Matthew Yglesias is insufficiently pessimistic about Russia, capitalism and democracy, not to mention the Olympics:
One would like the end of the Cold War and the collapse of Communism to be seen not as something in which America “won” and Russia “lost.” Russian people are, after all, much better off in 2010 than they were in 1980. But people have national pride, and Russians were once the core ethnic group of a mighty power and now simply have a nation-state that, while large, is clearly slipping behind other contenders in a whole variety of ways. The Olympics is a basically harmless venue for nationalistic passions, but these sentiments generally get played out in ways that are very much not harmless.
It’s really not at all clear that the median Russian is much better off in 2010 than he or she (especially he) was in 1980. For one thing, male life expectancy was 62.7 in 1980 and 61.8 in 2008. Though to a large extent this stems from the fact that it’s now much easier and cheaper to purchase alcohol, cigarettes, and heroin, which I guess you could think of as being “better off” in some ways.
More important, it is even less clear that Russian people are better off now than they would have been if the Communist Party were still running a unified Soviet Union with a reformed, semi-privatized market economy. The examples of China and Vietnam suggest that they are not. And the incredible rise of China to Olympic superpowerdom has followed the country’s economic rise to prosperity under an authoritarian single-party political system. Which serves as evidence for a lot of Russians that trying to move towards a Euro-American model of governance by driving the CPSU from power in 1991 might have been a mistake.
Filed under: Health, Health care reform | Tags: Financial Services, Health, Health care, Health insurance, Insurance, Megan McArdle, Poverty, Universal health care
A few days ago apparently Megan McArdle posted (which seems to be supplanting the verb “wrote” in modern usage) an argument along the lines of “we don’t really know how big an effect universal health insurance has on saving people’s lives.” This occasioned furious blogospheric responses from Matthew Yglesias, Austin Frakt and others. That in turn prompted Megan to explain that she wasn’t saying that lack of insurance doesn’t kill people, but that she doesn’t think we really know how big the effect is, and that the size of the effect makes a difference to arguments that ground the need for universal insurance in that effect. She sums up:
The mortality question is really important, but it doesn’t touch non-mortality outcomes, which are even harder to measure comprehensively. It doesn’t touch on the financial questions raised by medical bankruptcies–I think they’re overstated by the Himmelstein/Woolhandler crowd, but that doesn’t mean I think they don’t exist. It doesn’t address the social justice questions. It just says, this is probably not the best grounds upon which to make the case for national health care, because we don’t have a good handle on the number.
As I understand it, the estimate is that lack of health insurance leads to up to 45,000 premature deaths per year.* [Addendum: Megan points out that the studies she cites find no increase in mortality at all. True; see below for more.] I have no reason to believe this figure is wrong and no time to investigate it, but putting that aside for the moment, the reason why people who argue for universal health insurance have often come to use the increased-deaths argument is that opponents of universal health insurance so often refuse to accept any other arguments. All of the things Megan notes above — the medical bankruptcies issue, the social justice issues, as well as others like the economic inefficiencies issues due to reduced labor mobility, the quality-of-life issues, the population health issues, the question of whether cost reduction is possible without universal coverage, etc. — these are all routinely dismissed by many conservative commentators. When I post on the impossibility of continuing as we are with our ridiculously broken health insurance system, I routinely get responses like: “Will people be dying in the streets? I think not.” For such people, one must demonstrate that people will in fact be dying in the streets, and are in fact dying in the streets, before any reforms will be countenanced.
It is, to me, obvious that the US’s health insurance system is a travesty. Health care in the US costs 150% or more what it costs abroad, and is no better; insurance costs three times as much in premiums (abroad, the rest of the cost is covered by taxes, which spreads the burden equably so that the poor get care when they need it); there is a serious risk in the US that you will lose your insurance because you get sick, which ought to be demonstration enough that the object you are buying does not work to do that thing it is supposed to do. But conservatives have spent the past 18 months working out ever-more-sophisticated arguments to convince themselves that the sun don’t rise in the morning, and by now they’ve just about got the job done. In the face of this, people who support universal health insurance have found themselves resorting to the quickest shorthand justification of its necessity: lack of universal health insurance kills poor people. It’s a solid argument because 1. you would expect it to be true, all else being equal, and 2. studies find that it is in fact true. But if conservatives want liberals to stop talking about it for whatever reason, they should do what Megan begins to do in that paragraph: they should start taking a serious look at all the other reasons to have universal health care (medical bankruptcy, social justice, labor mobility, increased ability to cut medical spending when benefits are distributed more equally, etc.) and evincing some willingness to achieve those goals and some serious approach for doing so. As I recall, Megan’s plan for doing this was universal government-paid catastrophic health insurance, which seems like an OK idea to me; I’d like to hear more about it.
Filed under: Health
Welp, just called my congressman, Jerry Nadler (D-NY), to urge him to vote for the Senate health reform bill. The lady who took my call had my name in her computer with my voting address and everything, and I spent at least 15 seconds on the phone telling her he should pass the damn bill.
So now that’s taken care of! Time to move on to cap-and-trade. If I give Kirsten Gillibrand a call I bet she’ll get right on it.
Filed under: Health, Human Rights | Tags: Advocacy Organizations, Amnesty International, Barack Obama, Congressional Budget Office, Health care, Human Rights, Human Rights and Liberties, United States
Amnesty International is a great organization. But I sometimes wonder whether its senior officers believe that politics is the art of taking ludicrously unrealistic moral stands, failing to accomplish anything, and preening. This evening I received an email from the director of Amnesty’s Demand Dignity Campaign, Sameer Dossani:
Our policy experts have been watching this legislation develop and the proposed outcome does not look good. Right now, the Senate is hotly debating its version of the bill, but they’re way off track. The Congressional Budget Office projects that around 24 million people will still be uninsured in 2019!1 That is unacceptable.
Because this month is a crucial window for media attention on the health care system, we’ve got to push the debate further to include human rights as a key focus. It’s up to human rights advocates to point out how the proposed reform falls short of true universality, equity and accountability.
I beg to differ: it’s up to human rights advocates to point out that if the Senate bill does not pass, the number of uninsured in America will likely rise past 50 million in the next few years, and tens of thousands of Americans per year will continue to die because they lack adequate insurance. The only thing this sort of holier-than-thou nonsense accomplishes is to help the for-profit insurance industry defeat health insurance reform. If it doesn’t get done now, it’s certainly not going to get done next year after Democrats have lost their 60-vote supermajority in the Senate, nor will it get done after Barack Obama is defeated in 2012 due to his failure to deliver on major legislative goals.
It’s crucial to have some relatively absolutist human-rights advocacy organizations that continue to push for first-best solutions on moral grounds and to oppose compromises. But it’s not crucial for them to intervene after it’s too late to make changes, when they can only contribute to cynical efforts to defeat reformist legislation. In fact, it’s crucial, at such moments, for them to keep quiet and store their powder for the next moment when they can actually make a positive difference. I mean, seriously. How pure is the ivory in Amnesty International’s tower?
But not for the reasons you think.
Add: The ad was produced by a guy named Ray Griggs (here’s his LinkedIn page and a review of his apparently awful superhero spoof). The spoof apparently had a significant budget and major-name cast like Tom Sizemore, which isn’t bad for a guy whose only previous credit was an apparently equally awful CG-heavy short called “Lucifer“. (Yeah, the angel.) So the question is who’s bankrolling him, and why haven’t they explained who they are in the political ad he’s produced, and does that violate any laws.
Grigg was also in the Fox News last month for producing an iPhone app which featured offensive caricatures of various lawmakers, along with their phone numbers. Apple initially rejected, then accepted the app.
Filed under: Health
Megan McArdle doesn’t much like Ezra Klein’s point that if Congress won’t follow through with the Medicare cuts projected in the health reform bills, we’re all screwed, because if Congress won’t cut Medicare the government will go bankrupt. She says this is nonsense:
First, bankruptcy is not inevitable; it is theoretically possible to raise taxes to cope with Medicare growth, though it would be extraordinarily painful to do so. In the face of fiscal crisis, it might also be possible to make Medicare cuts that we have otherwise been unable to stick with. But as any competent development economist will be happy to tell you, every dollar you add, or interest group you create, makes it less likely that this sort of resolution will happen….
Bankruptcy becomes much more likely, and more rapid, once we have used up the easiest source of funds we had to cope with our existing obligations. This is true whether those funds are refund checks, or politically difficult spending cuts.
We have to recap the argument again, as usual. The CBO says health care reform shrinks the deficit through a combination of tax hikes, spending cuts, and (in the case of the Senate bill with its tax on employer health benefits) “bending the curve” on healthcare inflation. Yes, say McArdle and others, but many of the spending cuts are in Medicare and Congress will never really follow through on those. Well, says Klein, if Congress won’t follow through on Medicare cuts, the government is going bankrupt anyway. No, says McArdle, but (omitting a distracting analogy about buying a boat) 1. adding to the government’s other liabilities (even if they’re paid for) makes it more difficult to pay those Medicare liabilities, and 2. universal health insurance creates new interest groups which will protest against needed cuts in Medicare expenditures. So it makes it more likely that the government will go bankrupt.
Point one: it actually took me a long time to figure out what McArdle is saying here. She’s saying, okay, let’s say we need to cut $50 billion a year out of Medicare spending in 2030 to avoid defaulting on the national debt. That’s going to be harder to do if we already cut the easiest $20 billion to pay for universal health care starting in 2013. I think this is a very different argument from the one Klein is responding to. He’s responding to the argument that the cuts projected in the CBO score won’t happen. If that’s true, he’s correct: we are all screwed. McArdle is saying, okay, but if they do happen, they make subsequent needed reductions in Medicare harder. That’s a plausible argument. I would argue that it’s wrong because it looks at the political consensus around health care in the wrong way.
Right now, Medicare cuts are politically off-limits. You need to have a countervailing political claim to make them possible. The need to create universal health insurance coverage is that countervailing claim. Our political system has never been able to approach the idea of cuts to Medicare. Until now. Barack Obama is the first president who may be able to pass Medicare cuts, because he’s doing it as part of a bid for universal health insurance.
Point two: People who receive government subsidies for their health insurance and Medicare recipients are not one group who will stand together to oppose cuts. Rather, they are two completely different constituencies with almost no spillover who will fight against each other for government funds. I see no reason to believe that working-class families who get their and their kids’ health insurance subsidized will be more likely to defend budget-busting expenditures for seniors. I see plenty of reasons to think they will do the exact opposite. It would seem to me that from a pure-politics perspective, there will be more of a constituency for Medicare cuts with this reform than without it.
For that matter, McArdle herself has long been arguing basically the opposite of what she argues here, in terms of the political effects of universal coverage on the healthcare economy. In pretty much every country with government-regulated universal coverage (i.e. every developed country except America), government intervenes to drive health costs down, and governments deny expensive, ineffective care, because taxpayers have a limited willingness to pay. In other words, expanding coverage creates the political will to control healthcare inflation. Which is what Klein is saying too.
As Robert Reich details, the slow elimination of the public option as any part of health care reform is a demonstration of the complete dominance the private health insurance industry has retained over the process. What this means is that essentially creating more or less universal coverage in the US is going to mean putting another 30 million Americans on private health insurance, and having the taxpayers pay their premiums. In theory, later down the road, now that the government is picking up the tab for everyone’s health care, we could start forcing private sector reforms to bring down costs. That’s what happens in, say, the Netherlands, with its all-private universal health insurance system. But the problem is that the process of health sector reform has conclusively demonstrated that private industry has so much power in the American political system that it’s beginning to seem implausible that Congress could ever vote to force cost reductions on any private industry, the health industry included.
Ultimately, one should start to hit a point where taxpayers refuse to subsidize private industry any more. To date, this point has been put off by deficit spending. At some point, however, it’s going to become impossible to do that anymore: some years down the line, government borrowing needs will become so astronomical that they will start to force bond yields up again and crowd out private investment. At that point, business interests will start to balk. Then the government will be faced with a choice: raise taxes, or cut services. What will happen at that point?
Taxes on the politically powerful wealthy will not be raised sufficiently to meet the government’s debt needs. Rather, taxes will be raised on, and services will be cut for, the politically powerless. That means the poor. The poor will pay higher taxes and receive less medical care and worse education. The government will eliminate infrastructure investment. That’s how America works. It’s a two-class society, where class divides are reinforced and exacerbated by the control of the wealthy over the political system.
I’m married to a Dutch woman, so I have the option of moving to the Netherlands, a far more egalitarian society with a government that, up to this point at least, has largely proven itself up to the task of facing the country’s major social and political problems. (We’ll see what happens if Geert Wilders wins the next elections.) In some ways, I would prefer to live in America. And I could in fact prosper in America: I’m a skilled professional from the upper sector of America’s class distribution, so I could take advantage of my background to make a lot more money than I could in the Netherlands, and not have to kick much back in taxes to provide a social infrastructure or educational opportunity for the poor. America’s political system would allow me, as a member of the elite, to siphon off more of the country’s wealth. I’m pretty sure I could live well in America. But that’s because of the extent to which American society has become corrupt and exploitative, and joining up with a project like that is in many ways pretty unattractive.
Megan McArdle writes that the claim “We will control health care costs, because we have to”
is a disturbingly common argument heard when one points out that the costs of the domestic programs we have are so far impervious to cost control. Apparently, it is safe to enact a program that is going to blow a 10-gauge hole in the Federal budget, because the mere fact that we can’t currently afford to pay for it will force us to, um, do something.
Both the House and the Senate health care reform bills pay for themselves, according to the CBO. So it’s not clear what program Megan thinks will “blow a 10-gauge hole in the Federal budget.” But here’s the broader point: the US is going to have to shrink the amount the government pays for health care. This is true whether or not we create universal health insurance, because growth in Medicare and Medicaid costs will bankrupt the government otherwise over the next 2 decades. The question is who will pay for this shrinking of the amount we pay for health care. Under the current system, the following groups are paying for it: the working poor, who are gradually being priced out of the private health insurance market but don’t qualify for Medicaid. And the sick, who are slowly being kicked out of private health insurance at any point where insurers can find a legal loophole that enable them to kick them out. To be more precise, then, it’s the unlucky sick who are paying, those who get fired while sick, whose business go bankrupt while they’re sick, who filled out something wrong on a form that gets their coverage rescinded, etc.
This is an unacceptable way to pay for the rising cost of health care — by denying coverage to the working poor and the unlucky sick. Before we decide how we’re going to cut government spending on health care, we have to ensure that everyone in the country has health insurance. And the method of saving money should not be, by and large, to cut services to the poor. We in the US believe that no one should go without health insurance or basic, decent health care because they are too poor to afford it. That’s why we have Medicaid and Medicare. It is utterly irrational to continue to guarantee large overpayments to seniors on Medicare Advantage while the working poor are gradually forced to go without health insurance entirely. We need to set up a system that guarantees that everyone gets health insurance. Then we can start making cuts, once there’s a way for such cuts to be shared by everyone, on the basis of solidarity, rather than just cutting the throats of the working class.
One of the commenters on a recent post took a libertarian stance on government’s role in obesity-related issues, and that prompted me to reflect that I’ve never really understood what it is that libertarians think about government’s role in urban planning. For instance, yesterday Elana Schor had a nice post on the DC Streets blog about a recent national conference of metropolitan area planners. Here’s how she describes the focus of the conference:
Leinberger, an experienced land use strategist, described the core question as: “What kind of built environment do we want? Over the past 50 years, it has been imposed by a bureaucracy, either in D.C. or by the state capitals.”
But as more planners and local residents come to the (non-partisan) conclusion that “it’s time to be conscious about what kind of development our transportation choices spark,” as Leinberger put it, what can the federal government do to help local success go national?
A liberal position might be that the things metropolitan area planners should be doing include building out bicycle transit options so they’re safe and universal, doing more mixed residential/commercial zoning and development to encourage walkable neighborhoods, etc.
As far as I can tell the libertarian position would be that metropolitan area planners don’t actually exist and did not just hold a conference in Washington DC to discuss all the things they don’t do which don’t determine the shape of America’s built environment. Or else it’s that they shouldn’t exist and we should just eliminate the government’s role in building or regulating the country’s physical environment, and see how that works out for a while. I’m not really clear on this.
Filed under: Health
Heather MacDonald argues that the idea that the health care system should focus on prevention is nonsense because
Prevention lies overwhelmingly within the realm of individual behavior, but our modern reflex of transferring agency from favored victim groups—in this case, millions of artery-clogged, waddling Americans—onto less-favored entities guarantees that we see the problems of Fat America as the failure of doctors to practice the right kind of medicine.
Well that’s sure wrong! Prevention lies overwhelmingly outside the realm of individual behavior. For instance, basically none of the foods we eat are prepared by our individual selves. We’re either eating meals that were cooked by a family member for our entire family, or meals that were prepared by a restaurant or cafeteria, or we’re eating snacks that were made by companies and sold by corporations. In rare instances, we may be eating a piece of fruit, or something we cooked ourselves from scratch, and in that case prevention really does lie within the realm of individual behavior. But that’s pretty uncommon.
To put it more clearly: the amount of healthy fruits and vegetables we consume is largely predicted by our socio-economic class. In what sense is this “in the realm of the individual”?
Similarly, how much exercise we get during the course of the day is pretty much determined by the transportation layout of the neighborhoods and conurbanities we live in, which, unless we’re named Robert Moses, we probably didn’t individually shape. How much particulate matter we breathe is determined largely by regional power generation and transportation choices and government rules. And so forth.
Ah, but there’s no way for society to intervene to make a purposive change in those sorts of things! Except of course for how public anti-smoking campaigns and taxes have slashed the rate of smoking to less than half what it was in 1965. Was that “in the realm of the individual”? Or how when France instituted a nationwide campaign to stop the rising rate of child obesity through school-based monitoring and exercise and diet interventions, it, well, stopped the rising rate of child obesity. At a level less than 1/4 that in the US.
Scotland is adopting the French small-town anti-obesity program, known as EPODE. But we can’t do that because…what’s the conservative/libertarian argument again? That Americans are stupider, less disciplined and naturally fatter than French people? Or something?