Come for the politics, stay for the snark.

If you thought you’d already seen people saying the stupidest things possible on the internet, prepare yourselves.

Many life forms that would benefit from greater intelligence, sadly, do not have it.

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

They were going to turn on one another at some point. It was inevitable.

The fight for our country is always worth it. ~Kamala Harris

“In the future, this lab will be a museum. do not touch it.”

Stop using mental illness to avoid talking about armed white supremacy.

I don’t recall signing up for living in a dystopian sci-fi novel.

Reality always lies in wait for … Democrats.

Republicans are the party of chaos and catastrophe.

Republicans in disarray!

Republicans cannot even be trusted with their own money.

They love authoritarianism, but only when they get to be the authoritarians.

With all due respect and assumptions of good faith, please fuck off into the sun.

“I was told there would be no fact checking.”

It is possible to do the right thing without the promise of a cookie.

Come for the politics, stay for the snark.

Is it negotiation when the other party actually wants to shoot the hostage?

Dear media: perhaps we ought to let Donald Trump speak for himself!

The republican caucus is covering themselves with something, and it is not glory.

Beware of advice from anyone for whom Democrats are “they” and not “we.”

If you don’t believe freedom is for everybody, then the thing you love isn’t freedom, it is privilege.

I’d hate to be the candidate who lost to this guy.

The lights are all blinking red.

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On The Road – Paul in St. Augustine – A National Park Here, a National Park There

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Paul in St. Augustine

A bit of Hawaii, Monument Valley, and the North Rim of the Grand Canyon.

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I spent a week visiting Hawaii, spending time in Honolulu to hike to the top of Diamond Head, boating along the Na Pali Coast State Park on Kauai, and Maui to take the Road to Hana, tour the Island via helicopter, and visit Haleakalā National Park. The crest of the volcano is at 10,023 feet above sea level. When I visited in 2004, you would encounter dozens of bicyclists at the top, waiting for the sunrise. Which meant that you had to avoid them as you made the drive down the volcano.

Friday Afternoon Open Thread: “Light At the End of the Tunnel”

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There’s an old Irish saying: Live, horse, and you’ll get grass. It comes from the days when short rations and dark days during February and March led to calamitous livestock deaths, just before the season of new growth. Observing Lenten privations wasn’t optional then, and it looks like it won’t be now… but *if* we can all hold on, well…

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Hoodoo Economics (Open Thread)

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Ron Johnson is pissing on people’s heads and telling them it’s raining:

From The Hill:

GOP Sen. Ron Johnson (Wis.) on Friday blocked an effort to pass a second round of stimulus checks, arguing coronavirus relief needs to be targeted and raising concerns about the country’s debt.

The motion Johnson cock-blocked was from fellow Republican Josh Hawley (and also Balloon Juice favorite Bernie Sanders). Hawley is trying on a “conservative populism” frock that seems to be all the rage among potential 2024 GOP presidential primary contenders in the Trump lame duck era. Marco Rubio has made similar noises.

Prediction: GOP donors will reassert their will by slamming their wallets shut the day Biden is sworn in. Hawley, Rubio and the rest will soon be singing Ron’s tune about the deficit again, even though a just deity would smite every one of them for such hypocrisy after the pre-pandemic corporate tax giveaway, etc.

Open thread!

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Behavioral Health Care Quality Ratings on the ACA Exchanges

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This morning, Psychiatric Services has published an article that I co-authored with Drs. Jean Abraham and Coleman Drake as well as Sih-Ting Cai. We examined Behavioral Health Care Quality Among Marketplace Insurers in 2019##. This is in the same vein of work that we published in Journal of General Internal Medicine earlier this fall.

We looked at 2019 care quality ratings for four attributes:

  • antidepressant medication management
  • follow-up care for children prescribed ADHD medication
  • follow-up care within 7 days after hospitalization for mental illness
  • initiation and engagement of alcohol and other drug dependence treatment

We were curious if plan characteristics mattered, so we looked at ownership status, Blue Cross affiliation, Medicaid Managed Care status and if the insurer offered a Preferred Provider Organization (PPO) option. Our priors were that non-profits, and Blues would have higher quality and Medicaid Managed Care organizations would have lower quality.  We thought that PPOs would show lower quality as the insurer has less leverage with their provider network than HMOs and EPOs.

So what did we find?

We found a few noteworthy things.

Average quality ratings across all domains are low.  Antidepressent medication treatment and management led the pack at 62% of eligible patients receiving the desired standard of care while initiation of drug and alcohol treatment was the laggard at 23% of eligible patients receiving the desired standard of care.  This is a big difference compared to our care quality paper where three out of the four metrics we examined had at least 75% of patients receiving the expected standard of care.  Behavioral health is an area of possible and significant improvement in care delivery.

Secondly, we found that insurers that were good in one domain were likely to be good in another domain but the correlation was not particularly large or strong.

Although the correlation coefficients were positive for all pairs, only four were statistically significant and were moderate in magnitude (r=0.15–0.33, p<0.05). Specifically, correlation coefficients were largest between follow-up after hospitalization for mental illness and antidepressant medication management (r=0.33) and between follow-up after hospitalization for mental illness and initiation and engagement of alcohol or other drug dependence treatment (r=0.27).

 

Finally, we again found that non-profits were more likely to be better than average in making sure their members get the desired standard of care for antidepressant medication. Blues and PPOs had no statistically significant difference in care. Medicaid Managed Care Organizations performed significantly worse on three out of the four metrics.

So what does this mean?

Picking plans is tough. Picking on quality is tough. Right now, the ACA’s subsidy structure which is a price linked system tied to a floating benchmark (2nd cheapest silver) that can be strategically gamed means, that if we assume there is a premium-quality trade-off, low quality plans can undercut high quality plans. Insurers don’t get paid for quality directly. They may get paid for quality through risk adjustment, but that is a long delay with uncertain results.

It also means that behavioral health care quality is not particularly good. Even the best insurer classes (non-profits) don’t have great ratings on the four measured metrics. We need to do better.

## https://doi.org/10.1176/appi.ps.202000115

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Friday Morning Open Thread: We Are What Our Experiences Make Us

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From the Washingtonian, an unexpectedly prescient article (by an underappreciated reporter) about Biden’s response to that tragedy, written back in 1974:

Joseph Robinette Biden, the 31-year-old Democrat from Delaware, is the youngest man in the Senate, which makes him a celebrity of sorts. But there’s something else that makes him good copy: Shortly after his election in November 1972 his wife Neilia and infant daughter were killed in a car accident. Suddenly this handsome, young man struck down in his moment of glory was prey to scores of hungry reporters clamoring to write soul-searching stories.

According to his staff he was hounded for weeks by the media. “It was awful in the beginning,” says Chazy Dowaliby, a press aide. “A few weeks after Neilia’s death we got a call from Sally Quinn of the Post. She wanted to do a story on the Senator as Washington’s most eligible bachelor. Naturally we said no but it wasn’t easy because she kept calling all the time. She wasn’t the only one. Women’s Wear Daily called morning, noon, and night. And so did every female magazine in the country. They all wanted to write some kind of weeping willow story on him and he knew it. So he told us to refuse all press calls.” Biden wouldn’t even talk to journalists like the Post‘s David Broder, and he wouldn’t appear on the “Today” show or “Face the Nation” or “Meet the Press.”

Although time has softened the pain of those early months in the Senate, Biden’s staff still protects him. The few reporters admitted in the past eighteen months have been asked to concentrate on Joe Biden, Senator, rather than Joe Biden, tragic figure. But the combination of youth, death, and a Kennedy-style upset victory continues to fascinate the press…

Biden had little time to savor his victory. The week before Christmas 1972 he was in Washington putting a staff together. His wife, baby daughter, and two young sons were driving home on a highway west of Wilmington after shopping for a Christmas tree when a hay truck hit their station wagon. The car was thrown over an embankment, and Biden’s wife and daughter were killed. The sons lived—four-year-old Joseph, known in the family as Beau, was in traction for weeks. Two-year-old Hunt was hospitalized with a serious head injury.

Biden was devastated. He wanted to resign. Majority Leader Mike Mansfield persuaded him to stay, promising him several prestigious committee assignments. The Senate passed a resolution allowing him to be sworn in at the hospital bedsides of his sons. That was more than a year ago, and at the time he wasn’t sure he’d be able to stay in the Senate through 1973. He said he would resign if his Senate duties took too much time away from his sons. “They can always get another Senator, but my boys cannot get another father.”

Biden says he no longer allows himself the luxury of long-range planning, but he enjoys the prestige of being a Senator and seems committed to finishing his six-year term. In fact, he says he might consider running for President. “My wife always wanted me to be on the Supreme Court,” he says. “But while I know I can be a good Senator, and I know I can be a good President, I do know that I could never be another Oliver Wendell Holmes. I know I could have easily made the White House with Neilia. And my family still expects me to be there one of these days. With them behind me anything can happen.”…

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On The Road – Steve from Mendocino – Reed College

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Steve from Mendocino

I hate children.  They’re noisy and messy and, above all, inconvenient.  I had a vasectomy at 24 years old and never regretted it.

In my late forties, as a gift to my wife who really loves and wanted children, I offered to get a vasectomy reversal.  Nothing happened, despite our enthusiastic attempts, so I flew to St. Luis for a second reversal by a doctor who had the reputation as the best in the country for reversals.  Nothing happened, so we decided to adopt.  After a mountain of paperwork for both the American and Chinese governments, we boarded a plane for a two week stay in China dedicated to retrieving the child selected for us by the Chinese government, resolving any medical issues that might crop up, and finalizing paperwork for the Chinese and the American governments.

We changed planes in Beijing and landed in the afternoon at Wuhan (yes, that Wuhan), where the group of prospective parents ate a nice lunch and then prepared to pick up the 10 or 12 babies that had been designated for us.  The babies were ferried from orphanages around that part of China to this central location because some busy-body American wrote an article about the appalling conditions in the orphanages without noting that China was a poor country that genuinely loves children but has to get by with far less than Americans are accustomed to.

At 7:00 o’clock in the evening, the new parents gathered at the elevator landing of our floor and waited with eyes glued on the elevator movements.  The doors finally opened and out came a flock of orphanage workers carrying bewildered and squalling babies.  The name of our assigned baby was called out (in Chinese, of course), and my wife stepped forward, took our daughter, and was promptly peed on.  We whisked her off to our room to clean up, and my wife set to reassuring our terrified and outraged daughter who’d just been kidnapped by strange looking aliens.  That only made matters worse, of course, so we gave her space on the bed and I started playing a game of I would look away when she looked at me and she would look away when I looked at her.  She was glued to my chest for the next two weeks.

Three years later, we got pregnant, of course, and finished our family making.  Over the course of the following years, I discovered that, in addition to being loud and messy and inconvenient, kids have magic and joy and charm and love.  Who could have known?

At Thanksgiving of 2014 my wife, my younger daughter, and I drove to Reed College to visit our elder daughter.  Reed is interesting for a number of reasons, not least of which is that there are fewer than 1,500 students total.  It’s small and odd and, yes, persistently radical in its politics.  While my daughter found this last quality tedious, the education is excellent and respected.

My tour of the campus lasted roughly 20 minutes but I came back with quite a few nice pictures.  It was one of those rainy days where the sun pops out periodically and casts incredible patches of light on the late fall leaves.  Those conditions are special.

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This is the ODB (old dorm block), which, I understand, was one of the original 3 Reed buildings. Now it’s just one dorm of several.