My brother and the failure of TrumpCare

Why, please ask yourself, do the Republicans, after years of wishing to replace the Affordable Care Act, have no replacement even they can support? One clear answer is illustrated by my brother, Jason Levitis, an unsung American hero. I've mostly kept quiet about this, because he has, but the cat is out of the bag, Jason is out of government, and the time has come. In his recent article in Vox, his byline reads, "Jason A. Levitis is a senior fellow at the Solomon Center for Health Law and Policy at Yale Law School. He led ACA implementation at the Treasury Department during the Obama administration." That's all true, but Jason was on this long before the ACA was law. He was the single most frequent visitor to the White House throughout the entire Obama administration, and he wasn't there for the tour. I feel safe in saying that no one in the world knows the Affordable Care Act better than my brother, or has thought more deeply about why each part of it functions as it does. When President Trump said, "Nobody knew health care could be so complicated," my response was, "actually, my brother knows exactly how complicated."

I can clearly remember Jason telling me that he was going to reform the U.S. healthcare system in the year 2000. He and I were both recovering from injuries, limping through the newly reopened Hayden Planetarium at the American Museum of Natural History. Both of us, as patients, had been screwed by the healthcare system. Our parents, both physicians, had recently retired early because they just couldn't stand being part of that system anymore. As we crept along, two very similar looking young men on canes, to an evening planetarium show, he explained matter-of-factly that he had decide that the most important thing he could do was fix American Healthcare. This, he explained, would require years of work to understand the system, probably a law degree, the building of connections in the policy world, and an activist White House brave enough to succeed where "HillaryCare" had failed. His younger brother, I had to admit he was talented enough to carry out each step, and still found it improbable.  As we watched billions of years of galactic evolution whiz around us, I wondered how long my always swirling brother could focus on this very long-term plan.

Seventeen years later, he is still following his plan. He built his detailed understanding of the system as a Senior Analyst in the health economics department at the Greater New York Hospital Association. Then he got his law degree at Yale. Then he built connections and expertise in health law at Connecticut Voices for Children. He moved from there to being a Senior Analyst and Counsel at the Center on Budget and Policy Priorities, a DC think tank that is just as wonkish and unflashy as its name implies. He testified before various state legislatures about earned income tax credits and other stuff that I only understand because he explains it well, and I thought his singular focus on health policy had melted. I was wrong. He had become a respected part of DC health policy wonkdom, and with his co-wonks was working up a national policy resembling Massachusetts’s health reforms, aka RomneyCare. By 2008, when Obama ran for president, their framework was far better developed than the final TrumpCare bill that failed today.

President Obama appointed Jason as Senior Advisor to the Assistant Secretary for Tax Policy, Department of the Treasury. In practice, Jason worked day and night, often over 100 hours a week, writing the text of the bill that would come to be known as the Affordable Care Act. He would come to an important family event and would pull out two Blackberries, communicating on both simultaneously with the half dozen other people writing the bill with him. He would go into the bathroom and be arguing with somebody about the wording and punctuation of some sentence that was likely to be challenged in court.  He fought for fine policy details that his training in both law and economics told him would actually help the American people, not just make good TV. He sat next to Obama's people as they testified before Congress, feeding them the details they needed to give full answers. He undertook endless last-minute rewrites to try to meet the demands of that one last wavering Democratic Senator. Once the bill became law, he spent years writing the regulations needed to implement it. He, with a few close colleagues, is the policy brain of the Affordable Care Act.

I tell you all of this not only to praise my brother, although he clearly deserves it. The Affordable Care Act has brought health coverage to millions of Americans, slowed the increase in healthcare costs, spurred needed innovation and raised standards across the American healthcare system, and in the process saved countless lives. My purpose here is not to litigate the merits of the law, but to point out the intellectual rigor at the heart of the Affordable Care Act, and contrast it with the mushy sloganeering and flailing demagoguery that is the Republican approach to health legislation. The entire Republican machine spent years scheming to replace the ACA, made that their mantra, and have utterly failed to find any solution that isn't demonstrably, disastrously worse. There is no Republican reflection of my brother, no Nosaj Sitivel, because one can't take the details and ramifications as seriously as Jason does without rejecting conservative "principles." There is no health policy wonk taken seriously by Republican leaders who saw these problems  two decades ago and resolved, without ideological baggage, to learn how to increase healthcare access and quality. There is no one in the Republican establishment willing to fight for effective policy that is hard to explain and harder to sell. So as many years as they spent railing against Obamacare's imagined failings, and promising to replace it with bottled heaven, they remain incapable of offering any substance. TrumpCare failed because nobody involved in writing it actually cares.

You want to know how to improve on the ACA? Ask my brother. He, of course, has detailed, well researched, carefully considered lists of fixes. Will our current all facade, no building, leaders implement any of that? Of course not, they want the ACA to fail so they can blame Democrats. But with the defeat of the American Health Care Act of 2017, it seems much more likely that government with an honest interest in good policy will be back. Facts matter, logic matters, policy matters, even in politics. And that is reason for hope.

Toddler naturalist

It was only 45 minutes until dinner and my girl was antsy. We decided to head out into the woods and see what we could see. We got on a bike brought along an almond and raisin snack, a water bottle, a doll, and stuffed orangutan. Five minutes later we were standing in the woods outside of town looking at this piece of wood. "This is a perfect cover object," I told Tigerlily. It was flat or even slightly concave underneath, it was on the soil but not in the soil, it was broad, and it was in the sunlight. "I want to look under it," she said. We lifted it up and found this shiny black toad.

We talked about toad poison and washing hands before eating. She hadn't finished her raisin and almond snack so only I held the toad.

Next we went for a little walk in the woods. She said she wanted to find insects. Instead, we found blackberries.

Or rather, she stumbled into them and I recognized what they were. I tried one just to make sure they were good, and they were. I didn't use my hands. Toad poison.

She left only the underripe ones. On our way back to our bike, she said, "what's this? An insect?" It was a beautiful dragonfly that I had walked right past. I couldn't get a good picture of it but you can get a sense of how colorful it was. 

Now it was dinner time and we walked straight back to our bike. My girl was tired and hungry but learning about the woods and was ready to come home.

Coming home now

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I have been asked to review another paper. It is for a very good journal. I have published with them and thought their editorial office did a good job. It is on a topic I am very interested in and know the literature on quite well. It is a professional responsibility.

I have no time. I have a million projects and papers I am behind on. I have a bunch of papers I could get out relatively quickly if only I had the time, and I really need to get papers out. When I was a kid and my father came home late every night, I swore I would never "accept a bunch of extra work responsibilities just because my colleagues relied on me." My daughter is so damn cute and changing so fast. Every time I see her she says, "I need you Daddy, I need you!" (actually more like, "I ne-Jew Daddy, I ne-Jew!!!"). How can I ignore an adorable two year-old who not only needs me, but tells me so? I can't.

I said yes to the review, because that is what I am supposed to say. I will do it, and do it right. Sigh. But not tonight.

Spanning the vastness

When I was but a lad, my siblings and I used to accuse my father of knowing everything, a charge he would always deny, observing that even excluding those things which are not known to anyone or are secret, and restricting ourselves to academic knowledge, there is more to know than any one person or any thousand people could possibly know.

To see why this is so, consider the sheer volume of scientific literature being produced. ISI Web of Knowledge, an online tool used primarily by scientists for finding scientific literature relevant to their work, indexes the contents of over 23,000 academic and scientific journals. Many lesser known, newer or otherwise less main-stream or traditional journals are not indexed at all. One needs to go to other databases to find information published in books, or in dissertations, or, or, or.

Like my father (as I am in most things), I find myself far too mortal to know any meaningful fraction of anything, even if we restrict ourselves just to academic biology. I'd say there are roughly 8000 peer-reviewed journals in which biological work is regularly published, and if you add up all the papers I skim through, it is probably the equivalent number of pages of the output of two or three of these. The papers I read in detail if assembled together would surely make up much less than the output of a single journal. And I put more time into reading and therefore less into writing than is optimal for my career.

One result of this is that I frequently find out that there exist thriving sub-disciplines of biology of which I have almost no knowledge. For example, only last week I for the first time heard the word "metabolomics." Google Scholar lists over 6000 papers in the last year on this rapidly expanding field about which I know no more than I could guess based on the name.

My knowledge of transcriptomics was quite as absent three years ago. Transcriptomics is the study of RNAs in the cell, generally in the context of gene expression patterns. I became interested in transcriptomics because I proposed that mortality risk during embryonic development would be highest at those stages at which gene expression patterns were changing fastest. I was a doctoral student at the time, and my adviser asked me if there was any way of testing this idea. I had to admit I didn't know if it was possible to test because I didn't know enough about the field I have since learned is called transcriptomics. The answer is that yes, there is a way of testing the idea, but it will cost a couple of hundred thousand dollars, and require collaboration with people who read different journals than I do. I will never be an expert in transcriptomics, but I can find a colleague who is, but has little knowledge of evolutionary demography, and invite him to collaborate on a project that combines our expertise. And this is why science can be a somewhat unified pursuit despite having far more product than one person can read even the titles of.  

I referred in my last post to one of my advisers at Berkeley, and one of my all around favorite human beings, Ron Lee. Ron would always advise me to think about my relative advantage, by which he meant I shouldn't just work on the most interesting or best questions, as there are far too many. Rather, I should choose among them by considering which questions I was better placed, given my strengths and resource, to answer than was anyone else likely to work on the question. Ron's advice has always served me well, and so I do consider this before starting any project. Frequently, as with this developmental transcriptomics and demography project, my relative advantage arises from the fact that I am combining two fields separated enough that no one else is likely to ask the question any time soon. Evolutionary demography and developmental biology do not, as a rule, talk to each other. Many fields of biology have almost no communication with each other, leaving vast unexplored interdisciplinary territories (unless that is all in some set of journals I haven't come across yet).

Why no "grandfather effect"?

Much of my time at present is consumed by setting up an experimental test of what is known as the grandmother hypothesis. The grandmother hypothesis, in short, is the best guess we have as to why the females of humans and a few other species can live well past the age of reproductive cessation. In most species, and indeed in human males, there is no significant post-reproductive lifespan. Individuals are physiologically capable of reproducing for as long as they live. But the females of humans, a few other primates, a couple of cetations and maybe elephants go through menopause and then can live a significant portion of their lifespan after that. Our closest relatives, the chimps and bonobos, apparently go through menopause at the same age as our females, but live at most a few years after that.

Evolutionarily, this makes sense. If one is no longer increasing one's lifetime reproductive success, staying alive offers no obvious selective advantage. No point in investing in physiologies and structures that will last 100 years if one is only going to reproduce for 50 years. Better to put those resources into having more kids now.

But under a certain set of circumstances, reproduction does not end with, or shortly after, childbirth. If your young aren't really able to take care of themselves for a decade or two, you aren't done reproducing until they don't need you any more. In most hunter gatherer societies, the survival rate of five year olds whose mothers die is quite low. So for human women, having a kid in the last several years of life was likely a waste of time.

Worse, the kid who didn't make it took time and resources that could have been put into other kids, and childbirth, particularly late in life, is dangerous. Plus, elder human females are important for helping their daughters raise their own young, and learn how to do so. It has been shown that young mothers in several societies have a higher success rate raising kids if their mothers are around. The women who stopped having kids and focussed on the kids and grandkids they already had, and avoided the risk of late life childbirth, are thought to have ended up getting more of their genes into future generations than women who kept giving birth as long as they lived. If so, and if this variation in life history was heritable, which seems likely, this differential reproductive success would inevitably lead to a population with more and more women stopping early and fewer and fewer giving birth late in life. This is, we think, why we ended up with this "grandmother effect" of women living well past reproductive age.

The benefit of having a grandmother around seems to be restricted to maternal grandmothers. And this observation, that paternal grandmothers don't seem to make as much of a difference (at least in the societies studied) to the survival of their grandkids, points to at least two possible reasons why we don't see a "grandfather effect" to go along with this "grandmother effect."

First, in most societies, at least those studied in this context, males are providing less in the way of vital care. So if a women has a son who has kids, perhaps she is less involved in care, or in teaching how to care, because her son is not as involved as his mate in that care, and the daughter-in-law is not nearly as likely to look for advice and help from her husband's mother than her own mother. And perhaps this same logic applies to grandfathers on both sides. If they are not who the primary caregiver can go to for help and advice, the advantage of having them around to help is smaller.

Second, paternal grandmothers are less certain of which is really their genetic grandchild. If a woman gives birth to a daughter, and watches that daughter give birth to babies, she can be very confident that those are her descendants. If a woman gives birth to a son, and then watches that husband's mate give birth, there is a significant chance (and we have the genetic data to substantiate this) that the baby was fathered by some other man, and those babies aren't her genetic kin. So investing in them heavily may not be doing her any good. This argument is doubly true for grandfathers. The daughter who is giving birth may not even be his. A couple of generations removed, and who can be sure?

A final reason males may not have evolved to have a post reproductive period comes back to that risk in late life childbirth. Men don't give birth, so the risk to late life survival posed by late life reproduction may be greatly reduced, or completely absent. Without that trade-off, why not keep on breeding as long as possible?

Family of Science

I won't make a habit of this. But I thought posting this here would give the reader some sense of the environment that leads a young man to grow up and start Blog of Science!
For reasons unclear to me, my family has chosen to comment on my recent post "Not the end of the world" elsewhere, rather than on Blog of Science, so I have reproduced our discussion here. GML is my father, KAL my mother and JAL my brother. The following messages are in approximately chronological order:

The great physicist Enrico Fermi pointed out that interstellar travel is not very difficult for a technologically advanced and rich civilization, as long as it is designed for travel times of decades or centuries (or longer if a big colony is sent in a "generation ship". Each new colony would then grow and develop for some centuries, even a millennium, and then send out new ships (first to scout and then to colonize), and that this process would spread a civilization about our galaxy in a fairly short time, astronomically speaking, perhaps a few million years. Surely, the idea goes, at least one species somewhere would do this. This led to his famous question, "Where is everyone?" Many answers have been suggested, but the relevant one here is self-destruction, probably not by a physics experiment gone wrong, but by war within the species.
Our species has been said to need a "Moral Equivalent of War" to give us some outlet for our natural aggressive and us-them tendencies. This MEOW idea appeals to me, but I am not clear what it would be.
-GML

Dad, correct me if I'm wrong, but it was my impression that ETs wouldn't need to travel between stars for us to notice them. I thought even the level of radio noise that we currently produce would be plenty for us to notice if anyone were producing it within a few zillion light years. So the fact that we haven't heard anything (despite SETI and other projects looking for non-random radio signals) suggests not just that no one out there is traveling, but that no one out there is using radio waves, i.e., is technically advanced at all. Is that not right?
-JAL


There are a lot of assumptions we are making here.
Of which these are a few:
1. We are assuming that an advanced civilization uses radio waves to
communicate. Why do we assume this? We think we are advanced, and we
use radio waves. Perhaps radio is grossly inferior to something else we
ain't thought of yet, so nobody uses it.
2. They don't care if we hear them or not. Why do we assume this? We
don't worry about ETs detecting us, so we think they don't care if they
are detectable or not. Perhaps for one reason or another, many
civilizations consider it unwise or undesirable to broadcast their
presence.
3. We assume that if they are out there broadcasting radio, we would
pick up the signal. I don't know how far off we could pick up
broadcasts from a planet transmitting like Earth, unless we
specifically targeted that point in space, but I assume it is a
relatively small section of the galaxy.
4. We assume that if we picked up their signal, we would recognize it
as nonrandom. Given that we have no idea what form life on other
planets would take, it seems hubristic to assume that we would
recognize their transmissions as a sign of intelligent life.
5. We assume that if they picked up our signals, they would then
continue behaving in a way that would allow us to detect them. Imagine
there are technologically advanced aliens 100 light years away. They
detect rapid environmental change on earth, infer a rapidly developing
early technological civilization that behaves rather voraciously. Until
they know more, do they want the aliens (us) to know they are there?
The overarching point is that we know too little to know anything
except that we don't know. If we assume we are looking for ourselves,
which is what we often assume, we are wrong. The aliens are not going
to be biologically, psychologically or technologically familiar. they
are not going to live in a niche that would be amenable to us, and they
are not going to develop all the same technologies or develop them in
the same order. They are not going to have the same weaknesses and
strengths. They are not going to be in the same phase of develoopment,
or a similar one, to where we are. They are not necessarily going to
match our current definitions of either intelligence or life. It is fun
to speculate about and make up hypotheses, but we don't know enough to
draw any conclusions or moral lessons from. We know that either there
is no one out there, or that they are undetectable given our current
technology, or for one reason or another we have failed to detect them,
or have failed to notice detecting them. Everything else is SciFi.
-DAL

There is no reason why alien "life" should be carbon-based, or have discrete "bodies," or use the same senses we do (light, sound), or be on the same size scale as we - they might be miles across or microscopic or made up of filaments - or need the same amount of ambient radiation, heat, pressure, or environmental stability. There need not even be "individuals" with separate lives and separate mortalities. Probably some relatively fluid medium is needed - it would be hard to imagine solid rock being able to assume the complexity necessary for communication and reproduction. Otherwise I think that most human thought about the topic uses way too many chauvinistic assumptions. Long, thin necks and three-fingered hands, indeed!
-KAL

Interesting point. There are several factors to consider. The radio-based SETI and similar programs (mostly piggy-backing onto other equipment since Senator Proxmire made fun of it and got the U.S.Gov't to make it illegal to spend gov't money for it) make various reasonable (but not necessarily correct) assumptions about what frequencies would be used, as most free of background noise, etc., but at moderate interstellar distances such signals would be very hard to sort out, anyway. Also, higher-tech systems than radio (tachyons, gravity waves, links through space warps, etc.??) could be used, so lack of radio broadcasts does not mean lack of high technology. Another thought is that any sensible advanced species would carefully refrain from broadcasting its location, for fear of hostiles killing off possible competitors. No-one really knows, but the pay-off could be so great, technically and intellectually, that it seems worthwhile to put a little money into listening for interesting patterns; even if we do not find ETs, we may hear some natural phenomena worth knowing about. This has already happened, as when the pulsars (at first jokingly termed LGM for Little Green Men) were discovered.
-GML

Dan is quite correct in all his points, except perhaps in regard to our ability to recognize non-randomness. This is based on mathematics, mainly, not on biology or (I hope) human psychology. I certainly think that mathematics is universal; though I have no non-human examples as evidence. I believe that in some sense we discover mathematics, and do not just invent it.
-GML

Once mathematics is applied to trying to recognize patterns in real data, it becomes science, and all the limitations that come with science apply. We have to look at a particular set of time scales on a particular set of frequencies for a deviation from some mathematically defined but psychologically chosen null hypothesis. And all that means we don't really know if we could detect an alien deviation from random.
Regarding mom's point, it is very true, there is no reason to assume life on other planets would be carbon based. I wouldn't dismiss some sort of solid state lifeform though. Silicon can do amazing things.
-DAL

How about my idea that "life" elsewhere may accept very different conditions re solid/not solid "body" (or no actual body at all), tolerance/requirements for temperature conditions or radiation exposure, apparent passage of time per actual time passage, inevitability of mortality, use of other senses than sight/hearing, etc? Perhaps we haven't heard from anyone because we are actually very atypical in our characteristics and wouldn't think of the more common communication modalities. Or maybe no one else is out there and we are truly unique. Sometimes I think we exist only because the universe requires at least one set of observers in order for it to exist.
-KAL

Very true, that any collisions that CERN will make have happened, more powerfully, many times out in space, with no-one to register and measure them.
The Big BAng, from what I read, supposedly did not create any mass-energy, hard as that is to believe. The idea is that the expansion of the universe is, in proper physical book-keeping, measured in negative units, while the mass-energy is in positive units, and that these just cancel each other out. As you note that Stephen said, "on a minute scale the universe is a froth of energymass popping in and out of existence, but that these things were usually so small and numerous they mostly canceled each other out, leaving the energymass in the universe very close to
constant." Larger sized quantum fluctuations are shorter-lived than smaller ones, and if the universe is thought of as a nearly-zero mass virtual particle, it can last a very long time. Mass-energy versus time is one of those complementary trade-offs found in quantum physics, such as (knowledge of?) a particle's momentum vs. (knowledge of?) its position.
-GML

So we can get de novo mass-energy as long as we are willing to accept an equal amount of de novo space-time with it?
-DAL

Yes, in a sense, we can get more mass-energy along with more space-time, but only in a new universe, I gather. A prominent current theory is that black holes create new baby big bangs which then expand as full fledged universes; if the characteristics of a given universe leads to lots of black holes, that kind of universe will end up with lots of descendant universes with similar (but not identical) properties, leading to universes with successful characteristics (physical constants, etc.) becoming more numerous and predominating, in a Darwinian fitness paradigm. This theory is supposedly testable by figuring out what set of physical constants, etc., should be most successful in making black holes of the right sorts, and seeing how well this matches our universe.
-GML

But Darwinian evolution requires:
1. Mutations leading to variation
2. Heritability of that variation
3. Fitness differentials based on the heritable mutations
With regard to black holes as baby universes, we have no reason to assume 1 or 2, only that if 1 and 2 were to be true, that 3 could be true.
Also, your last comment implied that in order to be stable, a big bang event would have to result in something that in some strange sort of reckoning had zero mass. Black holes are not known for having zero mass.
There also seems to be the difficulty that black holes are not closed systems. Mass can go in and through quantum variation of location, evaporate off. Universes on the other hand are generally thought to be closed.
-DAL