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The Likely Failure of Obamacare After ‘National Federation’

By Edward Zelinsky

As virtually all Americans now know, the Supreme Court, by a 5-4 vote, sustained the Patient Protection and Affordable Care Act (“PPACA”). President Obama hailed the Court’s decision as confirming “a fundamental principle that here in America — in the wealthiest nation on Earth — no illness or accident should lead to any family’s financial ruin.” The President and his supporters tell us that PPACA will provide health care coverage to 30 million uninsured Americans. From the President’s vantage, the Court’s decision in National Federation of Independent Business v. Sebelius guarantees the desired expansion of health care coverage.

This superficial analysis of the Court’s decision is wrong. Two key elements of National Federation hobble the enforcement of PPACA. First, that decision eliminates the penalties for those states that decline to expand their Medicaid rolls. That decision also deprives Congress of the ability to enforce vigorously the individual health insurance mandate.

National Federation thus makes likely the failure of the President’s policies to expand health care coverage by eviscerating the enforcement of those policies. Health care coverage will increase somewhat because of the expansion of Medicaid and the individual mandate imposed by PPACA. However, in light of National Federation and the Court’s neutering of the penalties enforcing PPACA, the increase in medical coverage will be nowhere near the President’s aggressive goal.

Consider first the expansion of Medicaid, which provides medical services to low-income Americans and is administered and partially-financed by the states. Roughly half of the 30 million Americans whom the President forecasts will benefit by PPACA will receive their new health care coverage from the expansion of the Medicaid program. Since state participation in Medicaid is voluntary, the states need not expand Medicaid coverage as President Obama seeks.

To overcome states’ resistance to the costs of expanded Medicaid coverage, PPACA would have penalized any state rejecting such expansion by cancelling such state’s existing federal funding for its present Medicaid programs. For any state, this loss of its existing federal funding would be a financial disaster. Thus, it was likely, before National Federation, that all states would (however reluctantly) have accepted the expansion of Medicaid sought by President Obama to avoid the loss of their current Medicaid financing from Washington.

However, Chief Justice Roberts’s opinion in National Federation declares it unconstitutionally coercive for the federal government to withhold existing Medicaid funding from those states which refuse to expand Medicaid. In the Chief Justice’s terms, PPACA’s threatened termination of states’ existing Medicaid funding “is a gun to the head…[an] economic dragooning that leaves States with no real option but to acquiesce in the Medicaid expansion.”

By invalidating PPACA’s Medicaid penalty provision, National Federation makes the expansion of Medicaid a take-it-or-leave-it proposition for the states. Given their pressing financial problems, most states will leave it, as a state refusing to expand Medicaid coverage will now suffer no financial harm from that refusal.

While the states’ financial troubles are in part attributable to current economic circumstances, more fundamentally those troubles stem from the states’ underfunded pension and health care commitments to their employees. Neither those commitments nor the underfunding are going to be resolved anytime soon. While the federal government committed in PPACA to full funding of expanded Medicaid coverage in the early years of such expansion, the federal government made no such guarantees for the long-term.

Hence, financially-strapped states will now refuse to expand Medicaid coverage since, because of National Federation, there is no longer any financial penalty for such refusal. In contrast, proceeding with such expansion risks long-term costs the states are ill-prepared to incur. Had Congress been confident that states will voluntarily expand their Medicaid obligations, Congress would not have included in PPACA the financial penalty the Court has now invalidated.

The rest of the forecasted gain in health care coverage stems from the individual mandate, the requirement imposed by PPACA that most Americans have “minimum essential” health care coverage. A majority of the Court (including Chief Justice Roberts) declared that Congress lacks the power to enact the individual mandate under the Constitution’s Commerce Clause. A different majority (also including the Chief Justice) sustained the mandate as a constitutionally-permitted tax.

The media are largely treating this as a technical matter of little practical import. Not so: As a tax, Congress possesses limited authority to actually enforce the mandate.

The individual insurance mandate is a constitutional tax, the Chief Justice declared, because Americans without health coverage can pay the tax rather than obtain such coverage: “Under the mandate, if an individual does not maintain health insurance, the only consequence is that he must make an additional payment to the IRS when he pays his taxes.” And, the Chief Justice further notes, “for most Americans the amount due will be far less than the price of insurance.”

Even before National Federation, there were those who feared that many Americans would pay the tax rather than purchase health insurance. The Obama Administration itself estimated that four million Americans will choose to pay the tax instead of acquiring health care coverage. Chief Justice Roberts’ opinion invites Americans to do just this.

Because Congress precluded the IRS from using many of its standard enforcement techniques to collect this tax, many Americans will simply decline to pay the tax — without anything happening to them.

Prior to the Court’s decision, Congress, to bolster the mandate, might have augmented the penalties for not purchasing medical insurance. Congress, for example, might have considered declaring it a federal misdemeanor for an individual to willfully refuse to carry medical coverage.

However, National Federation precludes this kind of enhanced enforcement as beyond Congress’s authority under the Commerce Clause. Hence, the Court’s decision, sustaining the individual mandate as a tax but rejecting the mandate under the Commerce Clause, makes the future enforcement of the mandate less effective than it would otherwise be.

Some states will voluntarily expand Medicaid coverage. Some individuals will be prodded by the individual mandate to acquire health insurance. However, the quantum of increased coverage is unlikely to be anywhere near the President’s goals now that the enforcement of PPACA has been eviscerated by the Court’s decision in National Federation.

This is particularly bad news for the insurance industry. That industry had accepted the statutory obligation to issue health insurance to everyone at standard rates in return for the offsetting commitment that there would be 15 million newly insured individuals paying premiums for such insurance. Under PPACA and National Federation, the insurance industry is still stuck with the costly obligation to sell insurance to everyone at standard rates but now will not see all of the promised premiums, as many Americans will simply pay the tax to the federal Treasury.

At the end of the day, National Federation, if not quite a Pyrrhic victory, makes likely the failure of the President’s policies expanding health care coverage by eviscerating the enforcement of those policies. While health care coverage will increase somewhat because of PPACA, that increase in medical coverage will, as a result of the Supreme Court’s decision, be nowhere near the President’s aggressive goal.

Edward A. Zelinsky is the Morris and Annie Trachman Professor of Law at the Benjamin N. Cardozo School of Law of Yeshiva University. He is the author of The Origins of the Ownership Society: How The Defined Contribution Paradigm Changed America. His monthly column appears here.

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A new era at the American National Biography

In April 2012, the American National Biography gladly received a new general editor: Susan Ware. Mark Carnes welcomed his successor, saying, “A superb choice! Susan Ware is an outstanding biographer, a proven editor, and a wonderful person. She will thrive in a job whose importance does not preclude it from being great fun.” We’re excited to have Susan leading the ANB and she’s offered a sneak peak of her plans for improving and extending this fantastic resource.

By Susan Ware

It is hard enough following in the footsteps of Mark Carnes as the general editor of the American National Biography, which also means following John Garraty. Then my husband started referring to me as the next Sir Leslie Stephen, and as a lifelong feminist who has been reading Virginia Woolf since I was a teenager, this was almost too much historical lineage to shoulder. But once I began to settle in to my new job, those insecurities began to melt away as I was reminded what fun it can be to spend one’s professional life in the pursuit of biography.

One reason I am settling in so nicely is that I had great training as the editor of the biographical dictionary, Notable American Women, at Radcliffe from 1997-2005. In fact, Notable has been central to my entire career as a historian. In 1972, I drew on the first volumes for my senior thesis in the then-new field of women’s history at Wellesley College. The next volume which came out in 1980 contained my first published articles as a newly-minted Harvard Ph.D. Then I had the chance of a lifetime to edit the final volume, which appeared in 2004.

Of course the biographical equivalent of sibling rivalry made it difficult to contemplate transferring allegiance from Notable to the ANB, but in the end what drew me to accept the new position was the chance to continue to add and update entries online. This wonderful option allows the scholarship at the core of biographical dictionaries to be current with just the click of a keystroke.

It is to this vision of the ANB as an ongoing, evolving project that I plan to dedicate my energies as general editor. More specifically, my overriding priority is to ensure that the ANB reflects the overall diversity of American history in all its myriad aspects: not just the usual trilogy of race, class, and gender, but also occupational diversity, geographical diversity, and so much more. In line with how American history is taught, my goal is to have the ANB look like and reflect the complexity of American society.

I’ve only been on the job for less than two months, but I can already offer an example of how the ANB will be richer when a commitment to diversity is front and center. It comes from a field which is actually somewhat overrepresented: baseball players. (Why so many? Probably because it is so easy to line up sports-crazy authors for these essays.) How could it be possible to increase the field’s diversity once Negro League pioneers like Satchel Paige, Josh Gibson, Cool Papa Bell, and Oscar Charleston had been included?

Meet Toni Stone (1921-1996), the first woman to play professional baseball. A gifted African-American athlete, Stone played second base on various Negro League teams in the 1950s as a regular member of the line-up, not just as a curiosity on the roster. Because of a fine new biography called Curveball by Martha Ackmann, who in her other life is an Emily Dickinson scholar at Mount Holyoke College, Toni Stone now can take her place as a true pioneer in the history of baseball. Needless to say, I’ve already signed up Martha to do the entry for the ANB.

I’m sure you can see my larger point. Even in a field like baseball, there is a lot more diversity than you might expect. You just need to know where to look and who to ask.

But I can’t do this alone, and I would like to ask for your help. Have you come across interesting figures that you think deserve to be in the ANB? Send us their names. Have you found certain areas of the ANB somewhat weaker than others? Let us know and we will try to beef them up. Are you willing to write entries on specific individuals or a general field? Forward your name and we will see if we can do a little “matchmaking” on our end.

If you eyeball the published volumes of the ANB on a library shelf, or think about the vast quantities of information contained in its online database, you instantly grasp that biographical dictionaries are collaborative undertakings, far beyond what an individual scholar could ever accomplish. As the new general editor of the ANB, I am inviting you to be part of this process. I look forward to your comments and suggestions flooding my inbox.

Susan Ware can be reached at sdware[at]acls[dot]org. At Oxford University Press, please contact Ryan[dot]Kidd[at]oup[dot]com.

Susan Ware is the new General Editor of American National Biography. She is an accomplished historian, editor, and the author of seven books, including biographies of Billie Jean King, Amelia Earhart, Molly Dewson, and Mary Margaret McBride. She served as the editor of several documentary collections and of the most recent volume of Notable American Women, published in 2004, which contains biographies of 483 women from over 50 fields. Educated at Wellesley College and Harvard University, Dr. Ware taught at New York University and Harvard. She has long been associated with the Schlesinger Library at the Radcliffe Institute for Advanced Study, and is active in a variety of professional organizations. She has extensive media experience in radio, television, and documentary film and is committed to bringing women’s history and feminist scholarship to a wide popular audience.

The landmark American National Biography offers portraits of more than 18,700 men and women — from all eras and walks of life — whose lives have shaped the nation. First published in 24 volumes in 1999, the ANB received instant acclaim as the new authority in American biographies, and continues to serve readers in thousands of school, public, and academic libraries around the world. Its online counterpart, ANB Online, is a regularly updated resource currently offering portraits of over 18,700 biographies, including the 17,435 of the print edition. ACLS sponsors the ANB, which is published by Oxford University Press.

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Three Myths About the Muslim Brotherhood

By Steven A. Cook

Since Egypt’s Supreme Presidential Election Commission declared Mohamed Morsi the winner of the presidential election, there has been a lot of commentary about the Muslim Brotherhood. Morsi, an engineer by training, was a long time member of the Brotherhood and was a member of its political department. Morsi has resigned from both the Brotherhood and its party, Freedom and Justice, but that is more symbolic than substantive. The Muslim Brotherhood is now in control of the Egyptian presidency, previously the fulcrum of power in the political system and observers are asking, “Who Lost Egypt?” The answer is no one; 51.7 percent of Egyptians voted for Morsi. The race was close and, no doubt, there are Egyptians fearful about their future, but there has been so much mythmaking about the Muslim Brotherhood, it is worth debunking a few.

1. A History of Violence?

It is true that beginning in 1941, the Muslim Brotherhood established a para-military group called the jihaz al sirri or “the secret apparatus” and stockpiled weapons. It is also true that during the late 1940s, the Brothers were among a number of political factions that destabilized the Egyptian political system. In December 1948, a Brother named Abdel Magid Hassan murdered Prime Minister Mahmoud Fahmi Nuqrashi. Yet since that time—indeed, since the Brotherhood’s founder, Hassan al Banna, was assassinated while getting into a taxi in downtown Cairo in February 1949—the organization has not been involved in violence. There is, of course, the allegation that the Brothers were behind the attempted hit on Gamal Abdel Nasser in October 1954, but there continue to be questions whether the would-be assassin, Mahmoud Abdel Latif—who was a member of the Brotherhood—was working on behalf of the Islamists or another group intended to discredit the Brotherhood. No one has been able to prove the story one way or the other, but it is curious that not only did Nasser survive Abdel Latif’s eight shots fired from close range, but he was unscathed and went on to finish his speech, which was a turning point in his political career. The Brothers were subsequently dismantled and ceased to be a significant force in Egyptian politics until the 1970s, when they officially renounced violence.

Observers often point to the fact that Sayyid Qutb and Ayman Zawahiri were Muslim Brothers to confirm the group’s violent tendencies. In the case of Zawahiri, he had a brief flirtation with the Brothers in his teens, though it is unclear whether he was actually a member of the organization. Zawahiri was arrested in 1966 (at the age of 15) for being a Brother, but it is more likely that he was part of a vanguard that split from the mainstream Brotherhood in the late 1950s and 1960s. This vanguard was a radical faction that followed Sayyid Qutb—a Brother and an intellectual architect of jihadism—and whose members wanted to engage in a direct confrontation with Nasser and the Egyptian state. Although the Brotherhood’s Supreme Guide, Hassan al Hudaybi, tolerated the vanguard for a time, the two factions ultimately fell out over doctrinal issues as well as over al Hudaybi’s desire to seek an accommodation with the leaders of the Egyptian regime.

2. From Shura to Democracy?

It has become accepted wisdom in some circles that the Muslim Brotherhood is a force for progressive change, even democracy, in Egypt. Since the mid-1980s when the Brotherhood entered electoral politics in a coalition with the allegedly liberal Wafd party, its leaders have embraced the rhetoric of political reform. On the eve of the 1990 parliamentary elections, the Brotherhood’s then Supreme Guide Mohamed Abul Nasr penned an open letter to President Mubarak in which he boldly stated, “Freedom is dear and it is preferable for you to avoid your nation’s anger and riots. It cannot be imagined that any people will remain under subjugation and repression after hearing and witnessing surrounding nations achieve their freedom and dignity…A nation’s power is derived not from material power, but from the entire citizenry’s liberty, the people’s trust in the government, and the government’s trust in the people.” Those are reassuring (and prescient) words—even 22 years after the fact—but the Brothers have always been rather fuzzy about what democracy means to them, falling back on the concept of shura or “consultation,” which could or could not be the foundation of Egyptian democracy. They have also been vague about shari’a. While Morsi and Brotherhood big wallas have said that they will implement Islamic law, members of the Brotherhood’s Freedom and Justice Party told the American foreign policy establishment during a visit in March that they support “the principles of shari’a, but not necessarily its particular legal rulings.” I guess that sounds fine to the uninitiated, but the statement amounts to nothing more than obfuscation.

It is entirely possible that the Brothers are democrats despite themselves. Here is the theory: Hammered as they are between the military, which still controls the guns, and other political forces including revolutionaries who mistrust the Islamists and thus can stir up trouble, the Brotherhood could determine that their only source of power is through the ballot box. As a result, the Brothers will seek regularly scheduled, free and fair elections as the only way to legitimate their power. In time, this will transform the Brothers into committed democrats. Never mind (cliché warning) that elections don’t make democracy, but this is roughly what happened in Europe and how theocratic parties of the 19th century became today’s Christian Democrats. There are many insights to be gleaned from Europe’s experiences, but it is important to remember that history can be a guide, but it is not a blueprint.

In the end, the intellectually honest answer about the Brothers’ commitment to democracy is, we just don’t know. It’s an empirical question. Let’s pay less attention to what they say and focus on what they are doing.

3. The Brothers and US

If there is any consensus in Washington about the Brothers and the U.S.-Egypt strategic relationship, it is cautious optimism. Headlines in the Washington Post that declare “Egypt’s President is a U.S. critic, but could be an Ally” have contributed to the idea that “maybe everything will be OK,” which currently prevails inside the Beltway. Hope springs eternal, but observers should not be so sanguine about the relationship. No doubt, the Brothers need decent relations with the United States given Egypt’s dire economic situation, which is why we have been hearing endless tales of the Brothers’ vaunted pragmatism. The sky is not falling and the sun will rise tomorrow, but this emphasis on the pragmatism of the Brotherhood may be leading to false expectation. After all, for more than 30 years the Brothers have run against the U.S.-Egypt relationship and they used those ties to discredit both Anwar Sadat and Hosni Mubarak. Cairo’s relationship with Washington is also deeply unpopular with Egyptians; it developed precisely because Sadat and Mubarak were authoritarians who, to varying degrees, could disregard public sentiment. It would thus be amazingly unpragmatic for the Brotherhood, alleged agents of democratic change, to continue close ties with the United States.

Analysts should also not forget from whence the Brotherhood comes. As I wrote a few weeks ago,

It is important to remember that the origins of the Muslim Brotherhood lie in Hassan al Banna’s dismay over foreign—i.e. Western—penetration of Egypt that damaged traditional values. I am not saying that the Brotherhood hasn’t changed since the early 1920s when al Banna first arrived in Cairo, but mistrust of the khawaga is part of the organization’s DNA. To be sure, the Brotherhood espoused a pan-Islamic message at times, but at a basic level, the Brothers are good nationalists. Fast forward to the January 25uprising, which was about dignity and national empowerment, and you understand further why a President Morsi is unlikely to make his first international visit to the United States.

We shouldn’t expect a breach in relations, but with President Morsi, the U.S.-Egypt relationship is bound to be far more difficult than the previous three decades when Mubarak aligned himself closely with the United States.

This article originally appeared on CFR.org.

Steven A. Cook is the Hasib J. Sabbagh Senior Fellow at the Council on Foreign Relations. A leading expert on Arab and Turkish politics, he is author of The Struggle for Egypt: From Nasser to Tahrir Square.

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Mindfulness is more than stress management

By Holly Rogers, M.D.

At the university counseling center where I work, the students are limp with relief when the semester finally grinds to an end and summer arrives. For college students and graduate students around the country, summer brings a much-needed break from the pressures of the academic year. However, academic pressures are not the only challenges facing emerging adults, young people between the ages of 19-29. They are typically dealing with a wide range of challenges and stressors that are related to their stage of life; they are in the midst of a developmental process that can take quite a bit of fortitude to resolve.

Emerging adults are in the business of developing their adult identities, the primary task for this age group. They are engaged in the enterprise of exploring career options, making decisions about their life path, trying on different relationships, suffering disappointments and searching for meaning from it all.

What exactly does it look like to develop an “adult identity”? Basically, it looks like a young person starting to make decisions based on his or her own unique preferences and perspectives. You see the adult identity forming when the young woman discovers, not so much that her parents were right, but rather that her own values have evolved to the point that her wonderfully laid back and cool boyfriend is starting to look aimless and lazy. You see it in the young man whose parents and peers really think he should be a doctor, but he discovers he’d prefer to teach. You also see it in the young man who decides to return to or reject his family’s religious rituals, the young woman who changes political parties, and the young gay person who bravely allows those close to him to see his true self. These are all ways that emerging adults start to identify and express the values that will guide them as they progress through life.

The emerging adults who will have the best luck with this quest, are the ones who take the time to become acquainted with their authentic desires and their core values. Decisions based on this level of self-understanding are more likely to lead to greater life-satisfaction.

So how does one start to understand his or her authentic desires and core values? One of the best tools I know of is the practice of mindfulness meditation. Mindfulness is the skill of bringing your awareness into the present moment, forgetting your worries about the future and your regrets about the past as you focus your attention, without judgment, on your moment-to-moment experience.

Perhaps somewhat surprisingly, the ability to maintain present-moment awareness has tremendous physical and psychological benefits. Mindfulness has become extremely popular in this culture, with proponents pointing out it’s myriad of positive effects on our immune systems, cardiovascular systems, and moods, to name just a few. Many people learn mindfulness for its inherent health and stress-management effects. For emerging adults though, the perks of mindfulness practice can go beyond these basic health benefits.

Mindfulness meditation, when practiced regularly, allows you to become familiar with the workings of your mind in a way that can have profound consequences. “Mindfulness” is the translation of the Pali word “vipassana”; it can also be translated as “insight” or “clear-seeing”. Vipassana meditation is an ancient Buddhist meditation and it is a practice that leads to self-transformation through self-understanding. In addition to deep self-knowledge, vipassana meditation also develops certain qualities of mind including gratitude, compassion, contentment, and patience. The practice has been brought to the west and is often taught in a secular form, separate from its Buddhist roots. Whether it is linked with Buddhism or not, the practice has the potential to create transformative self-knowledge, the sort of self-knowledge that is particularly valuable to emerging adults.

One of my students articulated her experience with mindfulness meditation beautifully when she said, “I started this practice because I felt anxious and thought it would help me sleep. But it has become so much more than that to me. For the first time, I’m recognizing how all the judgments I have about myself keep me from doing the things I want to do. I don’t think I’ll ever see myself the same way again.”

Self-knowledge and greater life-satisfaction can benefit us all at any age, but for emerging adults, these gifts can have particular value. So if you are an emerging adult with some time on your hands this summer, I offer you a challenge. Make a commitment to spend at least ten minutes every day looking quietly inwards. For ten minutes, pull out your ear buds, shut off your phones, and close your laptops. Sit in a comfortable chair, but don’t lounge; sit with your back straight and your feet flat on the floor. Close your eyes, and allow yourself to begin to notice the feel of your breath as you slowly inhale, then exhale. Almost immediately, your mind will begin to work, producing thoughts about all manner of things: what you need to do, what you want to do, who you like, who you don’t like, why you are right and everyone else is wrong. See if you can notice these thoughts as they start up, then let them drift away as you bring your attention, without judgment or criticism, back to the sensations of your breath. If you are like me and pretty much everyone else I know, you will have the opportunity to notice your thoughts and come back to your breath over and over and over again. Remember, you are not trying to stop your thoughts, just notice and release them.

Every day, for ten minutes, do nothing but sit, feel your breath, notice when thoughts arise and return your attention to your breath. It sounds simple but it is not easy. Allow yourself to be curious and patient. Find a good book about mindfulness and read it. See what happens.

Holly Rogers, M.D., is a Psychiatrist at Counseling & Psychological Services, Duke University and a Clinical Associate in the Department of Psychiatry, Duke University Medical Center. She is the co-author of Mindfulness for the Next Generation: Helping Emerging Adults Manage Stress and Lead Healthier Lives with Margaret Maytan, M.D., M.A., a Clinical Associate in the Department of Psychiatry, Duke University Medical Center.

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How to become a doctor in the UK

By Iqbal Kahn

If you ask many people, “How long does it take to train as a doctor?”, the response would probably be five years. And many people joke that it takes longer to train as a vet than a medic! However the simple answer is that a doctor is always training in one form or another, and that as medical professionals, we should always be striving to be the best.

A new, common training structure brought in in 2007 sees doctors completing an arduous five to six years at medical school, before starting their careers on the wards proper. This entails a series of placements spread across two years designed to introduce them to the different fields or specialties within a medical career.

Next follows a period of up to eight years of training within their chosen specialty. During that time, doctors are faced with attaining membership of their chosen Royal College. For example, paediatricians must become members of the Royal College of Paediatrics and Child Health by completing a succession of written and practical exams.  Only then do they become a consultant.

These exams are extremely challenging and test the candidate’s medical and scientific knowledge. The pass mark is set so that less than 50% of candidates sitting the exam pass and only the best prepared and the brightest ones will get through. Over the years, I have met many excellent doctors who have failed to progress into their chosen careers because they stumbled at this hurdle too many times and eventually gave up.

Each exam can cost several hundred pounds to sit, and most candidates will need to take three exams across this stage of training. Coupled with the very real chance they’ll need to resit their exams, the investment can run into several thousand pounds, on top of the debt they accrued whilst at medical school.

However you could argue that whilst these doctors are cash rich, they are definitely time poor. Alongside their studies, doctors are still juggling their 48-hours per week work commitments. Draw the short straw on your rota, and you could face an exam at 9 a.m. at the other end of the country, in the middle of a week of night shifts.

Given these challenges, it’s not uncommon for candidates to revise for up to four months in the lead up to their exams. Approaching exams in the same professional manner in which they deal with patients on the wards is critical. Everyone has a preferred learning style, but practising suturing skills with your partner may not be entirely practical! So in the lead-up to the exams, many candidates will prepare by answering hundreds, if not thousands of questions, using books and online materials.

The exams themselves are timed and long! Depending on the specialty, candidates can be expected to answer in excess of 100 questions in four hours — tough going when you need to carefully read, assimilate, and then make a clinical judgement on the information you’re presented with.

We expect our doctors to be just as competent at the ‘softer’ skills too. The patient-focused exams test candidates’ abilities to ask the right questions, give the right answers, but most importantly offer the patient a treatment and management plan that is bespoke to them. We focus a lot on ‘outcomes’ in healthcare, but we should always remember that the outcome is what the patient wants, and not necessarily what we feel best.

The UK has one of the most rigorous approaches to medical training and I’m pleased that that’s the case. We are clear in our expectations of doctors, and we do expect a lot of them, but it means that we get only the best working in the NHS.

Iqbal Khan is a Consultant Gastroenterologist and General Physician at Northampton General Hospital. He is also an Honorary Lecturer with the Universities of Leicester and Oxford. He has written two textbooks for candidates preparing towards the MRCP(UK) exam and is a Moderator for the PASSit online revision website, from Oxford University Press.

Pass your Royal College exams first time with PASSit, the new revision service from Oxford University Press. PASSit provides high quality questions with clear, detailed answers and explanations, to make sure the knowledge sinks in. There are tools to track your progress and target your revision, designed to make revision work for you. Give yourself the best chance, and revise with PASSit. Start revising today!

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Video: why millions survive cancer

More than 12 million cancer survivors just in the United States alone are alive today as a result of the extraordinary advances in science and medicine. In this video for Why Millions Survive Cancer, Lauren Pecorino illuminates the enormous recent progress in fighting cancer, painting an intriguing portrait of scientific breakthroughs, the leading scientists behind these key discoveries, and the steps that we can all take to reduce our exposure to cancer.

Click here to view the embedded video.

You can read further OUPblog posts by Lauren Pecorino here.

Lauren Pecorino was born in New York City and grew up on Long Island, NY. She received her PhD from the State University of New York at Stony Brook in Cell and Developmental Biology. She crossed the Atlantic to carry out a postdoctoral tenure at the Ludwig Institute for Cancer Research, London. She is a Principal Lecturer at the University of Greenwich where teaches Cancer Biology and Therapeutics. The teaching of this course motivated her to write The Molecular Biology of Cancer: Mechanisms, Targets, and Therapeutics, now in its second edition. Feedback on the textbook posted on Amazon from a cancer patient drove her to write a book on cancer for a wider audience: Why Millions Survive Cancer: the Successes of Science. The paperback publishes this month.

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Does the Supreme Court care what the public think?

As we continue to look back on Thursday’s Supreme Court decision on the Affordable Care Act, the question of how the Court’s opinion was influenced by the public has been raised. To provide some background, we excerpted The U.S. Supreme Court: A Very Short Introduction by Linda Greenhouse.

Scholars regard the relationship between the Supreme Court and public opinion as elusive. Lee Epstein and Andrew D. Martin, two leaders in the empirical study of judicial behavior, titled an article: “Does Public Opinion Influence the Supreme Court? Possibly Yes (But We’re Not Sure Why).” The article surveyed the political science literature on the question, much of it inconclusive and contradictory. At best, the authors conclude, there seems to be an association between the Court and public opinion, but not enough evidence to “make the leap from association to causality,” that is, to prove that public opinion actually influences the Court. But in any event, public opinion does not travel a one-way street. While the public may influence the Court, at least some of the time, the Court may also influence the public. One classic image, dating to early in the country’s history, is of the justices as teachers, “the Supreme Court as republican schoolmaster,” in the phrase of a well-known article that documents the role of the early justices as they rode circuit, summarizing the law in their charges to grand juries, and serving in this manner as “teachers to the citizenry.” The author concludes that “whether the justice should teach the public is not and cannot be in question since teaching is inseparable from judging in a democratic regime.”

As in the Lilly Ledbetter episode (Ledbetter v. Goodyear Tire & Rubber Co., Inc., 2007), a Supreme Court decision can serve as a catalyst for public debate. Sometimes a grant of cert serves that function, well before a case has been decided or even argued. The Court’s willingness in the mid-1990s to consider whether the Constitution protects a right to physician-assisted suicide brought that issue from the shadows and placed it under a public spotlight. Public conversation and debate continued even after the Court answered the constitutional question in the negative in Washington v. Glucksberg (1997), and polls have subsequently shown steadily rising support for the ability of terminally ill people to have a doctor’s assistance in ending their lives. One study of public opinion on this issue concluded: “Court cases, in this realm as in others, place a human face on an otherwise quite abstract philosophical and legal controversy.”

Defenders of the Supreme Court’s exercise of judicial review must occasionally contend with the criticism that it is essentially undemocratic — “counter-majoritarian” — for unelected life-tenured judges to have the last word on the constitutionality of legislation enacted by the people’s elected representatives. The force of this critique waxes and wanes to the extent that the Court appears out of alignment with public opinion. It is not hard to understand why misalignment would occur with some regularity. Shifts in electoral majorities in response to changes in the public mood can occur much faster than changes on the Supreme Court, where tenures last decades. The first of Franklin D. Roosevelt’s nine Supreme Court appointees, Hugo L. Black, not only outlasted the Roosevelt administration but remained on the Court through the Truman, Eisenhower, Kennedy, and Johnson presidencies before retiring more than halfway through Richard Nixon’s first term. Between mid-1994 and mid-2005, a period of considerable political turmoil, punctuated by the contested election of 2000, there were no Supreme Court vacancies at all. The justices whose behavior provoked the Roosevelt court-packing plan were criticized from the Left; the Warren Court from the Right; and the Roberts Court, to a somewhat more modulated degree, from the Left again.

And yet, over time, the Court and the public seem to maintain a certain equilibrium. Public opinion polls regularly reflect that “diffuse” approval for the Supreme Court — that is, approval of the institution in general, rather than of particular actions — is higher than for other institutions of government. Of course, that fact alone is not particularly revealing. Surveys also demonstrate repeatedly that the current state of civics education is poor, and that the general public knows very little about the Court. For example, only 55 percent of the respondents in a 2005 survey agreed that the Supreme Court can declare an act of Congress unconstitutional. (Only one-third could name the three branches of government.) So perhaps the public expression of trust in the Supreme Court reflects a leap of faith rather than actual

knowledge; people want to believe in some governmental institution, and they are more likely to be able to identify what they don’t like about the political branches. Or perhaps the expression of public support for the Court reflects what political scientists call the “legitimation hypothesis,” the theory that once the Supreme Court rules on an issue, a measurable proportion of the public will come to the conclusion that “if they believe it, it must be right.”

Or perhaps, reflecting the awareness of public opinion displayed by the justices quoted at the beginning of this chapter, the Court brings itself into alignment over time, avoiding decisions that will take it far out of the mainstream of public opinion. That would not be surprising. The political scientist Robert A. Dahl observed more than a half century ago that the Supreme Court “is an essential part of the political leadership,” part of the “dominant political alliance.” It was therefore understandable, Dahl said, “that the policy views dominant on the Court are never for long out of line with the policy views dominant among the lawmaking majorities of the United States.”

Linda Greenhouse is the author of The U.S. Supreme Court: A Very Short Introduction. She was the New York Times Supreme Court correspondent for 30 years, covering thousands of decisions written by 18 different justices. She was awarded a Pulitzer Prize in journalism (beat reporting) in 1998. She in now Knight Distinguished Journalist in Residence and Joseph Goldstein Lecturer in Law at Yale Law School and writes a biweekly opinion column on the Supreme Court and the law for the New York Times web site. Her books include Becoming Justice Blackmun: Harry Blackmun’s Supreme Court Journey and Before Roe v. Wade: Voices That Shaped the Abortion Debate Before the Supreme Court’s Ruling (with Reva B. Siegel).

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The transformation of listening with the Walkman

By Amanda Krause

Not long ago, I saw an image floating around the Internet. It simply displayed two items — a cassette tape and a pencil — along with the following statement: “our children will never know the link between the two.” Upon a quick search to locate that image the other day, it looks like it was the topic of a reddit post back in 2011. But as viral things tend to do, it lingered, making its way into Facebook posts and into Internet “age tests” aimed at prompting either confusion or nostalgic reflection.

I came across a response blog post by Jeffrey Weston that had altered the image — it now contained a pen rather than a pencil — arguing for the pen’s superiority in rewinding the tape. Regardless of whether you used a pencil, a pen, or your pinky finger, a sentence he included about the image caught my attention. He wrote “what’s triggering this nostalgia of course is not really about rewinding a cassette with a pencil, it’s what the cassette was used for.” The memory of winding the tape is joined by a wider range of personal, music-filled memories: navigating fast forward and rewind processes, making and listening to mixtapes, and of course, the Sony Walkman.

In fact, this year marks the 33rd anniversary of the Sony Walkman; the TPS-L2 version was introduced back on 1 July 1979. Thirty-three years and the manufacturer only just stopped production of the cassette-playing Walkman in 2010. (A side note: Interestingly, that announcement came a day before the ninth birthday of the iPod.)

Originally called the Soundabout in the US and the Stowaway in the UK, the Walkman transformed listening. It was designed specifically as a playback only stereo optimized for headphone use; one that could be used while walking around. It may have not been the first portable device, but it was an unprecedented combination of portable and private listening. As Jeffery Weston recalled, “sound was viral on a scale as small as a piece of plastic and some magnetic tape.”

Sony Walkman MZ-R50, 2008. Photo by Picopon. Creative Commons License.

Like a lot of media, researchers have researched Walkman listening in the past (for example, Hokosawa in 1984 and Schonhammer in 1989). But one piece of research that really attracted my attention was published in 1998 by Shing-Ling Chen. Chen examined the impact of the Walkman on listeners’ experiences. By analyzing the journals of individuals who listened to music via Walkmans, the author considered how the Walkman blurred the line between public and private space. The Walkman allowed for a private listening experience to happen in a public setting and it allowed for nomadic listening. With this handheld device, the listener began to really have control over the music he or she was listening to.

The following is a brief recapped list of Chen’s findings regarding Walkman experiences:

It influences the perception of time.
Its use is contextualized.
It can help alter/ reinforce one’s mood.
It can be used to accompany monotonous tasks (like when cleaning or cooking).
It can bring relief to the listener.
It can act as a companion.
It can motivate, energize, and/or drive a person (like when exercising).
It can be used to isolate the listener from the outside world.
It can provide a soundtrack to what’s happening.

The same could be said about an iPod. Go ahead, reread the list but this time think about MP3 players. Had I not explicitly stated that the list was about Walkmans, presented alone, it’s very likely that it would have been assumed to be about today’s popular, mobile MP3 technology.

So just as Chen concluded that the pervasiveness of the Walkman in the participants’ daily lives indicated that their social lives really couldn’t be understood without including an understanding of their experiences with the Walkman, the same applies to the way we interact with music via technology today.

The Walkman may have met its technological obsolescent death, but like any technology it wasn’t going to last forever. And who knows what new technology will take over in the future. But for now, we need a better understanding of how we listen and use music in our daily lives. And that’s the goal of my current research: I’m exploring the avenues we now have at our disposal, like playlists, and web streaming, and even listening and sharing through Facebook. Never before has music been as ubiquitous in our everyday life and the control, accessibility, and portability that the Walkman’s successors provide require new research.

So while I look fondly at the image of pencil and cassette tape, I wonder too what the image will be in the future when we get nostalgic about our mobile MP3 players.

Amanda Krause graduated with a master’s degree in Applied Music Psychology from Roehampton University, UK in 2010 and is currently doing doctoral research at Curtin University, Australia. Her research interests include musical experiences and behaviors in everyday life, with a particular emphasis on the role of digital and social technologies. She tweets as @StudyListening and invites everyone to participate in her research at www.researchaboutlistening.com.

If you’re interested in learning more about music and psychology, check out The Social and Applied Psychology of Music by Adrian North and David Hargreaves. It considers the value of music in everyday life, answering some of the perennial questions about music.

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Five things you need to know about the Affordable Care Act

With the Supreme Court’s decision on the legality of the Affordable Care Act finally made, we pulled together a quick list of things you should know from Health Care Reform and American Politics: What Everyone Needs to Know by Lawrence R. Jacobs and Theda Skocpol.

(1) Most Americans don’t know what it means to them.

Americans reacted to the passage of the Affordable Care Act with continued ambivalence, with opinions divided roughly down the middle in incessant polls asking whether the new law was the right thing to do. During many months of partisan battles and legislative maneuvers about the new legislation, groundless warnings about “death panels” and draconian cuts to Medicare unnerved many people—and the entire mess was confusing. Not only right after passage, but in subsequent months, most Americans have told pollsters they are not sure what is in the legislation. People don’t understand what reform actually means for them—or what it portends for the future of our economy. With the Supreme Court decision looming until Thursday’s announcement, most Americans have yet to fully absorb the impact of the Affordable Care Act.

(2) Most people benefit from the Affordable Care Act.

The winners of health reform are the vast majority of Americans. When the provisions are effectively implemented, seniors, the sick, and middle Americans — including many families in the upper middle class — will receive wider and easier access to health insurance benefits protected from trickery by the insurance industry. The number of working-age Americans and their children who have to go without basic health insurance will decline by a remarkable 32 million people. This comes from the nonpartisan CBO, which projects that coverage will be extended to 94% of all Americans and legal immigrant residents (up from 83% today). About a third of the remaining uninsured will be undocumented or illegal immigrants, who are not eligible for coverage under the reform law.

(3) The affluent will pay more but will ultimately benefit.

The newly reformed U.S. health care system provides, on balance, a good deal for the vast majority of Americans. At the very top of the economic ladder, though, the payoff for families making more than $250,000 a year is mixed. They will share in general improvements in insurance, and, of course, many wealthier Americans place a high value on a better health care system for all their neighbors, as well as for themselves. They want their children to grow up in a healthier America, where teachers and policemen and clerks can enjoy health security, too. Still, the rich are asked to pay a bit more to make this better system possible. On the plus side of the ledger for privileged folks, richer families will benefit along with all other Americans from new restrictions on insurance companies that prohibit caps on coverage and egregious abuses such as finding a pretext to drop beneficiaries when they get sick.

(4) The Affordable Care Act will help the economy.

Health reform will impact the economy in ways that help everyday Americans, while producing an overall boost to job growth. People will be able to build careers and found businesses secure in the knowledge that they can get affordable insurance for their families. Employers will have to navigate new rules—and larger employers may pay new fees. But all employers will benefit from more fluid job markets, healthier workers, and reduced costs—especially for employers who have already been providing health care coverage for their employees. As for businesses in the U.S. economy’s vast health care sector, they are going to win, on balance, enjoying more customers and opportunities for growth and profits. “Wall Street Welcomes New Health Prescription,” proclaimed a banner headline in the business section of a leading metropolitan newspaper right after Congress voted on Affordable Care. Traders in health industry stocks know how to penetrate the partisan and ideological fog to see the economic bottom line.

Lest we think that only Wall Street will win, so will the Main Street economy. Without comprehensive health reform, perhaps a quarter of U.S. workers have been locked into their jobs—afraid to pursue new openings out of concern to hold on to health benefits, or choosing a less than optimal job because it has health benefits and an otherwise more attractive job does not. “Job lock” is certainly bad for Americans trying to get ahead. And it is bad for the whole economy, too, because a mobile workforce is more dynamic, efficient, and entrepreneurial.

(5) We can afford to provide most Americans with health care through tax revenue and cost controls in the Affordable Care Act.

According to the design of Affordable Care, the mammoth bill is to be paid by the affluent, well-to-do businesses, and established medical providers. Just over half the bill for health reform is to be paid by taxes and fees that fall on the wealthiest Americans and on businesses (including health care giants and employers that have been free-riders in the past). The remainder of the revenue to defray costs in health reform comes from trimming what the federal government and nation were previously slated to pay over many years to health care industries and providers. Significantly trimmed subsidies to private insurance companies involved in Medicare are a substantial source of savings. “Bending the curve” is the term for this—and it reflects the fact that even if only slight reductions can be made now in the rate of price increases charged by physicians, hospitals, and health care companies of all sorts, such slight reductions can nevertheless add up to big savings over time. The authoritative and nonpartisan CBO projects that the law’s combination of increased revenue from taxes on the affluent, plus cost restraints, will more than cover the price tag for health reform. Better, the CBO projects that future federal expenditures on health care will come down from previously assumed levels enough to reduce the federal government budget deficit by about $140 billion during the first ten years of the new program. CBO projects further improvement in the bottom line for deficit reduction during the second decade of Affordable Care. In short, Affordable Care as enacted is a deficit-reducer, not a budget buster.

Lawrence Jacobs and Theda Skocpol are the authors of Health Care Reform and American Politics: What Everyone Needs to Know, which we have a sneaking suspicion may already be undergoing revision and updates. Lawrence R. Jacobs is the Walter F. and Joan Mondale Chair for Political Studies and Director of the Center for the Study of Politics and Governance in the Hubert H. Humphrey Institute and Department of Political Science at the University of Minnesota. Theda Skocpol is the Victor S. Thomas Professor of Government and Sociology at Harvard University, a member of the National Academy of Sciences, and past president of the American Political Science Association.

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Will health care reform work in the end?

In light of the Supreme Court decision yesterday upholding the Affordable Care Act, I thought this brief excerpt from Health Care Reform and American Politics: What Everyone Needs to Know by Lawrence R. Jacobs and Theda Skocpol was in order. — Blog Editor Alice

Matters are far from settled for the Affordable Care framework that promises significant new benefits for the vast majority of Americans to be paid for by taxes on the wealthy and fees from businesses. The U.S. political system gives disproportionate leverage to the privileged and well-organized economic interests—the very groups that Affordable Care designates to pay for improved health care for all of their fellow citizens. The fat cats don’t like it, and they have potent weapons at their disposal to fight back—money for media campaigns, legions of lobbyists, and now, with the Citizens United decision by the Supreme Court, an unlimited ability to contribute to electoral campaigns. With every resource at their disposal, such groups will continue to weigh in as regulations are written at the federal level—and also as rules for insurance exchanges are devised in fifty different states. They will stalk the new law in the courts. And they will use the electoral process to elect Representatives and Senators and governors and state legislators who share their sympathies—people they can lobby, along with administrators, to make changes in taxes, subsidies, and rules. Much of this will happen out of public view, as it will be complicated and not easy to dramatize on cable news.

We will not know for a decade or so how far the push-back gets. The sway of the powerful may well produce a steady rollback of many of the specific ways in which Affordable Care helps middle-income and lower-income Americans. It is just too easy and tempting for public officials of either party to enact tax breaks for the rich, or adjust regulations and subsidies as demanded by well-heeled business interests. Each little change will seem small enough for an individual legislator, including a Democrat, to rationalize. But the little concessions to the status quo and to the rich and the powerful will add up.

There are also rosier scenarios—either much rosier or somewhat rosier. Perhaps the new law will withstand most of the initial attacks—and dodge many of the concerted efforts to trim back taxes, relax rules, and reduce help for everyday Americans. Vigilant citizens can help to hold the line, yet key stakeholders are also likely to prevent certain kinds of rollbacks. Affordable Care rules say that insurance companies can no longer deny applicants because of “pre-existing” adverse health conditions, or charge them huge, surprise payments when they become sick, or dump them altogether when they become costly. These new insurance rules are so popular that no political party in power is likely to be able to get away with going back to the pre-2010 status quo ante. Consequently, insurers who do not want the rules without additional paying customers will aim to protect public subsidies that enable millions to buy insurance. Another powerful force for holding the line against rollbacks is the AARP, which seeks to protect improved subsidies for prescription drugs and preserve help for nearly retired people who get laid off and need to purchase health insurance on their own. Conservative and liberal activists alike may also win victories in states or regions that they want to preserve, giving them a stake in the survival of Affordable Care. Conservatives might have a favorite market-based system, for example, while progressive reformers might succeed in setting up public options or even a single payer system in particular states or regions.

In short, if Affordable Care survives lawsuits and immediate resistance from more conservative delegations in Congress, its prospects will start to rise. Americans always turn out to value and support major social programs that help individuals and families gain basic security with dignity. Social Security and Medicare were only enacted after ferocious opposition on par with resistance to the Affordable Care Act, and both remained politically controversial for some time after initial enactment; but as they were carried through and the initial visions of reform were realized in practice, these laws became beloved and indispensable to most American families. Social Security and Medicare also encouraged older citizens, regardless of educational or income levels, to become more attentive about government; before these programs were established, seniors voted at about the same level as other Americans, but now they are the nation’s most regular voters, vigilant about politicians who might mess with their benefits and rights.28 The same may happen with Affordable Care in due course, after its meaning becomes clear to most Americans—including to the younger, minority men and women and the less affluent of all backgrounds who are, in truth, the biggest winners in the emerging health care system. New generations of voters may come to rely upon Affordable Care’s protections and subsidies, and staunchly defend them in future elections and public debates. Many conservatives have fiercely opposed comprehensive health reform precisely because they fear it will be very popular once fully in place.

Even if Affordable Care withstands just some of the counterreactions to come, the limitations of the purely negative strategies pursued by conservatives and Republicans in the health reform battles of 2009 and 2010 will become apparent. The decision by Republicans in Congress to just say no to negotiations for bipartisan bills in effect removed them from the negotiating table after the Senate Finance Committee completed its work in the early fall of 2009. This, in turn, opened the door for moderate and liberal Democrats to make reform legislation more progressive in late 2009 and early 2010—above all, to insert taxes on the rich that will be very hard to roll back, because doing so would balloon the federal deficit.29 What is more, the continuing right-wing clamor for repeal months after the White House signing ceremony belies the fact that the new Affordable Care legislation is already “on the books,” that it is, day by day, month by month, restructuring how individuals and businesses pay for and receive health care. Unless an entirely unexpected judicial ruling strikes down all the legislation, significant parts—including regulations hemming in the behavior of insurance companies—will almost certainly endure. Health care in the United States will not go back to the way it was before March 23, 2010. Ongoing struggles over the full implementation of Affordable Care have a way to go, but they will not reverse all that has been legislated. In one way or another, we have already seen an irreversible shift in U.S. politics, along with an historic expansion in the social rights of American citizens.

Lawrence Jacobs and Theda Skocpol are the authors of Health Care Reform and American Politics: What Everyone Needs to Know, which we have a sneaking suspicion may already be undergoing revision and updates. Lawrence R. Jacobs is the Walter F. and Joan Mondale Chair for Political Studies and Director of the Center for the Study of Politics and Governance in the Hubert H. Humphrey Institute and Department of Political Science at the University of Minnesota. Theda Skocpol is the Victor S. Thomas Professor of Government and Sociology at Harvard University, a member of the National Academy of Sciences, and past president of the American Political Science Association.

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