Medicine
Moving the goalposts
As much as I’m disappointed by the outcome, I have to love Nate Silver’s analogy/analysis of the failed push for a public option. Essentially, Silver’s take is that the core group of conservative Democrats were never going to accept a public option, said so early, repeated it whenever they were asked, and so, a bill containing a public option was never going to beat a filibuster.
Suppose the following scenario plays out when you’re trying to buy a used car:
Dealer: The price of the car is $2,000.
You: For that beat-up Honda Accord? I’ll give you $1,200.
Dealer: Nope, it’s $2,000.
You: How about $1,500?
Dealer: I’m going to stick with $2,000.
You: Will $1,700 get it done?
Dealer: My best and final offer is $2,000.
You: Give a guy a break! $1,875?
Dealer: $2,000.
You: $1,995 and a free Slurpee coupon?
Dealer: Now we’re talking — step into my office.Is that a negotiation in bad faith? Is the dealer moving the goalposts? No. He’s being very stubborn and very firm — but he’s also being very explicit about what he wants. It’s possible that you were an incompetent negotiator and that maybe if your first offer had come in a little lower, or a little higher, you could have gotten a better price. But more likely the dealer simply had more of the leverage and ultimately $2,000 is an acceptable price to you, even if it’s more than you were hoping to pay.
Progressives did just about everything in their power to try to get a decent public option into the bill. They threatened. They bargained. They complained. They organized. They persuaded. They begged. There was the opt-in, the opt-out, the trigger, the Medicare buy-in. There was no lack of initiative or creativity. And they actually had quite a bit of success: from 43 votes in August, they got up to perhaps as many as 48–52 for a strong-ish public option, and 57–59 for a weak-ish one. People like Kay Hagan, Tom Carper and Kent Conrad, to varying degrees, came on board.
But just because you perceive yourself as being in a negotiation with another party doesn’t entitle you to win that negotiation, or even to split things halfway. Sometimes your adversary doesn’t think there’s anything to negotiate at all. Sometimes they would in theory be willing to negotiate if you could find the right leverage point, but there’s nothing that fits the bill, for all your best efforts. Sometimes their first offer is pretty much as good as it’s going to get, and not merely a negotiating ploy.
What’s that? Oh, yes. Silver explicitly excludes Sen. Joe Lieberman (Prick — CT) from this analysis. Lieberman’s about-face on the Medicare buy-in proposal, motivated seemingly only by a desire to get payback from progressives who didn’t support him against Ned LaMont, would be comic if it didn’t play with people’s lives.
Beyond Starbucks: Physical APIs
Some great ideas are sparking here, helped along by Robin’s notion of a “Starbucks API.” Noah Brier calls it a “physical API” (see also the smart comments) and Kit Eaton at Fast Company extends the concept (tongue-in-cheek) to Microsoft, Apple, and Twitter. But I like Drew Weilage’s proposal at Our Own System the best:
The idea: create a “physical API”… of the Mayo Clinic or Cleveland Clinic. Copy their entire way of doing business and paste it into hospitals around the country. In a nicely wrapped package deliver their systems for decision-making, integration, coordination, and expertise. Include their human resources practices, innovation efforts, and technology. Import their employment model, their bargaining power, and of course brand recognition. This is a beta release so if anything is left out, it can be included in a later version.
Mix with water. Implement. Poof! Great health care!
Just think about it, Local County Hospital, powered by the Mayo Clinic or Our Lady Health Care System, supported by the Cleveland Clinic; it’s a definite brand extender.
Seriously — this has, potentially, amazing public policy implications. My dad, who’s worked in the government for-practically-ever in Wayne County/Detroit (first at the jail, then in public health, then in lots of places), always used to stun his bosses, co-workers, everybody, because whenever they ran into a persistent problem or one they couldn’t solve, he would get on the phone to people he knew in Oakland County, or Chicago, or Denver, to see how they handled it, who would in turn refer him to other people, etc.
You can get these information bottlenecks even when there’s no competing interests, and nothing proprietary — it’s just hard (without an API) for people to know where or how to look.
What Canadian Expats Miss About Canada
The NYT asked:
In history class, in seventh grade (or as we like to say in Canada, grade seven) we learned the story of the American Revolution — from the British perspective. Turns out you were all a bunch of ungrateful tax cheats. And you weren’t very nice to the Loyalists. What I miss most about Canada is getting the truth about the United States.
— MALCOLM GLADWELL, a staff writer for The New Yorker and the author, most recently, of “Outliers: The Story of Success”
I also liked this quip from Simpsons writer Tim Long:
I miss the snow. Yes, I know the United States gets snow, but to my Canadian eye, American snow is like American health care: sporadic, unreliable and distributed unevenly among the population.
Getting Better
I don’t know why, but I’ve always thought of surgery as primarily a cerebral pursuit; a great surgeon is so because he’s clever and smart. A short passage from Gawande’s [commencement] address reveals that perhaps that’s not the case:
In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful — the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.
So surgeons learn surgery in the same way that kids learn Kobe Bryant’s post moves from SportsCenter highlights?
Actually, Gawande reminds me a little bit of Tony Gwynn’s method of obsessively recording pitchers to see what pitches they might use against him:
What began as a casual “let’s take a look at how I swing” Has developed into a Spielberg-like production.
On the road, Gwynn carries two extra bags packed with video equipment and supplies. He has tapes of himself against every pitcher he has faced in the National League, showing every at-bat he has been able to film.
In his hotel room, before every game, he uses a small video replay machine to review the tape of that night’s pitcher.
“I kind of take things to an extreme,” said Gwynn, who edits and compiles his own tapes. “I know all I have to do is see the ball and hit the ball and I will put my bat on the ball. I know that, but it’s not enough…
“I don’t keep a journal. Most of it is mental anyway. Once you watch these tapes as much as I do, you know. I think I would be as good a hitter without the tapes, but this is fine tuning. I really don’t look at myself that much, but rather I look at how the guy has pitched me in the past. Maybe they will try it again, maybe not. But it will be in my mind knowing what they might do, and that is an advantage to me as a hitter.”