It's the costs, stupid

In my last entry I wrote:

Now, are health-care costs spiraling out of control? That's the impression I have. So I'm more than sympathetic to the urge to do something to get those costs under control.

...

If the movers of this misbegotten legislation (from both houses) genuinely want to keep ordinary people from feeling pain, they will have to do real work to understand why costs are spiraling out of control, and take on those root causes.

I'm pleased (and sorry) to say my impression is correct: just read Sarah Kliff's piece in Vox, "The Senate bill does nothing to fix America's biggest health care problem". That problem is, of course, cost.

The biggest problem facing American health care is our prices.

In the United States, we pay outlandishly high prices for our trips to the doctor, hospital visits, and prescription drugs. In the United States, an MRI costs, on average, $1,119. In Australia the scan costs $215, and in Switzerland $503. It is the exact. Same. Scan.

She goes on to list a sorry number of instances where costs in the U.S. are outlandishly out of line with the rest of the developed world.

Incidentally, as Kliff noted at the very start of her piece, Obama's Patient Protection and Affordable Care Act didn't address the insane costs of medical care, either. That's a major reason people have legitimate grievances against it.

However, before you sharpen your pitchforks and ready your torches, don't demonize the medical community. The situation in the U.S. is a byproduct of the majority's conviction that the free market should not be curtailed unless it's absolutely necessary. Other nations have decided that only the entire nation's population can negotiate fair prices for medical care. Those nations thus have sharply reduced the room health care providers have to jack their fees.

If you're a free-market supporter you may recoil from this heavyhanded approach. You may think that people should take greater responsibility for their own health care; that they should wield their small leverage as individual consumers to reward the providers and private insurers that best balance service and cost.

The thing is, we used to have much greater market freedoms — until the expense and frustration drove a critical mass of voters and legislators to create the PPACA. As a free-market enthusiast you may hate the PPACA, but you must acknowledge that the status quo ante was dismal.

The lesson I take away from the history of how we got to where we are, politically speaking, is that people are not able to optimize for their health care. This doesn't mean people are stupid or lazy. Rather, it means health care is a hard subject for people to reason about because it's fraught with uncertainty.

You know you're not going to live forever, but do you know how sick you're going to get? Do you know when or if major illness will strike you or your family?

Of course not!

That uncertainty makes the kind of rational economic planning that the free market requires all but impossible for individual consumers.

Furthermore, the health care available to us isn't a function of how sick we're likely to get, but rather how much money we make and whether we're fortunate enough to work for an employer large enough to negotiate favorable rates with insurers. (Or, of course, we could be lucky enough to be independently wealthy, making health care accessible no matter how sick we become.)

Finally, when we do need medical care, we're frequently not in a position to bargain for it. If you're bleeding because of a car crash, you need surgery and you need it now. Will your insurance cover it? Ultimately that's a function of

• what insurance plans were available,
• how much you could pay, and
• how carefully you read the fine print

when you signed up.

The first two factors were mostly or entirely out of your hands. The third, as a rule, overwhelmed you because you're not a lawyer, nor could you afford to hire a lawyer to read through it for you. Insurers, meanwhile, employ squads of lawyers to ensure they pay out only what they absolutely must in claims.

And what happens when, as almost certainly will happen, you and your employer part company? If you're lucky, you'll go to work for another employer large enough to have negotiated good insurance. If not, you're on your own. Do you know more freelancers than you did a decade or two ago? So do I. Draw your own conclusion about whether the segment of the working-age population that is covered by large-employer health insurance is growing or shrinking.

The idea that a fully free market will result in the most efficient, lowest-cost health care on average is no longer credible. I think the experience of the U.S. is proof enough that individual consumers have no chance in the free market when it comes to health care. The deck is stacked against all but the wealthiest of us.

So when free-marketers like Rand Paul and his quasi-libertarian compatriots in the Republican Party demand that health care be liberated from government interference, I can only conclude they're blinded by their unthinking faith in the principles of the free market. They haven't thought through what our experience as a nation has been, nor have they themselves had to make the hard choices the rest of us have, constrained by market forces we can't tame.

Health care is simply too expensive in the United States, and it's not because of the PPACA's taxes. It's because as a nation, we have not chosen to understand the unique characteristics of health care that make it impossible for individual consumers to tame the market.

Cutting to the chase

D.C. Republicans are pushing back on the idea that the Senate's now-delayed bill to reform health care — the so-called "Better Care Reconciliation Act" — is imposing "cuts" on Medicaid.

The White House says that Republicans are being victimized by a broken budgeting system that unfairly casts their fiscal restraint as callous cutting.

“Generally speaking, we spend more every single year on Medicaid,” Mick Mulvaney, the White House budget director, said in an interview this month. “We are not gutting or filleting or kicking people off those programs. We are trying to slow the rate of growth of government.”

Give Republicans the benefit of the doubt for a moment. Accept that Mulvaney and Congressional Republicans aren't the devils in suits that they're caricatured as in left-of-center discussions. Look at it from the standpoint of genuine concern about the growth of government spending, particularly over what seems to be the explosive growth of federal health-care spending.

Okay. Now take a fresh look at the Congressional Budget Office's conclusion that the Senate's bill would force 22 million people to relinquish their health insurance by 2026.

Does the nobility of Republicans' cost-cutting motives change the CBO's findings?

Of course not.

Mulvaney and Congressional Republicans can claim they're not kicking people off vital federal programs, but if they fail to fund the programs to the extent necessary, kicking people off vital federal programs is precisely what Mulvaney and company will have done.

Now, are health-care costs spiraling out of control? That's the impression I have. So I'm more than sympathetic to the urge to do something to get those costs under control.

But Congressional Republicans and the administration seem to be trying to take the easy way out by simply saying, "No more than X dollars will be spent — how X is divided is up to somebody else".

That's not good enough. If the movers of this misbegotten legislation (from both houses) genuinely want to keep ordinary people from feeling pain, they will have to do real work to understand why costs are spiraling out of control, and take on those root causes.

Anything short of that major effort will put the lie to the claim that those elected officials aren't "gutting or fllleting or kicking people off those programs".

Republicans, the ball's in your court. Tackle the hard problems underlying our health-care cost crisis. Show the rest of us you're not silent-movie villains foreclosing on widows and orphans — because that's the image you're cultivating with your slapdash legislative efforts so far.

Companies and the public interest

Rebecca J. Rosen has a piece in The Atlantic positing the question, "Is the problem with tech companies that they're companies?"

Rosen's thesis is that some well-known companies' professed ethos, whether it be Facebook founder Mark Zuckerberg's desire to foster community or Google's much-lampooned "don't be evil" (which may or may not be its actual company slogan any more, if it ever was), runs head-first into the modern consensus of a for-profit public corporation's purpose, which is to maximize profit for its shareholders.

Rosen's proposed solution to this conundrum, though, isn't much of a solution.

While she approvingly cites Stanford professor Rob Reich's comments about creating ethics committees to guide corporate boards of directors, the description of that work is that it would "[take] into account various values they prize". Meanwhile, she says elsewhere that "Reich believes that some sort of oversight is necessary to ensure that big tech companies make decisions that are in the public’s interest".

It's difficult enough to know who the amorphous "they" are whose values are to be taken into account. In Facebook's case, is it Mark Zuckerberg, his collective workforce, Facebook's shareholders, or some combination thereof? Rosen's (perhaps suitable) vagueness on this point, though, is merely a speed bump of a concern compared to the brick-wall obstacle of whether "their" values, whoever "they" are, really represent "the public's interest".

I'm not sure I trust Facebook any more than I trust Hobby Lobby to understand "the public's interest". Even with the best and least controversial of intentions — who can argue with "don't be evil"? — when it comes to turning intentions into actions, everyone prioritizes different values. Everyone claims to be opposed to discrimination, for instance, but what happens when one's sincere religious belief that same-sex marriage is immoral (and thus harmful to the public good) comes up against a same-sex couple desiring your company's services for its nuptials? Somebody is going to feel discriminated against, no matter what happens. How do you define "the public's interest" in this case?

You can't. Not yet, anyway. And this is just the most extreme example of "the public's interest" being a very, very difficult concept to pin down.

Ethics committees probably couldn't hurt as companies who are, wittingly or not, disrupting long-held habits and social constructs, struggle to define their paths forward while portraying themselves as good corporate citizens (and perhaps believing that, too). But none of us should be under the illusion that even the most painstaking ethics committee will be able to guide a corporation in "the public's interest" — because if this era has a defining conundrum, it is that even the public cannot agree on what "the public's interest" is.

Public service is not about personal loyalty

After James Comey's testimony to the Senate Intelligence Committee, I think all of us, Trump supporters and Trump critics, can agree on one thing.

Donald Trump values loyalty to himself above all else.

This isn't news, of course, but it's good to get confirmation from someone who dealt with him face-to-face (to Comey's outspoken regret).

For a guy who runs his own privately-held business, it might — might — be okay to demand unequivocal loyalty. Even so, the Godfather jokes write themselves.

But the President doesn't run his own privately-held business.

Before the President-elect and his appointees can assume their offices, they take an oath to defend the Constitution.

It is, of course, highly improper for the President to demand personal loyalty as Trump routinely does. That demand puts an intolerable strain on an honest subordinate:

• If he sincerely pledges loyalty to Trump, he violates his oath of office.
• If he refuses to pledge loyalty to Trump, Trump will find a reason to fire him. James Comey is Exhibit #1 on that score.
• If he only pretends to pledge loyalty to Trump, he looks like he violated his oath of office and Trump can later use his supposed pledge against him. (Trump himself does not show loyalty to subordinates who incur his wrath or get in his way.)

Now that Trump's Mafia-like insistence on personal loyalty is public knowledge, honest men and women will shun serving in his administration. The public will assume Trump executive-branch nominees are his lackeys first, and public servants second (if at all). We will assume that Trump and his administration are corrupt because they do not hold themselves accountable to anything but Trump's whims and Trump's self-interest.

I'm not so lost in cynicism that I assume all presidential administrations are mere tools to make the President and his cronies wealthy and powerful. That's only the story of Trump's administration. It's disgusting. And it's a disaster for the rest of us, who will be left to clean up the mess.

The stench coming from 1600 Pennsylvania Avenue is the reason we can't afford Mob-like "Dons" as President.

Trump has got to go.

Lies, damned lies, and Scott Pruitt

Via the Atlantic, an unusually clear instance of Trump administration bullshit.

On Sunday’s “Meet the Press,” Scott Pruitt, the head of the Environmental Protection Agency, claimed that the U.S. has created 50,000 jobs in the coal sector since the fourth quarter of 2016....

...

Quite simply, the coal sector has added about 1,000 jobs since October 2016—not 50,000. Coal could not have added 50,000 jobs in the last eight months, since that is essentially the size of the entire coal industry, according to the Bureau of Labor Statistics....

Pruitt wasn't spinning a half-empty glass as half-full. Pruitt was lying on an unusually large scale.

The Democratic Party's problem

The Democratic Party has a well-deserved reputation for snatching defeat from the jaws of victory. Perhaps its greatest failure in the recent past was in the 2016 presidential election, which provides a textbook example of its core problem.

The party stands for nothing. Nothing memorable and stirring, anyway.

Think of the 2016 Democratic Party presidential primary. Only four candidates tried to run, and three of them were dyed-in-the-wool technocrats. The battle boiled down to the technocrat with the highest name recognition, Hillary Clinton, and the upstart populist Bernie Sanders. The party chose the technocrat to go up against the buzzsaw who redefined electoral politics in 2016. In spite of Trump's innumerable (and seemingly fatal) flaws, she lost. She has a lot of excuses but refuses to accept that (1) the race should never have been as close as it was, and (2) the reason it was so close was less Trump's appeal than her own failure to enthuse a lot of people.

Consider the Democratic Party's highest-profile leaders in Congress, Chuck Schumer and Nancy Pelosi. They are defined by nothing except adherence to stale party stances. And they're the ones who, in turn, define the party for everyone else.

The party is run by technocrats who are skilled at the infighting game in Congress. That's okay for governing, but it's hopeless for campaigning.

Now, I'm not dumping on technocrats. I have a technocratic mindset myself. But technocrats are lousy at politics, because politics is as much about emotion as wisdom. You can't run a democracy without emotional appeals because a democracy of any size is full of people who don't know and don't care about any but a tiny handful of the myriad of issues that that democracy faces. You can't reach these people with dry, rational arguments. You also can't reach them with measured hectoring, which is Pelosi's and Schumer's specialty. You have to rouse them with appeals to basic emotions.

Hate, anger and fear are basic emotions, and they seem to work really well with modern Republican voters. However, at least in modern times, the Democratic Party has a poor track record of harnessing these emotions on behalf of its candidates. Lots of people have speculated on the reasons for this dichotomy between the parties; I shall not. I will assert, though, that people are more motivated to vote for a candidate with an inspiring message than for the candidate perceived to be the lesser of two evils. Given the Dems' obvious inability to marshal the more negative emotions anywhere near as effectively as Republicans, Democrats must find a message people can rally around, a message more inspirational than "We're not as bad!"

Deciding who is human

Missouri state representative Rick Brattin doesn't think homosexuals are human.

"When you look at the tenets of religion, of the Bible, of the Quran, of other religions, there is a distinction between homosexuality and just being a human being," Brattin told the House floor.

Brattin also advocates teaching creationism and has advocated for the idea of "legitimate rape". To say he's hopelessly in the thrall of the most fundamentalist strain of Christianity is to say the sky is blue.

Rick, there's a distinction between being a self-righteous, small-minded, judgmental cretin and just being a human being, too. I think there are verses in your Holy Bible that talk about that. Maybe you should read them and think about who you are.

Stop reacting, start acting

Dear Leader pulled the U.S. out of the 2015 Paris climate accord. Color me shocked.

I've spent the afternoon and evening being outraged. Now that I've gotten past my visceral reaction, I'm turning my back on him.

He's a narcissistic infant. We know it. Now, will we waste our time repeating the obvious, or cope with it?

We must exercise our power as consumers, voters and citizens. We must keep tabs on which companies and elected officials take advantage of Dear Leader's free pass to fuck our future. We must name them, shame them and do our very best to make them pay for screwing over everybody in search of next quarter's profits and the next election.

I'm sure there's more we can do. Let's find everything we can.

We have to stop screaming about how far Dear Leader and his enablers have their heads up their asses. We have to be guided by a positive vision to make the world better in spite of them.