Friday, February 26, 2010

It Had to Happen Sometime

Really, I know, one of the problems with focusing on hot button issues is that you tend to forget that, among the millions of topics you don't discuss, you and your rhetorical opponents probably share a lot of common ground. Today, Charles Krauthammer moves out of his normal, limited sphere of subjects and standard demagoguery to discuss "the price of modernity", and (IMHO) gets it right.

Toyota's problems remind me of my first car, a 1960's-era VW Beetle. (A car that, despite its virtues, was not an unreasonable inclusion in this list of the worst cars of all time.)
I owned about half a dozen Beetles, and repaired hundreds, which gave me an abiding respect for the Beetle's construction quality (at least until the factory was moved to Mexico) and first-hand knowledge of its unforgivable faults - the windshield washers depended on air from the spare tire, the cylinder heads constantly worked loose, and the windshield defogging system often left you blinded at critical moments.
And talk about accelerator problems? In cold Saskatchewan winters, ice and snow would accumulate by the accelerator pedal. I would clear it away, but I also carried a bottle of antifreeze to periodically melt away the ice I could not otherwise remove. Why? Because if I did not, sooner or later when I hit the gas the ice would bend the tab that held the accelerator cable and... instant deceleration I could do nothing about without stopping the car, bending the tab back and reattaching the cable. Really nice on a highway. And what fun in the winter - it's 20 below zero (C) and the windows inevitably frost up on the inside - I had to choose between constantly scraping the window with one hand while peering through the tiny hole I cleared in the ice, or driving with the side window open and scraping less frequently. And that antifreeze had more than one purpose - in the winter months the car required a periodic splash into the gas tank to keep ice from forming in the gas line. Heck, the car was a few years older than I was, so nobody would have expected state-of-the-art, but if a modern manufacturer were to build vehicles with the same quality we enjoyed in the 1960's and 70's, Ralph Nader would be able to turn Unsafe At Any Speed into a multi-volume series.

Those developing and manufacturing products should strive for perfect safety, but there's always going to be a cost-benefit trade-off and in some contexts "perfect safety" is not something that can actually be obtained. As society has become safer, our perceptions of what constitutes an "unreasonable risk' has shifted. Most notably for children, a lot of activities that were taken for granted in past generations - e.g., going to the park to play or riding on public transportation - are widely considered "too dangerous" to do without adult supervision. If I were to extend the trend to the point of a reductio ad absurdum, we could reach a point where it's deemed too dangerous to go outside because we might get hit by lighting - something that once was an example of an absurdly remote event transformed into an unacceptable risk.

Thursday, February 25, 2010

"Putting Patients in Control"

Another wrinkle in the concept of putting patients in control of their own healthcare. Not only will most lack the expertise, time, or information necessary to make a choice, they may not even be presented with a choice. That is, the choice may be made by their doctor, for reasons not disclosed to the patient. Taking a look at medical devices,
“Doctors and technology companies are working in tandem,” [Jeffrey Lerner, the CEO of the ECRI Institute] explained. “The doctor has no idea of what the cost is and the consumer has no say in what products are chosen, for example, for hip and knee replacements.” He said doctors don’t care about the prices, and hospital CEOs don’t want to fight with their medical staffs, who can take their business elsewhere if fees are reduced. One student, who works as an operating room nurse, piped up and said that she had observed doctors threatening to do just that—take their cases to another hospital.

Lerner noted that health care consumers can’t bargain and find out the price of the devices and things that were implanted during surgery. Are they really getting the highest quality, lowest price artificial knee? Contracts are secret, and hospitals or doctors can be sued if they reveal what’s in them. “The laws are being used by companies against the consumer,” he said.
The result?
Bottom line: the doctor is both the buyer and seller of medical services for the patient. It seems to us that this is an area ripe for media exploration, especially since the president is now claiming that the reform proposal “puts American families and small business owners in control of their own health care.”
The type of control described in the President's memo is on a whole different level1 than the WSJ/Newt Gingrich-brand of control under which, save for when catastrophic coverage kicks in, patients are expected make their own decisions about care and pay out of pocket or from a HSA. Yet once you choose your doctor, your further options may disappear into the maze of contracts and non-disclosure provisions. Dr. A charges less than Dr. B, but he's contractually prohibited from explaining why? What a wonderful context for making informed choices.

No matter who is promising control, it's important to think hard about what that really means.
1. The memo speaks of control via making insurance affordable, setting up competitive health insurance markets, imprved accountability, ending discrimination based upon pre-existing conditions, and improving the budget over the long-term; choice of procedure or medical device isn't mentioned.

George Will's Filibuster Bluster

You can always count on George Will for a good laugh. He's more predictable than a broken watch. Talking about a possible Senate amendment to the Senate's existing healthcare reform bill, Will writes,
If the Senate parliamentarian rules, as he should, that most of the legislation is ineligible for enactment under reconciliation, the vice president, as Senate president, can overrule the parliamentarian. This has not happened since 1975, but liberals say desperate times require desperate measures.
George Will and his amazing crystal ball - he knows what will be in a bill that hasn't been finalized, knows that it will be "ineligible for enactment under reconciliation", and frets that Joe Biden will pull a move last perpetrated by... a Republican. To tie this to another of Will's faux controversies, if we don't do something about the steam coming out of Will's ears, even he may come to believe that global warming is caused by man.

As you have probably predicted, Will quickly resorts to his usual tactic of "making stuff up"
Some liberals argue that the Constitution is unconstitutional. Their reasoning is a non sequitur: The Constitution empowers each chamber to "determine the rules of its proceedings." It requires five supermajorities (for ratifying treaties, endorsing constitutional amendments, overriding vetoes, expelling members and impeachment convictions). Therefore it does not permit requiring a sixth, to end filibusters.
If you're a follower here, you know that I'm not impressed by straw man / "hollow man" arguments that "some people" do or believe one thing or another, "completely inventing an opponent and an opponent's argument, and then attacking that and claiming victory". (I love how Will refers to the non sequitur - The Nonsequitur is a blog he would benefit from, even if he is a frequent target of its analyses of bad logic.) What liberals make this argument? From what I can see, the population is limited to a set of imaginary voices contained within George Will's head.
Liberals also say the filibuster exacerbates the Senate's flaw as "inherently unrepresentative." That is, the Founders -- who liberals evidently believe were dolts or knaves -- designed it to represent states rather than, as the House does, population.
From the Hollow Man to a cross between an appeal to authority and... whoah - was that a non-sequitur?
A. The Founding Fathers intended the Senate to represent states rather than being apportioned by the population of each state;
B. The Senate's filibuster rule is opposed by liberals on grounds unrelated to how Senators are selected;
C. ?????
D. Therefore, liberals think the Founding Fathers were dolts or knaves.
Um... yeah.
Liberals fret: 41 senators from the 21 smallest states, with barely 10 percent of the population, could block a bill.
Another hollow man. Sure, I've heard people criticize the filibuster on the basis that it gives disproportionate power to states that have small populations; but that's not "fretting" - it's a description of what can actually happen. We're back to the way Will addresses global warming - he starts by ignoring the facts, then proceeds into an attack on people who have the temerity to speak from the facts. Moreover, as Will concedes, it's hardly the case that the Democrats were the first to question the filibuster and, in fact, past Republican attacks were overtly directed at its constitutionality. Will writes,
In 2005, many Republicans, frustrated by Democrats blocking confirmation votes, wanted to ban filibusters of judicial nominees. They said such filibusters unconstitutionally prevent the president from doing his constitutional duty of staffing the judiciary.
And thus they called the filibuster undemocratic, called for the Senate to decide certain issues by majority vote, and threatened the "nuclear option" - calling a point of order in the Senate and having Vice President Dick Cheney declare the filibuster of judicial candidates to be unconstitutional. Yet somehow I don't recall this much steam blasting out of Will's ears.... Seriously, compare and contrast his December 6, 2004 Newsweek piece on the nuclear option - he reconsiders his own prior endorsement of ending judicial filibusters, then attempts to take the position of a wise elder, advising his party of choice. The issues may be fundamentally the same but, unless they're doing crazy things like trying to limit corporate campaign contributions, Will can't seem to muster any outrage against Republicans, let alone the ad homimen, straw man, cherry-picked quotes of founding fathers, and other dubious attacks that pepper his editorials about "liberals". Were Will to read the Constitution, he might discover that the Founding Fathers were content to have legislation pass in the Senate based upon a bare majority, with the Vice President voting if necessary to break a tie. Supermajority requirements come from the Senate's own rules.

Viewing his editorial charitably, beyond his contempt for the real and imaginary people he calls "liberals" all Will can be said to have demonstrated is that the Senate's filibuster rule is not inconsistent with the Constitution. He appeared to understand, back when the Republicans were threatening the "nuclear option" that would attack the constitutionality of the filibuster, that we're talking about a Senate rule. The Democrats haven't threatened such a move. They've only indicated that they might move certain legislation through the Senate through the reconciliation process, as George W. Bush frequently did, if they can't obtain a cloture vote and what the Republicans (without any objection from Will that I can recall) used to call an "up or down vote". There is discussion of amendment of the Senate's rules, but I can't think of a single Senator who is calling for more than a modification of the current rule - a rule that has been modified at several points in the Senate's history - as opposed to its abolition. Given that it takes 67 votes to change the rule, and given that the Democratic Party is not echoing the Republican threat to abolish it through a "nuclear option", it seems pretty safe.

The editorial reduces to a sleight of hand by Will - he's conflating the Senate's reconciliation process with the filibuster. Sorry, George, we're talking about two different rules here, even if they (like many other Senate rules) may come into play on the same piece of legislation.

Tuesday, February 23, 2010

Um... Do I Smell Bad?

By now, you've all seen this cleverly produced Old Spice commercial:

After seeing the commercial my daughter turned to me and asked, "Daddy, can you get that?"

Don't Skip to the End....

The Wall Street Journal offers up an editorial on healthcare that's surprisingly wonkish. Although it is selective in its sources in order bette support its thesis, authors Jason Fodeman and Robert Book do a decent job of laying out some of the problems that contribute to healthcare inflation and why they're difficult to address. Waste, unfortunately gets a passing mention. To their credit the authors don't try to overhype medical malpractice costs and give only passing mention to "defensive medicine". They also offer an interesting analysis on why technological advancement doesn't reduce healthcare costs in the manner that it has reduced costs in pretty much every other industry.

Unfortunately, having laid a decent foundation, the quality of their analysis deteriorates markedly when they start addressing the Democratic reform bills, and disappears when they start proposing "solutions" of their own. For example, they object to "limits on out-of-pocket spending" in the proposed bills as "strengthen[ing] the incentives for most patients to engage in excessive spending". You know, as opposed to being told, "Sorry, your insurance doesn't cover this much chemotherapy in a year, and you're broke." No doubt, some patients will receive more medical care once annual or lifetime caps are removed, but let's not gloss over how much of that care is needed.

They also complain that the "tax on health insurance", presumably the Senate Bill's excise tax on "Cadillac policies", will not inspire insurance companies to fashion cheaper policies, and that the cap won't keep up with inflation such that more plans become taxed with each passing year. I am skeptical of their first point. The excise tax appears designed to bring about the second outcome. The goal is to make people opt for less comprehensive plans, consistent with various Republican reform proposals, and it's designed to reach more and more people each year. If the authors are correct on the first point the entire construct is misguided. But this is essentially a concession to the political right - I don't see the authors expressing support, in the alternative, for the House Bill's surtax on the nation's highest wage earners. That's not even mentioned. The House's hobbled "public option" won't be a money-saver? Again, that's by design. But what does it matter, given that almost nobody believes it will be part of the final bill.

The authors present a peculiar argument on "comparative effectiveness research", complaining that it somehow creates a "one-size-fits-all approach to health care" and that even if an equal or superior, much cheaper non-invasive treatment is identified, "some patients prefer the most invasive and intensive procedures available despite the risk of significant side effects". But they're deliberately missing the point. First, there's no reason to believe that the goal of effectiveness research is to impose, or even propose, "one size fits all" solutions. Doctors and patients will benefit from the information when making choices about how to proceed. Second, if data analysis indicates that a particular treatment is enormously cheaper than its alternative, with equal or superior outcomes, insurance companies should be able to say, "The treatment we cover costs $1,000 per year. You're free to get that $100,000 risky surgery you want instead, but we'll only cover the first $1,000." Funny how quickly the authors forgot their own argument about personal responsibility for medical costs. The idea that this research might lead to somebody being told that their only approved treatment is a pill that "might [trigger] a potentially fatal adverse drug reaction" is just plain silly.

The authors go from there to the slippery slope, arguing that "regulators" could impose so many coverage requirements and guidelines on private insurance companies that they "effectively deny[] care to patients except under specified conditions", and ban providers from accepting any payment outside of the insurance reimbursement. Never mind that nobody has proposed such a plan, and that it would be political suicide for a party to try to implement such a plan. They also propose that the government could force insurance companies to offer an enormous set of services while simultaneously capping insurance rates at a level that makes it impossible for insurers to turn a profit, leaving the non-existent "public option" as the only available insurance option. Where's my tinfoil hat?

The authors fall flat on their face when they introduce their "real reforms that could control costs and improve care". Or, to be more fair, they drop any remaining pretense that they're building a case based upon data and switch into an ideological mode. What a surprise - reform number one is to abolish Medicare and Medicaid in favor of private insurance plans, "allowing [enrollees] use their benefits to enroll in the health plans that deliver the best value according to their own preferences and values." Never mind that Medicare has pioneered many cost-saving approaches to health insurance that have been emulated by private insurers, or that "Medicare Advantage" insurers required a subsidy in order to compete with Medicare's basic package of services.

And seriously, let's say that a Medicare enrollee chooses coverage that's inadequate to cover a catastrophic medical condition or end-of-life care. They transition more quickly to the combination of Medicare and Medicaid, because they have less insurance to cover their needs. Then what? If they lack sufficient coverage to pay for their care, and the HSA they set up based upon "their own preferences and values" is long-exhausted, they get dumped on the street? Because in the alternative the cost is still borne by the taxpayer, or is passed along to other healthcare consumers who pay for their care. As for Medicaid, which the authors argue is woefully insufficient in its reimbursement rates, suddenly recipients are going to get better services and care because a private insurance company is in the mix, taking out a profit before reimbursing their care providers? Or, as seems to be the case, is the type of "empowerment" the authors describe about sharply reducing the set of services available to Medicaid recipients.

The authors continue by making plain that yes, they in fact would prefer all Americans to enjoy minimal health insurance coverage coupled with HSA's. They describe a 2005 study that found that "patients in consumer-driven health plans were twice as likely to inquire about cost and three times more likely to select a cheaper treatment plan compared to patients in traditional plans" - well, given that some of them probably didn't have the funds to pay for the more expensive treatment, that's hardly a surprise. On the whole, these plans reduce costs for employers, increase profits for insurance companies, and significantly increase costs to consumers. Why? Because you no longer have an insurance adjuster demanding documentation that a less expensive treatment has been tried and failed, or arguing that a less expensive diagnostic study is likely to be sufficient to diagnose a patient's condition. Patients lack the time and information necessary to make the type of informed decision at issue, even if they're comfortable second-guessing their doctor. Frankly, even if we assume that they have the necessary information and the luxury of time, many patients lack the skills necessary to evaluate the information. Perhaps, if the authors take the time to think about it, they'll realize that to be a big part of the reason people go to doctors in the first place, rather than

The authors also whip out the notion of "a real national market for health insurance". No, that doesn't mean introducing new insurance companies into your state. It means allowing insurance companies to administer the plans they already offer, but while enjoying the regulatory framework of a different state. The authors want to allow insurers to reduce the scope of covered services offered in your state to those required (or should I say "not required) by the state with the fewest requirements, the fewest insurance regulations, and the fewest consumer protections in the nation. Federalism? That's a different type of "conservatism" - the author's branch involves an expansive use of the Interstate Commerce Clause in the manner of the New Deal Supreme Court decisions that, well, conservatives used to deride. The idea that you should be able to keep the insurance you have? Fuggedaboutit.

You want to kick over the apple cart, start from scratch, and impose a nationwide social experiment in consumer driven health care? Then why not show some backbone and make that the debate.

Does Anne Applebaum Own a Map?

Seriously, Anne Applebaum posits the following:
The defining moment of [Barack Obama's] presidency may well come at 2 a.m. some day when he picks up the phone and is told that the Israeli prime minister is on the line: Israel has just carried out a raid on Iranian nuclear sites. What then?
Well, if his next move isn't to fire a whole lot of people who didn't wake him up sooner, I'm not sure what it would be. Seriously, is Applebaum picturing a Middle East with a vastly different geographic layout than the one she might find if she looked at a map, and also imagining an alternative history where the U.S. has no military presence in the Middle East or Persian Gulf?

Does Applebaum imagine that the Israeli bombers would get permission from Turkey to fly through its airspace for the bombing run, without the U.S. learning of the plan? Does she imagine fighter jets trying to fly to the north of Turkey, over the Black Sea, without the Russians noticing and with the permission of... say, Greece, Bulgaria, Russia, Georgia and Azerbaijan... again securing the consent of those nations and without the U.S. finding out? Does she imagine that they'll fly over Jordan or Saudi Arabia, without the consent of those nations, then through Iraq, without the massive U.S. military force in Iraq looking up in the sky and saying, "Hey, those aren't our jets!" I can almost picture the pillow talk at the Applebaum mansion.
"Radoslaw, honey, is it realistic that Israel could bomb multiple targets in Iran, with the President not being able to do anything about it and not finding out until after the fact?"

"Anne, sweetie, that would be impossible - a neocon fantasy."

"I'm going to run with it anyway. Good thing that I write for the Washington Post editorial page."
Also, while I acknowledge that it's fun to imagine that every crisis in the world happens at 2:00 AM, Eastern Standard Time, you would think that by now Applebaum would be cognizant of the fact that the world has more than one time zone. Operation Opera, Israel's 1981 attack on Iraq's nuclear facility, was launched at 8:55 AM EST, allowing President Reagan ample time to finish his breakfast and coffee before getting "the call".

No, the tough decision for the President would be to determine what U.S. fighter jets, scrambled to intercept Israel's bombers, should do.

It's fair to note that Applebaum isn't entirely ignorant of the 1981 raid, noting that Israel "had no qualms about sending eight jets to take out Saddam Hussein's nuclear reactor in Iraq in 1981". That, for what amounted to an unobstructed raid on a single, highly visible facility. How many fighter jets does she imagine Israel will deploy to strike only the most significant Iranian targets (that we know about) to bring about a significant setback in Iran's nuclear ambitions?

Good grief, if it were as simple as taking out a single, effectively undefended site in pre-war Iraq or Syria, with the worst consequence being a public lecture, it would be done already. Instead, again, take a look at that map. To Iran's immediate east, one country in which we're at war. To Iran's immediate west, another country with which we're at war. Applebaum is not so clueless that she doesn't hint at the consequence to the U.S. of an Israeli attack.
If that ever happened, then the 2 a.m. phone call would be followed by retaliation, some of which would be directed at us, our troops in Iraq, our ships at sea. I don't want this to happen - but I do want us to be prepared if it does.
So... she wants the U.S. fighter jets, scrambled in response to Israel's massive bombing run - probably half or more of Israel's air force overflying a NATO country or U.S.-controlled airspace without permission - to shoot down Israel's bombers? Or is she calling for a resigned acceptance - "If Israel sends 80 or more fighters and bombers across U.S.-controlled airspace, we have to let them through, even though it will severely undermine all of our diplomatic and military actions in the region, so let's plan for the post-attack world in which Iran is arming insurgent groups in Syria, Iraq, Afghanistan and Pakistan, is turning a blind eye to cross-border raids that severely strain or break the supply lines we use to support our troops in Iraq and Afghanistan, and the possibility of other retaliation against U.S. targets around the world and the likelihood of having to invade Iran." No, what Applebaum appears to want is for the U.S. to first permit the attack and then to follow up by invading Iran.
But I do hope that this administration is ready, militarily and psychologically, not for a war of choice but for an unwanted war of necessity.
It's fair to ask, if Applebaum imagines that the invasion of Iran, which would be ruinous for our current war efforts and for the U.S. economy, is an inevitable consequence of what she admits will be a hit-or-miss Israeli attack on Iran's nuclear sites, what world does she live in where Israel's attack could be regarded as sane?

Meanwhile, a few column inches to the left, Richard Cohen ponders his navel lint and asks, "Is Iranian President Mahmoud Ahmadinejad crazy like Adolf Hitler, or is he crazy like, of all people, Richard Nixon?" Typical of people who are either ignorant of Iran or who are dishonest about Iran, Cohen implies that Ahmadinejad somehow has his finger on a nuclear trigger - never mind that Iran does not yet have nuclear weapons or that Ahmadinejad has no control over the military. Since we're talking about Richard Cohen, I'm going to assume ignorance.

Let's skip right past the fact that the U.S. routinely attempts to paint as "crazy" the leaders of foreign nations that it wants to depose, or would otherwise prefer to be deposed. Which is not to say that we don't occasionally encounter world leaders who exhibit signs of mental illness or megalomania. Heck - over the centuries we've elected a few. Let's ignore the fact that there are politicians in this country, right now, who attempt to make political hay out of threats to attack Iran, and that Iranians could reasonably ask, "Was that old man, standing on a stage and signing 'bomb bomb bomb Iran' crazy, or merely pretending to be crazy?" What's his conclusion to his ramble on "Iran and the crazy factor"?
I have no idea whether Ahmadinejad merely acts crazy or is crazy.
Then why the [bleep] are you writing a column on the issue, rather than leaving the subject to somebody who actually knows something about Iran?
I do know, though, that Iran seems intent on getting nuclear weapons and the missiles to deliver them. I also know that nothing the United States and its allies have done has dissuaded Ahmadinejad (or the mullahs or the Revolutionary Guard Corps) from his goal.
If you bypass Cohen's confusion about the power structure in Iran, his keen gift for stating the obvious shines through, once again. Yes, Iran is intent upon getting a nuclear weapon. Their investment in their nuclear program, and the manner in which they've spread the program out among numerous hardened sites, should clue pretty much anybody in to that fact. The most we can accomplish without going to war is to convince Iran not to have an overt nuclear weapons program - but they will continue their "nuclear energy" program and even a lawful, peaceful program will lead to a point where they're able to produce weapons grade uranium pretty much at will.

It's also obvious that two successive U.S. administrations have looked at the costs and benefits and have decided that the cost of a military intervention sufficient to stop Iran's nuclear weapons program vastly outweighs the benefit of such an attack. Cohen and Applebaum ask us to see the situation through Israeli eyes. Fair enough. But the U.S. and Israel are different countries with different goals for the region. It's easy for Cohen to sneer out an insult at those who recognize that fact:
Former national security adviser Zbigniew Brzezinski even suggested that if Israel tried such a thing, the United States might have to back it down with force. The Brzezinski Doctrine is refreshing in its perverse boldness: We shoot our friends to defend our enemies.
Good grief, Richard, talk to your colleague. Is Cohen so stupid that he believes the U.S. is better served by potentially being drawn into a third war in the Middle East, against a much stronger enemy than we face in either Iraq or Afghanistan, with the likely consequence being that a decade of military and diplomatic efforts in the Middle East are wasted, than by making it clear to Israel that it won't permit an attack that could bring about that consequence? Because the only significant distinction between what Brzezinski suggests and what Applebaum concludes is that Brzezinski recognizes that the U.S. could prevent the Israeli attack, whereas Applebaum prefers to pretend that it could not while recognizing the parade of horribles that could easily follow the attack. Of the three, only Brzezinski addresses the reality of the situation. No, Richard, you moron: It's not about "shoot[ing] our friends to defend our enemies" - it's about forcing a friend to stand down when the consequence of its actions would be devastating to our military and diplomatic goals for the region, and potentially crippling to our economy if Applebaum is correct about the inevitability of expanding the Iraq and Afghanistan wars into Iran.
Update: Brzezinski responds to Cohen:
I hope that Richard Cohen's characterization of my opposition to Israel's use of U.S.-controlled airspace over Iraq as a policy of "we shoot our friends to defend our enemies" is a case of unintentional or exuberant distortion. What I have said repeatedly is that an Israeli attack on Iran through U.S.-controlled airspace would make the United States complicit, and the United States would then become the target of Iranian retaliation.

That is why the United States should make it clear that its airspace is not available for a unilateral Israeli attack, and that a violation of it could lead to an incident reminiscent of the attack on the USS Liberty, about which I added "it is nothing to be wished for."
Exuberance would be an odd explanation. But unintentional? If there's an error, it would be in Cohen's reading of Brzezinski as suggesting that the U.S. might have a military alternative to allowing an Israeli attack to proceed, unimpeded, leading to his taking great offense at the U.S.S. Liberty reference.

The reference to the U.S.S. Liberty is unambiguously about a possible U.S.-Israel military confrontation - given the history of that incident, I don't see that any other interpretation is possible. It's possible that Brzezinski was worrying about what the U.S. might do if Israeli fighters lock radar on U.S. jets sent to intercept their bombers - does the U.S. stand down or do things potentially escalate into shooting. But the possibility of shooting appears to be what inspires his conclusion "it is nothing to be wished for."

This part could also be applied to Applebaum:
One should not lose sight of the larger issue involved in loose advocacy of an Israeli attack on Iran that would implicate the United States in an act of war. Those advocating such an attack not only overlook the fact that such an incident might be designed to draw the United States into war with Iran but, even worse, the fact that U.S. acquiescence would mean nothing less than abdicating to Israel the decision on whether to go to war. Such an abdication is hardly in America's interest, and it is not the way that decisions involving American lives should be made.

Sunday, February 21, 2010

Lead, Follow or... Get In The Way?

Evan Bayh demonstrating that he's not so much part of the solution as he is part of the problem. In short, he's obstructing reforms of student loans that will bring about cost savings and efficiencies by having the government directly provide student loans, out of concern that doing something that's good for the country will affect the financial services that profiteer off of the status quo... and did you notice that Sallie Mae is a major employer in his state.

This story has been covered in many locations; I'm just following up on my "lead, follow or get out of the way" quip by noting that it is possible to do worse than to duck out the door whenever things get rough.

Friday, February 19, 2010

There's More Than One Health Insurance Death Spiral

Paul Krugman's column today explores the "California Death Spiral", more specifically how health insurance rates spiral upwards when healthy people start dropping out of the market.
Why the huge increase? It’s not profiteering, says WellPoint, which claims instead (without using the term) that it’s facing a classic insurance death spiral.

Bear in mind that private health insurance only works if insurers can sell policies to both sick and healthy customers. If too many healthy people decide that they’d rather take their chances and remain uninsured, the risk pool deteriorates, forcing insurers to raise premiums. This, in turn, leads more healthy people to drop coverage, worsening the risk pool even further, and so on.
It's worth noting that factions of the political right, led by people like Newt Gingrich, are intent upon bringing a similar death spiral to the cost of comprehensive health insurance, not just in the individual market (where it's already extraordinarily expensive) but also in relation to group insurance available through employment. The preference is that people purchase catastrophic health insurance, while paying substantial deducibles and co-pays and the cost of routine medical care through a "health savings account" - that is, you pay out of pocket, but with a possible tax break. These plans are profitable for insurance companies, significantly cheaper for employers, and... significantly raise health care costs for individuals, but what does that matter, right?

When you see Democratic Senators talking about "Cadillac health insurance plans", or proposing ways to surcharge or tax comprehensive health insurance plans, the reforms they propose aren't really much different from Gingrich's. That shouldn't be surprising, given that Senators from both parties are effectively owned by business and insurance lobbies - the groups that want this "reform". If you limit an employer's tax deduction for health insurance and fail to raise the limit each year in an amount consistent with healthcare inflation, run-of-the-mill comprehensive health insurance plans fall under the "Cadillac" provision. It becomes more and more expensive to offer comprehensive care, so employers will switch to plans that offer less coverage. They're already doing that, so it should go without saying that increasing their costs will accelerate the process.

You will note, of course, that few are being honest about the true nature of the debate. You don't see people like Gingrich explaining why you, as an individual, will benefit from having the insurance you like "taken away". You're more likely to see the opposite - that, even as they advocate for reforms likely to take away "the insurance you like", those same people are berating the Democratic proposals under the guise that they'll remove your choice of insurer and have a "government bureaucrat" decide what coverage you get - "pay no attention to the man behind the curtain".

You will not hear any of these people address how most nations of the industrialized world manage to provide universal, comprehensive health care at a lower cost than the U.S. pays for its current system - they prefer that the public not be aware of that fact. You'll certainly not hear them admit that their proposal is a giant social experiment that could leave many people technically insured but unable to afford the copays and deductibles requisite to actually obtaining health care services.

The same people who advance this experimentation - catastrophic coverage combined with HSA's - for the nation are contemptuous of a "public option". I have yet to hear a cogent explanation of why from a single one of them, beyond the fabrication that a "public option" substitutes "government bureaucrats" for "insurance industry bureaucrats" when it comes to the administration of the policy. I suspect that their objections come principally from concern that a public option will deliver a lot more at a similar cost to the "catastrophic policy plus HSA" plans they (and their industry backers) prefer. Even if you implement a hamstrung, watered-down public option, available to relatively few people (see, e.g., the current House Bill), you will create a paradigm where people on the outside are likely to look at its costs and benefits and decide that they want in. The obstacles the House Bill imposes on a public option had the CBO projecting that it would be slightly more expensive than private insurance, but I suspect many people would choose it anyway - for the relative comfort that the government is far less likely than a private insurer to try to find a way to avoid paying for medical services they obtain, let alone trying to retroactively revoke the policy, and on the assumption that the government is much less likely to raise rates by 30+% in a single year.

If you pick around in their leavings, you can find the skeleton case that the Gingrich-types would present for their preferred approach to health insurance. It does appear that profits to insurers would go up, and that employers would generate significant cost savings. Although to date, as previously noted, the effect has been to increase the financial burden on employees, advocates argue that as more and more services are excluded from health insurance, market forces will result in their being offered at lower prices.

I am not at all convinced that their belief would hold true - there's a huge market of uninsured and underinsured individuals, right now, and doctors and hospitals aren't exactly rushing to serve that market. But here's the thing: if they believe what they claim, they should be prepared to make an honest case for it. Instead, they serve up hysterical falsehoods about the Democratic proposals, lie about what the public option is and how it would work, and otherwise attempt to distort the debate.

Is that what you would expect from somebody who believes his own argument, or is it what you would expect from somebody who's afraid his ideas will collapse if subjected to even light public scrutiny?

Thursday, February 18, 2010

George Will Knows Snobbery....

For that matter, George Will exudes snobbery. But does he know "loathing"? I mean, it's fun to jump on the contrived story line, "Everybody Hates Sarah", but isn't the reality quite different? Perhaps a small number of people loathe Sarah, but the vast majority of her critics have no appreciable emotional investment. Meanwhile, what does George Will hope to accomplish by spotlight on her... in an effort to prove that she's a non-entity? Attack of the 50 foot eyesores, redux.
She is not going to be president and will not be the Republican nominee unless the party wants to lose at least 44 states.

Conservatives, who rightly respect markets as generally reliable gauges of consumer preferences, should notice that the political market is speaking clearly: The more attention Palin receives, the fewer Americans consider her presidential timber. The latest Post-ABC News poll shows that 71 percent of Americans - including 52 percent of Republicans - think she is not qualified to be president.
Fair enough. But if we're going by that poll, 37% of Republicans hold a "strongly favorable" view of Palin, while 45% of conservatives and 29% of independents believe she's qualified to be President. Despite the effort of George Will's peers to breathe life into her presidential hopes, I agree with Will - she's not going to be the Republican nominee or, if that somehow happens, the result will be catastrophic for the party. But who says she wants to be the Republican nominee. Perhaps will didn't notice that she blew off CPAC 2010, widely considered to be a "must attend" event for Republican Presidential contenders, in favor of a paid gig at the Tea Party Convention. If you assume she's in it for more than the money, step back and consider what her goals may be.

Leading a political movement, flying around the nation on private jets to campaign events, speaking to adoring fans during the day and sleeping in luxury hotels at night, surrounded by suck-ups and sycophants. Depending upon your personality, that could be heaven, hell, or somewhere in-between. But I'm thinking that for Sarah Palin it's heaven.

I agree with Will that Palin's brand of populism isn't going to land her in the White House, save perhaps on a visitor's pass, but....
In 1992, Ross Perot, an only-in-America phenomenon -- a billionaire populist -- won 19 percent of the popular vote. But because of the winner-take-all allocation of electoral votes, he won none of those.
I forget, George, who won that election again? The Republican? Oh, right....

Seriously, if all she does is tread water in the polls, Palin has incredible power as a spoiler in the next Presidential campaign - extorting concessions from the party in return for not running, or sucking away enough votes to ensure President Obama's second landslide victory. And if you look at her actions, her speeches, her advisors... she knows it. And sorry, George, your inability to turn your eyes away from her is evidence not of her weakness, but of her power.

Wednesday, February 17, 2010

The RNC's 2010 "Obama Agenda Survey" Push Poll

Talk about your push polling. Michael Steele, hard at work (and far from being an honest man) serves up the following. If he had a sense of humor, perhaps it could be read as parody.
There is so much about the Obama agenda that most Americans do not know, thanks to the non-stop, swooning coverage of the ultra-biased media.

But with your help, we are going to expose the Obama agenda for all Americans to see so that we create a groundswell of opposition.
A few "did you knows", that exist principally in Republican Party propaganda and right-wing radio:
That's why we are asking where you stand on Barack Obama's promise to raise taxes...

...On his plans to give amnesty to illegal immigrants, which could lead to billions of dollars of government handouts and possibly bankrupt Social Security...

...And how do you feel about Obama's efforts to nationalize health care and have it run by bureaucrats in Washington, D.C?

These are Obama's top priorities!
All the quality of one of those email forwards you get from people who are clueless about the facts or issues, but get ginned up by disinformation from the likes of... Michael Steele. And away we go....
  1. Do you agree with Barack Obama and the Democrats that taxes should be raised for the sake of "fairness," regardless of the negative impact it is likely to have on the economy?

  2. Do you believe the federal government has gone too far in bailing out failing banks, insurance companies and the auto industry?

  3. Do you support amnesty for illegal immigrants?

  4. Should English be the official language of the United States?

  5. Are you in favor of granting retroactive Social Security eligibility to illegal immigrants who gain U.S. citizenship through an amnesty program?

  6. Are you in favor of the expanded welfare benefits and unlimited eligibility (no time, education or work requirements) that Democrats in Congress are pushing to pass?

  7. Do you believe that Barack Obama's nominees for federal courts should be immediately and unquestionably approved for their lifetime appointments by the U.S. Senate?

  8. Do you believe that the best way to increase the quality and effectiveness of public education in the U.S. is to rapidly expand federal funding while eliminating performance standards and accountability?

  9. Do you support the creation of a national health insurance plan that would be administered by bureaucrats in Washington, D.C.?

  10. Do you believe that the quality and availability of health care will increase if the federal government dictates pricing to doctors and hospitals?

  11. Are you confident that new medicines and medical treatments will continue to be developed if the federal government controls prescription drug prices and sets profit margins for research and pharmaceutical companies?

  12. Are you in favor of creating a government-funded "Citizen Volunteer Corps" that would pay young people to do work now done by churches and charities, earning Corps Members the same pay and benefits given to military veterans?

  13. Are you in favor of reinstituting the military draft, as Democrats in Congress have proposed?

  14. Do you believe that the federal government should allow the unionization of Department of Homeland Security employees who serve in positions critical to the safety and security of our nation?

  15. Do you support Democrats' drive to eliminate workers' right to a private ballot when considering unionization of their place of employment?

Lying and scaring people worked pretty well for the Republicans for six of the eight Bush years, so why not give it another chance?

Tuesday, February 16, 2010

Because High School Drop-Outs Are So Good For The Economy

Some Utah "conservatives" want to make it easier to drop out of high school.

According to the Center for Labor Market Studies, barely more than 60% of high school dropouts between ages 16 and 24 worked in 2007, with average annual earnings of $8358. For their peers who finished high school but had no further education, just shy of 70% worked with average earnings of $14,601. For the same groups, 6.3% of drop-outs were incarcerated in 2006-2007, as compared to 1% of high school graduates.
Over their working lives, the average high school dropout will have a negative net fiscal contribution to society of nearly -$5,200 while the average high school graduate generates a positive lifetime net fiscal contribution of $287,000. The average high school dropout will cost taxpayers over $292,000 in lower tax revenues, higher cash and in-kind transfer costs, and imposed incarceration costs relative to an average high school graduate. Adult dropouts in the U.S. in recent years have been a major fiscal burden to the rest of society. Given the current and projected deficits of the federal government, the fiscal burden of supporting dropouts and their families is no longer sustainable.
Yes, that's negative $5,200. Yet, wow... some legislators actually believe that creating more drop-outs is responsible fiscal policy.

Update: Eight states are participating in a much more sensible experiment that shifts some high school students into community college during what would otherwise be their 11th and 12th grades of high school. This approach costs more than keeping them in high school, and they must meet academic standards to be approved for the program, but the hope is that the program will keep kids who might otherwise drop out in an academic or vocational program that will lead them into decent jobs. Unfortunately it does not appear that the community college tuition will be fully funded.

To Be Non-Violent, You Gotta Be Armed?

David Kopel instructs us that it's important to any movement of non-violence that the people involved in the movement have both the right to bear arms and the arms necessary to defend themselves against those opposed to their goals. Taken to its logical extreme, Kopel should be arguing that any group we expect to follow the MLK model of non-violence be sufficiently armed that they are safe and secure in their own homes. I can't see him arguing that, let alone imagine it happening.

Calls for non-violence arise in asymmetric conflicts and, not surprisingly, it's only the side with little to no power that's expected to be non-violent. "If they would lay down their arms and be non-violent, this conflict would quickly come to an end." "Well, if non-violence is the solution, why don't you lay down your arms?" "Don't be ridiculous - we would be giving up everything we've accomplished... they would run roughshod over us...."

Within the context of an independence movement or armed conflict, for non-violence to work you need three basic things:
  1. A significant number of people who are willing to be injured or killed in order to achieve their movement's goals;

  2. Awareness among groups able to effect change that the injuries and killings are occurring; and

  3. A consequent awakening of strong desire by those groups able to effect change to take the political (and perhaps military) steps necessary to effect change.

Human history indicates that those three stars are rarely in alignment.

When the dominant power makes absurd demands (e.g., "Until there's absolutely no violent resistance as defined by us, for an arbitrary period of time also defined by us, we will continue the present course"), it means that they're not serious about changing their approach.

Similarly, when they make demands such as "you must unilaterally disarm, then you must become entirely non-violent, and then we'll consider making concessions", perhaps simultaneously working to exclude or censor the media from the conflict, their primary goal isn't to achieve peace - it's to knock out the second element described above.

Unemployment - Cause and Effect

David Brooks shares another version of his "conservatives need to hug more" view of society. An alternative description, "simplistic answers to difficult problems." This line caught my eye:
Men who are unemployed for a significant amount of time are more likely to drink more, abuse their children more and suffer debilitating blows to their identity. Unemployed men are not exactly the most eligible mates. So in areas of high unemployment, marriage rates can crumble — while childbearing rates out of wedlock do not.
While respecting the fact that prolonged unemployment can create a lot of stress, and can contribute to substance abuse and alcoholism, I suspect that on the first point Brooks is confusing cause and effect. That is, men who are abusive alcoholics, possibly also with a poor sense of their own identities, have trouble landing jobs. The less functional they are as human beings, the longer it takes them to find employment.

His second point isn't much different. Unemployed men and women who, over the long-term, stay in areas of high unemployment are not likely to be hot prospects for the employment market. A lot of the men who stay in dysfunctional communities without either jobs or getting married are a cause of the community's dysfunction, not a symptom.

Since I'm already writing about the editorial, let's look at Brooks' number one solution....
First, we need to redefine masculinity, creating an image that encourages teenage boys to stay in school and older men to pursue service jobs.
I am not sure how much of the problem with dropping out of high school lies in a notion that "Lurnings fer gurls". But around here, I see a lot of older men working service jobs. I would venture that in the areas where Walmart gets thousands of applications for a single entry level job, no small number of the applicants are older men. Where is Brooks getting the idea that older men are spurning work in the service industry, as opposed to losing out on a relatively low number of jobs to other applicants?

"And All We Have To Do Is... Nothing!"

Shahed Amanulla has an editorial in The Guardian complaining that the Obama Administration, specifically Hillary Clinton, has disappointed the Muslim world.
In his April 2009 speech in Cairo, President Obama pledged to create a new relationship between America and the Muslim world through shared values, cooperation, and a renewed effort to alleviate specific policy concerns commonly felt among Muslims.

Nearly a year later, however, Secretary Clinton faced a tough crowd at the sixth annual US-Islamic World Forum, where she pleaded for patience in the face of unrealised goals. "I understand why people might be impatient," explained Clinton. "But building a stronger relationship cannot happen overnight or even in a year." That may be so, but it was little solace for many Muslim observers who momentarily put aside their skepticism in the hope that the US would use its newly-found moral high ground to press for change.
Now, no doubt, there are many things that the U.S. could do on its own that could benefit the Middle East, and it can act unilaterally on any number of issues. But... why should it? There are entrenched political interests that favor the status quo, and many citizens of the U.S. are very disappointed in how difficult it is to achieve change, domestic or international, even to the point of questioning if the Obama Administration wants change. Even when there aren't entrenched interests that favor a particular policy, the government is slow - if it only takes months to change a policy position, by any comparative measure that's government moving at the speed of light.

There are entrenched interests in the U.S. that want to continue the status quo in the Middle East. There are entrenched interests that believe the U.S. is not sufficiently confrontational with the Middle East. There are factions that would like the U.S. to invade Yemen, and would love it if the U.S. invaded Iran. There are huge numbers of U.S. voters who are terrified of the Muslim world, and are easily stirred up over trivialities arising in the so-called "war on terror".

In that context, what has the Muslim world offered to Obama, that he can hold up as evidence that a softened approach will bring about results beneficial to the United States?
It is disappointing to have hopes dashed, but maybe a bit of cold water is a good thing. While it has been great to see a real shift of attitude in Washington towards the Muslim world – and, unrealised goals aside, there is no reason to believe this has changed – perhaps it is more realistic for those involved in conflicts in the region to not depend on others to lead the charge in solving their problems.
Or perhaps it's more realistic to recognize that if the nations of the Arab world don't change their approach to their internal problems, to regional problems, and to extremism, they make it difficult for any U.S. administration, no matter how sympathetic to the need for change, to effect change. "Insanity: doing the same thing over and over again and expecting different results."

The author's focus is in no small part on the situation in Israel, the occupied territories and the situation in Gaza. Understandable. But for decades the Arab states of the Middle East have shamelessly exploited the Israel-Palestine conflict in order to divert the public's attention from internal problems, and some states have actively perpetuated or worsened the plight of Palestinian refugees who live outside of Israel and the occupied territories. When can we expect the Muslim world to insist upon relief and equality under the law for the Palestinian refugees who live, for example, in Lebanon? Or to pressure Hamas to reform its charter - a big psychological hurdle, certainly, but one that could have tremendous symbolic importance? Arab states need no help from the United States to resolve problems that are entirely under their own control, and they have no room to blame Israel for what happens outside of its borders. For their own policies.

Having a U.S. Administration that wants to change its approach to the Muslim world is in no way a justification for failure to work for change from within. If you think about it, it's a time when reformists should be working harder than ever.

Monday, February 15, 2010

Because Nothing Says "I'm Presidential" Better Than Quitting

I recognize that people see Sarah Palin as a potential presidential contender despite her habit of quitting jobs that she finds difficult, but must we extend that "reasoning" to every quitter on the block?
For months now, Bayh has been screaming at the top of his voice that the party needs to reorient toward a more popular, centrist agenda -- one that emphasizes jobs and fiscal responsibility over health care and cap and trade. Neither the White House nor the Senate leadership has given him the response he wanted. Their bungling of what should have been a routine bipartisan jobs bill last week seems to have been the last straw.

* * *

Quitting the Senate was a no-lose move for the presidentially ambitious Bayh, since he can now crawl away from the political wreckage for a couple of years, plausibly alleging that he tried to steer the party in a different direction -- and then be perfectly positioned to mount a centrist primary challenge to Obama in 2012, depending on circumstances.
Earth to Charles Lane: That's not what people mean when they say "When the going gets tough, the tough get going."

It's more like... the scene from Idiocracy in which Private Bowers (Luke Wilson) explains, "Every time [the C.O.] says, 'Lead, follow, or get out of the way,' I get out of the way.
Pvt. Joe Bowers: Why me? Every time Metsler says, "Lead, follow, or get out of the way," I get out of the way.

Sgt. Keller: Yeah, when he says that, you're not supposed to choose "get out of the way." It's supposed to embarrass you into leading - or at least following.

Pvt. Joe Bowers: That doesn't embarrass me.
Then again, Bowers does end up in the White House, so maybe Bayh and Palin are on to something.... (My wife's initial reaction to Idiocracy was "This isn't a comedy - it's a horror movie.")

Update: James Fallows has called upon Evan Bayh to lead. Is anybody taking bets?

Being Used Isn't The Problem....

... It's being used but not getting paid.

AAA-Rated Fables

Fables, updated for the bailout era.

Bipartisanship vs. Delusional Thinking

Ross Douthat, I suspect, is hoping to flatter and redeem Republicans when he writes,
For President Obama, being “bipartisan” means incorporating a few right-of-center proposals into an essentially liberal legislative package. For Republicans, it means doing only those things that legislators of both parties can agree on — a far more stringent standard, and one that would produce a very different bill.
In what country, in what government, and in what era, has what Douthat describes as the Republican model of "bipartisanship" existed? For that matter, and with all due respect to how good politicians can be at lying with a straight face, is there a Republican in either the House or Senate who could provide that "definition" without at least smirking? We're not that far out of the Bush Administration....

Douthat, not at all surprisingly, is nebulous in his criticism of the current House and Senate bills:
The right seeks a functioning marketplace in health care, subsidized but not micromanaged by the government.
Both bills, of course, do that. They preserve the present system.
However many small steps the Democratic legislation takes in that direction, its biggest step goes miles the other way — toward a world where consumers are required to buy a particular kind of health insurance, insurers are required to sell it to them, and the cost of health care gets held down, ultimately, by price controls and bureaucratic supervision.
What language in either bill does Douthat believe requires consumers "to buy a particular kind of health insurance"? I mean, other than the kind that is provided by private health insurance companies. As for insurers being "required to sell it to them", translation: allowing people with pre-existing conditions to obtain health insurance, that is actually something that the Republicans want as well - at least in theory. The price of health care being held down by "by price controls and bureaucratic supervision"? Where can I find that in either bill? Dropping in the word "ultimately" is not an excuse for misrepresenting what is actually in the proposed legislation.

If Douthat's comments are to be construed as consistent, his argument becomes laughable:
Like the Democratic bills, [Senator Judd Gregg's] proposal would mandate that everyone buy health insurance — but it would emphasize catastrophic coverage, rather than comprehensive plans.
The individual mandate goes hand-in-hand with forbidding insurance companies from denying coverage based upon pre-existing conditions. Douthat just got through telling us that the Republicans don't want to restrict insurance companies from denying coverage. Now it's a cornerstone of what he apparently believes to be the best GOP idea for reform? And let's not forget that another cornerstone of the Republican Party's objections to the Democratic bill is the mantra that "people like the insurance they have" - Is Douthat calling that claim out as an obstructionist lie? Because "emphasiz[ing] catastrophic coverage" (that is, replacing comprehensive health insurance policies with catastrophic coverage and HSA's) would drastically change the health insurance coverage enjoyed by the typical American, and not in a manner many are likely to view as change for the better. Douthat follows up on his distortion that the Democratic bills will require consumers "to buy a particular kind of health insurance" by advocating for Gregg's proposal that is designed to do exactly that?

Beyond a single Senator's proposal, like Newt Gingrich and John C. Goodman before him, rather than admitting that the GOP has a dearth of ideas Douthat resorts to the ideas of people outside the Republican Party.
Writing in The Weekly Standard, for instance, Jeffrey H. Anderson has proposed covering an extra 10 million Americans with a mixture of tax credits for the uninsured and better-funded risk pools for people with pre-existing conditions. One could imagine Republicans taking Anderson’s “small bill” into negotiations with the Democrats and emerging with a compromise that spent somewhat more money but kept the basic mix of tax credits and risk pooling intact.
An individual projecting that his proposal, unscored by the CBO, will eventually insure 10 million Americans. That's better than the GOP's actual proposal, projected by the CBO to insure 3 million over ten years, but remains a pale shadow of what the Democratic proposal is projected to achieve. Further, Anderson's editorial relies over and over again upon his conception of what "the American people" supposedly want. Leaving aside the fact that we don't live in a direct democracy, the American people overwhelmingly support a public option. Do Douthat and Anderson support that as the will of the people, or are they only concerned about "what the people want" when poll results coincide with their own pre-existing views? (Obviously, that's a rhetorical question.)

Douthat admits,
“Imagine,” of course, is the operative word.
Obviously. Beyond Judd's proposal, which Douthat hasn't indicated is supported by even one other Senator and which implicates most of the objections Douthat claims the Republicans have with the Democratic proposals, Douthat's defense of the GOP relies entirely upon his imagination. So when he whines, "The Democrats haven’t shown any interest in a fresh start," really, what does he expect? That they give up bills that have achieved majority support under Douthat's conceit that it's reasonable to complain that a bill is not "bipartisan" unless the minority party agrees to every detail?

Friday, February 12, 2010

Gingrich & Goodman Idea #10: "Make Medical Breakthroughs Accessible to Patients"

The final "GOP idea" shared by Newt Gingrich and John C. Goodman is to "Make medical breakthroughs accessible to patients".
Breakthrough drugs, innovative devices and new therapies to treat rare, complex diseases as well as chronic conditions should be sped to the market. We can do this by cutting red tape before and during review by the Food and Drug Administration and by deploying information technology to monitor the quality of drugs and devices once they reach the marketplace.
The FDA doesn't get much love from anybody. When it doesn't approve medications or medical devices quickly, it is a behemoth that must be streamlined. But when it makes a mistake, approving a dangerous drug or device, even if the error was caused in part by streamlining the same critics previously demanded. At the far extreme, some call for eliminating the FDA and simply letting the market do its magic - I guess if enough patients die, people will figure out that they don't want a particular medication, treatment or medical device.

With some of the FDA's sluggishness it does appear that a new device or treatment could be a genuine boon to patients, and could potentially decrease medical costs. Consider, for example, the artificial pancreas. The FDA describes itself as having taken a "proactive role" in the development of the technology, but diabetes patients still wait. The FDA cites concerns about safety and the accuracy of sensors - after all, an error in the administration of insulin could be lethal - and that at best an artificial pancreas won't function as well as the real thing. But no question, there are diabetes patients who would accept that risk and find the FDA's caution to be both excessive and frustrating.

But let's take a step back for a moment. Let's assume that the FDA's approval process could be streamlined, such that new devices and drugs could be approved much more quickly without jeopardizing patient health. Although there are exceptions, and the artificial pancreas may prove to be one, how often have new medications and new technologies reduced the cost of health care? Usually they have the opposite effect - investment in new technologies and the high cost of patented drugs and devices push overall healthcare costs up. With due respect for Gingrich's love of science fiction, how does he expect that a proliferation of drugs and devices, not fully tested, will decrease health care costs as opposed to increasing them - not only to pay for the patented technologies themselves, but to treat patients who experience bad outcomes due to errors resulting from an accelerated approval process?

If Gingrich and Goodman have answers then, once again, I expect that this is a proposal that would get broad bipartisan support. Without answers, given their insistence that the reform bill be revenue-neutral, I expect that the GOP will be quick to reject it.

(Return to Parent Article.)

Gingrich & Goodman Idea #9: "Stop Health-Care Fraud"

I guess it's hard to come up with a list of "10 GOP ideas", which I suppose John C. Goodman and Newt Gingrich include non-GOP ideas, ideas at odds with actual GOP ideas, and even Democratic Party ideas in their list. As with "making health insurance affordable", it's rather silly for either party to try to lay claim to fighting fraud.
Every year up to $120 billion is stolen by criminals who defraud public programs like Medicare and Medicaid, according to the National Health Care Anti-Fraud Association. We can help prevent this by using responsible approaches such as enhanced coordination of benefits, third-party liability verification, and electronic payment.
Were the GOP to propose legislation with a serious likelihood of combating fraud, I think it would pass by overwhelming support from both parties. But... this isn't actually a GOP priority and they have proposed no such bill.

Who is making a crack-down on fraud a priority? Well, it's not Newt Gingrich:
"The Obama administration is committed to turning up the heat on Medicare fraud and employing all the weapons in the federal government's arsenal to target those who are defrauding the American taxpayer," HHS Secretary Kathleen Sebelius said during a news conference at the Justice Department with Attorney General Eric Holder.

"But our joint efforts don't just stop at the jailhouse door," she said. "Every dollar we can save by stopping fraud can be used to strengthen the long-term fiscal health of Medicare, bring down costs and deliver better service to Medicare beneficiaries."

The government's job will be anything but easy.

During the past five years, thousands of Medicare fraud offenders have shown that they can outsmart the vulnerable healthcare system for the elderly and disabled. Their weapons: cash kickbacks to Medicare patients, manipulation of medical records to justify bogus charges, and use of different billing codes to get around Medicare's technology to block false claims.
Maybe Gingrich missed the speech?
The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud, as well as unwarranted subsidies in Medicare that go to insurance companies -- subsidies that do everything to pad their profits but don't improve the care of seniors. And we will also create an independent commission of doctors and medical experts charged with identifying more waste in the years ahead.
Without wanting to diminish the importance of empowering patients, it should be noted that if you restructure Medicare's payment system such that each doctor can "renegotiate and reprice their services" with each individual patient, as Gingrich and Goodman propose, you're significantly increasing the opportunity for fraud.

I'll give Gingrich and Goodman credit for having the President's back on this issue, but I'm surprised they don't know that President Obama is a Democrat.

(Return to Parent Article.)

Gingrich & Goodman Idea #8: "Eliminate Junk Lawsuits"

One of the interesting aspects of healthcare reform has been how quiet the insurance industry has been. When you hear people like Newt Gingrich talk, you would think that "tort reform" was perhaps the most pressing issue that must be addressed as part of a reform package. But instead the insurance companies appear happy with the status quo.

If you think about it, the insurance industry has good cause to be happy with the status quo. Despite their squawking about evil "trial lawyers," they have achieved their "tort reform" goals in pretty much every state. They have consistently focused on four goals: limit damages awards, so that the most severely injured individuals recover get little compensation for their pain and suffering; abolish "joint and several damages" and implement the "empty chair defense" to force plaintiff's lawyers to sue every conceivable defendant and drive up the costs of litigation; require notice periods and "certificates of merit" before a lawsuit can be commenced so as to prolong and again drive up the cost of litigation; and shorten statutes of limitations and implement statutes of repose, such that patients have a narrow window of time to make their claims before they're permanently barred from doing so, regardless of a claim's merit.

I read an article recently by a doctor who was sued as part of a malpractice case and who was ultimately dropped from the suit. She asked her defense lawyer "Why was I sued" and the defense lawyer lied, "I don't know." The defense lawyer does know. If you have a system of "joint and several liability", you can sue those you believe are most responsible. If a defendant believes others are in fact responsible, or are more responsible, the defendant can bring those others into the case. Insurance companies have worked very hard to abolish joint and several liability and to create the "empty chair defense" - so that a defendant can point to the "empty chair" where that defendant "should be sitting" and argue at trial that the plaintiff didn't sue the actual culprit, and that the actual culprit is responsible for most or all of the damages. That defense may amount to lies and innuendo, but courtroom arguments won't support a defamation case and the goal is to win, right? So to avoid that outcome the plaintiff now brings every conceivable defendant at the start of the litigation. This pro-insurance industry reform increases the cost and burden of litigation, and measurably harms the health professionals (and others - this isn't limited to malpractice) who are brought into claims to avoid the "empty chair defense". Plaintiff's lawyers would be happy to go back to joint and several liability with the onus on the defendant to bring in a supposedly culpable third party, and that should work out quite well for doctors, but the insurance industry is not going to give up this "reform".

Of the four leading "reforms", arguably the "certificate of merit" should help avoid "junk lawsuits" but in reality malpractice lawyers work hard not to file meritorious claims. Even without that requirement, due to the high cost of litigation, malpractice lawyers pay medical professionals to help them screen their cases - they don't want to waste their time and money on cases they cannot win. The dubious claims get filed because lawyers lack the information necessary to fully assess the merits of the claim without discovery - without forcing that information out of the defendants and their insurance companies. The certificate of merit prepared for such a case is prepared by a doctor who is similarly forced to make assumptions about what happened. So in practice it's a great way to generate revenue for doctors who prepare certificates of merit, drive up the cost of litigation and drag out the settlement process, but does little to ensure that a case is meritorious.

Some realities of medical malpractice litigation:
  • Most malpractice cases are correctly decided.

  • Those in which are arguably wrongly decided in favor of the plaintiff have smaller-than-average recoveries, and claims without merit are "generally resolved appropriately".

  • About one in six malpractice cases are wrongly decided in favor of the doctor.
the malpractice system performs reasonably well in its function of separating claims without merit from those with merit and compensating the latter. In a sense, our findings lend support to this view: three quarters of the litigation outcomes were concordant with the merits of the claim.
And, when "non-error claims" were made, it was not for a lack of diligence by the plaintiff's lawyers:
The profile of non-error claims we observed does not square with the notion of opportunistic trial lawyers pursuing questionable lawsuits in circumstances in which their chances of winning are reasonable and prospective returns in the event of a win are high. Rather, our findings underscore how difficult it may be for plaintiffs and their attorneys to discern what has happened before the initiation of a claim and the acquisition of knowledge that comes from the investigations, consultation with experts, and sharing of information that litigation triggers.
The most serious problem identified?
Although the number of claims without merit that resulted in compensation was fairly small, the converse form of inaccuracy — claims associated with error and injury that did not result in compensation — was substantially more common. One in six claims involved errors and received no payment. The plaintiffs behind such unrequited claims must shoulder the substantial economic and noneconomic burdens that flow from preventable injury. Moreover, failure to pay claims involving error adds to a larger phenomenon of underpayment generated by the vast number of negligent injuries that never surface as claims.
That's right - not enough people injured by malpractice receive fair compensation for their injuries. All of that information coming from the New England Journal of Medicine.

One of the criticisms of the malpractice system is that too much of the money that goes into the system goes to the cost of litigation, with too little ending up in the pockets of an injured plaintiff. It's a fair criticism. It's also fair to recognize that delay and increased cost are a defense lawyer's friend, and the plaintiff's lawyer's enemy. A dream case for the plaintiff's lawyer would involve calling the defendant's insurance adjuster, negotiating a fair settlement, executing the settlement agreement, and getting a check at the earliest possible date. It almost never happens. Instead, even when liability is blindingly obvious, insurance companies want to make plaintiff's lawyers work for the money, and benefit from prolonging litigation during which time a severely injured plaintiff may decide that they would rather take a small settlement now than have to wait additional months or years to be more fully compensated. Returning to the New England Journal of Medicine:
Frivolous litigation is in the bull's-eye of the current tort-reform efforts of state and federal legislators. The need to constrain the number and costs of frivolous lawsuits is touted as one of the primary justifications for such popular reforms as limits on attorneys' fees, caps on damages, panels for screening claims, and expert precertification requirements. Our findings suggest that moves to curb frivolous litigation, if successful, will have a relatively limited effect on the caseload and costs of litigation. The vast majority of resources go toward resolving and paying claims that involve errors. A higher-value target for reform than discouraging claims that do not belong in the system would be streamlining the processing of claims that do belong.
Plaintiff's lawyers would get on board with that. Why won't Newt Gingrich's clients in the insurance industry?

Frankly, "tort reform" is a subject that a few poeple find interesting, but makes most people's eyes glaze over. That's why the insurance industry and its shills use misleading sound bites "junk lawsuits", "lawsuit lottery", etc., to mischaracterize the facts. (Why don't "tort reform" advocates ever show us the paraplegic in a wheelchair, or the severely brain injured child, who "won" this "lawsuit lottery"?) When there's real scholarship available from credible sources, such as the NEJM article quoted above, it's disgraceful that the mainstream media gives unquestioning coverage to the insurance company spin than they do to the facts, but... that's pretty typical of mainstream media coverage of contentious or scientific issues.

Speaking of shills....

The Newt Gingrich, John C. Goodman editorial is subtitled, "We don't need to study lawsuit reform for one minute longer", so I guess they've read the NEJM article and... yeah, right. They don't want to study lawsuit reform for one minute longer lest some facts enter the debate. It's enough to declare that "The current system is broken" then demand "reforms" that will ensure that even fewer victims of medical malpractice receive any compensation, and fewer of the rest receive fair compensation. And of all states to hold up as an example, Texas - a state that went farther than any other to kowtow to the insurance industry to the significant detriment of victims of malpractice. Tort reform was sold on lines like this: "52 counties in Texas now have no obstetrician. Wide swaths of Texas have no neurosurgeon or orthopedic surgeon". Four years after "tort reform", the number of counties without obstetricians is unchanged--152 counties still have none, according to the Observer's examination of county-by-county data at the state Medical Board... Nearly half of Texas counties--124, or 49 percent--have no obstetrician, neurosurgeon, or orthopedic surgeon. Those specialists aside, 21 Texas counties have no physician of any kind." Let's not forget the New Yorker article, in which a doctor turns a spotlight on high medical costs in Texas:
Some were dubious when I told them that McAllen was the country’s most expensive place for health care. I gave them the spending data from Medicare. In 1992, in the McAllen market, the average cost per Medicare enrollee was $4,891, almost exactly the national average. But since then, year after year, McAllen’s health costs have grown faster than any other market in the country, ultimately soaring by more than ten thousand dollars per person.

“Maybe the service is better here,” the cardiologist suggested. People can be seen faster and get their tests more readily, he said.

Others were skeptical. “I don’t think that explains the costs he’s talking about,” the general surgeon said.

“It’s malpractice,” a family physician who had practiced here for thirty-three years said.

“McAllen is legal hell,” the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn’t lawsuits go down?

“Practically to zero,” the cardiologist admitted.

“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures.
So Texas-sized "tort reform" left it with one of the highest cost, most wasteful healthcare markets in the nation. And when confronted with that fact doctors still try to blame "malpractice litigation" even though virtually no malpractice suits are filed.
In 2006, Medicare spent fifteen thousand dollars per enrollee here, almost twice the national average. The income per capita is twelve thousand dollars. In other words, Medicare spends three thousand dollars more per person here than the average person earns.
It must make Newt Gingrich very proud.

All of that said, let me briefly touch on the reasons why I don't think that the insurance companies are eager for the federal government to impose Texas-style "tort reform" upon the nation, and are instead appear largely content with the softer reform measures that exist in both the House and Senate bills. It's not that they're trying to silence their shills, but even Gingrich put "malpractice reform" eighth on his list of "ideas". If you impose a national cap on damages, it's likely to be higher than many state caps - many such caps were imposed decades ago and have not since been raised - and to be indexed to inflation.

Further, it's easier to target Congress with a litany of cases in which a cap brought about an unjust result, both because you're targeting one legislative body instead of fifty and because you're better able to get media attention, potentially having the cap raised in subsequent years. It's hard to make a "conservative" case for a federally imposed statute of limitations for malpractice cases, and you suffer the same consequence - it is easy to find examples of people, particularly people injured as minors, whose claims were cut off by a statute of limitations before they realized the severity or cause of their injury, or before they were legally competent to pursue the claim. A national statute of limitations could significantly expand the number of people able to bring claims currently time-barred under state law. Imposing an abolition of joint and several liability would be hard to disguise as anything but an intrusion on states rights. Further, all of these restrictions would be subject to appeal to the U.S. Supreme Court which, although largely pro-industry, might nonetheless have a difficult time finding a constitutional basis for supporting the federalization of a single type of tort, or reading the 7th Amendment out of the Constitution.

You would also think that a "conservative" like Newt Gingrich would want to empower states - any of which can, right now, emulate Texas - to enjoy the right to fashion their own remedies consistent with their own views of public policy. Surely he's heard of this thing called "federalism"? Instead, as with insurance regulation, he'll apparently support anything his industry sponsors want even if it undermines federalism. Of course, that's no surprise if you look at his track record.

(Return to Parent Article.)

Thursday, February 11, 2010

"Creating Jobs"

A report from the Center for Labor Market Studies at Northeastern University, The Depression in Blue Collar Labor Markets in Massachusetts and the U.S., presents the following table:

If that holds true across the nation, as I expect is largely the case, it is easier to see why the jobless rate is so high - and why it's so difficult to attack unemployment. In a real estate crash, with a worsening commercial real estate sector, it's not very realistic to expect a significant number of construction jobs to emerge, even with huge stimulus bills. Despite a government effort to save General Motors and Chrysler, without which the manufacturing jobs picture would look a lot worse, there's no obvious way to generate more domestic manufacturing jobs.

So instead you have people who may well have strong vocational skills, but who are competing for jobs that have for now disappeared from the economy, or are trying to find jobs in other fields where job availability is better, but for which they lack experience and often also lack appropriate job skills.

Even if it's part of a solution, I don't see the answer as being "a bigger jobs bill", and as I've previously observed it's pretty clear why a lot of government tactics appear designed to "reinflate" the housing bubble - how else are you going to affect unemployment in the construction sector, which is so high that it distorts the overall unemployment picture and is unlikely to significantly improve over the next few years by any other means? About the only thing the government can do is create a massive "public works" program to directly employ a significant percentage of the population until the jobs picture improves - and I don't think that's politically viable, even if it could be done in a relatively cost-effective manner and we could identify appropriate work for the program to perform.

The report does make suggestions, but I just don't see how they can be implemented on anywhere near the necessary scale to make a short-term difference, or even how they will benefit the majority of the affected workers in the longer term. The numbers are just too large, and the impediments to creating stable, long-term manufacturing jobs or new construction jobs cannot be discounted.