Tuesday, May 21, 2019

Presidential Pardon Reform Update

Status check on Presidential Pardons.

As predicted, The Trump Abomination is desecrating the power of the pardon to further depths, now possibly ready to pardon murderers and perpetrators of war crimes. The New York Times lead editorial for Monday, May 20 takes note with horror:

As readers might remember, this issue has attracted our attention previously. Our long term solution is to pass a constitutional amendment that would require that every pardon be co-signed by the Speaker of the House.

So my writing partner David Levine, my long time next door neighbor and professor of law at UC Hastings, and I responded to the editorial in a letter that was just published:

To the Editor:
Yes, President Trump’s heinous use of the pardon as a political and evasive tool is unpardonable. Until Watergate, the tool was rarely abused. In an increasing trend, however, we have had Gerald Ford’s pardon of Richard Nixon, George H.W. Bush’s notorious, and probably self-exculpatory, Iran-contra pardons (encouraged by his attorney general, William Barr), the sordid pardon by Bill Clinton of the fugitive financier Marc Rich that you cite, George W. Bush’s commutation of Scooter Libby’s prison sentence and now Mr. Trump.
Since the power is constitutional, legislative remedies are unlikely to be sufficient to counter the trend. Instead, we need a constitutional amendment that would require that all pardons be co-signed by the speaker of the House. Requiring two signatures would improve the odds of decency in the decision.
Budd N. Shenkin
David I. Levine
Berkeley, Calif.

In a very nice coincidence, on this very same day David and I received word that the Constitutional Law Quarterly would like to publish our essay on this subject that is the successor to my February post.
This is good news! The strategy is to get the word out, to put it on the agenda of post-Trump Abomination reforms. All potential constitutional amendments are long shots, but it would appear that this one is certainly meritorious. At least we think so.

Budd Shenkin

Saturday, May 18, 2019

Medicare For All? The Need for Competing Plans

When I see something about Medicare and Medicaid policies that don't make sense, I wonder about Medicare For All.  I believe that there should be universal access to medical care, and that taxes should be used for payment.  But does that mean only one payer, Medicare?

When Managed Care Medicare was rolled out here in CA, each county had to have at least two competing plans that patients and clinicians could sign up with, so they competed against one another.  I think the same should apply if there is to be MFA, and hopefully more than 2 plans competing.  That way, we would have a better chance of getting good policies.  Nothing is quite so intransigent as a large governmental agency to which people have no alternative.

For physicians, imagine, for instance, one of the plans in an area with the policy: "We Don't Claw Back."  Or one plan that had an effective physician advisory board. 
For patients, imagine that one of the plans had an effective feedback program, where physician failures of patient-friendly procedures had a ready conduit for complaints to be processed and published.  Or the opposite - imagine a way for the word to get out about how effective and thoughtful certain doctors, clinics, or hospital services were, in a thoughtful and informed way that a plan could handle but Yelp cannot.

Imagine a communication program among doctors, hospitals and patients mounted by one of the plans, that enabled all participants to make progress together.

Large, bureaucratic organizations cannot and will not behave this way unless prodded, and even then, smallness is most often better.  Medicare would be fine for collecting the money, bargaining with pharma, setting basic standards, and monitoring comparative results.  But when it comes to specific policies, details and nuance matter, and details and nuance are beyond the capabilities of large bureaucracies.

I believe in competition and alternatives, supported by open information.  Regional and local competition is essential.

Budd Shenkin

Saturday, May 4, 2019

College Student Anxiety - A Research Finding, And A Challenge To Be Met

In an excellent piece of research, my friend Richard Scheffler has shown convincingly that American college students are experiencing an epidemic of increasing anxiety.  

Here is the telling graph:

Percent of Students Diagnosed or Treated with Anxiety Disorder in the past 12 months, 2008-2016

This second graph is also useful:

Percent of Students Diagnosed or Treated with Anxiety Disorder in the past 12 months by Gender and Race, 2008 and 2016


Richard’s coming article gives evidence that these alarming rates are true and not artifacts, and are, if anything, understated.  Last Thursday he presented the findings at our home campus, UC Berkeley, to a largely student audience with a panel that included both the Chancellor and the director of student health services.  Richard’s figures seemed quite believable to audience and panel alike.

Why is this happening?  There are guesses.  Many students lack money in the present and are heavily indebted for the future; they face insecurity of their housing (some are even technically homeless!), and a surprising number experience food insecurity.  Many students are actually on food stamps, and many visit food banks.  Even with the evident dysfunctionality and inequality of wealth in the United States, this is hard to imagine, but it is fact.  Students also report that they work “too hard,” and compete in how hard they are working and how much sleep deprivation they are experiencing.  This could be construed as a cultural element.

Faced with these problems, many of the students are understandably anxious.  They feel helpless and don’t know what to do about it, or where to turn for help.  They do access health care services for counselling in increasing numbers, taking it as a personal problem, which it undoubtedly is, even if there are systematic forces that conspire to produce their individual problems.

In addition to their insecurities about their present situations, it’s hard to imagine that they are not also insecure about what will happen to them in the future.  Some majors can lead immediately to jobs, but others not, and as we know, even if the economy as a whole thrives, many individuals suffer, especially in the recently-graduated population.  The crisis in student debt has been well documented, and it would be a dull student indeed who would not be aware of that future burden.

The university student population has always been subject to anxiety.  It can be a fraught time of life.  It is often their first time away from home, the first time dealing with so many issues on their own, including deciding on their own evolving personal identity, their increased work load and the consequent need for internal academic discipline.  But Richard’s findings clearly depict that the current students are not in the same situation their parents and grandparents found themselves.  The new anxiety is not like the old anxiety in either form or extent.

What is to be done?

What does one do with this research finding?  Understandably, there are calls to find the “root cause” of the epidemic.  Where is our Dr. John Snow to discover that the Broad Street Pump is the source of the cholera epidemic, and fix it with one dramatic move?  

Alas, the causality diagnosis is unlikely to come quickly, if at all.  The cause is probably multi-factorial, involving influences that vary from nationwide to regional to local to individual, from hard economic facts to softer cultural ones.  And while it’s always good to have an idea of causality, the search can often provide a basis for inaction – the so-called analysis paralysis.  The common cry of “we need more research” can lead to steps that benefit the research community more than the afflicted.

Those of us who have held executive positions are familiar with needing to act under conditions of imperfect information.  What we try to do in such situations is to take a best guess at what will help and pursue that course, while being sure to continue to collect information that will help to correct our course, and to suggest other steps we should consider.  

At Richard’s presentation, with the Chancellor and the director of student health services and all the students and student representatives present, all minds naturally gravitated to the Cal campus.  That’s where my mind turned also.  I thought, what would I do if I ran the UCB zoo?

I think of two different requirements for action: how to organize it, and what to do for initial remedial steps.  Organizationally, it is the responsibility of the leaders to establish priorities, not just by fiat, but in consultation with the membership in the organization.  (I would stay “stakeholders,” but I hate that cliché.)  I would gather the major campus forces  – students, faculty, administrators, parents, alumni, others – and tell them that I propose to declare student anxiety a major problem that needs to be addressed as a very top priority, but would wait briefly for their feedback.  Just that declaration would be important, as the consequences would be substantial.  

Personally, I would opt for an Anxiety Czar and an advisory board with political weight and professional knowledge.  (Just as a plug for my profession of pediatrics, I would include on the board a doctor or two who specialize in the health of adolescents and young adults.)  A high priority job needs a highly qualified leader, highly qualified participants, high visibility to the Chancellor and other university and system leaders, and a generous budget.  Unlike what Obama did with the ACA website rollout, I would ensconce an “A Team” from time zero rather than waiting for a crash and have to fix it.  That’s what a high priority means.  The Anxiety Czar himself or herself would be the most important appointment, and would need to be someone who really knows how to move a large bureaucratic organization with many different centers of power and many different agendas, and who would know how to raise the priority of student welfare, since students frequently reside at the bottom of the list.  

In addition to the advisory group over the Anxiety Czar, I would also have an intermediate group between the Czar and the individual groups, where group leaders, students and administration and health and other professionals could share their insights and experiences with one another, and forward information to the Czar above, and to the individual groups below.  Intermediate groups can be powerful, so long as they are not agents of the power above. 

I could go on about organizational requirements, how the Chancellor should think seriously about how she could and should be personally involved, but I won’t.  Except to say that I would make myself personally visible in meeting individually with student groups, and I would insist that administrative and faculty leaders do the same.  Vulnerability to visible failure is often a motivating force.  Otherwise, I probably don’t know enough about the campus to opine, and specific knowledge of the players is essential.

Operationally, it’s important to think about anxiety both generally and specifically.  Anxiety involves a sense of insecurity, focusing mostly on the future.  It helps the anxious person to feel that someone cares about them, and it’s even better if that someone has some power to act.  At Berkeley specifically, it’s useful to remember the ever-present legacy of the Free Speech Movement.  Behind the ideology, if you listen to the rhetoric, you hear, “no one cares about us.”  One of the most famous speeches in American history – no exaggeration, imho – is Mario Savio’s, and what is he saying?  No one cares about us; we are product to them.  But we are human beings! 

It’s hard not to think that feelings of being overlooked and not cared for, especially in the first years away from home, are endemic to a large university.  And truthfully, it’s a fine line to walk between giving care and intervening unduly, as most parents know.  “Being cared for” is not something that will be fixed by posting signs around campus: “We Care!”  It can be demonstrated by overt steps to solve problems, like housing and food.  But probably most effective will be honest old-fashioned and probably expensive human person to person contact.  

I would recommend especially small group contacts, where students can be reinforced in their feelings of not being alone, where caring relationships can develop, and where at the same time information can be obtained to inform actions from above.  My own plan would be to ensure that each student had at least one small group where he or she would be member.  The leadership of the group would have to be carefully chosen and groomed – leaving groups to pure self-help could be both destructive and ineffectual.  If there were a central unit that would act both for organizing and training group leadership, and also receiving feedback from the groups so that leadership could get better information of where anxiety seemed to come from, and what steps might be working and which ones not, then progressive honing in on effective responses would be enabled.  I would make the network of information flow very visible, and publish continuous summaries on line of what information is flowing, and I would make sure that it is not just information qua information, but information that can lead to action.  

Then, I would publish exactly what actions are being taken on the information.  Students don't just want sloppy kisses of love, they want actions.  An antidote to anxiety is agency.  Is the information being translated into action?  That's the responsibility of the Administration.  In retrospect, wouldn't the administration of Clark Kerr have wished they would have known what the problems in the student body were beforehand, and moved to solve them?  Studying history can lead to improved actions.

The reports of food insecurity are very credible.  If I ran the zoo, I would declare that food insecurity is not an individual problem, but a systematic one, and that the system would be taking responsibility.  There are many ways to get people food.  I would use them.

The housing problems are well known.  If I ran the zoo, I would declare that housing is not just an individual problem but a systemic one.  I would make it the University's responsibility to ensure that decent housing would be available to all at a decent price.  It might involve a severe system change, including University housing registration and allocation of privately held places, and reduced enrollment when sufficient housing could not be located.

Yes, both of these steps on food and housing might be viewed as decreasing student responsibility and learning how to cope in the modern world.  They might be socialistic in tone.  On the other hand, to my way of thinking, it should never have gotten to this stage in the first place.  Is their a better solution?

Medical services have already been decentralized, we heard at the panel discussion.  Counseling and medical attention to mental health are important.  It would be useful to combine the group efforts with these medical efforts and have a continuum of general group, therapeutic group, and individual therapy for anxiety, and for other conditions that warrant attention.  Medical administrators know the difficulty of categorical programs, and how they need to be integrated with comprehensive services.  This common medical administrative problem would be a good reason to include a clinical administrator on the leadership team.

Richard and his group have done a service for UCB and for the university communities nationwide in documenting and highlighting this now apparent epidemic of anxiety in their midst.  There are many research avenues to pursue; further facts would be important.  But it is important to act now.  It is the time for administrative excellence.

One can only hope that the problem is seen clearly and the challenge accepted. 
We shall see.

Budd Shenkin