Later On

A blog written for those whose interests more or less match mine.

Politics of climate change, a video by Sen. Sheldon Whitehouse (D-RI)

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Written by LeisureGuy

27 April 2017 at 6:41 pm

A party that protects its ignorance: LA Times “GOP shuts out doctors, experts, Democrats — pretty much everybody — as they work on Obamacare repeal”

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The GOP is willfully ignorant, and Noam Levey’s article in the LA Times provides an excellent example.

President Trump and House Republicans, in their rush to resuscitate a bill rolling back the Affordable Care Act, are increasingly isolating themselves from outside input and rejecting entreaties to work collaboratively, according to multiple healthcare officials who have tried to engage GOP leaders.

The White House and its House GOP allies are hoping to reschedule a vote on their overhaul plan in the coming days, following last month’s embarrassing retreat when the bill was pulled shortly before a vote.

But they continue to refuse to reach out to Democrats. Even Senate Republicans have been largely sidelined, though their support will be crucial to putting a measure on Trump’s desk.

And senior House Republicans and White House officials have almost completely shut out doctors, hospitals, patient advocates and others who work in the healthcare system, industry officials say, despite pleas from many healthcare leaders to seek an alternative path that doesn’t threaten protections for tens of millions of Americans.

“To think you are going to revamp the entire American healthcare system without involving any of the people who actually deliver healthcare is insanity,” said Sister Carol Keehan, president of the Catholic Health Assn., whose members include many of the nation’s largest medical systems.

Health insurers, who initially found House Republicans and Trump administration officials open to suggestions for improving insurance markets, say it is increasingly difficult to have realistic discussions, according to numerous industry officials.

“They’re not interested in how health policy actually works,” said one insurance company official, who asked not to be identified discussing conversations with GOP officials. “It’s incredibly frustrating.”

Another longtime healthcare lobbyist, who also did not want to be identified criticizing Republicans, said he’d never seen legislation developed with such disregard for expert input. “It is totally divorced from reality,” he said.

The result may be a short-term victory for House leaders and the White House as Trump nears his 100-day mark, assuming they muster the votes this time. But prospects for final passage of a healthcare overhaul bill remain dim.

House Speaker Paul D. Ryan’s office did not respond to a request for comment.

Trump and senior House Republicans have steadfastly defended their bill, however, promising it would lower healthcare costs while preserving protections for vulnerable Americans.

“The plan gets better and better and better,” Trump said last week at the White House. “And it’s gotten really, really good. And a lot of people are liking it a lot.” . . .

Continue reading.

Written by LeisureGuy

27 April 2017 at 5:29 pm

The Noakes trial exposes the power and dishonesty of business-funded research

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I blogged yesterday links to posts about the Noakes trial in South Africa: he tweeted a recommendation for weaning a baby onto a low-carb high-fat diet (e.g., not focused on cereals) and as a result became the target of a vindictive campaign to smear his name and wreck him professionally, a campaign that failed utterly.

It’s an amazing clown show. The organization charging Noakes stalled until they could do a meta-analysis to disprove his findings, but the meta-analysis was so badly flawed it was clearly intended merely as an attack: it included studies that did not meet the criteria established by the meta-analysis authors, it included several studies that showed that supported the advice Noakes gave.

In addition the organization issued a press release in October of last year saying that Noakes had been found guilty. But the trial was not over and in fact the final decision was just announced. Although the press release was quickly retracted (after it had gone viral on social media in South Africa), its release does show bad faith (and incompetence) by the organization that brought the charges.

It’s quite a drama if you read it all. Nina Teicholz (a favorite of mine for her excellent book The Big Fat Surprise).

The best articles seem to be in FoodMed.net, and they have a category for the Noakes trial. The articles are listed in descending chronological order, so start with the last article listed and read your way up. It really is fascinating.

Written by LeisureGuy

27 April 2017 at 4:00 pm

How the South betrays its citizens

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Kevin Drum has a good post. Here’s one of the charts from the post:

Written by LeisureGuy

27 April 2017 at 3:02 pm

Salt: The single most important ingredient

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Samin Nosrat writes in the NY Times:

Growing up, I thought salt belonged in a shaker at the table, and nowhere else.

I never added it to food, or saw Maman add it. When my aunt Ziba sprinkled it onto her saffron rice at the table each night, my brothers and I giggled. We thought it was the strangest, funniest thing in the world.

I associated salt with the beach, where I spent my childhood seasoned with it. There were the endless hours in the Pacific near our home in San Diego, swallowing mouthfuls of ocean water when I misjudged the waves. Tidepooling at twilight, my friends and I often fell victim to the saltwater spray while we poked at anemones.

Maman kept our swimsuits in the back of our blue Volvo station wagon, because the beach was always where we wanted to be. She was deft with the umbrella and blankets, setting them up while she shooed the three of us into the sea. We would stay in the water until we were starving, scanning the beach for the sun-faded coral-and-white umbrella, the landmark that would lead us back to her.

She always knew exactly what would taste best when we emerged: Persian cucumbers topped with sheep’s milk feta cheese, rolled together in lavash bread. We chased the sandwiches with handfuls of ice-cold grapes or wedges of watermelon to quench our thirst.

That snack, eaten while my curls dripped with seawater and salt crust formed on my skin, always tasted so good. Without a doubt, the pleasures of the beach added to the magic of the experience, but it wasn’t until many years later, while I was working at Chez Panisse, that I understood why those bites had been so perfect from a culinary point of view.

It was there that Chris Lee, a chef who took me under his wing, suggested I pay attention to the language the chefs used in the kitchen, how they knew when something was right — these were clues for how to become a better cook. Most often, when a dish fell flat, the answer lay in adjusting the salt. Sometimes it was in the form of salt crystals, but other times it meant a grating of cheese, some pounded anchovies, a few olives or a sprinkling of capers. I began to see that there was no better guide in the kitchen than thoughtful tasting, and that nothing was more important to taste thoughtfully for than salt.

One day, as a young cook in the prep kitchen, I was tasked with cooking polenta. Milled from an heirloom variety of corn, the polenta at Chez Panisse tasted of sweetness and earth. The chef, Cal Peternell, talked me through the steps for making it, and I began cooking. Consumed by the fear of scorching and ruining the entire pot — a mistake I had seen other cooks make — I stirred maniacally.

After an hour and a half, I brought Cal a spoonful of the creamy porridge to taste, looking up at him with equal parts respect and terror. “It needs more salt,” he deadpanned. Dutifully, I returned to the pot and sprinkled in a few grains of salt, treating them with the preciousness I might afford, say, gold leaf. I thought it tasted pretty good, so I returned to him with a spoonful of my adjusted polenta.

This time he marched me back to the pot and added not one but three enormous palmfuls of kosher salt. The perfectionist in me was horrified. I’d wanted so badly to do that polenta justice, and the degree to which I’d been off was exponential. Three palmfuls!

Cal grabbed spoons and together we tasted. The corn was somehow sweeter, the butter richer. All of the flavors were more pronounced. I had been certain he had ruined the pot and turned my polenta into a salt lick, but the term salty did not apply to what I tasted. All I felt was a satisfying zing with each mouthful.

Having experienced the transformative power of salt, I wanted to learn how to get that zing every time I cooked. I thought about the foods I loved to eat growing up — and that bite of seaside cucumber and feta, in particular. I realized then why it had tasted so good. It was properly salted.

Salt and Flavor

James Beard, the father of modern American cookery, once asked, “Where would we be without salt?” I know the answer: adrift in a sea of blandness. Salt has a greater impact on flavor than any other ingredient. Learn to use it well, and food will taste good.

Salt’s relationship to flavor is multidimensional: . . .

Continue reading.

Written by LeisureGuy

27 April 2017 at 2:29 pm

Posted in Food

America’s Other Drug Problem

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Marshall Allen reports in ProPublica:

Every week in Des Moines, Iowa, the employees of a small nonprofit collect bins of unexpired prescription drugs tossed out by nursing homes after residents died, moved out or no longer needed them. The drugs are given to patients who couldn’t otherwise afford them.

But travel 1,000 miles east to Long Island, New York, and you’ll find nursing homes flushing similar leftover drugs down the toilet, alarming state environmental regulators worried they’ll further contaminate the water supply.

In Baltimore, Maryland, a massive incinerator burns up tons of the drugs each year — for a fee — from nursing homes across the Eastern seaboard.

If you want to know why the nation’s health care costs are among the highest in the world, a good place to start is with what we throw away. Across the country, nursing homes routinely toss large quantities of perfectly good prescription medication: tablets for diabetes, syringes of blood thinners, pricey pills for psychosis and seizures.

At a time when anger over soaring drug costs has perhaps never been more intense, redistributing discarded drugs seems like a no-brainer. Yet it’s estimated that American taxpayers, through Medicare, spend hundreds of millions of dollars each year on drugs for nursing home patients — much of which literally go down the tubes.

“It would not surprise me if as much as 20 percent of the medications we receive we end up having to destroy,” said Mark Coggins, who oversees the pharmacy services for Diversicare, a chain of more than 70 nursing homes in 10 states. “It’s very discouraging throwing away all those drugs when you know it can benefit somebody.”

No one tracks this waste nationwide, but estimates show it’s substantial. Colorado officials have said the state’s 220 long-term care facilities throw away a whopping 17.5 tons of potentially reusable drugs every year, with a price tag of about $10 million. The Environmental Protection Agency estimated in 2015 that about 740 tons of drugs are wasted by nursing homes each year.

This is, of course, part of a bigger problem. The National Academy of Medicine estimated in 2012 that the United States squanders more than a quarter of what it spends on health care — about $765 billion a year.

ProPublica is investigating the types of waste in health care that academics and politicians typically overlook. Our first installment examined the tens of millions worth of equipment and brand new supplies that hospitals jettison.

Today we look at the wasteful, and potentially harmful, ways nursing homes dispose of leftover meds — and how some states, like Iowa, have found a solution.


On a recent Wednesday in Des Moines, Ami Bradwell, a certified pharmacy technician, popped open the lids of several 31-gallon bins full of prescription drugs. In each were hundreds of what are known as “bingo cards” filled with rows of pills in sealed bubbles.

“Metformin — for diabetics,” Bradwell said, holding up a card of large white pills. “It’s not crazy expensive, but it’s in high demand.”

She held up an entire box of the anti-nausea drug Ondansetron. It goes for about $5 a pill, according to the website drugs.com. “Expensive.”

Another card had three large pills stuffed in each chamber, a find Bradwell called “a ‘jackpot’ card. You can’t live without it because it’s a seizure medication.”

Bradwell works for the nonprofit SafeNetRx. Each week the group takes in dozens of bins full of such drugs, as well as boxes mailed in from across Iowa and several other states — pharmaceutical trash that exists because, for convenience and cost, long-term care pharmacies often dispense nursing home patients’ medications in bulk, a months‘ worth at a time.

Should a patient die, leave or stop taking the drug, what’s left is typically tossed. The drugs have already been paid for, by Medicare in most cases, so there’s little incentive to try to recycle them. In some states, such reuse is against the law.

Some of the cards Bradwell examined that day were missing only a few pills. One card had been thrown out even though it only lacked one of its 31 doses of oxybutynin, which reduces muscle spasms of the bladder. The remaining 30 are worth more than $13.

“There are literally millions of dollars of prescription medications thrown away every day in this country,” said John Forbes, an Iowa pharmacist who dispenses SafeNetRx’s recovered drugs to his low-income patients.

Although most states technically allow some leftover drugs to be recycled, Iowa is one of the few rescuing a significant percentage of the drugs from destruction. The state funds the program for about $600,000 a year, said SafeNetRx CEO Jon Rosmann, who calls it a “common sense” solution. In fiscal 2016 the program recovered and distributed drugs valued at about $3.4 million. This year it’s on pace to top $5 million. . .

Continue reading. There’s a lot more, and it is interesting.

Written by LeisureGuy

27 April 2017 at 2:06 pm

What Trump and his staff are learning in the White House

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Politico has a fascinating report by Josh Dawsey, Shane Goldmacher, and Alex Isenstadt:

The 70-year-old leader of the free world sat behind his desk in the Oval Office last Friday afternoon, doing what he’s done for years: selling himself. His 100th day in office was approaching, and Trump was eager to reshape the hardening narrative of a White House veering off course.

So he took it upon himself to explain that his presidency was actually on track, inviting a pair of POLITICO reporters into the Oval Office for an impromptu meeting. He sat at the Resolute desk, with his daughter Ivanka across from him. One aide said the chat was off-the-record, but Trump insisted, over objections from nervous-looking staffers, that he be quoted.

He addressed the idea that his senior aides weren’t getting along. He called out their names and, one by one, they walked in, each surprised to see reporters in the room—chief of staff Reince Priebus, then chief strategist Steve Bannon, and eventually senior adviser Jared Kushner. “The team gets along really, really well,” he said.

He turned to his relationships with world leaders. “I have a terrific relationship with Xi,” he said, referring to the Chinese president, who Trump recently invited for a weekend visit at his Mar-a-Lago resort.

Finally, he rattled off the biggest hits of his first three months and promised more to come.

It was classic Trump: Confident, hyperbolic and insistent on asserting control.

But interviews with nearly two dozen aides, allies, and others close to the president paint a different picture – one of a White House on a collision course between Trump’s fixed habits and his growing realization that this job is harder than he imagined when he won the election on Nov. 8.

So far, Trump has led a White House gripped by paranoia and insecurity, paralyzed by internal jockeying for power. Mistrust between aides runs so deep that many now employ their own personal P.R. advisers — in part to ensure their own narratives get out. Trump himself has been deeply engaged with media figures, even huddling in the Oval Office with Matt Drudge.

Trump remains reliant as ever on his children and longtime friends for counsel. White House staff have learned to cater to the president’s image obsession by presenting decisions in terms of how they’ll play in the press. Among his first reads in the morning is still the New York Post. When Trump feels like playing golf, he does — at courses he owns. When Trump feels like eating out, he does — at hotels with his name on the outside.

As president, Trump has repeatedly reminded his audiences, both public and private, about his longshot electoral victory. That unexpected win gave him and his closest advisers the false sense that governing would be as easy to master as running a successful campaign turned out to be. It was a rookie mistake. From the indignity of judges halting multiple executive orders on immigration-related matters—most recently this week—to his responses to repeated episodes of North Korean belligerence, it’s all been more complicated than Trump had been prepared to believe.

“I think he’s much more aware how complicated the world is,” said former House Speaker Newt Gingrich, who serves as an informal administration adviser. “This will all be more uphill than he thought it would be because I think he had the old-fashioned American idea that you run for office, you win, then people behave as though you won.”

Trump has had some successes. He nominated and saw confirmed a new Supreme Court justice, rolled back Obama-era regulations, and oversaw dramatic military actions in Syria and Afghanistan. He has signed rafts of executive actions, unilateral decisions familiar to the former Trump Organization president.

Yet he approaches the 100-day mark with record-low approval ratings and no major legislative accomplishment to his credit. Nothing hit Trump harder, according to senior White House officials, than the congressional defeat of his first major legislative package—the bill to repeal Obamacare. As he sat in the Oval Office last week, Trump seemed to concede that even having risen to fame through real estate and entertainment, the presidency represented something very different.

“Making business decisions and buying buildings don’t involve heart,” he said. “This involves heart. These are heavy decisions.”

More than 200 of Trump’s campaign promises are scribbled in marker on a whiteboard in Steve Bannon’s West Wing office, which he calls his “war room.” Other pledges are printed and taped beneath a poster that says: “Make America Great Again.”

“Deport 2 million criminal illegal immigrants,” reads one pledge. Others call for all of President Obama’s executive orders to be reversed and for the U.S. to exit the North American Free Trade Agreement, or NAFTA. A few have large check marks next to them. Another sign notes 11 have been delayed. It’s a visual encapsulation of how Bannon sees the presidency about keeping promises.

In Kushner’s office, just steps away, there’s no “Make America Great Again” memorabilia. Instead, the whiteboard lists deadlines for bipartisan projects in his newly-founded Office of American Innovation on infrastructure and veterans’ affairs. Kushner often talks about the presidency like it’s a business, describing it privately as “entrepreneurial” and in “beta mode.” He often doesn’t mind when Trump flip-flops, if it’s in the service of striking a deal.

The gap in worldview and temperament between the two has produced the most combustible, and consequential, conflict in the West Wing. In the first days following Trump’s inauguration, it was Bannon who pushed to speed through a blitz of executive orders, including the ill-fated travel ban. And it’s been Kushner, a 36-year-old real estate scion, who’s leaned the other way, encouraging his capricious father-in-law to espouse less divisive positions.

“It’s an ideas and ideology battle every day,” one senior administration official said.

Perhaps the defining and unanswered question of the Trump presidency is what he truly believes in. Is he the inflexible immigration hardliner who described undocumented Mexican immigrants as “rapists” in his June 2015 kickoff speech or the president who recently said those brought here illegally as children should “rest easy” because he doesn’t plan to deport them? Will he try to make deals with Democrats? Or will he devote himself to Bannon’s nationalist agenda? And, other than winning, what does Trump really want?

No single day was more telling about the ambiguity of Trumpism than April 12. It was that day that Trump not-so-quietly reversed himself on at least four of his campaign promises. He canceled a federal hiring freeze imposed in his first week. He flipped on labeling China a currency manipulator. He endorsed the Export-Import bank that he had called to eliminate. He declared NATO relevant, after trashing it repeatedly on the campaign trail.

“I said it was obsolete,” Trump said. “It is no longer obsolete.”

Trump’s critics and supporters alike are equally flummoxed about what this president stands for. . . .

Continue reading. And do read the whole thing. Later:

“I kind of pooh-poohed the experience stuff when I first got here,” one White House official said of these early months. “But this shit is hard.”

and then later after that:

But they’re learning. One key development: White House aides have figured out that it’s best not to present Trump with too many competing options when it comes to matters of policy or strategy. Instead, the way to win Trump over, they say, is to present him a single preferred course of action and then walk him through what the outcome could be – and especially how it will play in the press.

“You don’t walk in with a traditional presentation, like a binder or a PowerPoint. He doesn’t care. He doesn’t consume information that way,” said one senior administration official. “You go in and tell him the pros and cons, and what the media coverage is going to be like.”

And more:

“He has always been a guy who loves the idea of being a royal surrounded by a court,” said Michael D’Antonio, one of Trump’s biographers.

Many of those aides spent the opening weeks of the presidency pushing their own agendas – and sparring with one another. Priebus brought into the White House his chief of staff, chief operating officer and chief strategist from the RNC; Bannon has his own P.R. person and two writers from Breitbart; Kushner brought allies from the business world, and recently recruited his own publicity adviser; Conway has her own chief of staff; now Ivanka Trump has a chief of staff, too.

Written by LeisureGuy

27 April 2017 at 1:55 pm

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