Tuesday, January 20, 2015

Yet more from the NEJM

Just finished writing this post when I see yet another Perspective article in the New England Journal regarding the ACA.

The Perspective article details the enormous problems for Obamacare that  a win for the plaintiffs in the Supreme Court case King v. Burwell would entail. It is clearly important to proponents of the Affordable Care Act that the plaintiff's case be weak and that the defense prevails. Indeed, the strength of the plaintiff's case is of such great consequence for Obamacare that you would think that the editors would want to see that it was covered fairly.

Here is the sentence regarding the argument at the heart of the case: "The case hinges on enigmatic statutory language that seems to link the amount of tax credits to a health plan purchased 'through an Exchange established by the State.' According to the plaintiffs in King, that language means that consumers who buy insurance through federally run exchanges don't qualify for subsidies"

The authors cannot get around the fact that the law states that only participants in exchanges established by state governments are entitled to subsidies (contrary to how the subsidies are currently being distributed).  When the authors say that the wording "seems" to link eligibility for tax credits to buying insurance through a state--rather than the federal--exchange, what they mean is that the law does make that link: they just can't bring themselves to state so plainly, hence the weak attempt to introduce uncertainty.

Of greater interest, the NEJM editors also let the word "enigmatic" slip by. Surely they could have at least provided some hint that the rationale here is not at all enigmatic. Perhaps the best way to understand the rationale is listen to Jonathon Gruber, a key architect of Obamacare, plainly lay the rationale out (lately proponents of the bill have--for obvious reasons--tried to make Gruber's role disappear). Anyone paying attention to the ACA litigation--including the NEJM editors--must be aware of the relevant Gruber videos: they received a lot of attention when they were uncovered. The linkage of subsidies to state exchanges is logical, not mysterious: the purpose is to strongly incentivize states to set up exchanges. Relevant discussions and links to the pertinent Gruber recordings can be readily found through Googling: here is one and another and a third.

Dear NEJM: please think about the balance between functioning as a journal of political advocacy and your general credibility.

Sunday, January 11, 2015

The Lancet: much, much worse

(Continued from prior post:  The politicalization of two major medical journals: bad and much, much worse)

In contrast to the NEJM, the Lancet has long evidenced obvious biases. This has done much to severely damage its credibility. The Journal is run for Elsevier by Jon Horton, who seems to be a man of the European left. His editorial judgments have landed the journal in trouble before. For example, he published two politically-motivated studies from a group at Hopkins purporting to look at deaths in Iraq attributable to US military actions. These studies were later found to be seriously flawed and biased by politically-motivated funding.

Worse, though, is Horton's turning what should be a prestigious journal of clinical medicine into a platform for obnoxious anti-Israel propaganda. Recently, as just one example, he discredited himself and his journal by publishing a letter in the middle of the most recent Gaza war authored by a group of viciously anti-Israel activists. Among others, the authors included two who have worked with the former Ku Klux Klan member and current neo-Nazi David Duke and also a maoist, pro-Hamas, strident anti-Israel activist. Later, as the antisemitism underlying the letter became more evident, Horton claimed to be sorry for publishing it. He has yet to remove it from the Lancet's website.

The Lancet reflects poorly on Elsevier and, arguably, on the British medical establishment. Elsevier needs to rethink its staffing of the journal.

The politicalization of two major medical journals: bad and much, much worse

The New England Journal of Medicine purports to take no position, pro or con, on Obamacare. The Editor-in-Chief and Executive Editor have come out in favor, yet, somehow, despite their biases--they claim--the Journal itself has not staked out a position. This is risible.  I subscribe to and very much like the NEJM, but ever since the Affordable Care Act (ACA) was first proposed, the Journal has been flogging Perspectives and other articles written by advocates as if it were a journal of politics and political policy: routinely publishing articles that could just as easily be found on the Op-Ed pages of newspapers or in any number of--primarily left-leaning--political/policy journals. Yes, they have published articles written by skeptics here and there (I can recall only one right now), but basically the Journal has been pushing Obamacare since the get-go: it's not subtle.

No forum for pro-ACA writings would be complete without an essay or two from the egregious Jonathon Gruber. The NEJM's conflict of interest policies has spared the Journal criticism for not disclosing Gruber's financial links to the ACA: if readers took the time and looked closely enough, they could find the NEJM's mandated disclosure (there has typically been no disclosure elsewhere he has been published or quoted). However, I doubt that even NEJM readers who found the disclosures knew at the time of the magnitude of Gruber's financial interests in the ACA. These amounted to millions of dollars: $400,000 from the feds alone.  Would the Journal let a consultant being paid millions of dollars by Amgen write a perspective advocating for more Epogen use?  If so, would a hard-to-notice financial disclosure statement be adequate, or would perhaps a disclosure need to be included in the text?

One final question: now that we know that Gruber has intentionally obfuscated important facts about Obamacare and has attempted to deceive the Congress and US electorate on key policy points, does the NEJM need to go back and look at his articles?  I bet they would have a second look at, say, a clinical trial that was published by an investigator later have found to have published fraudulent manuscripts.

I really like the Journal. It has been painful to see the Journal become so politicized during the ongoing debate surrounding Obamacare. The claim cited above that the Journal has not taken a position is belied by the articles that make it into its pages.

Continued in next post: Much, much worse