Grab Bag

April 2, 2010

Health Care Nullification?

Re: the idea of nullification as broached by some conservatives about healthcare: We fought a war with each other over this kind of stuff back in the 1800s. The outcome of that war settled, decisively, this question. States are not allowed to nullify federal law; the only chance of the health care law not being implemented is for a constitutional challenge to be upheld. Really, what that involves is convincing Justice Kennedy that your side is right. In other words it’s a total toss-up, but any question as regards healthcare is likely to be decided by a 5-4 vote either way. In all honesty, though, the best thing for conservatives to do if they don’t like this law is to do something they didn’t do while it was being written: negotiate.

I think almost everyone agrees that this law isn’t perfect, but that doesn’t mean that the solution is to act like it never happened, or to be obstructionist, or to try to get it repealed. The votes for repeal simply do not exist, and won’t for a long time, if ever. Once this law starts to come into effect, many of the measures will prove too popular to be repealed. So the solution, if you’re conservative and unhappy or liberal and unhappy (like me), is to work together to negotiate fixes on portions of the law that aren’t working as intended. And of course there will be portions of the law won’t work as intended; all laws have portions that don’t work. This doesn’t mean, however, that the law was a bad idea, or that it is irretrievably broken. It just means it needs fixed. Of course, on something as polarizing as healthcare, we’ll see the rhetoric of failure; don’t believe it. This is how the US legislative system works, and it works best when both sides work together despite disagreeing on a lot of things, not when one side sticks its fingers in its ears and refuses to play ball.

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A further complaint I have with this law is the poor job it does of cost control. The main elements of cost control that are still in the law are mainly ones relating to economies of scale. There are a few mandates for insurance companies to spend less money on administrative expenses and more money on actual care. The idea is that this will bring costs down, and it might. Some. The biggest savings will come from adding 32 million people to the pool of the insured. Medicare, for example, spends far less per beneficiary than most health insurers, partially because of lowered administrative costs and partially because of the economies of scale that the number of Medicare beneficiaries gives to the program. Adding both of these together should have much the same effect on private insurers.

One way that we could have figured in more cost savings was to change the payment system. It’s pretty well-known that doctors and hospitals are paid by the amount of care they give, not the quality of care. A shift to paying for outcomes would have gone a long was towards “bending the cost curve.” But any ideas of pursuing that path were lost amid cries of “rationing!”—as though your health insurer doesn’t already ration your care—and fears that the US’s position as an “innovator” would be lost.

To the first: there’s no real reason that a shift to outcome based payment should result in “rationing.” We could avoid these unfounded fears by adopting the Mayo Clinic model, which pays doctors a set salary. That option was brought up and ultimately discarded, which is disappointing to me. At any rate, what the controversy over “rationing” demonstrates is the inability of Americans to have real conversations about death. I think we are, as a country, terrified of dying. Death represents the antithesis of the American mythology, and so when someone starts talking about “end of life” care and “quality based” care rather than “quantity based” care people start to freak out and act like death isn’t something that happens to Americans. I’m reminded of a Nada Surf song, “Look alive; you see these bones? What you are now, we were once. Just like we are you’ll become.”

To the second: there’s also no real reason to suggest that a shift in philosophy of care would topple America from its position as an innovator. The current system is set up to reward people for finding new, novel ways of curing problems that no-one new existed. People are rewarded for making products, tests, and procedures just because. What the shift would necessitate is a focus on a different kind of innovation. Rather than using the best, shiniest, new medical Rube Goldberg people would be rewarded for breakthroughs in efficiency and effectiveness. That’s innovation; it just doesn’t get the same headlines that “miracle pill!” gets.

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Some people, prominently Michelle Bachman, don’t like the Census. I hate to sound like I’m picking on conservatives all the time, but most of the people who’ve been making noise about this have been just that: capital-C Conservatives. They charge that the census is unconstitutional; that the results will be politicized; that the Obama administration will use the results to spy on and marginalize them.

First, the census is blatantly constitutional. How constitutional, you ask? It is in the constitution explicitly. (Article I, Section II) Not filling out the census, then, is actually the unconstitutional act, and is in fact a federal offense. For people who are so obsessed with the Constitution you’d think they’d get this.

Second, yes, of course the results will be politicized. How? By everyone because every census is. Census results are used to determine the number of representatives a state gets to Congress, and the gain or loss of seats means that state legislatures have to redraw the district maps. This is always politicized because people want to draw the lines in such a way as to be most favorable to them. The extremes of this are gerrymandering, and both sides are guilty of it. Iowa does a pretty good job of it, I think. With our five representatives we have two that are pretty much lock Republican seats and two that are safely Democratic, with one seat (Second District) usually up for grabs. We look set to lose a seat pending the results of this census, so the redistricting will surely be contentious in Iowa.

Census information will also be used to determine where federal funding should go, and where programs should be started. That is always a political battle, but you’d think that Conservatives would realize that when the Republicans get power back (and that will happen eventually) that accurate census information would mean that they’d be able to spend money in ways that are amenable to Conservatives.

The idea that President Obama and his administration would use census information to spy on people is… laughable, really. You have more to fear from your cell phone than from the Census Bureau. Unfortunately, this kind of conspiracy theory has some traction in some circles. But you’d think that common sense would eventually seep in here. Not filling out the census form means that, for statistical purposes, you don’t exist. Meaning you don’t count when they apportion Congressional seats; meaning you don’t count when they determine where funds go; meaning you don’t count when they look at zoning and tax laws. Really, not filling in your census is worse than not voting.

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A Russian view of the Moscow Metro bombings:
I was talking to my host brother my first night in Nizhny, and Ivan said he was pretty suspicious of the bombings. It wasn’t until a few days later that any Chechen separatist movements claimed responsibility for the attacks, and we’ve seen in other terrorist attacks that groups who had nothing to do with the atrocities will take credit for the carnage. The two stops targeted were directly under Red Square and under the headquarters of the former KGB. Furthermore, Russian Police investigators came to their “Chechen Women” conclusion very quickly. Ivan’s suspicious that it may have been an inside job, engineered maybe by an oligarch who wanted the government off his back, or by the government itself in order to justify crackdowns. I personally think Occam’s Razor applies here; Chechens aren’t very happy with the Russian government, and women have been used to set off these bombs before. I think the conclusion by Russian investigators was a pretty sound one, but I think it is revealing the amount of cynicism on the ground here in Russia.

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Japan recently defeated a proposal to list Bluefin Tuna as an endangered species. Well, Japan and a few African countries that depend upon exports to Japan for their economic well-being. I think this is disgusting. Almost every single ecologist agrees that tuna is on the verge of crashing into extinction. A huge proportion of the world’s tuna ends up in Japan, and for a single country to be able to effectively wield a deciding vote on a matter of biodiversity this grave is very troubling to me. Of course the United States does this all the time, and I don’t think that’s ok, either. Tuna are a huge predator in the seas, and if we hunt and fish them to extinction it will have an enormous effect on the balance of power in the ocean.

Japan also does this with whaling. Humans hunting whales is almost as unfair as hunting moose from helicopters; there’s seriously no contest. Japan claims exemptions from the comprehensive whaling bans on scientific grounds, and every summer they kill hundreds of whales. This is another ridiculous claim. Scientists the world over to research on whales without hunting and killing them, and there’s not really a good reason why Japan should be allowed to continue doing so under their exemption.

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The biggest change I’ve noticed here in Nizhny since coming back is that it looks a little bit more run down than last year. Paint is peeling; sidewalks and steps are crumbling; the buses and trams look a little worse; the roads have more potholes. Very plainly the money is simply not there in Russia to keep things infrastructure related in good repair. Some of this is due to the recession. Most of it is a hangover from the fall of the Soviet Union.
Russia’s recent growth (it only achieved Soviet level GDP a couple of years ago) has been down mostly to the exploitation of the country’s national resources, oil and natural gas in particular. As long as the prices of those commodities continued to go up, then things were rosy in Russia. Those prices have cratered. But all of that is pretty immaterial, because very little of that money produced by private companies in Russia is actually going to the Russian government. (There are, of course exceptions. Gazprom is controlled by the government.) This is directly due to the economic policies forced upon Russia as the Soviet Union fell.

Russia operates under free market principles that would make Margaret Thatcher and Ronald Reagan parade in the underwear. It is truly a wild west situation, and it was even worse (there’s my bias) at the beginning of the 90s. There was an enormous amount of capital flight from the country, as the oligarchs who gained control of the formerly nationalized companies fled offshore. Under the Soviet Union the money that these corporations made stayed with the state and was reinvested in the infrastructure of the Soviet Union. Now the money leaves the country and is spent on Chelsea FC. The result has been the unraveling of Russian infrastructure and its manufacturing base. Without the state keeping things up and running everything is breaking down now.
I would never suggest that the benefits of Soviet economic policy outweighed the human toll the Soviet regime exacted. Some of the economic policies were directly responsible for millions of deaths in Ukraine, for example, and the command economy meant that resources were expended with very little eye towards efficiency and ecological impact (see: Chernobyl). I will say, though, that the transition of a highly centralized market to a privatized one was an absolute disaster for the ordinary Russian. I am, of course, not an economist, and I’m sure that the architect of Russia’s shock therapy financial reforms, Jeffrey Sachs, would still defend his choices. I can’t help but wonder if there wasn’t a second way.

In close proximity to Russia are the Scandinavian countries, most of which are on the verge of being socialist. They also happen to be very democratic, and very happy. Source Here It seems to me that a measured transition towards Scandinavian style economics and government might have been a better, more sustainable long-term proposition.

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So my final point deals with exactly what I was alluding to in the last bit. I had a long conversation with a friend recently about healthcare, and the government in general. My friend is a fairly conservative guy, and when finally pushed to describe my political beliefs I said, “You’re afraid of big government running your life. I understand that. My reading, and experience, over the last few years has made me much more wary of corporations and their ability to influence and control my life than I am of the government.” Of course it is possible for a government to go too far, but what we’ve got going for us in the US is a long established sense of democratic representation.

Corporations are powerful. Even McDonald’s can periodically overcome my distaste of their policies because their advertising is so pervasive and a double quarter-pounder just tastes so. damn. good. Modern corporations are responsible for fleeing expensive labor in Western countries for cheap labor in industrializing countries. There they can do everything cheaper because the regulation on them is more lax. Workers are paid a pittance and work in shocking conditions; the factories themselves belch pollution into the environment of the very people they are exploiting. All so that we can buy a $120 pair of Nikes. In this way big corporations do a double disappearing act. They steal money from the Western consumers who buy their products by refusing to employ them in anything other than retail jobs shilling for shoes/cars/clothes/whatever rather than manufacturing, and they steal money from the developing world by refusing to pay a living wage and devastating the landscape of these countries. The money made and saved goes straight to the top, enriching the already rich.

The weakening of government regulation has also meant that corporations now have even more direct influence on the very policies that regulate them. Lobbyists are incredibly powerful in the government , and that’s a direct result of the government refusing to stand up to corporations over the past thirty years. We got “too big to fail” corporations because we refused to trust bust.

The common response to these criticisms is that America wasn’t founded under “socialist” principles, but instead on the values of capitalism. I’d like to point out that Adam Smith published The Wealth of Nations in 1776. Capitalism was a pretty new idea in the world when the US was founded, and the authors of the Constitution could not have conceived of a company with a reach so vast as to threaten to systematically ruin the entire world economy in the way that Lehman Brothers did in 2008. The world isn’t static, and it is very different from when the US was founded. Acting like this isn’t so out of misguided fidelity to “the Founders” simply ensures that corporations will continue to exploit people around the world.

I don’t even think that democracy and capitalism are necessarily compatible. Capitalism is working best right now in China, which is hardly a beacon of freedom in the world. The advantage granted by the Chinese government to corporations is that they’re essentially allowed to do whatever they want to increase their profits. It makes a degree of sense. Capitalism views people essentially as no more than dollar signs, as profit; authoritarian governments tend to see their populations in a similar way. In the West democracy and capitalism grew up together, allowing democracy to develop safeguards against the depredations of unrestricted capitalism.
To throw that away because “socialism” is bad is silly. We almost did it in the 80s. Reagan and Thatcher pursued Milton Freidman’s free-market gospel in the West and pressured governments in the industrializing world to do the same. As a result we are now treated as little more than consumptive animals, things to be exploited for profit. We’ve lost sight of the essential, intrinsic value of human life and replaced it with a dollar sign. I can’t help but think that this ends up substantially abridging our freedom of choice. As companies get bigger their systemic reach grows ever larger. When you buy a Pepsi and a pack of Fritos you’re paying the same company; your choice is an illusion. If you’re afraid of the government, remember; you can vote out your representatives. Getting enough shares to vote out a CEO or Board of Directors on a Fortune 500 company takes more money than most of us will ever have.

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