You might never have heard of the National Guideline Clearinghouse, guideline.gov. To be frank, neither had I. Now it’s gone. After Monday, the Trump administration will shut down guideline.gov, a move it announced in April, blaming budget constraints.
What was the National Guideline Clearinghouse? In short, it was an online database of all the best health care practices from medical societies and other researchers — a one-stop shop for doctors who were trying to figure out the best way to treat their patients and wanted to find out the medical consensus.
As Jon Campbell, a senior investigator at the Sunlight Foundation’s Web Integrity Project, put it in a great story late last week in The Daily Beast:
When doctors want to know when they should start insulin treatments, or how best to manage an HIV patient in unstable housing — even something as mundane as when to start an older patient on a vitamin D supplement — they look for the relevant guidelines. The documents are published by a myriad of professional and other organizations, and NGC has long been considered among the most comprehensive and reliable repositories in the world.
About 200,000 people visited guideline.gov every month, according to the Council of Medical Specialty Societies, which sent the administration a letter in June urging them to find some alternative course to shutting down the website entirely.
There is a lot of medical information floating around — as Ivan Oransky wrote at STAT, some doctors have gotten a bit of sick of the guideline craze because they believe it removes some of the “art and flexibility” from medicine. The value of the clearinghouse was that it put guidelines through a vetting process, allowing doctors to have more faith in their objectivity, and that it put all of them in one place rather than forcing doctors to scrounge through various academic journals and websites.
As CMSS wrote in its letter urging the Trump administration not to shutter guideline.gov without a backup plan:
Physician members across our specialty societies access NGC’s evidence-based guidelines to provide high quality, value-based care to their patients. Given the current Administration’s focus on reducing physician burden, it should be recognized that NGC reduces the time that clinicians spend sifting through multiple society websites and peer-reviewed publications.
There was a benefit to having an unbiased party — the federal government, in this case — collecting this information. That prevented conflicts of interest from getting in the way of good medicine. From the Daily Beast:
The vetting role played by the NGC is a critical one, says Roy Poses, with the Patient-Centered Outcomes Research Institute.
“Many guidelines are actually written mainly for commercial purposes or public relations purposes,” said Poses, and can be subtly shaped to promote a given course of treatment. A guideline written for the treatment of depression, for example, may emphasize pharmaceuticals over talk therapy.
“The organizations writing the guidelines may be getting millions of dollars from big drug companies that want to promote a product. The people writing them may have similar conflicts of interest,” Poses said. NGC’s process provided a resource comparatively free of that kind of influence.
Budget cuts were blamed for guideline.gov being closed. The website was overseen by the Agency for Healthcare Research & Quality, a sub-agency of the Health and Human Services Department.
AHRQ has long been a Republican target — House Republicans and President Trump have proposed eliminating it entirely, though they have never actually acted on that plan. As Oransky wrote at STAT, AHRQ “has been suffering death by 1,000 cuts for years.” It’s lost about $120 million in funding since 2010, adjusted for inflation.
But that still leaves a $330 million budget, and running guideline.gov costs an estimated $1.2 million. For a resource valued by doctors, which seems so useful in making sure American patients can get quality care, could the Trump administration really not find a million dollars?
I posted that question to AHRQ. This is the response I received from Alison Hunt, the agency’s spokesperson:
The difficult decision to shutter the NGC was made by AHRQ’s leadership in response to our current budget, and the expiration of funding that supported the NGC. Likewise, the contract to support the NGC ends this year. Federal rules prohibit redirecting money from another program area.
Hunt also said that intellectual property rules prevent AHRQ from keeping the current guideline.gov online even as a static resource that would no longer be updated.
The administration had said that it received interest from outside groups about maintaining the NGC, but it appears nothing came together to stop the site from shutting down after Monday.
There is some hope. Check out this Twitter thread to see the work people are doing to try to preserve and recreate the clearinghouse. The medical knowledge that had been compiled on guideline.gov has not been erased from the earth, by any means. But it will be harder to find.
This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inboxalong with more health care stats and news.
Join the conversation
Are you interested in more discussions around health care policy? Join our Facebook community for conversation and updates.
Trump is hard on traditional allies and soft on Putin because that’s what he thinks.
Asked point-blank by a Reuters journalist, “Do you hold Russia at all accountable for anything in particular” that has contributed to the decline in the US-Russia bilateral relationship, President Trump delivered the defining answer of his foreign policy: He does not.
Having offered earlier in the week scathing, specific indictments of the European Union’s immigration policy, of the FBI’s investigation of the 2016 election, of the United Kingdom’s efforts to negotiate a “soft” version of Brexit, and of Germany’s energy infrastructure policies, Trump had no specific criticisms of Vladimir Putin’s domestic or international policies.
Trump’s staff keeps trying to cover for him, by leaking to the press various versions of a story in which Trump has basically normal policy views but happens to not be fired up about the election hacking, but Trump’s words say otherwise. It’s true, of course, that he’s not bothered by Russians committing crimes to help him win the election. But he’s also not bothered by anything Putin does at all, which is why he was worth helping in the first place.
via @jonathanvswan - President Trump no longer doubts the basic intelligence assessment that Russia interfered in the 2016 election — he just seems incapable of taking it seriously, and tells staff that is simply what nations do. https://t.co/0pAIIMUcGp
That’s unusual, it’s troubling, and it’s worth taking seriously.
But most of all, it’s worth taking Trump on Russia literally, not as the offhand ramblings of an ignorant celebrity candidate but as reflecting essentially the closest thing to a considered policy view that we are going to get from Trump.
Trump’s stunning answer on the bilateral relationship
It’s worth reading Trump’s full answer to the question about whether he holds Russia accountable for anything in particular just to see how long the answer is — how much time he had to think of something, and the extent to which the only specific wrongdoing he can name is on the part of the FBI for conducting an investigation of Russian crimes (emphasis added):
Yes, I do. I hold both countries responsible. I think the United States has been foolish. I think we have all been foolish. We should have had this dialogue a long time ago, a long time, frankly, before I got to office. I think we’re all to blame. I think that the United States now has stepped forward along with Russia. We’re getting together and we have a chance to do some great things, whether it’s nuclear proliferation in terms of stopping, we have to do it — ultimately, that’s probably the most important thing that we can be working on.
I do feel that we have both made some mistakes. I think that the probe is a disaster for our country. I think it’s kept us apart. It’s kept us separated. There was no collusion at all. Everybody knows it. People are being brought out to the fore. So far that I know, virtually, none of it related to the campaign. They will have to try really hard to find something that did relate to the campaign.
That was a clean campaign. I beat Hillary Clinton easily and, frankly, we beat her. And I’m not even saying from the standpoint — we won that race. It’s a shame there could be a cloud over it. People know that. People understand it. The main thing — and we discussed this also — is zero collusion. It has had a negative impact upon the relationship of the two largest nuclear powers in the world. We have 90 percent of nuclear power between the two countries. It’s ridiculous. It’s ridiculous what’s going on with the probe.
Later, asked specifically about Russian-backed hackers stealing Americans’ private correspondence, Trump said, “My people came to me, [Director of National Intelligence] Dan Coats came to me, and some others, and said they think it’s Russia. I have President Putin; he just said it’s not Russia. I will say this. I don’t see any reason why it would be, but I really do want to see the server. But I have confidence in both parties.”
That’s the president of the United States saying he has equal confidence in the president of Russia and the American intelligence community. It’s a politically baffling thing to say — so baffling that I don’t buy the common hot take that Trump’s slipperiness on this question merely reflects resentment at having the legitimacy of his election win challenged. After all, all he’s doing with this kind of rhetoric is undermining his own position.
Fox’s Kilmeade explains that Trump sees every Russian interference question as an accusation that his victory wasn’t legitimate. So he can’t say: Yeah, they interfered. I am quite sure this is exactly right.
The simplest explanation for why a president who happily outsources his domestic policy to Paul Ryan and his judicial nominations to the Federalist Society insists on freelancing around Russia is that there is a genuine meeting of the minds between Trump and Putin across a broad range of issues.
Trump’s quietly revealing comments on a German gas pipeline
Russia hawks in the United States and Europe have long been concerned about German plans to build a natural gas pipeline, known as Nord Stream 2, that would give Russian fossil fuels more access to the European market. Trump, who often likes to criticize Germany but rarely likes to criticize Russia, surprised many observers by criticizing this pipeline at the NATO summit in Brussels late last week.
It seemed, superficially, like Trump was finding a way to integrate his passion for making trouble for German Chancellor Angela Merkel with something resembling a normal American foreign policy. But such hopes were quickly dashed by his performance in Helsinki.
Trump repeatedly railed against the Nord Stream 2 pipeline between Russia and Germany, asking why the US should protect Germany from Russia when Berlin purchases so much gas from Moscow. Putin won’t like that line one bit. Interesting to see if it comes up in Helsinki pic.twitter.com/j019Mi4lJl
Asked by a Russian journalist about both the pipeline and how he would characterize the US-Russia relationship, Trump made it clear that his concern about the pipeline isn’t that it would give Russia undue political leverage over Germany but simply that it would be bad for American fossil fuel interests:
I called him a competitor, and a good competitor he is. I think the word competitor is a compliment. I think that we will be competing when you talk about the pipeline. I’m not sure necessarily that it’s in the best interests of Germany or not. That was a decision that they made. We will be competing. As you know, the United States is now, or soon will be, but I think it is right now the largest in the oil and gas world. So we’re going to be selling LNG. We’ll have to be competing with the pipeline. I think we will compete successfully. Although there is a little advantage locationally. I wish them luck.
I discussed with Angela Merkel in pretty strong tones. But I also know where they’re coming from. They have a very close source. We will see how that all works out. But we have lots of sources now. The United States is much different than it was a number of years ago when we weren’t able to extract what we can extract today. So today, we’re number one in the world at that. I think we will be out there competing very strongly. Thank you very much.
Trump’s view on the relationship of NATO to Nord Stream is so stupid that it’s almost hard to believe this is what he’s saying, but it’s consistent with his overall worldview.
While a normal US leader might worry that Russo-German energy ties would undermine Germany’s ability to lead an independent Europe on a political level, Trump’s objection is clearly backward — he doesn’t think it’s worth America’s while to contribute to Europe’s defense via NATO if Europe is going to turn around and buy Russian gas. He defines Russia as a “competitor” to the United States exclusively in the commercial sphere rather than the geopolitical one.
That’s why he called the European Union a “foe” in much stronger terms — on the level of competition for export markets,Europe really is a bigger competitor than Russia.
If you view world affairs through an exclusively mercantilist lens, as Trump does, then America’s closest allies (mostly rich democracies) are our biggest enemies and deterring Russian expansionism is a waste of time and money. It’s time to accept that this is what Trump really thinks and that he is governing accordingly.
Trump is constrained, but he’s getting stronger
It’s easy to forget now, but Trump entered the White House with an unprecedentedly low level of support from his own party.
A dozen Republican senators and a gaggle of vulnerable House members refused to say that they were voting for him, while Speaker Ryan said he would no longer defend or campaign with Trump. And Trump as a candidate was personally hostile to a number of established GOP figures, and expressed heterodox views on a wide range of policy issues. In theory, that could have set up an unusual political dynamic in which congressional Republicans subjected Trump to an uncommonly stringent level of oversight for a same-party president, and Trump engaged in an uncommonly high level of policymaking that cut across established party lines.
Instead, Trump and GOP leaders rather quickly reached a tacit compromise — no restraint whatsoever on Trump’s personal corruption or financial conflicts of interest, and no attempt by Trump to pursue the heterodox agenda on infrastructure, health care, antitrust, etc. that he promised on the campaign trail.
The deal has worked well on domestic issues, culminating in the nomination of Brett Kavanaugh to succeed Anthony Kennedy on the Supreme Court. But on foreign affairs, it’s begun to fall apart after a mostly successful 2017. Coats, Defense Secretary James Mattis, and others with conventional conservative Republican views hold the key advisory jobs in the Trump administration, but Trump is clearly not interested in actually taking their advice because he thinks that advice is wrong.
He is acting to unravel America’s global trading relationships, doing what he can to undermine NATO and the European Union, trying to find an excuse to wriggle out of defense obligations to South Korea, and otherwise implement the mercantilist vision he articulates over and over again.
It’s time to stop psychoanalyzing Trump’s statements — and time for congressional Republicans to stop issuing toothless statements denouncing them — and take this seriously as the president’s governing agenda.
"If you view world affairs through an exclusively mercantilist lens, as Trump does, then America’s closest allies (mostly rich democracies) are our biggest enemies and deterring Russian expansionism is a waste of time and money. It’s time to accept that this is what Trump really thinks and that he is governing accordingly."
Who likes it when players get into foul trouble? Well, maybe nobody, but it’s one of the most interesting strategic aspects of college basketball. While people have been thinking about ways to eliminate the individual limit on personal fouls, I’d feel very strongly about preserving the five-foul limit if officiating were perfect.
Mainly because I don’t like fouls and of all the deterrents to fouling, the personal foul limit is the most important. One can look at how the foul rates of reserves change when they become starters to get an idea of that. Almost surely, any softening of the individual foul limit will result in more fouls being committed. Which leads to more free throws and a slower-paced, less-entertaining game.
Of course, officiating isn’t perfect and never will be, and it sucks when someone gets a foul they don’t deserve. And I’m sure coping with foul trouble is an annoying part of a coach’s job during a game. But it’s also necessary. As I discovered when looking at this issue in 2016, players are more conservative defensively when they get in foul trouble, so expecting coaches to ignore the situation is unrealistic if they are doing their jobs right.
Furthermore, there are reasons you’d rather have a player available for the end of a potentially close game than just simply playing him until he fouls out. On the flip side, a player whose effectiveness is reduced due to foul trouble might still be better than the alternatives and if that player isn’t particularly foul-prone to begin with, there’s little need to bench him. Naturally, each coach handles these decisions differently. (And because this issue doesn’t seem to be well-understood, I suspect many are using a sub-optimal approach.)
With that in mind, I’ve added something called ‘2-Foul Participation’ to the team scouting reports which gives us a blueprint for each coach’s philosophy. Often I find myself watching a game and a player picks up his second foul in the first half. Off to the bench he goes. But is he headed to the bench for good? What are the chances he sees the floor again before intermission? We can’t get inside the coaches head or see the future so there is no way of knowing for sure, but coaches have tendencies. However, unless you watch a lot of games involving the team in question and either have an amazing memory or take a bunch of notes, there is no reference for what a coach’s tendencies are.
This is an effort to change that. 2-Foul Participation is simply the percentage of time that a starter with two fouls in the first half has been allowed to play. If a starter picks up a foul with ten minutes left in the first half and plays one of those remaining minutes, then he’s participated in 10% of the minutes he could have. Add up the possible minutes for all starters and the minutes on the floor and you get the team’s number for the whole season.
That figure was around 20% for all of big-time college basketball last season, a number that has been dropping steadily since 2010, the first season for which we have complete play-by-play data. Coaches are gradually getting more conservative about playing guys with foul trouble in the first half. Even with foul rates declining to historic lows last season, coaches were less willing to play a guy after he picked up his second foul. It makes one wonder if there is a level of fouling low enough to make coaches reconsider their philosophy.
Perhaps there is some strategic use for this information. I don’t know. If you know a coach will sit a player with two fouls for the rest of the first half, then to some extent that player is already in foul trouble with one foul. They are one foul away from fouling out in the first half! Maybe one can do something with that information or maybe not. This is one of many reasons why I am not a coach.
Mainly, though, this is for informational purposes. You no longer have to guess if a coach will let a player with two fouls play. In addition to the data being added to the team scouting reports, it’s also on the coaching resumes and on a leaderboard page of its own. Now we can be enlightened that Bryce Drew is willing to let his players play while Tony Bennett isn’t.
Why only look at cases of two fouls and not three or four fouls? Well, in an a stunning coincidence, coaches universally agree that starters with two fouls are no longer in trouble when the second half starts. That provides a neat limit on the time frame to examine. There is no similar agreement on when it’s safe to play someone with three or four fouls, requiring the need for a more complex, and thus less transparent, method to measuring foul trouble tendencies in those cases. Besides, I’d expect 2-Foul Participation goes pretty far in explaining how a coach handles those other situations.
As far as the accuracy of this information, the usual caveats apply when deriving stats from play-by-play data. Substitution data can occasionally be wonky, and about 10% of the time it is not possible to know who is on the floor. Nonetheless, given the distinct trends we see among coaches, the data is plenty good enough for our purposes.
There are a few other measures on the leaderboard page. There is the total amount of time starters have two fouls and the total time they are on the floor. This is mainly for bookkeeping purposes and to help you and I catch gross errors in the calculations. I also created an adjusted 2-foul participation measure. In practice, there is a tendency for coaches to give backcourt players more latitude with two fouls and also there are trends in time as well. (Peculiarly, the most likely time for a coach to play someone with two fouls is with 4-5 minutes left in the half.)
Adjusted 2-foul participation accounts for these trends but in reality there are very few coaches for whom this makes a significant difference. I’ve also shown bench minutes on the page. There’s an inverse correlation between the willingness to play guys in foul trouble and how much one trusts one’s bench. Although, the cause and effect aspects of this relationship certainly vary from team to team.
Finally, I’ve provided the distribution of 2FP for all 3,159 teams over the past nine seasons below. The distribution has a long right tail, which means that most teams are below average. For instance, the difference between the 10th and 40th ranked teams last season was the same as the difference between 226th and 351st. So while there’s certainly a fun trivial distinction to being last (congrats, John Beilein for earning the title last season), in reality there’s not much functional distinction between 300th and 351st in any given season.
The near southeast quadrant of the District, from the Capitol dome down to the banks of the Anacostia river, has one ZIP code split in half by I-695, better known as the Southeast Freeway. Although these two areas look incredibly different at first glance, upon closer inspection they form a curious natural experiment.
One has seen frantic new housing construction, while the other has not. One has seen dramatic rent increases, and the other has not. Which one was the cause, and which the effect?
The law of conservation of buildings
North of I-695 is Capitol Hill, where one of the country's largest, oldest, and most fiercely-guarded historic districts has steadfastly maintained the neighborhood's physical character. The streets of colorful, low-rise rowhouses look much the same as they did 25, or even 125, years ago.
Proposals to build new buildings — even for something as uncontroversial as a supermarket and mid-rise, mixed-income apartments adjacent to Metro — must undergo a gauntlet of reviews, lawsuits, and counter-lawsuits that can drag out for several years and cost millions of dollars. The process is so daunting that hardly anyone even bothers trying, and so few new housing units have been built in recent years.
In fact, according to a recent Brookings analysis by Jenny Schuetz, four Metro-adjacent Census tracts in the area saw essentially no new housing units built between 2008 and 2015.
The neighborhood has more than doubled in in size, going from 3,000 to 6,200 housing units, and services have also blossomed, with the local restaurant count going from 20 to 52. The dozen tower cranes looming overhead herald even greater change to come.
Where are rents skyrocketing?
So, which neighborhood has seen rents skyrocket over the past five years: the "instant neighborhood" of glitzy high-rises, or the stodgy, drafty old rowhouses?
According to Zillow, rents in Capitol Hill have increased by almost 20% in the past five years — substantially faster than overall inflation, which has increased by 7%. Meanwhile, rents in the Capitol Riverfront have fallen slightly by about 8%, staying at levels which are (by the official definitions) affordable at the area median income. Not long ago, shiny new high-rise apartments around Navy Yard rented for more than the old rowhouses on the Hill. Now that many shiny high-rises have been built, they've become the cheaper option despite their "luxury amenities."
Even as thousands of new residents have poured into Capitol Riverfront (most of whom aren't exactly rich), thousands of new apartments have opened. Those new residents can just move into new buildings instead of bidding against existing residents for existing apartments. Current residents report that landlords are eager to cut deals on lease renewals to keep residents from decamping to even newer, glossier buildings.
By contrast, people who want to move to the Hill, or even just move to a different apartment on the Hill, must compete for just a few empty apartments. As a result, prices are bid up. (Zillow's estimates skew towards the higher end of available rentals. It mostly draws upon units listed for rent, but its statistical model also takes into account the broader mix of units.)
Turns out both neighborhoods have seen lots of construction
Stopping new apartments from going up didn't stop the rent from going up in Capitol Hill. Indeed, it didn't even stop new construction: instead of new apartments, large and breathtakingly expensive new homes went up within the immaculately retouched shells of the old homes.
Schuetz's report on building permits found very few new units built on the Hill — but did find plenty of new construction. Instead of tower cranes building hundreds of new homes at a time, the Hill (and other neighborhoods like it, like Takoma) saw hundreds of renovations and additions that transformed inexpensive old houses into luxury showplaces.
The number of units and overall population remains stable, even while housing prices surge: the median price of Hill houses has increased 59% since just 2010, and over one-fourth of units sold for over $1 million. Even as the "neighborhood character" of historic rowhouses has stood still, the neighborhood's population and social character have been transformed as ever-higher housing prices exclude all but the wealthy.
As Dan Reed recently pointed out about Bethesda, "keeping our neighborhoods insulated from change has real costs — as in, they become enclaves for the wealthy." The same process has played out in Adams Morgan, where steadily rising demand for a static number of homes has resulted in a situation that scholars have called "advanced exclusion."
New construction happens only where values are high
New construction, on its own, doesn't cause higher rents. Instead, the causal direction runs the other way: high rents enable new construction, since new construction is expensive. (Practically anything is more expensive new than used, and that includes buildings.)
Sure enough, Brookings found a positive relationship between housing prices and construction permits in DC. As the upper-left graph shows, more construction permits were issued in DC census tracts with higher housing values, but as the upper-right graph shows, those permits weren't usually for new homes.
That new construction will occur in whatever form that zoning allows. Where zoning allows apartments, apartments will get built. Where zoning only allows single-family houses, single-family houses will get built — just ever-larger and more elaborate.
The causal direction gets complicated
Since higher property prices are often accompanied by new construction, many people see shiny new buildings or fancy new shops and blame the new things for the neighborhood change. After all, changes to a neighborhood's buildings are easy to see, while changes to the people in the buildings are more subtle. Yet that approach focuses on symbols, rather than substance, and often mistakes cause for effect.
Miriam Zuk, director of Berkeley's Urban Displacement Project, tells On Common Ground that "places where development is happening [are] where rents are rising. People are already feeling the squeeze, and when they see new housing, it's the most visible and tangible thing to grab onto."
The relationship between supply, demand, and construction is indeed complicated by a feedback loop: amenities, particularly service businesses and conveniences. As local economist Lyman Stone tweeted, "At the very local level, greater density yields greater incentive for businesses to locate in the area, and raises amenity values."
For instance, the many more residents around Capitol Riverfront enticed more restaurants and shops to open in the neighborhood, which in turn made the area more attractive to even more new residents.
This feedback loop is why many urban planners and economists point out that the principle of more housing supply lowering rents doesn't necessarily apply at the neighborhood level. Rick Jacobus, a housing advocate, writes in Shelterforce that "New development may lower prices regionally even while it raises prices in a specific neighborhood."
This "induced demand" phenomenon more readily occurs with highways than with housing. A large number of individuals can easily consume additional road space, just by driving faster and farther for a few more minutes apiece. Yet moving house is different than driving: moving is a tremendous chore, so a much smaller number of households would have to consume much more housing in order to absorb the newly built space.
Prices can stabilize, given enough units, but won't drop far
Jacobus continues: "In established neighborhoods, no matter how much building is going on, the new supply will be small relative to the overall market so increased supply will have almost no impact on rents."
"If you build more housing in a neighborhood, you can accommodate more people, and demographic change is likely to be slower. If you don’t build housing, you make neighborhood change a zero-sum game, and likely accelerate displacement," writes Joe Cortright about how Fruitvale, a multiethnic neighborhood in Oakland, may have mitigated displacement by expanding onto adjacent industrial land. (A similar tale can be told of Chicago's Chinatown.)
Yet don't look for prices in Capitol Riverfront to completely collapse anytime soon. New high-rises are inherently expensive to build, so if prices fall below construction costs ("replacement cost" in the industry, or "marginal cost of production" in economics textbooks), construction will pause.
The rest of DC looks more like the Hill than the Flats
These widespread apartment bans have pushed population growth elsewhere, Schuetz writes: "when developers can’t build luxury housing in affluent neighborhoods, the pent-up demand for high-end homes will spill over into nearby middle-income neighborhoods."
Since the average DC neighborhood is more like slow-growth Capitol Hill than boomtown Capitol Riverfront, Zillow's rent graph shows DC-wide rents tracking the Hill's steady rise upwards rather than the Flats' plateau.