Category Archives: Politica economica

Fatto. Analisi. Impatto di @vitalbaa su newslist.it di @masechi DA LEGGERE!

Come si dovrebbe legiferare e regolamentare in un paese civile, applicando continuamente AIR (analisi di impatto della regolamentazione) e VIR (verifica di impatto della regolamentazione) prima e dopo il processo decisionale.

L’articolo è l’ulteriore dimostrazione dell’interesse della newslist.it del grande Mario Sechi

Una vita sregolata

di Vitalba Azzollini

Il sottotitolo di questa newsletter  – “Fatto. Analisi. Impatto” (ma anche “Agenda”, come dirò) – è un invito a nozze per chi si occupa di regolamentazione. Quelle tre parole sono, al contempo, presupposto e spinta per l’evoluzione dell’ordinamento. Mi spiego meglio. Il mutamento della realtà è costante, il diritto deve tenere lo stesso ritmo: l’analisi dei fatti, quindi del contesto, così come quella degli impatti delle norme che intervengono sui fatti, è imprescindibile per ogni buon regolatore. Può aggiungersi anche altro. La regolamentazione è un costo, poiché impone oneri e limiti ai soggetti privati, spese di elaborazione ed attuazione a quelli pubblici. Un rule maker realmente accountable deve essere in grado di giustificare in modo trasparente che, tra le diverse opzioni normative a sua disposizione, ha scelto quella più efficace in termini di costi e benefici, dati i fini perseguiti. La scarsa attenzione a questo processo di valutazione ponderata ha determinato nel tempo discipline sovrabbondanti, inutili o poco coerenti. E i conseguenti effetti negativi su produttività, concorrenza, competitività del sistema economico nazionale sono evidenti (e attestati da studi sull’attrattività di diversi Paesi).

Dunque, “Fatto. Analisi. Impatto” è, in sintesi, il metodo che i regolatori nazionali – specificamente governo e autorità “tecniche” – dovrebbero  seguire (il condizionale è d’obbligo, come spiegherò oltre), non foss’altro perché è da anni un obbligo di legge. Come si attua in concreto questo metodo? Si attua, da un lato, mediante l’analisi di impatto della regolamentazione (AIR), strumento che serve a definire esattamente il problema da risolvere; individuare gli obiettivi perseguiti e costruire indicatori di carattere quantitativo che consentano di verificarne il grado di raggiungimento; consultare gli stakeholder; esaminare le varie opzioni di intervento (inclusa la cd. “opzione zero”, ossia il non intervento); comparare i vantaggi e gli svantaggi di ognuna di tali opzioni, considerandone gli effetti concorrenziali sul mercato e quantificandone il “prezzo” per cittadini e imprese; delineare un attendibile scenario del futuro funzionamento dell’opzione selezionata, soprattutto dei suoi possibili effetti inattesi o indesiderati, sulla base dei dati disponibili al momento della sua scelta. Dall’altro lato, il metodo citato si attua mediante la verifica di impatto della regolamentazione (VIR), che serve per vagliare il reale grado di raggiungimento degli obiettivi prefissati, misurato sulla base degli indicatori predefiniti; “manutenere” le leggi vigenti, onde permetterne nel tempo la correzione a seguito di eventuali disfunzioni o l’aggiornamento in relazione a sopravvenuti mutamenti fattuali e giuridici; abrogare le norme non più necessarie.

Ricapitolando, il metodo riassunto in “Fatto. Analisi. Impatto” – valutazione ex ante dell’adeguatezza della regolamentazione ed ex postdella sua concreta e perdurante efficacia – serve non solo a tenere l’ordinamento al passo di una realtà in costante trasformazione e a imporre ai regolatori di giustificare le proprie scelte in maniera trasparente, ma a garantire il buon funzionamento delle leggi. Quindi, è un metodo idoneo ad assicurare una regolamentazione di qualità. Come il Consiglio di Stato ha evidenziato in un recente parere – ove riassume i numerosi interventi in tema di better regulation da parte del legislatore nazionale, nonché dell’Unione Europea e dell’OCSE – “una norma ‘scritta bene’, che rispetti i requisiti di ‘qualità’ (…) in termini di consapevolezza dell’impatto su cittadini e imprese, reca un beneficio ulteriore – e costi sociali minori – rispetto ai benefici che il suo contenuto ‘di merito’ già prevede”. In altre parole, la valutazione degli impatti, garantendo la qualità delle regole, offre un “valore aggiunto” economicamente stimabile in termini di “maggiore efficacia, efficienza, sostenibilità e ‘durabilità’ delle normative”.

“Fatto. Analisi. Impatto” è il metodo che i regolatori nazionali dovrebbero seguire, dicevo usando scientemente il condizionale. Ne spiego la ragione. Come rilevato sempre dal Consiglio di Stato – e come si legge puntualmente nella Relazione sullo stato di attuazione della analisi di impatto della regolamentazione, presentata ogni anno dal Governo al Parlamento – le relazioni AIR sono il più delle volte poco approfondite, prive degli indicatori quantitativi utili a consentire la verifica dell’effettivo impatto delle norme; mancanti dell’analisi economica delle opzioni alternative di regolamentazione e lacunose riguardo all’opzione prescelta; carenti nell’analisi di “fattibilità”, cioè incuranti della successiva fase di attuazione, anche in termini di stima delle risorse – finanziarie e umane – necessarie. Quanto alle VIR, affermare che non ve ne sono molti esempi sarebbe un eufemismo. Questa è la foto del “metodo” – anche per i fallimenti serve metodo – con cui i regolatori nazionali hanno nel tempo affossato ogni italica aspirazione di better regulation. Peraltro, svuotando di significato AIR e VIR, hanno costantemente disatteso anche il c.d. regulatory budget (che impone di non introdurre nuovi oneri amministrativi senza averne prima eliminati altri), reso le consultazioni pubbliche dei meri pro-forma, ossia atti di politica fittizia, e molto altro. Ma qui mi fermo.

“Fatto. Analisi. Impatto” è il metodo con cui, in questa newsletter, partendo dai fatti esaminati, vengono tratte conclusioni, fondandole su analisi di dati e impatti svolte trasparentemente. E trasparenza è la caratteristica ineludibile di ognuno degli strumenti di better regulationsopra citati, nonché la chiave di volta per comprendere il loro insufficiente utilizzo, di AIR e VIR soprattutto. La trasparenza delle decisioni di regolazione – cioè la trasparenza delle valutazioni degli impatti, anche attraverso la loro pubblicazione su siti istituzionali – metterebbe i governanti nella condizione di dover rendere conto del proprio operato, consentendo all’elettorato di giudicarli con dati di fatto. Detto in termini più banali, ne disvelerebbe i poco realistici annunci di riforme mirabolanti, così come il mancato ottenimento di effetti previsti con noncurante leggerezza. Dunque, gli strumenti che garantiscono la qualità della regolazione, nonché la trasparenza del processo di rule making, contribuirebbero alla responsabilizzazione democratica dei rule makers stessi, date le conseguenze reputazionali (e soprattutto elettorali) cui potrebbero dar luogo. E’ più chiaro ora il perché in Italia tali strumenti non vengono usati – anzi, sono spesso demonizzati da politici e supporter – con la conseguenza che le leggi sono fatte male e operano ancora peggio?

Dimenticavo: nel sottotitolo di questa newsletter vi è anche la parola “Agenda”, cioè il “da farsi”, e ai fini di quanto detto sopra conta anche quella. La trasparente programmazione dell’attività normativa e, quindi, l’elenco delle iniziative di regolamentazione previste in un arco temporale preciso – con pubblicazione sui siti web istituzionali anche dei motivi per cui il programma non viene eventualmente rispettato – rappresenterebbe un impegno, la cui violazione nuocerebbe alla credibilità di chi l’ha assunto.

“Fatto. Analisi. Impatto. Agenda”. Così si chiude il cerchio.

Chi è l’autore. Vitalba Azzollini, giurista. Lavora presso un’Autorità di vigilanza. Scrive in tema di diritto su riviste on line (tra le altre, La Voce e Noise fron Amerika), blog (Phastidio e Istituto Bruno Leoni) e giornali. Autrice di paper per l’Istituto Bruno Leoni.

Annunci

Una lettura obbligatoria: Exponential Organizations di Salim Ismail @WRicciardi @leadmedit

Una lettura estiva (forse sarebbe meglio dire uno studio estivo) di un libro affascinante: Exponential Organizations di Salim Ismail, edito da Marsilio nella collana Nodi.

Che cos’è un’organizzazione esponenziale? Essa è un’organizzazione il cui impatto (o output) risulta notevolmente superiore – almeno dieci volte – rispetto ai competitor, grazie all’utilizzo di nuove tecniche organizzative, che fanno leva sulle tecnologie in accelerazione.

Gestire organizzazioni esponenziali focalizzate sui clienti e non sui competitor esterni e sulle strutture interne tradizionali richiede una svolta epocale, paragonata a una nuova “era cambriana”. Richiede una nuova cultura e nuove e più dinamiche competenze.

Ho raccolto alcune frasi che mi hanno particolarmente colpito! Buona meditazione a tutti noi perché molti dei temi trattati riguardano anche la sanità!

  1. L’unica costante del mondo d’oggi è il cambiamento, e il ritmo del cambiamento sta aumentando.
  2. L’accelerazione (del cambiamento) è costituita dalle 6 D: digitalized, deceptive (ingannevole), disruptive (dirompente), dematerialized, demonetized, democratized.
  3. L’utilizzo di strumenti lineari e di tendenze del passato per fare previsioni su di un futuro in accelerazione è deleterio (vedi i casi di Iridium e Kodak).
  4. Gli esperti, in quasi tutti i campi, messi di fronte ad una crescita di tipo esponenziale, continuano sempre a pensare in un’ottica lineare, ignorando l’evidenza davanti ai loro occhi.
  5. Il vecchio detto secondo cui un esperto è “qualcuno che ti dice perché qualcosa non può essere fatta” è oggi più vero che mai.
  6. Nessuno degli indicatori tradizionali quali l’età, la reputazione e le vendite attuali possono garantire la sopravvivenza di un’azienda.
  7. La legge di Moore afferma che il rapporto prezzo/prestazione della potenza di calcolo raddoppia ogni diciotto mesi.
  8. “Le nostre organizzazioni sono fatte per resistere ai cambiamenti che arrivano dall’esterno” piuttosto che per accoglierli, anche quando sono utili (da John Hagel).
  9. Le strutture organizzative aziendali esistono proprio per annientare i fattori dirompenti di cambiamento.
  10. La maggior parte delle organizzazioni complesse si basa sulla cosiddetta “struttura a matrice” … Questa struttura è efficace nel garantire il controllo, ma è disastrosa in termini di individuazione delle responsabilità, di velocità e di propensione al rischio … Con il tempo, le funzioni orizzontali acquistano sempre più potere … Per le grandi organizzazioni con struttura a matrice attuare il cambiamento rapido e dirompente è qualcosa di estremamente difficile. Quelle che ci hanno provato, infatti, hanno sperimentato che il “sistema immunitario” dell’organizzazione tende a rispondere alla minaccia percepita attaccando.
  11. Le organizzazioni esponenziali hanno la capacità di adattarsi a un mondo in cui l’informazione è pervasiva e onnipresente e di convertirla in vantaggio competitivo.
  12. I tratti comuni delle organizzazioni esponenziali sono: il Massive Transformative Purpose (Mtp), cinque caratteristiche esterne denominate Scale e cinque interne denominate Ideas. Per essere un’organizzazione esponenziale, un’azienda deve avere il Mtp e almeno quattro caratteristiche.
  13. Il Mtp non è la missione: il Mtp è aspirational. Il fuoco è su ciò che si aspira a raggiungere.
  14. Scale: staff on demand; community and crowd; algoritmi, leveraged asset; engagement
  15. Ideas: interfacce; dashboard; experimentation; autonomia; tecnologie sociali.
  16. Il concetto di autonomia non implica non rendere conto a nessuno delle proprie azioni. Secondo Steve Denning, “In un network esistono ancora le gerarchie, ma esse tendono ad essere basate sulle competenze, e fanno affidamento più sull’accountability tra colleghi che su quella dovuta all’autorità, cioè sul dover rendere conto a qualcuno perché sa qualcosa e non per il semplice fatto che occupa una determinata posizione indipendentemente dalle competenze. Il ruolo del manager si trasforma, non viene abolito”
  17. Un’organizzazione esponenziale tende a essere una zero latency enterprise cioè un’azienda in cui si annulla l’intervallo tra ideazione, approvazione e realizzazione.
  18. In passato il lavoro si concentrava principalmente sull’importanza del quoziente intellettivo (QI), oggi il quoziente emotivo (QE) e quello spirituale (QS) stanno diventando indicatori sempre più rilevanti.
  19. Un secolo fa, la competizione si giocava principalmente sulla produzione, Quarant’anni fa, invece, il fattore decisivo divenne il marketing. Oggi, nell’era di internet, in cui produzione e marketing sono diventati merci e sono stati democratizzati, tutto ruota intorno a idee e ideali.
  20. Il piano strategico quinquennale è in sé uno strumento obsoleto … Esso è un suicidio per un’organizzazione esponenziale … L’unica soluzione è stabilire un Massive transformational Purpose (Mtp), costruire la struttura aziendale, adottare un piano (al massimo) annuale e osservare la crescita, con aggiustamenti progressivi e in tempo reale a seconda delle necessità.
  21. Nel mondo delle organizzazioni esponenziali, lo scopo (Mtp) è più importante della strategia e l’execution ha la precedenza sulla pianificazione.
  22. Arianna Huffington ha detto: “Preferisco lavorare con una persona meno brillante ma che sa fare gioco di squadra ed è chiara e diretta, piuttosto che con qualcuno molto brillante ma dannoso per l’organizzazione”.
  23. In un’organizzazione esponenziale, la cultura (con il Mtp e le tecnologie sociali) è il collante che garantisce la tenuta del team nonostante i salti quantici della crescita esponenziale. Secondo Chip Conley “la cultura è ciò che accade quando il capo non c’è”. E secondo Joi Ito “la cultura si mangia la strategia a colazione”.
  24. Sta diventando sempre più facile acquisire potere, ma è sempre è più difficile mantenerlo.
  25. Consiglio ai CEO delle grandi aziende di affiancare a chi occupa posizioni di leadership i venticinquenni più brillanti, per colmare il gap generazionale e tecnologico, per permettere a questi giovani di crescere più velocemente e per innescare un meccanismo di mentoring al contrario.
  26. Se siete un manager di Amazon e un dipendente viene da voi con una grande idea, la vostra risposta di default deve essere : Se volete dire di no, dovete motivare questo rifiuto con una relazione di due pagine spiegando perché non ritenete l’idea valida.
  27. Jeff Bezos (Amazon) ha detto: “ Se sei focalizzato sui competitor, devi aspettare che siano loro a fare la prima mossa, prima di agire. Concentrarsi sui clienti, invece, consente di essere dei pionieri”.
  28. Il miglior modo per definire questa macrotransizione verso organizzazioni esponenziali è considerarla un passaggio dalla scarsità all’abbondanza … Secondo Dave Blakely “queste nuove organizzazioni sono esponenziali perché prendono qualcosa di scarso e lo fanno diventare abbondante”.

Terremoto e paradossi economici @WRicciardi @drsilenzi @redhenry88

Titolo su Milano Finanza: “Il paradosso del terremoto: le spese per la ricostruzione non incideranno sul deficit e daranno una mano al pil”. E’ l’articolo più interessante e utile pubblicato sui quotidiani. Il passaggio chiave è questo: “La contabilità della ricostruzione ha a che fare con le disposizioni del nuovo articolo 81 della Costituzione, in cui si prevede la deroga all’obbligo del pareggio di bilancio, facendo dunque ricorso all’ indebitamento, solo quando si debbano fronteggiare un ciclo economico o circostanze eccezionali. Tra queste ultime, sono espressamente considerate le gravi calamità naturali. Spetterà al Parlamento, con una conforme deliberazione di Camera e Senato assunta a maggioranza dei rispettivi componenti, dichiarare che si versa in una delle citate situazioni. Anche il Fiscal compact, ma in maniera più generica, considera due circostanze eccezionali che consentono di derogare all’ obbligo di pervenire al pareggio strutturale del bilancio: si tratta degli “eventi inconsueti non soggetti al controllo della parte contraente interessata che abbiano rilevanti ripercussioni sulla situazione finanziaria della pubblica amministrazione”, e quindi nel nostro caso delle gravi calamità naturali. La deviazione temporanea è ammessa, purché non comprometta la sostenibilità del bilancio a medio termine. Nel caso di gravi calamità si attiva la clausola di flessibilità che consente di peggiorare il deficit congiunturale, ma si deve trattare infatti di spese una tantum, che si esauriscono con la soluzione del problema insorto. Tutte le spese pubbliche e le sovvenzioni concesse ai privati a seguito di una calamità naturale concorrono a far aumentare il prodotto, dacché mobilitano risorse materiali e umane che altrimenti sarebbero rimaste inerti. A differenza di qualsiasi investimento, o altra spesa pubblica, di questi interventi non si tiene conto ai fini del rispetto degli obblighi costituzionali ed internazionali sul pareggio di bilancio. La considerazione è ancora più amara se si pensa che le spese edilizie volte alla messa in sicurezza a fini antisismici, sia che derivino da spese pubbliche dirette, sia che dipendano da detrazioni di imposta a favore dei privati che le effettuino, non hanno lo stesso trattamento di favore”. Sì, è un paradosso.

Mario Sechi, Il Foglio List, 25 agosto 2016

PER UNA RIFORMA DEL REGIME FORFETTARIO PIÚ GIUSTA @WRicciardi @drsilenzi @Giorgioinfranca @OGiannino

di Giorgio Infranca, Avvocato in Milano 

Diciamolo chiaramente. Il regime forfettario, così come disegnato nel ddl stabilità 2015, non risponde minimamente alle attese dei piccoli imprenditori e dei giovani lavoratori autonomi ma, a dire il vero, nemmeno alle esigenze del Paese.

In seguito alla decisione del Consiglio UE n. 2013/678/UE del 15 novembre 2013 che ha autorizzato l’Italia ad aumentare la soglia di esclusione dall’Iva fino a 65.000 euro, ci si aspettava una riforma diversa, di tutt’altro spessore.

Capisco che innalzare la soglia dei ricavi a 65.000 euro mantenendo l’aliquota attuale del 5% sarebbe stato eccessivo ma prevedere un sistema di tipo progressivo sarebbe stato opportuno.

Il sistema disegnato dal Governo nel ddl stabilità prevede delle soglie di ricavi differenziati e dei coefficienti di redditività diversi in funzione dell’attività svolta che, a semplice lettura, si pongono in contrasto con gli artt. 3 (principio di uguaglianza) e 53 (principio di capacità contributiva) della nostra carta costituzionale.

Il nostro ordinamento è fondato (o lo dovrebbe essere) su un principio semplicissimo: chi guadagna di più, deve pagare di più.

Decidere, sulla base di presunzioni, l’accesso differenziato a un regime fiscale agevolato in funzione dell’attività svolta non è in linea con questo principio (peraltro, come sottolineato da molti commentatori, il limite di 15.000 euro per i professionisti è evidentemente un non senso).

Una soluzione ci sarebbe, ovvero quella di immaginare un sistema progressivo, basato su una soglia di ricavi massima maggiore di quella attuale (magari fino a 45.000 euro), uguale per tutti e tre aliquote crescenti in funzioni del reddito.

Determinato il reddito imponibile secondo la disciplina attualmente in essere (reddito di impresa o di lavoro autonomo costituito dalla differenza tra l’ammontare dei ricavi o compensi percepiti e le spese sostenute), si potrebbero prevedere tre aliquote diverse.

Se il reddito:

– è pari o inferiore a 15.000 euro, imposta sostitutiva pari al 5%;

– tra 15.001 e 30.000 euro, imposta sostitutiva pari al 10%;

– tra 30.001 e 45.000 euro, imposta sostitutiva pari al 15%.

Un sistema così delineato darebbe ai giovani imprenditori e professionisti una prospettiva di crescita e una grossa spinta al Paese.

Una cosa è dire: superata la soglia dei ricavi fissata a 15.000 euro, devi passare al più oneroso regime ordinario, un’altra sarebbe dire: man mano che cresci paghi qualcosa in più (un 5% in più) fino alla soglia massima di reddito pari a 45.000 euro (preciso che prevedendo quale limite dei ricavi euro 45.000 difficilmente qualcuno potrà avere un reddito imponibile di 45.000 euro. Questo vorrebbe dire infatti avere costi zero, il che è praticamente impossibile).

Lo Stato peraltro recupererebbe anche del sommerso: con la soglia fissata a 15.000 euro il rischio di evasione è ovviamente molto più alto, specie in considerazione delle conseguenze gravose di uscita dal regime.

Il tempo per cambiare rotta nella direzione giusta ancora ci sarebbe, la volontà chissà.

di Giorgio Infranca, Avvocato in Milano 

Studio Roveda e Associati

@Giorgioinfranca

2013: The Year In Healthcare Charts @pash22 @Medici_Manager @WRicciardi

By Dan Munro , http://onforb.es/1bU2qCK

This is the 3rd and final installment of my year-end series for 2013.

Part 1: Healthcare’s Story Of The Year For 2013 – Pricing Transparency(here)

Part 2: Top Ten Healthcare Quotes For 2013 (here)

Like the Top Ten Healthcare Quotes, this collection of 15 charts is far from complete or comprehensive, but they are ones I found to be representative of a broader healthcare trend or story. In most cases, the charts are self explanatory, but in others they are simply gateways into larger, more compelling stories.

Given the complexities around data collection and presentation – there is often a lag between the current year and the latest available data from a major/reliable source.

As a part of what I called the “story of the year” (Healthcare Pricing Transparency – here) was this chart from Elizabeth Rosenthal’s multi-part series on “The $2.7 Trillion Medical Bill.”

NYTPriceComp

Source: The $2.7 Trillion Medical Bill by Elizabeth Rosenthal (here)

While it’s too early to call it a trend, this chart for ER visits (1996 – 2010) is notable because 2010 is the first time in 14 years that the consecutive upward trend was broken. The unknown at this stage is why and if it will continue (lots of speculation and debate), but it’s an important barometer for reasons around cost and healthcare more broadly.

ERVisits

Source: CDC / National Center for Healthcare Statistics (PDF here)

The Milliman Medical Index is another broad indicator around annual healthcare costs for a family of 4 with PPO coverage.

Milliman2013

Source: 2013 Milliman Medical Index (PDF here)

For Health Insurance Premiums alone (no accounting for “out-of-pocket” expenses), the Kaiser Family Foundation gave us these two related charts:

Kaiser1

Kaiser2

Source: Kaiser/HRET 2013 Employer Health Benefits Survey 2013 (PDF here)

According to Medscape – Orthopedics edged out Cardiology and Radiology as the specialty with the highest average annual compensation for 2012 (reported in 2013).

Medscape2012

Source: Medscape Physician Compensation Report 2013 – (26 slides here)

Obesity and related illnesses saw coverage from every direction throughout 2013. Once again, the relatively small town of McAllen Texas (population of about 135,000 and profiled by Atul Gawande in The Cost Conundrum – 2009here) was front and center again in a story by The Washington Post that included this provocative chart on the correlation (by U.S. region) of childhood obesity and poverty (as measured by the Federal Poverty Limit):

WaPoObesity

Source: The Washington Post – Too Much of Too Little by Eli Saslow(here)

This next chart has broad healthcare implications and the dubious distinction of making an entirely different list – “The Most Important Charts in the World” (at least according to “Wall Street’s ‘Brightest” Minds).

FoodStamps

Source: Wall Street’s Brightest Minds Reveal The Most Important Charts In The World [Chart #57 – Monthly Food Stamps by Nicholas Colas of the ConvergEx Group – here]

Another contributing factor to several healthcare related illnesses is the global consumption of sugar – and soda in particular. Once again, at least according to Credit Suisse, the U.S. is an outlier relative to all of the other industrialized countries.

CSGlobalSoda

Source: Credit Suisse Research Institute – Sugar: Consumption At A Crossroads (PDF here)

From their Biennial Health Insurance Survey, The Commonwealth Fund delivered this chart as a part of broader analysis that concluded: “In 2012, nearly half (46%) of U.S. adults ages 19 to 64, an estimated 84 million people, did not have insurance for the full year or had coverage that provided inadequate protection from health care costs.”

TCWFund

Source: The Commonwealth Fund Report – Insuring the Future (PDF here)

Reducing the number of uninsured continues to dominate the healthcare headlines more broadly and Sarah Kliff at the Washington Post used this chart to summarize the effect of the ACA on coverage by 2016.

SarahKliffWaPo1

Source: Obamacare Explained In 2 Minutes by Sarah Kliff at The Washington Post (video here)

No less than 3 of healthcare’s larger topics (Big Data, Gamification and Wearable User Interfaces) made it to the top of another chart – Gartner’s Hype Cycle for Emerging Technologies. All 3 appeared at (or near) the “Peak of Inflated Expectations.” Clearly the trend that Gartner was identifying is larger than just healthcare, but healthcare is a part of the broader picture too.

GartnerHC

Source: Gartner Hype Cycle For Emerging Technologies 2013 (here)

Big Pharma continued to make restitution to the Department of Justice for past grievances around overly aggressive marketing of some of their drugs. Just this month, GlaxoSmithKline announced their intent to change some of those practices – which included paying doctors (in a variety of ways) to sell their branded drugs. This chart (created by ProPublica for a larger piece on the flow of dollars from big pharma to providers) doesn’t include the Johnson & Johnson settlement on behalf of their subsidiary Janssen for $2.5 billion which was finalized and announced just last month (here).

PharmaDoJ

Source: Big Pharma’s Big Fines by Lena Groeger for ProPublica (here)

Pricing transparency throughout the year revealed wide variations – some of which was explained by L.E.K. Consulting in their analysis which produced this chart (for a broader discussion on the profit profiles ahead for hospitals under the Affordable Care Act). They make a compelling argument that only one of the 4 different payment types seen by hospitals is profitable and this one category of payment has to offset the negative margin of the other 3.

LEKFigure1

Source: Hospital Economics and Healthcare Reform by Tip Kim and Scott Miller for L.E.K. Consulting (PDF here)

This final chart is one I’ve used extensively in the past, but has now been updated with OECD data for 2011. The older version was using data from 2009. Not much change – but strengthens the argument that we still have a long way to go in our healthcare reformation and transformation.

OECD2011

Source: OECD Health Data 2013 (Access the OECD StatExtracts Databaseonline here)

 

Colonoscopy ‘Potentially Inappropriate’ for 30% of Seniors @Medici_Manager

Cheryl Clark, for HealthLeaders Media, March 12, 2013 http://bit.ly/YKa2Fn

During the year after an influential U.S. task force advised providers to stop routine screening colonoscopies in seniors over age 75 because risks of harm outweigh benefits, as many as 30% of these “potentially or probably inappropriate” procedures were still being performed, with huge pattern variation across the nation, especially in Texas.

“We found that a large proportion of colonoscopies that are performed in these older patients were potentially inappropriate based on age-based screening guidelines,” says Kristin Sheffield, PhD, assistant professor of surgery at the University of Texas Medical Branch at Galveston, lead researcher of the study.

For patients between 70 and 74, “procedures were repeated too soon after a negative exam,” increasing the odds of avoidable harm, such as “perforations, major bleeding, diverticulitis, severe abdominal pain or cardiovascular events,” she says. The guidance, from the U.S. Preventive Services Task Force, which was released in 2008, also set a 10-year interval for routine colonoscopies for people between age 70 to 75 unless the patient develops certain symptoms.

The task force’s prior guidance issued in 2002 had no age limit recommendation, Sheffield says.

“For some physicians, more than 30% of the colonoscopies they performed were potentially inappropriate according to these screening guidelines,” she says. “So this variation suggests that there are some providers who are overusing colonoscopy for screening purposes in older adults,” Sheffield said.

Her report, published in this week’s JAMA Internal Medicine,looked at Medicare data from the Dartmouth Atlas between October 1, 2008 and September 30, 2009, to see hospital referral region patterns of variation across the nation as a whole. For the state of Texas, Sheffield used claims data from smaller hospital service areas, so she could see practices of individual physicians who performed colonoscopies.

She discovered that Medicare beneficiaries were much less likely to have a “potentially or probably inappropriate” colonoscopy if they lived in a non-metropolitan or rural area. Practitioners who were more likely to perform potentially or probably inappropriate colonoscopies were more likely to have been graduated from medical school before 1990 rather than after, and were more likely to perform a higher volumes of the procedure on Medicare beneficiaries each year.

The data was de-identified, so as not to reveal the practice pattern of an individual physician by name.

“Our purpose was not to point fingers at individual physicians or specialties. We just wanted to examine patterns in potentially inappropriate colonoscopy, because patterns can illustrate issues in everyday practice. It can help illuminate and show the range of practice in terms of the range of inappropriate colonoscopies.

Sheffield says that it may be that colonoscopists were simply slow to adapt the recommendations to their practices in certain parts of the country. In a subset of cases, she acknowledges, there may have been legitimate reasons why a physician recommended the procedure in a patient, and perhaps failed to code it properly for the claims database.

“For example, in adults between the ages of 76 to 85, there are some considerations that would support the use of screening colonoscopy, for example, a patient has a higher risk of developing an adenoma. But in general, screening guidelines indicate that should be exception, rather than the rule.”

And if that were the case, there wouldn’t be such a huge variation. For example, in the wedge of west Texas that includes El Paso, the percentages of colonoscopies that were potentially inappropriate was between 13.3% and 18.79%. But in large areas including Austin, Corpus Christi, San Antonio Houston, and Waco, the percentages ranged between 23.3% and 34.9%.

Nationally, areas of higher potentially inappropriate colonoscopies­—with rates between 25.27% and 30.51%— included eastern Washington state, Idaho, and eastern Nevada, Minnesota, parts of North and South Dakota, all of New England, Arkansas and large portions of North Carolina and Tennessee.

Low utilization areas—with rates between 19.45% and 22.64% — included New Mexico and north Texas, Central and Northern Inland areas of California, and all parts of Florida except Pensacola and areas of South Florida.

The issue included a related article and related commentary.

In the related article, Alexia M. Torke, MD, and colleagues, of the Indiana University for Aging Research, interviewed several dozen patients about their reasons for screening. They found that these patients considered screening at their age to be an automatic part of healthcare, and “a moral obligation.”

For example, one told investigators that discontinuation of routine colonoscopy screening, at age 84, “would be the same as me taking my life. And that’s a sin.”

Discontinuation would mean a much more difficult and significant decision they would have to make.

And they were skeptical of recommendations that they should not have screening, saying it would threaten their trust in their doctors and make them suspicious that a guideline they shouldn’t be screened was made only to save money.

“Public health education and physician endorsements (of cancer screening) may have created a high degree of ‘momentum’ for continuation screening, even in situations in which the benefits may no longer outweigh the risks or burdens.”

In an invited commentary, Mara Schonberg, MD, MPH, of Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, noted that as much as colonoscopies are celebrated as a preventive therapy, they also cause harm.

“Harms of cancer screening are immediate and include pain and anxiety related to the screening test, complications…(e.g., bowel perforation from colonoscopy,) or additional tests after a false positive result, and overdiagnosis (finding tumors that would never cause symptoms in an older adult’s lifetime). Overdiagnosis is particularly concerning because some older adults experience significant complications from cancer treatment.”

She blames “unbalanced public health messages” for contributing to “perceptions that cancer screening should be continued indefinitely,” she also points to the physician’s recommendation as a strong driver of whether a senior citizen undergoes one.


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

Shared Decision Making to Improve Care and Reduce Costs @Medici_Manager

Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D.

http://www.nejm.org/doi/pdf/10.1056/NEJMp1209500

A sleeper provision of the Affordable Care Act (ACA) encourages greater use of shared decision making in health care. For many health situations in which there’s not one clearly superior course of treatment, shared decision making can ensure that medical care better aligns with patients’ preferences and values. One way to implement this approach is by using patient decision aids — written materials, videos, or interactive electronic presentations designed to inform patients and their families about care options; each option’s outcomes, including benefits and possible side effects; the health care team’s skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians, and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes, reductions in unwarranted variation in care and costs, and greater alignment of care with patients’ values.

However, more than 2 years after enactment of the ACA, little has been done to promote shared decision making. We believe that the Centers for Medicare and Medicaid Services (CMS) should begin certifying and implementing patient decision aids, aiming to achieve three important goals: promote an ideal approach to clinician–patient decision making, improve the quality of medical decisions, and reduce costs.

In a 2001 report, Crossing the Quality Chasm, the Institute of Medicine recommended redesigning health care processes according to 10 rules, many of which emphasize shared decision making. One rule, for instance, underlines the importance of the patient as the source of control, envisioning a health care system that encourages shared decision making and accommodates patients’ preferences.

Unfortunately, this ideal is inconsistently realized today. The care patients receive doesn’t always align with their preferences. For example, in a study of more than 1000 office visits in which more than 3500 medical decisions were made, less than 10% of decisions met the minimum standards for informed decision making.1 Similarly, a study showed that only 41% of Medicare patients believed that their treatment reflected their preference for palliative care over more aggressive interventions.2

There’s also significant variation in the utilization of procedures, particularly those for preference-sensitive conditions, which suggests that patients may receive care aligned not with their values and preferences, but with their physicians’ payment incentives. Among Medicare patients in more than 300 hospital regions, the rate of joint-replacement procedures for chronic hip arthritis varied by as much as a factor of five, and the use of surgery to treat lower back pain varied by nearly a factor of six. Other studies have found wide regional variation in the treatment of early-stage breast and prostate cancers and in the use of cardiac procedures.

Section 3506 of the ACA aims to facilitate shared decision making. Primarily, it funds an independent entity that would develop consensus-based standards and certify patient decision aids for use by federal health programs and other interested parties. In addition, the secretary of health and human services is empowered to fund, through grants or contracts, the development and evaluation of these tools. Decision aids are meant to be evidence-based and inform patients of the risks and benefits of tests and treatments, their relative effectiveness, and their costs. Health care providers will be eligible for grants to implement these tools and to receive training and technical support for shared decision making at new resource centers. The ACA also authorizes the Center for Medicare and Medicaid Innovation to test shared-decision-making models designed to improve patients’ and caregivers’ understanding of medical decisions and assist them in making informed care decisions. For approaches that provide savings or improve quality of care, implementation can be mandated throughout Medicare without additional legislation.

Randomized trials consistently demonstrate the effectiveness of patient decision aids. A 2011 Cochrane Collaborative review of 86 studies showed that as compared with patients who received usual care, those who used decision aids had increased knowledge, more accurate risk perceptions, reduced internal conflict about decisions, and a greater likelihood of receiving care aligned with their values. Moreover, fewer patients were undecided or passive in the decision-making process — changes that are essential for patients’ adherence to therapies.

Studies also illustrate the potential for wider adoption of shared decision making to reduce costs. Consistently, as many as 20% of patients who participate in shared decision making choose less invasive surgical options and more conservative treatment than do patients who do not use decision aids.3 In 2008, the Lewin Group estimated that implementing shared decision making for just 11 procedures would yield more than $9 billion in savings nationally over 10 years. In addition, a 2012 study by Group Health in Washington State showed that providing decision aids to patients eligible for hip and knee replacements substantially reduced both surgery rates and costs — with up to 38% fewer surgeries and savings of 12 to 21% over 6 months.4 The myriad benefits of this approach argue for more rapid implementation of Section 3506 of the ACA.

The Department of Health and Human Services could quickly launch pilot programs for shared decision making while it works to standardize and certify decision aids. The International Patient Decision Aid Standards Collaboration has developed evidence-based guidelines for certification indicating that decision aids should include questions to help patients clarify their values and understand how those values affect their decisions; information about treatment options, presented in a balanced manner and in plain language; and up-to-date data from published studies on the likelihood of achieving the treatment goal with the proposed intervention and on the nature and frequency of side effects and complications. In addition, it would be helpful to include validated, institution-specific data on how often the specified procedure has been performed, the frequency of side effects and complications, and the cost of the procedure and any associated medication and rehabilitation regimens. We believe that decision aids should be written at an eighth-grade level and should be brief.5

In our view, it seems most critical to begin with the 20 most frequently performed procedures and to require the use of decision aids in those cases. Many decision aids have already been rigorously evaluated, so CMS could rapidly certify these tools and require their use in the Medicare and Medicaid programs. To give such a requirement teeth, full Medicare reimbursement could be made contingent on having documentation in the patient’s file of the proper use of a decision aid for these 20 procedures. Providers who did not document the shared-decision-making process could face a 10% reduction in Medicare payment for claims related to the procedure in year 1, with reductions gradually increasing to 20% over 10 years. This payment scheme is similar to that currently tied to hospital-readmissions metrics.

In addition, the improved quality of care and savings gained through shared decision making can be maximized by integrating this approach into other ACA initiatives. For example, the documented use of patient decision aids could be used as a quality metric in patient-centered medical homes, accountable care organizations, and systems caring for patients eligible for both Medicare and Medicaid. Eligibility criteria for incentives to adopt electronic health record technology might be expanded to include the use of shared decision making and patient decision aids. Moreover, information gathered by the Patient-Centered Outcomes Research Institute (PCORI) could be incorporated into certified decision aids and used to provide physicians and patients with valuable information for making health care decisions. Data about the effectiveness of shared-decision-making techniques could also be collected and disseminated by PCORI for continuous improvement of these approaches.

Unfortunately, implementation of ACA Section 3506 has been slow. More rapid progress on this front would benefit patients and the health care system as a whole.

Selling Proton Therapy to the Public: High Costs Without Benefit @Medici_Manager

In Trentino si sta mettendo in funzione la protonterapia! Auguri per la sostenibilità!

Written by Daniel Wolfson on March 20, 2013 http://bit.ly/WEuqap

Arriving in a train station in a Northeast city the other day, I was struck by the number of advertisements for proton therapy at a local academic medical center (AMC) plastered throughout the station and in local subways. The ads feature a bicycle racer with the tag line: “THE WIND IN YOUR FACE IS WORTH PROTON THERAPY: A cancer treatment that has fewer side effects.”

A bold statement, I thought, considering several studies have shown that proton therapy provides no long-term benefit over traditional radiation and comes with significantly higher cost for most conditions. There are a limited number of conditions—such as pediatric oncology—where proton therapy is shown to be effective.  Most striking, however, was the fact that this ad was specifically created to target a public that is not aware of the proton therapy’s marginal benefit and in what limited conditions it is effective.

“Marginal benefit” is when two procedures have small differences in benefits but large cost differences. Usually the more expensive intervention yields more benefits, like fewer side effects. But in this case, we have a procedure with no added benefits that is a lot more expensive.

Proton therapy uses atomic particles to treat cancer rather than X-rays. The particle accelerator is the size of a football field and costs about $180 million. According to the Yale study, Medicare pays over $32,000 for the treatment compared to under $19,000 for radiation. When applied to treat prostate cancer, outcomes were no different than intensity-modulated radiotherapy. Urinary function side effects were slightly better within six months but those advantages disappeared with 12 months post-therapy.

The ad directly contradicts the findings of this study and claims that proton therapy has fewer side effects than traditional therapy. This claim is true for pediatric cases but not for prostate cancer, the one primarily targeted by these ads.

What bothers me the most is that an AMC is peddling a more expensive procedure with no clear added benefit to the public through a massive advertising campaign. Isn’t there a moral imperative for an AMC to work in the best interest of their community based on the best available clinical evidence? Isn’t this supposed to be the era of value services? If they must advertise the therapy (possibly to recoup some of their costs or at least break even), why not target referring physicians rather than an unsuspecting public that is prone to request the latest and greatest technology just because it’s new? Perhaps referring physicians are wise to the lack of proton therapy’s marginal benefit and the AMC is hoping they will acquiesce to their patients’ demand for this marginal procedure. Is the public to know what cases are best for this type of therapy and for which conditions it is not well suited?

We should expect more and we should demand better. Proton therapy is clearly a more expensive procedure where a just-as-effective procedure exists. Quality and safety has not been raised, only the cost of medicine.

Costi standard in sanità: i documento del Convegno N.I. San. @Medici_Manager

Ecco i documenti del II Workshop Nazionale sui Costi Standard tenutosi il 18 Ottobre 2012 aSan Giovanni Rotondo, a cura del N.I.SAN.

http://bit.ly/YmOKuR

The European debt crisis: Defaults and market equilibrium @martinmckee @Medici_Manager

Cite as: M. Lagi, Y. Bar-Yam, The European debt crisis: Defaults and market equilibrium. NECSI report, Sept. 27, 2012.

http://necsi.edu/research/economics/bondprices/Bond_Prices.pdf

During the last two years, Europe has been facing a debt crisis, and Greece has been at its center. In response to the crisis, drastic actions have been taken, including the halving of Greek debt. Policy makers acted because interest rates for sovereign debt increased dramatically. High interest rates imply that default is likely due to economic conditions. High interest rates also increase the cost of borrowing and thus cause default to be likely. In equilibrium markets, economic conditions are used by the market participants to determine default risk and interest rates, and these statements are mutually compatible. If there is a departure from equilibrium, increasing interest rates may contribute to—rather than be caused by—default risk. Here we build a quantitative equilibrium model of sovereign default risk that, for the first time, is able to determine if markets are consistently set by economic conditions. We show that over a period of more than ten years from 2001 to 2012, the annually-averaged long-term interest rates of Greek debt are quantitatively related to the ratio of debt to GDP. The relationship shows that the market consistently expects default to occur if the Greek debt reaches twice the GDP. Our analysis does not preclude non-equilibrium increases in interest rates over shorter timeframes. We find evidence of such non-equilibrium fluctuations in a separate analysis. According to the equilibrium model, the date by which a half-default must occur is March 2013, almost one year after the actual debt write-down. Any acceleration of default by non-equilibrium fluctuations is significant for national and international interventions. The need for austerity or other measures and bailout costs would be reduced if market regulations were implemented to increase market stability to prevent the short term interest rate increases that make country borrowing more difficult. We similarly evaluate the timing of projected defaults without interventions for Portugal, Ireland, Spain and Italy to be March 2013, April 2014, May 2014, and July 2016, respectively. The markets consistently assign a country specific debt to GDP ratio at which default is expected. All defaults are mitigated by planned interventions.

Press Release: Is the Eurozone Crisis Really a Crisis?

CAMBRIDGE (Sept. 27) — As the European Central Bank prepares to dig deeper for the billions of Euros to bail out Spain and Italy if necessary, scientists at the New England Complex Systems Institute have asked whether the Eurozone’s debt crisis was actually the result of flawed fiscal policies or blind panic in the markets. Their answer is: yes, the debt crisis is real, but that market overreactions made it much worse by driving interest rates higher at a critical time, leading policy-makers to over-react. The repercussions include the halving of Greek debt a year earlier than necessary had the markets been in equilibrium.

For the first time, NECSI’s study quantitatively demonstrates how interest rates implicitly behave according to sovereign debt. The bond market effectively has a pre-set debt threshold it expects a given country to default at. For each country, this value is always present in interest rates, even when default is unlikely. As sovereign debt approaches the threshold, however, interest rates rise until mounting pressure triggers a default. This is the pressure which forced Greece, Ireland, and Portugal to accept bailouts and adopt austerity measures, and which is currently mounting on Italy and Spain.

This is the type of equilibrium behavior that is generally assumed to be a feature of financial markets. By quantifying this behavior, however, the study lays the groundwork for spotting when interest rates are knocked out of equilibrium by external actors.

The study tracked annual interest rate changes from 2001 to the present. Long term, the annually averaged interest rates followed the equilibrium curve closely. But in 2011 and 2012, daily market interest rates rose much more rapidly than the equilibrium model would predict. In a separate study, NECSI’s researchers confirmed that when markets departed from equilibrium, there was insufficient economic justification for the increases. In these cases, bond prices were driven by speculator-led bandwagon effects, and perhaps even outright market manipulation.

“The vulnerability of sovereign debt markets to bandwagon effects has led to painful austerity measures that may not have been necessary,” says Professor Yaneer Bar-Yam, a co-author of the study. “Policy-makers should have had more time to devise and test alternative strategies.”

This includes the ECB’s recent offer to purchase short-term bonds in the secondary market that the bank’s president Mario Draghi promised would address “distortions in financial markets.”

“Having a common European response to the debt crisis is a good idea,” said Bar-Yam, who in past research has pointed out the flaws in leaving countries to face speculator attacks alone. “As a united front they are less vulnerable to speculative bubbles or crashes.”

Still, he emphasizes the importance of allowing markets to stabilize themselves. “The lack of stability is triggering policy responses that swing wildly every time the market hiccups because of the risk of crashes. If the markets were to be stabilized by simple trading policies, this wouldn’t be necessary.”

According to the researchers, policy-makers could respond only when there are real problems, not the phantoms generated by market panic.

For media inquiries, contact:

Karla Bertrand, Press Relations
karla@necsi.edu, 617-547-4100

Clare Froggatt, Program Coordinator
clare@necsi.edu, 617-547-4100

 

The drug industry. Pick your pill out of a hat @Medici_Manager @doctorpreneur

Da The Economist http://www.economist.com/node/21563689?fsrc=scn/tw_ec/pick_your_pill_out_of_a_hat

Bad Pharma. By Ben Goldacre. Fourth Estate; 430 pages; £13.99. To be published in America in January by Faber and Faber; $28. Buy from Amazon.com,Amazon.co.uk

DOCTORS like to project an air of authority when making their clinical decisions. Patients like it too, for it is reassuring to think that one’s health is in the hands of an expert. It would be unsettling if, upon prescribing you a drug, your doctor admitted that the scientific research about what exactly the drug did, and how effective it was at doing it, was patchy and distorted, sometimes to the point where nobody has any real idea of what effects the drugs they are prescribing are likely to have on their patients.

But that is the reality described in “Bad Pharma”, Ben Goldacre’s new book. A British doctor and science writer, he made his name in 2008 with “Bad Science”, in which he filleted the credulous coverage given in the popular press to the claims of homeopaths, reiki therapists, Hopi ear-candlers and other purveyors of ceremonious placebos. Now he has taken aim at a much bigger and more important target: the $600-billion pharmaceutical industry that develops and produces the drugs prescribed by real doctors the world over.

The book is slightly technical, eminently readable, consistently shocking, occasionally hectoring and unapologetically polemical. “Medicine is broken,” it declares on its first page, and “the people you should have been able to trust to fix [its] problems have failed you.” Dr Goldacre describes the routine corruption of what is supposed to be an objective scientific process designed to assess whether new drugs work, whether they are better than drugs already on the market and whether their side effects are a price worth paying for any benefits they might convey. The result is that doctors, and the patients they treat, are hobbled by needless ignorance.

So, for instance, pharmaceutical companies bury clinical trials which show bad results for a drug and publish only those that show a benefit. The trials are often run on small numbers of unrepresentative patients, and the statistical analyses are massaged to give as rosy a picture as possible. Entire clinical trials are run not as trials at all, but as under-the-counter advertising campaigns designed to persuade doctors to prescribe a company’s drug.

The bad behaviour extends far beyond the industry itself. Drug regulators, who do get access to some of the hidden results, often guard them jealously, even from academic researchers, seeming to serve the interests of the firms whose products they are supposed to police. Medical journals frequently fail to perform basic checks on the papers they print, so all sorts of sharp practice goes uncorrected. Many published studies are not written by the academics whose names they bear, but by commercial ghostwriters paid by drug firms. Doctors are bombarded with advertising encouraging them to prescribe certain drugs.

The danger with a book like this is that it ends up lost in abstract discussion of difficult subjects. But Dr Goldacre illustrates his points with a plethora of real-world stories and examples. Some seem almost too breathtaking to be true—but every claim is referenced and backed up by links to research and primary documents. In scenes that could have come straight from a spy farce, the French journal Prescrire applied to Europe’s drug regulator for information on the diet drug rimonabant. The regulator sent back 68 pages in which virtually every sentence was blacked out.

And of course, the upshot of all this is anything but abstract: doctors are left ignorant about the drugs they are prescribing, and which will make their patients sick or get well, or even live or die. Statins, for instance, lower the risk of heart attacks, and are prescribed to millions of adults all over the world. But there are several different sorts of statin. Because there is little commercial advantage to be gained by comparing the efficacy of the different varieties, no studies have done so in a useful way.

Bereft of guidance, doctors must therefore prescribe specific statins on the basis of little more than hunches or personal prejudice. As Dr Goldacre points out, if one drug is even a shade more effective than its competitors, then thousands of people prescribed the inferior ones are dying needlessly every year for want of a bit of simple research. That is a scandal. Worse, the bias and distortions that brought it about are repeated across the entire medical industry. This is a book that deserves to be widely read, because anyone who does read it cannot help feeling both uncomfortable and angry.

12 Catastrophes the Next President Must Avoid @Medici_Manager

BY DAVID ROTHKOPF | NOVEMBER 5, 2012 http://www.foreignpolicy.com/articles/2012/11/05/12_catastrophes_the_next_president_must_avoid

The more I come to understand about political leadership, the more I realize that some of the greatest achievements of America’s best leaders didn’t make the headlines and seldom show up in history books.  They were the things those leaders did not do, the paths they did not take, the wars they did not fight, the disasters they avoided.

Recently, Evan Thomas reminded us of one of the best examples of such leadership in Ike’s Bluff, his excellent new biography of Dwight Eisenhower. Eisenhower, demeaned by John F. Kennedy as a dull paper-pusher of a president, masterfully resisted the pressure from within his own party to dangerously confront the Soviets.  He avoided a cataclysmic war by overseeing a process that allowed Washington leaders to come to understand that there was a better path by which we could contain the Soviets, through strength combined with forbearance, and allow the weakness of their system to undermine them over time.

Other presidents have similarly succeeded by avoidance. George H.W.  Bush, to cite another example, deserves great credit for ensuring that when the Soviet empire did fall, as Eisenhower had much earlier worked to make happen, the transitions in Eastern Europe were peaceful.  Where there could have been chaos Bush reached out to other world leaders and produced an orderly handover of power. He also waged a war against Iraq after its invasion of Kuwait in which he made the wise decision not to continue on to Baghdad, avoiding a messy conflagration like that which would later consume his son’s presidency.

Both Eisenhower and Bush paid a price for their successes. Eisenhower’s image was for decades shaped by the Kennedy caricature of him, and it is only now that he is rightfully gaining recognition as being among the best presidents of the last century.  Bush did not win a second term as president in part because his accomplishments were too subtle to resonate with the public during the 1992 campaign.

We get a distorted view of real leadership when we discount sometimes hard to see accomplishments that come from presidents with vision, restraint, and a knack for behind-the-scenes deftness. This struck me again last week when President Obama and New Jersey Gov. Chris Christie toured the devastation wrought by Hurricane Sandy. They were hailed as leaders for their very public reaction to a crisis when in fact, real leadership would have involved avoiding the crisis in the first place — or reducing its consequences, as we might have done had Obama, Christie, and other officials taken warnings about the consequences of climate change, severe weather, and deteriorating infrastructure more seriously.  Indeed, just exercising enough prudence to take the measures that many urban planners around the world already do in areas threatened by such severe storms (regardless of their views about why such storms are now occurring with greater regularity) would have made the consequences of Sandy less grievous.

With Sandy fresh in our minds and Americans headed to the polls, it is worth looking ahead to consider what other avoidable catastrophes might be better measures of the next administration than stories the evening news can more easily point a camera at each night. Here are a dozen:

1. War with Iran — and a Nuclear Arms Race in the Middle East

The easiest war to avoid may be the one everyone sees coming. But in the case of conflict with Iran, it will not be so simple. In the first instance, to stop Iranian weapons development will require a more credible threat of military action from powers capable of derailing the program than currently exists.  Next, while there are sensible arguments that suggest Iran’s acquisition of nuclear weapons is not only unavoidable but may not be disastrous given our deterrent capacity, the bigger risk is not from Iran but from a world in which Iran’s rivals across the Persian Gulf, such as Saudi Arabia, to others in the region and emerging powers elsewhere around the world enter a nuclear arms race. Such a race would both geometrically increase the likelihood such weapons might be used but it would also sap precious resources from struggling economies that would better spend them elsewhere. It will take toughness with Iran and a recommitment to a new, more effective global nonproliferation regime as a top priority to avoid all those traps.

2. Regional Conflagration in the Middle East

The Greater Middle East has not been more dangerous since the darkest days of the Cold War. Today instability from Tunisia to Pakistan means there’s a real possibility of crises spreading rapidly — and connecting up with each other. Syria, already now a proxy conflict between Iran on the one side and various Gulf states on the other, is one such example. But imagine the consequences of a collapsing regime in Jordan or, even more likely, of what the coming reckoning in a fractured Iraq will look like. The next U.S. administration will be tempted to lean back and indeed, must embrace solutions led by regional actors more than ever before. But as with Iran, it will take vastly more effective use of formal and informal global mechanisms to keep a lid on this region.

3. Escalating U.S. Involvement in an Unraveling Africa

Africa is the new Middle East. It is rich with resources, unstable, and targeted by insurgents, extremists, and major powers for both these reasons. Civil wars, corruption, historic instability, Islamic extremists, humanitarian crises, more active U.S. and European military presences, and rising stakes for China and other emerging powers have created a volatile situation that could gradually escalate into the world’s newest quagmire.  Will the next U.S. president be sucked into the trap of incremental escalation like the that led to the Vietnam War?

4. The Next 9/11

Among those who have done the most with the least credit are those up and down the U.S. chain of command who have forestalled terror attacks. Since 9/11, the record of protecting the homeland and Americans around the world has been admirable. But the next president will have to do that, and then some: by avoiding another 9/11, I mean something more than confounding the plots of terrorists. I mean avoiding events that suck America into the orgy of political hysteria, government spending, and violating our own most cherished principles that marked our “war on terror.” It is not enough simply to neutralize terrorists. We need to ensure that we regain the perspective that allows us to respond to threats proportionally and in ways that do not damage our standing in the world or ability to lead.  (Note: Waves of drone attacks, cyber incursions, and special ops only meet the first half of this guideline.)

5. A Trade War with China

With sluggish economies in the United States and China and both countries engaging in artificial devaluation of their currencies, it’s easy to imagine scenarios that lead to conflict as blame-shifting escalates and populist impulses rule. That’s especially the case given that China through subsidies and other unfair practices has yet to start playing by the international trade rules it accepted over a decade ago. But confrontation could easily get out of hand, threaten China’s new leadership, and deteriorate into a real trade war.  Not only is this economically unhealthy for the world’s two largest (and very interdependent) economies but it would be diplomatically devastating since many of the biggest problems require a kind of cooperation between the two sides we have seldom seen before.

6. A U.S. Fiscal Catastrophe

The “fiscal cliff” is only the first among many huge challenges associated with getting America’s financial house in order. Failing to address these could further undercut America’s credit rating, our ability to invest in our future or protect ourselves, and even lead to default. Neither the world economy nor our own can withstand more of the kind of brinksmanship and denial practiced by Washington in the past decade. Tax increases and spending cuts in programs beloved by both political parties in America are absolutely essential to beginning a trajectory of improvement in this critical area.

7. A Japan-Style American Stagnation

Austerity alone will not, however, do the trick. America is at a moment of huge opportunity. Of the world’s developed economies, we are the one showing the most resilience.  We are home to a potential bonanza associated with new energy resources and we can borrow to invest in much needed infrastructure upgrades at very low cost (provided we do so wisely). We can make our educational system more effective at training the workers of tomorrow.  But this requires more than just speeches and modest gestures.  We must make growth a priority and yet do so in ways-such as removing regulatory obstacles, shifting from defense spending to investment spending at home, embracing foreign investment-that avoids the kind of multi-decade downturn that has straightjacketed Japan since the 1990s.

8. Economic Shocks from the Eurozone

While Europe made some progress in recent months toward calming market unease, austerity measures are likely to produce political pushback of a potentially extreme nature in the next couple of years. What’s more, global shocks from other international crises, whether a war in Iran or an escalating Middle East conflict, could make the bad situation in Europe worse and compound any geopolitical misfortune with nasty economic consequences.  Such political reversals could also renew discussion of breaking up the European Union (which may or may not be a bad thing) and make markets very skittish again (which would be).  The United States will have to find a way to remain actively engaged but this may become even more challenging as some of the promising “fixes” of 2012 turn into the setbacks of 2013 and beyond.

9.  Shocks From a Warming Climate

It may be too late. We may not be able to reverse the changes to our environment that are making severe storms more common, melting our ice caps, and producing record high temperatures. If that’s true, then we face a choice: reactive or proactive adaptation. Right now, we merely react, responding to disasters. But we could strengthen our sea walls, improve our electricity grids, rebuild ports and bridges and roadways. Of course, this should not supplant efforts to rein in carbon emissions-and we should embrace the fact that shifting from coal to gas power will help spur the American domestic energy revolution and create jobs and growth at home.  But the bigger point is that great leaders will be measured by how few tragic photo ops their successors feel obligated to stage in the wake of crises.

10. The Next Financial Market Crisis

Here’s the bad news: Global markets are rife with more risks today than they were in 2008. There are more too-big-to-fail banks. There are larger and more complex and opaque oceans of derivatives churning. There is still no global regulation. There are still major markets containing big bubbles from Chinese real estate to the price of gold worldwide. In short, there is still the potential for such a massive meltdown that it could make the crisis that ushered in the Obama era look like mere prelude. It is time to get much more serious about U.S. and international oversight and enforcement, investing in the tools and people needed to identify and avoid future upsets.

11. 1960s-Style Social Unrest

It seems a long shot. And indeed, social crisis from the Middle East to China to an increasingly nationalistic and xenophobic Europe is more likely. But American leaders must focus on what they can control. And if inequality continues to grow in the United States; if our underclass, with its skyrocketing high school dropout rates, continues to fall faster and faster behind; if fiscal austerity forces us to shrink social programs and shrinking tax bases crush the ability of cities to tackle their problems (or pay their pensions), America may see unrest evoking that of the 1960s…or worse. We run a great risk if we view what is happening in this country merely as a cyclical slowdown. Any society that pushes the rich and poor farther and farther apart is broken. And we need to address the problem just as we did the racial divides that haunted us in the ‘60s-as a matter of grave national urgency.

12. An Era of Permanent War

Cyberwar is often called “white collar conflict.” This is both a blessing and a curse. It is stealthy and may cause less loss of life than traditional armed conflicts. But this makes it more tempting to engage in. And a world in which nations constantly probe and injure one another from afar could turn out to be vastly more dangerous in the long run. Cyberattacks will produce damage that demands retribution. Trust and stability will be undermined. And societies will reel not just from attacks that target infrastructure or markets but also from the civil liberties likely to be constrained in an effort to reduce the likelihood of future intrusions. The next American administration needs to be careful that it does not see such attacks-or the other “limited footprint” tools of war, from drones to special operations-as so “low risk” that it over-utilizes them. Otherwise, we’ll be creating more risks than we alleviate.

Associazioni di pazienti: una questione di trasparenza @Medici_Manager @SIHTA_Italia

Nel 2007 una prestigiosa rivista medica come il British medical journal lanciava l’indagine Le associazioni di pazienti devono ricevere soldi dall’industria farmaceutica?. A distanza di anni il tema è ancora dibattuto, ma troppe associazioni di pazienti non sono ancora consapevoli di quanto e come il conflitto di interessi le tocchi direttamente, quali rischi comporta, come si possono affrontare. E soprattutto sono ancora poche le associazioni che lo dichiarano, in particolare in Italia.

Su 157 siti di associazioni di pazienti e cittadini italiane, poco meno del 30% dichiara di ricevere soldi dall’industria farmaceutica. Tutte però ricevono finanziamenti, come risulta dai siti delle industrie farmaceutiche finanziatrici. E’ il risultato di un’indagine condotta dall’Istituto Mario Negri e pubblicata di recente sulla rivista ad accesso libero PLoS ONE. L’ammontare dei finanziamenti viene riportato solo da tre associazioni, pari al 6% delle associazioni dichiaranti, le attività finanziate dalla metà.

Una situazione analoga accade in altri Paesi, con qualche differenza: su 69 siti di associazioni di pazienti e cittadini con sede negli Stati Uniti, Regno Unito, Australia, Sud Africa e alcune associazioni internazionali, di cui nessuna italiana, il 45% dichiara di ricevere finanziamenti dall’industria farmaceutica, nessuno dichiara l’entità dei finanziamenti.

Il punto critico della trasparenza non riguarda solo le associazioni di pazienti: dall’indagine dell’Istituto Mario Negri risulta che anche le industrie farmaceutiche, in particolare quelle con sede in Italia, lasciano a desiderare riguardo alla completezza delle informazioni sulle sponsorizzazioni riportate sui propri siti. Tra le 17 industrie farmaceutiche considerate, 13 (76%) dichiarano almeno un’associazione finanziata, di queste solo il 15% dichiara l’ammontare dei finanziamenti, il 30% le attività finanziate. Tutte hanno dato soldi ad almeno un’associazione di pazienti o cittadini considerata nell’indagine, come risulta dai siti delle associazioni.

Come per i finanziamenti ai medici, anche per i rapporti con le associazioni di pazienti le industrie farmaceutiche dovrebbero dichiarare le associazioni che finanziano, quanti soldi danno, per quali attività e progetti, pubblicando informazioni complete, aggiornate e accessibili sui propri siti internet. Allo stesso modo dovrebbero essere dichiarate le forme di sostegno indiretto, molto frequenti, come per esempio pagare spese o iscrizioni per partecipare a corsi o convegni, o fornire strutture e servizi.

Anche le associazioni di pazienti e cittadini che ricevono soldi dall’industria devono andare in questa direzione, e dichiarare in modo accessibile e completo i finanziamenti ricevuti.

Per alcune associazioni questo in parte già succede, e il dibattito interno su questi temi è avviato da tempo, molte altre sono ancora agli inizi: avviare un confronto tra associazioni di volontariato su questi temi può aumentare la consapevolezza critica e favorire uno scambio sulle pratiche di gestione dei rapporti con gli sponsor.

Questo testo è stato pubblicato su Partecipasalute

Per saperne di più

Kent A. Should patient groups accept money from drug companies? Yes. BMJ 2007; 334: 934-935.
Mintzes B. Should patient groups accept money from drug companies? No. BMJ 2007; 334: 334:935
Colombo C, Mosconi P, Villani W, Garattini S. Patient organizations’ funding from pharmaceutical companies: is disclosure clear, complete and accessible to the public? An italian survey. PLoS One. 2012;7(5):e34974. Epub 2012 May 9.
Ball DE, Tisocki K, Herxheimer A. “Advertising and disclosure of funding on patient organisation websites: a cross-sectional survey” BMC Public Health (2006) 6:201.http://www.biomedcentral.com/1471-2458/6/201
Godlee F. A sunshine act for Europe. BMJ 2011;343:d6593

Love or nothing: The real Greek parallel with Weimar @Medici_Manager @martinmckee

Athenians sitting in front of anti-government graffiti

Of all the operas written during Germany’s Weimar Republic (1919-33), probably the most haunting is the last.

Kurt Weill’s The Silver Lake, written with playwright Georg Kaiser, tells the story of two losers – a good-hearted provincial cop and the thief he has shot and wounded – as they make their way through a society ruined by unemployment, corruption and vice.

After spending a week again in Greece – amid riots, hunger and far right violence – I finally understood it.

The opera was meant to be Weill’s path back into the mainstream. It was his first break from collaborating with Bertolt Brecht, and was scheduled to open simultaneously in three German cities on 18 February 1933.

But on 30 January Adolf Hitler was appointed Germany’s chancellor.

The first performances of The Silver Lake were disrupted by Nazi activists in the audience and on 4 March 1933 it was banned. The score was torched, together with its set designs, in the infamous book-burning ceremony outside the opera house in Berlin.

It is easy to see why the Nazis didn’t like The Silver Lake. Weill was Jewish; the Nazi theatre critics found the music “ugly and sick”. Moreover the plot contains an allegory of the political situation on the eve of the Nazis’ rise to power.

But there has always been something else about The Silver Lake that goes beyond politics. Something hard to fathom.

Spending time in Greece, as the far right Golden Dawn party breaks up theatre performances with impunity, and street violence is common, I finally know what that something is.

The Silver Lake is ultimately about how people feel when they switch from resistance to hopelessness. And about how strangely liberating hopelessness can be.

Greece right now is a place with a lot of hopelessness. Its own prime minister, Antonis Samaras, has compared its atmosphere to that of the Weimar Republic.

“Greek democracy stands before what is perhaps its greatest challenge,” Mr Samaras told the German newspaper Handelsblatt. He said social cohesion is “endangered by rising unemployment, just as it was toward the end of the Weimar Republic in Germany”.

The comparison seems plausible: there are far right gangs meting out violence on the streets – a report last week identified more than half of all officially recorded racial attacks as perpetrated by people in paramilitary uniforms. Every demonstration ends with tear gas and baton charges.

There is mass unemployment. There is the collapse of mainstream parties. The press and broadcast media are struggling to remain independent, indeed solvent.

Yet the comparison with the “end of Weimar” only holds if you know nothing about the Weimar Republic itself.

Sadly this condition is common. School students are rightly taught lots about Nazi Germany – but not very much about the detail of how it came into being.

Here’s a short summary. In the elections of 1928 the Nazis, who had – like Golden Dawn in Greece – been reduced to a splinter group in the years of economic recovery, got just 2.7%.

But in March 1930, as the Wall Street Crash cratered the German economy, a cross-party coalition government of the centre left and right collapsed. It was replaced by the first of three “appointed” governments – designed to avoid either the communists or the now-growing Nazis gaining power.

It was led by Heinrich Bruning. Faced with a recession, Bruning followed a policy of austerity, while keeping Germany’s currency pegged to the Gold Standard (much as Greece as follows a policy of austerity dictated by euro membership). This made the recession worse.

As unemployment rocketed, so did the Nazi vote: in a shock breakthrough they came second in the elections of September 1930, with 18%. But Bruning was determined to crack down on both the right and left: he banned the Nazi paramilitary organisation, the sturmabteilung, along with the rival communist uniformed militia.

As recession worsened, the Nazis grew massively: they won the election in 1932, gaining 14 million votes (37%). The socialists and communists combined polled higher. And the parties of the centre collapsed. Yet the presidential system of appointing governments now allowed these very centrist parties to go on ruling Germany – now under a new Chancellor, the aristocrat Franz Von Papen.

Von Papen unbanned the Nazi stormtroopers in June 1932 and, as historian Ian Kershaw puts it in his definitive biography of Hitler: “The latent civil war… was threatening to become an actual civil war.”

By the end of 1932, with the communists now also growing rapidly, the political establishment made one last final attempt to keep Hitler out of power. Right wing general Kurt Von Schleicher was appointed chancellor, and tried to form a government with everybody from the left wing of the Nazis to the socialist trade unions. But this too fell, opening the door to Hitler.

Kershaw wrote: “Only crass errors by the country’s rulers could open up a path [for Hitler]. And only a blatant disregard by Germany’s power elites for safeguarding democracy – in fact, the hope that economic crisis could be used as a vehicle to bring about democracy’s demise and replace it by a form of authoritarianism – could induce such errors. Precisely this is what happened.” (Hitler: Hubris)

These names – Bruning, von Papen, Schleicher – troublesome though they are to remember, should be as famous as the words Stalingrad, Arnhem and Dunkirk.

These were the men who tried and failed to use a mixture of austerity, tough policing and what we might now call “technocratic” rule to save German democracy. They failed.

And herein lies the parallel with Greece: a country committed to austerity, whose centrist parties are clustered into a coalition which represents the forces of conservatism and social democracy. The coalition sees itself as the last bulwark against a government of the far left and is trying to crack down on extremism using a police force which has itself been criticised for extremist leanings.

But despite these parallels, Greece is not on the brink of a Weimar-style collapse.

Nor is it “in civil war” as claimed by a leader of the far right Golden Dawn movement on Newsnight last week. If anything, Greece has levels of instability and political radicalisation close to the levels seen in Germany in early 1930, not late 1933.

The problem is: Greece is approaching 1933 levels of economic collapse.

Unemployment was 30% in Germany when Hitler took power; it is 25.1% and rising in Greece. GDP collapsed by about 7% in both 1931 and 1932 in Germany. Its current rate of collapse in Greece is roughly the same: 7% per year. Germany’s banks had gone bust in 1931. Greek banks are effectively part nationalised already.

You can see the physical impact of this on Stadiou Street in Athens. I have reported from there numerous times in the past two and a half years, but this last time it looked desolate.

There was an arcade where, just over a year ago, I remember blogging about how small specialist businesses in Greece were doomed: the pen shop, the stamp collecting shop, the stationary store. They’re all gone now.

So is much of the street itself. The Art Nouveau cinema burned out last year; the Marfin Bank, next door, torched with the deaths of three workers during a riot in 2010.

On the walls somebody has spray-canned “Love or Nothing”. Right now there is a heck of a lot of nothing: shops closed, stripped, barred, graffitied, the fascias chipped off as ammunition in riots, burned out, gone.

And nowhere is the human impact of this weird situation, clearer than when you talk to young people.

I met Yiannis and Maria in a bare flat in Exarchia, the bohemian district of Athens. Despite their bruises and bandages they took some persuading to go on camera – anonymously and in their hoodies – to put on record their allegations of brutality in police custody.

What struck me, beyond their allegations (which are denied by the police,but partially corroborated by a coroner’s report), was their detachment from regular life.

They expected the police to be brutal, and to be fascists. They were outraged that they’d had to listen (they allege) to Golden Dawn propaganda in the police cells. But they were reluctant to bring a complaint within the system.

For tens of thousands of young people life is already lived in a semi-underground way: squatting instead of renting; cadging food and roll-ups from their friends. Drifting back to their grandparents villages, sofa surfing. Yiannis is a sporadically employed technician in a cultural industry; Maria a highly qualified professional who waits table.

The British author Laurie Penny has captured the situation in a recent memoir of a trip to Athens: “We came here expecting riots. Instead we found ourselves looking at what happens when riots die away and horrified inertia sets in.” (Penny L and Crabapple M, Discordia, Random House 2012)

Horrified inertia is now seeping from the world of the semi-outlawed young activists into the lives of ordinary people.

What people do – whether it is the black-hoodied anarchists in Athens or the young farmers in Thessaly on their third of fourth bottle of beer by lunchtime – is retreat into the personal.

It’s no longer “the personal is political” – but the personal instead of the political. True, demonstrators still turn out in large numbers, as in last week’s General Strike. But they go through the motions – of demonstrating, of rioting even.

“It’s just for show on both sides, the cops and the anarchists,” I was told by my Greek fixer as we legged it through stampeding people and tear gas.

A year ago the buzzword was “anomie” – the fear of anomic breakdown, in which small groups and communities just give up on law and order and make their own. I reported on it then:

Watch Paul’s report on anomic breakdown from September 2011

There is not even much anomic activism anymore; the movement that defied road tolls and disrupted the sale of repossessed homes – which was large in the Spring – is tiny now.

If anything captures the buzzword of late 2012 in Greece it is the person who sprayed the slogan “Love or Nothing”. It’s less about anomie, more about depression.

What has depressed much of Greek society – from the liberal centre right to the liberal left – is the rapid rise of Golden Dawn.

In the two elections of May/June 2012 it scored between 6-7%. Nothing like a 1930-style breakthrough.

But it has begun to do DIY law enforcement against migrants with no intervention from the police. At street markets in Messolonghi and Rafina its uniformed activists checked the permits of migrant stallholders, demonstratively destroying those who did not have permits.

With electoral data showing – on one count – 45% police personnel voting for Golden Dawn, there is rising concern that support for the far right is beginning to skew the operational priorities of the police at local level.

When I challenged Golden Dawn’s second in command, Ilias Panagiotaros, he claimed support within the police at “60% or more”. And he gave a chilling explanation of how Golden Dawn’s extra-judicial actions were affecting the rule of law. Referring to the market stall attacks he said:

“With one incident, which was on camera, the problem was solved – in every open market all over Greece illegal immigrants disappeared. There was some pushing and some fighting – nothing extraordinary, nothing special – only with one phone call saying Golden Dawn is going to pass by the police is going there meaning the brand name [of Golden Dawn] is very effective…”

Greece, in truth, has a massive and apparent problem with illegal migration. The centres of many cities are – or were until this summer – full of young, male migrants from Afghanistan, Somalia, Sudan and increasingly Syria.

Many Greeks do fear them, and they perceive them as a threat to social order and a traditional lifestyle – in a country that never had any colonies and therefore did not experience high ethnic diversity until recently.

The new policy – known as “Hospitable Zeus” is to round migrants up and put them in camps: police in plain clothes or uniforms visibly stopping every person of colour on the street, checking their papers, and if the papers are not in order processing them ultimately to a migrant detention camp.

Even as human rights groups protest this, and demand access to the camps, Golden Dawn has protested outside them on the grounds that conditions are too good there, and that deportations are not fast enough (about six thousand have been detained, with maybe three thousand deported). And even as the police round up the migrants, Golden Dawn’s policy is to terrorise them off the streets, and mount a legal campaign against companies who employ them.

The Greek media, meanwhile, has taken its cue to reinforce the association of migrants with crime. For those seeking an alternative view there are only the newspapers of the far left: the main liberal newspaper – Eleftheropia, an equivalent to the Guardian – went bust and has closed.

Economically, the Greek coalition is getting ready to impose the latest and last round of austerity: 13.5bn euro a year cuts and tax rises, in order to release 31bn euro worth of bailout money.

The moment it puts this to parliament we can expect a big and unruly protest. After that the Coalition just has to hold on and hope that its own electoral support does not go the way the German centrist parties went after 1932.

Unfortunately for them, however, electoral support is slipping. While New Democracy has maintained its poll rating at 27% (compared to 29% in the election), Pasok – the former governing socialist party – is down to 5.5%, neck and neck with coalition partner Democratic Left. The combined poll rating of the pro-austerity parties is now 38%.

Golden Dawn polled 14% last week, while the left wing Syriza party is leading the polls at 30% (taking many votes from the Communists, who are now down to 5%).

However, these poll ratings are unlikely to be tested in an election anytime soon. The EU is working overtime to keep the current coalition together, and as Pasok’s support dwindles to rock bottom, it has no incentive to risk an election now.

So for the majority of people who want the austerity to stop, and who do not want to be gassed, truncheoned, menaced or even to go on strike, there is only the “love or nothing” strategy.

Anecdotally the use of anti-depressants is rising. Penny’s book tells numerous tales of former political activists simply stunned by drink and drugs.

Which brings us back to The Silver Lake.

The “love interest” in Kurt Weill’s opera doesn’t start until the second half, with the arrival of Fennimore, a young woman trapped in a castle with the two losers and a scheming, reactionary aristocrat who has duped them out of their money.

Once Fennimore appears, the music becomes mesmerised and lyrical; it focuses on the combined hopelessness of the two men and the girl.

And in the final sequence – a dream-like 15 minutes during which the men set out to cross the castle’s lake, certain they will drown – there is a mixture of ecstasy and despair.

“You escape from the horror,” Fennimore sings; “that may destroy all we know. Yet the germ of creation will struggle to grow.”

“All this can be a beginning

“And though time turns our day back to night

“Yet the hours of dark will lead onwards

To the dawning of glorious light.”

I have always struggled to understand this ending: why, in the last days of Weimar, did Kurt Weill not pen some anthem of defiance against Nazism rather than a work which, ultimately, expresses resignation?

On the streets of Athens there is already the answer. You can feel what it is like when the political system – and even the rule of law – becomes paralysed and atrophies.

The “hopeless inertia” begins to grip even the middle classes, as the evidence of organised racist violence encroaches into their lives.

Faced with an economic situation dictated by the European Central Bank and the International Monetary Fund, and a street atmosphere resembling Isherwood’s Berlin, the natural human urge is not fight but flight.

Flight away from danger – flight into the cocoon of drugs, relationships, alternative lifestyles, one’s iPod.

After the first-night disruption of The Silver Lake in Leipzig this is how its director, Douglas Sirk, described the scene at the theatre:

“The sturmabteilung filled a fairly large part of the theatre and there was a vast crowd of Nazi Party people outside with banners and god knows what, yelling and all the rest of it. But the majority of the public loved the play… And so I thought at first, well, things are going to be tough but perhaps it isn’t impossible to overcome…[But] no play, no song, could stop this gruesome trend towards inhumanity.” (quoted in Kurt Weill On Stage, by Foster Hirsch)

And this is how the director of Corpus Christi, Laertis Vasiliou, whose play was once again disrupted by far right demonstrators in Athens on Thursday night, described it in a message to me just now:

“We went ahead with the performance, which started with two hours of delay because of the fight outside the theatre between the police against the Christian fundamentalists and the Nazis. It was like hell. The noise from outside was clear inside the theatre during the performance. People were beaten up by Nazis and Christian fanatics.”

The differences with the final days Weimar, then, are clear. Under international pressure, the Greek state is still capable of upholding the rule of law; centrist parties, though atrophied, still hold the allegiance of more than one third of voters; there has been no decisive electoral breakthrough by the far right.

Crucially, no major business or media groups, and no significant portion of the elite, have swung behind the far right as happened in Germany.

But this flight to inertia, depression, to personal life may also be more pronounced than in Weimar. Weimar Germany was after all a society of intense political engagement; of hierarchical politics, lifelong commitment to social movements, trade unions, military veterans’ groups.

So while the crisis may be on a scale weaker than the one that collapsed democracy in Greece, the forces holding democracy together may also be weaker.

When I interviewed Golden Dawn MP, Ilias Panagiotaros, two weeks ago, he was clear as to the party’s project: if Syriza wins the election, “we will win the one after that”.

“Revolution will take place after two elections by giving first place to Golden Dawn; now we are third, and maybe we will get second place – so it’s not a dream that in one, two or three years we will be the first political party.”

The leaders of the international community, busy negotiating the last-ditch austerity package that is supposed to precede a strategic rescue of the country know what the stakes are.

If they fail, a whole generation of Greek young people will be left, like Weill’s protagonists in The Silver Lake, with a choice between love or nothing.

Where the Candidates Stand on Medicare and Medicaid @ProPublica @Medici_Manager

Ecco come funziona l’informazione e la discussione su grandi temi politici nei paesi civili!

Possiamo chiedere ai nostri candidati alle prossime elezioni politiche, e ai giornalisti che li intervistano,  di farci sapere che cosa si impegnano a fare per il nostro Servizio Sanitario Nazionale?

by Suevon Lee ProPublica, Sept. 14, 2012 http://www.propublica.org/article/where-the-candidates-stand-on-medicare-and-medicaid

Medicare and Medicaid, which provide medical coverage for seniors, the poor and the disabled, together make up nearly a quarter of all federal spending. With total Medicare spending projected to cost $7.7 trillion over the next 10 years, there is consensus that changes are in order. But what those changes should entail has, of course, been one of the hot-button issues of the campaign.

With the candidates slinging charges, we thought we’d lay out the facts. Here’s a rundown of where the two candidates stand on Medicare and Medicaid:

THE CANDIDATES ON MEDICARE

Big Picture

Earlier this year, the Medicare Board of Trustees estimated that the Medicare hospital trust fund would remain fully funded only until 2024. Medicare would not go bankrupt or disappear, but it wouldn’t have enough money to cover all hospital costs.

Under traditional government-run Medicare, seniors 65 and over and people with disabilities are given health insurance for a fixed set of benefits, in what’s known as fee-for-service coverage. Medicare also offers a subset of private health plans known as Medicare Advantage, in which roughly one-quarter of Medicare beneficiaries are currently enrolled. Obama retains this structure.

The Obama administration has also made moves that it says would keep Medicare afloat. It says the Affordable Care Act would extend solvency by eight years, mainly by imposing tighter spending controls on Medicare payments to private insurers and hospitals.

In contrast, Rep. Paul Ryan, Mitt Romney’s running mate, has proposed a more fundamental overhaul of Medicare, which he says is on an “unsustainable path.” On hiscampaign website, Romney says that Ryan’s proposals “almost precisely mirrors” his ideas on Medicare. But he’s been fuzzy on other aspects of the plan.

A Romney-Ryan administration would replace a defined benefits system with a defined contribution system in which seniors are given federal vouchers to purchase health insurance in a newly created private marketplace known as Medicare Exchange. In this marketplace, private health plans, along with traditional Medicare, would compete for enrollees’ business. These changes wouldn’t start until 2023, meaning current beneficiaries aren’t affected – just those under 55.

Under the Romney-Ryan, the vouchers would be valued at the second-cheapest private plan or traditional Medicare, whichever costs less. Seniors who opt for a more expensive plan would pay the difference. If they choose a cheaper plan, they keep the savings.

Who’s covered

In the current system, people 65 and over are eligible for Medicare, which Obama has said he would keep for now.

Romney has proposed raising the eligibility age for Medicare beneficiaries from 65 to 67 in 2022, then increasing it by a month each year after that. In the long run, he wouldindex eligibility levels to “longevity.” Ryan’s budget plan proposesraising Medicare eligibility age by two months a year starting in 2023, until it reaches 67 by 2034.

Many others looking to keep Medicare solvent have also proposedraising the age of eligibility.

The Congressional Budget Office estimates that raising the minimum age from 65 to 67 would reduce annual federal spending by 5 percentBut it would also result in higher premiums and out-of-pocket costs for seniors who would lose access to Medicare.

Obama’s health care law also adds some benefits for seniors, such as annual wellness visits without co-pays, preventive services like free cancer screenings and prescription drug savings.

Proposed Savings

The Affordable Care Act is projected to reduce Medicare spending by $716 billion over the next 10 years. These reductions, as detailed by Washington Post’s Wonkblog, will come mostly from reducing payments to hospitals, nursing homes and private health care providers.

While Ryan criticized such spending cuts in his speech at the Republican National Convention, his own budget proposed keeping these reductions.

“The ACA grows the trust fund by giving more general revenue to the Treasury, which then gives the trust fund bonds. But it then uses the money from those bonds to expand coverage for low- and middle-income people,” explains Dylan Matthews on Washington Post’s Wonkblog.

Romney hasn’t really come up with a solid answer: he previously said he would restorethe $716 billion savings that the health care law imposes. Per this New York Timesstory, the American Institutes for Research calculates this would increase premiums and co-payments for Medicare beneficiaries by $342 a year on average over the next 10 years.

For more on where the candidates stand on the $716 billion, the private health policy Commonwealth Fund offers this helpful explanation.

Caps on Spending

Both Obama and Ryan have set an identical target rate that would cap Medicare spending at one-half a percentage point above the nation’s gross domestic product.

But they have different ideas on mechanisms to achieve it.

The Affordable Care Act establishes a 15-member Independent Payment Advisory Boardthat, starting in 2015, would make binding recommendations to reduce spending rates. As Jonathan Cohn points out in the New Republic, the commission is prohibited from making any changes that would affect beneficiaries.

Ryan has proposed hard caps on spending and derided this panel of appointed members as “unelected, unaccountable bureaucrats.” When laying out his plan in a 2011 memo, Ryan wrote that to control spending, “Congress would be required to intervene and could implement policies that change provider reimbursements, program overhead, and means-tested premiums.”

Romney hasn’t stated clear proposals for imposing a cap on spending.

THE CANDIDATES ON MEDICAID

Big Picture

Though, it’s far less discussed on the campaign trail, Medicaid actually covers more people than Medicare. The joint federal-state insurance program for the poor, the disabled, and elderly individuals in long-term nursing home care currently covers about 60 million Americans.  The Affordable Care Act has expanded Medicaid coverage further. Beginning 2014, Medicaid will include people under 65 with income below 133 percent of the federal poverty level (roughly $15,000 for an individual, $30,000 for a family of four). This was estimated to cover an additional 17 million Americans as eligible beneficiaries.

In June, however, the U.S. Supreme Court ruled that states could opt out of the Medicaid expansion. A ProPublica analysis estimated that the 26 states that challenged the health care law, and thus may possibly opt out, would account for up to 8.5 million of those new beneficiaries.

Romney and Ryan would overhaul this current system by turning Medicaid into a system of block grants: the federal government would issue lump sum payments to the states, who would determine eligibility criteria and benefits for enrollees. These grants would begin in 2013.

Effects on spending

The Congressional Budget Office estimates that Medicaid expansion under the new health care law would cost an additional $642 billion over the next 10 years.

Under the Ryan plan, federal Medicaid grants would be adjusted only for inflation, but not health care costs, which grow at a much higher rate. The CBO estimates Ryan’s plan would save the federal government $800 billion over the next 10 years. Another study conducted by Bloomberg News shows that the block-grants could decrease Medicaid funding by as much as $1.26 trillion over the next nine years.

Actual Impact                                                                                                     

The New York Times points out that more than half of Medicaid spending goes toward the elderly and disabled. An Urban Institute analysis estimates the Ryan plan would result in 14 million to 27 million fewer people receiving Medicaid coverage by 2021.

Though rarely mentioned by any of the candidates, Medicaid costs are soaring to cover the elderly who require long-term nursing care. As the Times’ details how, states saddled by high Medicaid costs have begun turning to private managed care plans to blunt the cost.