How we fix the NIH

 I was on the beach in Florida with a business school prof friend of mine a couple of weeks ago and he blew my mind.  I like big ideas about how to change things for the better.

He’s always up to something interesting.  When I asked him, “what are you working on?”  he surprised me.  “Fixing the NIH grant system,” he told me.  What!?!  He gets paid as a consultant to jump in to an area he may not be familiar with, do some research, and then be the answer man.  Someone from the NIH was in a executive managment course he teaches and described the grant “problem.”  I love this guy because he approaches complex problems like such a boy scout, with an earnest optimism that any situation can be improved. Whether it be how to get our 6th grade basketball team to play better offense, or how to fix the national debt, he’ll say, “here’s what you do..” and roll out a Four Point Plan.  It’s funny…at the same time, I can’t help but play the devil’s advocate and bring up all the complexities and possible roadblocks.  But this is an important topic, so let me step out of the way and tell you what he said …

His primary recommendation was to crowd-source solutions to revamping grant review.  This is his entry for what he proposes to be an open competition for proposals on how to fix the grant review process.  His basic idea is simple, but would be revolutionary.  He proposes that projects should be categorized and evaluated in four separate research categories, based on how the work relates to existing paradigms, and that NIH funds should be evenly split amongst these bins.  This concept of research diversification is taken from the business world, and it’s designed to speed progress and limit risk by spreading support for knowledge generation across classes of research. A key element of this plan is that competition for funds be within these groups so we fund the best of each type. Based on research he did with NIH scientists, the categories he proposes, are:

1.  Pre-hypothesis or exploratory studies.  These are experiments and projects that may not claim to have a paradigm or hypothesis but are designed to gather new information.  

2.  Replication studies.  We had a discussion about this one because I don’t think anyone in science really sets out to do work replicating the work of someone else.  My friend told me that respondents to his questionnaires told him otherwise.  In any event, in a way, this is the most intriguing category to me because it addresses the crisis of reproducibility in science while at the same time giving validity to scientists who are technically adept and hard working but who may not want to compete in other areas.  no one I know in science would admit that that We had a discussion about this

3. Paradigm extending studies. This is where most NIH-funded work currently fits.  Many bemoan this “safe” way of funding research, and one great strength of this system is to limit the amount of resources that go into “incremental” work.

4. Research that may develop a new paradigm.  This is the type of work that gets the most press and that everyone vocally supports.  Fresh thinking, new ideas, etc.  It’s an intriguing and common-sense ideal to compartmentalize this type of work, to recognise that paradigm breaking is high risk and that not all resources should be put in this basket.

Image

A final important point of this scheme is that if it is adopted across institutes (?!) it would facilitate consolidation of bureaucracy.  By imposing a constant framework like this one, it would allow cross-institute comparisons.  And lastly, he proposes to grade the success of grantees with a new objective measure of knowledge generation.  The belief being that papers and patents are not a sufficient index of how well the money was spent.  How should we measure how much useful knowledge is generated by a grant?  That’s the big question, and he says let’s open that up to crowd-sourcing.

What do I think?   I have mixed feelings about shaking up the grant system just at the point when I think I’ve learned the game.  But, it’s clear grantsmanship is a game, and that we owe it to eveyone involved to make it more transparently about funding the best research.  The more I thought about this system, the more I can see its benefits.  The primary road blocks I see to implementing this system are lack of political will, and getting study sections organized to deal with this restructuring.  Study section culture is rigid and I’m not sure whether study sections would subclassify the grants they get or whether new study sections would be needed.  I’m really curious about what my colleagues think of this scheme.

 

Is science a polytheistic religion?

“The experimental method is concerned only with the search for objective truths, not with any search for subjective truths…An anticipative idea or an hypothesis is, then, the necessary starting point for all experimental reasoning.  Without it, we could not make any investigation at all nor learn anything; we could only pile up sterile observation.”

    –Claude Bernard, An Introduction to the Study of Experimental Medicine

Image

Claude Bernard: “Oui, I’m dead…but do I look naive to you?”

The other day, I told Dr. Isis I wanted to do a PubStyleScience on epistemology, and she said, “I don’t get it… what’s so hilarious about that?” Or words to that effect. Imagine my shock and surprise!  A bunch of scientists, sitting around, drinking and arguing about the meaning of everything?  It’s the *perfect* topic for PSS!!  So, let me explain my interest in the topic…

I like to share science and the culture of science with anyone who’s interested, especially to show a relaxed side of science to younger people who may be put off by narrow-minded cultural attitudes. PubStyleScience is a science culture experiment along these lines.  Let’s open the doors and windows of the scientific enterprise!  I see many sci’s on Twitter motivated to expose and correct sexism and racism in the scientific enterprise, to promote fairness and transparency.  We can agree that there is some bullshit cultural baggage with science community, but I’m more interested in the subtle baggage that keeps us from doing the best science.  I am often surprised at how scientists embrace groupthink.  In the abstract, the NIH (for one) declares a love for radical departures and fresh interdisciplinary ideas.  And yet, as a scientists love to run in a herd, and in evaluating others, demand conformity.  Professional science should be open to a diversity of participants.  This is a moral principle, and a conviction that the progress of science will benefit from the participation of a wider range of voices.

So what I’m interested in is the *positive* side of scientific cultural evolution.  My tweeps rail against what they don’t like about the old culture…but what are we *for?*  For most of the scientists I interact with, we can easily agree on the extreme ends of “unacceptable,” e.g.sexim and racism.  But there are softer cultural values that are not clear-cut, but messy.  How should we define the differences between “good culture” and bad?  An example of the changing mores of science is the idea of “Kerning,” a word which was coined several years ago after an earnest but tone-deaf opinion piece by cancer biologist Scott Kern.  

In it, Kern lamented the erosion of a lab culture that valued working through the weekends.  His “where’s the passion?” lamentation was lambasted by Drugmonkey and Dr. Isis.  While I agree with some criticisms of Dr. Kern’s piece, e.g. science should not be closed to people with families that need to work 9-to-5, I sincerely believe that intense, clock-ignoring passion is a critical ingredient for good science.  Can we revisit the passion and hard work debate?

As the culture of science evolves, I want to understand and communicate to the next generation two pillars:  a new, open and diverse culture of science, as well as the essentials of the scientific method.  And here’s the question that I would like to discuss:  are these two pillars utterly distinct, or does diversity in science require being open to different views of the scientific method?  This is where the philosophy comes in:.  How do we separate conjecture from reality?  How can we know what is true?   Science is not set of sciencey facts or topics, it’s a philosophy, a way of thinking, an approach to understanding the universe.  I worship the scientific method, I admit.  But if science is inherently human process, Is Claude Bernard search for objective truths naive?  If the process of science is inherently human activity, one that may not lay claim to objective truth, I start to wonder:  is there a clean line between the method and the culture?

Then, my mind was blown when I stumbled on to the existence of a Feminist Theory of Science.  Being the interweb, I should have known this has been discussed before.  But it’s a radically new idea to me.  And the next obvious question:  if there is a feminist science, is there an Irish theory of science and a jewish theory of science and a South American theory of science?  Does everyone get their own science?  Hmm…not sure, but I don’t think so.  I think there should be a core set of values.  Where do we draw the lines?  This is a question of epistemology.

Is there any real-world relevance to this philosophizing?  I just got back from a new investigator meeting at the National Cancer Institute (NCI) where we were deluged with data and information about the byzantine workings of the NIH.  The NIH recognizes that URMs (under-represented minorities) are under-represented among NIH grant awardees, and that this problem is getting worse given the changing demographics of the USA.  The NCI is working to try and fix this problem , but as I was being intensely immersed in the bizarre culture of US science funding at the NIH, I couldn’t help but wonder if our narrow view of “proper” science culture is part of the problem.   The NIH also seems to have mixed feelings about “big science.”  Big versus small science deserves it’s own post, but briefly, the NIH pays lip service to the importance of individual investigator grants, and yet, they sacrifice many R01s for big science projects.  Let’s have a whiskey and discuss.

Image

Neil deGrasse Tyson, astrophysicist and science communication superstar

 “This ad­ven­ture is made possible by generations of searchers strictly adhering to a simple set of rules. Test ideas by experiment and observation; build on those ideas that pass the test, reject the ones that fail; follow the evidence wherever it leads and question everything. Accept these terms and the cosmos is yours.” –Neil deGrasse Tyson, on Cosmos

Unsolicited advice for a triaged grant

A scientist on Twitter lamented the other day that she had her A0 grant triaged. As an expert in triaged and unfunded grants who eventually overcame to get funded R01s, here’s some unauthorized, off-the-cuff advice.

What happened to this scientist’s grant that caused it to be triaged? Of course I don’t know for sure, but I’m willing to bet one reviewer read the grant carefully and saw strengths as well as weaknesses, but the other reviewer was dismissive with a cursory read. The problem is, without uniform enthusiasm, triage happens. Due to flat/declining funding over the past dozen years, competition is more intense today than ever before and study sections are encouraged to triage grants mercilessly.

I may seem vague, but that’s intentional. With a triaged grant, the problem is not likely to be with the details of the methodology but rather with the overall excitement for the proposal. When she wrote the grant she probably thought very carefully about the experimental design and feasibility of experiments. What was missing was zazz.  That’s right.  The missing ingredient was essentially jazz hands.

From 30,000 feet, the Specific Aims page, you want your reviewers to be thinking, “Wow!! Can she do that??” The rest of the grant is focused on making the case that, “you bet your ass I can.”

I’ve had discussions about whether a triaged grant can be salvaged for resubmission. While there’s always stories of grants going from triage to funded, this is the exception. Experienced hands put a triaged grant on the shelf for year, and try something completely different. Preliminary data, may be recycled, but a new approach, a new set of Aims are needed. This is debatable of course but what’s not debatable is that there was a serious enthusiasm gap and the grant needs to be rethought.

My tweep commented that “I really liked this grant!” Let me be provocative and say that this was part of the problem. If you “like” your grant, who is going to love it? you don’t need to like your grant, you should be psychotically passionate about it. You should have scary eyes for your aims, and bring unreasonable amounts of firepower to bear. I like to watch the lobby scene of the Matrix to get the idea.  In The Matrix analogy, the experimental tools of your experimental design are the guns.  Note how Neo and Trinity treat their weapons,  dropping them when they are spent and moving on without hesitation.  Do Neo and Trinity “like” their guns?  Tools are used simply to achieve the goal.

Another problem with a scientist “liking” her grant is that it sets her up for feeling discouraged by its rejection. Nut up. This is business. Don’t get discouraged, get angry. Take a couple of personal days for reflection, but then pick yourself up, dust yourself off and get back into the fray. Keep writing.

Change of gears.  The PubScience in me wants to say,  “Hey, young ‘uns, let’s cut the B.S., you’re listening to advice from old man telling you how to act like him.  An alternative explanation for a rejected grant, is that the NIH only likes to fund old people.

I’m being facetious, but only a little.  Who still thinks it’s a good idea to have the fate of  creative and groundbreaking ideas decided upon by a committee monoculture? I agree completely that the NIH grant process needs to be rebooted, as @MBEisen and @Drugmonkeyblog have discussed (and I refer you to them for a more systematic and objective (?) discussion).

Briefly, and irreverently, my view on what’s wrong with the NIH process is that the smarter people try to be, the more danger there is in them being dumb asses.  This view of course was influenced by my own sordid grant history.  My currently R01 funded project is not what I started out with — I had two projects that failed agonizingly to obtain successful R01 funding, after 3 rounds of grant reviews each.  First one, then the other broke my heart as the A2 scores came back nearly the same as the A1 score, unfundable, after massive efforts to respond to A1 reviews.  (@drugmonkeyblog recently wrote about this phenomenon)  It’s deeply ironic to me that the “deal-breaker” criticism of each grant was neutered by the passage of time.   My first R01 application included an Aim on making and using a mouse knock-in model of the disease I was studying.  The final judgement was that without the engineered embryonic stem cells in hand, there was no way the grant should be funded.  It was rational decision on the part of the reviewers.  I was depressed, but their judgement seemed fair.  And yet, a similar knock-in model was later successfully created by another lab, and the insights it has yielded have yet to live up to our hopes.  To my mind, the “alternate approaches” I outlined in my grant may have been the better approach.

The case of my second project makes me smile even more ruefully.  Although I now had a disease model in hand, my experiments were considered  unworthy because my model did not, in my reviewers’ opinion, adequately recapitulate human disease.  The primary reason I pursued my Myc-driven model of acute myeloid leukemia (AML) was that it looked, to my hematology-trained eyes, exactly like human AML.  But, the scientist experts on study section noted, my mice had AML that was oligoclonal (comprised of not a single malignant clone, but several), and this was clearly not the case for the human disease.  Case closed.  Sigh.  Except… now, a few years later, we know that human AML is, in fact, oligoclonal.  Oops.

People often inquire about the experiments I proposed in that grant, but we had to drop working on it.  My bottom line is that while the writer of an unscored R01 needs to do some serious re-working, the NIH also has some serious re-working to do to address the reality that the job of a scientist has become predominantly about playing the grant game, which takes years of experience for most of us, rather than rewarding the smartest creative minds, which are usually younger than the grey-beards we reward now.

If your loved one is sick, you need to tweet about it

The last Pub Style Science on patient blogs was a blast, as usual, but there was something more I wanted to say about medicine and interweb communication. Still thinking about what social media can do for medicine because I’ve been on service recently spending hours and hours working with leukemia (and lymphoma and myeloma) patients, fighting a myriad of problems with them. Mostly, of course, it’s their diagnosis, a horrible disease that is the enemy. But a fight against cancer can be a long battle and there are countless small issues that are much of the day-to-day work.  With a cold, statistical eye, I don’t know how significant the “little things” are to someone’s overall survival, but I feel they matter, at the very least for a person’s quality of life, and also for the patients’ families who have a strong desire to care for their loved ones in the best possible way.

The simple mechanics of patient care–did the nurse have the items she needed when she needed them?  Was a problem dealt with promptly or did wait until after the weekend?– can cause significant anxiety for patients and their families.  These days, when there is drama, my first instinct is, “I should tweet that,” I should make some noise, get some attention to the issue, maybe putting a spotlight on the problem will help fix it.  But I must not.

Image

Does the on-line community realize that this simple act is not acceptable in the hospital, I wonder?  Sure, there are privacy issues, HIPAA concerns (which are distinct IMO), but I feel the greatest damper on speaking openly, the over-arching concern, is a culture of fear based on concerns of liability and lawsuits. The hospital has “patient liaisons” that hear complaints.  What these folks do is, in fact, risk management. Will a patient sue?  Will a federal regulator impose a hefty penalty?  The sad reality is that in 2014 the financial risks involved with open communication supersede any potential benefits.

This means that there are untapped potential benefits to be had.  Brilliant people with investor backing are working overtime to develop internet-based technologies for a new era of medicine.  Big data.  Genome sequencing.  Quantified selves. Eric Topol is right that the medical industrial complex is ripe for “creative destruction.” The old ways of delivering medical care are going to change significantly in the next 10 years, many predict.  Established players and start-ups are putting resources into ideas that they hope will get them a piece of the huge healthcare money pie.

The Pub Style philosophy is that science should have an open-door accessibility. It reminds me that the tech needed for Schumpeter’s gale in medicine might be relatively low tech.  Simplification is likely to be a critical element in a transformative process, especially now that are (finally) enormous pressures to reduce costs. Giving voice to frustrated health care customers is a simple idea that could be a growth industry. What will seem in retrospect as a simple solution is waiting to be invented, and it may just as likely come from a college dropout working in his basement as it is to come from a university or large corporation.

How visiting China convinced me that America will maintain its lead in science

When I was a post-doc in the late ‘90s, the NIH budget was doubling.  Our lab grew quickly  from 4 people to 14.  I told my friends, family and students that I had the best job in the world–there was no way in the foreseeable future that research budgets would be cut. How quickly things change!  Like many of us, I’ve been dismayed by the deterioration of research funding in the US over the past several years, and have lamented that the era of US leadership in science is over.

I hosted a Chinese physician in my laboratory last year, and two weeks ago, in return for his cancer research experience, he invited me to his hospital to give a lecture on multiple myeloma and do some sightseeing.  I had last been in China before, just after college, over 25 years ago, and I was eager to see how much had changed.  Before I left, my head was filled with reports of China’s economic and scientific growth.  Senior investigators are being wooed there and pharmaceutical companies opening R&D labs.  China, I’d heard, is increasing, not decreasing its investment in research funding and with the funding situation so bad in the US, the “declining America, rising China” meme made sense.  My in-laws recently returned from a sightseeing trip last month to Shanghai and Beijing and were impressed with signs of prosperity.  The day before my trip, I had lunch with my former post-doc, born and raised in China, now working in Little Rock.  He surprised me by saying the New York Times, CNN and Bloomberg were biased against China.  “You never hear any good news about China!” he insisted. “There are still many poor people, but 100s of millions have been lifted out of poverty…you never hear that.”  I realized he was right.  We hear a steady drumbeat of stories on worker abuses, pollution and political repression. Maybe I would see in China additional signs of the economic boom that we aren’t told about.  The US economy has been struggling for years, and perhaps the good times for US science are in the past.  I went to China last week thinking I would see the future. We in the US are out of cash, out of optimism and enthusiasm. Maybe I would see what research would look like in the 21st century…but I came back with a renewed sense that the US remains in a privileged position and is likely to lead the world in scientific research in years to come.

I was invited to Nanning, capital of the Guangxi province in central China, to give a talk on multiple myeloma, the cancer we study in my lab. Usually, my talks focus on my lab research, but I was told that the doctors in the audience would not be interested in basic science.  “You are different that way, doctors in the US care about the science.” I’m not sure I agreed with that assessment, but thought it interesting. New drugs developed in the US over the past decade have transformed myeloma treatment but these miracle drugs are not affordable to the vast majority of Chinese. In China, cancer patients must pay out of pocket for their chemotherapy–drugs that are notoriously expensive.  Lenolidomide (Revlimid(R)) can cost $400 / pill (and require daily doing for years) so most Chinese myeloma patients receive thalidomide, which has worse side effects).

“These days, the relationship between doctors and patients is strained.”  I was stunned to hear that there have been a series of incidents across China of dissatisfied patients attacking and stabbing their doctors.

Medical care in China seems like a free-market system like libertarian-leaning conservatives suggest replace Obamacare.  And it looks to me like a nightmare.

After my talk, I took a road trip to see sights in Guilin. Nanning is a medium-sized city away in the Southwest away from the tremendous prosperity of the coasts. It was easy to see signs of rapid urbanization in the form of newly constructed high-rises, but often these were unfinished or unoccupied. The economic miracle of modern China has not yet reached all areas of the country.  There is a widening gap between rich and poor (like in the US) and if the growth of the Chinese economy slows (as it must) there may be difficulties ahead for China’s poor and middle class.

Image

The Lijiang River in Guilin rivals Yosemite Valley for spectacular scenery. These mountains stretch on for miles and miles.

This past year, I started participating in social media and find myself increasingly enjoying the immediate information access, the camaraderie and dialogue on the internet.  But while in China, there was no access to Twitter or Facebook, not to mention the New York Times or CNN.  In China, the social media free-for-all that exists in the US is carefully controlled.   Truthfully, I’ve been sypathetic to some anti-twitter essays that appeared lately, and I admit it felt good to get away from the Twitter maelstrom for a while and get back to writing letters for a few days.  There’s a pleasure in taking time to read, think and write.  And yet…when curtailed by the government, I couldn’t help but wonder whether China’s information flow control is having effects on the creative process there. The electronic salon is invigorating.  Twitter’s “hive-mind” is undeniably useful for personal and professional support, feedback and networking.  (Not to mention frequent hilarity!)  It’s their loss that they are barred from this community.

Another striking feature of Chinese work life is a lack of professional mobility. That is, daunting hurdles exist to changing geographic location, making professional moves near impossible. Colleagues can’t easily move to Shanghai or any other city in their own country.  Not only are government benefits tied to their province, but the personal networks are critical–without contacts even a talented professional can not succeed due to bureaucracy.  In the US we take for granted that connections can be made rapidly and that our credentials are portable.  In China, deep personal connections that take years to develop are key.  Promotions are given on the basis of long work history under senior faculty.

As a post-doc, I had the view that science was how we found objective truth.  The post-modern philosophy that said that even scientific truth was a social construct annoyed me.  Dr. Rubidium teased me a few weeks ago on a Pub-Style Science for espousing this perhaps naive view of science — transcending fallible human foibles like racism and gender issues.  Fair enough. And yet, in China the ubiquity of the State, the necessity of political thinking, may have an effect on the process of science and scientific thought.  The effect of this politicization is that the work of science is seen as performing tasks for the Boss, rather than as a creative process. Although I agree with Rubidium that the sociology of science can’t be ignored, at the same time, I believe it important when we focus on uncovering nature’s truths. The truth and beauty of science are beyond the political.

Hundreds of millions of Chinese have been lifted from poverty and the economy has had a spectacular boom, which should give pause to free market fundamentalists in the US who insist that government is incapable of helping people or business.  My post-doc said that he thought that rather than be enemies, China and the US should be “married.”  A strange expression, I thought at the time, but now I understand.  We do have a lot to learn from each other and the competition can and should be friendly and mutually beneficial.

The contraction of US spending on research continues to be painful.  But we still have the organizational infrastructure, a lack relative lack of corruption (believe it or not), and a culture of optimistic progress that the world still looks to.  In Doris Kearns-Goodwin’s “The Bully Pulpit” she quotes magazine editor and muckraker S.S. McClure on his casting about for answers to America’s woes at the turn of the last century:  “There is no one left, none but all of us.”

Want an academic job? Hold your tongue.

At our house last night we had a Hanukkah party with a mix of friends and co-workers.  We had a dozen kids over and they loved lighting menorahs and playing dreidel for chocolate hanukkah gelt.  I got joy watching kids who have never done this before having a blast too.

In the midst of the latkes and blintzes, I overheard a conversation about blogging that –while it may not have surprised my seasoned interweb colleagues– shocked me a little.   A senior scientist mentioned googling a potential faculty recruit and found the person’s blog describing the trials and tribulations of a life in science.  The faculty member said the blog, while it was to be commended for its forthright tone, was so informal and laced with profanity that the professor could not help but hold the blog against the potential faculty member.  A second senior scientist nodded in agreement.  It was the consensus that aspiring young scientists should steer clear of such activities.

“Wow, that blog sounds like any one of a number of people I know,” I thought.  Over the past year, I have made friends with a friendly group of scientist-bloggers whom I have grown to admire for their passionate activism.  The comments of my interwebophobic colleagues sent a chill down my spine.  Real negative consequences of speaking one’s mind on a personal blog.  Yikes.  Of course, people get in trouble for what they say on the internet/twitter..but yes, I am just coming to the realization that there are consequences within the science community for saying things about that community.  Community, hm.

To my pseudonymous colleagues, this is old news.  This story  only provides the “derp” for why one should take care with one’s identity while blogging/tweeting. I wanted to bring this up here for young folks starting out so they do not have any illusions about how the world may or may not be changing in terms of online communication.  If you don’t have tenure yet, use a pseudonym.

book_burn

And I’d also like to express disappointment and frustration with my old guard colleagues who saw zero problem discriminating against a faculty recruit on the basis of their personal thoughts and the tone in which they were expressed.  That’s sad.  Maybe if the blog revealed attitudes and ideas that were at odd’s with the mission of the university, OK.  Criminal activity, sure.  But filtering out faculty members for speaking their mind about the process of science seems like a stupid old guard thing to do and against the principles of the academy.

I have tenure and still feel pressure to shut my mouth.  I’m not going to because in my naive brain, the whole point of tenure is having the freedom to say what I like.  We are losing valuable insights by muzzling people before tenure.

 

“Like the Federalist Papers don’t count because ‘Publius’ wrote them?”  - my mom on people who don’t take psueds seriously.

Dark times for fans of Obamacare

“The healthcare.gov rollout was just pathetic.  A disaster stuffed in a travesty…wrapped in incompetence.  They call that a Tur-clusterfuckin.”   – Samantha Bee on the Daily Show

I’m an optimistic person, but the Obamacare rollout got me depressed.  I was waiting with baited breath for the exchanges to open and prove the naysayers wrong, but well, instead this disaster has given people on both sides of the aisle pause. Who knew the tech-savvy Obama administration would fail so hard on a web site?

The crappy healthcare.gov  site might have been forgiven if Obama had not been caught in a lie about people being able to keep their insurance.  “If you like your current plan, you can keep it, period,” he repeated.  It’s painful to acknowledge that the administration knew this was coming and lied about it.  But that’s what they did.

We know Obama fibbed about people keeping their plans because many people need to lose their current plans for Obamacare to work. He could have been more honest by saying, “the Affordable Care Act will force dramatic changes. In the end, it will be for the best, but before the dust settles, it will cause tremendous disruption.” Yeah, they would not have gone for that in Topeka.

There is a push to “fix” this…to change the law so that people can keep their current insurance.  As Ezra Klein has noted, this could be a political winner, but would be a policy mistake.

More bullshit will fly in the media because more disruption will come.  Employers will start to follow the money, and will choose the “penalty” option and will continue dropping coverage for employees.  In the long run it will be a good thing for employees to get healthcare for themselves because uncoupling health insurance from employment will help the labor market be more efficient. Reform opponents will claim this a disastrous consequence of Obamacare but it will be another sign of it’s intended effect–to draw people into the individual market for health insurance.

Image

If the exchanges ever work properly, individuals will be able to comparison shop for health insurance plans.

Right now the headlines are about how few people have signed up so far, but these numbers will only grow.  If the previously anemic individual market can be allowed to develop, the law may still be a big success. Obamacare is a huge experiment that is just getting started. It’s too early for an Obamacare autopsy. Time will tell.  I’m going to put my head down for a year before deciding how it really all went.

Unseen and underreported, there are other positive changes and incentives in Obamacare, e.g. incentives for hospitals to provide better care and coverage for preexisting conditions.  We already take these reforms for granted.

The Obamacare debacle has highlighted one huge accomplishment the GOP has under its belt: by refusing to cooperate with their opponents, extreme right Republicans are successfully making “the government doesn’t work!” a self-fulfilling prophesy.  I remain optimistic about Obamacare, mostly because there is so much room for improvement in our current system.  But watching the partisan sniping over Obamacare has eroded my faith and optimism in our ability to work together as a nation on obvious  national priorities.  Healthcare, education, research…it seems this areas will flounder for years to come as we, through our elected officials, bicker, consumed by nonsensical political ideologies.

English: President Barack Obama's signature on...

English: President Barack Obama’s signature on the health insurance reform bill at the White House, March 23, 2010. The President signed the bill with 22 different pens. (Photo credit: Wikipedia)