The Elephant

by Dave Schuler on March 18, 2010

Once again the real world is overwhelming my active participation in the blogosphere. Before I leave again for that real world I’d like to drop a thought for consideration.

The U. S. healthcare system is absolutely enormous and unfathomably complex. Within its boundaries it includes examples of nearly any approach to delivering healthcare services anywhere in the world and, frequently, at sizes that rival those approaches elsewhere. Most of us are probably aware of the fee for services model—it’s the approach to healthcare delivery that most of us encounter on a day to day basis but it isn’t the only approach.

We have not just one but several fully socialized healthcare systems. The largest is the Veterans Administration healthcare system. With spending of $96 billion per year it’s about 2/3’s the size of British National Health. There’s also the Indian Health Service. At roughly $4 billion dollars per year it rivals many other countries’ complete healthcare systems.

HMO’s frequently employ capitation systems. That’s a system under which healthcare providers are paid based on the number of patients they treat rather than what services they perform for these patients per se. Capitation is essentially the system that Italy employs.

The federal government’s employee healthcare system and the Medicare system approximate the single-payer system that some people advocate for the United States. France and Germany both have systems that can in rough terms be considered single-payer systems paid via payroll deductions.

As you can see within our singular system we encapsulate nearly all other systems. What baffles me is that, for some reason or other, the idea that an employer-based private insurance fee for service system is the system we have in this country. But that’s just part of the elephant not the whole elephant.

I think I may have mentioned before that in my real life over the years I’ve had clients who were individual physicians, hospitals, pathology laboratories, big companies, small companies, insurance companies, pharmaceutical companies, and companies that manufacture medical equipment and that the normal course of my business causes me to look at my clients’ books and gain some sort of understanding of how my clients’ businesses actually work. I can’t claim to have a clear view of the whole elephant of healthcare but I’ve learned the views of those who see the trunk very clearly, the ears very clearly, the legs very clearly, and so on and, as a consequence, I think I have a pretty good idea of the general outlines of the elephant and a few flashes of great clarity now and again.

Given that experience and viewpoint I’d like to give you this to chew on. Despite its many good even great qualities our system is looney. There’s no conceivable way that everybody can get all the healthcare they want and healthcare providers can get whatever they want for providing it. Furthermore any system in which the government with its deep pockets and regulatory capability bids against private individuals for healthcare services is either good or sustainable. It’s a flywheel ready to spin off.

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Using Education As a Model for Healthcare

by Dave Schuler on March 17, 2010

As I was driving between appointments this morning I heard an interview on the radio with Theodore Marmor, a grizzled veteran in the Washington battles over healthcare reform. In the course of the interview he said something that I think is worth pondering. He said something to the effect that the Obama Administration has been posing the issue of healthcare incorrectly and should have been making the analogy with education. Like education, he said, healthcare shouldn’t be a “market good” but should be something that we expect to be provided to all.

Leaving aside for the moment the improperly posed dichotomy of market goods versus, presumably, non-market goods and whether most Americans would actually be satisfied with a healthcare system that functioned as effectively as the public education system does, I think it’s a perfectly good analogy as long as you’ve got the courage to follow it to its logical conclusion.

First, education is and has been something that is preponderantly a state and local responsibility. If healthcare were to be treated like education, we’d abolish the Medicare system in favor of state and local programs that performed similar functions. Here in the United States we spend roughly $1 trillion per year on education. The federal government’s contribution to that is a relative pittance of that, perhaps 15%.

Second, when all is said and done there’s a limit on how much public education is provided to an individual. Generally speaking, it supports kindergarten through 12th grade without charge to the student or the student’s parents. After that the individual is expected to contribute substantially to financing his or her own education and the best, most prestigious educational institutions charge mightily for that. There’s not even a pretense of equality.

So, to follow through with the analogy, are proponents of treating healthcare like education suggesting that a fixed menu of healthcare should be offered without charge to an individual or the individual’s parents until the individual reaches age 25, at which point financing his or her healthcare would be left to the individual? If that’s what’s being suggested I must have been asleep during class.

Checkups, immunizations, and routine treatment would be covered. Pediatric intensive or extraordinary care wouldn’t. For most people, most of the time this could well be adequate and might even be an improvement over what they experience now. I would certainly be less expensive.

I think it also is worth pointing out that most teachers are employees of the public school systems and primary education is considered for the most part an entry-level field (and compensated commensurately). The starting salary for a teacher in the city of Chicago is around $40,000. If the only healthcare that most people ever experienced was delivered by RN’s (the comparable in this analogy of healthcare and education), I doubt we’d hear quite as many complaints about healthcare being too expensive. Ineffective, maybe, but not too expensive.

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The Disconnect

by Dave Schuler on March 17, 2010

My work appears to be counter-cyclical. Last year was one of my busiest years ever and this year is right up there as well. I have a long, busy day ahead of me and this may be the only post I’m able to sneak in.

Recently I’ve been reflecting on the similarities among many of the issues of the day—global warming, the financial crisis, healthcare reform, and some foreign policy issues. One of the things that I see in common among them is that I’m really called to wonder how true all the hubbub about them is because of the way that people are behaving.

The easiest example of this to point out is the many advocates of serious reform in our production of greenhouse gases who in their own behavior from jetting off to conferences in the four corners of the world, frequently in private jets, to the homes they live in or the vehicles they drive don’t appear to reflect the sense of urgency that they’re preaching to the rest of us. But it isn’t the only example. Take the financial crisis, for example.

There’s almost no end to the culprits you can point a finger at in the still ongoing financial crisis: short sellers, investment banks, commercial banks, AIG, the ratings companies, the Fed, the SEC. You might think that the greatest attention would go to those who have the greatest fiduciary responsibility among whom I would think about the ratings companies, the Fed, and the SEC. We haven’t seen a wave of outrage directed against those (except, maybe, the Fed) and we certainly haven’t seen a wave of firings in those places. Quite the contrary, those most proximally responsible, e.g. Treasury Secretary Timothy Geithner, have received promotions.

That’s the relationship I see among these very different issues. The disconnect between individual behavior and presumed urgency.

I can think of lots of possible reasons for this. It’s frequently pointed out to me that people aren’t rational, in which case while, yes, they’re behaving irrationally but, then, that’s what people do. That strikes me as a cop-out. Are people really behaving that irrationally? Or are they merely responding in fairly expected ways to the incentives they have?

Another explanation I hear pretty frequently is that it’s all a plot. Increasing the regulatory power of the federal government in the financial markets, more federal intervention in the healthcare market, cap and trade, and so on are all power grabs. While they may all be instances of not letting good crises go to waste, the crises themselves are real. There really are serious difficulties in the financial sector, our healthcare system really does need substantial change, and we really are releasing too much carbon dioxide into the atmosphere (or, at least, we’re consuming too much in the way of fossil fuels). One does not preclude the other. Power grabs don’t rule out real problems.

It could be wishful thinking or stupidity. Or a belief in group action, a denial that the behavior of a group is the sum of the behaviors of the members of the group. Or a combination of all of the above.

I find this disconnect disheartening, even unsettling. I don’t see it as hypocrisy so much as a general failure of leadership. In our society leadership doesn’t just mean compelling people to do things or telling them to do things. From babyhood on we learn more by the behaviors that are modelled for us than by those we merely hear about.

When you practice expanding government power while preaching small government, practice profligacy while preaching thrift, practice elitism while preaching egalitarianism, or practice deceit while preaching openness, people will learn the expansion of power, profligacy, elitism, and deceit.

I’m hurried so I may not be articulating this too well. Or I may be unnecessarily concerned. I hope I’m not just disconnected.

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Iditarod 2010: And the Winner Is…

by Dave Schuler on March 17, 2010

Yesterday at 5:59pm CDT Lance Mackey made Iditarod history by becoming the first musher to win the grueling 1,049 mile race in four consecutive years:

No other musher has won four Iditarods in a row. Mackey’s time into Nome — 51 seconds under nine days — was the second-fastest in the 38-year history of the race. He arrived with 11 of the 16 dogs he started the race with.

“He could take your dogs and beat his team with your dogs. That’s how good of a musher he is,” said Hugh Neff, a Mackey friend who sometimes raced alongside the Fairbanks musher in the Iditarod and Yukon Quest. “It ain’t just about the dogs — it’s about him. And the magic he has that nobody else seems to have.”

Mackey’s win relied on what’s become his trademark of surprisingly long runs with little or no rest in order to outpace faster dog teams. With his famed lead dog Larry now running with Jamaican musher — and Mackey apprentice — Newton Marshall, the 39-year-old relied on leaders Maple and Rev.

I was busy with a client so I was unable to watch him cross the finish line. However, my wife was glued to the set, watching via video streaming over the Internet.

The race is far from over. As of this writing fewer than 15 mushers had completed the race—there are still 50 some-odd to go before the red lantern is hung out and this year’s Iditarod is completed.

The picture above is from the Anchorage Daily News, the best source for Iditarod coverage.

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The Council Has Spoken!

by Dave Schuler on March 17, 2010

The Watcher’s Council has announced its winners for the past week. This week the winner in the Council post category was Joshuapundit’s “Obama Tells Israel They Have No Right To Their Religious Shrines”. Second place honors went Bookworm Room’s “Obama Care and abortions”.

The winning non-Council post was Joel J. Sprayregen/ American Thinker’s“Obama’s Iran Policy Collapses to the Accompaniment of Mockery Around the Globe”. Second place honors went to Chicago Boyz’s “Seizing the Opportunity to Destroy Western Civilization”, which I nominated.

The complete results are here.

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Then What?

by Dave Schuler on March 16, 2010

Megan McArdle asks this about healthcare reform:

Assume this passes; what happens afterward? I don’t think that many people believe that the answer is “Nothing: the bill becomes law, and we sing happy smurf songs all the way to the longest life expectancy in the Western world!” Even the bill’s proponents expect it will need some follow-up work. But what will that follow-up work look like?

Her view of the “worst case scenario for Democrats” is that a reaction not unlike that which followed the Catastrophic Care Act of 1988 sets in. I’ve been reminding of that possibility for some time. That’s what always occurs to me when progressives chortle about the enduring character of entitlements. It ain’t necessarily so.

To refresh your memory the Medicare Catastrophic Care Act of 1988 was an amendment to the Medicare Act passed under Ronald Reagan. It provided protection against catastrophic medical expenses under the aegis of the Medicare system and, indeed, it’s not a bad idea and not dissimilar to things that I’ve seen proposed lately. Despite its merits the system was phenomenally unpopular for a fairly obvious reason: the benefit was paid for with a Medicare premium tax to be paid by everyone eligible for Medicare.

Human nature is remarkably durable over time; just as today people have little problem with accepting benefits, it’s paying the tab they don’t much care for. The act was repealed in a panic as long-serving Congressmen came under heavy fire for their support of the act.

Here’s my prediction. The House will ultimately pass the Senate bill. The Congress will then add more benefits and repeal the meager “curve-bending” components of healthcare reform via reconciliation. People will see tax increases, premium increases, employers dropping their employee insurance plans at an accelerating rate, and not much in the way of benefits (that’s the way the law is written). Will the Congress then repeal the bill in a panic? Beats me. Either way we’ll be in worse shape than we would have been in had we done nothing, passed Wyden-Bennett, or about a half dozen other approaches.

Congress will have lost its appetite for healthcare reform (although progressive strategists will not). And Medicare’s default will be that much closer.

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Anniversary

by Dave Schuler on March 14, 2010

Today marks the sixth anniversary of this blog. Over the period of the last six years I have written nearly 5,500 posts and had more than 1,000,000 visitors. These days I’m getting about 1,000 hits per day.

Over the period of the last year I’ve come much closer to accomplishing one of the goals I had when I began posting: the discourse here has become much more lively. I hope that trend continues.

I’d also like to thank, once again, Joe Katzman of Winds of Change, my primary inspiration for blogging, Dean Esmay of Dean’s World whose invitation to publish the Carnival of the Liberated exposed me to a wider audience, and James Joyner of Outside the Beltway, whose invitation to become an associate blogger there exposed me to an even wider audience and, importantly, renewed my interest in blogging. Doing virtually all of my foreign policy blogging at OTB, as I promised James I would do, has been quite a challenge, like writing verse in the sonnet form or swimming with one hand behind your back. It’s caused me to focus on other things here at The Glittering Eye.

I’d also like to thank my regular readers here who inspire me, energize me, goad me, and keep me honest.

My previous anniversary posts are here:

2009
2008
2007
2006

I don’t seem to have posted a first anniversary post.

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Which Weighs More?

by Dave Schuler on March 14, 2010

Who produces the fewer carbon emissions, somebody who drives a Prius or somebody who drives a Suburban?

It’s a trick question. You can’t determine the answer from the information you’re being given in the question. It depends on miles driven, driving conditions, driving practices, and even the temperature. Recent models of Prius seem to be getting 40-50 mpg in the real world and recent models of Suburban seem to be getting 15-20 mpg in the real world. Consequently, all other things being equal a Prius driver who drives 300 miles per week will drive will use more gas and, consequently, produce more emissions than a Suburban driver who drives 50 miles per week.

Consequently, if your objective is fewer emissions, policies which result in people driving less might be more effective in achieving your goal than getting everybody to drive hybrids. Driving less will result in fewer emissions whether you’re driving a Prius or a Suburban.

In a digression a Prius can’t remotely be considered a green vehicle unless you limit your definition to consumption of hydrocarbons. If you include, for example, the amount of rare earth elements used in its manufacture, how noxious some of them are, and the lack of any way to dispose of them properly, we might think twice before subsidizing a rush to hybrids. In a digression within a digression, China is one of the major producers of rare earth minerals if not the major producer. Would you like to trade oil dependency for rare earth dependency?

In another digression, have you ever heard of the Jevons paradox? It’s the principle according to which the more efficiently a resource is used, the more of it is used. It was proposed in 1865 by William Stanley Jevons who observed that improvements in the efficiency of the use of coal had lead to more coal being consumed in England.

In my view there are two sorts of political opinion polling. The first is scientific, an attempt to acquire knowledge. The other is a form of advocacy, an attempt at justifying what you want to do.

I have no objection to the former but I think the latter is almost always pernicious. It relies too heavily on narrow and probably misleading questions. So, for example, issue polling in which the benefits of the policy being promoted by the pollsters are divorced from its costs is, essentially, meaningless. It is a form of deception.

Which weighs more, a pound of feathers or a pound of lead?

Updated

Another example of questions that are misleading based on how they are structured occurred to me. Which is better for you, a diet in which 10% of its calories are from fat or one in which 30% of its calories are from fat? I think that most would answer that the diet in which 10% of its calories are derived from fat is better for you but it ain’t necessarily so. A better answer is “it depends”.

It depends on lots of things including your genetics and how much you eat.

Most of the statements about diet are based on the assumption of a 2,000 calorie per day diet. Unfortunately, many Americans eat significantly more than that. To put it in perspective for most people, if they select the foods they eat with a certain amount of care, a 1,200 calorie a day diet can be nutritionally adequate. A Big Mac Value Meal has about 1,200 calories but it’s not nutritionally adequate. In addition to having far too much fat it has far too few of most nutrients including vitamins A, B complex, and C.

I don’t think I know anybody who limits their daily calorie consumption to one Big Mac Value Meal per day.

Do I need to point out that somebody who’s eating 10% of his or her calories from fat and consuming a 3,600 calories per day diet (40 grams of fat) is consuming the same amount of fat as somebody who’s consuming 1,200 calories per day of which 30% is derived from fat (40 grams of fat)? Now to be completely honest and fair, it’s darned hard to have a nutritionally adequate diet at 1,200 calories that’s 30% fat. But it’s possible.

And there’s some recent scholarship which suggests that some people do a better than others on a diet composed mostly of carbohydrates. Some people do better on Atkins (high protein). Some people do better on Pritikin (low fat). Some people find it practically impossible to lose weight on diet that’s proportionally high in carbohydrates. One size does not fit all.

Here’s an example of an article that’s undoubtedly well-intentioned and, presumably, reasonably well-informed but nonetheless wrong. It’s just too simplistic.

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Iditarod 2010: Reaching the Coast

March 14, 2010

The leaders in the 2010 Iditarod, Lance Mackey, Jeff King, Hugh Neff, and Hans Gatt, have all reached Unalakleet, on the Bering Sea. The remainder of the race takes place along the shores of the sea to Nome. The next two, Mitch Seavey and John Baker, are twenty miles behind, not a great [...]

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The Essential Obama

March 12, 2010

David Brooks thinks that partisans left and right are misreading President Obama:
If you ask a conservative Republican, you are likely to hear that Obama is a skilled politician who campaigned as a centrist but is governing as a big-government liberal. He plays by ruthless, Chicago politics rules. He is arrogant toward foes, condescending toward allies [...]

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