Tuesday, January 29, 2013

Blaming the Patient

"Discrimination against heavy people, by the general public and medical professionals, might be a greater health and social problem than any extra pounds they may be carrying" argues UCLA Professor Abigal Saguy, PhD, in a provocative essay in the Washington Post.  "Despite the fact that body weight is largely determined by an individual’s biology, genetics and social environment, medical providers often blame patients for their weight and blame their weight for any health problems they have" she writes, comparing such "size profiling" to "racial profiling." 

"Both types of profiling" she continues "lead to false positives (people wrongfully accused or medically overtreated) and false negatives (people who get away or are medically undertreated)."

I think comparing "size profiling" to the horrible continued legacy of racism is a stretch, but Dr. Saguy has a point--some clinicians seem quick to blame their patients for being overweight.  And also for smoking, for abusing drugs and alcohol, for eating unhealthful diets, for not exercising enough, for not taking their prescribed medications and for not following their physician's advice.  I have heard some internists rail against patients who are "not taking responsibility" for their own health, demanding to know what the ACP is doing to make people accept more responsibility.

I can sympathize with physicians who are doing everything they can to help their patients improve their health, only to encounter patients who continue to do bad things to their health.  Especially, if the physician is subjected to performance measures that penalize them when their patients don't have the desired outcomes.  No one wants to be blamed for things outside of their own control!

But this is true of patients as well.

 The "blame the patient" attitude assumes that how much we weigh or how sick or well we are is mostly a matter of will power. Sure, there are things that each of us can do (and don't do) that can help make us less or more healthy.  But many of these things--eating better, exercising more, not smoking, not drinking to excess--may be very difficult or even impossible for some people to achieve because of genetics (family history of alcoholism and other substance abuse), culture and community (the diet your grew up with, the food choices available to you in your community, exposure to crime and violence), stress, literacy, physical and emotional abuse, how you were raised by your parents, the quality of your schools--the list goes on and on.  And even if you do everything right, it may not work--eating well and exercising does not guarantee that someone won't be overweight.  And being overweight doesn't guarantee you will get sick.

The "blame the patient" philosophy also shows up in public policy proposals: high deductible health plans that by definition mean that the sick will pay more out-of-pocket (because they need and use more health services) than the well (because they need and use fewer health care services); higher co-payments for receiving non-emergency care in emergency rooms (which disproportionately affect poor people in poor health who may not have good access to community-based primary care); and proposed regulations that allow employers to charge higher health insurance premiums or impose other rewards and penalties to employees based on how well they achieve improvements in their own health status. 

Yesterday, House Democrats sent a letter to the Obama administration, objecting to a proposed rule that allows employers to establish "health-contingent wellness programs" that "allow differential rewards based on health status factors, including a person's cholesterol, blood pressure, weight or body mass index."   The lawmakers argued that such programs would undermine the ACA's prohibition on discrimination against persons with pre-existing conditions, and would disproportionately harm "certain population groups, including racial and ethnic minorities, such as  Hispanics, African-Americans, and some Asian groups [with] a higher proportion of known genetic predisposition for certain illnesses that are screened through biometric measurement such as cholesterol or blood sugar levels."  

ACP, in a comment letter on the same proposed rule, similarly stated "that wellness programs must not be used as a means to discriminate against the sick and vulnerable. Wellness programs must be developed to encourage prevention and improve health rather than penalize those who are medically unable to meet wellness program goals." 

And ACP's ethics policy, developed by its Committee on Ethics, Professionalism and Human Rights, states that "Incentives to promote behavior change should be designed to allocate health care resources fairly without discriminating against a class or category of people. The incentive structure must not penalize individuals by withholding benefits for behaviors or actions that may be beyond their control. Incentives to encourage healthy behaviors should be appropriate for the target population. The American College of Physicians supports the use of positive incentives for patients such as programs and services that effectively and justly promote physical and mental health and well-being."

Objecting to stigmatizing and punishing patients because of their body weight, health status, genetics, and personal choices is not the same as arguing that patients shouldn't be engaged in, and responsible for, making contributions to their own health.  Physicians can and should engage patients in shared decision-making about their health.  They should engage patients in helping them understand their risk factors and how they might help reduce their risks.  They should help them succeed and also support them if they fail. 

Physicians can also advocate for public policies to engage and empower patients in healthcare decision-making--such as for reimbursement changes to allow physicians to spend the time required for effective shared decision-making and creating positive incentives to help people access effective weight-loss or other wellness programs. While advocating against policies to stigmatize and punish people for their health status.

As my mother might say, no one likes a scold.  Let's stop scolding people for supposedly not doing enough to stay healthy.  And instead, lets start helping them be as healthy as they can and make sure they are cared for when they are sick, no matter what they did or didn't do when it comes to taking care of their own health or the genes they inherited from their parents.

Today's questions:  Do you agree with Dr. Saguy that many in the medical profession stigmatize patients for being overweight and other aspects of their health?  How do you feel about programs that would penalize people for not achieving measurable improvements in their health?

Thursday, January 24, 2013

Is Global Capitation a Better Way to Pay Primary Care Physicians?

Despite  the clamor about new ways of paying physicians, the reality is that most continue to be paid under a fee-for-service basis, and likely will be for some time.  Even under the ballyhooed “new models”, like Medicare’s Accountable Care Organizations  and Comprehensive Primary care Initiative (which is based on the Patient-Centered Medical Home concept), most physicians will continue to be paid principally on a fee per-visit and procedure basis.  In the case of ACOs, it is  fee-for-service plus/minus shared savings, and in the case of Comprehensive Primary Care Initiative, it’s fee-for-service plus monthly risk-adjusted care coordination payments for each patient seen by the practice, linked to measures of performance.

Might it not be better to drop fee-for-service altogether, and instead pay primary care physicians on a global capitation basis?  Under global capitation, primary care physicians would get a set amount of money each month for each of their patients, with the monthly amount per patient being adjusted upward or downward based on the relative complexity/risk of each patient in the physicians’ panel.

ACP members Drs. Allan Goroll and Bob Berenson, and two other co-authors, proposed such a fundamental change in how primary care physicians are paid, in an article published five years ago in the Journal of General internal Medicine.  They studiously avoided calling their proposal capitation, because “proposing a comprehensive, aggregate payment is likely to evoke memories of primary care capitation with its pejorative connotations; however, there are important differences, which lead us to avoid using the term ‘capitation’ to describe our system. The most important differences are risk/needs-adjustment, paying for performance to guard against underservice, and budgeting sufficient monies to support teams and infrastructures. These features are essential to avoiding the withholding of necessary care and the shunning of complex patients that too often occurred under the capitation initiatives of the past decade."

From a payer’s perspective, the advantage of primary care capitation, or comprehensive aggregate primary care payment if you prefer, is that it makes spending much more predictable and controllable—the payer gives the primary care physician a set amount of money, and the physician is then responsible for keeping spending within that amount.  It also eliminates most of the cost to the payer of claims processing, billing, and utilization review systems and personnel, since the only “bill” that has to be processed is a monthly check to the physician, and with no health insurance claims being submitted, no claims to review.  Since the physician would have to live within the budget set by the monthly capitation payment, there would be no need to review the physicians’ utilization of tests, procedures and visits.

The idea of providing care within a monthly global budget, though, is precisely what many physicians fear.  They worry that the monthly payments won’t be adequate to cover their costs.  They worry that they will have to skimp on care in order to come out ahead.  They worry that even if the initial monthly payment is sufficient, payers would have an incentive to ratchet it down over time to save more money.  They worry that the payments won’t adequately adjust for the complexity and risk of the patients that they have in their practice.  They worry that the budget will put them at risk for things they can’t control, such as services provided by non-primary care physicians that the patient is also seeing.  They remember that under the primary care capitation schemes popular in the mid-90s, the best patients were the healthy ones who never needed much care and the worst were the sick ones who needed more services, because the physician was paid the same amount no matter how sick the patient was. 

Dr. Goroll and his co-authors recognize and try to allay these concerns, by differentiating their model from the discredited transfer of insurance risk on the back of doctors form of primary care capitations that physicians (rightly) object to.   They propose that the monthly payments “be directed to cover all practice expenses and salaries related to operating a robust, modern primary care practice, one that would qualify as an ‘advanced medical home’ for adults, a practice structure that enables efficient provision of comprehensive, coordinated, patient-centered care” so that “total practice revenue would markedly increase compared to that under RBRVS.”  

Also, “Payment for hospital and specialist services and ancillaries such as medications, laboratory tests, and imaging studies would remain the responsibility of payers and not the practice” and “a validated risk-adjustment framework that incorporates the full spectrum of important risk determinants, including those accounting for patient behaviors will be needed.”

Finally, the authors note that “in a cost-conscious society, it is unlikely that the new payment model will be adopted widely if it is viewed as a give-away to primary care physicians/practices. Conversely, primary care physicians are likely to reject the model if it appears to be yet another attempt to use them as gatekeepers or insurance companies. Our model tries to avoid both pitfalls by assigning most of the financial/actuarial risk to insurers while recognizing the responsibility of primary care practices to be financially and clinically accountable.”

I think it is time for primary care physicians to balance their legitimate reservations about anything that smells like capitation with an openness to consider the potentially big advantages, to them and their patients, of a model like that proposed by Dr. Goroll and his colleagues.  

The three things that I hear primary care physicians complain the most about is that they are under-paid, over-hassled, and overly-controlled by payers who feel compelled to second-guess everything that they do.  A Comprehensive Primary Care Monthly Global Capitation model, if it offers sufficient revenue in exchange for practice transformation with adequate risk adjustment, could result in primary care physicians getting paid more for their services, remove the hassle of having to submit bills and associated documentation requirements, and put the primary care physicians--not the payers!--in control of managing costs and quality within a budget—all while making health care spending more predictable and potentially, saving money for the system.  That sounds like a win-win to me. What about you?

Today’s question: What do you think about replacing fee-for-service and RBRVS with paying primary care physicians on a monthly, risk adjusted global payment basis, with the aggregate payments being “sufficient to cover all practice expenses and salaries related to operating a robust, modern primary care practice”?

Thursday, January 17, 2013

Curiouser and curiouser!

Trying to figure out what is going on with health care costs is like Alice’s adventures in Wonderland, things are just getting curiouser and curiouser. To illustrate:  which of the following statements do you think are correct?

1.    It’s been 50 years since health care costs increased this slowly.
2.    The U.S. spends more on healthcare than any other country but our health is much worse.
3.    Last year continued a three year trend of historically low Medicare cost increases.
4.    Looking ahead, Medicare spending is projected to climb at a rate the country can’t afford.
5.    ObamaCare is driving up premium costs.
6.    ObamaCare is keeping healthcare cost increases down to historically low levels.

A credible case, based on the evidence, can be made for every one of the above statements, including the ones that appear to be in contradiction to each other!  Let’s boil down each one, in order.

#1: “It’s been 50 years since health care costs increased this slowly.”  True!  In 2011, health care spending grew only 4.4%, the lowest in fifty years, and that trend continued into 2012.

#2:  The U.S. spends more on healthcare than any other country but our health is much worse.” True!  NPR reports on a new Institute of Medicine study that found “Americans are actually less healthy across their entire life spans than citizens of 16 other wealthy nations” and “the gap is steadily widening” despite the fact we spend much more on health.  (So much for American Exceptionalism!)

#3: “Last year continued a three year trend of historically low Medicare cost increases.”  True!  According to official government numbers, Medicare per capita costs went up by only a fraction of a percent In 2012 (0.4%), much less than the rate of growth in the economy (3.4% growth per capita). Over the three year period from 2010-2012, Medicare spending per beneficiary grew an average of 1.9% annually, or more than 1 percentage point slower than the average annual growth of 3.2% in per capita GDP (that is, at GDP-1.3).

#4:  “Looking ahead, Medicare spending is projected climb at a rate the country can’t afford.”  Probably true, but maybe the trajectory isn’t quite as worrisome as it used to be—or is it?  On one hand, the government report cited earlier, projects that, “The slow growth in spending per beneficiary from 2010 to 2012 combined with the projections of spending growth at GDP+0 for 2012-2022 is unprecedented in the history of the Medicare program. If sustained, the slower growth would improve Medicare’s ability to meet its commitments to seniors and persons with disabilities in future generations.”   But the qualifier “if sustained” leaves a lot of room for doubt. The Fiscal Times notes that, “ ‘Even though spending per beneficiary is projected to grow at or below the rate of per capita GDP, the number of Medicare beneficiaries is projected to grow at approximately 3 percent a year,’ the HHS report says. The 50 million beneficiaries today will grow to more than 85 million in 2035. ‘As a result, aggregate Medicare spending will account for a growing share of GDP over the next decade.’”

Okay. Let’s move onto #5:  “ObamaCare is driving up premium costs.”  It is true that many insurers are raising  premiums in the small and individual insurance market, but experts disagree on how much of that is due to ObamaCare, and how much of it is due to loosely-regulated insurance companies gouging the consumer.  The conservative Wall Street Journal editorial page predictably pins the premium increases on Obamacare, arguing that the reason insurance companies are raising premiums is because of the law’s “newly imposed mandates” and taxes.  The liberal New York Times editorial page predictably pins the blame on insurance companies, noting that the “jarring discrepancy [between double-digit premium increases and unusually low rates of national health care spending increases] suggests that both the federal government and the states need more power to reject premium increases that can’t be justified.”

(I agree with those who say it is counter-intuitive for health insurance premiums to be going up by double-digits when health spending increases are the lowest in half a century.  A small part of the increase might legitimately be due to ObamaCare’s mandates and taxes, although the law’s critics forget that people are getting better benefits and protections as well, but shouldn’t premiums be at least somewhat related to the costs of care, so that as health care spending slows, premium growth should slow as well?   If they aren’t, then insurance companies sure got some explainin’ to do, and regulators shouldn’t just accept the excuse that it is all ObamaCare’s fault).

 And now for # 6 (drum roll): “ObamaCare is keeping healthcare cost increases down to historically low levels.”  Critics point to the premium increases to say “absolutely not” and supporters to the three year spending slowdown to say “absolutely yes.”  The rest of us aren’t so sure.  Maggie Mahar shifts through the competing claims and concludes that “one thing is certain:  medical spending trends are headed in the right direction.  At last, we seem to be breaking the back of healthcare inflation.”

I wish I could be as certain as she is—we are heading in the right direction, but I don’t know that it can be sustained. And we still have that “little” problem of demographics:  more older and sicker people needing health care benefits, fewer healthy and younger workers being around to pay for them.

Maybe we should all just take a deep breath and admit we don’t really know what is going on with health care spending.   Liberal supporters of ObamaCare shouldn’t rush to the judgment that it has “broken the back” of health care inflation, especially since most of its supposedly cost-saving delivery system reforms are just getting started.  Conservative critics of ObamaCare shouldn’t rush to the judgment that it is causing premiums to explode, especially since most of its coverage mandates and taxes won’t fully go into effect until next year, and its supposedly cost-saving delivery system reforms are just getting started. 

Let’s all acknowledge that it is good news for everyone if the three-year slowdown in health spending can be sustained, no matter who or what is responsible, since that would make it a whole lot easier to reduce the federal budget deficit and keep care affordable for individuals, families and employers. 
Let’s admit we don’t know why health care costs aren’t increasing as fast as they used to, and we don’t know if the trend can be sustained. 

Let’s face up to the fact that we still as a country spend more on healthcare than anyone else (even if the rate of increase has slowed) and our health is worse in most respects, and that can’t be good news.
As I said, it’s getting  curiouser and curiouser.

Today’s question: What do you make of the data on health care spending?

Friday, January 11, 2013

Can Team-based Medical Homes Eliminate the Primary Care Physician Shortage?

It’s a rare thing when a single study has the potential to rock the health policy world by directly challenging conventional wisdom, but that’s the case with one published on Sunday in Health Affairs, the go-to journal for policy wonks.  It offers the prospect that the much ballyhooed shortage of primary care physicians may not happen after all, because team-based models—the Patient-Centered Medical Home (PCMH) in particular—have found a way to provide good access to primary care for more patients, using fewer clinicians.  (The full article is available only to Health Affairs subscribers).

The article specifically found that primary care workforce capacity can be stretched to take care of more patients when primary care physicians work as a team with nurse-practitioners (NP) and physician assistants (PA) in a patient-centered medical home. In which, the non-physicians take care of the majority of patients with routine presenting problems while the physicians take care of patients with more complex diagnostic and treatment challenges.   This, by itself, is not a new concept—there is a broad consensus that an “all-hands-on-deck” approach will be needed to meet the current and future demand for primary care.  There also is a broad consensus that collaborative teams of physicians, NPs, and PAs can deliver care more effectively and productively than individual clinicians working in their own disconnected silos.

This study, though, goes so far as to say that multi-disciplinary clinical teams in a PCMH, supported by health information technology, have the potential of eliminating primary care physician shortages.   How so? 

“We show that by implementing partial pooling of patients by two or three physicians and diverting as little as 20 percent of patient demand to nonphysician professionals or using electronic health record–enabled electronic communication, or both, most if not all of the projected primary care physician shortage could be eliminated.”

In other words: the authors believe that electronic communications can substitute for many primary care visits;  NPs and PAs working with physician can handle a good proportion of primary care visits, and primary care physicians can handle the rest.  They also suggest that PCMHs could make primary care more attractive to physicians, helping to increase supply:

“In addition, the use of nonphysician professionals to deal with more routine problems and the decreased need to respond to urgent requests for care that comes with shared practice can increase the attractiveness of primary care careers for new physicians, adding to the forecast supply. In fact, recent data suggest that this trend may have already begun.”

If you accept their analysis, you would need fewer primary care physicians to meet demand, far fewer than the studies projecting shortages of tens of thousands of primary care physicians.
It is important to note that the authors did NOT say that NPs can replace primary care physicians, nor do their findings support the call for more “independent” NP-run practices.

There are obvious limitations to the study.  For one thing, it principally is based on modeling and simulating how models like the PCMH could help meet the demand for primary care more effectively, and then comparing those simulations to accepted studies of primary care physician workforce studies.   The authors acknowledge that there are “barriers” to team-based PCMHs that need to be accounted for, but my sense is that the barriers are much greater than they think. For one thing, they may have more confidence in the ability of electronic health records and current electronic communications to substitute for primary care visits than is merited, given the dissatisfaction many physicians have with the current information systems available to them and patient skepticism about them. 

They also didn’t address the reality that for the numbers of PCMHs to increase to the point where they could have a major impact on projected workforce demands, there needs to be a sustainable payment model to support such practices. 

Nor did they address the reality that many primary care physicians are so frustrated that they are looking for a way to get out of practice altogether, or at least to drastically reduce their patient volume by converting to “concierge” practices.   While it is true that more physician practices are making the transition to PCMHs, we are losing more and more, good primary care physicians even as we try to re-invent the system.

It is one thing to model an ideal team-based, technology-enabled multi-disciplinary medical home and how this model might affect the number of patients that can be effectively seen by a practice, and another for policymakers to conclude that PCMHs can “eliminate” the primary care shortage.
At the same time, the study makes an important contribution in illustrating that how we organize and deliver primary care in the United States can make a big difference in the number of physicians and other clinicians we will need.  Turning out more primary care physicians just to increase the numbers of them will not be as effective as determining the most effective ways to organize primary care to meet demand, including how to best to combine the skills of all primary care clinicians (physicians, nurses and physician assistants) in accord with patients’ needs and demands, and then build workforce and payment policies to support the most effective models.   This is how other parts of the economy have dealt with mismatches between supply and demand.  That is, they increase productivity by determining the requisite number of people, with the right combination of skills and technologies needed to meet increased demand using fewer resources.  They don’t just produce more of the same. 

Bottom-line: I believe that this one study is not enough to throw about the much larger body of research that shows that the United States is facing a growing shortage of primary care physicians.  But they are onto something: PCMHs and multi-disciplinary clinical care teams can be a big part of the solution. And we need to begin to integrate analysis of workforce supply and demand with determining how best to organize the delivery of primary care in the United States.

Today’s question: What do you think of the authors’ premise that team-based models that pool primary care physicians with NPs, and that use electronic communications to substitute for some visits, can eliminate the projected primary care physician shortage?

Wednesday, January 2, 2013

The Good, the Bad, the Ugly, and the Really, Really Ugly

Are you uncorking the champagne to toast Washington for not going over the fiscal cliff?  I didn’t think so . . . me neither.

How could anyone toast a Congress that took the country (again) to the brink of economic chaos?  Who waited until the 11th hour (literally) to clear a bill that prevents huge tax increases on just about everyone and huge cuts in just about everything?  That wasn’t able to assure Medicare patients and their physicians  that there wouldn’t be a 27 percent cut in payments the very next day?  That waited until 11 p.m. on January 1 to come to an agreement, even though it has known for more than a decade that the Bush tax cuts would expire after 10 years, has known for more than a year that across-the-board budget sequestration cuts would automatically go into effect and that Medicare physician payments would be cut by nearly 30 percent on the first of the year, and that has known since at least 2002 that the Medicare SGR formula is fundamentally unworkable and need to go? That in the end, could only agree to prevent the SGR cuts for another year, but with no plan or timetable to advance a permanent solution?  (Read what ACP had to say about the fiscal cliff deal and the lack of an SGR solution).

Sure, there is (some) good in the fiscal cliff deal, some that is bad, and a lot that is ugly, really ugly, especially when it comes to the sad state of policy discourse and decision-making in the United States.  Let’s run it down.

The good:  Congress didn’t take us into another recession by allowing the country to go over the fiscal cliff.  Medicare payments to doctors won’t be cut by nearly 30 percent.  Most Americans won’t see their federal income taxes go up, except for higher income individuals and families.   Defense and domestic programs won’t be cut across-the-board—yet.   Congress rejected a proposal to cancel  an increase in Medicaid payments to primary care physicians (went into effect yesterday) to offset the cost of preventing the Medicare physician payment cut. 

The bad:  The one-year extension of current Medicare rates to physicians was a repeat of the same old, enact a temporary patch now to stop the immediate cut and put off until later a permanent solution, failed approach to the Medicare SGR Congress has taken every year since 2003.  This was the best they could do? Even though ACP offered Congress an achievable and realistic framework  to repeal the SGR and move to better payment framework? Even though organized medicine collectively offered Congress a similar set of payment reform principles?   Also bad: Congress also couldn’t come to an agreement on an alternative to across-the-board budget sequestration cuts, deciding instead only to postpone them until March 1. 

The ugly:  Congress did nothing to address the rising costs of health care, except for further ratcheting down Medicare payments to hospitals, ambulances, Medicare Advantage plans, and physicians who provide imaging services.  The plan it passed does not make a meaningful contribution to reducing the federal budget deficit, although it will bring in somewhat more tax revenue (from higher income persons) than if the Bush tax cuts were renewed in their entirety.  Congress and President Obama again missed an opportunity to agree on a Grand Bargain to increase revenue, reform the tax code, and reduce spending on entitlement programs, although they reportedly weren’t that far apart on the numbers.  

The really, really ugly: The political process—and the flawed outcome it produced—was so embarrassing and unworthy of a great country that it led National Journal writer Ron Fournier to ask “Can we fire Washington over the fiscal cliff fiasco?”   He  writes that “the ‘fiscal cliff’ process was secretive and sloppy, and the nation’s so-called leadership lacked the political courage to address our root problems: joblessness and debt. Instead, the White House and congressional leaders set the stage for another maddening confrontation two months from now, when the nation’s credit will be held hostage again to Washington’s incompetence.”   It was so ugly that the Speaker of the House of Representative, John Boehner, reportedly gave the finger and issued the F-bomb  to Senate Majority Leader Harry Reid!

And that is the really, really ugly thing to think about.   Less than two months from now, the across-the-board sequestration cuts go into effect, unless Congress and the President can agree on an alternative.  Just two months from now, Congress will need to enact legislation to authorize the Treasury department to borrow more money to honor existing obligations (the debt ceiling), and Republicans already are saying that they will demand more spending cuts in exchange while President Obama says he won’t negotiate with them on it, not this time, not again.  Remember, it was the debt ceiling debacle of the summer of 2011 that led to the failed “Super Committee” and the across-the-board sequestration cuts that were delayed for two months, but not canceled, by the new law.  The consequences of defaulting on the country’s debt obligations would be far more serious and detrimental to the U.S. economy than going over the fiscal cliff.  And that’s not all: a temporary measure to fund the federal government expires at the end of March, leading to the prospect of another tussle over spending and the possibility of a government shut-down.  
Good bye and good riddance to the 112th Congress, arguably the worst since members of Congress were caning each other before the Civil War!

Personally, I have been involved in observing and influencing government for more than three decades now, and I have never seen Washington so polarized, never seen supposedly responsible people in Congress being willing to gamble (again and again) with the country’s economic health to make an ideological point, never seen so many who think compromise is a dirty word, and never seen a Congress so unable to pass legislation until the clock has run out and the wolf is at the door. 
The deal that was passed was better than the alternative of going over the cliff, but the politics that has produced it was so divided and so dysfunctional and so ugly that maybe the best we can hope is that it can’t get any worse—or can it?

Today’s question: What do you think of the fiscal cliff legislation and what it says about our country’s capacity to govern?