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Come for the politics, stay for the snark.

Boeing: repeatedly making the case for high speed rail.

“The defense has a certain level of trust in defendant that the government does not.”

So it was an October Surprise A Day, like an Advent calendar but for crime.

Fuck these fucking interesting times.

So fucking stupid, and still doing a tremendous amount of damage.

Good lord, these people are nuts.

Also, are you sure you want people to rate your comments?

We will not go back.

if you can’t see it, then you are useless in the fight to stop it.

Is it irresponsible to speculate? It is irresponsible not to.

Since we are repeating ourselves, let me just say fuck that.

American history and black history cannot be separated.

Disappointing to see gov. newsom with his finger to the wind.

Since when do we limit our critiques to things we could do better ourselves?

Stand up, dammit!

Let there be snark.

If you voted for Trump, you don’t get to speak about ethics, morals, or rule of law.

The poor and middle-class pay taxes, the rich pay accountants, the wealthy pay politicians.

The media handbook says “controversial” is the most negative description that can be used for a Republican.

I would try pessimism, but it probably wouldn’t work.

Books are my comfort food!

We need to vote them all out and restore sane Democratic government.

Giving in to doom is how authoritarians win.

… gradually, and then suddenly.

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You are here: Home / 2020 / Archives for March 2020

Archives for March 2020

COVID-19 & National Security Part VI: America is Not Suffering From a Failure of Intelligence, It is Suffering From a Failure of, and an Absence of, Leadership

by Adam L Silverman|  March 31, 202011:08 pm| 193 Comments

This post is in: America, COVID-19, Covid-19 & National Security, Domestic Politics, Election 2020, Silverman on Security

There have now been several pieces written that describe the US’s failing and flailing response to the SARS-CoV2 outbreak and COVID-19 epidemic as a failure of intelligence. The simple reality is that these analyses are wrong. They are not a failure of intelligence. As a former senior advisor to a number of senior leaders, I can honestly say that you can present senior leaders and decision-makers with the timely, accurate information they need to know, but no one can make them think. No one can make them accept it, process it, and act on it accordingly. And I was fortunate in that the senior leaders and decision-makers I served wanted timely, accurate information, were willing to consider it, and used it to inform their decision making. This is unfortunately not the case with the President. And this is clearly not a failure of intelligence, because we have excellent reporting indicating that timely, accurate information about SARS-CoV2 was presented to the President beginning in January 2020.

What we actually have is a failure of leadership. The President’s, the sycophants he’s surrounded himself with, members of the Republican caucuses in the House and the Senate, among Republican governors who are afraid of mean tweets and the President’s base, and among the publishers, editors, and executives at conservative news media outlets – from Fox News to talk radio to conservative digital news. The leak of the letter sent yesterday by  Captain Crozier, the commander of The Theodore Roosevelt to his chain of command is just further evidence of what we’ve been observing since January in regard to the SARS-CoV2 outbreak and since January 2017 with this administration in general. With the exceptions of Director Wray at the FBI and Director Haspel at the CIA, there is not a single cabinet secretary or equivalent senior political appointee in this administration that would have even been nominated for, let alone confirmed to, their positions in any other administration with the possible exceptions of Secretary Chao and Attorney General Barr because of their previous senior cabinet appointee experience in previous administrations. You would not see any of these people in these positions in any other Republican administration. The few actually competent and qualified senior appointees, all of whom were generals (Mattis, Kelly, McMaster) with the exception of DNI Coats, are long gone. And the qualified subordinates they hired are long gone as well. What we’re left with is an incurious president who thinks he knows the price of everything, but really knows the value of nothing, as well as the price of nothing too and a bunch of senior appointees who would either never be considered for political appointments in any other administration or, at best, would be considered for deputy assistant positions at best. They, like their subordinates, have been selected for and/or retained because of professed and displayed loyalty to the President. These subordinates wouldn’t even be considered for the most junior positions in any other administration.

As an example, I honestly cannot think of a single good reason why the Acting Secretary of the Navy needed to do his media appearances today from NY City with the USNS Comfort as the backdrop except that someone explained to him that he was doing them for an audience of one, the President. And that audience wanted to see the USNS Comfort. It is this performative sycophancy that we are seeing revealed each and every day.

The United States is not just suffering through the SARS-CoV2 virus and COVID-19 epidemic. At the national level it is suffering from not just a lack of good leadership, but actual bad, self serving, and ultimately destructive leadership beginning with the President and throughout his administration. We are suffering from it in Senator Majority Leader McConnell and House Minority Leader McCarthy and their caucuses in each chamber of Congress. And we are suffering from it at the state level in a number of states with Republican governors, like FL, AZ, SC, GA, MS, and AL, who have decided that they would rather suck up to the President and demonstrate their fealty to him and his base of supporters rather than even attempt to aspire towards competency.

Open thread!

COVID-19 & National Security Part VI: America is Not Suffering From a Failure of Intelligence, It is Suffering From a Failure of, and an Absence of, LeadershipPost + Comments (193)

Respite Open Thread: The Goats of the Great Orme

by Anne Laurie|  March 31, 20205:59 pm| 120 Comments

This post is in: Nature & Respite

I think I just got a group of goats in Llandudno arrested.

Let me explain… first, I saw this from inside a dark pub (the one I live in currently). I thought I was seeing things. So I took some video: pic.twitter.com/RtxYG6htLC

— Andrew Stuart (@AndrewStuart) March 27, 2020

And they sent a patrol car down who turned on the big red lights. So, I’m sorry if the goats got arrested. But they were being very naughty.

Also, close the gates behind you on the Orme.

And stay 2m apart at all times.

?? ?? ?? pic.twitter.com/xczGrVoawL

— Andrew Stuart (@AndrewStuart) March 27, 2020

Goat update: they’re back, and they’re gathering in groups of more than 2 ?? pic.twitter.com/Bc2N42SPGo

— Andrew Stuart (@AndrewStuart) March 28, 2020

I, for one, welcome our new goat overlords pic.twitter.com/Fk5x6XaCLM

— Andrew Stuart (@AndrewStuart) March 30, 2020

show full post on front page

Respite Open Thread: The Goats of the Great OrmePost + Comments (120)

I Say Again

by John Cole|  March 31, 20204:33 pm| 172 Comments

This post is in: COVID-19

Now is a terrible time to have hypochondriacal tendencies and a chest cold. Had one of those “wake up feel fine, three hours later feel like shit and nap, rinse and repeat” colds for several days, now it is in my chest and throat and I am on meds. No fever, loss of appetite, or anything corona related, but still irritating as all hell.

Looks like April is going to be a real bad one this year. Do we all know anyone working in one of the hot zones who would could group together and help out?

I Say AgainPost + Comments (172)

It Could Be Worse (Gallows Humor, Kinda-Not-Really Respite)

by Tom Levenson|  March 31, 20204:05 pm| 97 Comments

This post is in: COVID-19, Open Threads

There are actually worse ways to respond to the epidemic than those attempted by serial sexual criminal and bankrupt Donald Trump. He’s bad; terrible. But Belarusan President Alexander Lukashenko is undeniably worse.

As death tolls have skyrocketed globally and many countries have closed their borders and shut down nonessential businesses, Lukashenko has advanced his own solutions to the crisis, urging citizens to drink vodka and visit saunas.

It Could Be Worse (Gallows Humor, Kinda-Not-Really Respite

Not for such a manly man (or his deeply unfortunate country) are vapid, bourgeois trifles like epidemiology and public health.  The measures undertaken by just about everyone else, including, however imperfectly, the US are to Lukashenko, “frenzy and psychosis.”

What to do, then, to lead la vida Lukashenko?

“It is better to die on your feet than live on your knees!” he told a reporter just before the game. “Sport, especially on ice, is better than any antiviral medication. It is the real thing.”

It isn’t funny, not really. Such insanity is a death sentence for too many Belarussians–a country that has seen way more than its share of misrule and misery.

But viciously, bitterly humorous? Maybe a little.

Open thread, especially for jokes of the oppressed.

Image: Annibale Caracci, Boy Drinking, 1582-1583.

It Could Be Worse (Gallows Humor, Kinda-Not-Really Respite)Post + Comments (97)

Can You Hear The People Sing?

by Major Major Major Major|  March 31, 202012:38 pm| 165 Comments

This post is in: Open Threads

This came across my feed and absolutely made my day. Just the pick-me-up I needed to make it through the afternoon. Seems like the sort of thing my family might have done, back when I was the younger brother’s age and hadn’t realized that musicals were gay and must be shunned*.

This is the talented Marsh Family.

Here are three minutes and fifty four seconds that will make your day better. Promise.

A COVID-19 lockdown version of Les Mis — with lyrics.

“One Day More.?❤️??pic.twitter.com/Ax3nqJaxcg

— Rex Chapman?? (@RexChapman) March 31, 2020

Here’s a nice open thread for you all! Apologies if I’m bigfooting somebody, though it looooks unlikely.

*Well I got better.

Can You Hear The People Sing?Post + Comments (165)

Election Year Excellent Read: The Financial Times Interviews Rep. Jim Clyburn

by Anne Laurie|  March 31, 202010:43 am| 242 Comments

This post is in: Election 2020, Excellent Links, Proud to Be A Democrat

.@WhipClyburn: “When I say, ‘I don’t get mad, I get even’, there’s one person who is going to hear from me.

His name is Michael Moore.” https://t.co/FvzXpSoi3v

— Reily Connaughton (@reilyseanconn) March 28, 2020

Whether Trump likes the idea or not, there will be an election this fall. Among other things, some interesting suggestions from Rep. Clyburn on Biden’s potential VP:

… I met Clyburn for the first time shortly before last month’s South Carolina primary, where his endorsement of Joe Biden almost single-handedly saved the former vice-president’s campaign. The 14-term lawmaker would not say then which candidate he was going to endorse. But he had told some people at his accountant’s funeral the previous week — because, he says confidently, “they would never betray Jim Clyburn”.

As we sip our drinks, I ask him when he told Biden. The pair met on the USS Yorktown, an old aircraft carrier turned museum, six days before the primary. He delivered the good news, but included a stern warning to his friend to stop reading speeches from a script.

“Here’s what I said to him,” Clyburn tells me. “You know these issues well enough not to be reading from a text . . . People can’t feel you when you read it.”

Using lessons he learnt from his father as a “PK” (preacher’s kid), he gave Biden some advice. “There’s a reason that preachers preach in threes,” Clyburn recalls saying. “I want you to answer every question in three ways: here is what my presidency will mean to you, here’s what it will mean to your family, and here’s what it will mean for your community.”…

Armed with Clyburn’s backing, Biden won in a landslide; according to the exit polls, 61 per cent of the voters said the endorsement influenced their decision. That dramatic victory then propelled Biden to win in a slew of states the following week, earning him clear frontrunner status over the leftwing Vermont senator Bernie Sanders.

Clyburn is used to having power in his state. For the past three decades, he’s hosted a fish fry during the Democratic primaries which has become virtually mandatory for would-be candidates to attend. In the course of the 2008 primary, Clyburn criticised Hillary Clinton; on the day that Barack Obama beat her in South Carolina, Clyburn remembers Bill Clinton phoning him at 2.15am, bellowing, “If you bastards want a fight, you damn well will get one.”

Did he ever think his endorsement of Biden would have such an impact? Clyburn says that people underestimated the latent support for Biden — before proudly adding that two women approached him after the primary to say, “Thank you for saving the Democratic party.”

Clyburn has come a long way since his youth in Sumter, a city near Columbia. In his 2014 memoir, Blessed Experiences, he recalls how his high-school band was asked to participate in the Sumter Christmas parade in 1955, the year after the Supreme Court struck down the segregation of public schools. But he and his black bandmates were forced to march at the end of the parade, behind the horses…

He says he lives by an adage from John F Kennedy, which goes something like: “I never get mad, but I will get even.” I joke that Oscar Wilde said it first, with “revenge is a dish best served cold”. Clyburn breaks into a smile: “Kennedy stole a lot from other people, he might have stolen that line.”…

But inexorably the conversation is drawn back to Biden. Clyburn says he would restore civility in politics. For instance, he says, Biden shuns the “bombastic” approach taken by the “Bernie bros” — the moniker for the most radical wing of Sanders’ movement.

Centrist Democrats worry that, should Biden win the nomination, Sanders will hold back from actively campaigning for him. Clyburn does not sound confident that Sanders will help unite the party, or rally his supporters behind Biden. “What’s that old mafia saying — that fish rots from the head.” As he slowly knocks off his crustaceans one by one, he has a warning for one famous supporter of Sanders.

“When I say, ‘I don’t get mad, I get even’, there’s one person who is going to hear from me. His name is Michael Moore,” Clyburn says. The film-maker and longtime Sanders supporter claimed after Biden’s victory in South Carolina that the state was “not representative” of the United States. “I don’t want to say much but I’m going to have a lot to say.”

Come on, I press, and he happily obliges. Reminding me that Biden won more than 60 per cent of the black vote in South Carolina and bigger percentages in Alabama and Mississippi, he says: “According to Michael Moore, South Carolina doesn’t matter because here’s what ‘the people’ want.” He says Moore is dismissing the voices of the most important segment of the Democratic electorate — black voters.

I ask whether Clyburn thinks Biden will pick Stacey Abrams, 46, the African-American former minority leader of the House in Georgia and rising Democratic star, as his running mate to help woo younger voters in November.

“I doubt it,” he says. “There’s something to be said for somebody who has been out there.”

Clyburn does want to see a black woman on the ticket, though. And some Democrats believe that Biden, who has vowed to pick a woman, will also be under heavy pressure to repay Clyburn for his critical endorsement.

Clyburn says there has been a lot of talk about Kamala Harris, the California senator who struggled in the Democratic primary. He says a “sleeper” in the race is Susan Rice, who served as national security adviser to Barack Obama. But he also stresses that “the bench of black women is much deeper than people think”.

While he believes Abrams does not have enough experience, he has his eyes on another Georgia politician. “There is a young lady right there in Georgia who I think would make a tremendous VP candidate, and that’s the mayor of Atlanta, Keisha Lance Bottoms.”

It’s getting late, so we secure “one for the road”. I ask the former history teacher how he sees America’s place in the world. “We’re where Germany was in 1933 after the election of Adolf Hitler,” he warns. But he adds a note of optimism, saying that African-Americans can lead the charge against Trump. He cites as inspiration a hero of the 1930s: Jesse Owens, winner of four gold medals at the 1936 Berlin Olympics…

Michael Moore retweeting something calling Nancy Pelosi a white supremacist. This coming from a man who recently said South Carolina does not “represent the United States.” pic.twitter.com/IKtbpf6ekn

— Michael Bennet secured unemployment benefits (@gdigitalzsmooth) March 28, 2020

Election Year Excellent Read: The <em>Financial Times</em> Interviews Rep. Jim ClyburnPost + Comments (242)

A case for alternative payment methods

by David Anderson|  March 31, 20208:56 am| 8 Comments

This post is in: Anderson On Health Insurance

I want to highlight a paper from the Journal of Clinical Oncology Practice by Cole et al##.

The research team looks at three drugs that have similar survival benefits for Chronic Myeloid Leukemia (CML).  One drug, imatinib is now generic while the other two drugs are still brand name, patent protected drugs.  The outcomes the researchers looked at were ER visits, inpatient hospitalizations and annual health care costs.

RESULTS:

included 1,417 receiving imatinib, 1,067 receiving dasatinib, and 647 receiving nilotinib. The 1-year risk of safety events was… higher risks among patients receiving dasatinib (RR, 1.17; 95% CI, 1.06 to 1.30) and nilotinib (RR, 1.07; 95% CI, 0.93 to 1.23) compared with those receiving imatinib. Over a median of 1.7 years, the cumulative incidence of safety events was higher among patients receiving dasatinib (HR, 1.23; 95% CI, 1.10 to 1.38) and nilotinib (HR, 1.08; 95% CI, 0.95 to 1.24) than among those receiving imatinib. One-year health care expenditures were high (median, $125,987) and were significantly higher among patients initiating second-generation TKIs compared with those receiving imatinib (difference in medians: dasatinib v imatinib, $22,393; 95% CI, $17,068 to $27,718; nilotinib v imatinib, $19,463; 95% CI, $14,689 to $24,236).

CONCLUSION:

Patients receiving imatinib had the lowest risk of hospitalization or emergency department visits and 1-year health care expenditures.

So what does all of this mean?

The first take-away is that treating CML is expensive no matter what drug is chosen. Insurance design fails when one treatment option could have an annual price of $115,000 while the other choice has a total annual cost of $140,000.  Deductibles are being met in the first few weeks of treatment no matter what choice is being made.  Coinsurance shuts off as maximum out of pocket limits are hit fairly quickly.  Our regular tools to shift people to high value care instead of low value care are grossly ineffective at these price levels.

Secondly, imatinib leads to fewer side effects and it is cheaper than the other two drugs. It ties the other two drugs on survival and beats the other two drugs on side effects and cost.  It dominates.  Yet, only 45% of the treated population get the drug that is at least as good and significantly cheaper than the alternatives.

This is a case where alternative payment models for care can be very effective in shifting physician behaviors.  If a CML diagnosis triggers a bundle that is designed to be big enough to readily pay for average cost of care for imatinib plus a little bit more, two things will happen.  First, some physicians will change their prescribing behavior towards imantibib and away from the brand name drugs.  That could make the market slightly more valuable for other generic makers to enter and drop prices significantly.  Secondly, the average price of the brand name drugs will decrease to hold onto marketshare.

CML seems to be an area where there is significant volume, significant controllable price variation and meaningful clinical near substitutes.  Those attributes makes CML an attractive alternative payment method target.

## https://doi.org/10.1200/JOP.19.00301

A case for alternative payment methodsPost + Comments (8)

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