An admirable explanation that hits on the distributional ins and outs I referred to earlier this week.
Howard Dean says of the community center proposed at Park51:
I think another site would be a better idea.
(Actually, he said it would be a “better i-deer,” but being from New England, I find this endearing.)
In response to criticism from Glenn Greenwald, Dean writes (in part):
My argument is simple. This Center may be intended as a bridge or a healing gesture but it will not be perceived that way unless a dialogue with a real attempt to understand each other happens. That means the builders have to be willing to go beyond what is their right and be willing to talk about feelings whether the feelings are “justified” or not. No doubt the Republic will survive if this center is built on its current site or not. But I think this is a missed opportunity to try to have an open discussion about why this is a big deal because it is a big deal to a lot of Americans who are not just right wing politicians pushing the hate button again. I think those people need to be heard respectfully whether they are right or whether they are wrong.
What I’d like to ask Dean, proud defender of civil unions for homosexual couples, is this: couldn’t this same argument be made in favor of asking those pesky lesbians to refrain exercising their right to attend their high school prom?
I have moved on today to taking a look at John Goodman’s “Characteristics of an Ideal Health Care System.” Goodman has an informative and always pointed Health Policy Blog. He is President of the National Center for Policy Analysis, and the last page of his paper notes that the Wall Street Journal once called him “the father of Medical Savings Accounts.”
I expect I’ll be writing more about Goodman’s Ideal Plan, but one thing leaped out at me straightaway as somewhat curious. Like most proponents of Medical Savings Accounts, Goodman appears to want insurance to come in the form of low-premium/high-deductible plans.
Not being utterly callous, Goodman is willing to subsidize the purchase of insurance, to some extent (although he’s willing to offer subsidies of identical amounts to rich and poor alike). In order to determine the level these subsidies should be set at, Goodman argues that we already a socially set number: it is “the amount we expect to spend (from public and private sources) on free care for that person when he or she is uninsured.” Goodman then cites Texas, which he says spends an average of about $1,000 per year per uninsured person on free care. He then notes, “Interestingly, $4,000 is a sum adequate to purchase private health insurance for a family in most Texas cities.”
Although writing in 2001, Goodman’s $4,000 Texas insurance policy must have been a high-deductible policy. According to this Health Affairs article, average job-based family coverage was $588 per month in 2001, or $7,056 per year. Surely a $4,000 policy, in the non-group market no less, would involve a significant deductible. If so, then the following is what I find curious:
A common misconception is that health insurance reform costs money. For example, if health insurance for 40 million people costs $1,000 a person, some conclude that the government would need to spend an additional $40 billion a year to get the job done. What this conclusion overlooks is that we are already spending $40 billion or more on free care for the uninsured, and if all 40 million uninsured suddenly became insured they would – in that act – free up the $40 billion from the social safety net.
If those $4,000 policies (in 2001) were high-deductible policies, then at least some, and perhaps many, trips to the ER by those with such policies will incur expenses that would not be reimbursed by their insurance. But if so, then the $40 billion that would go toward subsidies to insure the currently uninsured would not necessarily offset the entire $40 billion in free care that we provided to them now.
I really feel scummy pointing out that this health reform proposal with which I wholly disagree is not the free lunch Goodman presents it as. Ick.
I’ll hopefully have more thoughts on this soon. This post is just to get the two money quotes down.
In designing my upcoming course on ethical issues in health reform, I’ve been reading a lot of health economics, despite not knowing very much at all about the subject. And not knowing much at all leaves me helpless to evaluate disputes between health economists. A rule of thumb in these cases is to find out which experts are considered level-headed and always worth listening to by most of their peers. Again, how else could I proceed.
Two such experts in health economics are Victor Fuchs and Joseph Newhouse. Fuchs is well-known in many circles for his book, Who Shall Live? Newhouse is well-known for leading the RAND Health Insurance Experiment in the 1970s-80s. This week I have been reading article from Fuchs’ book entitled “Economics, Values, and Health Care Reform,” and a recent article by Newhouse on the recent health care reform law and the residual issues we are left with. Each is worth reading, but the latter is really, really informative, especially because Newhouse both praises the law for (what I see as) its virtues and expresses deep skepticism and concern over other elements. (If you want the paper, let me know in the comments.)
Here are two quotations from the aforementioned papers that I hope to return to in the coming weeks. First, Fuchs:
There are only two ways to achieve systematic universal coverage: a broad-based general tax with implicit subsidies for the poor and the sick, or a system of mandates with explicit subsides based on income. I prefer the former because the latter are extremely expensive to administer and seriously distort incentives; they result in the near-poor facing marginal tax rates that would be regarded as confiscatory if levied on the affluent.
And here’s Newhouse:
Although necessary to achieve compliance, the subsidies will have the negative effect of increasing marginal tax rates. Consider a family of four whose income is $55,250, or 250 percent of the federal poverty level. Their current marginal tax rate is 22.65 percent plus any state or local income taxes. Assuming that, as of 2014, the family buys the most generous health insurance plan covered by the subsidy, the premium will be limited to 8.05 percent of the family’s income. This feature of the law will effectively add 8.05 percentage points to the family’s marginal tax rate, since any additional dollar of income will reduce the subsidy by eight cents. Thus, the family’s marginal tax rate will rise by roughly a third. Economic research suggests that this would be likely to reduce the labor supply of those who are not the principal income support of the household.
Being a liberal and being largely ignorant in the way of health economics, I’m often too tempted to dismiss the sorts of concerns expressed here by Newhouse. Sometimes I have good evidence for this, as when I dismiss claims that raising the minimum wage will eliminate jobs. Sometimes I have to admit that I’m just not sure what to think about claims that it would be easier to ignore.
Paul Krugman explains how we should think about all those claims that this or that trust fund is going broke. But one of my favorite explanations comes from Explananda’s friend Steve Laniel from an October 2009 post:
In any case, Medicare is “headed for insolvency” because it works off a fixed budget. Well, Part A (hospital insurance) does. Parts B (reimbursing doctors), C (Medicare Advantage), and D (the drug benefit) are funded out of general revenues, so they can only go insolvent when the U.S. government goes insolvent. Medicare Part A is forced to be responsible in a way that the rest of the U.S. government is not. Why does no one ever talk about the Department of Defense being “headed for insolvency”? If Landrieu is so concerned about the public fisc, why doesn’t she push for the DoD to be funded out of a dedicated payroll tax? Then every few years, we could go through a public rending-of-garments ritual over the DoD’s impending bankruptcy. I would enjoy this very much. At least then we’d have parity: conservative Republicans shedding crocodile tears over how Medicare will have to be cut to keep it afloat, and my party doing the same for the military.
Finally, a point from Dean Baker that I’ve not seen made before:
[W]orkers, and only workers, pay Social Security tax. It is a payroll tax that is capped at just $106,000, so the chairman of Goldman Sachs pays no more in Social Security tax than a senior teacher or firefighter who may also hit the wage cap. By contrast, most of the general budget is financed through personal and corporate income taxes, which disproportionately come from higher income taxpayers. So it matters hugely that the bonds held by the trust fund are repaid from general revenue, as opposed to coming from additional Social Security taxes.
I need to think more about the full distributional implications of this point. But I think the takeaway is that while a regressive payroll tax raised general funds for years under the guise of a medicare or social security “trust fund,” the accounting vehicle of the Trust Fund ensures that the inevitable “fix” when outlays outstrip revenues will not add insult to injury by also being regressive. Instead of increasing the regressive payroll tax, the revenues used to fix program deficits are those supplied by more progressive taxation on upper income individuals and corporations.
So everyone knows about Robert Gibbs’ remarks quoted in The Hill:
“I hear these people saying he’s like George Bush. Those people ought to be drug tested,” Gibbs said. “I mean, it’s crazy.
The press secretary dismissed the “professional left” in terms very similar to those used by their opponents on the ideological right, saying, “They will be satisfied when we have Canadian healthcare and we’ve eliminated the Pentagon. That’s not reality.”
Today Think Progress has a post documenting many occasions on which Obama himself has insisted that the American people hold him accountable. But they forgot one:
It is also worth noting that in this clip Obama praises the grassroots “agitating” that ultimately “forced elected politicians to be accountable.” This marks an interesting contrast with his Nation magazine interview with David Sirota, in which Obama
gently but dismissively labeled Wellstone as merely a “gadfly,” in a tone laced with contempt for the senator who, for instance, almost single-handedly prevented passage of the bankruptcy bill for years over the objections of both parties.
I’ll admit that I have always wondered whether Obama took the tone and stance that Sirota ascribes to him.
In his recent book “Health Reform Without Side-Effects: Making Markets Work For Individual Health Insurance,” influential right-of-center health economist Mark Pauly writes:
If anything, among the middle class there is more overuse [of medical care]…than underuse…[But for] lower-income households in America (given moderate risk levels) and for high-risk households (given moderate income), this reasonable state of affairs does not apply. Generous subsidies for better care are needed for them. Fortunately, subsidized insurance can both provide financial protection and reverse moral hazard for community benefit, stimulating the use of care that others value more than the [lower-income or high-risk] person can or does. (7; emphasis added)
Reading the entire book, one gets the impression that although Pauly has his own preferences about where reforms should go, he is only comfortable offering a health economist’s map: such a map cannot tell you where you should go, it can only tell how you should proceed given where you are and where you want to end up. For example, on p. 95 we are told that “For those for whom low income or large family size prompts a social desire for more generous subsidies, those subsidies should be offered in the form of vouchers…” (emphasis added). Here the sociological fact of a shared desire among members of the populace is identified as the basis for a recommendation of how such a society should proceed. Unfortunately, Pauly never tells us how we should proceed if there are others, as there always are, who have a “social desire” that conflicts with that of their fellow citizens.
Heavy reliance on actual preferences in the course of making policy recommendations is not surprising among health economists working withing the framework of welfare economics. For within that framework, actual preferences are king. This is one point of divergence between welfare econ and other forms of normative theory, including various forms of consequentialism, which do not necessarily identify welfare with the fulfillment of actual preference: sometimes we can be wrong about what is good for us. But welfare economics is unlike these other theories in another way. On most consequentialist views, what ultimately matters is human happiness, such as the happiness I might create if I give a homeless person a meal tonight that he would have been too poor to buy on his own. For welfare economics, however, preference satisfaction is an end in itself; we don’t go looking behind the satisfaction to see how much happiness or utility we create. How, then, do we take into account differing strengths of individuals’ preferences? The answer is that welfare econ determines the degree of benefit by looking to how much one would have been willing to give up to achieve it. This leads to the view advocated by Judge Richard Posner in his paper “Utilitarianism, Economics, and Legal Theory”: “The only kind of preference that counts…is thus one that is backed up by money” (119).
On such a view–and such a view just is a standard welfare econ view–a parent who has no money to send his child to college simply does not have a normatively relevant preference that his child go to college. Using cognate language, it might be said by welfare economists that while the rich parent values her child’s continued education, the poor parent does not.
But is that really what a welfare economist would say? It sure is. Consider again that last line I quoted from Pauly: “Fortunately, subsidized insurance can both provide financial protection and reverse moral hazard for community benefit, stimulating the use of care that others value more than the [lower-income or high-risk] person can or does.” As Steve explains, moral hazard occurs when one engages in increased costly behavior precisely because one has insurance that indemnifies one against the costs associated with that behavior. In the health care context, moral hazard occurs either when one engages in more unhealthy behavior because one knows one has access to medical care, or when one goes to the doctor more because one has insurance that will pay for it. So Pauly is saying that if others want to give low-income or high-risk folks medical care (i.e. if they have the relevant “social desire” to do so), they can support policies that will give these people the subsidies they need. But here “need” is interpreted at one remove from the common sense notion. In Pauly’s view, those who cannot afford health care need funds not only to access care. They also need the funds simply to value that care. This is why those others who support the provision of subsidies are said by Pauly to “value [that care] more than the [lower-income or high-risk] person can or does,” and it is why the care purchased with the subsidies is in the first instance interpreted as a “community benefit”–after all, it is only the community that is willing to pay what it takes to get care for the poor.
I point this out simply because we should ask ourselves whether we should give any credence at all to a normative framework that is deaf to preferences that are not backed up by money. After all, on this framework, if no better off people in society had a social desire to give poor people subsidies, there would literally be no one in society who cares that the poor lack health care–not even the sick poor themselves! I’m not saying that this is the dominant framework for policy decisions here in the U.S. But it is the framework that many elites would like to be the dominant framework, and it is a framework that evidently found its way into one of the more sensible right-of-center discussions of health care reform I have read. Then again, this is what we should expect, given that it itself is backed up by decades of dispositive economic theory, right?
Matt Yglesias recently had a post on the proposed cuts in the SNAP program (a.k.a. foodstamps program) intended to offset proposed increases in child nutrition programs (e.g. school lunch programs). Yglesias cites this Monica Potts post that gives some background:
It’s worth noting that the increases in the food-stamp program were designed in the stimulus bill to be phased out once food-price inflation caught up to the expanded benefits, but because inflation was lower than expected, the benefits were going to last longer than anyone originally expected. It’s hard to imagine a situation in which politicians wouldn’t view those bigger-than-expected increases as free money. And it’s a small comfort to know the pot was raided for good rather than for ill.
This got me thinking of Mollie Orshansky, the brains behind the U.S. official poverty measure. That measure took the cheapest of four “economy food plans” and multiplied it by three, since at the time, in 1963, food constituted roughly one-third of the average family budget. Longtime critics of this measure have pointed out that the cost of food has increased much more slowly than the price of nonfood staples in the average family’s budget. Since the amount allocated for nonfood items is determined by the amount “needed” for foodstuffs, the official poverty measure fails to take differential rates of price growth into account.
This historical lag in food prices doesn’t necessarily entail a similar expected lag after the passage of the stimulus bill; but it is somewhat ironic that the issue of slow food price inflation has come up again in the context of policies ostensibly designed to aid the poor and near-poor but which end up adding insult to injury. After all, perhaps one way to make amends for screwing over the poor with an inadequate measure of non-food related resource deprivation might be to allow them a bit more in the way of food-related resources.
For more on recent and salutary developments in how the U.S. measures poverty, see this Yglesias post from March.
Arthur Conan Doyle. The Hound of the Baskervilles
A family haunted by a legendary curse, a wily villain, and Sherlock Holmes on the case. This novel, perhaps the most famous of the Sherlock Holmes mysteries, is a ripping good yarn. It also happens to be the first one I’ve read. I hope the others are as good.
Charles Petzold. Code: The Hidden Language of Computer Hardware and Software
This book is a superb introduction to the subject of how computers work. It starts in the most basic way talking about counting and binary and electricity, then moves from telegraph relays to the simplest circuits, builds all the way up through ever more complex computing machines, and ends with a brief explanation of high-level programming languages. Each step along on the way is set out by the author with impressive clarity and patience. Indeed, there is nothing in the first half of the book that would be over the head of an intelligent 12 year old. The second half of the book is a bit more challenging, but a motivated reader should be able to get through it without any background at all in the subject. Highly recommended for ages 12 and up.
Lenore Skenazy. Free-Range Kids: Giving Children the Freedom We Had Without Going Nuts Without Worry
Skenazy, a newspaper columnist, made headlines a few years ago when she let her nine year old ride the subway home alone and then wrote a column about it. In response to being branded “America’s Worst Mom” (which epithet she has borrowed for her book cover) she started a blog about worry free parenting and then wrote this book on the subject. Skenazy’s line is pretty simple: Too many parents these days drive themselves nuts with worry trying to avoid the most statistically improbable outcomes; that this has an unfortunate and unnecessary stunting effect on our children; and that the social norms that have coalesced around this worry make it really hard to stay sane yourself, e.g., you can be branded America’s Worst Mom if you let your nine year old take the subway home alone (along a route the child knows, with change for a phone call, and when both child and parent feel the child is ready for the adventure). (If my memory is not mistaken, my unusually precocious cousin was allowed to wander around Hong Kong when not much older than this when his family was passing through.)
I agree for the most part with Skenazy, and I’ve encouraged Yoon to read the book in the hope that we can agree to try to be as sane as possible when raising our son. The book did become a bit monotonous, though, since there’s only so much cheerleading for a mostly reasonable proposition that I can handle.
Robert Graves. Good-Bye To All That
Graves, the poet and novelist, was a British schoolboy in the period just before WWI and then fought in the trenches for much of that war. After the war, he studied for a time at Oxford. These three periods of his life brought him into contact, sometimes glancing, sometimes intimate, with just about every literary and cultural figure in Britain from Siegried Sassoon to Bertrand Russell to Thomas Hardy to T.E. Lawrence.
In his early thirties Graves left Britain for the island of Majorica and rarely returned. Good-Bye To All That was his bitter parting shot. I have always been fascinated by the disillusionment generated by WWI, and was especially interested by this aspect of the book. In this respect, it makes a nice companion to Vera Brittain’s Testament of Youth, which I wrote about briefly last year.
I will be away from the blog until late August/early September. Apologies for the inconvenience.
(Seriously though: I’m teaching a course this semester on ethical issues in the recent health care reform debate. I expect, therefore, to be posting a lot of posts soon that should have 2009 in their date, but don’t.)
Whew! Busy, busy. But at least I can read on the subway on my way to work.
Adrienne Mayor. The Poison King: The Life and Legend of Mithradates, Rome’s Deadliest Enemy
Rome fought four wars—the so-called Mithradatic wars—against Mithradates in the first century B.C. The wily, resourceful Mithradates makes such a perfect subject, and the story of his setbacks and accomplishments is so much fun, that I’m surprised that Hollywood hasn’t been all over him. Perhaps now they will be. Mayor tells his story with real verve. Mithradates was especially famed for his extensive toxicological investigations—for practical reasons he was very interested in how to poison others and how to build up immunity to poisons that others might use on him—and Mayor, an expert in ancient toxicology, is especially well-suited to relate this part of the story. Where the evidence grows thin, at the beginning and the ends of Mithradates’ life in particular, Mayor allows herself speculative passages that might have been more suitable to a historical novel. But that’s partly just a matter of taste, and these passages are usually marked out very clearly as speculative. This book is recommended.
Janice Gross Stein and Eugene Lang. The Unexpected War: Canada in Kandahar
Solid, though now somewhat dated (published 2007), account of Canada’s involvement in Afghanistan. Emphasizes the extent to which policy was not really driven by larger strategic considerations, but rather emerged through a series of accidents. My only complaint is that the book might be a bit opaque to readers unfamiliar with Canadian politics. This is a pity, since I think it would be really useful for Americans to have a sense of what the war looks like from the perspective of a close coalition partner.
Edward Gorey. Men and Gods: Myths and Legends of the Ancient Greeks
This book is a children’s classic published in 1950 and recently resurrected by the New York Review of Books in their excellent children’s series. The stories are well told, though it dragged in places. That might just be me, though—I’ve never had much interest in Greek myth. A chart at the back helps the reader keep track of Latin equivalents of Greek gods and heros, but there is no introduction explaining why Gorey chose to use the Latin equivalents in the first place.
Félix Fénéon. Novels in Three Lines
This is a collection of three line news summaries written by Fénéon for a French newspaper over the course of 1906. The summaries occasionally touch on politics, but they’re mostly about every day pieces of news: suicides, burglaries, assaults, and accidents. This might sound monotonous—and actually I would recommend that people not try to read the book through cover to cover without a break—but Fénéon’s summaries are, as the title of the book suggests, absolute masterpieces of compression. Fénéon was an anarchist and an important behind-the-scenes literary and cultural figure in late nineteenth and early twentieth century France. He wrote little and the contents of this book were only saved for posterity by lucky chance.
For years I wondered why comment spammers didn’t try to sneak comments into discussion threads by re-posting existing (legitimate) comments in that thread, but with a link back to their site in their signature. The illusion of topicality would make it harder for human and spam filter alike to catch on. Alas, just a month or two ago I started to see this technique show up on this site. Congratulations so far go to D.C. and Steve: Some bot found you worth emulating.
Also, gosh I’m busy these days.
My son Oliver wasn’t due until April 5th, but the little rascal managed to sneak himself into the world ahead of schedule on Sunday in an early morning c-section. Both mother and child are recovering well.
Louis Begley. Why the Dreyfus Affair Matters
Alfred Dreyfus, a captain in the French army, was accused in 1894 of selling secrets to a German military attaché. A note had been discovered indicating that someone was selling secrets to the attaché. The note was real; just about everything else that became associated with the case was not. The only actual evidence brought against Dreyfus was the claim that the handwriting on the note was his own. It was not. Dreyfus’s first trial, resulting in a conviction, was a travesty involving significant judicial misconduct, in which antisemitism played a crucial role.
And then things got really bad. As evidence identifying the real culprit started to surface and Dreyfus’s few supporters rallied against an obviously bad decision, Dreyfus’s superiors dug themselves into a deeper and deeper hole. As the 1890s wore on, the Dreyfus Affair became bewilderingly complex, with forgeries, suicides, conspiracies, missteps on the part of Dreyfus’s supporters, and stunning reversals on both sides.
The conservative, militarist, antisemitic response to the scandal was essentially to point out that for Dreyfus’s supporters to be correct, a deep rot would have to have infected the military, a pillar of French society, and parts of the political establishment. Since this was unthinkable, so too was Dreyfus’s innocence. They were wrong, of course, and it is a mistake that continues to be instructive.
Why the Dreyfus Affair Matters is a tightly written account of this affair, which so thoroughly rocked French society in the 1890s. I’ve just called the plot bewilderingly complex. Begley is to be commended for having written such a clear and engaging account of it. One highlight of the book is a brief but penetrating discussion of the Dreyfus Affair in Proust’s In Search of Lost Time, which should be accessible to people who haven’t slogged through it, but especially interesting for those who have.
I’m not sure Begley did as good a job explaining why the Dreyfus Affair matters. Begley finished his book just as Obama was elected. Begley, who is clearly no fan of the Bush administration, takes a few stabs at connecting the Affair to current events. The lack of due process and forms of incarceration found at Guantanamo are compared to the travesties of Dreyfus’ trial and exile on a remote island. A brief section on official reactions to whistle blowers connects a defender of Dreyfus’s to Joseph Wilson. This, I take it, constitutes the main part of Begley’s answer to the question raised by the title of his book.
This is weak stuff.* There are of course similarities between any two miscarriages of justice. But even if the similarities were more striking than they are, they wouldn’t tell us why the Dreyfus Affair matters today. You can be entirely ignorant of the Dreyfus Affair and still be offended by the scandal of Guantanamo Bay. All you need for that is a functioning conscience. If you’re not offended, you’ll hardly be convinced by a series of strained analogies with the Dreyfus Affair.
I’m not sure I’ve been able to get very deeply into the question of why any historical incident matters, but here are two fairly obvious (non-competing) answers as they bear on the Dreyfus Affair.
First, from history we (sometimes) find out why we are a certain way now. My understanding is that French society and politics is the way it is today in part because of the reverberations and aftershocks of the affair. Begley has nothing (that I can recall) to say about contemporary French politics or culture, focusing mainly on the United States. That’s fine, but I don’t believe the United States was shaped in significant ways by the Dreyfus Affair, and it’s an American audience that he seems mainly interested in addressing.
Second, studying history can broaden our sense of what’s possible. There are all kinds of contingent features of society and human nature that look fixed and permanent, and all kinds of things that seem certain at any moment that turn out to be thoroughly mistaken. I think the Dreyfus Affair matters, and not just in France, in this way. Many of those involved in persecuting Dreyfus, even after it was, or should have been, clear that he was innocent, acted in ways that were utterly irrational, stupid, and blindly defensive. It was unthinkable to many that such trusted figures of the establishment could behave this way. But it is an incontrovertible fact that they did. It was unthinkable in particular to people who thought a certain way: people with a streak of authoritarianism, who were reflexively inclined to give people in power the benefit of the doubt.
As I said above, this is instructive. It gives us a nice morality tale about the dangers of trusting officials in authority. It’s a story that ought to leave us a little more paranoid, a little less trusting of authority. But as instructive as it is in this sense, it would be a mistake to think that we can simply take the case and apply its lessons to contemporary political issues. As controversial as Guantanamo is, I don’t see how parallels between Guantanamo and some now unambiguous miscarriage of justice at the end of the 19th Century are going to be less controversial. The Dreyfus Affair, like most history, matters, but in a less direct and much more subtle way than that.
* Though Begley’s criticisms of certain French judicial procedures that worked against Dreyfus, such as an acceptance of hearsay, is certainly relevant to the issue of whether the American military tribunals contain stringent enough protections against abuse.
A politician got tossed yesterday from the New Brunswick legislature after giving another politician the finger. This write up of the story doesn’t come close to conveying how hilarious the audio recording of the incident is. As a friend of mine remarked, they sound like a bunch of kindergarten kids.
Via Kegri.
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