SCIENTISTS FOR SCIENCE-BASED Policy (even more, and again)--open letter

Here's a self explanatory email:

Dear NAS Colleagues,

We are deeply appreciative of your decision in spring 2018 to sign the Statement to Restore Science-Based Policy in Government. website https://scientistsforsciencebasedpolicy.org/ 

We are writing now to update you.  This past month we contacted members newly elected in 2019 and 2020, asking if they would like to add their names to the Statement. Although much has happened in the past two years, we decided to keep the text of the Statement  unchanged.  Its wording remains as relevant today as earlier, perhaps even more so.

We are pleased to report that about 62 percent of the new members have signed, raising the total number to over 1220.  We are now distributing the explanatory statement below to selected journalists. This statement is also available at

https://faculty.wcas.northwestern.edu/~cfm754/nas_open_letter_history.pdf

We would be happy if you would disseminate this information as you think appropriate.  Moreover, should you be in touch with members who have not yet signed the Statement and wish to do so, please have them email us and we will add their names.

Regards,

Charles Manski, Ben Santer, and Ray Weymann,  NAS members

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Here's the closing paragraph of the original (and reissued) letter:

"Scientific evidence and research should be an important component of policymaking. We therefore call on the Federal Government to maintain scientific content on publicly accessible websites, to appoint qualified personnel to positions requiring scientific expertise, to cease censorship and intimidation of Government scientists, and to reverse the decision to withdraw the United States from the Paris Agreement."

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And here are the opening paragraphs of the historical context document:

"Pandemic Exposes Fatal Consequences of Dismissing Scientific Expertise
1,220 members of the National Academy of Sciences call for science-based policy
July 16, 2020

“Ignorance and wishful thinking are not effective response strategies in the face of a global pandemic or global climate change,” said Dr. Ben Santer, one of three co-organizers of this open letter. “We need to restore science-based policy in government – but we also need to ensure that science is valued in public discourse and in all levels of our educational system.”

"This call for restoring science to policymaking has a several-year history. In the summer of 2016, while campaigning for the Republican nomination for the U.S. Presidency, Donald J. Trump publicly announced his intention to withdraw the United States from the Paris Climate Accord. This announcement – and Mr. Trump’s public dismissal of climate science as “a hoax” – prompted four members of the U.S. National Academy of Sciences to write an open letter (http://responsiblescientists.org). The letter’s purpose was to affirm the reality and seriousness of human-caused climate change. It pointed out the severe and long-lasting consequences of an eventual U.S. withdrawal from the Paris Climate Accord. At the time of its publication in September 2016, the open letter had 378 NAS signatories."

Policing in our decentralized American democracy

The current dismal news about how American minorities are often more endangered than protected by American police forces raises a market design problem.  How can police departments be reformed, in a vast, diverse democracy, where the responsibility for policing falls largely on the smallest government units, namely towns and cities and counties?

While many responsibilities are local, government at the state and federal level (and the courts) have a role in regulating police work and in providing collective resources such as training that can't be provided effectively at the municipal level.

Here's the May 2015 (Obama era) report published by the Office of Community Oriented Policing Services (COPS):

 Final Report of the President’s Task Force on 21st Century Policing, Washington, DC: Office
of Community Oriented Policing Services. May 2015.

The overall thrust of the report is that policing is a community activity (the word "community appears 318 times), and should have a "guardian" rather than a "warrior" culture. The report has many chillingly timely recommendations. E.g.:

"2.7 RECOMMENDATION: Law enforcement agencies should create policies and procedures for policing mass demonstrations that employ a continuum of managed tactical resources that are designed to minimize the appearance of a military operation and avoid using provocative tactics and equipment that undermine civilian trust."

"6.1.3 Action Item: The Federal Government should support the continuing research into the efficacy of an annual mental health check for officers, as well as fitness, resilience, and nutrition."

"6.4 RECOMMENDATION: Every law enforcement officer should be provided with individual tactical first aid kits and training as well as anti-ballistic vests."
********

The 2016 presidential elections intervened, and this report was shelved.  Many of the authors have retreated into a private sector consulting organization named after the report on 21st Century Policing:

"21CP is an outgrowth of many of its consultant’s experiences on the President’s Task Force on 21st Century Policing. That Task Force produced a pioneering report on contemporary policing, creating a common-sense law enforcement agenda based on input from criminal justice experts, community leaders, law enforcement, and civil liberties advocates. The recommendations have been endorsed by the Major Cities Chief Association, embraced by the National League of Cities, and heralded by community organizations and civil rights activists.

"21CP Solution’s trusted police leaders and experts work on the ground in police departments across the country – leading large departments and assisting smaller agencies. Public safety in partnership with the community is not a theoretical enterprise for 21CP."

One imagines that some of these individuals could be recruited to government service if a different administration takes office in Washington in 2021.

One of the principals in 21CP, who was the director of the Office of Community Oriented Policing Services  at the time the above report was issued, is Ronald L. Davis, who came to COPS from East Palo Alto (where I lived briefly in 1978 while visiting Stanford, and near where I now live), where he was chief of police.  Here's an excerpt from the announcement of his appointment to COPS in 2013:

"Attorney General Eric Holder today announced Ronald L. Davis as the director of the Office of Community Oriented Policing Services (COPS).  Davis comes to COPS from the East Palo Alto Police Department, where he served as Chief of Police since 2005.
...
"In East Palo Alto, Davis led an organizational reform and community-policing effort that increased public trust and confidence and achieved dramatic crime and violence reductions in a city once dubbed the murder capital of the United States.  Davis also partnered with the  Department of Corrections and Rehabilitation to implement a pilot parole-reentry program that provided programming and enforcement services and a job program with the California Department of Transportation.  The East Palo Alto Police Department was the first police agency in the state to operate a state-funded reentry program.  Return-to-custody rates dropped from more than 60 percent to less than 20 percent during this program."
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Under the current administration in Washington, the Federal government has stepped back from police reform in a number of ways.  Here's a story that ran yesterday in the Guardian:

Trump's scrapping of Obama-era reforms hinders police reform
Trump’s justice department has dropped the use of consent decrees to bring federal oversight of troubled police departments  by Ed Pilkington.

"Under Donald Trump, the US justice department has allowed federal mechanisms designed to impose change on racist police agencies to wither on the vine. As a result, law enforcement agencies that practice racial profiling, use excessive force and other forms of unconstitutional policing are now free from federal oversight.

"The most important of those tools, known as consent decrees, were deployed extensively by the Barack Obama administration in the wake of previous high-profile police killings of unarmed black men. They included the death of Michael Brown in Ferguson, Missouri, in 2014; 12-year-old Tamir Rice in Cleveland, Ohio, that same year; and the 2015 death of Freddie Gray in Baltimore, Maryland.

"Under Obama, 14 consent decrees were enforced upon troubled and discriminatory police agencies. By contrast, none have been issued in the more than three years of the Trump administration.
...
"Consent decrees fall under the 1994 Law Enforcement Misconduct Act that was passed by Congress in the wake of the brutal beating of Rodney King by Los Angeles police three years earlier. The statute allows the US government to sue local police agencies that engage in “patterns and practices” of unconstitutional policing and fail to comply with essential reforms."
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For the record, here is the Law Enforcement Misconduct Statute, 42 U.S.C. § 14141, which is part of U.S. civil rights legislation:

§ 14141. Cause of action (re-codified at 34 U.S.C. 12601)

(a) Unlawful conduct

 It shall be unlawful for any governmental authority, or any agent thereof, or any person acting on behalf of a governmental authority, to engage in a pattern or practice of conduct by law enforcement officers or by officials or employees of any governmental agency with responsibility for the administration of juvenile justice or the incarceration of juveniles that deprives persons of rights, privileges, or immunities secured or protected by the Constitution or laws of the United States.

(b) Civil action by Attorney General

Whenever the Attorney General has reasonable cause to believe that a violation of paragraph (1) has occurred, the Attorney General, for or in the name of the United States, may in a civil action obtain appropriate equitable and declaratory relief to eliminate the pattern or practice.

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Two stories in the Washington Post together frame the current political moment:

Here's the first:
‘Defund the police’ gains traction as cities seek to respond to demands for a major law enforcement shift  By Derek Hawkins, Katie Mettler and Perry Stein   June 7, 2020

"Though long a concept floated among left-leaning activists and academics, officials from Washington to Los Angeles are now seriously considering ways to scale back their police departments and redirect funding to social programs. The moves would be a strong show of solidarity with protesters, who are clamoring for social justice and to strike back at what they see as an oppressive force across the country."

And here's the second:
Protesters hope this is a moment of reckoning for American policing. Experts say not so fast.  By
Kimberly Kindy and Michael Brice-Saddler   June 7, 2020

"Charles H. Ramsey, a former chief in the District and Philadelphia and co-chair of President Barack Obama’s Task Force on 21st Century Policing, said perhaps the biggest obstacle to nationwide change is the unwieldy way in which police departments are organized. With every city, town, state and county fielding its own force, he said, it’s hard to standardize training and policies.

“Regionalizing them would be a solid first step,” Ramsey said. “But then you get into the politics. Every county and every mayor; they want their own police force, they want their own chief.”

"For that reason, a coalition of nearly 400 disparate organizations is focusing on securing federal reforms. Last week, the group — including the NAACP, the Center for Reproductive Rights and the American Music Therapy Association — sent a joint letter to congressional leaders calling for legislation to combat police violence.

“With so many police departments, it is important that there is federal action,” said Vanita Gupta, a former head of the U.S. Department of Justice’s Civil Rights Division and CEO of the Leadership Conference on Civil and Human Rights.

"Although past efforts at policing reforms stalled in Congress, Booker expressed optimism, noting that civil rights legislation has always traveled a bumpy road. "

Medical triage for Covid-19: if/when it comes to that, how should it be organized?

So far I haven't heard of any actual medical triage in the U.S. in which life-saving treatment for Covid-19 is rationed.  There has been a good deal of discussion of how to avoid this, and of the short supply of masks, gowns, sedatives for intubation, and health care personnel.  Much of that discussion  has focused on reallocating scarce resources to where they are needed (from where they are not so scarce (e.g. California Ventilators En Route to New York, Other States), so that rationing of e.g. ventilators doesn't become necessary.  But if the infection curve doesn't flatten enough, triage may well be coming, at least in some places. (Here's an up to date account of a hard hit rural hospital near New Orleans that hasn't yet had to triage, but might be getting close if nearby hospitals were to stop taking transfers of patients.)  

Already in Italy there was a period (maybe still) when patients over age 70 (and later over 65) were not being given ventilators because of an actual shortage of ventilators compared to the number of patients who needed them. So it makes sense that, along with the discussion of how to prevent the need for triage, there is an ongoing discussion of how to manage it, if  there comes a time and place where there aren't enough vents to go around. (I have already heard a somewhat related discussion in the U.S. about whether patients on vents should be resuscitated--given the small chance of recovery, and the exposure of health care workers to Covid-19 during a resuscitation attempt.)

As in discussions of repugnant transactions, discussing allocation of scarce resources provokes lots of debate about who should get what, and what kind of distinctions should and should not be made. 

Here are longish excerpts from several interesting contemporary accounts:

Here's an article in the March 23 New England Journal of Medicine:

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

by Ezekiel J. Emanuel, M.D., Ph.D., Govind Persad, J.D., Ph.D., Ross Upshur, M.D., Beatriz Thome, M.D., M.P.H., Ph.D., Michael Parker, Ph.D., Aaron Glickman, B.A., Cathy Zhang, B.A., Connor Boyle, B.A., Maxwell Smith, Ph.D., and James P. Phillips, M.D.

"Rationing is already here. In the United States, perhaps the earliest example was the near-immediate recognition that there were not enough high-filtration N-95 masks for health care workers, prompting contingency guidance on how to reuse masks designed for single use.2 Physicians in Italy have proposed directing crucial resources such as intensive care beds and ventilators to patients who can benefit most from treatment.3,4 Daegu, South Korea — home to most of that country’s Covid-19 cases — faced a hospital bed shortage, with some patients dying at home while awaiting admission.5 In the United Kingdom, protective gear requirements for health workers have been downgraded, causing condemnation among providers.6 The rapidly growing imbalance between supply and demand for medical resources in many countries presents an inherently normative question: How can medical resources be allocated fairly during a Covid-19 pandemic?

...

"According to the American Hospital Association, there were 5198 community hospitals and 209 federal hospitals in the United States in 2018. In the community hospitals, there were 792,417 beds, with 3532 emergency departments and 96,500 ICU beds, of which 23,000 were neonatal and 5100 pediatric, leaving just under 68,400 ICU beds of all types for the adult population.12 Other estimates of ICU bed capacity, which try to account for purported undercounting in the American Hospital Association data, show a total of 85,000 adult ICU beds of all types.13

"There are approximately 62,000 full-featured ventilators (the type needed to adequately treat the most severe complications of Covid-19) available in the United States.14 Approximately 10,000 to 20,000 more are estimated to be on call in our Strategic National Stockpile,15 and 98,000 ventilators that are not full-featured but can provide basic function in an emergency during crisis standards of care also exist.14 Supply limitations constrain the rapid production of more ventilators; manufacturers are unsure of how many they can make in the next year.16 However, in the Covid-19 pandemic, the limiting factor for ventilator use will most likely not be ventilators but healthy respiratory therapists and trained critical care staff to operate them safely over three shifts every day. In 2018, community hospitals employed about 76,000 full-time respiratory therapists,12 and there are about 512,000 critical care nurses — of which ICU nurses are a subset.17 California law requires one respiratory therapist for every four ventilated patients; thus, this number of respiratory therapists could care for a maximum of 100,000 patients daily (25,000 respiratory therapists per shift).

...

"Previous proposals for allocation of resources in pandemics and other settings of absolute scarcity, including our own prior research and analysis, converge on four fundamental values: maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.24-29 Consensus exists that an individual person’s wealth should not determine who lives or dies.24-33 Although medical treatment in the United States outside pandemic contexts is often restricted to those able to pay, no proposal endorses ability-to-pay allocation in a pandemic.24-33

...

"These ethical values — maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients."

**********

Here's a Washington Post story with a good summary of much of the discussion and disagreement about how different patients (and groups of patients) might be prioritized if ventilators have to be rationed:

Who gets a shot at life if hospitals run short of ventilators?

States, hospitals scramble to set guidelines that could prioritize pregnant women, health-care workers — and even some politicians

By Ariana Eunjung Cha and Laurie McGinley April 7, 2020 

"Pregnant women would get extra priority “points” in most if not all plans, U.S. hospital officials and ethicists say. This is not controversial. There also has been some discussion about whether high-ranking politicians, police and other leaders should be considered critical workers at a time when the country is facing an unprecedented threat.

...

"Catholic groups have called on hospitals to treat pregnant women as two lives instead of one. AARP, formerly the American Association of Retired Persons, has decried age cutoffs for ventilator access in some plans. Last month, the Arc, a disability rights group, filed multiple complaints with the Department of Health and Human Services objecting to plans that disadvantage those with “severe or profound mental retardation” or dementia.

...

"Bioethicist Brendan Parent, who served on a New York state task force that developed a highly regarded framework for rationing, sees hospitals and states following two paths.

"One group takes a utilitarian view of doing “the greatest good for the greatest number,” giving preference to those with the best chance of surviving the longest. Others are more focused on ensuring social justice and ensuring vulnerable groups have an equal chance.

...

"UCLA’s plan goes to great lengths to avoid possible discrimination, stating that medical teams may not consider a long list of criteria for ventilator allocation including gender, disability, race, immigration status, personal relationship with hospital staff or “VIP status” — an important reminder given the medical center’s proximity to Hollywood.

...

"In UCLA’s plan, front-line health-care workers and administrators may be given priority access to lifesaving treatment, when their return to work means more people are likely to survive the crisis. If all the allocation criteria are applied and there’s still a shortage of medical resources, then care should be allocated on the basis of a lottery, the document says.

...

"One of the most striking differences among plans is how they deal with the elderly and disabled. Some have strict age cutoffs, or explicit criteria that disadvantage those with certain conditions.

...

"Using life expectancy or remaining life years can also be problematic for those with disabilities, civil rights groups say. The typical life expectancy for a person with Down syndrome, for example, is 60 years, as compared to about 78 years for someone without the condition.

...

"Inova’s Motew said ethical principles allow for prioritizing “some individuals who provide more lifesaving opportunities if they could live” — and that this could include “government leaders.” He compared it to military medicine, in which those who are in a position to go back to help win the war are treated first."

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And here are some thoughts on what we might learn about medical triage from considerations that come up in allocating school places among different populations for whom some positions are reserved.  The idea is that different groups of patients would have places reserved for them, through the kind of political process that reserves places in schools for different demographic groups, with priorities within groups, and ordering of reservations among groups. Once those issues are settled by some political process, the problem starts to look like school choice with affirmative action, and in the model proposed by these authors (who are well acquainted with school choice), deferred acceptance algorithms emerge:

Triage Protocol Design for Ventilator Rationing in a Pandemic:
A Proposal to Integrate Multiple Ethical Values through Reserves
Parag A. Pathak, Tayfun Sonmez, M. Utku Unver, M. Bumin Yenmez
April 2020

Abstract: In the wake of the Covid-19 pandemic, the rationing of medical resources has become a critical issue. Nearly all existing triage protocols are based on a priority point system, in which an explicit formula specifies the order in which the total supply of a particular resource, such as a ventilator, is to be rationed for eligible patients. A priority point system generates the same priority ranking to ration all the units. Triage protocols in some states (e.g. Michigan) prioritize frontline health workers giving heavier weight to the ethical principle of instrumental valuation. Others (e.g. New York) do not, reasoning that if medical workers obtain high enough priority, there is a risk that they obtain all units and none remain for the general community. This debate is particularly pressing given substantial Covid-19 related health risks for frontline medical workers. In this paper, we propose that medical resources be rationed through a reserve system. In a reserve system, ventilators are placed into multiple categories. Priorities guiding allocation of units can reflect different ethical values between these categories. For example, while a reserve category for essential personnel can emphasize the reciprocity and instrumental value, a reserve category for general community can give higher weight to the values of utility and distributive justice. A reserve system provides additional flexibility over a priority point system because it does not dictate a single priority order for the allocation of all units. It offers a middle-ground approach that balances competing objectives. However, this flexibility requires careful attention to implementation, most notably the processing order of reserve categories, given that transparency is essential for triage protocol design. In this paper, we describe our mathematical model of a reserve system, characterize its potential outcomes, and examine distributional implications of particular reserve systems. We also discuss several practical considerations with triage protocol design.

And from the conclusion:

"In our formal analysis, we characterize the entire class of reservation policies that satisfy three minimal principles though implementation of the deferred-acceptance algorithm. As such, we also provide a full characterization of affirmative action policies."
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There are of course other models of triage than school choice. In transplantation, there's a shortage of both deceased and living donors, to the extent that many people who need transplants will never get them. The allocation of deceased donor organs is handled not entirely differently than generalized school choice of a particularly dynamic sort (potential recipients of a deceased donor kidney that suddenly becomes available are categorized into groups, not just by blood and tissue types which have immediate feasibility implications, but also by age and by how difficult it will be to find them a feasible match, and prioritized within groups mostly by waiting time and health status, differently for different organs).  Living donors (almost all are donating a kidney) are much less regulated, and through kidney exchange are mostly allocated through an exchange system that is fairly blind to group membership, although the statistics that are collected pay attention to people in a variety of categories.  The point of kidney exchange of course is not just to allocate scarce resources, but to make them less scarce.  That is a goal to think about whenever triage becomes necessary, or starts to look like it might.

Thomas Toch on school choice and the presidential campaigns

Toch: School Choice Is Here to Stay. But How to Make It Fair and Equitable for All Families? High-Tech Common-Enrollment System Can Help

"The leading Democratic presidential candidates — liberals Elizabeth Warren and Bernie Sanders, but also moderates Joe Biden and Pete Buttigieg — have derided publicly funded charter schools as a threat to traditional public schools. But charter schools and the new, more consumer-oriented public education landscape they represent are here to stay.
...
"In this climate, the policy question is not whether we should have public-sector choice. Instead, we should be asking how to make choice systems in public education efficient and fair for all families. One promising answer: common-enrollment systems that allow families to select traditional public schools or charters through a single, centralized selection process powered by algorithms that match as many students as possible to their top choices.
...
"But taking advantage of expanding public options traditionally meant navigating myriad application timelines and deadlines without information to make clear comparisons.

"It meant oversubscribed schools pulling names out of paper bags, families pitching tents on sidewalks — or paying others to camp out for them — to get to the front of waiting-list lines and schools cherry-picking applicants to get the most attractive students. It was a system favoring the well-educated, the wealthy and the well-connected.

"For schools, that system made planning almost impossible. Many students were admitted to multiple schools but didn’t let schools know their plans, causing thousands of waitlisted students to change schools even after the start of classes, leaving administrators guessing about revenue and staffing, and disrupting instruction.

"But in recent years, the District of Columbia, Denver, New Orleans and a handful of other cities have launched a new way of matching students to schools that addresses these problems."
********

In the manner of journalists with space limitations, Toch goes on to attribute these advances to "Alvin Roth and colleagues."  Of course, prominent among those colleagues are the two leaders in the modern school choice revolution, Atila Abdulkadiroglu and Parag Pathak.

Transplantation under scrutiny in Washington and the media: compilation of recent links by Greg Segal, via Frank McCormick

The organ transplant ecology is complex, with sometimes perverse incentives in the interfaces among OPOs (Organ Procurement Organizations), donor hospitals, and transplant centers (not to mention dialysis clinics, nephrology practices, government agencies, and subcontractors like UNOS).  Frank McCormick forwards the following compilation distributed by Greg Segal, mostly focused on recent criticisms (some more informed than others) of OPOs. (Having recently spent a day talking to OPO leaders, and not long before that to those running transplant centers, I'm aware that there are different opinions on the multiple causes of  problems afflicting transplantation

Frank writes:
"Greg Segal (founder & CEO of Organize, which is attempting to reduce the U.S. organ donation shortage) sends along this excellent compilation of references for those who want to comment on two current proposals by agencies of the Department of Health and Human Services (HHS):

a.    Health Resources and Services Administration (HRSA): “Removing Financial Disincentives to Living Organ Donation” (deadline – 2/18/20)

 https://www.federalregister.gov/documents/2019/12/20/2019-27532/removing-financial-disincentives-to-living-organ-donation

b.    Center for Medicare and Medicaid Services (CMS): “Revisions to the Outcome Measure Requirements for Organ Procurement Organization” (deadline – 2/21/20)

https://www.federalregister.gov/documents/2019/12/23/2019-27418/medicare-and-medicaid-programs-organ-procurement-organizations-conditions-for-coverage-revisions-to#open-comment

Key points for comments (due by February 21st at 5pm ET, via submission here)

• Although 95% of Americans support organ donation, objective research suggests that organ procurement organizations (OPOs) only recover about 35% of potential donors, leaving as many as 28,000 organs unrecovered every year.
• Because the majority of patients on the organ waiting list are in need of kidneys, OPO underperformance contributes to a $35 billion annual expense to Medicare. 
• As Senators from the Finance Committee wrote in a February 10th 2019 oversight letter: “Because OPOs operate as regional monopolies, rigorous oversight is critical to ensure that all 58 OPOs are faithfully executing their mission of organ recovery.”
• As Secretary of Health and Human Services Alex Azar said: “We’re going to stop looking the other way while lives are lost and hold OPOs accountable."
• With almost 115,000 patients waiting for a lifesaving organ transplant, it is imperative that CMS implements the proposed metrics as strongly and quickly as possible, especially since the majority of OPOs (37 of 58) are failing one or both key metrics.

Context on why OPO reform is critical to helping more patients access organ transplants

• Every day, 33 Americans die or are removed from the organ waiting list because a transplant is unavailable. Additionally, because there is such a large gap between supply and demand, many Americans in need of transplant never even reach the waiting list. Research indicates that the true death toll may be as high as 118 Americans per day just from the kidney shortage alone.
• The shortage of deceased donor organs results in part from inefficiency from federal monopoly contractors, called organ procurement organizations (OPOs), which too often fail to recover organs for transplant. (See NYT whistleblower video.) 
• Research cited by the Trump Administration shows that a more efficient organ donation system could recover up to 28,000 more organs for transplant each year.
• This includes 17,000 kidneys; almost 8,000 livers; 1,500 hearts; and 1,500 lungs.
• Because of costs to Medicare, OPO reform could also save up to $12 billion over 5 years in avoided dialysis costs.
• A key problem is OPOs are allowed to self-interpret and self-report their own performance, leading to a lack of transparency and accountability. As a result, no OPO has lost a government contract in decades.
• In fact, reporting suggests the current standards are unenforceable.
• The New York Times Editorial Board highlighted “an astounding lack of accountability and oversight in the nation’s creaking, monopolistic organ transplant system is allowing hundreds of thousands of potential organ donations to fall through the cracks.” 
• HHS/CMS’s proposed rule, published on December 17th, moves to objective data from the Centers for Disease Control, and shows the majority of the nation’s 58 OPOs are failing proposed performance metrics.
• CMS estimates that just bringing OPOs up to minimum compliance standards would mean 5,000 more deceased donor transplants every year. 
• Responses to the proposed rule are due by February 21st at 5pm ET.

Additional Resources

• Day One Project paper co-authored by Donna Cryer (President & CEO of Global Liver Institute), Jennifer Erickson (former Obama staffer), Crystal Gadegbeku (Council member, American Society of Nephrology and Section Chief of Nephrology, Temple University), Greg Segal (founder & CEO of Organize), and Abe Sutton (former Trump staffer)
• Senate Finance Committee oversight letter to Inspector General inquiring about OPO underperformance, fraud, waste and abuse, and conflicts of interest
• Senate Finance Committee oversight letter to UNOS inquiring about abdication of oversight responsibilities over OPOs 
• Representative Katie Porter oversight letter regarding OPOs, specifically the LA-based OPO known as One Legacy
• Senators Elizabeth Warren and Richard Blumenthal oversight letter to CMS regarding OPO performance and evaluation metrics
• Patient groups writing to Administrator Verma calling for OPO accountability: American Association of Kidney Patients, American Society of Nephrology, Cholangiocarcinoma Foundation, Fatty Liver Foundation, Global Liver Institute, Liver Education Advocacy and Prevention Services, Renal Physicians Association
• Politico Pulse Podcast interview with Greg Segal about the need for OPO reform

News

• Washington Post on Senate Finance Committee OPO oversight letter
• Associated Press on HHS proposed OPO rule

• Politico Pulse on HHS proposed OPO rule
• Full Frontal with Samantha Bee on OPOs never losing contracts
• Kaiser Health News about UNOS and OPOs losing organs in transit

Op eds

• USA Today: Andy Slavitt and Adam Brandon, “Here's how organ donation reform could save thousands of lives, billions in tax dollars”
• The Hill: Jennifer Erickson & Abe Sutton, “It’s Time to Provide Needed Reform to the Organ Donation System”
• New York Post: Dara Kass, “America’s Deadly Failure on Organ Donations”
• CNN: Bakari Sellers, “Dealing with a broken organ donation system after my 4 month old had liver failure”
• STAT: Laura and John Arnold, “A simple bureaucratic organ donation fix will save thousands of lives”
• Washington Post: “The Trump administration is actually doing something great on health care”
• Washington Post: Erika Zak, 39-year old mother who died during transplant, “A posthumous letter to my daughter”

The blowback following Trump's executive order concerning dialysis

It turns out that traditional dialysis providers are not rallying behind President Trump's suggestion that home dialysis could serve many more patients.

The Washington Post has the story:

Trump touted a kidney-care initiative in his State of the Union. But things are not going so smoothly. 
By Christopher Rowland

"The Trump administration has delayed a signature health-care initiative to boost the number of U.S. kidney patients who undergo dialysis at home and get transplants, amid resistance from kidney doctors and large dialysis companies whose payments from the Medicare system could be reduced under the plan.

Trump listed his plan to improve kidney care as a key initiative in his State of the Union speech this week.

But doctors and large dialysis corporations are seeking to remove or reduce proposed financial penalties for underperforming clinics. The new plan was supposed to take effect Jan. 1, but now the timetable is unclear."

Anat Admati on Economics and Politics

The title of Anat Admati's essay makes an abstract unnecessary. She's thinking of financial economics, but much of what she says will be of interest to market designers as well.

There is No Economics without Politics
Every economic model is built on political assumptions
By Anat Admati

"...historian Adam Tooze laments the narrowness of economics. He quotes economist Abba Lerner, who famously said in 1972: “Economics has gained the title Queen of the Social Sciences by choosing solved political problems as its domain.”

President Trump's Executive Order on kidney care

On July 10, while I was in China, President Trump issued an executive order touching on all aspects of care for kidney patients, including dialysis and transplantation from both deceased and living donors.

Here's the text of that executive order:
Executive Order on Advancing American Kidney Health
 Issued on: July 10, 2019

Because I anticipated being potentially incommunicado when the executive order was announced, I had filed an op-ed article (giving my proxy to my coauthor Greg Segal for any necessary last-minute edits) to be published on CNN's web site, applauding the order:
The Trump administration's organ donation efforts will save lives
By Alvin E. Roth and Greg Segal
Updated 1:20 PM ET, Wed July 10, 2019

As it happens, a reporter for PBS news hour reached me by phone in China, and so I got to chime in in person:
Trump’s plan to combat kidney disease aims to save money and lives. Can it?
Health Jul 10, 2019 4:39 PM EDT


The part of the executive order that touches most closely on my work on kidney exchange is Section 8:

"Sec. 8.  Supporting Living Organ Donors.  Within 90 days of the date of this order, the Secretary shall propose a regulation to remove financial barriers to living organ donation.  The regulation should expand the definition of allowable costs that can be reimbursed under the Reimbursement of Travel and Subsistence Expenses Incurred Toward Living Organ Donation program, raise the limit on the income of donors eligible for reimbursement under the program, allow reimbursement for lost-wage expenses, and provide for reimbursement of child-care and elder-care expenses."

Regarding deceased donor transplants, Section 7 says

"Sec. 7.  Increasing Utilization of Available Organs.  (a)  Within 90 days of the date of this order, the Secretary shall propose a regulation to enhance the procurement and utilization of organs available through deceased donation by revising Organ Procurement Organization (OPO) rules and evaluation metrics to establish more transparent, reliable, and enforceable objective metrics for evaluating an OPO’s performance.

(b)  Within 180 days of the date of this order, the Secretary shall streamline and expedite the process of kidney matching and delivery to reduce the discard rate.  Removing process inefficiencies in matching and delivery that result in delayed acceptance by transplant centers will reduce the detrimental effects on organ quality of prolonged time with reduced or cut-off blood supply."

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Here is some of the news coverage:

Trump signs executive order revamping kidney care, organ transplantation By Lenny Bernstein July 10 (Washington Post);
Trump signs executive order to transform kidney care, increase transplants 
By Jen Christensen and Betsy Klein, CNN Updated 4:21 PM ET, Wed July 10, 2019

This executive order is well worth supporting, and it will need support to achieve the goals it outlines.  The Secretary of Health and Human Services has been directed to do things in fairly broad terms, and we'll have to watch carefully to see the results, which will be interpreted, contested, and implemented through multiple political/regulatory processess

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Regarding removing financial disincentives for kidney (and liver) donors, I'm on the advisory board of the federally funded National Living Donor Assistance Center (NLDAC), which has been able, under very tight constraints, to reimburse some donors for some travel expenses (see related posts here).  A minimalist interpretation/implementation of the Executive Order would be to relax some of the constraints on whose expenses and which expenses can be reimbursed, and to increase NLDAC's budget accordingly.  A more expansive interpretation would be to remove some of those constraints so that no donor would have to pay to rescue someone with kidney failure by donating a kidney.

Repugnance in the runup to elections

Primary elections give political hopefuls a chance to try out their views on many things, including controversial transactions and markets, that some find repugnant.  The many potential Democratic candidates should give us an opportunity to hear about some of those (although none of them are likely to be part of platforms in the general election...)

Here's a CNN headline that cuts to the chase:

Drugs, sex work and gambling embraced by 2020 hopefuls
"A Democrat wants to legalize sex work. A Republican governor is trying to legalize sports betting in his state. The vast majority of Democrats running for President want to legalize marijuana.
...
"The effort led by Sen. Cory Booker to legalize marijuana doesn't really even feel that controversial. Not all of his potential rivals for the Democratic primary have signed on, but most have.
...
"Sen. Kamala Harris supports legalizing sex work, which she discussed with the website The Root, complaining that current law ends up hurting women more than johns and pimps who can benefit from prostitution.
"When you're talking about consenting adults, you know, yes, we should consider that we can't criminalize consensual behavior as long as no one is being harmed," she said."
...

"A 2018 Supreme Court decision cleared the way and among those pushing for sports betting is Maryland Gov. Larry Hogan, a Republican successful in a blue state and who has publicly teased a primary challenge to Trump.

"The odds are good that we're going to have sports betting," Hogan joked in January."

Should (government) economists be licensed? (Replies from a panel of academic economists)

The question below, on Occupational Licensing for Economists, is the latest question answered by the distinguished panel of (academic) economists who make up Chicago Booth's IGM Forum.  (IGM = Initiative on Global Markets.)

It took me a moment to parse the question, i.e. to figure out that "disagree" means that requiring a Ph.D. would be a good thing. (A number of those who did disagree nevertheless noted that the word "requiring" was perhaps stronger than they would like.)

For no particular reason, I'm reminded of the old Soviet joke about the party chairman reviewing the Victory Day Parade of troops marching and flying and riding before him in the Kremlin. At the end of the parade comes a jeep full of men in suits, and he inquires of the Field Marshall next to him on the grandstand: "Comrade Field Marshall, who are those people, and why are they in the parade?" To which the Field Marshall replies: Comrade Secretary, those are the economists. You have no idea the damage they can do."

I say it's a Soviet joke, but of course I heard in English, as a child in New York. So, during a visit to Moscow, I took the opportunity of saying to one of my local colleagues "I know a joke that I was told was an old Soviet joke." He listened to me tell it, and before I could identify the men in suits, he jumped in with the equivalent punchline he knew "they are Gosplan!"    So it turns out to be an old Soviet joke in Moscow as well as in NY.

That said, and to the point of the IGM question above, here in the U.S. I find myself missing the government economists of yore...

Understanding Markets Can Save Lives: Congressional Briefing and Reception, April 18

The Consortium of Social Science Associations (COSSA), of which the American Economic Association is a member, is sponsoring a Congressional Briefing on April 18. If you're in Washington next Tuesday you could come and cheer on those Congress folks who are interested in supporting science.

WHY SOCIAL SCIENCE? Because Understanding Markets Can Save Lives: Congressional Briefing and Reception

April 18 @ 3:00 pm - 6:00 pm

Discussion with Alvin Roth, Winner of the 2012 Nobel Prize in Economics

Tuesday April 18, 2017
3:00 pm – 4:30 pm
Reception from 4:30 – 6:00 pm
2167 Rayburn House Office Building

RSVP by April 13.

Dr. Alvin Roth is the Craig and Susan McCaw Professor of Economics at Stanford University, and the George Gund Professor Emeritus of Economics and Business Administration at Harvard University. Dr. Roth’s fundamental research in market design has revolutionized kidney exchanges, allowing incompatible patient-donor pairs to find compatible kidneys for transplantation. Dr. Roth’s matching theories have also been applied to school matching systems used in New York City, Boston, Denver, New Orleans, and several other cities, among other applications.

Come learn how social science can have real, significant impacts on our everyday lives, often in unexpected ways.

This widely attended event is made possible with support from Representative Eddie Bernice Johnson and SAGE Publishing.