Andrew Sullivan's Blog, page 305

Is The Israeli-Palestinian Conflict Intractable?

Damon Linker thinks so:

The Palestinians hope that a growing chorus of global condemnation will eventually drive Israel either to pull back from the West Bank, thereby allowing the establishment of a fully independent Palestinian state, or to grant full political rights within Israel to the Palestinian people — a move that would turn Israel into a binational state.

Neither has any chance of happening.

Which means that the Israeli-Palestinian conflict has reached a condition that the ancient Greek philosophers would have described with the term “aporia” — meaning “to be at a loss” or “impassable.” There is no peace process. No way forward. This might change down the road. But for now it is our lamentable but unsurpassable reality.

But Judis argues that the Obama administration could still make progress if it got on board with the Palestinians joining the UN:

The U.S. could exert leverage on its own, but it may not want to act like Israel’s overlord, and there are other things that the  U.N. could do that might prod the Israeli government to negotiate an end to the occupation.

If the United States had not threatened a veto, the Security Council could have made Palestine a member state. After having to helped to found the state of Israel in 1947—when negotiations had failed between Palestine’s Jews and Arabs—the  U.N. would be doing likewise for the Palestinians. As a more extreme step—if U.N. disapproval failed to budge the Israelis—the Security Council could also vote sanctions against Israel, directed specifically at goods from settlements in the occupied territories, to get it to adhere to Resolution 242, which was passed in the wake of the Six-Day War in 1967, and which requires Israel to “withdraw from territories occupied in the recent conflict.”

Akiva Eldar agrees:

In order to end the occupation and save the negotiations, Kerry must present the sides with an accelerated timetable for the acceptance of Palestine as a full-fledged member of the UN. Until then, the sides will have to reach agreements about land swaps, arrangements in Jerusalem and the refugee problem based on the Arab Peace Initiative. If Israel keeps barricading itself behind unfounded demands such as Palestinian recognition of a Jewish state and opts to expand settlements, it will become the occupier of a UN member state. From there, the road to the International Criminal Court in The Hague will be very short. On the other hand, if we continue the traditional dance — one step forward and two steps back — we will all fall flat on our faces.

Can Data Make Medicare Healthier?

Yesterday, the Centers for Medicare & Medicaid Services (CMS) made public a huge amount of Medicare payment data. Prior to the release, Nicholas Bagley explained what the information entails:

CMS will publicly release comprehensive data on physician billing practices in Medicare, including information about specific, identifiable doctors. The move is controversial: the AMA, for one, is “concerned” that the data “will mislead the public into making inappropriate and potentially harmful treatment decisions and will result in unwarranted bias against physicians that can destroy careers.” And I’ll bet a few doctors in Miami, with its extraordinary rate of Medicare spending, are sweating bullets.

Darius Tahir considers the impact of the release:

One possibility is that releasing the data shames some providers into more responsible behavior.

As Amitabh Chandra, an economist and professor of public health at Harvard, suggested, fear of bad publicity might cause some higher-charging doctors to cut back on their reimbursements. And while individual consumers are unlikely to spend much time investigating doctors, professional researchers in the media and in academia will.

In fact, they already are. Initial reporting from the Wall Street Journal indicated that the top 1% of providers accounted for 14% of Medicare billing, with ophthalmologists making up roughly one-third of the top 1,000 billers. A report from the Department of Health and Human Services’ inspector general argued that the agency should scrutinize that specialty more closely, and this data shows why.) The New York Times on Wednesday reported that two Florida physicians who had the highest Medicare reimbursements in the country were also generous donors to the Democratic Party.  CMS hopes to encourage more such investigating, and not just from professional reporters. It has sponsored a contest for coders, calling on them to take the data and render it in a form that’s usable and interesting. The winner gets $20,000.

Suderman digs into the data:

It’s going to take a while to fully process all this information, but a couple things stand out already from the stories that have been written so far. One is the sheer scale of the payments involved. The data set doesn’t cover anywhere close to the entire Medicare program, but it offers a look at $77 billion worth of payments to 880,000 medical professionals in the year 2012. From that group, The Washington Post notes, about 4,000 physicians billed the program more than $1 million. And a handful billed in excess of $10 million.

It won’t surprise many people that the highest billers are concentrated in the sunny state of Florida. The state has a heavy concentration of seniors. It’s also a haven for Medicare fraud. And the data suggests a possible correlation between unusually high billing and payment funny business.

Max Ehrenfreund focuses on how drug prescribing jacks up Medicare spending:

A dose of Avastin costs only $50. A dose of Lucentis costs $2,000. Both Avastin and Lucentis are made by the same company, and they’re remarkably effective in treating a form of macular degeneration that was long the leading cause of blindness among the elderly, The Post reported. They are very similar on a molecular level and probably cost about the same amount to manufacture.

Nonetheless, doctors prescribe Lucentis almost as often as Avastin. They also make more money doing so. Medicare is legally obliged to pay for any drug a doctor prescribes, and doctors also receive commissions of 6 percent to cover their own expenses. The commission a doctor collects on each dose of Avastin would be only about $3, as opposed to $120 on each dose of Lucentis. Congress and the courts have refused to allow Medicare to save money by scrutinizing doctors’ decisions.

As a result, taxpayers spent about $1 billion in 2012 more than they would have if doctors had been prescribing Avastin. Avastin, for all intents and purposes, has been shown to be equivalent to Lucentis in six studies and one massive review of Medicare records.

Jason Millman asked the top 10 Medicare billers why they were paid so much money. One explaination:

Jean Malouin, a family practitioner in Ann Arbor, Mich., and the highest-ranking woman on the list, suggested her perch at No. 17 is misleading. “I am most definitely not a high volume Medicare biller!” she wrote in a email.

Malouin said that she has a small private practice but is also the medical director of an experimental University of Michigan project trying to improve care and cost-efficiency at nearly 400 clinics across the state. All the project’s claims are paid in her name, which probably explains why the data show she treated more that 200,000 patients and collected about $7.6 million from Medicare.

Where The Hard Left Says No

The rescinding of an honorary degree to Ayaan Hirsi Ali is not exactly an act of punishment. No one has a right to any such degree and Brandeis is fully within its rights to breach basic manners and fail to do basic research about an honoree’s past work. And Ayaan has indeed said some intemperate and extreme things at times about Islam as a whole. But to judge Ayaan’s enormous body of work and her terrifying, pioneering life as a Somali refugee by a few quotes is, I’m afraid to say, all-too-familiar as an exercise in the public shaming of an intellectual for having provocative ideas. There seems to be an assumption that public speech must seek above all else to be “sensitive” rather than provocative, and must never hurt any feelings rather than tell uncomfortable truths. This is a terrible thing for liberal society as a whole and particularly terrible for a university campus, where freedom of thought should be paramount (although, of course, the hard academic left every day attempts to restrict that freedom).

The “outrage” at heterodoxy applies particularly to any members of an “oppressed” group who try and challenge the smelly little orthodoxies they are supposed to uphold. The venom and hatred seems to ramp up if the heretic is also a woman or African-American or gay or Latino or Jewish. For a woman of color like Hirsi Ali to challenge the religion of Islam is far more threatening to the p.c. left than, say, a Sam Harris or a Christopher Hitchens. The latter can be dismissed as white males (there’s no prejudice like p.c. prejudice); Hirsi Ali not so much.

Here, after all, is the biography of a woman the left wanted Brandeis to dishonor: a young Somali girl forced to endure genital mutilation at the age of five and who was going to be forced into an arranged marriage if she did not flee her country; a refugee from brutal misogyny whose attempts to expose Islam’s treatment of girls and women led to death threats because of a documentary she wrote, and whose director was subsequently murdered. She runs a foundation that aims to protect girls and women in America from being abused at the hands of Islamic traditionalists. It’s worth noting that for the hard left, none of this really matters. Or perhaps it matters more. Because her credentials are so strong, the attempt to mark her as a bigot is that much more strenuous.

This double standard goes both ways, of course.

The Fox News right is always desperate to get a member of a minority to challenge p.c. orthodoxy just because they’re a minority – giving some individuals far more weight than the cogency of their arguments might otherwise deserve. It is as if both sides cannot acknowledge that ideas are ideas – and that the human mind can entertain them, regardless of gender or skin color or sexual orientation.

So, unlike Bill Kristol, I have no objection to Brandeis’ awarding Tony Kushner an honorary degree. I find Kushner’s politics drearily socialist and some of his work agitprop. But he provokes; he’s a really gifted playwright; he makes enemies; and engages the world of ideas forthrightly from the farthest reaches of the left. Why can we not debate if establishing the state of Israel was a mistake, for example? Why, for Kristol, is that topic out of bounds? Why on earth would a university choose not give a man an honor just because he once dared to make that argument? Kushner was challenging his own ethnic group just as powerfully as Hirsi Ali is challenging her own. But here is the question: why is he lionized and Hirsi Ali disinvited? Why are provocative ideas on the “right” less legitimate than provocative ideas on the left?

That’s why this is dismaying. Not just because Brandeis has, within its rights, behaved shabbily; but because it wants to rig the public debate in favor of one set of arguments over another. There are many places that one might expect that to happen – but not a university.

Attacking With Natural Gas

Keith Johnson outlines how Russia has used energy as a weapon in its conflict with Ukraine:

Russian President Vladimir Putin raised the prospect Wednesday of making Ukraine pay in advance for the natural gas that it buys from Russia, a potentially ruinous move for the credit-challenged Ukrainian government. Ukraine’s total gas debt to Russia now totals more than $16 billion, Russian officials said. … Moscow has jacked up the price it charges Ukraine twice in recent days by a total of more than 80 percent, making gas sold to Ukraine among the priciest in Europe.

In a brazen display of chutzpah, Moscow justified the second price hike after abrogating a 2010 treaty between the two countries. Under the terms of that so-called Kharkiv accord, Moscow offered price discounts to Ukraine as a lease payment for the Russian naval base in Sevastopol, on the Crimean Peninsula. Now that Russia has forcibly annexed Crimea and taken over the naval base, it argues that discount no longer applies.

Putin is also threatening European countries with gas shortages if Ukraine doesn’t pay its bill:

Russian President Vladimir Putin sent a letter to 18 European leaders Thursday saying that a dispute over Ukraine’s gas debt to Russia could impact gas distribution throughout the continent, urging them to offer financial assistance to the indebted country. … Although the International Monetary Fund has already agreed to provide Ukraine with between $14 and $18 billion to avoid a default,that figure is far smaller than what Putin claims the country owes. In his letter, Putin says that Ukraine owes Russia $17 billion in gas discounts on top of a potential $18.4 billion debt due to a 2009 fine. He said that this debt grows by billions every day.

Meanwhile, as Matt Ford explains, losing Crimea has dealt a severe blow to Ukraine’s goal of energy independence:

The loss of Crimea only further weakened Ukraine’s already-tenuous energy security. Almost all of the fuel for Ukraine’s 15 state-owned nuclear reactors, which accounts for almost half of the electricity the country generates, comes from Russia. Ukraine’s domestic reserves of uranium are paltry, and it lacks the enrichment capacity to turn what it does have into usable fuel. Russia, by comparison, is a net uranium exporter to Europe and owns nearly half of the world’s enrichment capacity.

Ukraine still has some domestic-energy alternatives in the long term, but these require significant investment. The country possesses the third-largest shale gas reserves in Europe, estimated to hold nearly 1.2 trillion cubic meters, but commercial extraction isn’t slated to begin until 2020 at the earliest. That timeline might have been overly optimistic even before the revolution, considering the environmental impact of hydraulic fracturing (“fracking”) and the public resistance that comes with it. Another complicating factor is location: one of the two large fields, the Yuzivska field, falls almost entirely within the Donetsk and Kharkiv oblasts, two of the eastern regions in which Ukraine has accused Russia of fomenting revolts.

The Economist expects that, over time, Europe will decrease its dependence on Russian gas:

The shock of the Crimean annexation should speed up sluggish European decision-making on storage, interconnection, diversification, liberalisation, shale gas and efficiency. And though the decision-makers may detest Mr Putin, in private they will admit that he may thus have done them a favour. They already knew what to do. They just didn’t want to do it.

(Graphic from The Economist)

Colbert To Take Over For Letterman!

I wondered why there was so much excitement on the set last night. Some details:

Colbert is expected to shed his ultra-conservative character for Late Show, which is perhaps the biggest question mark surrounding his hiring. Though he’s been going through the broad motions of being a late-night host since 2005, he hasn’t been “himself” on the air. Yet Colbert’s fellow Comedy Central host Jon Stewart assured Vulture: “He’s got a lot more he can show. He’s got some skill sets that are really applicable, interviewing-wise, but also he’s a really, really good actor and also an excellent improvisational comedian. He’s also got great writing skills. He’s got a lot of the different capacities. Being able to expand upon [those] would be exciting.”

Text Of The Day

The husband on the iPhone after my appearance on Colbert last night:

You were great. But seriously: THE SOCKS. What the fuck? Have I taught you nothing? Your new suit looked so sharp and dapper … And the socks. Jesus.

(Love you!)

And I was so proud of the suit.

Will Democrats Pull The Lever For Paul?

In the primaries, Beinart suspects liberals will flock to Rand:

While things could always change, the 2016 Democratic nomination is so far shaping up as the least competitive, non-incumbent presidential primary contest in memory. It looks increasingly likely that if Clinton faces any opposition at all, it will be from a Don Quixote like Bernie Sanders or Brian Schweitzer, not a challenger with any genuine political base or ability to raise substantial money.

For Rand Paul, that’s fabulous. It means lots of Democrats and independents will cross over to vote in Republican primaries, where the action is. And most of them will vote for him.

Allahpundit thinks “Beinart’s theory is likelier to play out as a true Operation Chaos, with Dems voting strategically, than them voting for Paul in earnest”:

[I]t’ll be conventional wisdom among both Democrats and many Republicans come 2016 that Paul, if nominated, simply cannot win. Beinart himself describes Paul as a right-wing McGovern in the making. If you’re a Democrat voting in an open GOP primary, you might vote for him for that reason, that he’s a patsy.

Yglesias Award Nominee

“I would argue that conservatism and the cause of limited government are undermined by loose talk and an excessive animus toward the federal government. These days, in fact, conservatives would be well served to focus a good deal more attention on the purposes of government, not simply its size. I say that because during the Obama era the right has been very clear about what government should not be doing, or should be doing much less of, and for understandable reasons. But it has not had nearly enough to say about just what government should do. That needs to be corrected — and in the process conservatives need to be careful to speak with care and precision about our Constitution and the role of the federal government in our history,” – Pete Wehner, Commentary.

This was in response to Jim DeMint’s surreal attempt to force American history into his rigid ideology. Somehow, in DeMint’s imagination, the civil war was won without “big government.” But the federal government is never “bigger” than in wartime, its powers never so expansive. When that federal government is sending troops to conquer half the country, how much “bigger” can it get? You can totally see why Chait pounces thus:

Everybody knows the slaves were freed by Ronald Reagan, and he did it by cutting taxes.

Kilgore goes deeper:

[DeMint's ]rap is based on a series of palpable falsehoods that are extraordinarily common in the exotic world of “constitutional conservatism:” the deliberate conflation of the Declaration of Independence with the Constitution (this is how they sneak God and “natural rights”—meaning property and fetal rights—into the latter); the idea that the Civil War was about everything other than slavery; and the claim of Lincoln’s legacy, even though the Great Emancipator was in almost every respect a “big government liberal” as compared to the states rights Democrats—DeMint’s ideological and geographical forebears who touted the Constitution even more regularly (and certainly more consistently) than today’s states rights Republicans.

But this is more than a debate. DeMint now runs the Heritage Foundation, and has run it into the ground with know-nothingism and partisanship.

What was once a right-of-center oasis in rigorous social science, economics, social policy, science proper and other academic disciplines, is now a purely political operation, run by ideologues. And the consequences of replacing solid research with ever-more abstract ideological posturing are dire. A major political party is flying blind a lot of the time.

Look at the response to the ACA. Heritage once innovated several features of Obamacare; now the GOP scrambles to produce anything as a real alternative that can grapple with some of the same issues. Paul Ryan issues a report on poverty that rests on fatal misunderstandings of social science. Another potential candidate, Ben Carson, puts out a book with fake quotes pulled off the Internet. And the seriously smart ones – Ted Cruz, par exemple – specialize and revel in demagoguery they must know is irrelevant to governing.

This is the mark of a party more interested in selling books to a devoted audience, not a party capable of actually running a government. Which is why, in my view, the GOP is increasingly conceding the full responsibility of running a country in favor of a constant stream of oppositional pirouettes and rhetorical excesses. That may win a few midterms; but it will never win a general. Nor should it.

(Photo: Jim DeMint by Mandel Ngan/AFP/Getty)

Why Aren’t Gay Men On The Pill? Ctd

During a recent “Ask Anything” taping with Dave Cullen, to discuss his book Columbine for the 15th anniversary this month, he opened up about his experience with Truvada, which he’s been taking for almost a year now:

Meanwhile, the in-tray is starting to fill up with responses to my post:

Thank you so much for your writing on Truvada and celebrating it for the godsend that it is. I’m in a serodiscordant couple, so to hear it described as a “party drug” makes me feel ill. If eliminating fear at the heart of a relationship is a party, then, yeah, that’s a party I’ll go to. If wanting to fuck the person I love safely makes me a whore, well then I suppose I’m a whore. The names can’t hurt our community as much as HIV has. So if takes being called names to finally end this virus, then let them call us whatever they want.

Another:

Your blog has been one of the few places I can go for reassurance about PrEP ever since going on it six months ago. I am 28 years old and have grown up in a generation of gay men that has been taught that not using condoms is tantamount to instantaneous seroconversion. When I first started taking Truvada, I was excited to share my experiences with friends and loved ones. But since that time, I have decided to no longer disclose my use of prep, since I have experienced a significant amount of backlash from friends as well as prospective sex partners. It can sometimes be a passive remark, like a friend telling me that this is a “lifestyle choice.” Other times, it is a more brash statement, like “truvada whore”. They assume I am on the pill because of a sex life that is somehow more licentious than my counterparts that are not on prep, which isn’t true.

The advent of PrEP has created a unique relationship between those who are taking steps to prevent HIV seroconversion and those who already have HIV: a shared interest in treating and eradicating a devastating health threat. But in our own community, we continue to face backlash thanks in no small part to misinformation propagated by groups like AIDS Healthcare Foundation. On one side we see a group looking toward effective treatment options built on a foundation of openness. On the opposite side is a swath of gay men who stigmatize those who have HIV, and yet, are simultaneously wary of those men who take pills to prevent getting the HIV disease. A paradox, if ever there was one.

Another reader:

OMFG you spoke the truth here, thank you. What’s frustrating is that so few people are speaking it. Unfortunately, I am recently (December 2013) HIV positive. (Don’t date pathological liars.) However, the drug cocktail (Complera in my case) is amazing, and I’m already undetectable with no side effects, but it would of course be better if I weren’t on it in the first place.

I’d been active in HIV/AIDS related work heavily 15-20 years ago, when I was much younger, and fell out of it for various reasons, so it’s been an education diving back into the weeds of it. Because of highly effective treatment options, HIV is a fundamentally different disease than it was in 1999, when I was last in a job working with mostly HIV+ patients. It’s now a treatable, chronic condition and not a terminal illness, and one that’s harder for treated patients to transmit and one for which it’s possible for non-patients to get a pretty effective prevention drug for.

Yet it feels like the public health and prevention strategies are still stuck in 1992, when the disease was still a death sentence. No wonder HIV infection rates amongst gay men are rebounding. We need to fight the disease as it exists today. That disease profile includes the current prognosis, transmission risks and prevention tools, each of which has changed dramatically since current HIV public health measures came into place. It’s happening, but not fast enough, and that slow pace is causing more people (like me) to get infected unnecessarily.

Andrew, you can sometimes be a pain in the ass, riding your hobby horses, and sometimes I want to slap you. It’s your best AND your worst quality, and it can be infuriating, even when I agree with you. But it’s moved the needle before (gay marriage, anyone?), and I think you have an opportunity to move the needle here to save lives and reduce the infection rate. Agree or disagree with you, when you get passionate on a topic, you’re hard to ignore and you force the conversation into the open, and this is a conversation that’s not being had in the open enough.

So please make this the first of many posts on the subject, and infuriate and annoy the hell out of us. You’ll do a world of good.

A Prescription For A Full Belly

Research shows that one in three American adults with chronic disease have trouble paying for food or medicine. Erin Marcus considers how to address this link between illness and food insecurity:

The SNAP program, for the most part, operates independently of the health system. Applicants aren’t required to meet with a health professional, and most internists and other adult medical specialists don’t routinely make direct referrals to the program.

But what if SNAP were more like WIC, and referrals to the program became second nature for clinics serving chronically ill, low-income people? … One idea might be for clinic check-in staff to screen patients for food insecurity when they arrive for their appointment, perhaps by having them answer some questions on a tablet or mobile phone that would automatically trigger a referral to SNAP. It doesn’t have to be complicated—one study found that a single question—“In the past month, was there any day when you or anyone in your family went hungry because you did not have enough money for food?”—was effective at determining food insecurity among parents at a clinic serving low-income children.