Minority Rights, Minority Aggression

 

I read Linda Greenhouse’s analysis of the current Supreme Court and Chief Justice John Roberts in the New York Times today: “In its sweeping disregard of history, precedent and constitutional text, the chief justice’s 5-to-4 opinion in the voting rights case was startling for its naked activism….” http://opinionator.blogs.nytimes.com/2013/06/29/the-real-john-roberts-emerges/?hp

So I was thinking.

No state system is 100% democratic.  Even in Athens, it was only men and landholders (I think) who got to vote.  Thus, the US constitution and common practice has many aspects where the rights of minorities can be protected.

In our contemporary Unitec States, one such minority is the monied (and unmonied) White interests, as represented primarily by the Republican Party.  Here are the ways they have protected themselves.

One – the constitution provides that all states shall be represented equally by two senators in the US Senate.  Most of the smaller population states are in the West and South, and they are Republican.  The Republicans are thus over-represented in the Senate.

Two – the Senate has adopted rules that make a super-majority of 60 votes mandatory for many important issues, thus protecting the minority party, which is now the Republican Party.  This rule makes the minority doubly protected in the Senate.

Three – Gerrymandering.  The House districts may be arranged every ten years by the ruling party in most of the states.  Politicians being what they are, most of the districts are now non-competitive by party, and incumbents are the rule.  In addition, and as the power of government in the states was largely Republican in the last iteration, the House Republican majority is likely to continue for many years.

Four – Tactics to disenfranchise voters.  In this last election many states took egregious steps to make voting more difficult for those more likely to vote Democratic – the poor, the elderly, etc.  

Five -- The role of money in politics and government.  Even before Citizens United, raising money for political campaigns had for decades given more and more ascendance to them that has.  

Six – the Supreme Court.  This was designed to be a non-democratic feature of government, with hopefully wiser heads appointed for life.  The Republicans have appointed the majority of the current occupants, all of whom are virulent right-wingers, with the exception of Anthony Kennedy, a man of the Right but with interesting divergences.

Sometimes lack of democracy is a good thing.  Untrammeled democracy could tax the rich beyond recognition and cripple the country.  Time has shown that an independent judiciary is important.  Some of these will change with time.  But as it stands now, the only thing holding up the Republican Party is their tenacious and aggressive pursuit of a minority agenda by any and all means. 

I guess everyone realizes this, but it's nice to put it down and look at it.

Budd Shenkin

Swedish and US Health Care - Professor Frank's Ideological View

If you are an economist, you have been raised to think that your tools can be applied all over the place.  If you are an economist and a newspaper columnist, your weekly obligation will lead to an uneven output, shall we say.  And so it is with Cornell professor of economics Robert Frank and his weekly column in the Sunday New York Times business section.  My son Allie has brought today’s column to my attention: http://www.nytimes.com/2013/06/16/business/what-sweden-can-tell-us-about-obamacare.html?ref=global-home&_r=1&

Professor Frank is spending a month in Sweden – that is the professorial gig, is it not?  (Full disclosure – my neurosurgeon father Henry Shenkin used to get red in the face decrying the traveling predilections of professors while he, Henry, did real work with real people under hard conditions.  Programmed as I am, it’s hard to forget his feelings as I hear about the visiting professor gig.)  While there, he asks health economist friends about the Swedish health care system.  Having lived in Sweden for a year doing research on their health care system, and having published about it twice in the New England Journal of Medicine decades ago, and having followed health policy in the US for decades, this is something I know something about.  So when Professor Frank takes out his economics glasses, and opines on the comparison of the Swedish health care system with American care and Obamacare, my critical faculties are engaged.

What I find is an ideological view of a liberal economist that seems to combine a very superficial knowledge of both systems.  Pretty much what one would expect from someone on vacation – I mean, visiting professor – for a month and shooting the shit with colleagues.

First, the Swedish health system is not ridden with bureaucratic inefficiencies, they say, so Frank opines that Americans shouldn’t fear it either.  Oh, yeah?  So if Swedish government can run it, then American government can, too?  That’s not worthy of Frank.  And he completely glosses over the fact that the power over health care for the 9 million population in Sweden is in the Landstings, the county governments.  How would that translate to the US?  No answer needed.  The capacities of governments in different countries are different.

Second, compare infant mortality rates and male death rates between ages 15 and 60, and America comes out short, which to Professor Frank is an indictment of the United States health care system.  That’s a poor argument.  Infant mortality does little to measure differences in health care systems in advanced countries.  What it measures more is economic disparities, and the US has a lot more poor people than Sweden.  As to the male death rate, there is recent evidence on this, which I think I have shared on this blog.  The increased death rates for Americans has to do with violence, suicide, and motor vehicle accidents, none of which are attributable to the health care system.  It does have to do with availability of guns, I imagine, and most importantly with the number of miles traveled by car, which is much more in the US than in Sweden.  After the age of 50 death rates of Americans are comparable to the most advanced countries.  So the argument of poorer quality because of the organization of health care does not wash.

OK, after indicting the health care system on these flimsy statistics he recants in the next paragraph, but in a silly way.  He says that more Swedes commute by bicycle and thus avoid obesity – actually, the public transport system is the real difference, and obesity is not the issue, accidents are the issue.  And he mentions the income disparity.  But doesn’t this destroy his argument in the paragraph before?  Poor show.

Third, he commends Swedish large hospitals for efficiency, and condemns American “boutique hospitals” for people with high cost health plans.  This is crap.  The US has a lot of big hospitals, and many of these are the worst offenders in cost – see UCLA, for instance.  The problem with American health care has something to do with efficiency, but more to do with prices.  The largest hospitals in the US command higher prices because of their mini-monopolies in local areas.  And the proliferation of under-utilized, high cost machines is less of a problem in the US than it used to be.  The problem here is lack of regulation of technological proliferation and pricing, rather than the size of hospitals.  You have to have either real competition or real regulation, each with its own strengths and weaknesses.  Sweden has state ownership and control.  The problem in the US is we have neither effective regulation nor sufficient competition.

The tip-off on his ideology is in the riff on “boutique hospitals.”  These exist, but they are probably cost-savers.  One important proposal for future health care organization calls for more and more “centers of excellence,” some of which would be these very “boutique hospitals.”  He is just ideological here, thinking that "boutique hospitals" are for the affluent only.  Get Medicaid payments to competitive levels, and make Medicare payments rational, and there would be no problem.

Fourth, he says Sweden centralizes care so that more operations are carried out by more experienced facilities and surgeons.  That’s true, but this happens in the US as well.  Frank notes parenthetically at the end of the article that there can be a three-month wait in Sweden for a hip replacement, but says this is acceptable as a trade-off for centralization.  Maybe it is, but what other inefficiencies from the patient point of view are there?  I don’t know since I haven’t been there in a long time, but I guarantee they are there.  I remember, for instance, talking to Swedish friends about their primary care.  I said that with the polyclinic system there had to be a decrease of personal relationships.  Yes, they said, but isn’t objectivity a good thing, too, not to be swayed by the personal relationship?  I don’t think Americans would agree.  Centralization has its problems that the Swedish system has tried to address by introducing elements of competition – but we don’t hear any of that in this article.

Fifth, he says that since Swedish care is non-profit and they are charged with high quality mission, they won’t withhold care, as for-profit institutions in the US will.  Whaaa?  The problem with for-profit is supposed to be doing too much, not too little!  And the problem at Kaiser, a large non-fee-for-service institution, is withholding care.  Frank is severely off track here – it’s just ideology talking.

Sixth, more hip-replacements in Sweden are attributed positively to the fact that the system is well funded and care options are generous.  But his argument is heads I win tails you lose.  If there were fewer hip replacements, he would say this is evidence of runaway profit-mongering by operation-hungry surgeons and institutions in the US. I think I know what he is trying to say here, that despite the capacity of a state system to withhold care for financial reasons, that doesn’t seem to be happening in Sweden if you take this one operation as a measure.  But just citing one operation as a proxy for generosity and quality doesn't work.  For all we know, all those hip operations could be a result of the pressure from the Swedish orthopods who want more and more work for their cadre, and more and more residents – who knows?

I happen to be a Swedophile, and I think there is much in Sweden worth emulating.  If we were Swedes, it would probably work very well.  We can certainly learn from some elements.  But to gloss over bureaucratization on the say-so of Swedish economists reveals the essence of his one-sided view.  And I hope I am not defending the American health care system, which needs revolutionary change and is not likely to get it.  But ideological columns like this are not likely to advance the cause.

Like my father, it gets me so mad when somebody thinks he is so smart he can plop himself down for paid-for month in a foreign country and talk to some economist friends, and come up with something worth saying in a New York Times column.  I’m sure he’s smart, and he is probably a nice guy, and our ideas on health care are probably not very different, but this article is, well, let’s just say, not fully thought out.

Budd Shenkin

The Only Priority -- Climate Change

Why are we all on earth any different from the Titanic?

We are all together headed toward a common fate, albeit with different levels of comfort along the way.  In fact, we on Earth are even more isolated than they were on the Titanic.  We are as confident as they were in the indestructibility of our world, in our case because we have always been safe so why would it change?  They were assured they were safe, despite iceberg sightings, because the Titanic was unsinkable.

From that perspective, as we go about out daily lives with concerns for winding down wars, instituting a new health care system, fixing economics, we are rearranging the deck chairs, because just as the Titanic was sailing toward an iceberg and discounting the danger because they were unsinkable, we are sailing toward climate change, aka global warming, aka a disaster that will disrupt severely the world as we know it.

Why don’t we pay more attention?  Why is it number 17 or something on the concerns of Americans?  Are we the proverbial frogs in the gradually heating water which will be boiled slowly?

Jared Diamond observed in Collapse that humans arriving on a previously uninhabited island will kill and make extinct all the large animals and some of the small ones, and cut down all the trees, and thus establish their own demise or devolution into abject poverty.  Why are more modern humans on the island named Earth any different?  In contrast to the islanders, we have modern science which can foretell our demise or devolution.  But the bulk of mankind does not listen.  The ignorant and the selfish – the 90% -- generally just deny.  The science is bad, they think, or the doomsayers discount the power of innovation.  Well, the science isn’t bad, it’s good.  Innovation can’t come fast enough because of the lag in changing greenhouse gases; there is no vacuum cleaner for carbon dioxide, and there will not likely be one anytime soon, especially as population continues to increase and deforestation continues. 

The United States needs to take responsibility.  The advanced countries made the mess and we should clean it up.  But we won’t.  Nor will the aggressive behemoth called China.  It is a sad day when such ignorance and selfishness triumphs.  But there it is. 

I don’t know what I can do individually, certainly nothing significant, and I make my negative contribution as I fly here and there in airplanes.  But what would the difference be if I stopped?  I’m not a saint, but probably we should try to go solar, turn off some appliances in the Hawaii house while we’re not there.  “Raise awareness.”

Obama is smart, although not scientific and certainly not much of a leader of a country let alone the world.  But where the hell is he?  At the very least he could “raise awareness,” do his executive actions, and make the case for the long term – and it’s not even so long term at this point.

Jennifer Granholm has a great and innovative plan, not that it would save us, but it’s something – do a Race to the Top for states to innovate in clean energy, using corporate profit repatriation as a source of funding: http://gspp.berkeley.edu/events/webcasts/a-clean-energy-proposal-race-to-the-top.  She presented it to a group of us the other night, but it was not going to politically popular with Republicans.  And when she presented it to the Obama Administration she was pooh-poohed, it seems.

I just read yesterday in Tom Friedman’s column about the size of Syrian families – 16 children is not unusual.  In the 70’s and 80’s health care improved but the practice of having large families so that some survived has not yet relented.  (I learned about this ironic phenomenon of health improvement leading to more population and subsequent increased impoverishment in medical school, in our public health club – it wasn’t important enough to present to the general class, I guess.)  Adjustment takes time, and there are thus many more souls on our small planet to run out of water, food, and probably firewood – although not coal perhaps.  Nothing makes people more desperate and angry and violent than hunger.

The dystopian future continues to beckon.

Budd Shenkin

Obama - View to the Future

 

Many of us have felt that Obama is a rather ineffectual President, not able to take the offensive and rally the troops.  President Bystander.  Maurine Dowd is an outstanding avatar of this view.  (See also today’s post from Not Running a Hospital on leadership and Obama -- http://runningahospital.blogspot.com/2013/05/a-continuing-display-of-weak-leadership.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+blogspot%2FmJlm+%28Not+running+a+hospital%29.)  My own view has been that, aside from his inherent elitism and probable introversion and inability to meet and have fun with other people he doesn’t know well, he reached high office too soon.  He hadn’t met enough people to know whom to appoint where, and he hadn’t found out yet how the game works in Washington.  An anti-LBJ.

On the other hand, my friend Michael Nacht says there is nothing he can do.  In the first term it was crystal clear that the Republican game plan was to oppose everything strenuously, even what were previous Republican positions.  Michael thinks that this mindset continues, that it’s all politics and nothing but.  The failure of the Democratic leadership to reform the Senate rules to make a filibuster be a real filibuster as of old – thanks Carl Levin! – simply nailed the coffin further shut, as has the failure of Democratic leadership to arise more broadly.  Maybe this view is right, I don’t know.

That being said, one has to acknowledge, as was brought forward pre-election, that the list of Obama accomplishments is more impressive than immediately comes to mind.  Can’t list them now, because they don’t immediately come to mind, but repealing Don’t Ask Don’t Tell was one of them.  (Transparency in government, honor to whistle blowers, and freedom of the press are not among them – Eric Holder sucks.  I saw a comparison to Alberto Gonzalez today, as someone who holds on to his job because he retains the “confidence of the President” … that’s a “wow” moment.)

Other people say that Obama is actually meeting his goal, which was to exceed the record of the two previous Presidents, to get us out of instead of into wars, and not to have a sex scandal.  Low the bar might be, but passivity actually helps him meet these goals.  Who knows what thoughts lurk in the mind of the President?  The Shadow?

Nonetheless, say that Obama’s domestic accomplishments will be low in this term.  Say that his foreign accomplishments will be low profile and subtle.  What should Obama do to make his positive impression on the history books? 

I have what would have to be a very unpopular suggestion – form commissions and make plans for the future!  Set the future agenda!  That’s right, you heard it first here.  What could be more unpopular than commissions?  Those traditional means of doing nothing?  Those producers of paper to sit on the shelves.  Yuuuch.

But, on the other hand, Keynes said: “The ideas of economists and political philosophers, both when they are right and when they are wrong are more powerful than is commonly understood. Indeed, the world is ruled by little else. Practical men, who believe themselves to be quite exempt from any intellectual influences, are usually slaves of some defunct economist.”

I’m not asking for something so deep as that, philosophy.  But what about producing very official documents that might influence the future, the Obama Project.  The most prominent problem has had a commission, the Simpson-Bowles Commission on fiscal responsibility.  I don’t agree with it, actually, and I would get a successor, Simpson-Bowles II, and have it headed by Krugman and joined by Bernanke after he leaves office and Stiglitz maybe.  And add George Schultz for balance.

The most important problem we face, as opposed to the seemingly most urgent, is climate change.  Get an official commission and plot out a way that developing economies can develop, China and India can get enough energy to continue rapid growth specifically, new technologies can develop rapidly, what can be done internationally, etc.  There are lots of plans around, but get something ex cathedra.  Best and the Brightest, however discredited that may be, but policy informed, not self-inflated like the guys who got us into Vietnam.

You can think of four or five other commissions on other issues pretty easily, I bet.  And then, a commission on commissions – what are the priorities?  I go after climate change first, but maybe that’s not right.  Maybe you would want to attack lower hanging fruit first, though I doubt it.  The C on C would figure out how to orchestrate the accomplishment of the goals of the commissions.

Yes, this is the piest in the skiest proposal one could think of, ridicule-beset even as I write this.  But it wouldn’t have to be a centerpiece of the Administration.  It could just be a series of commissions that would be billed as an experiment in governance.  At least the vision would be lifted from shoe tops to horizon.  Call me a wonk, call me pointy headed.  Hey, that’s not so bad!  At least I’m thinking.

Budd Shenkin

Genetic inheritance

The growth of genetic analysis is a wonder to behold.  My father observed that he had personally witnessed and participated in the most profound change of technological culture the world had ever seen.  He was born in 1915, when the major means of transportation in Philadelphia was still the horse.  He died in 2007, 38 years after man reached the moon, not to mention the much-noted invention of Saran Wrap.

I graduated from med school in 1967.  We did know about DNA and genetics in general, very general.  We knew very little about immunology, maybe up to chapter 2 of a now 50 chapter book, I'd guess.  Pharmacology was still utterly empirical; no one thought through genetic makeup; no one figured out which molecules would glom onto which receptors on a cell wall, I think.  It was still so totally hit or miss.

The story of anthropology was also aborning in that time.  Africa had been identified as the origin of man, but from pure fossil evidence from the Olduvai Gorge, not genetics.   The path of migration hadn't been identified; that would have to await genetics.  Now we know that Africa holds the greatest genetic heterogenicity in the world, which is evidence for being the place of our origin.  We can also pinpoint the female inheritance side, the male inheritance side, and trace the migration of groups.

And now, totally amazingly, for less than $200, or in my case totally free since I got it as a Christmas present, you can take a little sample of your inner cheek and send it to the Genographic Project and receive back the story of your heritage.  To summarize my story, my genetic makeup is 58% Mediterranean (surprise!), 21% Southwestern Asian, 18% Northern European, and 2% Northeast Asian.  My hominid ancestry is 2.2% Neanderthal, and 2.5% Denisovan!!!  My closest matches are Iranian and Sardinian (?).  Probably should visit those two places as a "homecoming."

Go to genographic.nationalgeographic.com and look around.  It's a new world in finding out about the old world.

Budd Shenkin

Are The Democrats Blowing It Again?

 

Six years in office and 2006 brings a stinging Republican defeat, because the Republicans blew it.  They could have consolidated their victory if they hadn’t been so incompetent. 

Two years in office in 2010 and the Obama forces are routed.  Obama’s whole career shows the fruits of Republicans blowing it, not to diminish the undoubted campaigning expertise and energy of Obama.  Bobby Rush was his last really credible opponent who didn’t blow it.  But in office, their trumpet becomes a weak reed, they don’t know how to put spine in the country, the stock market reels and Obama says hardly a word – he is an economic illiterate, which doesn’t help, and the advisors are poor.  So they lose big time.  Lost the big mo.

2011-12 – Republicans have it in the bag, an incumbent never having won with such weak jobs numbers.  OK, good Obama campaign, smart, smart on the ground electronic cyber campaign.  But, the Republicans field the worst set of candidates this side of Mad Magazine.  Even then, weak as Romney and the Republicans were, they probably would have won, were it not for the 47% video, and other self-immolations.  Did Obama win, or did Romney lose?  It was a cooperative effort.

Cut to my taxi ride home Sunday night.  My voluble but eloquent Pakistani driver, age perhaps 50, inquired about my trip, and as I told him about the Academy of Pediatrics and my worries about Obamacare, he averred that he was strongly for it.  “People need insurance,” he said.

He makes about $60,000 a year,  “I’ll get it, right?” he said.

I said that my best guess, not knowing as much as I would like about the plan – which shows something in itself, since it is my field and I am not lazy about getting information – would be that at that level of income he would have to pay about half of the cost of insurance himself.  That took him back a bit.

Then I said, it’s not certain that your family would be covered.  A recent IRS decision was that for an employed individual, if the cost of the insurance policy for just the employee would be 9.5% or less of his or her income, the insurance policy would qualify.  But the cost of family coverage could be much more.  In this case the penalty for not getting insurance would not be applied.  In other words, for a substantial section of the employed public, families would not be covered.  This was what I hoped for as a business owner, which I no longer am, since I thought it would damage my business.  As a citizen, a Democrat, and a health care policy analyst, I think it’s ridiculous if families won't be covered.

So it’s possible my taxi driver, if he is an employee, could have his family out in the cold.  He said to me, “You are making me nervous.”  I told him I was nervous myself.

Here is a man who is telling his friends that Obamacare will be a good thing.  Will his hopes be dashed?  Will his friends turn on him and say, “See?  You were foolish to be taken in by the government and the politicians.”

It will all be coming down in 2014, which I know I needn’t remind you, dear reader, is a midterm election year, when the party in power is at maximum risk.

Recall the conversation in the Theda Skocpol seminar last week, where the gathering speculated as to why the “good news” of Obamacare hadn’t swept the nation, and why the Democrats hadn’t trumpeted more strongly.  My own diagnosis was incompetence.  Who would trumpet?  Obama doesn’t know details, and he is only responsible for a clarion call now and then.  Nancy Pelosi is not articulate, although she is a hero of mine.  Harry Reid?  Sibelius does talking points only and not very convincingly.  There is no one from the White House.  We are getting sounds of silence.

What we need is management of expectations.  There needs to be a knowledgeable, articulate spokesperson.  Probably Don Berwick hoped to be that person, but he was banished by the Republicans.  Daschle probably wanted to be that person also.  But in fact, the Democrats never found that someone.  The advantages of Obamacare need to be highlighted now, one by one, as they come in, and the challenges they are facing and hoping to overcome, and a play by play recitation mixing hope with reality.  Hope and progress needs to be heralded by trumpets and drums.  Instead, what we will get is a denouement that startles everyone with the deficiencies, and leaves the taxi driver embarrassed and embittered, and leaves the Democrats with a 2014 that resembles 2006.

And health reform?  I think it’s here to stay, but enthusiasm and appreciation of the positives would sure make for a better entrance than disappointment in the inevitable deficiencies.

Anyway, that’s my fear.

Budd Shenkin

More Incompetence

OK, two posts in one day.  New record. 

Here is another note from Kaiser Health News - http://www.kaiserhealthnews.org/Stories/2013/April/09/consumer-groups-protest-administration-delaying-out-of-pocket-limits-caps.aspx. 

Consumer Groups Fear Patients Could Be Hit With Large Out-Of-Pocket Costs.

Why will this happen?  Because the Administration has not yet figured out - they have only had three years - how to adjust employers' arrangements for health insurance that combines multiple policies.  Health plans and employers ask for a delay, and they get it with no comment from HHS.  I have heard the excuse - seriously - that while the government was not sure how the lawsuits against the constitutionality of PPACA would come out, they were reluctant to allocate resources to preparing for implementation.

Really?  Do I hear the cry of further incompetence?  You would think, if PPACA is the "signature statement" of the Obama Administration, it would not be government business as usual.  It is just disheartening.

Budd Shenkin