ACCUMULATING PERIPHERALS


The rational opposition by mattsteinglass
August 29, 2009, 1:04 pm
Filed under: Conservatism

There is a smart, reasonable conservtive discourse in America, but I barely ever see it outside the writing of Conor Friedersdorf and a few other bloggers.

Related thought: if we banned all discussion of politics on for-profit television stations, political discourse in America would improve immeasurably. True? Eh, maybe not, but it was a try.



Craziness in politics by mattsteinglass
August 28, 2009, 1:13 pm
Filed under: Conservatism

Megan asks how liberals know that gun toters at Obama events are militia members. I was going on the information Michael Roston points out, that two of the guys prominently featured on the news were members of the same far-right group, and the guy who did a pre-planned YouTube interview with one of them used to be in a ’90s militia.

On the “crazed” question, I think there may be a philosophical issue, in that we largely define “craziness” as a drastic deviation from a norm of behavior. These guys are getting put on TV, and their behavior is eliciting so much reaction, largely because people feel it is a drastic violation of social norms. Obviously you can’t take that kind of attitude too far; people speaking in tongues appear to be doing something rather crazy to most Americans, but that form of behavior is a socially protected, defined zone where we allow and want people to feel free to do whatever it is they feel spiritually prompted to do. Carrying a gun to a political rally is different — as is carrying a gun into a church, for that matter.

I’d compare it to the way one would say John Yettaw, the guy who swam across the lake to visit Aung San Suu Kyi, was “crazy”: he clearly had expectations about the way other people would respond to his communicative behavior that were completely at odds with the way people actually could reasonably be expected to react. That kind of communicative disconnect really is a typical part of what we think of as “craziness”. Obviously, within the circles in which the gun-toting folks move, their behavior is not outside the norm at all. So, again, you don’t want to psychiatrize dissent. But it is also true that groups of people can evolve collective expectations about how people outside their group will perceive their behavior that are a form of collective insanity. And to me, the idea that you can not think that someone else ought to feel threatened by the fact that you, a private citizen, show up to a political event heavily armed, is a kind of crazy collective belief that some people on the right have developed amongst themselves over the years. These people are not foaming at the mouth. But the social assumptions they’ve managed to convince themselves of are nuts.



The foreskin police by mattsteinglass
August 27, 2009, 11:36 am
Filed under: Uncategorized

Easily the most amusing and hysterical reaction to the news that the CDC may recommend circumcision because it helps prevent AIDS came from the Daily Dish reader who wrote in:

It’s my dick. It’s my dick. It’s my dick. It is no one else’s dick but my dick.  And I should have the choice to circumcise it when I am old enough to make that decision.

Let me reassure this guy: no one is planning to do anything to his dick. Assuming, that is, that he is more than 8 days old. But with respect to the practice of circumcision, the important point is this: he’s my son. Not yours. Parents have the right to decide on medical treatment for their children, presuming such medical treatment is not actively harmful. And parents have the right to include their children in cultural rites and practices, again presuming no harm is done.

In the case of circumcision, the evidence shows that it prevents the transmission of HIV and other STDs. There is some disputed evidence, on the other hand, that it reduces sexual pleasure; and there are some ludicrous and hysterical people claiming that it damages the bond between mother and child. This certainly sounds plausible; we all know Jewish men don’t enjoy sex, and have trouble bonding with their mothers. Not.

What, then, of female circumcision? Well, I understand, perhaps wrongly, that there are some forms which are not particularly medically invasive, and which do not entail significant medical consequences. I think that such forms of female circumcision are a matter of cultural practice that should be left up to parents to decide. The more invasive forms of female circumcision entail serious negative medical consequences. Obviously that’s not cool. And female circumcision is carried out on girls aged 7 to 12 or even older; at that age, the child gets a vote, too. In any case, this doesn’t have much to do with anything, because we’re talking about a medical recommendation.

But the main point is that if the guy who wrote the email were circumcised, he wouldn’t have written the email. Men who are circumcised don’t complain about it. There may be some vanishingly small number of guys who are upset about the fact that their parents circumcised them. It’s a weird thing to be upset about. The whole issue of treating this as some kind of mutilation of a rights-endowed human being who should be allowed to decide for himself seems to me like an insane metastasis of the American fixation with individual rights-based ideology. Children are born into families. Those families have cultures and beliefs, and are entitled to make decisions about how their children will be treated, shaped, and raised.



Oh yeah? Wanna bet? by mattsteinglass
August 26, 2009, 9:44 pm
Filed under: Conservatism

Are Guns at Protests Really Dangerous? – Megan McArdle .

Megan is right: the people carrying guns openly at anti-Obama rallies probably won’t fire them. I don’t think we should be complacent about any risk of people shooting each other at political rallies. I am confident that the possibility of a gun being discharged at an anti-Obama rally before the next midterm is greater than 0.5%. That is a risk I don’t see the point of tolerating. If Megan wants to take a 100-to-1 bet on that happening — $500 to me if it happens, $5 to her if it doesn’t — I’d take that bet.

Megan then asks that we stop calling the gun-toters “crazed militia members”. I don’t know who used that phrase. But both the “crazed” and “militia member” demographics are highly overrepresented among people who bring guns to Obama rallies, compared to the population as a whole.

The point of the argument, though, isn’t really about the likelihood of a shootout. The point is that a gun is an instrument of violence. People who bring guns to rallies may feel they are saying “I have the right to carry a gun, and that is an important value that I feel is part of being an American.” But liberals who see conservatives at rallies carrying guns think they are saying, roughly, “I am prepared to use armed violence in defense of my views.” And obviously since our views differ, that is a threatening message to get.

The politics of this issue are very heavily bound up with the fact that anyone who carries a gun openly in the US is at least 90% likely to be a right-wing white Christian heterosexual male. If there were large numbers of muscular black guys with Malcolm X or Black Panther Party t-shirts walking down residential streets in Phoenix carrying AR-15s, or lots of Wiccan diesel dykes showing up at anti-Sarah Palin rallies with abortion rights signs and Glocks in their belts, there would be some NRA members who had no problem with that. But the large majority of regular center-right folks who normally support gun rights and oppose Obama would be very uncomfortable with that sort of thing.



Ted Kennedy, on the mountaintop by mattsteinglass
August 26, 2009, 7:16 am
Filed under: Health, Politics

In all likelihood we are about to see Ted Kennedy’s name dragged through the mire by pathological right-wing sleazebags. Before that happens, I’d like to thank a guy who spent four decades trying to keep phrases like “a fair society” and “economic justice” from completely disappearing from America’s lexicon and its conceptual vocabulary. The idea that society could actually be more or less fair is really not so fantastical or revolutionary. In fact, if you stopped most Americans on the street and asked them, “Do you think society should be fair?”, they would probably answer yes. But for some reason only a few politicians seem to be willing to run on that bedrock principle, and Ted Kennedy was one of them.

It’s only natural that for somebody who believes in fairness, universal health insurance and education are the places to start. I first heard of Ted Kennedy in 1980, when I was in 6th grade, and he ran a primary campaign that challenged Jimmy Carter from the left. The theme of the campaign was that Carter had gone so far towards placating centrist deficit hawks and defense hawks that he had lost any clear focus on what it meant to be a Democrat, to stand for social justice. Kennedy lost the campaign. This is a quote from his concession speech. Remember, it is August 12, 1980.

We cannot have a fair prosperity in isolation from a fair society. So I will continue to stand for a national health insurance. We must — We must not surrender — We must not surrender to the relentless medical inflation that can bankrupt almost anyone and that may soon break the budgets of government at every level. Let us insist on real controls over what doctors and hospitals can charge, and let us resolve that the state of a family’s health shall never depend on the size of a family’s wealth.

The President, the Vice President, the members of Congress have a medical plan that meets their needs in full, and whenever senators and representatives catch a little cold, the Capitol physician will see them immediately, treat them promptly, fill a prescription on the spot. We do not get a bill even if we ask for it, and when do you think was the last time a member of Congress asked for a bill from the Federal Government? And I say again, as I have before, if health insurance is good enough for the President, the Vice President, the Congress of the United States, then it’s good enough for you and every family in America.

As I just wrote on the Economist’s Democracy in America blog, Ted Kennedy could stand up and make that speech today, and he wouldn’t have to change a word. It is as true today as it was 29 years ago. Go read the rest there. Meanwhile, it would be really nice if Kennedy’s death helped focus Democrats on pushing through the universal health insurance he spent his life trying to achieve.



Well that's weird by mattsteinglass
August 25, 2009, 6:05 am
Filed under: Uncategorized

Having looked over Megan McArdle’s proposal for health care reform, I think I agree with its basic outlines. I agree with scrapping the tax break for employer-provided health insurance. I disagree with the idea of scrapping community rating and guaranteed access. When Megan notes at the end of her post that she might support a universal mandate, for example, I don’t understand how it’s even possible to have a universal mandate without guaranteed access. How can you demand that sick people buy insurance when private insurers are allowed to refuse to cover them?

Megan’s solution for the problem of unaffordable health care premiums for people who are sick, or likely to become so, is a reinsurance system that would reimburse insurers for customers whose costs rise above a certain level, perhaps $50,000 or $100,000, or 10-20% of annual income (lower for lower incomes). This would make it attractive for insurers to insure even people who are likely to get very sick, since their liability will be limited. Presumably when Megan says a “reinsurance system” she means a government-funded reinsurance system, since this is obviously a loss-making enterprise. Alternatively, it might be a mandatory kitty that all insurance companies need to pay into, but that would raise the cost of premiums and be effectively indistinguishable from a community rating system, which Megan says she doesn’t want because it pushes up premiums. Anyway, I would be curious to see the numbers. How much would it cost for the government to cover all health care costs that go above a lifetime $50,000 or $100,000 limit, or over 10-20% of annual income? Megan says this would be cheaper than the current reform proposal. I have no idea whether that’s true; it does not seem at all self-evident.

The other reason for confusion about this proposal is that Megan says she opposes health insurance reform because she is afraid that once government spending tops 50% of all spending, cost controls on drugs and technology are inevitable, and that will retard innovation. But without an estimate of how much the government would end up spending on her reinsurance program, there is no way to assess whether it wouldn’t have the same effect she decries in the Obama proposal.

Megan also says she would means-test Medicare. (And Medicaid, but I don’t know what that means; Medicaid is already means-tested.) I’m fine with this in principle but I think it works poorly in practice; means-testing is hard to do, requires more bureaucracy, and creates perverse incentives for the elderly to dump their assets. If you’re looking for egalitarian impact, it’s more efficient and has roughly the same effect to just raise Medicare taxes on wealthy people, including the wealthy elderly. Essentially you just charge the wealthy more for the service rather than deny them the service. But this isn’t a very big objection.

I think the basic thing I’m confused about is: what does Megan see as the goal of her proposed changes? Does she want to make sure everyone has insurance? Is she trying to save costs? Or what?



A world full of magic health-care ponies by mattsteinglass
August 24, 2009, 1:14 pm
Filed under: Health

Megan McArdle has now provided the Economist with a positive and logically argued program for health insurance reform. That makes her more responsible than any Republican politician in the United States of America. Another way that she’s more responsible than Republican politicians is that she states quite openly that she is opposed to universal health insurance. She’s trying to do something else with her insurance reform proposals, not achieve universal coverage. I’m not 100% sure I understand what it is that she’s trying to do. And a number of things she says on the way to making her case for reform aren’t, if I understand correctly, true. But a lot of other things are true, and it’s interesting to take a look at the argument.

I ought to respond by looking first at what Megan says her positive program is. The fact is, it’s late at night and I don’t have time to think that out. Also, it features a resort to some measures, like reinsurance, that I’m not familiar with. I’ve seen people vaguely make the reinsurance argument before, but I’ve never seen a plan that relied on it as a way to solve the problem of high premiums for people who are at high risk of illness actually getting far enough along in the political process to sustain serious critique. So I’ll have to hold off on that. In the meantime let me just respond to a few of her answers to questions.

First, on the idea that no one has proposed getting rid of private insurance: in fact, a lot of people have proposed getting rid of private insurance (or at least, private insurance that is not essentially a tightly-regulated utility).

Some people have indeed proposed getting rid of private insurance. That is not the bill that is moving through Congress, and it is not relevant. Republicans have manipulated confusion between the actual reform proposal and the British and Canadian systems to deceive the public about the type of reform that is being proposed. Megan is not deliberately misleading the public along those lines. But she is being misleading: she tries to blur the distinction by saying that private insurance under regulated private universal health insurance systems, like Switzerland, the Netherlands, and France, inevitably becomes “a tightly-regulated utility”. She doesn’t explain what she means by this (insurance companies are pretty tightly regulated already), and she doesn’t explain why she feels there is no difference between a government system and a tightly-regulated private utility. Phone and electric companies are tightly-regulated utilities, but surely if the government proposed nationalizing them, Megan would consider that more than a semantic change. What Megan is doing here is assuming the consequent. If she wants to make a case that these reforms eliminate the essential functions provided by private insurance, whatever those are, she has to make that case.

In fact, to a first approximation nearly everyone who is pushing these changes wants the government to guarantee universal coverage. When they are talking to each other, they sell these bills, which none of them much likes, as being another step on the slippery slope to single payer. So it’s not unreasonable to fear that that’s where we’re headed.

It’s not unreasonable to fear that that’s where we’re headed, but the rest of this claim is just wrong. The overwhelming majority of advocates of single-payer support the continued existence of a private industry for supplemental insurance. And a lot of people don’t even want single-payer; at this stage most people on the liberal, pro-reform side support a French or Dutch-style system rather than a Canadian one. Even people who want a public plan because they believe it will evolve into a universal program for basic coverage still want to preserve the option for private supplemental insurance. Megan considers such a supplemental private insurance sector to be a neutered joke, but that is her belief. If she wants to argue that case, again, she has to argue it.

Second, the changes will not eliminate perverse incentives. The dominant strategy of an individual in a world with the “strong” public option is to pay the tax surcharge, refuse to buy insurance, and then go on the public plan if you get sick. The weakest bills, on the other hand, simply command people who feel that they cannot buy insurance to buy it anyway, and subsidise some of them.

A universal health insurance plan based on private insurance has to include an individual mandate. That’s the way it is. If you want universal health insurance that doesn’t have a mandate, you need to go with a single-payer system for basic insurance. If you don’t support one of these two options, you are against universal health insurance. And Megan is if I understand it correctly quite openly opposed to universal health insurance. But it’s true that the right way to design these systems is to force anyone who doesn’t buy private insurance to buy into the public plan, rather than pay some kind of “penalty”, so Megan is right that a system implemented the latter way (like Massachusetts’) would be flawed.

Third, I’m looking at what happens in countries with these systems. What happens is that they quickly resort to price controls on inputs, because otherwise the costs start marching upward. I think it’s reasonable to assume we will follow the price control strategy, which is not, historically, a good way to build a functioning market.

Given that health care in other OECD countries is superior to health care in the US on as many measures as not, and costs between 40% and 65% of what it costs in the US, and that everyone in those countries gets insurance, it would seem that whatever systems they are implementing are in fact good ways to build functioning markets in health care. The health care market is inevitably distorted from the get-go. This is hardly an original observation. It’s distorted because most care is paid for by insurers, not patients, and because society implicitly guarantees health care for everyone because society believes in some measure of basic equality. As in other economic spheres, such guarantees drive up prices. Various other measures may be taken, such as price controls, to counteract that distortion. But it’s not the regulations that create the distortion. It’s the nature of the market.

I actually think that the other thing most people are worried about, rationing, is less likely. America seems to lack the political will for it. But of course that means that costs are going to hit 30% of GDP pretty soon, with a good chance that this will trigger a major political crisis if the government is covering 60% or more of the spending. Those high-end claims driving costs are not for abusive knee surgeries; they’re for organ transplants, cardiac care, cancer treatment, and preemies. There are no magic ponies we can ride to painless cost savings.

If there weren’t a lot of ineffective care going on in the US, nobody would be opposed to comparative effectiveness research. In fact we know that the counties with the highest medical costs in the country have basically no difference in treatment outcomes from the counties with the lowest medical costs. They’re doing more procedures and buying more care, but it doesn’t seem to be doing anyone much good in most cases. And we know that the most effective integrated health care organizations, like the Mayo Clinic and the VA, deliver better care at much lower cost than the broader fee-for-procedure private-insured system. If some organizations are doing it better and cheaper than others, that means that there are in fact magic ponies we can ride to painless cost savings. Or rather: there are magic ponies we can ride to cost savings that will be painless for patients. They may involve some financial pain for people who are currently charging too much for useless services.

You know, if I owned a really crappy fast-food restaurant down the street from a McDonald’s, and I was providing worse food at higher prices in less attractive surroundings, I might find that my revenues were in trouble. And the question might arise, what should I change? The logical answer would be, let’s look at what McDonald’s is doing and figure out how to do that. Lately I get the feeling that if I were an American conservative, my answer would be: it’s hopeless; either we need to spend more for better ingredients and tastier food, which will drive up prices, or we need to cut expenditures and make our food even worse. There are always trade-offs! American liberals are arguing, you know, not only are there a few other wealthy countries doing health care better and cheaper than we are; every other wealthy country seems to be doing it better and cheaper than we are. If those are magic ponies, the world seems to be full of magic ponies.




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