Daily Kos

On Cancer Screening, Politics, and Communication

Sun, 22 Nov 2009 13:48:36 GMT

There's no way this complex issue can be covered in one post, but thankfully there have been some really thoughtful pieces written by others that we can pull from. For example, my own comments led to this headline on the AtlanticWire: Politics Beats Science in Cancer Screening Debate, featuring a terrific piece by Kevin Sack in the NY Times (Screening Debate Reveals Culture Clash in Medicine), comments by Ezra Klein (WaPo), Arthur Caplan (MSNBC), and David Dayden (Firedoglake). The author of the AtlanticWire piece jumps to the heart of the issue and writes:

According to the panel, the timing of the new pap smear guidelines is entirely coincidental. But politicians — already taking steps to distance themselves from the obviously unpopular mammography guidelines — seemed wary Friday. The anger from women, doctors, and advocacy groups over the relaxed screening guidelines is revealing, pundits say. They argue that it reveals a divide between the hard science of cancer screening and the explosive, personal politics of health.

Kevin Sack's piece adds something to the debate in the form of a graphic showing that mammogram utilization has fallen recently in other age groups, and that a steady bit more than 60% of women 40-49 get yearly mammograms (for those interested, a state by state table is here.)

Presumably for the 40% that don't get yearly mammograms, this represents no change. But the recommendations have been presented to younger women as if something important is being taken away from them, rather than what the panel actually said: that the experts suggest that they cannot determine whether yearly mammograms in that age group for low risk women are helpful or harmful and that the best thing to do is discuss it with your own doctor.

The balance of benefits and potential harms, therefore, grows more favorable as women age. The precise age at which the potential benefits of mammography justify the possible harms is a subjective choice. The USPSTF did not find sufficient evidence to specify the optimal screening interval for women aged 40-49.

That, of course, assumes you have a doctor, and that's where the interface between health reform and this topic is most obvious.

As to what the risk is from breast cancer, and why the recommendations were changed away from "just do them", this St. Louis Post-Dispatch piece notes:

The British Medical Journal published an article to help people understand the risk in simple terms.

It means that if 1,000 women don't get mammograms, we can expect four of them to end up dying of breast cancer. If all 1,000 women do get regular mammograms, three will still die of breast cancer.

No matter the odds, many doctors and patients say any life saved is worth everyone getting the mammograms.

"We're all in agreement that this is not the best tool, but does that mean we should take the next step and not screen at all?" said Dr. Burton Needles, medical director of the cancer center at St. John's Mercy Medical Center in St. Louis. "Most of us who treat patients with cancer feel that the benefits still outweigh the risks of screening."

For more details, Kossack charliehall (biostatistician) wrote this more detailed diary on studies available through the Cochrane database, and noted the same result as above: women in the screening group were just as likely to die as women in the no-screening group.

Given that kind of information, the panel suggested individualized care over rote screening for everyone. And on the topic of relying on routine breast self-exam, which was another recommendation from the panel, Orac (pseudonym of a practicing surgeon from ScienceBlog's Respectful Insolence) notes:

The USPSTF's recommendation not to teach breast self-examination (BSE) is another point of controversy. Despite a lot of enthusiasm for the practice, Cochrane Reviews and other evidence have failed to find convincing evidence that routine regular BSE saves lives. I wish it were otherwise, but it appears not to be, even though there are compelling anecdotes out there of women who did find a lump on BSE and it turned out to be cancer. Unfortunately, overall, the evidence to support BSE is weak. On the other hand, even the Cochrane Collaboration, which I have in the past sometimes accused of methodolatry and "nihilism" with respect to screening concluded:

Some women will continue with breast self-examination or will wish to be taught the technique. We suggest that the lack of supporting evidence from the two major studies should be discussed with these women to enable them to make an informed decision. Women should, however, be aware of any breast changes. It is possible that increased breast awareness may have contributed to the decrease in mortality from breast cancer that has been noted in some countries. Women should, therefore, be encouraged to seek medical advice if they detect any change in their breasts that may be breast cancer.

Indeed, on a purely practical level, I see nothing wrong with women being taught to be aware of how their breasts normally feel and to bring to a physician's attention any changes that concern them and still encourage that, but there really is no good evidence to support BSE.

To add to that, Our Bodies Ourselves (Boston Women’s Health Book Collective) wrote that the case against screening is not new:

New government guidelines recommending that women start screening for breast cancer at age 50 instead of 40 set off a round of criticism this week and caused much confusion for women who for years have been told that early detection saves lives.

But a number of women’s health organizations, including Our Bodies Ourselves, the National Women’s Health Network and Breast Cancer Action, for years have warned that regular mammograms do not necessarily decrease a women’s risk of death. Premenopausal women in particular are urged to consider the risks and benefits.

In fact, the NWHN issued a position paper in 1993 recommending against screening mammography for pre-menopausal women. It was a very controversial position at the time — even more so than now. The breast cancer advocacy movement was in its infancy and efforts were focused on getting Medicare and insurance companies to cover mammograms. What the NWHN found — and other groups have since concurred — is that the potential harm from screening can outweigh the benefits for premenopausal women.

The above statement is important for several reasons. This is not a male view of the world superimposed on women. It's also not a view suddenly brought into the discussion by those wanting to focus on cost and cost alone. it predates this health bill, and it predates cost control discussions in the House and Senate, and in the Obama administration. More from Our Bodies Ourselves:

I don’t believe the new guidelines are politically motivated, nor are they "patronizing" to women simply because they call into question the stress related to biopsies and false positive results. Rather, the guidelines provide a useful framework for helping each of us to decide when is the best time to begin screenings and the intervals at which they should be repeated.

Personal health remains just that: personal. Note what the World Health Organization has to add on BSE:

There is no evidence on the effect of screening through breast self-examination (BSE). However, the practice of BSE has been seen to empower women, taking responsibility for their own health. Therefore, BSE is recommend for raising awareness among women at risk rather than as a screening method.

++++++

So what do you do when you feel you are sitting on data that contradicts the status quo? How do you convey that information to the public? It's not like there's nothing written on the topic. Recognizing the political and social impact of the guidelines is a must, and failure to do so is a mistake, one that science and government types seem to make a lot. These particular guidelines won't be implemented immediately in any case. Physicians and the public still need to read and accept them. The likelihood of any such thing happening, or participatory and reasoned dialog occurring with the public with the current political atmosphere, is nil (now, those are odds we can all understand.) But if the recommendations make sense, further supporting data will present itself and the discussion will go on.

Note that none of the above has anything to do with insurance companies. That's a side issue, more likely to be settled in the health reform debate than with these recommendations. But if Republicans want to make an issue of this (and they will), they are going to have to make an issue of evidence-based medicine.

Evidence-based medicine (EBM) aims to apply the best available evidence gained from the scientific method to medical decision making. It seeks to assess the quality of evidence of the risks and benefits of treatments (including lack of treatment).

EBM recognizes that many aspects of medical care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBM, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.

Our own Christopher Hughes recently wrote a diary on evidence-based vs anecdotal medicine.

"Experience," or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.

Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that's the way we've always done it, or because we have scientific research to back up our decisions?

That is the future of medicine. These guidelines will stand or fall on their merit, but given the fact that the US is 19th of 19 in preventable deaths, the way we do things is going to have to change. And that may mean recognizing when cancer screening is helpful and useful (colonoscopy) and when it's not (Pap smears before age 21.) And it may also mean allowing ourselves to debate the issue without accusing each other of trying to kill women. Personally speaking, I really haven't tried to kill any women all this week, and I don't intend to start this weekend. But if we don't discuss this, we won't make any progress on preventable deaths. And that, my friends, is progress that has to happen.

For the meantime, I am sorely tempted to suggest that if you want people to get mammograms, tell them they can't, and if you want to get people not to get flu shots, tell them they have to.

Your Abbreviated Pundit Round-up

Sun, 22 Nov 2009 12:50:53 GMT

Sunday punditry. Read it early, talk about it late.

Frank Rich on Sarah Palin:

But no matter how much Palin tries to pass for "center-right," she’s unlikely to fool that vast pool of voters left, right and center who have already written her off as unqualified for the White House. The G.O.P. establishment knows this, and is frightened. The demographic that Palin attracts is in decline; there’s no way the math of her fan base adds up to an Electoral College victory.

Yet among Republicans she still ties Mitt Romney in the latest USA Today/Gallup survey, with 65 percent giving her serious presidential consideration, just behind the 71 for her evangelical rival, Mike Huckabee.

Maureen Dowd:

Yet Democrats would be foolish to write off her visceral power.

As Judith Doctor, a 69-year-old spiritual therapist, told The Washington Post’s Jason Horowitz at Palin’s book signing in Grand Rapids, Mich., "She’s alive inside, and that radiates energy, and people who are not psychologically alive inside are fascinated by that."

No one should confuse winning the GOP nomination (which she can do) with winning the election (when 60% think you are not qualified, you can't.) Maureen goes to to say Obama's too intellectual, blah, blah, blah.

Ron Brownstein via Ezra:

"I'm sort of a known skeptic on this stuff," [MIT health economist Jonathan] Gruber told me. "My summary is it's really hard to figure out how to bend the cost curve, but I can't think of a thing to try that they didn't try. They really make the best effort anyone has ever made. Everything is in here....I can't think of anything I'd do that they are not doing in the bill. You couldn't have done better than they are doing."

Gruber may be especially effusive. But the Senate blueprint, which faces its first votes tonight, also is winning praise from other leading health reformers like Mark McClellan, the former director of the Center for Medicare and Medicaid Services under George W. Bush and Len Nichols, health policy director at the centrist New America Foundation. "The bottom line," Nichols says, "is the legislation is sending a signal that business as usual [in the medical system] is going to end."

More of same from Center on Budget and Policy Priorities:

The health reform bill that Senate leaders unveiled yesterday meets two rigorous fiscal tests: it reduces deficits over the next decade and beyond, and it puts long-term downward pressure on health care costs.

There are, however, still issues with affordability:

The health reform bill that Senate leaders unveiled on November 18 makes health coverage more affordable for millions of households of modest means, as compared to the bill that the Senate Finance Committee approved last month. The amounts that many families and individuals would pay for coverage would be less than under the Finance Committee proposal.

For people between 134 percent and 154 percent of the poverty line, however — people with incomes around $25,000 to $28,000 for a family of three — premiums would actually be higher than the already significant amounts they would have to pay under the Finance Committee bill. Modifications are needed at some point as the legislation moves forward to ensure that near-poor families and individuals do not face insurance premiums and cost-sharing charges that many of them could have difficulty affording.

David Broder does his own rigorous analysis, Beltway style: he asks "every expert" that agrees with him what they think of the new health care bill and ignores the CBO and the ones that don't.

Via Jay Rosen on twitter, this:

The job cuts at the Washington Post on Friday have produced a round of comments, broadly summed up by Steve Yelvington earlier today. They certainly begged the question that occurred to me as a former employee of both the Post and WPNI, its soon-to-be merged online operation: "What explains this kind of decision?"

They've decided the dead tree paper is more important than the web site.

CIDRAP:

Health officials in Wales today announced the identification of a cluster of patients in a Cardiff hospital who are infected with oseltamivir-resistant pandemic H1N1 influenza.

Also today, Duke University Medical Center in Durham, N.C., reported that oseltamivir-resistant H1N1 viruses were found in four very sick patients hospitalized there over the past 6 weeks. A Duke press release said all four patients had been in the same hospital unit, but it did not specify how many were there at the same time.

This is what we dread. Small numbers, but keep an eye on this.

Sunday Talk - Christmas Come Early

Sun, 22 Nov 2009 06:07:13 GMT

Like a gift from God, Sarah Palin's Rogue-A-Palooza tour (w/special guest) descended on America this week.

Over the next few months, hundreds of millions of Palin's Facebook friends will visit book stores – many for the first time – to meet their idol face to face.

And a sexy time will be had by all.

Meanwhile, the Jews will be flocking to Israel.

Open Thread & Diary Rescue

Sun, 22 Nov 2009 04:16:04 GMT

Tonight's Diary Rescue was brought to by the fine work of the following Rescue Rangers: shayera, jlms qkw, Yat Pundit, grog, sunspark says, and dadanation who also mimicked being the editor.

The Diaries, Rescued

Librarian Dem tells the story of an encounter with some patrons in Library users against health care bill. (shayera)

KibbutzAmiad shares a personal story in Just another murder-by-spreadsheet death. (shayera)

change the Be shares what I'm thinkin right now, and it's positive thoughts about Levi Johnston. (jlms qkw)

CornSyrupAwareness highlights the hypocrisy of the right when it comes to spending priorities in For the GOP Stimulus Spending In Iraq is A-OK (Picture Diary). (grog)

DParker looks at two cases pending before the Supreme Court and answers the question How does the criminal justice system create injustice? (grog)

teacherken offers an interesting Advent reflection in 21 November 1943 Dietrich Bonhoeffer. (YatPundit)

bob zimway discusses Multiple Personality Disorder in Treating A Dissociative Disorder with Marijuana. (YatPundit)

Minerva isn't talking about Superman when reminding us why relying on private insurance companies to do the right thing all by themselves is a very bad idea in There, up in the sky - its a bird... its a plane... (dadanation)

The Extras, Usual

jotter brings us High Impact Diaries: November 20, 2009.

carolita has tonight's Top Comments 11-21-09 – Enlightened Edition.

The Paragraph, Closing

Please use this as an Open Thread as well as your chance to promote your favorite diaries of the day. Respectful engagement is most welcome here. Please keep in mind that each Diary Rescue's daily purview extends from 3pm PST yesterday to 3pm PST today. Shamelessly self-promote or pimp for a friend in this Open Thread!

Legislative committee to consider Sanford impeachment

Sun, 22 Nov 2009 03:42:04 GMT

The South Carolina House Judiciary Committee is convening next week to hear arguments on whether whether Gov. Mark Sanford needs to take a permanent hike from the Governor's office:

State lawmakers have considered impeachment for months, but this announcement is the first formal consideration of such a move. It came two days after the State Ethics Commission said it had found probable cause to hear ethics complaints against Mr. Sanford, also a Republican.

The commission, whose nine members were appointed by the governor, did not say what charges it would pursue, but it reviewed several accusations against Mr. Sanford: that he had used state airplanes for personal or political reasons, bought high-priced plane tickets in violation of policy, failed to disclose trips on private planes and misspent campaign contributions.

...

Mr. Harrison has appointed a committee of four Republicans and three Democrats to meet next Tuesday. A majority vote of the full 25-member Judiciary Committee would be required to bring the matter up for a House vote when it convenes in January. If the House votes to impeach, Mr. Sanford would be suspended from duty immediately.

The Senate would then conduct an impeachment hearing. It is not clear what would happen if the Senate failed to take up the impeachment resolution, but it is possible the governor could remain suspended indefinitely as state business proceeds.

Couldn't happen to a nicer guy.

Chris Matthews gets that tingly feeling up his right leg

Sun, 22 Nov 2009 02:52:05 GMT

This is what counts as a liberal these days?

Steve Benen pretty much nailed it with these observations:

Obama isn't "leading with his chin"; he's tackling the issues in front of him. That's what presidents do. Obama bowed to the Japanese emperor as a matter of protocol, and no one cares except the media establishment. Obama isn't "dithering" -- though it's good to know Chris Matthews is willing to read directly from Dick Cheney's script -- he's crafting a forward-thinking U.S. policy, which is what Bush/Cheney should have done a long time ago.

Purely from a business point of view, doesn't MSNBC realize that between this sort of nonsense and Glenn Beck, it shouldn't be a mystery why ratings for The Ed Show are regularly beating Hardball's live broadcast.

The Schumer/Landrieu/Carper Compromise Plot Thickens

Sun, 22 Nov 2009 01:58:07 GMT

Earlier today, Landrieu talked about working with Schumer and Carper on yet another iteration of a public option compromise, along the lines of his state-based triggered co-ops.

Schumer's spokesman flatly denied this, sending this statement:

"Since Leader Reid announced the opt-out public option would be included in the Senate bill, Senator Schumer has not approached anyone about compromises. He is fully behind the level playing field opt-out, which he himself helped advance."

--Schumer spokesman Brian Fallon

Just now, in the press availability following the vote, here's Harry Reid:

Q: Senator Lincoln today made it very clear that she's not going to support any kind of public option. Senator Lieberman has said the same. What do you see as the chances it will be in the final bill.

Reid: First of all, I support a strong public option. I welcome Senator Schumer, Landrieu and Carper, who Senator Landrieu said are working together to find a public option that is acceptable to all Democrats....

Q: Did you just say that you've tasked Senator Schumer, Carper and Landrieu or ...

Reid: No. It's my understanding that Senator Landrieu said today that she's working with Senator Schumer and Carper to come up with an alternative.

Interesting. Either someone is not being entirely truthful, or we have a major miscommunication in leadership. I've asked leadership staff for clarification and will report back when I've heard anything.

Update: Leadership staff declines to comment, but one Senate Democratic aide e-mails "As far as I know it's absolutely true that Senator Schumer has been having these conversations about a public option compromise well before we had this vote tonight."

Update 2: And Schumer's spokesperson, Brian Fallon, adds

Leading up to tonight's vote, some senators expressed a desire to discuss the public option currently in the Senate bill. Of course, Senator Schumer did not rule that out. But no such talks have yet taken place, and there is not any compromise at hand beyond what Leader Reid has already inserted into the bill. Senator Schumer remains a strong proponent of the opt-out, level playing field public option.

So both Reid and Schumer are strong proponents of the opt-out, but talks on further compromise continue. Meaning triggers are headed our way, unless the progressives take a very strong stand in committing to voting against them.

Senate Votes to Move Forward to Talk More about Voting on HCR

Sun, 22 Nov 2009 00:56:42 GMT

With all of the Democrats, and Lieberman, having already agreed to vote in favor of tonight's vote to allow the healthcare reform legislation come to the floor for debate, the actual voting is pretty much a foregone conclusion, unless Olympia Snowe goes on a wild hare and decides to get all bipartisany on us.

Nonetheless, this is a rather historic event, since we haven't gotten this far on healthcare reform in the Senate, well, ever. Sen. Dodd is in the chair for the vote, in the place where Senator Kennedy would have been.

Watch:

Update: Sen. Dodd makes the call. 60 vote yea, 39 nay. The motion is agreed to.

Update 2: Voinovich was the Republican who didn't vote.

Nice little moment between Reid and Dodd just now at their presser on Kennedy--Reid had just spoken with Mrs. Kennedy, who was very pleased and told him that she was sure the Senator was there with them in spirit.

Update 3: E-mailed statement from the White House, here's Gibbs:

"The President is gratified that the Senate has acted to begin consideration of health insurance reform legislation. Tonight’s historic vote brings us one step closer to ending insurance company abuses, reining in spiraling health care costs, providing stability and security to those with health insurance, and extending quality health coverage to those who lack it. The President looks forward to a thorough and productive debate."

Late afternoon/early evening open thread

Sun, 22 Nov 2009 00:18:04 GMT

What's coming up on Sunday Kos ....

Behind the scenes, United States and Russian negotiators have been hard at work hammering out a new START, or Strategic Arms Reduction Treaty. The Treaty expires on December 5, 2009, and it looks like neither of the legislative bodies in either country will ratify it in time. Plutonium Page will explain what the obstacles are, and how the two countries will handle the gap between the missed deadline and actual treaty ratification.

DarkSyde will introduce a few glitches in the incredible human immune system and exposes some aberrations of our dysfunctional healthcare system in "Resistance is Futile."

When we think and talk politics and strategy, there are distinctions that too easily get blurred. Laura Clawson will highlight some of the fault lines.

DemFromCT will review how the breast cancer screening panel misaligned the science, the politics and the commmunication... and why it matters.

Last month, Germany, France, the United States, Russia, Britain, and China met with Iranian nuclear negotiators to discuss a deal in which Iran would send most of its low-enriched uranium out of the country to be further enriched and fabricated into fuel for the Tehran Research Reactor. Since then, a lot has happened, including Iran's official rejection of the deal as well as a new, troubling report from the International Atomic Energy Agency on Iran's nuclear facilities. Plutonium Page will discuss all of this in detail, and what it means for the future.

Alexander: Dems want to dump Americans in "medical ghetto"

Sat, 21 Nov 2009 23:30:04 GMT

What would a health care debate be without some good ol' fashioned race-baiting from the G.O.P.?

Transcript:

Dumping of 15 million low-income Americans into a medical ghetto called Medicaid that none of us or any of our families would ever want to be a part of for our health care...

..Moving 15 million Americans into this medical ghetto...

...Moving 15 million low-income Americans into a program called Medicaid which is a medical ghetto is not health care reform.

Way to stay classy, GOP.

GOP health care derangement syndrome: Stop me if you've heard this one.

Sat, 21 Nov 2009 22:46:03 GMT

Government takeover! Destroying America! The end of the world as we know it!

Yes, we've heard it all before. But did you know how many times, and for how long?

The fact is that the Republican Party told teabaggers' grandmas (of "death panel" fame) that Social Security was going to be the end of America. And today you can't swing a euthanized cat without hitting a Republican at a microphone insisting he's Social Security's greatest champion.

Republicans likewise told teabaggers' dads that Medicare would be the end of America. And today you can't swing a... oh yeah, you've heard that one.

Today, of course, Republicans will spend the entire day telling teabaggers themselves that the health insurance reform bill will be the end of America.

Gosh, poor America! That's a lotta ends!

Not sure you remember just how sure Republicans were about all those ends? Remind yourself with this trip down Fevered Nightmare Lane.

Consulting Generals Shape Policy

Sat, 21 Nov 2009 22:02:04 GMT

The Department of Defense told the watchdog Project on Government Oversight Thursday that it won't let the public see a congressionally mandated revolving-door database of Pentagon employees.

POGO wonders what the harm is in seeing a list of former government officials who are now working for defense contractors. We have campaign finance and lobbying disclosure – why not expose those circulating between the public and private sectors who might be a driving force behind government decisions and policies?

"Public access to the revolving door database represents the kind of open government that the public wants and deserves. If this Administration is serious about open government, it needs to provide public access to the database about the well-oiled DoD revolving door," said POGO's General Counsel, Scott Amey.

Indeed. But exposing bits of the interlocking directorate of the military-industrial complex can be, at the very least, embarrassing to the uniformed powers-that-be.

In a Wednesday story that Thomas Ricks says should get a Pulitzer, Tom Vanden Brook, Ken Dilanian and Ray Locker of USA Today reported:

Six months after Marine Lt. Gen. Gary McKissock retired in 2002, he did what many other ex-military leaders do: He joined the board of directors of a defense contractor, a company doing business with his former service.

McKissock also had a second job. The Marines brought him back as an adviser, at double the rate of pay he made on active duty. Since 2005, the Marines have awarded McKissock contracts worth $1.2 million, in addition to his military pension of about $119,000 a year.

McKissock is one of at least 158 retired admirals and generals the Pentagon has hired to offer advice under an unusual arrangement. Most of the retired officers, one to four stars in rank, have been paid hundreds of dollars an hour by the military even as they worked for companies seeking Defense Department contracts, a USA TODAY investigation found. That's in addition to pensions of $100,000 to $200,000 a year for officers with 30 or more years of service. ...

Of the 158 retired generals and admirals identified as having worked for the military as senior mentors, 80% had financial ties to defense contractors, including 29 who were full-time executives of defense companies. Those with industry ties have earned salaries, fees or stock options as consultants, board members or full-time employees of defense firms.

Nothing illegal in any of that. And good arguments can be made for its beneficial effects.

Those benefits are outweighed by the steep downside, however. Bad enough when retired officers now working for defense contractors show up to lobby among their previous subordinates - men and women who took orders from them not so long ago. It's no easy matter to break the entrenched habit of saying "yessir." This revolving-door practice has been going on since before Dwight Eisenhower delivered his farewell address nearly half a century ago.

But when the Pentagon and a contractor are both paying these former officers, the line becomes even more blurred.

In some cases, mentors also work for weapons-makers who have an interest in the military planning the mentors are assisting. A Marines exercise last year, which explored how to launch operations from ships, employed mentors who also had financial relationships with companies that sell products designed to aid those operations.

"This setup invites abuse," says Janine Wedel, a George Mason University public policy professor and author of a forthcoming book on government contracting. "Everyone in this story is fat and happy. Everyone, of course, except the public, which has virtually no way of knowing what's going on, much less holding these guys to account."

If retired generals advising the Pentagon also are "being paid by somebody who wants to make money off the government, I think it's important the public know that," says Sen. Claire McCaskill, D-Mo., who chairs the subcommittee on contracting oversight. "The reason ... is so the people have confidence that the decisions are being made based on merit, and not based on inside baseball."

That ought to qualify for the understatement of the year. At its least damaging outcome, seeking to please former commanders who now hold jobs with defense companies is bound to be on the minds of those officers who someday hope to retire and bring in the big bucks from those companies themselves.

Far worse is the effect such "mentoring" may have not merely on weapons and software acquisitions but also on the shaping of war planning itself. Combine that with retired generals and admirals being specially briefed by the Pentagon for their appearances on Foxaganda and other media masquerading as "independent experts" and you've got a noxious brew.

Despite the shrieks of alarm that will emanate from the armchair patriots over any call for monitoring, much less ending, these relationships, a reform injecting a smidgen of accountability and transparency would amount to barely a baby-step toward curtailing the military-industrial complex. But at least it might demonstrate to the still unaware just how deeply rooted the MIC has become.

Reminder to Senate Dems: Carper's Triggered Co-Ops Aren't a Public Option

Sat, 21 Nov 2009 21:16:04 GMT

So Landrieu and Lincoln say they'll vote to allow debate to continue so that the Senate can eventually vote on whether they want to vote to reform the nation's healthcare system. Lest you get too excited by their radicalism, here's the cold water on our collective enthusiasm.

After announcing her intent to support a health care debate this afternoon, Sen. Mary Landrieu (D-LA) told reporters she thinks Senate Majority Leader Harry Reid will soon have to choose between a triggered public option and no health care bill. She also says Sen. Chuck Schumer (D-NY)--the third-ranking Democrat in the Senate one of its most fierce and vocal public option advocates--has been tasked as a point man on the issue.

"I believe it's going to be very clear at some point very soon that there are not 60 votes for the current provision in the bill, and that the leader and the leadership are going to have to make a decision and I trust that they will figure out how to do that," Landrieu told reporters.

Blanche Lincoln raised the stakes on this on the Senate floor today, saying "I've already alerted the Leader and I'm promising my colleagues that I'm prepared to vote against moving to the next stage of consideration as long as a government run public option is included." She continues to argue falsely, just like Joe Lieberman, that the public option will cost the federal government too much, proving that not only Republicans can pick and choose what they like from CBO reports.

We're veering ever closer to the point where this bill is not going to do a whole lot more than force people to buy crappy insurance. The public option, as limited as it is, is the foot in the door to providing more and better options to more people. Without it, even as constricted as it has become, this bill isn't reform. It's telling the insurance companies they really shouldn't cherry-pick customers and leave people without care, and erecting a few more barriers for them to get around while they continue to do just that.

Triggered co-ops, the Carper plan that Schumer is apparently pushing, isn't a compromise. It's no kind of public option and should not be supported by anyone calling themselves a progressive. It's a capitulation. So Senators Brown, et al., it's your call. You said no more compromise. It's time to prove that you mean it.

Update: Schumer's staff e-mails to refute Landrieu's suggestion that he's been tasked with a compromise, or has been free-lancing on the issue, as another Democratic aide suggested. Schumer's spokesman Brian Fallon e-mails this statement:

"Since Leader Reid announced the opt-out public option would be included in the Senate bill, Senator Schumer has not approached anyone about compromises. He is fully behind the level playing field opt-out, which he himself helped advance."

--Schumer spokesman Brian Fallon

Ah, ~~palace~~ chamber intrigue. All I can say is stay tuned.

Reid Gets His 60 Votes, For Now

Sat, 21 Nov 2009 20:30:04 GMT

At least for continuing debate. Nelson, Lincoln, Landrieu, they're all in.

Senate Majority Leader Harry Reid (D-Nev.) has secured the vital 60th vote he needs to advance healthcare reform legislation with the announcement by Sen. Blanche Lincoln (D-Ark.) that she will vote with her party Saturday evening.

"I have concluded that it is more important to begin this debate rather than just simply drop the issue and walk away," Lincoln said on the Senate floor. "I'm not afraid of that debate."

Of course, Lieberman could pull a Lieberman, and change his mind on this one just for the hell of it (and because he hasn't been in the headlines very often lately), but for now there's no drama left in today's vote.

Now the real fight for a real public option. In agreeing today to continue debate on this bill, Lincoln vowed essentially to join a Republican filibuster.

I've already alerted the Leader and I'm promising my colleagues that I'm prepared to vote against moving to the next stage of consideration as long as a government run public option is included.

Midday open thread

Sat, 21 Nov 2009 20:16:03 GMT

James Fallows, in a post entitled Manufactured Failure, hits the Washington press hard on how purely awful its coverage was of President Obama's trip to Asia, how uniformly negative it was compared with the actual reporting in China.

Matt Taibbi deconstructs Sarah Palin:

Palin — and there’s just no way to deny this — is a supremely gifted politician. She has staked out, as her own personal political turf, the entire landscape of incoherent white American resentment. In this area she leaves even Rush Limbaugh in the dust.

The reason for that is that poor Rush is an anachronism, in the sense that his whole schtick revolves around talking about real political issues. And real political issues are boring.

Listen to Rush any day of the week and you’ll hear him playing the old-fashioned pundit game: he goes about the dreary business of picking through the policies and positions and public statements of Democrats and poking holes in them, arguing with them, attacking them with numbers and facts and pseudo-facts and non-facts and whatever else he can get his hands on, honest or not, but at least he tries. ...

Sarah Palin’s battlefield, on the other hand, is whatever is happening five feet in front of her face. She is building a political career around the little interpersonal wars in the immediate airspace surrounding her sawdust-filled head. And in the process she connects with pissed-off, frightened, put-upon America on a plane that’s far more elemental than the mega-ditto schtick.

The Justice Department drops charges against one of the Blackwater guards accused of manslaughter for the shooting deaths of 17 Iraqis in a public square in 2007.

The small ~~Illinois~~ Michigan town that wants the Gitmo detainees tells Liz Cheney they're not liking her fear-mongering.

Levi Johnston's mother gets sentenced to three years in prison for drug dealing.

With friends like these....

Rainn Wilson:

People who don't believe in evolution really shouldn't be allowed to get flu shots.

Now it seems that some economists are giving the stimulus package a thumbs up.

The White House blog offers a head start on reading the Senate health care bill:

On page 78 you’ll learn that the Patient Protection and Affordable Care Act ends discrimination based on pre-existing conditions. On page 17, it makes preventive care completely free, with no cost-sharing. (This might be of particular interest to those who have chosen to seize on concerns about the U.S. Preventive Services Task Force Recommendations on mammograms to spread baseless myths and advance their own political agenda.) Flipping back to page 16, you’ll find that insurance companies are prohibited from dropping your coverage or watering it down when you get sick and need it most. Also on page 16, you might notice that it puts an end to lifetime caps on coverage. Page 18 is where the bill extends family coverage eligibility for young Americans through the age of 26. On page 83 it requires insurance companies to renew any policy as long as the policyholder pays their premium in full – that means they can’t refuse to renew your coverage just because you get sick. Page 307 is home to tax credits for small businesses to help them afford insurance for their employees. And folks looking to scare our senior citizens about what reform means for them might be interested to check out page 923 and learn that it provides a 50% discount on drugs for seniors in the so-called donut hole.