Sometimes Impoliteness Overtakes Me

And I notice things like this in airport bookstores, and start to think quite nasty thoughts, like "other than having the superfluous word "BY" in it, this headline is quite apt. Perhaps she will henceforth be known to internet wits as TETTGEW...."

It's impolite, I know, but the stress of traveling makes one susceptible to the lures of the easy joke.

How Not to Discuss a Previously Foreseen Outcome

If anyone out there intends to discuss recent developments in the health care debate, here is a model of how NOT to initiate the discussion:

Say, Barack Obama: You bent over the entire left wing of your party and pissed all over your most loyal supporters to foster a back-room deal with AHIP in which you gave them the store while they used Max Baucus to give the public the shaft. Then they looked at the atrocious corporate welfare bill that the Baucus Dogs in Finance produced (on their orders), and decided that it did not go far enough to serve their special interests, and went all Harry and Louise on you. The insurance companies are a bunch of fucking snakes and if you didn't see that stab in the back coming, you are truly retarded.

Statements like this are completely uncouth and should not be uttered in polite society.

If Politico is to be believed, the White House did not see this coming.

UPDATE: An administration official called. The White House isn't happy.

AHIP chief Karen Ignagni met with White House and Senate Finance officials last week, and she said they were "a ways away from doing an analysis," the official said. "There is a feeling among White House officials that they were misled."

If this is accurate, it calls to mind frogs, scorpions, and aquatic adventures that end badly for everyone. The reliability of Politico is probably also a subject best excluded from polite conversation, however.

UPDATE: Speaking of which:

Nancy-Ann DeParle, director of the White House Office of Health Reform, said she was surprised by the report because she met last week with Ms. Ignagni and they vowed to work together.

An uncouth person might be tempted to remind DeParle about the worth of industry promises when political negotiatons turn away from their preferred outcomes and the track record of the insurance industry with regard to health reform, perhaps suggesting a degree of naivete or "retardation" on the part of the Office of Health Reform. A polite person would repress that temptation as if their life depended on it.

I've Got No Choice: Medicare Billing Perversities Will Force Me to Bilk the Public

At risk of being uncouth, there appeared today in the New York Times a letter to the editor by Dr. Richard Bazarian of Portland, Maine, that I found rather curious. Dr. Bazarian opined that the capricious decisions of medicare bureaucrats portend disastrous consequences under national public health insurance.

A foreshadowing of what is to come under government-led health care reform: An anonymous Medicare bureaucrat decides to change the billing code for a $30 drug so that physicians are reimbursed only about 25 percent of their cost. The annual savings nationwide: about $11 million.

Unintended consequences: The ophthalmologists who had been offering the drug, Avastin, off-label are unwilling to take the loss, and justifiably recommend that their patients switch to Avastin’s sister drug, Lucentis, which costs more than $2,000 per monthly dose. The annual cost to taxpayers: hundreds of millions of dollars.

In other words, an eye doctor stands to eat 75% of $30--$22.50-- each time he prescribes Avastin to a patient. Divided up, the $11 million estimated national savings reflects about 489,000 annual prescriptions of Avastin. Remember that number.

What's a rationally operating capitalist physician to do? Why, refer his patients to a drug that is sixty-six times as expensive and recoup all of the cost. At 489,000 prescriptions a year, that would translate not to "hundreds of millions of dollars," but nearly a billion. Of course, Dr. Bazarian magnanimously offers his patients a choice:

Today, an average day in my office, of 14 patients to be treated, 8 were scheduled for Avastin and 6 for Lucentis. When shown your article, all agreed to change to Lucentis. While they would like to be socially responsible, they don’t want to see their physician lose money on their treatment.

An uncouth person might suggest that a doctor has undue influence over his elderly patients, who are likely experiencing some anxiety over their impending blindness. Since these patients have no personal financial stake in the prescription decision, while the prescribing physician does, an uncouth observer might also point out the presence of a conflict of interest. An uncouth observer might also speculate that Dr. Bazarian and his colleagues, were they to express in writing this particular situation to their Congressmen or Congresswomen, or to the professional associations to which they belong, might have some influence to produce a productive remedy without resorting to an apparently spite-driven recourse of screwing Medicare.

A really uncouth person might engage in basic math and assess the outcomes of this typical day. Dr. Bazarian presses his elderly patients to adopt the name-brand drug in order to avoid harming the nice doctor who is helping them to retain their sense of sight. How does it work out for Medicare? Instead of (8*$4.50)+(6*2000)=$12,036, Medicare is on the hook for 14*$2000=28,000, a net loss of $15,964 . As for the doctor, by shifting eight patients to the name brand drug he saves himself $180. A spectacularly uncouth person might ask of Dr. Bazarian what he intends to do when his individually rational actions, replicated by his colleagues across the country, have the predictable systemic consequence of bankrupting Medicare and his pool of clients dwindles to the independently wealthy sufferers of macular degeneration in southern Maine. Might the doctor inquire of one of his Senators whether some sort of systematic overhaul of the health financing system might alleviate this one bizarre incentive? Might the doctor participate with others in an effort to remedy a procedural fault in the system that creates a perverse incentive? Might the doctor, to use the unfortunately coarse parlance of our times, suck it up and take one for the team, as most people in these troubled economic times have had to do? After all, the fact that the doctor claims to have offered his patients the final decision suggests that he recognizes the basic absurdity of his position, that his potential individual loss of an Andrew Jackson should outweigh the public interest of saving two large. It's not as though he has any choice in the matter. His patients insist that he give them the most expensive drugs the taxpayers can buy.

As a gentleman, however, I find it absolutely reprehensible that an honest physician would be forced by the absolutely irresistable power of perverse economic incentives to inflict eighty-three fold on the taxpayer the losses that public insurance would inflict on him, and therefore am swayed by the sheer power of this isolated anecdotal argument to reject the public option entirely.

True Gentleman-Lady: Judith Warner

Warner gets it: when people like Michael Moore attempt to shame and humiliate the malefactors of great wealth, they create hard feelings and no one can be happy. It would be far more polite and effective to invite the management ranks of Goldman Sachs and JP Morgan over for some coffee and really listen to them. Hear about their dreams, understand how bad it makes them feel to be called bloodsucking evil parasites. With a little understanding, they might be convinced to slightly modify the publicly visible manifestations of their ill-gotten wealth, which would allow everyone to live comfortably in the belief that nothing's wrong.

Also, Warner displays an astute political insight when she observes this:

Maybe Moore has spent too much time documenting the other side. He seems to have lost sight of the fact that the other side is out of power. Why play their game and risk letting them win?

See, Republican hissy-fits are the most potent political weapon in the land. If Democrats concede all matters of economic and social policy to them, thus neutralizing the power of manufactured outrage, there is a chance that Democrats may preside over a more polite and sane America, in which we are free to raise our precocious and well-adjusted children with common names spelled according to European conventions. Which is what we all want and need so desperately. It's a slim chance, but, since raising issues of governance, social responsibility, and systemic inequalities is totally gauche, it's the only chance we've got.

Unless they turn to Plan B, spite politics. Nothing beats that.