    I am sure they have plenty of the right kinds of insurance.

    Anyway, ya never know when it might be YOU.

  33. I’ve heard of policy that require 24 hours of antibiotics for pinkeye, but never for sore throats. How does the school know if it’s strep? Do they require you to release microbiology testing for every episode of sore throat? Or do you just need antibiotics for any illness before returning to school?

    Yeah, schools have crappy policies. I’d love to educate them.

  34. If we think the bulk of healthcare costs are incurred to prolong life, we as a country haven’t come to accept the cost related to keeping some one alive for say 3 months to a year. We just want everything done till at some point it becomes obvious that hospice would be better.
    I think in most places there is a degree of rationing. If you are in a position to pay and go the fast route you do that. In the home country they just started having medical insurance. You paid out of pocket First and then applied for reimbursement. At first there were no restrictions but after say three years the insurance company made it clear on how much they would reimburse you for certain procedures. My parents picked a doctor that was more expensive so they had to pay the difference but many other people found a doctor that didn’t charge more than what the insurance company would reimburse.

  35. I think school nurse expectations are highly dependent on where you live. I was listening to one of my techs talk about her son who broke his elbow in a school bus accident a few years ago but they didn’t take him in to the doctor for ~3 weeks because “he didn’t complain enough- we didn’t know it was broken.” I know another family who fixed their toddler daughter’s cut head with Superglue.

    I think working class people already avoid the medical system, based on the anecdata above, perhaps more than they should. I agree with Mooshi that the system needs to change, and that high deductible plans aren’t good for working class people, and with Louise that rationing care is a necessity. And to bring this back to politics, the families above are the working class people who are frustrated that people a notch beneath them get Medicaid and they get high deductible ACA plans.

  36. “Is this, as Meme suggests, a legacy from generous employer-provided health care plans from BITD?”

    Umm, yeah. I am used to the cost of my healthcare being completely invisible. My firm picks up my full share of the premium, which I think is like $1300/mo for a PPO. DH gets a cafeteria plan contribution for Kaiser for the rest of the family; our share for that is something like $1100 over what the company pays. But even that just disappears out of his paychecks, so it never “feels” like real money. And in return, pretty much everything costs me $20, with an ER visit maybe $50-$100. Medications: $20. Mammograms/colonoscopy/annual physicals: Free to $20. Blood tests: free. I mean, DD had foot surgery, DS has a broken foot; for each, we paid $50. Total. Including crutches.

    So if you asked me what does health care cost, I am anchored at “pretty damn cheap.” But the *real* story is more like $30K/yr just in premiums.

  37. “the families above are the working class people who are frustrated that people a notch beneath them get Medicaid and they get high deductible ACA plans.”

    Yes, I have heard this quite a bit. Vox did a great piece on this, based on interviews with people in Kentucky. Which tells me something – people would rather have the often-maligned Medicaid than a high deductible plan.

  38. People would rather have Medicaid because it’s “free” to the recipient. If they had to pay the real cost of either plan, it’s unclear what they would prefer.

  39. “As far as I can tell, many people want to pay very little, get everything covered for themselves at the exact moment that they want it (including new and cutting edge stuff) and not have to pay for anyone else’s care. So, basically magic.”

    I agree. I think people here are overestimating the sophistication of the average person’s thinking in this regard.

  40. Bright Horizons, which is one of the big daycare chains, has the strep policy – 24 hours after antibiotic has started. I notice they no longer have that specific policy for ear infections which as standard when my kids were in daycare, but they do have a general at the end that a kid can come back in after 24 hours on antibiotic.

    In our day, what this meant was a doctor visit every month or two, Daycare calls up, says your kid looks like he has an ear infection and has to go home now. He can come back in once he has no symptoms or has been on an antibiotic 24 hourse. Next month, we get the same call except now it is pinkeye. Those two conditions caused so many doctor visits.

  41. “If they had to pay the real cost of either plan, it’s unclear what they would prefer.”

    So how do they get people to pay the real costs in all those other countries that have universal coverage?

  42. Most other countries pay higher taxes and have less comprehensive/expensive medical services. They also pay less of GDP toward policing the world and pharmaceutical/medical device development costs so more tax dollars remain for healthcare.

  43. Here is a horrific article that shows one area in which our outcomes are not that good : maternal deaths during childbirth. This has been falling in other countries but has actually increased here since 2000. In particular Great Britain has done a very good job at getting the rate down – and Great Britain has many of the same issues we have : older mothers, racial diversity, a population with risk factors. Why can they do it and not us?
    http://www.npr.org/2017/05/12/527806002/focus-on-infants-during-childbirth-leaves-u-s-moms-in-danger

    “In every other wealthy country, and many less affluent ones, maternal mortality rates have been falling; in Great Britain, the journal Lancet recently noted, the rate has declined so dramatically that “a man is more likely to die while his partner is pregnant than she is.” But in the U.S., maternal deaths increased from 2000 to 2014. In a recent analysis by the CDC Foundation, nearly 60 percent of such deaths are preventable.”

  44. WCE said “more tax dollars remain for healthcare.”. But that isn’t it. These countries have LOWER healthcare costs, and outcomes as good as ours or better

  45. And, Laura, that’s the problem.

    If, instead, we had a system (assuming the same pricing and regulation of plans under which we currently operate) where your family, or mine, got the employer share as income and then paid out of pocket for there would actually be a market for “private insurance” because there would be lots of people in the market. Especially if we had the guts/balls to implement a Singapore – style setup where everyone has to participate. So pricing would not be distorted like it is now.

  46. And, Laura, that’s the problem.

    How is it a problem? Employers negotiate to purchase insurance from health insurers (each competing for business) and insurers negotiate with hospitals and providers (each competing for business) to purchase healthcare services at huge volume discounts. Going forward, you’d have a system where, rather than having all that work done by people paid to do it, you’d have it done by individuals on top of all the other things they have to do.

  47. Rhett – it’s that people, even really smart and aware people like LfB, are broadly unaware how much it costs to get healthcare (insurance + fees for service). If the costing were much more visible there would actually be marketplace demand to do something about controlling costs.

  48. I don’t think that marketplace demand is ever going to help control costs in this country. Again, you can nibble at the edges – but the healthcare services that respond well to the marketplace – for example visits for sports checkups, routine vaccinations, etc, that are now shifting to minute clinics – are not where the costs are. When mom is having a stroke, people don’t shop around. Stroke care IS a major cost in our system

  49. If the costing were much more visible there would actually be marketplace demand to do something about controlling costs.

    So you’re claiming employers are less cost sensitive than employees would be buying on the private market? As you must know, just because employers are buying doesn’t mean that aren’t price sensitive and there isn’t a market.

  50. “How is it a problem?”

    Well, one problem, from the employer’s perspective, especially large employers who are self-insured, is that it forces them to devote resources to health care management, rather than to their actual business.

    But more fundamentally, what is the health care issue that we want to solve? We know that a majority of health care costs are attributable to a relatively small number of very sick people. If we want to make sure that everyone who becomes one of those sick people is able to pay for their care without financial disaster, then isn’t the answer some form of mandatory catastrophic coverage that is not connected to employment status? We already have Medicaid for the poor/disabled and Medicare for seniors. Why is it unreasonable to expect non-poor, non-disabled working-age adults to provide for their own routine health care needs in the same way that they pay for their other needs, some of which — such as food and shelter — are more immediately “life and death” than most health care issues?

  51. Why is it unreasonable to expect non-poor, non-disabled working-age adults to provide for their own routine health care needs in the same way that they pay for their other needs, some of which — such as food and shelter — are more immediately “life and death” than most health care issues?

    Asked and answered. Your theory is that it will save money. We’ve demonstrated how it won’t. Yet you continue to make the same point. Can you address why you think it will offer substantial savings?

  52. Sorry Rhett, I missed the part where you demonstrated that running all health care expenses through health insurance plans saves money. Who is saving that money?

  53. “I missed the part where you demonstrated that running all health care expenses through health insurance plans saves money.
    Um, maybe take a look at all those other countries that save money by running all health care expenses through either insurance plans or a single payer plan?

    I continue to be amazed at the fact everyone wants to ignore good evidence of what actually works.

  54. Sorry Rhett, I missed the part where you demonstrated that running all health care expenses through health insurance plans saves money.

    You said routine health care needs not all healthcare expenses. Please provide some data to support the idea that “routine health care needs” are a primary cost driver and not: prenatal, end of life and chronic disease.

  55. Mooshi, even in countries, like Singapore, that have decent systems, it’s still not clear to me that aspects of their systems (like not providing healthcare for illegal immigrants) are transferrable to the U.S. When I listen to the daily reality of healthcare in southern Europe from a friend who lives part of the year there, it’s not clear to me that it’s superior to our current system.

    I hypothesize that cultural differences between countries may trump the effects of healthcare on health statistics. Germany’s system works in part because it involves Germans. The same system implementation would not work as well in Greece.

    The ACA was a decent attempt at a system for the U.S. Its limitations were actuarially predictable. It seems that the government budgeting process underestimates how people respond to incentives and that there is no such thing as a free lunch.

  56. I continue to be amazed at the fact everyone wants to ignore good evidence of what actually works.

    That’s because people care more about their ideology than about facts, and that applies all over the political spectrum.

  57. WCE, you can find flaws in all healthcare systems. But taken as a whole, and looking at a wide diversity of countries with similar wealth to us (which would exclude Greece) it is pretty clear that systems that include the basic components of universal coverage and negotiated prices work better than our system.

  58. But Rhett — what is the problem you want to address? Access to costly medical care, or third-party coverage of both catastrophic and routine health expenses?

  59. “I continue to be amazed at the fact everyone wants to ignore good evidence of what actually works.”

    You mean, like the evidence from the randomized study in Oregon demonstrating that Medicaid expansion didn’t improve health outcomes for recipients?

  60. Mooshi, I agree with your point on a statistical basis. I haven’t understood before that you were only comparing the U.S. to countries with wealth similar to ours.

    I think there would be more support for a public system if elites like me understood better how much worse our healthcare access would get under the proposed system. The ACA was unrealistic about trade-offs.

  61. Scarlett that was one too-short study, compared against the experience in country after country. Lower costs and better outcomes.

  62. Scarlett,

    I don’t really know what you’re advocating. You seem to think that huge efficiencies would be gained by making routine healthcare needs something that is budgeted for and paid out of pocket. But those costs aren’t a major driver of healthcare spending so the savings are marginal.

    Given that paying out of pocket for routine care is a minor issue, can we move past that and deal with the large cost drivers?

  63. You mean, like the evidence from the randomized study in Oregon demonstrating that Medicaid expansion didn’t improve health outcomes for recipients?

    In your mind how does that study translate into policy?

  64. I continue to believe that single payer is the way to go. I agree some form of mandatory catastrophic coverage that is not connected to employment status would be great, if we cannot get to single payer. What we have now is better than what we had before. What the house passed is a disastrous step back, IMO.

  65. I think that Oregon study did show that Medicaid works. It showed that Medicaid improved financial outcomes (and mental health). We don’t have the stomach to let people die on the streets. So, we have a really strange collection of ways to get people healthcare. Medicaid at its core is a restribution of wealth program branded under a healthcare idea.

  66. If we just have mandatory catastrophic coverage, what about the price of stuff that isn’t negotiated by the insurance companies? Both DH and I wind up seeing lab bills for several thousand dollars that get reduced to about $67 because of the negotiated price. Without the negotiated price, routine care becomes economically catastrophic.

  67. I don’t understand why we wouldn’t cover the cheap, routine stuff. It doesn’t really change the cost much and it encourages people to go to the doctor while reducing the economic issues of doing so. Surely those are not bad things when the cost doesn’t move the needle much.

  68. It is unclear if a healthcare system that encourages people to go to the doctor is a good thing. Maybe the doctor visit itself isn’t expensive, but the associated costs can be high. If we want to expand healthcare access, reducing the number needed to treat should be a cost focus. (Example: Should this breast lump be tested? Even if statistics say the answer is “No” with 99% confidence, what happens to the physician’s license in the other 1% of cases?)

  69. Even if statistics say the answer is “No” with 99% confidence, what happens to the physician’s license in the other 1% of cases?

    ADA would know better but I think there are standards of care and if you adhere to the standard of care then you’re not liable for a poor outcome.

    The “medical standard of care” is typically defined as the level and type of care that a reasonably competent and skilled health care professional, with a similar background and in the same medical community, would have provided under the circumstances that led to the alleged malpractice.
    In a medical malpractice lawsuit, it is almost always a qualified expert medical witness who will testify as to what the appropriate medical standard of care was under the circumstances — and how the doctor’s deviation from that standard played a role in the plaintiff’s injuries.

  70. Well, from an economic perspective, the best thing is for everyone to die young and quick. But I am not sure that is quite the point.

  71. Kate- exactly. People choose to spend more on healthcare as other needs (food, clothing, shelter, utilities) are met. The working class people I know who avoid interactions with the healthcare system are doing it because other priorities are more urgent. For a Totebagger, a 1% chance of dying from breast cancer due to lack of access to testing may be unacceptable. Someone with more pressing financial needs may decide that ~$Xk for lump investigation is not a priority.

  72. I think people often spend money and time on other things until the issue becomes big enough that there is no choice but to deal with it. Ignoring symptoms until that massive stroke or heart attack happens. If we are economically lucky, those people die. If not, they hang on with a poor quality of life while we pour money in to the situation. I would prefer that we get in earlier when a cath lab inserted stent can work.

  73. WCE,

    That’s the same logic Eric uses against Social Security. If people feel they need the money now they should be free to save it or spend it as they see fit. The obvious problem with that is the myriad cognitive biases that result in people over-weighting the present and the expense of the future.

  74. I think the obvious solution is death panels. But try getting anyone to agree with those.

  75. Agree on death panels. We need better marketing for those.

    I think “number needed to treat” and the decision to deny care to elites like me at some statistical risk is where the the tough choices lie. How many cath stents must be inserted to avoid one death/expensive bad outcome? It isn’t clear how many people with expensive, miserable conditions would avoid or significantly defer those conditions if they received more healthcare. The interaction between healthcare and personal choices affecting health is complex.

  76. “Given that paying out of pocket for routine care is a minor issue, can we move past that and deal with the large cost drivers?”

    Sure. Some of the largest cost drivers are behavioral. This study says 25% of employer health care expenses can be attributable to “Lifestyle-Related Modifiable Health Risks” such as obesity and smoking. http://journals.lww.com/joem/Abstract/2015/12000/The_Portion_of_Health_Care_Costs_Associated_With.5.aspx

    Other studies put that figure closer to 70%. http://www.nahu.org/legislative/policydocuments/NAHUWhitePaperCost.pdf

    These factors may explain the poor results in the Oregon Medicaid study.

  77. “I think people often spend money and time on other things until the issue becomes big enough that there is no choice but to deal with it. Ignoring symptoms until that massive stroke or heart attack happens. If we are economically lucky, those people die. If not, they hang on with a poor quality of life while we pour money in to the situation. I would prefer that we get in earlier when a cath lab inserted stent can work.”

    But you’re assuming that the reason people have heart attacks or strokes is because of lack of medical care. The massive Harvard Nurse health study found that 86% of the “coronary events” in the study population were attributable to aspects of an unhealthy lifestyle. http://www.health.harvard.edu/blog/200000-heart-disease-stroke-deaths-a-year-are-preventable-201309046648
    The notion that medical caregivers can, in 15 minute appointment slots, convince patients to stop smoking, lose weight, exercise, and adopt other healthy habits is not realistic.

  78. No – I think people cause a lot of their own issues. But I am not sure we are going to change people in any meaningful way. So, our options seem to be: (1) get to them early if there is some cheaper intervention that can help, (2) deal with them after the big terrible event and throw money at a situation that likely won’t change, (3) do nothing. We don’t seem to have the stomach to do #3 even when someone causes his own problems. So, I think we should focus on what we can do that falls in to #1.

  79. But if we can’t change people in any meaningful way, then what is the point of getting to them early?

  80. I think it is really hard to get people to make lifestyle changes. But sometimes there can be medical interventions that work and are one-time things. Like stenting a patient with a blockage before it gets really bad. Doubtful we can get that person to exercise/change diet to reverse the issue. But a stent can be placed before a heart attack and hopefully lead to many more active years.

  81. “How do you encourage people to regard routine health care costs in the same way as food, housing, utilities, transportation, and other life necessities for which adults are expected to budget?”

    I think you answered your own question in your anecdote (anecdatum?) about your DS.

  82. “I know another family who fixed their toddler daughter’s cut head with Superglue.”

    Wasn’t Superglue initially developed, or perhaps initially deployed, as a replacement for sutures?

  83. Kerri, just reading that URL without reading the article makes me wonder if that would make him lose his security clearance.

  84. Much like conflicts of interest, presidents can do what they want with classified info.

  85. Finn – Skimming quickly, it arguably is not illegal because he’s president but it greatly jeopardizes our assets and allies, possibly endangering both.

  86. I am sure that the people who were so incensed about Hillary’s emails and (non)classified info will be equally incensed about this. Amirite?

  87. He has zero judgment and discretion.

    “In his meeting with Lavrov, Trump seemed to be boasting about his inside knowledge of the looming threat. “I get great intel. I have people brief me on great intel every day,” Trump said, according to an official with knowledge of the exchange. “

  88. But if we can’t change people in any meaningful way, then what is the point of getting to them early?

    Statins and blood pressure meds? The unexpected decline in dementian may be due to better management of cholesterol and blood pressure. While we may not be able to make people change their lifestyle, we can get them on pills that are very cheap and may end up saving hundreds of billions in the future.

  89. Just WaPo is reporting this? Waiting for NYTimes or Politico or WSJ

  90. “Well, from an economic perspective, the best thing is for everyone to die young and quick. But I am not sure that is quite the point.”

    Well, young is a relative term.

    From an economic perspective, I think young would be defined, in this case, as shortly after the kids are old enough to launch.

  91. make him lose his security clearance

    He can’t. Presidents have he right to tell anyone anything at any time for any reason. He can’t lose that right without being impeached.

  92. On the original topic, I think that at least some people who are leading unhealthy lifestyles, if they are encountering the healthcare system on a routine basis, can be encouraged to make changes. Not all, but enough to help with overall costs.

  93. “What have we done to ourselves?” We elected the idiot uncle who sits on his recliner all day and yells at Fox News. We get what we deserve.

  94. Scarlett, to a large extent, I’m with you on this issue.

    I agree that there’s not a consensus yet on what issues all the different proposals are trying to address, or should address.

    I also agree that there’s a lot of conflating of health care and health insurance.

  95. “Statins and blood pressure meds?”

    My perception is that there are a lot of people who aren’t willing to make lifestyle changes to improve their health, but are willling to take medication, especially if that medication is free or inexpensive to them.

  96. A very good example- we have a local friend who had a stroke last year. He is a bit young for a stroke, but overweight. Now here is the thing – when he had last been to the doctor for a checkup, about 5 years ago, he was told that he had mildly high blood pressure. His wife and he are crunchy types, though, so he didn’t go on any medication, thinking he could just change it with lifestyle and some vitamins. The problem – their insurance is the high deductible style, and they live a little close to the edge since both he and his wife are in fields where they switch jobs a lot and are sometimes out of work. And he is a typical guy. So for 5 years, he never went back to the doctor. And then, last year, he had a stroke – not a massive one but one that was serious enough. When he got to the ER, they discovered that his BP was sky high. Although he had tried to make the lifestyle changes, he never followed through. Now he is on disability. It sucks. I think if they had better insurance, he might have gone back for followup visits, and would have been told that his BP was creeping up. I am sure he would have gone on meds because he isn’t a stupid guy. He was just a head in the sand guy, and his insurance plan didn’t help.

  97. ^i wonder if we could move the needle a bit by having more screenings/minor issues handled at work. Kind of like how we handle flu shots. Practically everyone in my office got a flu shot because it was free and super convenient. Just walk to the conference room on floor 11. We should open minute clinics that roam the halls of big employers.

  98. “My perception is that there are a lot of people who aren’t willing to make lifestyle changes to improve their health, but are willling to take medication, especially if that medication is free or inexpensive to them.”
    See my story above. For high blood pressure, going on meds is usually the best course. You don’t want to muck around with high blood pressure. I am speaking as one who is thin, eats well, exercises and is in shape – and takes blood pressure medication. When I was diagnosed, I asked the question “can’t I just make lifestyle changes?”. The doctor looked at me and said “you’re doing everything right. Your genetics have simply taken over”. (and yes, it runs in the family, on the side that tends to be slender and athletic)

  99. “So for 5 years, he never went back to the doctor. And then, last year, he had a stroke – not a massive one but one that was serious enough. When he got to the ER, they discovered that his BP was sky high. Although he had tried to make the lifestyle changes, he never followed through. Now he is on disability. It sucks. I think if they had better insurance, he might have gone back for followup visits, and would have been told that his BP was creeping up.”

    Or, he could have spent $65 on a home BP monitor, learned that his BP was high, and gone running back to the doctor for medication.

    But even then, he would have had to TAKE the medication. Every day. And make sure not to run out. https://academic.oup.com/fampra/article/21/2/125/509484/Why-hypertensive-patients-do-not-comply-with-the

  100. “i wonder if we could move the needle a bit by having more screenings/minor issues handled at work.”

    We could. But studies suggest that corporate wellness programs don’t actually work.

    “What research exists on wellness programs does not support this optimism. This is, in part, because most studies of wellness programs are of poor quality, using weak methods that suggest that wellness programs are associated with lower savings, but don’t prove causation. Or they consider only short-term effects that aren’t likely to be sustained. Many such studies are written by the wellness industry itself. More rigorous studies tend to find that wellness programs don’t save money and, with few exceptions, do not appreciably improve health. This is often because additional health screenings built into the programs encourage overuse of unnecessary care, pushing spending higher without improving health.”

    DH’s university offers a wellness program, but the monetary rewards are too low and the invasion of privacy concerns too great to motivate many employees to participate. And the involve gimmicks, such as the distribution of free FitBits — which went mostly to the already-fit faculty members who just wanted a free gadget — that fail to appeal to the real targets of these interventions.

  101. There is a difference between workplace welness programs (yoga! Weight Watchers!) and simple workplace screenings. WHen I worked in healthcare, we had mandatory screenings, and our head of development turned out to have BP so high they sent him home immediately. He had no idea. Another good catch.

  102. I think there is a difference between wellness programs and targeted things like flu shots. Everyone participated in the latter and hardly anyone participated in the former (except people who didn’t bill their time and were just looking for a way to kill time). But if they could do bp screenings and the like very conveniently, it could catch people who don’t otherwise go to the dr. I am sure there were many hypertensives where I worked.

  103. There has got to be a medical lifestyle interventionist or medical nag whose job is to follow up with patients to make the require lifestyle changes. This includes taking medication as a prevention. My friend had a heart attack in his thirties combination of lifestyle and genes. He fixed his lifestyle and thought he had fixed things. But didnt or wasn’t taking medication. I don’t know if he was rigorous in his follow up. He had another heart attack in his forties. Now he has to take medication. He has a good job all along with good health insurance. I was shocked to learn of the not taking medication bit because he lost significant weight, quit smoking and watches his diet.

  104. “But even then, he would have had to TAKE the medication. Every day. And make sure not to run out.”
    He does now, and he would have. The issue was, it was mild high BP 5 years ago, and a combination of head in the sand, penny pinching and belief in lifestyle modifications kept him away from the doctor. But he is a totebag guy, and does not have ADHD or any issues like that. I truly think a few encounters with a doctor over those years would have convinced him. There are more people like that than you might realize. And has for a home BP monitor, come on, this is a GUY. How many guys below retirement age are going to own a home BP monitor?

  105. My DH owns a home blood pressure monitor. I rarely have to remind him to check it. Maybe his awareness of the potential consequences is higher than your friend’s was.

  106. It’s very common among the granola-type Totebaggers to believe that everything is fixable by lifestyle changes, and also that Big Pharma is evil and trying to kill us all.

  107. “And has for a home BP monitor, come on, this is a GUY. How many guys below retirement age are going to own a home BP monitor?”

    He’s a Totebag guy, who knew he had a BP issue but didn’t want to pay for doctor visits. Amazon sells home BP monitors with 10,000 reviews for $65. He probably researched lifestyle modifications online — if he failed to google “how to monitor blood pressure to see if lifestyle changes are working,” that was a deliberate choice on his part.

    “There has got to be a medical lifestyle interventionist or medical nag whose job is to follow up with patients to make the require lifestyle changes.”

    My dad had a visit from just this person, after his second CHF hospital stay. The fellow came to his apartment and discussed the practical aspects of managing CHF, especially fluid/sodium restrictions, and made four weekly followup calls. By the time this guy appeared, dad had already mastered the CHF regime, but the “nag” told me that, in his experience, patients needed to hear the pitch from a non-family member, and multiple times, before it really sank in.

    But he also told me about another patient, who landed in the hospital after eating a massive fast-food meal that she admitted knowing was bad for her. Intervention only goes so far, and then patients really do have to make their own decisions.

  108. Or, he could have spent $65 on a home BP monitor, learned that his BP was high, and gone running back to the doctor for medication

    Should blood pressure meds require a prescription? They are $3 at Costco but you can’t get them without a +$100 appointment. And, if a prescription is required, how long should it be good for? I’d say no prescription should be required but I’d be willing to meet halfway and say they are good for 2.5 to 5 years.

  109. Scarlett, you just said it “but the “nag” told me that, in his experience, patients needed to hear the pitch from a non-family member, and multiple times, before it really sank in.”

    That is exactly what my friend needed. And the point of this is NOT whether he made a good or bad choice. The point is that he now costs the system a lot more, particularly since he is now on disability rather than gainfully employed, is sad. It is hard to get a lot of guys to go to the doctor even when they should, and putting more obstacles in their way via crappy insurance doesn’t help. This seems to be more of a morality play to you (BAD PEOPLE MAKING BAD HEALTHCARE CHOICES) but to me it just seems logical that some fraction of people who put off needed doctor visits could avoid costly outcomes if we make getting to the doctor a lower friction event. And even if it is just some of those people who respond, it still saves money.

  110. “Should blood pressure meds require a prescription”
    Yes. they have side effects, and need to be adjusted every so often. Many people end up taking a combo (not me, I am lucky to respond well to a low dose of a pretty lowkey med). And again, people need to be monitored. Your high BP doesn’t stay static. And those home BP monitors are not amazingly accurate. My mother died of the type of stroke caused by high BP. I am convinced, because of our family genetics, that she had high BP. And yet, she claimed she didn’t because she would go to the do it yourself BP tester at the Walgreens and it said she didn’t (my mother was another of those doctor avoiders who could have used a medical nag)

  111. “Or, he could have spent $65 on a home BP monitor, learned that his BP was high, and gone running back to the doctor for medication.”

    Or even if he didn’t want to spend the $65, he could’ve measured his BP for free every time he went someplace like CVS or Sam’s club that has a free BP meter.

  112. The question is, then, what general conclusions we should reach from all these anecdotes and some studies – he observation that most patients won’t follow (for a myriad of reasons) one or both of the lifestyle or medication recommendations to reduce what for lack of a better term is mid range US lifestyle induced pathology. Do we just say that anyone, whether on public medical assistance or private insurance or even in an employer group plan, loses his insurance and access to free or negotiated rate health care if he doesn’t reach certain benchmarks or undertakes activities deemed medically risky after getting medical advice? I can’t think that we are willing to invade privacy that way and obviously that invests the medical numbers of the decade with more certainty than is supportable. Do we just paint with a broad brush and say the the lower SES and the low-regular middle class without employer health care are 85% likely not to benefit in the long run, so covering them or subsidizing their health care (other than for children) is a waste of money, statistically of course, so we will leave them to get by as best they can. The hardworking cleaning lady (or if one assumes they are all undocumented, the hardworking heartland diner waitress) who needs her knees treated not only to live comfortably but to avoid poverty is collateral damage when we exclude the druggie video game addict or the hippie type who doesn’t monitor his blood pressure. Or do we tell someone like me that from 60 to 65, if no one will hire you to a job with benefits pre Medicare and you can’t buy insurance in the private market, just do your best not to get cancer or slide on a patch of ice or get your car hit by a drunk driver?

  113. Don’t a lot of the high deductible plans also cover physical exams and/or some screening independent of the deductible?

  114. I feel strongly about health care issues, but I am only posting at such length because I am trying to distract myself fro the degree to which Pres. Trump is unqualified for the office. We roll our eyes at him having two scoops of ice cream with his pie when everyone else is served one. We accept that the details of governance are too tedious for him. We know that he can’t be upstaged, and Comey was a bit too tainted front and center to last. But this latest security breach with the Russians is scary and damages not just the reputation but the security of the United States and its armed forces abroad in several ways. The only consolation is that the leak was immediate from concerned grown ups in the military and intelligence communities, and that we have more of a sense that no impulsive nuclear or similar order will ever be carried out.

  115. “Or even if he didn’t want to spend the $65, he could’ve measured his BP for free every time he went someplace like CVS or Sam’s club that has a free BP meter.”
    Yeah, that did SO MUCH for my mother, who might be alive right now if she had gone to a frickin’ doctor instead of relying on the monitor at Walgreens

  116. Meme, everytime Trump does something crazycakes, we all say “This is it. We have to be concerned NOW”. But the Republicans are never concerned, and we lurch on to something even worse. It just gets worse each time, but Ryan and McConnell don’t care.

    My husband keeps saying he is really worried for the next election, because of the damage that has been done now to our expectations of good behavior by our elected leaders. We could have someone far worse next time, and that person could come from the right or the left

  117. I don’t think the Republicans are going to do anything. A few have already said that it is fine. It isn’t classified if he says it isn’t. No $hit. Not the point.

    I do think the the IC community will stand up to him. Until he fires them all. Then we are effed.

    But none of this is unexpected. We knew we were getting a nut who couldn’t control himself. He has the self-control of a 2 year old.

  118. Those of you in MA, do you think the Libs would’ve had a better shot if their ticket had been reversed? This was a great opportunity for them, going up against two seriously flawed candidates, and Johnson shows himself to also be flawed.

  119. Pretend you are a Miss USA contestant. How would you answer this: “Do you think affordable health care for all US citizens is a right or a privilege, and why?”

  120. “People choose to spend more on healthcare as other needs (food, clothing, shelter, utilities) are met. The working class people I know who avoid interactions with the healthcare system are doing it because other priorities are more urgent.”

    This brings to mind once more Milo’s story about helping distribute meals to the needy, and seeing the needy having TVs bigger than Milo’s family’s TV.

    Different people have different priorities.

  121. Pretend you are a Miss USA contestant. How would you answer this: “Do you think affordable health care for all US citizens is a right or a privilege, and why?”

    Ooo! Would I get to go into negative rights and positive rights, and legal rights and moral rights, and the idea of “privilege” as exemption from duty? Also, do I have to wear high heels with my swimsuit?

  122. Finn’s question reminds me of a Facebook post I saw on the right to healthcare the other day. I haven’t decided to what extent I agree with it. “Healthcare cannot be a right because it depends on the labor of another. The right to another person’s labor is slavery.”

  123. if healthcare = education = the right to obtain existing information, then maybe the same argument applies. Most healthcare right arguments seem to imply a right to more than information.

    The right to interact with a teacher or to interact with a provider is very different from the right to teach yourself Calc III from an existing textbook.

  124. It’s not the right to a specific person’s labor. And whoever provides the service is being paid.

  125. I don’t understand the Facebook quote. We have firmly established that taxes are constitutional.

  126. RMS, I agree that the fact that healthcare providers ARE paid is definitely a flaw in the argument, but if healthcare is a right, isn’t it a right whether the providers are paid or not?

    One of the recent Oregon decisions that makes my libertarian-leaning heart sing is the decision to allow pharmacists to provide birth control pills without a prescription. Now women who can’t afford $X00 for a gynecologist exam can get on the pill! The requirement that a woman must see a healthcare provider to get a prescription for birth control pills has annoyed me since high school.

  127. but if healthcare is a right, isn’t it a right whether the providers are paid or not?

    No. Rights are contextual. In our society, we have medical professionals who are paid. If we lived somewhere where there was only an unpaid class of slave doctors, we would not have a right to medical care.

  128. IDEA creates rights but you can’t specifically enforce it against a single teacher. I really don’t understand the quote. It is a red herring.

  129. “And whoever provides the service is being paid.”

    The provider being paid requires someone to pay.

    RMS, I thought this might be up your alley.

  130. the decision to allow pharmacists to provide birth control pills without a prescription.

    Hey, we agree on something. But my reasons aren’t libertarian; my reasons are feminist. Women are not 3-year-olds who have to have Daddy make the important decisions for them.

    Of course I think all meds should be over the counter. But that’s for another day.

  131. Things get paid through taxes. Those are constitutional. There is no doubt about this.

  132. If healthcare is a right, is electricity a right? Why or why not? How is the context the same or different?

  133. The provider being paid requires someone to pay.

    So this is “taxes are slavery”? Yeah, I don’t have time to go back to 8th grade and argue about that. Look it up on Wikipedia.

  134. If healthcare is a right, is electricity a right? Why or why not? How is the context the same or different?

    Well. That’s an unusual comparison. Do I need electricity to live?

  135. Oh god, it doesn’t matter whether healthcare is a right or not. Our world is just BETTER if everyone is in good health, not spreading disease around or unable to learn in school because of chronic untreated health problems or standing in the street ranting because of untreated mental disease. Even the frickin’ Chinese have come to that conclusion. I don’t see why we want to continue this way.

  136. In the last century, there was a huge push to get electricity to everyone, not because it was a RIGHT but because people realized that society would jus tbe better if every one had electricity. Gah!

  137. MM – don’t forget the Obamaphones! We have a right to cell phones thanks to Reagan!

  138. Electricity and healthcare are both essential to modern life and require someone’s labor to produce. Modern hospitals can’t run without electricity and my preemie sons’ ventilators and nebulizers would have been useless without it. (In fact, when electrical engineers design the grid, hospitals get the most redundant power capability, without the extra charge that private companies pay.) Without heat, which electricity or its natural gas equivalent usually supplies, some people in a cold climate will die.

    So as a “rights” argument, electricity and healthcare seem about equally important to me- but we expect almost everyone to pay the electric bill.

  139. There are programs to help people who cannot afford their electric bills. And furthermore, the cost is not comparable.

  140. Yeah, so, again, and I’m actually not kidding, the word “right” has about 72 different meanings and you need to specify which one you’re talking about. Is it a negative right? I’ll use the well-worn parking permit example. If you have a negative right to park in a particular lot, that means you have a “hunting license”. You may not find a spot, but if you do, you can park there. Can’t find a spot? Sucks to be you. A positive right means you are guaranteed a parking space.

    The 16th Amendment means that there is a legal right to tax the populace, but is there a moral right? Libertarians say no. Taxation is theft. That’s a moral claim. The legal claim is entirely established by the 16th Amendment.

  141. And we spent a ton of taxpayer money getting the lines out to everyone.

  142. Aren’t bare feet the most appropriate footwear to go with swimsuits?

    Well, OK, maybe swim fins. It’d be fun to see the contestants try to look graceful walking in those.

  143. WCE, things like a right to education or a right to healthcare are what RMS referred to as positive rights — if you were the only person around such a right would be meaningless because someone has to act to make it happen. Whereas things like a right to freedom of worship or a right to be free from unjust imprisonment are negative rights — your government just has to refrain from acting to make it happen. So it is generally a larger commitment for a government to recognize a positive right.

  144. And again, it’s contextual, WCE. A right to electricity, if there is one, is dependent on living in a society with the appropriate infrastructure. And Kate’s right, there are government (and some private) programs to help with electricity.

  145. Aren’t bare feet the most appropriate footwear to go with swimsuits?

    Not a big beauty-pageant watcher, I see. Probably for the best.

  146. “Of course I think all meds should be over the counter. But that’s for another day.”

    Didn’t Rhett bring that up today?

  147. Did he? My bad. But yeah, if it’s really going to be a free market, then I don’t want gate-keepers for my antibiotics or my morphine. I want to go to the store with the cheapest prices and that’s that.

  148. But we don’t have a general right to healthcare. We have a mish mash of certain things like emergent stabilizing care and an obligation to obtain insurance policies with certain attributes or pay a tax. Should we have a right? Insofar as we are talking about universal care or some kind of guarantee of coverage? Yes. Because we are trying to live in a freaking society here.

  149. Well, and possibly a store known for having good-quality pharmaceuticals. Don’t be cutting my Valsartin with powdered milk.

  150. RMS, I agree with the point about multiple definitions of “right”, what constitutes “healthcare” and the need for context. That’s why the claim that “X is a right” with no context annoys me. I always view these questions in largely economic terms

    Being more expensive than electricity does not make healthcare a “right”.

  151. It makes it more likely that a redistribution of wealth is required to fund healthcare. You said that we expect most people to pay for their electricity. We don’t require everyone to do so. And it is cheaper than healthcare, so it is easier to do it without redistributing money.

  152. Being more expensive than electricity does not make healthcare a “right”.

    No, it doesn’t. Other things make healthcare a right. And you don’t need electricity in your house. You need electricity in the hospital. My homeless friends have no electricity, but they have Medicaid, and so when they go to the doctor they use that electricity.

  153. “So this is “taxes are slavery”?”

    No.

    If the person requiring health care cannot pay, but the provider is being paid, who is paying? It could require legislation (e.g., Medicaid), or charity, or subsidies (e.g., the private pay patients subsidizing indigent patients).

    I think HM just sort of addressed this.

  154. How did HM address it differently from the way I addressed it?

  155. “This seems to be more of a morality play to you (BAD PEOPLE MAKING BAD HEALTHCARE CHOICES) but to me it just seems logical that some fraction of people who put off needed doctor visits could avoid costly outcomes if we make getting to the doctor a lower friction event.”

    Not at all. You seem to think that providing an insurance card that pays for certain routine doctor visits is all that is necessary to keep hypertension patients compliant. The obstacles go far beyond the cost of the visit. Even patients who get the meds don’t take them, or don’t take them properly, and a series of quick doctor visits is not going to get them into compliance.

  156. “But yeah, if it’s really going to be a free market, then I don’t want gate-keepers for my antibiotics or my morphine. I want to go to the store with the cheapest prices and that’s that.”

    I’d pay more to a provider with good QC.

  157. I’d pay more to a provider with good QC.

    I did follow up with that.

  158. We need gatekeepers for our antibiotics or we are all going to end up with untreatable bacterial infections.

  159. We need gatekeepers for our antibiotics or we are all going to end up with untreatable bacterial infections.

    Welp, that’s the price of freedom.

    A true libertarian free market would allow you to buy what you wanted, and get medical advice from whomever you wanted. If I think I have a urinary tract infection, I’ll go to Safeway and get some amoxicillan. It might not be the right drug, but I don’t want to pay those expensive doctors. And who are they to say what I can and can’t buy?

  160. Why even get an antibiotic? Just spray a little essential oil in the air and call it a day. I hear they work wonders!

  161. “Different people have different priorities.”

    The WaPo ran this story over the weekend about dental care for the poor. http://www.washingtonpost.com/sf/national/2017/05/13/the-painful-truth-about-teeth/?utm_term=.b0c18c90ce8f

    Much discussion about the appalling state of teeth among many low-income people, including interviews with patients on the Eastern Shore who endured hours of waiting in line for free dental services. One of the patients on which the article focused had not been to the dentist in NINE years.

    One of the photos depicted a patient lighting a cigarette while waiting in line. The article did not address this issue, but smokers can spend thousands of dollars a year on cigarettes (which also contributes to poor dental health). Smoking is inversely related to income and education.

    How many smokers are among the group that claims to be unable to afford several hundred dollars a year on regular dental checkups, toothpaste, and floss? How much of the poor dental outcomes in this underserved population is attributable to high consumption of soda and poor dental hygiene (in addition to lack of access to fluoridated water)? The reporter chose not to go there.

  162. Separate from the abstract “healthcare as (positive) right” debate, the U.S. could do a much better job of using pharmacists to provide routine healthcare such as blood pressure medicine adjustments and maybe even refills for people with recurrent urinary tract infections, bronchitis or other repetitive ailments. For people who are subject to the same ailment over and over, I’m not sure how much value yet another doctor visit adds.

  163. If that’s the way you swing, then great.

    But really, why do the doctors get to gatekeep the meds? You could even make an exception for antibiotics on the grounds of harm-to-others, but why do I need someone with a magic license to graciously permit me to have my blood-pressure meds, my anti-depressant, and my statin? Kate, you’re kind of exempt from answering this because you’re not libertarian. But for Finn and WCE, what possible non-paternalistic explanation can there possibly be for the fact that the medical cartel won’t let me buy my drugs without paying a doctor?

  164. i don’t think that is what pharmacists want to do. Not is that what they are trained to do. Most don’t even want to do administer flu shots. The PA or NP at the minute clinic is much better suited for those things.

  165. And I will add, though it should not be necessary, that of course if I want a physician’s advice, I am free to seek it out (and pay for it).

  166. RMS, other than public health factors for opioids and antibiotics, I see no benefit to requiring a physician consultation, especially since Dr. Google has been so much better for me than Random Physician, partly because Dr. Google has unlimited time for questions.

    when I finally went in to get my mastitis treated, I’m pretty sure I googled the same information that my urgent care physician looked up. My interaction with the healthcare system has been sufficiently complex that I always consult Dr. Google before an appointment. In one case, it was clear that I was being told to wean unnecessarily.

  167. RMS, other than public health factors for opioids and antibiotics,

    Nope, nope, sorry, you can’t include opioids. They are not a harm-to-others issue in the same way that antibiotic-resistant superbugs are. If I want to become a drooling heroin addict, well, my body is my science experiment.

  168. People are going to start having lots of Rx interactions if we stop requiring an Rx and just make everything over the counter. Hopefully these people who cannot figure out how to FaceTime or use the google will know how to run a drug interaction checker and then select another appropriate drug in the same category that provides for the same coverage. And yay for more opioids everywhere. And I am sure there will be a significant portion of our comrades who think that if x dose is good, then 2x or 5x will be even better!

  169. People are going to start having lots of Rx interactions if we stop requiring an Rx and just make everything over the counter.

    You’re a terrible conservative. People should just be smart. They’re morally required to be smart, and if they aren’t smart, then they deserve everything they get. Sheesh.

  170. I disagree about opioids being a harm-to-others issue. Opioid addiction is a huge factor in crime, and I find the arguments to tax the public for a functional criminal justice system even more compelling than the arguments to tax the public for a functional healthcare system.

    Kate, I presume a pharmacist can run a drug interaction checker as well as a physician, especially for a refill where the interactions probably haven’t changed much. One of the reasons Europe has lower healthcare costs is that they allow pharmacists a larger scope of practice.

  171. Opioid addiction is a huge factor in crime,

    Ah, but would it be if I could just go to Safeway for my heroin?

  172. And alcohol is a huge factor in crime too, especially domestic violence, but lots of other kinds of violence too.

  173. And contrary to popular belief, opium poppies are really easy to grow and harvest. Michael Pollan (yes, that Michael Pollan) wrote a fascinating article about it, including his own poppy experimentation and inability to get a straight answer from law enforcement. “Eat food, mostly plants” indeed.

    http://michaelpollan.com/articles-archive/opium-made-easy/

  174. Are we making everything like sudafed where we have to get a pharmacist to give it to us? Over the counter stuff is usually just sitting on the shelves. Claritin used to require an Rx. Now you just go to CVS and buy it next to the Benadryl. It is on me not to take it with something that will blow up my heart. Hopefully no one gets a little wild and decides to take two SSRIs one day.

  175. Are we making everything like sudafed where we have to get a pharmacist to give it to us?

    I’m not. I’m putting it on the shelves with the aspirin and the metamucil.

  176. My pharmacist mentioned that if I could coax my nurse-practitioner into writing a script for Sudafed, I could have more than my precious 30 pills a month AND I wouldn’t have to show my drivers license.

  177. In Oregon, you can’t buy Sudafed without a prescription. Our pediatrician said he buys it when he goes out of state just like we do- requiring a prescription dramatically increases costs.

    I think there is enough evidence to say expanded OTC access to allergy meds wins the cost-risk-benefit analysis. It’s not that I believe no one benefits from a physician consultation. My argument is purely a cost-risk-benefit one.

  178. I would bet that there are some drugs that we could make OTC. But I personally don’t want people taking warfarin or anti-depressants or antibiotics unless they are under the care of a doc or similar health care professional. Most people, even smart people, don’t know enough about this stuff to handle it on their own.

  179. “How did HM address it differently from the way I addressed it?”

    Positive rights.

  180. One of the photos depicted a patient lighting a cigarette while waiting in line.

    I swear you are the one who introduced me to the raw carrot quote from Road to Wigan Pier.

  181. “But we don’t have a general right to healthcare.”

    Not currently.

    My answer to the question would probably be no, because there are currently US citizens who don’t have access to affordable health care, either as a right or a privilege.

    OTOH, we have laws that require emergency rooms to treat everyone who present themselves there regardless of ability to pay, so an argument could be made that the answer is yes.

    I think it’s a bit of a trick question because it asks about what is, not what should be.

  182. “How did HM address it differently from the way I addressed it?”

    Positive rights.

    I made that exact point at both 7:05 and 7:55. Several times lately I’ve made a particular point and someone else makes the same point and everyone gloms onto the next person. And I’m the one who introduced “stabby”, not Rhett.

  183. And I would not be wearing high heels.

    You’re no fun anymore.

  184. And I’m the one who introduced “stabby”, not Rhett.

    I know! I don’t know how anyone thought it was me.

  185. RMS – I’m so sorry! Thank you for introducing me to “stabby”. I use it nearly every day now. It is so perfect. It is my word of the year so far.

  186. I don’t understand why the healthcare discussion is framed in terms of right vs. not a right. Why can’t it be framed in terms of economic efficiencies? Health care is 1/7th of our economy, and sufficiently diverse that everyone will encounter the system at one entry point or another. Private industry and private markets have failed at controlling costs and ensuring broad access.

    This seems like exactly the industry we want government to regulate. Wby must we first frame it as a privilege or a right in order to move forward?

  187. Good post, Lark!

    RMS – I am chuckling at the thought of people buying heroin at Target. I suppose it is not funny, but it really is.

  188. Lark, the discussion of rights in context and the many definitions of the word made me consider a *goal* of a functioning healthcare system for all that is more like the Space Program of the 1960’s than either a right or a privilege.

    I don’t believe in a right to electricity, but if the power distribution system were destroyed by a foolish president, the resulting lack of context for the right to electricity would not (by my definition of “right”) change the right to electricity.

  189. Oh, I agree with you Lark. We certainly don’t have a right now. We could create one by statute or, under a different activist S act, maybe they could find one, but mostly I think we should regulate and provide it because it is a good thing to do for our citizens.

  190. So McMaster claimed the story was “false” in a carefully worded non-denial denial. Early this morning Trump tweeted that he had disclosed the information as is his right.

    The mind boggles. It’s fun to watch all those who latched on to McMaster’s statement instantly turn around and adopt the “It’s his right.” line. At long last, do they have no shame?

  191. @Rhett – It’s astounding. And it is the same scenario every single time. Trump does something stupid or shady. His surrogates spend a lot of time carefully spinning. Trump himself contradicts them outright. New spin. How exhausting to work for this nutjob!

  192. And of course, let’s not forget, McCain calls it “disturbing” publicly but will do absolutely nothing.

  193. @Ivy – all the hand wringing brings to mind the classic Dudley Moore/Peter Cook sketch, the Frog and Peach. The key excerpt, where DM’s straight man interviewer asked the proprietor of the Frog and Peach restaurant

    DM: Perhaps you could tell us something about your restaurant, the Frog and Peach, Sir Arthur? So when did you start this venture?….
    PC: I believe it was shortly after World War Two. Do you remember that, the Second World War?
    DM: Certainly, yes.
    PC: Ghastly business.
    DM: Oh yes.
    PC: Absolutely ghastly business.
    DM: Yes, indeed…
    PC: I was completely against it.
    DM: Well, I think we all were.
    SG: Ah yes, but I wrote a letter.

  194. L — of course! And I said it in that accent too. I’m a Python dweeb.

    The good news is that the GOP is setting such a low standard for patriotism, morality, integrity, and work ethic that the Dems can put Al Sharpton in the White House and the Repubs won’t have the standing to say jack shit about it.

  195. RMS, I disagree. Trump’s voters are all just dismissing this as fake news. They read totally different news sources from us. And given the Republican advantage in the Electoral College, and the fact that many voters vote based on “tribal affiliation” (and yes, that holds true for Democrats too), I doubt there will be that many swing voters. Especially if the Democrats go left.

  196. Lark, I agree with you. We need to stop worrying about whether healthcare is a right, and start thinking about models that actually work to lower costs and give us better outcomes. If China can do it, we should be able to do it too. Unless we have become the country of “can’t do”

  197. “It’s total bullshit,” said Charles Johnson, a prominent internet troll close to the administration. “I think The Washington Post is way over their skis.”

    I think Politico’s POV is showing.

  198. Republicans are not bolting

    What they say publicity and what they think privately are two different things. They are growing both scared and weary of the current administration’s missteps but aren’t at the point of bolting quite yet.

  199. I am thinking of the voters, not the people in Congress.

    Trump diehards aren’t all that large a fraction of the electorate even on the right.

  200. “I don’t understand why the healthcare discussion is framed in terms of right vs. not a right. Why can’t it be framed in terms of economic efficiencies?”

    In this particular case, it just happened that the question to Miss USA framed it in those terms.

    There’s no reason it can’t be framed in other terms, and IMO it should be examined in multiple terms.

  201. I’m curious how people think. If you were an accountant and you found out that the financial statements are wrong and you brought it to your boss’s attention and he said, “I hope you can let this go.” And you didn’t let it go and you got fired, we all know what happened. The people parsing Trump’s words to Comey, Do they know it’s a bullshit defense or do they actually believe it?

  202. Ross Douthat, one of the NYTimes pet conservatives, has never been a fan of Trump but boy is going for it today

  203. I am enjoying this snarky little quote “Read the things that these people, members of his inner circle, his personally selected appointees, say daily through anonymous quotations to the press. (And I assure you they say worse off the record.) They have no respect for him, indeed they seem to palpate with contempt for him, and to regard their mission as equivalent to being stewards for a syphilitic emperor.”

  204. rhett, I am having trouble parsing your words

    The people offering defenses of Trump – do they actually believe it or are they like lawyers for a guilty client, just attempting to offer the best defense even when they know their client is guilty?

  205. RMS – I am chuckling at the thought of people buying heroin at Target.

    Within living memory it was available over the counter. The main active ingredients in many patent medicines was a combination of heroin and cocaine.

  206. I think Douthat is correct. But do a majority of cabinet members have the guts to first speak out among their peers to build a coalition and then second go to congress with their opinion?

  207. So, for all the claims of bias “the media” was right about Trump. He is proving himself to be everything his detractors claimed he was.

  208. No, he is not proving himself to be Hitler.

    I mean his serious critics not some Slate writer looking for clicks.

  209. The main active ingredients in many patent medicines was a combination of heroin and cocaine.

    Well, cocaine and morphine or opium. I don’t think you can ingest heroin.

  210. I don’t think you can ingest heroin.

    Sure you can. Bayer’s first Heroin™ based product was a line of cough drops. It’s not as good of a high though but if you can’t inject or smoke it the best option for high quality street heroin is to rub it on your gums.

  211. A contrary view on the 25th amendment option.

    “I’ll put aside the untried and unexplored nature of the provision (although just looking at it I can imagine multiple questions, potential loopholes, and challenges available to Trump if it’s used against him). 2

    The main reason not to use it is that the real chief complaint against Donald Trump is that he threatens U.S. democracy not (chiefly) by breaking laws, but by undermining the norms which are just as important to democratic governance as the laws and constitutional provisions. And therefore efforts to remove him should be especially careful to abide by those norms. The 25th amendment is for use in Wilson-like cases where the president is really, truly incapacitated. While mental illness could qualify, the many armchair diagnoses we’ve seen of Trump simply do not clear the constitutional bar.”

    https://www.bloomberg.com/view/articles/2017-05-17/no-the-25th-amendment-isn-t-the-way-to-boot-trump

    Douthat would appear to have the better argument, in my view, but this is an untried legal area. Perhaps the “current and former officials” who leaked the story to the WaPo should step forward so that their credibility and motives for leaking could be evaluated along with the WH spin.

  212. Perhaps the “current and former officials” who leaked the story to the WaPo should step forward so that their credibility and motives for leaking could be evaluated along with the WH spin.

    They are, for the time being, trying to use the media as that is the only thing Trump pays attention to.

    http://theresurgent.com/i-know-one-of-the-sources/

  213. Scarlett,

    Fine, he’s too incompetent to be Hitler. Talk about damning with faint praise.

  214. Scarlett,

    You seem to agree it’s a Dumpster fire so far and his liberal critics have proven more right than his conservative supporters.

  215. Agree with Fred that getting the cabinet behind an ouster will probably be impossible.
    If I knew how to post clips quickly, it would be the scenes from The Turnabout Intruder on Star Trek, where the senior officers decide that Captain Kirk/Janice Lester is unfit to remain as Captain.

  216. I don’t think we should be attempting to rid ourselves of Trump by using the 25th amendment. If they can make an obstruction of justice charge stick, that is one thing. But absent that, we’re getting what the American people chose in the election, warts and all. This is how the system works.

    Putin has come out and is willing to turn over the transcripts from the meeting. LOL. You really can’t make this stuff up.

  217. But absent that, we’re getting what the American people chose in the election, warts and all.

    The longer he stays the more damage he inflicts on Republicans so at least that cloud has a silver lining.

  218. The guy has ADHD. Pence, could you see to it that he gets a dose of Adderall in his ice cream each day?

  219. Ideally this goes on long enough to really hurt them in the midterms. We’ll see! It is very exciting to watch. It is like we can see the history books writing themselves before our very eyes.

  220. “The people offering defenses of Trump – do they actually believe it or are they like lawyers for a guilty client, just attempting to offer the best defense even when they know their client is guilty?”

    Yeah, pretty much. And also – change the defense constantly. “Oh, that didn’t happen” *Trump admits that it did happen* “Oh, well, it doesn’t matter if it did happen. It’s totally fine. You Liberals are all just being nitpicky and crazy.”

    Gorsich, tax cuts for the 0.1%, and the rest of the agenda is worth it I guess. Plus, no one is REALLY breaking with the script – and until there is a critical mass, it’s probably politically risky to really criticize your de facto party leader too much, even if he is an incompetent crackpot. But you gotta imagine that most R’s in Congress would much, much rather have Pence in the Oval Office. At some point, is there going to be a tipping point? There have been so many points where it seemed like it might happen, but then…nothing.

    I mean, I have to say – if Trump had won as a Democrat (and let’s be honest – that is a realistic possibility because he’s no Republican anyway), what would I do?? I wouldn’t have voted for him in the primary, but what would I have done in the general? What would I do now? What would my Democratic senators do? I have no idea. Probably this if they controlled Congress.

  221. ” It is like we can see the history books writing themselves before our very eyes.”

    Right? It’s insane. I keep asking my parents if this is like living in the early 70’s. My dad says no because his primary concern was NOT getting drafted, and the news moved very slowly then.

  222. There is a wonderful book called Washington Journal which tells the story of Watergate based on diaries kept by the author, who was a Washington reporter at the time. I read it a couple of months ago, and yes, the book feels exactly the way things feel now.

  223. And a quote from Thomas Friedman’s NYTimes column today, on the moral bankruptcy of the Republican party
    “Personally, I’m not exactly a rabid Democrat. I’m more conservative on issues of free trade, business, entrepreneurship and use of force than many Democratic candidates. I think the country would benefit from having a smart conservative party offering market and merit-based solutions for our biggest challenges — from climate to energy to education to taxes to infrastructure — that was also ready to meet Democrats halfway. But there is no such G.O.P. today. The party has lost its moral compass.

    Just think about that picture of Trump laughing it up with Russia’s foreign minister in the Oval Office, a foreign minister who covered up Syria’s use of poison gas. Trump reportedly shared with him sensitive intelligence on ISIS, and Trump refused to allow any U.S. press in the room. The picture came from Russia’s official photographer. In our White House! It’s nauseating. And the G.O.P. is still largely mute. If Hillary had done that, they would have shut down the government.

    That’s why for me, in 2018, the most left-wing Democratic candidate for House or Senate is preferable to the most moderate Republican, because none of the latter will confront Trump. And Trump’s presidency is not just a threat to my political preferences, it is a threat to the rule of law, freedom of the press, ethics in government, the integrity of our institutions, the values our kids need to learn from their president and America’s longstanding role as the respected leader of the free world.”

  224. MM,

    But Nixon won in ’68 and won in a landslide in ’72. The break-in was during his reelection campaign in June of ’72. We’re already talking impeachment or 25 and it’s only a few weeks into the first term.

  225. The Trumpsters in my Facebook feed seem to mostly be concerned about the cancelling of Tim Allen’s show (I can’t believe he has a show!). It really has them all spun up. Not a peep about Trump.

  226. The Trumpsters in my Facebook feed seem to mostly be concerned about the cancelling of Tim Allen’s show (I can’t believe he has a show!)

    It’s really terrible, too, though that hardly sets it apart from most sitcoms. I didn’t even know it existed until a few months ago when the reruns showed up in syndication. I love Nancy Travis, but not enough to watch this show.

  227. I thought that the fact that Trump would be disinclined to pay attention to the details of governance was opening up a big opportunity for forces that I regard as dangerous to direct the ship of state, and that the Republican establishment would be so happy to have control that they would ignore the things I fear and consider unAmerican to achieve their long standing objectives such as low taxes on the rich, rollback of federalism and the welfare state, restocking the Supreme Court. I was wrong, not in assessing the squirming Republicans would have to do to support the Trump administration, but in assuming that Trump would actually hand over control to any Lord Chancellor or committee to run everything while he became more like a constitutional monarch. He has to be top dog, he can’t trust anyone, and the government positions can’t be filled because total loyalty to him is required. It is a good thing that a powerful nativist or alt right Lord Chancellor did not materialize, and that the Freedom Caucus is so intransigent that the Republicans can’t even get their act together in Congress to craft transformative legislation undoing the Great Society and all that followed. But the situation is unprecedented. We have had bad Presidents and have had non Presidents actually running the show. But not in an era with a divided legislative branch, and not since executive power was expanded under FDR and his successors.

  228. It’s really impossible to project, say, Watergate on the present day. Back then, you had to wait for the paper newspaper each day, and if you didn’t live in DC or NYC, you only had the wire service coverage. The news was on when it was on, and if you missed it, you were out of luck. Sure, the hearings were on all day long, but most people with jobs and families couldn’t sit in front of the TV for hours. It was so much harder to keep up, and that was when the sources were very limited.

  229. Back then, you had to wait for the paper newspaper each day

    Not to mention how much harder it was being a reporter. You couldn’t just google Mardian Nixon and have google spit back assistant to the counsel of the Committee to Relect. You had to spend days tracking that info down.

  230. Yes, All the President’s Men (the movie) is a wonderful study on the influence of technology on journalism. Typewriters. Corded phones with no answering machines. Pay phones. The wonders of the copying machine. Phone books.

  231. I listened to an interview with the author of Washington Journal on WNYC, and she made exactly that point. But she said that the rumor mill even back then was pretty constant and fast moving. People used phones more, but there were still lots of leaky sources.

  232. Yes, but the rumors were limited to a relatively small group, not shared with everyone via Twitter. And to the extent people were worried about bugged phones, they would have had to share the rumors in private conversations.

  233. House Speaker Paul Ryan (R-Wis.) said Wednesday he had full confidence in President Trump.

    That’s what they say about every executive right before they get fired…

  234. Ohhh boy. I’m on several “Indivisible” and “Resist” Facebook groups. Hillary’s new fundraising thing is bringing out the bitter divisions between the moderate left and the far left. “The enemy of my enemy is my friend”, but after 45 is gone, there’s going to be a bloody battle for the soul of the Left.

  235. There was a psychopathic kid in my nursery school. We had guinea pigs, and one day he picked on up and threw it to the ground so hard that it died. His mother told my mother, “There are days when I can hardly stand to look at him.” Mom was startled and just tried to keep me away from him. I assume he’s either dead or in prison now, or possibly in Congress.

  236. I just imagine my grandchildren going into history class one day and saying “My grandmother said Trump was a racist, misogynist, lying sack of s*&t!” That will happen if I do my job properly.

  237. “after 45 is gone, there’s going to be a bloody battle for the soul of the Left.”
    As well as for the soul of the Right. There is likely to be a lot of realigning.

  238. “Funding for college work-study programs would be cut in half, public-service loan forgiveness would end and hundreds of millions of dollars that public schools could use for mental health, advanced coursework and other services would vanish under a Trump administration plan to cut $10.6 billion from federal education initiatives, according to budget documents obtained by The Washington Post.”
    https://www.washingtonpost.com/local/education/trumps-first-full-education-budget-deep-cuts-to-public-school-programs-in-pursuit-of-school-choice/2017/05/17/2a25a2cc-3a41-11e7-8854-21f359183e8c_story.html?hpid=hp_hp-more-top-stories_edbudget-330pm%3Ahomepage%2Fstory&utm_term=.1210c143b8ff

    And why? To pay for school choice of course.

    I am sorry, I try to be rational and logical, but I really hate Republicans

  239. And they would eliminate the public service loan forgiveness program, so we can all stop suggesting that to others.

  240. “Funding for college work-study programs would be cut in half, public-service loan forgiveness would end and hundreds of millions of dollars that public schools could use for mental health, advanced coursework and other services would vanish under a Trump administration plan to cut $10.6 billion from federal education initiatives, according to budget documents obtained by The Washington Post.”
    https://www.washingtonpost.com/local/education/trumps-first-full-education-budget-deep-cuts-to-public-school-programs-in-pursuit-of-school-choice/2017/05/17/2a25a2cc-3a41-11e7-8854-21f359183e8c_story.html?hpid=hp_hp-more-top-stories_edbudget-330pm%3Ahomepage%2Fstory&utm_term=.1210c143b8ff

    And why? To pay for school choice of course.

    I’m thinking that might be a reasonable trade off

  241. Pseudo, given what you’re posting on the other thread, how can you say that?

  242. Providing money to the schools seems a lot like providing heroin to an addict. I haven’t seen public schools able/willing to use their funds responsibly. Enabling school choice means that it isn’t just families with wealth who are able to access education services for their children.

  243. Pseudo is right. The federal government has been throwing money at public schools for decades, to little effect. Using a fraction of those funds to pay for a bus to take Pseudo’s son to a functioning high school is worth a try.
    The hysterical tone of the Post piece is consistent with media coverage of most unorthodox educational initiatives. Never mind that these programs that would lose some funding may not be effective, or that most K-12 education is supported by state and local, not federal, funds. The narrative seems to be that any federal education program established in the past for favored groups must continue indefinitely, with increased funding, or else the Republicans are cruel and heartless destroyers of public schools. A little balance in these stories would be nice.

  244. So you want all the good public schools, of which there are many outside your tiny bubble, to be as shitty as yours? Charming.

  245. There is not one single chance in hell that the redirected monies would go to school buses. Certainly not in Pseudo’s area.

  246. So you want all the good public schools, of which there are many outside your tiny bubble, to be as shitty as yours?

    Yes, because that is likely the only way the elites might allow some improvement in the shitty schools. Otherwise, it’s all, “what do you expect from demographics like that”

  247. I think many of us “elites” are dying to fix the shitty schools. It is folks like Chris Christie. who for years has refused to fund the money that by law is supposed to be going to a lot of disavantaged districts to improve things. How he got away with it, I do not know. Many of us “elites” would like to move away from property tax funding, which is a huge source of inequity. Many of us “elites” do not want to visit the disaster that is now the Detroit school system, with completely unfettered school choice and unregulated for profit schools, on the rest of the country.

    Many of us “elites” in higher education work with disadvanted school districts to improve things. We put pressure when the schools try to drop AP Calculus. We spend weekends (and yes I do this) running STEM workshops so the kids in the shitty underfunded schools can get what their peers in wealthier areas get.

    I am also sick of the word “elite” – lets just put it right up there with “deplorable” – and with the idea that somehow liberals are controlling things for the sake of the elites. Generally, I find corrupt school boards are a bigger problem. Look at East Ramapo. You can find crap like thay on a smaller, less obvious scale in many places.

  248. Second sentence of rant is missing a piece :” It is folks like Chris Christie…. , who is responsible for a lot of the inequity.

  249. And Pseudonym, if you care about your school, why don’t you frickin’ get on the school board. Or run weekend math readiness workshops to actually HELP the kids who are having trouble in precalc. Give some of your time and expertise, ya’ know?

  250. I have been advising students on college readiness/classes to take for years. There is a subset of kids who regularly come to me for discussions on what classes to take in both high school and college. I have been on the school site councils for years, advocating for transparency about course requirements and I have made some progress. I have gotten changes in the classes available for all the kids at the school. I may well run for school board.

    But, changes are glacial and do not help the kids who are in school right now. Providing a way for parents and kids to vote with their feet might incent the school system to change,but it at least be more likely to provide a life line to the kids who would otherwise drown.

  251. Have you considered getting a local university involved? In NY we have a program called College Advantage in which a university works with area schools to set up college credit course at the school site. You can do calculus that way. My university does quite a bit of this with schools in Queens, and in fact, many NY area universities do it. And we are working now with a high immigrant high school to set up better computing courses, ones that align with skills needed for college.

  252. Our state has a program providing free in state tuition to low income kids. The only requirement is that student sign up in 8th grade and then stick through it for high school. The local school systems have dismal participation rates so DH set up a research study to identify the obstacles and help overcome them. Turns out that the biggest one was getting the kids to sign up in 8th grade. Adequate Area School District took steps to increase signups and had great success. Horrid Area School District did not. Could not be bothered to follow up with the study leaders and were not interested in improving their 8 grade outreach. And then they pay marketing firms to run tv ads trying to keep parents from moving their kids to voucher schools or to out of district enrollment in the Adequate District.

  253. We have often found that it is best to bypass school administrations and find interested teachers to work with.

  254. They are out there. We are working with a wonderful teacher in that high immigrant HS in Queens. He is setting up an AP CS program in his school. Because his students are underprepared, he is also putting together some feeder courses, to get the students ready. He is so enthusiastic, and knowledgable (he had worked in industry, and unlike some of the ex-engineers who turn to teaching, he is up to date and energetic). The schools in NYC in general have been pretty receptive to STEM intiiatives, especially since DeBlasio is really pushing it.

  255. Pseudo, how do you think school choice would work in your area from a practical standpoint? You need to have more than one school within a reasonable distance to create a choice. Do you think there will be a bunch of schools that will suddenly open within a reasonable driving distance?

  256. The school choice discussion is timely for me because I went to a “middle school choice” workshop for fourth grade parents. NYC has school choice on steroids. The process is so complicated that even highly-educated, affluent parents have difficulty understanding and navigating the system. I think what school choice proponents often forget is that the choice is bi-directional. Just because you want your child to attend a particular school does not mean that the school will accept him/her. The result is a mini-college application process at every transition point (elementary to MS, MS to HS). Obviously, the parents best equipped to navigate that system are the highly educated, affluent parents who can take time off from work to attend workshops and open-houses, and get their kids prepped and tested for the various selective schools, each of which (I learned at the workshop) has its own unique admissions exam. It is a lot of pressure on little kids and their parents. I would much rather have a suburban-type system where kids move seamlessly from a good zoned elementary school to a good zoned MS to a good zoned HS.

  257. DD….within a 35 mile radius, there are ten public high schools. 4-6 of them provide more classes, higher quality instruction. At least one is quite frankly too high powered at this point, given my son’s preparation.

    What I would see in the short term is that people who are frustrated with their current system but couldn’t leave would move their kids to a different school, either public or private. I know of at least two families who would like to put their kids in a different school who cannot do so because of finances. In the intermediate to long term, the public schools would improve or lose enough students that they would need to close. Likely more privates would open. In any case, kids would most likely be better off because they could choose a school that more closely fit their needs.

  258. DD….within a 35 mile radius, there are ten public high schools. 4-6 of them provide more classes, higher quality instruction. At least one is quite frankly too high powered at this point, given my son’s preparation.

    Okay, now I’m utterly confused. Why don’t you send the boy to one of the better public schools nearby?

  259. “I would much rather have a suburban-type system where kids move seamlessly from a good zoned elementary school to a good zoned MS to a good zoned HS.”

    Wouldn’t you have to move to the suburbs for that?

  260. Why can’t we have good zoned schools in the cities? It is just a failure of will.

  261. If there are nearby public schools at which you can pay tuition, that seems like the best solution for the boy. For your daughter, online calculus class sounds like a good idea if she actually needs calculus for her course of study. Even if she doesn’t get AP credit, she can take a placement exam when she gets there and place out. That was a strategy used in my family to save a few bucks on requirements, including first semester of college calculus and econ 101. (No online back then, but there were textbooks and associated workbooks.)

    I don’t see giving vouchers to less than affluent middle class and poor adults to send their kids to schools other basic local public option is any different from medicaid or health insurance subsidies. Tax dollars are replacing personal dollars prioritized for something else (even if it is food or rent, not cigarettes and cell phones). The argument from observation, anecdote and some studies but not all is that Medicaid makes no difference on say, 85 percent of outcomes, so why throw good money after bad. Lifestyle and personal choice trump govt intervention. I think studies showing no benefit on outcomes for voucher programs exist, and mixed results for within the public school system charter schools (which I support where practical). So why not treat this the same way?

    One possible answer is that after 150 years of public grammar school education, expanded to high school and land grant college and special needs education over time, we treat education as a right. If govt is bad at providing this service, or if the local funding model perpetuates disparities in opportunity as well as in results, we want to privatize to some extent and divert public money. We don’t treat health care as a right, there is no full public system, and even though the private system is poor at providing services to those who are geographically isolated or lack funds, we treat health care as a discretionary good. We laud the person who fixes her kid’s cut with superglue as resourceful in a bad situation, just as we praise the homeschooler with a poorly served child. Why is govt money good for the latter and not for the former?

  262. I always laugh at these discussions of choice since we have none whatsoever. We have exactly one middle school and one high school. That is because of the microdistricts. And why do we have microdistricts? Because resoundingly, that is what suburban NY (and NJ and CT and MA) parents want!!! The parents CHOOSE this by voting against any initiative that has even the faintest whiff of merging. We could never have school choice here without completely undoing the microdistricts, which might be a good thing.

  263. Meme makes some good points. I also like to point out that the voucher for private schools approach is very similar to our current model of higher education – and how well has that worked? Everyone gripes about tuition going up all the time, but it is because private and public schools are now competing for all those students who bring federal loan dollars. Why would it be any different in K12?

    I am not against public choice systems that operate within the mandate of the school district. I like the system used in the Hartford area, which relies a lot on magnet schools. One of my husband’s relatives teaches in a magnet school. It seems like a very excellent school that provides a lot of opportunity to poor kids (as well as middle class – they attract both groups). The reason I prefer to keep schools public and in the public system is because that gives parents the most control. Schools that are part of corporate chains, even non-profit ones, tend to take a “our way or the highway” approach and are not responsive to parents. This is something I especially hear about the KIPP schools.

  264. There are some good zoned schools in NYC. Our kids go to their zoned elementary, which is pretty good. Our zoned middle school is very good for kids in the honors program, otherwise not so good. You don’t find out if your kid makes the honors track until after you have committed to the school. Our zoned high school is not good. The fact that all of the best students leave for magnate schools outside their zones leads to a brain drain problem at the local high schools. Its chicken and egg: the best students don’t go there, so the schools don’t invest in things like AP classes, making it even less likely that the best students will go there.

    I have no desire to live in the suburbs; grew up in the ‘burbs and hated it. But I am often jealous of my suburban friends and relatives who plunk their kids in the local kindergarten and don’t have to think about schooling until college.

  265. “Why is govt money good for the latter and not for the former?”

    You answered this question — unlike the way it treats a free and appropriate public education, our legal and political system does not treat health care as a “right.” Or maybe it’s more accurate to state that we don’t treat health care as a service that the government is required to make available, at no cost to the recipient, from funds provided (under duress by) other citizens.

  266. City Mom,

    What you describe is common in Totebag urban areas — the elementary schools are “good” because all of the kids are from Totebag families, but as the schools get bigger in middle/high school and the attendance zone expands, they become more socioeconomically diverse and the families with resources go private. For lots of good reasons, of course, but unless there is an IB or other magnet program at the high school — or the family has a strong commitment to public education — the local zoned high school doesn’t attract the Totebag families. Giving Totebag and other motivated families the opportunity to place their kids in public or subsidized private schools with high-achieving classmates may accelerate this trend, but it was firmly in place in DC when we moved there 30 years ago. Do you think it’s really different now in NYC as a result of school choice programs?

  267. The reason I prefer to keep schools public and in the public system is because that gives parents the most control.

    Surely you jest.

  268. Nope. I don’t. In the public system, parents have a vote. When dealing with a corporate chain of schools, they don’t

  269. And as City Mom pointed out, school choice means not just that parents are choosing, but that schools are choosing too. Unless it is fully a lottery system, but that never seems very choice-y. You only get to choose the school whose lottery you won.

  270. Parents only have a vote if the district decides to allow it. Or if the parents can find pro bono counsel to sue the district and force it to comply with the law.

    “In a ground-breaking decision for school choice in California, the California Court of Appeal for the Fourth Appellate District today unanimously affirmed a decision rejecting the Anaheim City School District’s attempt to block a group of determined parents from converting their children’s failing school into a charter school.

    The decision paves the way for Palm Lane Elementary School to be converted into a charter school, after years of protracted legal proceedings against a school district that was unwilling to comply with the parents’ lawful request for change. Today’s decision also reinvigorates the efforts of parents across the state to invoke California’s Parent Empowerment Act, a law that allow parents to transform their children’s failing schools into charter schools.” https://www.kirkland.com/sitecontent.cfm?contentID=230&itemId=12782

    I doubt that the KIPP schools have ever done anything remotely as egregious as has this public district.

  271. Scarlett, there are of course abuses out there. I don’t know this situation, but if you ever read about East Ramapo, you will see an example of one the most abusive and corrupt school boards you could ever imagine. The problem there, is a toxic mix of religion, changing demographics, corruption, and a state legislature too afraid of the particular religious demographic to do anything about it.

    However, that is not typical of NY districts. Most of our district schools pretty well reflect what the majority of parents want. Yes, if you have different ideas, like my feelings on the rigid cutoffs for honors courses, you can feel shut out. But our district, and the ones around here, pretty much reflect the majority views. Maybe that is an advantage of microdistricts.

  272. Maybe that is an advantage of microdistricts.

    MM – our district school board proposed a budget increase of 4.73%, above the tax cap limit of 2.6%, so a 3/5 supermajority was required to pass it. It failed, getting only 53.5% yes votes. The key driver to the proposed increased was adding full day kindergarten which they’ve been discussing for only 20 years, beginning back when my oldest was 3. Back then, I would have voted for such a proposal; this year I voted no. I’m happy with the result.

    Interestingly, and the district was totally unprepared for the # of voters actually turning out so it was a complete zoo at the polling place, was that 6700 people voted vs last year, when the increase was <= the tax cap allowance, when 1900 people bothered to show up.

  273. “Back then, I would have voted for such a proposal; this year I voted no. I’m happy with the result.”
    Why? SImply because you don’t have a kid at that age, or was there something else wrong with the proposal?
    Even though I have no kids at that age, I would have voted yes (in the absence of other negative factors) simply because I think fullday kindergarten is really important. It was something we looked for when choosing a town to live in.
    But in any case, your district is going with the wishes of the voters, which is the point of local control. We had a bond issue fail, which was really sad because it meant my older kids had to suffer through a badly overcrowded school, but that was what people wanted.

  274. I hit enter before finishing. The district came back the next year with a leaner, meaner bond proposal, which did pass. So we ended up with better facilities eventually, but it just took too long for my older kids to benefit.

  275. “But in any case, your district is going with the wishes of the voters, which is the point of local control.”

    But not all voters are parents. In some districts, parents of school-age children are a minority of voters, and Fred’s comment may be an example of a situation in which the parents were outvoted. In theory and, IME, usually in practice as well, private schools are responsive to the wishes of parents because parents pay the bills and can vote with their feet. The “my way or the highway” response you cite may happen, but, again IME, it’s more likely to be a function of the parents failing to buy into the school’s mission or of the school being sufficiently attractive that families on the wait list can readily replace those who have complaints.

  276. Why?
    Because at the time district enrollment was growing, other programs were being added and our school taxes were not going up ~5%/year.

    There are other available (private/Catholic) options in town if people feel strongly enough that full-day kindergarten is a good move for their kid. Every kid in our town who wants to go to college does. It’s not as if they are developmentally disadvantaged by having only 1/2 day kindergarten.

    Today’s environment is different. Enrollment is down 6% in the last 10 years and projected to continue that path. The pipeline of 0-5 yo is down a bit more, and not all parents will opt for full-day anyway.

    What I said in my exit survey and also the supplemental survey on the district website, is that the school board and administration need to be prudent stewards and provide the most appropriate educational services within the (already burdensome) allowable tax increase approvable by a simple majority. If full day kindergarten is the top programming priority, maybe that means something else needs to be cut back or eliminated. Some decisions are hard, but they are being paid to make them.

  277. finishing…

    my biggest issue was the almost 5% tax increase, which if approved, is now the new higher base off of which future increases will be measured. In our area property values are not increasing much more than 2%/yr (no booms, but also no busts) and I do not expect my raise to be 5%, so it’s both a pocketbook and overall budget management issue for me.

  278. Charter schools here are certainly not responsive to parents. At. All.

    I hear what is being said about private schools, but that assumes they need you and your money. Here, there is enough demand that they really don’t. If you need something specific or different for your child (IEP accommodations, even if legally required), tough. Sue or leave are not viable alternatives for most parents.

  279. Interesting new study from a Harvard research center, showing the widespread negative coverage of Trump’s first 100 days:

    “Trump’s coverage during his first 100 days set a new standard for negativity. Of news reports with a clear tone, negative reports outpaced positive ones by 80 percent to 20 percent. Trump’s coverage was unsparing. In no week did the coverage drop below 70 percent negative and it reached 90 percent negative at its peak”

    https://shorensteincenter.org/news-coverage-donald-trumps-first-100-days/?utm_source=POLITICO.EU&utm_campaign=ab6d830a9d-EMAIL_CAMPAIGN_2017_05_19&utm_medium=email&utm_term=0_10959edeb5-ab6d830a9d-189799085

  280. Kerri,
    Maybe the solution in your area is more charter and private schools.

  281. “Trump’s coverage during his first 100 days set a new standard for negativity.

    So obviously that’s a sign of media bias and not because Trump’s an incompetent narcissistic nut bag.

  282. Scarlett – I disagree. There should be more public magnet schools and distributed more widely within each borough. The city-wide magnet/G&T schools are excellent; we just need more of them and more of them in accessible locations. When you have hundreds of qualified applicants for each spot, clearly there is demand.

    I’ve not been impressed with charter schools here at all. They don’t perform better even when they cherry-pick.

    Private schools – there are not enough of them so they’re ridiculously expensive.

    NYC’s issue is real estate. There is not enough affordable space for new buildings; capital budgets for old buildings are woefully underfunded; legacy effect of historical red-zoning and segregation still have a large impact. Once German community in LI only this past month was forced to change its “German only” housing codes.

  283. Well, I’ll agree with that assessment, for the most part, but many die-hard Trump supporters do not. He has a 42% approval rating among voters, and a barely 20% approval rating among the mainstream media. When the WaPo newsroom erupts in cheers at the publication of the Russia leak story, it’s pretty clear that they have moved beyond dispassionate coverage. https://twitter.com/GlennKesslerWP/status/864231063295582209

    “Democracy Dies in Darkness” and all that.

  284. Kerri, I agree that public schools should respond to clear parental demand for better schools, magnet, charter, GT or otherwise, but not sure I understand the effect of real estate. Does it cost more for a building to house a GT or magnet school than a mediocre regular public school?

  285. Well, I’ll agree with that assessment

    If it’s the truth (and you agree that it is) then what’s the problem? What would you prefer they do?

  286. Scarlett, one of the issues is that many areas do not have the population density to support many fine grained variations of charter/private schools. I am guessing for your average low density non Totebag burb, if we go to full voucher, you might find within reasonable transportation distance a traditional Catholic school, maybe something evangelical, something ala KIPP, and the traditional public which will now become the place where all the SPED kids end up. If there are Totebag families, maybe a Montessori, but if not…. These towns just can’t support that many schools, and who wants to have to drive their kids 30 miles each way to get to school?

    And the issue of kids on IEPs or 504s is huge. My oldest could never get his particular accomodations in a KIPP school. They are just too rigid. On my 2E mailing list, there are lots of posts from parents who can’t get their charter school to budge. Most of the time, the kids end up back in the public system.

    This gets back to my whole issue with school choice. In the end, we will end up spending tons of money to move to a system that won’t have particularly different outcomes. People who live in areas where parents aren’t much interested in education will have a “choice” of private/charter schools that don’t offer much in the way of AP courses, because that what those parents WANT, and people who live in very affluent areas will have schools with lots of AP and IB programs. Just like today. Except now my tax money will go to evangelical schools that teach crazy science, or extremist Muslim schools that teach girls to be downtrodden.

    I think there might be a way to manage charter schools better, but really, why not just use the magnet school model instead?

  287. I read (or skim) the WSJ (paper copy, I am old school with newspapers) cover to cover nearly every morning. The coverage there has been unrelentingly negative. The editors, of course, still find many ways to blame Democrats and Obama for much of Trump’s problems,* but still, the reporting and most op-eds are negative.

    When one of the most important newspapers in the US, with a clear and stated partisan tilt towards the Republican party, that wants Trump to succeed, has such negative coverage, I don’t know what more the news media can do. So Scarlett, I’m not sure I fully see your point.

    Also – a large number of Trump supporters were firm in their support because they were so opposed to Hillary (which I understand). As we get further from the election, and it’s no longer necessary to have a firm “side” (for lack of a better term as I type quickly), I think that support is going to soften. Will they still be Republicans? Yes. Will they still oppose most policy platforms of Democrats? Yes. But will they still be Trump All The Way, or will they look for other Republican candidates? I think the latter, if he can’t get some traction continues to implode.

  288. Checking back in to the school choice conversation. For all of the options available in NYC, there are still many students who get stuck in not so great schools. The top performing kids with highly involved parents find their way into highly-selective magnates and, to a lesser extent, charters. Others put their names into a lottery and hope for a spot in one of the non-selective but better performing non-magnates. That, too, requires some degree of parental involvement/ability to navigate the system. Kids who are unsuccessful in the lottery, or whose parents lack the significant bandwidth required to figure all of this out, get shunted off to their zoned school, meaning that the zoned schools are populated exclusively by kids who, for one reason or another, lacked a better option. Then the zoned schools are accused of “failing” when in reality they have a much tougher job to begin with.

    So, Scarlett, I agree with your observation at 4:23 that Totebag families often leave the zone after elementary school, but I think that school choice is a huge driver of that. Instead of investing in local middle schools and high schools that can serve the needs of the diverse neighborhoods that we live in (which include both Totebaggy and non-Totebaggy families), we have created a system that actively encourages the Totebags to leave their neighborhoods. As far as I can tell, very few people actually like this system. It creates a culture of high-stakes competition at younger and younger ages and perpetuates income and class inequality. Not to mention the inconvenience of having to travel long distances to and from school every day for the kids who go outside the zone.

  289. Scarlett – There little to no “new” space. Squeezing a charter school into an existing school is a nightmare – in cost, time and impact on the existing school students and staff. You do know that multiple schools share one building yes? Not everyone realizes this. How do you share a cafeteria, gym, library, lab space?

    Many/ most existing buildings are old, in poor shape and not built to today’s codes/needs. My kids’ school has had innumerable problems with computers and AC because the electricity was wired in 1950. It can’t handle the load.

    I’d think it would be easier to change existing schools into magnets or G&T than to squeeze in a charter. Part of the reason why there are so few private schools is the lack of space to put them.

  290. None of my city friends likes the choice system in NY. I think it is way too complex. In particular, one of my friends, who is weirdly Totebaggy/not-Totebaggy (from a prominent African-American family who did many amazing things but which has fallen on hard times), feels very strongly that the system failed her kid. Her kid went to a public school that is famous for its progressive take on education. It is very integrated because so many wealthy families wanted their kids there, but it also drew heavily from Harlem. That was great. But then her kid had to go into the school selection process, and he somehow ended up in a magnet school that was 90 mintes by transit from where they lived. The transit situation was untenable and he ended up missing school and fell behind. She moved him, but then he was in a large, lackluster HS and kind of got ignored. Transportation is a huge issue in these choice systems.

  291. “Transportation is a huge issue in these choice systems.”

    Absolutely. DS got into some great programs, but the transportation issue was a big problem. The city provides buses for grade schoolers who travel 1.5 – 6 miles, but beyond that, you are on your own. We considered sending DS to a school 3 miles away and having him ride he bus. It was a 75 minute bus ride & a 6:30am pickup time for 8am school! That’s not a typo! The routes are ridiculous picking up & moving kids all over the city.

    Our neighbors have two kids at two different ES (one gifted, one magnet) in two different directions. One is more than 6 miles so no bus even available. Luckily the dad works from home, but he spends 2 hours in the car each school day shuttling kids. It’s insanity.

    Even in HS when kids can get to school independently, commute times are an issue. We have three selective HS within easy distance but the others would be over an hour via L/bus. Lots of HS kids travel long distances to get to the selective enrollment schools.

  292. Totally agree with Ivy and Mooshi on transportation issues. As I dig into my summer project of researching middle school options, I have identified one that seems like a great fit for my kid, but I really don’t know if we’d be able to get him there and back every day. It would be about 90 minutes by subway, which I’m not ready to let him do alone at age 11, or we’d have to take him by car on a route that is notorious for gridlock.

  293. Lots of kids have long bus or car rides to travel to schools outside their immediate neighborhood. Kids at the famous TJ science magnet in Fairfax face ridiculously long commutes, but the school still has no difficulty attracting applicants. Two hours in the car (for the driver) was pretty typical among parents of independent or magnet school students when we lived in DC. We did it ourselves for years. It’s an unavoidable aspect of school choice in most communities where either distance or traffic, or both, is a factor.

  294. Scarlett, many parents can’t do that kind of shuttling of kids. So it isn’t really a choice for them, is it? This is what I mean when I say that school choice, as proposed, will give parents the facade of something better without the reality.

    The dumpy town where my sister lives, for years, had no restaurants except fast food, and a couple of cheap chains. This was partially because it is a dry town, and partially because those are the options favored by the majority of the residents. There really was no true choice, especially if you wanted something fresh and healthy. My concern is that in towns like hers, all over the country, the choice of schools will resemble the choice of restaurants. Which gets back to my central point – this would be a huge disruption for likely not much overall improvement of outcome.

  295. Mooshi — exactly. I am trying to decide whether this school is a real choice for us. I am lucky to have a flexible job, but its not so flexible that I can spend 4 or more hours each day in transit. For people who have rigid work schedules, this school would be a non-starter.

  296. Yup. For most families, having a choice of another school an hour or more away is the same as no choice. And lower income families are more likely to have transportation problems.

  297. MM, the alternative is to keep kids trapped in failing schools. Now, because they do have a choice, half of D.C. public school kids are in charter schools and many others are in private schools with vouchers. You want to tell those parents they are better off in the failing schools because they are convenient but they are voting with their feet and choosing the less convenient schools.

  298. Now is as good a time as any to update on the homeschooling. I don’t know if anyone other than Rocky is interested, but I’ll post it here since were stuck on schools.

    I pulled snowflake the eldest out of school about six weeks ago. (Of note, since then, three other children have left the classroom. Which kind of validates my impression that it was a shit show.)

    It’s been pleasant seeing much more of my older child, but I did not anticipate that the middle child would feel that her eldest sibling was on a prolonged to vacation with mom. There’s been a little bitterness. However, eldest is much better overall, so it’s definitely been a win for family dynamics.

    Academically, I think we have made great strides in reading. I have picked out age-appropriate for books that I think my daughter can read. I have been requiring her to spend 20 to 30 minutes each day working through them. She is becoming a reader of thick novels. This is a huge change. No longform reading was being done in school, which might have been age-appropriate. However, I think that my child needed a push to get to reading something other than Guinness book of world records and Garfield. I’ve been supplementing with workbooks picked up at the local thrift store. I am feasting on the wasted good intentions of toteBaggers.

    Math has also made great improvements. We have been doing a lot of focused math through the Beast academy. She’s developing a lot of fluency in the number operations that she is supposed to know, and I can see a big improvement. Also seen a huge shift in her attitude about math. She looks forward to the time together that we do “heart problems”. She’s developing a lot of fluency in the number operations that she is supposed to know, and I can see a big improvement. Also seen a huge shift in her attitude about math. She looks forward to the time together that we do “hard problems”.

    We have not addressed science or social studies or any other topics. I don’t know that there’s a lot of value in these right now and they certainly weren’t doing much at school. Next year will have some kind of strategy for that.

    We’re accomplishing school work in 2 to 3 hours per day. She is taking four hours per week in outside classes and a few other activities that she was doing before. I’m doing about half of the school time and my child care provider is doing the other half. I leave a list of things that can easily be done independently and they’re happy to check it off together. The logistics are a little strange, especially as I’ve been traveling, but it’s all working out pretty well.

    All In all, I’m happy we made the switch, and I’m a little regretful I didn’t do it many months ago.

  299. You know who,
    Thanks for the update! So glad it is working out for everyone. Are you going to continue formal lessons in the summer too?

  300. We’re accomplishing school work in 2 to 3 hours per day.

    So your middle child might be kind of right to be resentful…

  301. “who wants to have to drive their kids 30 miles each way to get to school?”
    “Lots of kids have long bus or car rides to travel to schools outside their immediate neighborhood.”

    At my kids’ school, it’s not unusual for kids to have commutes of over 30 miles each way, especially in the upper grades.

    My kids’ commute is not that long, but transportation has been an issue for us. If they stay in school late (e.g., DS has regular work shifts to 5:30, and sometimes stays late if some kid’s parents are late in picking up), it can take him an hour and a half to get near home because the bus service frequency drops (then DW or I will take 10 to 15 minutes to pick him up).

    We almost didn’t send DS to this school because of the transportation issue. Fortunately, we found a private bus company that provided service between the school and a point near our home, and the kids of a couple of friends helped him get from the bus to his classes.

  302. “We have not addressed science or social studies or any other topics.”

    Assuming your eldest is still in early elementary, reading and math are obvious priorities, and I think to a large extent they are prerequisites for science and social studies.

    Any plans for foreign language? IMO, that is something that can be started in a very low pressure, low stress way at this age with simple exposure to the language as spoken by native speakers.

  303. You know who, have you mapped out your kids’ schooling through HS yet?

    I’m curious as to how long you plan to homeschool your eldest, and whether you plan to follow the same path with your younger kids. Your middle kid would probably be less resentful if told that the same path awaits her.

  304. Scarlett, we have failing public schools because we allow it. Why not fix the schools so they don’t fail?
    And, it is true that the setting where school choice can be most successful is in dense urban areas, which is why many big cities already have choice systems,such as the one in NYC or the one in San Francisco. I just would prefer to see it done on a magnet school model, so that teacher turnover isn’t so high, and schools have to work with kids on IEPs without “counseling them out”, as seems to be a current charter school practice.

    In NYC, the charter schools benefit from large contributions from area companies, especially hedge funds. What happesn to the quality of the charter schools when the companies get bored with them, and move on to something else? Will the charter schools be able to compete without extra money?

  305. One of the reasons I prefer choice to remain under the control of the school districts, as is done with magnet schools, is to prevent travesties like this
    https://www.washingtonpost.com/news/answer-sheet/wp/2015/10/31/study-on-online-charter-schools-it-is-literally-as-if-the-kid-did-not-go-to-school-for-an-entire-year/?utm_term=.da985efc2082

    It is bad enough to have failing traditional schools, but why do we want failure in the supposedly “new and improved” model?

  306. We have a next year plan. It will probably be the same for the next few years – until middle school age. Middle child didn’t need to leave school this year the way that older did – she wasn’t in a dysfunctional place that was creating problems. She’d probably have a lovely year in public school next year, but for harmony and logistics, she will do what her older sister is doing.

    Next year, two kids will go to an art-based Montessori-ish enrichment program for two full days per week. One day they will go to a full day of forest school. These are mixed age programs with other homeschooled kids. We will math and read a little bit every day and a lot on the two weekdays.

    The youngest will stay on pre-k and K track for now. The local curriculum is heavy on play and not-hitting, the former a strength for the child, the later an area for growth.

    After that, I’m not really sure what will happen. I’m open to a number of outcomes – continuing homeschool, part-time home school, private. Our state has very liberal laws regarding homeschool and many people find it easy to take a class or two at the middle school and homeschool around that. There’s a private school that I love for middle school here, not sure if it provides sufficient value for the cost. So – the situation is fluid. In our family, we have 30+ school years left – so I imagine we will work through many possible solutions.

  307. Another study on the lack of effectivness of online charter schools
    http://steinhardt.nyu.edu/site/ataglance/2017/02/study-finds-students-in-ohio%E2%80%99s-online-charter-schools-perform-worse-than-peers-in-traditional-schools.html

    and another

    I thought the entire point of charter schools is that we can close them down quickly if they fail. So these should get shut down. However, I think the real goal is to put money into the pockets of these charter operators.

  308. MM, I haven’t paid much attention to online charter schools, but my sense is that there is far more potential for abuse in these programs than in bricks and mortar schools. A few years ago, I read “Work Hard, Be Nice” by Jay Matthews, a WaPo writer, about the KIPP schools. https://www.amazon.com/Work-Hard-Be-Nice-Promising/dp/1565125169
    Have you read it? The KIPP schools, though of course not perfect, have some impressive results with inner-city kids.

    “The study, conducted by independent research firm Mathematica, is the most rigorous research showing that the Knowledge Is Power Program, an acclaimed national chain of charter schools, provides a significant learning boost to middle school students in multiple subjects. It also found that while KIPP serves more low-income students than public school peers, it serves fewer special education students and English language learners.

    Three years after students enroll in KIPP schools, they had 11 more months of math knowledge than their peers, according to the study. The research showed KIPP students had eight more months of reading knowledge, 14 more months of science knowledge, and 11 more months of social studies knowledge.

    Even those who have watched the growth of charters with a wary eye said they are impressed.”

    http://www.huffingtonpost.com/2013/02/27/mathematica-2013-study-kipp_n_2768476.html

  309. Part of the reason it’s so hard to do research on online charter schools is because selection bias so dominates the research. I commented yesterday that I think Connections Academy has improved the math education of some homeschooling families. The homeschooling families I know of seem to have almost a bimodal distribution of “into math with top percentile kids” and “not into math with kids who may or may not meet math standardized test score expectations.”

    Anecdata is an acquaintance who pulled her daughter out of school because she was still struggling with multiplication tables in 5th or 6th grade. Her daughter was well-behaved and doing better than most of the class, so she never got any help/attention.

    I wish we lived in a world where we could say that things are statistically true or significant and still recognize that they are not true in every case, not be accused of racism/classism, and in fact we can’t say anything about a particular case based on statistics. At minimum, offering online charter schools to children who are working at or above grade level or progress at least a grade level annually (if they started off working below grade level) seems like a reasonable choice.

  310. The real issue to me is lack of oversight. There just seem to be so many abuses in the current charter school movement, and even though it was promised that the failures would be shut down, it doesn’t seem to happen. So I would prefer a school choice system that uses magnet schools because public schools are subject to far more oversight than charter schools.

  311. I am familiar with KIPP since they get a lot of reporting. Personally, I find them appalling, close to child abuse. I suspect the main reason for their results is something I have argued for many times: kids spend a LOT more time in the classroom.

    A few years ago, I read about a study in which lots of charter schools were compared, to see if there were common factors among the successful ones. It turned out that there were not a lot of common factors, but one of them was extended class time. I have to hunt that down and see what the other factors were.

  312. I would definitely support a solution where online publicly funded schools were held accountable based on student performance, support for students with special needs, etc. Given that magnet schools are infeasible in much of the country due to population density, I think online publicly funded schools are a good alternative.

    Online publicly funded schools could let small schools offer a wider range of courses to students with particular skills/interests without completely forgoing the peer experience. (The peer experience occurs both online and in the classes which are taken at the public school with peers.)

    I’ve recommended online education from our community college to high school educated moms at the indoor park who can’t attend regular classes due to childcare obligations. They usually need to start with a math review class and the community college offers a math tutoring center that lets them get help during nonstandard hours when their husbands are available to watch the kids. (The tutoring center is also a great source of work-study jobs for people who can tutor math.)

    You can probably tell I’m convinced that online education is a good model for certain situations.

  313. MM,

    On what do you base your low opinion of charter schools in general and KIPP in particular? Taking Michigan as an example, data reveals that 62 Michigan charter schools have been closed, including 22 in Detroit alone. So, there is the oversight you want. (By comparison, no traditional public school in Michigan has been closed for academic reasons.) Charter schools ARE public schools, remember. http://www.washingtonexaminer.com/setting-the-record-straight-on-betsy-devos-and-charter-schools-in-michigan/article/2608858

    Mathematic did a rigorous 5-year study of KIPP, and found “KIPP middle schools have positive and statistically significant impacts on student achievement across all years and all subject areas examined.” https://www.mathematica-mpr.com/our-publications-and-findings/projects/kipp-preparing-youth-for-college

    KIPP may not be the right choice for your kids, but they are clearly doing something right with low-income kids who would otherwise be stuck in failing public schools and whose parents are willing to sign on for the extra work and longer days.

  314. These are the magic words :”xtra work and longer days.”. That is what they are doing right, and that is what kids in all schools deserve. However, the character report cards, and eye tracking requirements are just creepy.

    I also wonder how these kids will end up doing in college…

  315. There is a lot of research that shows that online education is not very effective for at risk students. Online education seems to work best with very motivated, older, more advanced students – for example, working people who are pursuing further education. I don’t have time to find all the citations, but it is the reason that in higher ed, online education is increasingly targeting older students instead of traditional college age students.

  316. Mooshi, I think the magic word is “parents” not “extra work and longer days”. Presumably parents who choose KIPP do so because they think it’s a better alternative for their families than the schools they’re in. For my sons, being in a classroom with better behaved kids would probably be more important than either the longer day or the extra work. I don’t know if “classmate behavior” is a research variable but it should be.

    For some parents, less work and shorter days works better than the KIPP model. Here, those parents part-time homeschool. No one solution will be best for all families.

  317. You can probably tell I’m convinced that online education is a good model for certain situations.

    I don’t disagree entirely, but the socialization aspect of school is so important. You learn a ton of behavior rules from interactions with peers and teachers. Kids who are already a little behind the social skills curve could wind up seriously disadvantaged.

  318. Kids who are already working above grade level don’t need extra work and longer days. Nor do kids with learning issues for whom the existing amounts of work and seat time are already a challenge.

    However, kids who are performing below grade level, whose parents are not equipped to homeschool or supplement mediocre classroom instruction, can clearly benefit from the longer days and extra work that KIPP offers. It’s unfair to those kids to dismiss as “child abuse” the successful strategy that KIPP has developed. Again, the alternative for those kids is not the public schools in Westchester or Fairfax. I cannot understand the hostility to these options.

  319. I didn’t ever agreed that education is a right. I think I disagree with the concept that positive rights exist. Without full understanding of what a “positive right” is, I prefer to call positive rights “responsibilities.” I’m unsure when parental responsibility ends and when government responsibility begins, for education or anything else. I’m glad there is a foster care system but it’s an option of last resort. That’s how I view most nonsystemic roles of government.

    (Systemic roles are things that everyone shares, like GPS, spectrum, police, judicial system and transportation)

  320. With regard to how KIPP kids do in college

    “Currently, 81 percent of KIPP alumni enroll in college after graduating from high school. As of fall 2016, 44 percent of KIPP alumni have completed a four-year college 10 or more years after completing eighth grade. The four-year college completion rate for KIPP alumni is above the national average for all students and more than four times the national average for students from similar economic backgrounds.”
    http://www.kipp.org/events-press/kipp-announces-findings-first-ever-survey-kipp-alumni-college/

    Not too shabby.

  321. Mooshi – I support charter schools in general because I have been exposed to systems with good oversight, quick school closings, and locally a primarily non profit community based grounds up charter school movement. Just as we have fewer big box chain stores, MA voted down an unfettered charter school ballot initiative (when there were plenty of slots for additional charter schools available under the current system) to keep out the for profit chains. Local control in education can be considered good or bad depending on perspective.

    I see no only two solutions to providing full educational services. One is publicly supported online/homeschooling support. The state bureaucracy would still be involved in approving the vendors. Parents who were not satisfied with the choice of vendors or the local schools would still feel ill served, but it would be better than nothing, and people of limited means would have alternatives. Religious content could be provided, not at state expense, by the parents or the denomination or informal groups. As we have noted, the children of parents who don’t or can’t help them would still be screwed, but perhaps no more than today. The second solution is statewide or even region-wide exam boarding schools for the academically talented and other boarding schools for children with special needs that can’t be serviced at reasonable cost at home because of population density . Of course the exam schools would have the same ethnic dominance issues as the NYC exam schools, and the special needs schools would be indistinguishable from “institutions”. The additional funding would have to be at a state level – low density districts would be charged their regular per pupil rate. And then the local secondary schools would have even less incentive to offer a full college prep curriculum when there was a public alternative.

  322. The second paragraph in my post above refers to rural schools with limited population density and/or transportation issues. A similar argument about the online services could be made for remote medical services via telecommunication, which I believe Ada could comment on. And MA has KIPP academies in some of its worst neighborhoods. I believe they are successful and non profit.

    I know that kids need socialization, but many of the urban and rural “worthy” poor are associated with church or clan or other self regulating community that can socialize their kids (and isolated larger families do a lot of that in house anyway). ykw’s two working parent UMC self funded homeschool plan is an urban one with 3 days of formal outsourced services. But the homeschoolers I know (and I have known homeschoolers of all stripes for 40 years) usually take advantage of free or nearly free group activities and share knowledge within the community. In many places there are people like the WCEs or the kalebergs who can help out or give direction on science and math.

  323. Shockingly, I agree with Scarlett. KIPP and other schools are clearly working. They are not for everyone but they are working for the students who choose to attend. And isn’t this the point – to create choices so parents can find a school that works for their kids?

    I also agree that the primary factor is the parents. Wasn’t there a study a while back following kids who got into some charter school comparing them to the kids who entered the lottery and didn’t get in, and it showed no real difference in outcomes? I can’t find a reference for it so maybe I’m totally mistaken.

  324. Socialization definitely has different meanings in different contexts. When we were walking in downtown Portland with the kids and heard threatening comments, we both just ignored them but when Mr WCE and I talked later, he was more scared than I was. I have experienced threatening comments on dozens or hundreds of occasions, and I believe I am better at determining when someone is ACTUALLY going to try to beat me up than he is. Hanford schools failed him in that regard.

  325. Knowing when someone is actually going to beat you up is an excellent social skill to have.

  326. “I think I disagree with the concept that positive rights exist.”

    I do not understand – at all.

  327. To go back to the parking lot example: If I have a positive right to space #43 in the parking lot downtown, then someone (the parking lot management) has the responsibility to tow unauthorized cars from #43 so I can park there. Positive rights exist, and I can’t think why you’d call them responsibilities.

  328. “The right to demand that the government enforce your contracts is a positive constitutional right against the government”. Do you deny that that right exists? In what way is it a responsibility?

  329. RMS, your link was helpful. I was thinking of rights in the moral sense, abstractions we agree on even in the absence of an appropriate counterparty or any legal structure. Humans have rights to life, liberty and the pursuit of happiness. Animals have rights not to be tortured.

    Maybe I can rephrase my concern better as, “Rather than call an abstraction a positive right, it is better to call it a responsibility of a capable counterparty and to define it such that the counterparty is capable of meeting the obligation.” The reason Berkshire Hathaway has a business as a re-insurer is that people purchasing insurance want to make sure that insurers have both the contractual obligation and the wherewithal to fulfill their contracts. Re-insurers provide wherewithal.

    A right to healthcare that encompasses only vaccinations and communicable disease statistics is probably enforceable. A right to healthcare that encompasses every beneficial pharmaceutical, device and therapy is probably not enforceable. Who is the counterparty to a right to healthcare? If such a right exists, why was it not considered part of the Hippocratic Oath?

    Education is a bit easier, because I can see it as a “system” right and some state constitutions include it. My child can have a right to attend kindergarten at 5 years of age and study letters and numbers. This right may not be particularly useful if my child is already reading chapter books, but that doesn’t change my child’s *right* to attend kindergarten to learn his letters.

    Another point of debate is whether the government has to “meaningfully” fulfill a right. If a criminal defender has 10,000 cases, has the government adequately fulfilled its obligations to provide criminals with a public defender?

  330. The Hippocratic oath, which is completely irrelevant to this conversation, includes: I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

    And positive moral rights don’t just evaporate because you’ve decided not to believe in them.

  331. In Syria, people have a right not to be tortured. That right is being violated. That doesn’t mean the right evaporates. You seem to be unable to process the idea that there can be rights that are violated. Children have a right to be fed by their parents. Many evil parents violate that right. That doesn’t mean the right doesn’t exist.

  332. Maybe I misinterpreted the original question. I presumed that agreeing that a positive right existed meant there was a counterparty with a responsibility to meet an obligation, and that’s why I thought the important discussion was about whether there is a responsibility (by anyone) to act to enable a positive right.

    If positive rights are merely a concept, then I understand your point about abstract positive rights but it wasn’t the question I was trying to address. My interest is in creating workable, cost-effective systems in education and healthcare. If there is no counterparty and agreeing to the abstract right costs nothing to anyone, that’s a question for someone else.

  333. Few people have actually ever read the Hippocratic Oath, which is perhaps why people probably think that doctors take it and/or it is relevant. Short version: By Godess, I promise to help people, never perform abortions, never do surgery, never give chemo, never charge money to teach people about medicine, and uphold HIPAA.

    There are all kinds of modified oaths that medical students take, but everyone is just making it up as they go along.

    “I swear by Apollo the Healer, by Asclepius, by Hygieia, by Panacea, and by all the gods and goddesses, making them my witnesses, that I will carry out, according to my ability and judgment, this oath and this indenture.

    To hold my teacher in this art equal to my own parents; to make him partner in my livelihood; when he is in need of money to share mine with him; to consider his family as my own brothers, and to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to indentured pupils who have taken the physician’s oath, but to nobody else.

    I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrong-doing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly I will not give to a woman a pessary to cause abortion. But I will keep pure and holy both my life and my art. I will not use the knife, not even, verily, on sufferers from stone, but I will give place to such as are craftsmen therein.

    Into whatsoever houses I enter, I will enter to help the sick, and I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free. And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.

    Now if I carry out this oath, and break it not, may I gain for ever reputation among all men for my life and for my art; but if I transgress it and forswear myself, may the opposite befall me.”

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