Wednesday, April 23, 2014

Bringing a fire extinguisher to a flood

A few days ago,  a friend sent me a 297-word graduation speech by economics Nobel laureate Thomas Sargent, delivered in 2007, that's been making the rounds. The speech consists of twelve precepts, delivered with economists' economy, that have been hailed as a distillation of "everything you need to know about economics," as Ezra Klein -- too fond of such sweeping overstatement since launching Vox -- put it.

The piece rubbed me the wrong way, not because its precepts are not true, but because their uber-message seems out of step with our slow-growth, post-meltdown, austerity-hog-tied economy. The upshot, as Josh Barro summarizes it this morning, is that there's no free lunch. The two bullet points that bugged me in particular  were these:
4. Everyone responds to incentives, including people you want to help. That
is why social safety nets don't always end up working as intended.

5. There are tradeoffs between equality and efficiency.
To take the second first: sure. But as we've learned in the last few years, there's also tradeoffs between inequality and efficiency. When the top 1% grab 95% of the fruits of growth, they tend to 1) use their outsized capital unproductively, increasing their rents, 2) hollow out their customer base, and 3) extend their control over the political system, eroding checks on their own power and ensuring their further corruption.

Tuesday, April 22, 2014

In December 2008, support for ACA linchpins was broad and shallow

As the Affordable Care Act's first open enrollment season wraps up with a major surge, the law's implementation remains as polarized as public opinion and party rhetoric. States that ran their own exchanges and accepted the Medicaid expansion reduced their uninsured populations by three times as much as states that abstained on both counts, according to Gallup polling. California and Connecticut reached 175% of the CBO's projection for first-year private plan signups; Oklahoma, just 28%, according to Charles Gaba's spreadsheet. Meanwhile, as Obama declared, "the repeal debate is and should be over” and “the Affordable Care Act is working," Republicans geared up once again to make repeal and denigration of the law the centerpiece of their election strategy.

At this juncture, after five years of political mortal combat, it's instructive to look back at Americans' reactions when first confronted with the proposed core provisions of the ACA. The Kaiser Family Foundation probed opinions about those measures back in December 2008, polling over 1600 adults (thanks, Larry Levitt). By that point, the prospective law's outlines were clear, as all three Democratic candidates had proposed similar healthcare reform plans.

At first blush, respondents were enthusiastic about the mechanisms for expanding private-market health insurance: requiring employers to cover employees, and requiring individuals to buy affordable coverage. When asked to consider potential consequences of those mandates, however, respondents turned ambivalent.  The poll results might have been read to provide cover to Democrats to move forward. But they also pointed to multiple entry points for Republicans to exploit the pending legislation's tough tradeoffs.

Monday, April 21, 2014

Liberal Dem, Conservative Doc

As a front-page blogger at Daily Kos and creator of the site's popular Daily Pundit Roundup, Dr. Greg Dworkin (f.k.a.DemFromCT, now blogging under his real name) is a high-profile political liberal.  On Twitter, he is an enthusiastic if scrupulously evidence-based proponent of the Affordable Care Act, defending the efforts it embodies to extend access, control costs and improve quality in healthcare delivery.

As a pediatric pulmonary physician with nearly 25 years in private practice, however, Dr. Dworkin spontaneously describes his approach to systemic change in the medical delivery system as "conservative."  He is not hostile to concepts such as coordinated care, bundled payments or risk-based payment -- in fact he has adapted to many changes along these lines over the course of years. He just sees innovations on this front as incremental and experimental -- and to be judged on the basis of evidence that's not in yet.

Dr. Dworkin's thinking about healthcare reform is also, to a degree, conservative in a more political sense. While he sees no clear benefit as yet from reforms in the way doctors and hospitals are paid, he does witness patients growing ever more cost-conscious as health plan deductibles rise and prescription drug coverage grows more restrictive. In a recent discussion of what healthcare reform looks like from the physician's point of view, he placed more emphasis on the effect of newfound cost-consciousness in patients than on changing incentives for doctors.

As with bundled payments, he said, the advent of consumer cost-consciousness is "a process that's been happening for a long time -- it predates and goes in parallel with the Affordable Care Act."

Sunday, April 20, 2014

Program note

Blogging has been slower here because I'm working on two reported pieces. One, which I'll post tomorrow morning, is an interview with  Dr.Greg Dworkin, pediatric pulmonary physician and headline Daily Kos blogger, exploring what efforts to control healthcare costs look like from a physician's standpoint. While obviously politically liberal, Dr. Dworkin, like most doctors, is an empiricist and therefore "conservative" in the sense of requiring evidence before crediting any given reform measure.

Happy Easter, everyone. I gather it's all about "chocolate eggs and Jesus risen," as C.S. Lewis once heard a 4 year-old murmuring to himself.  In metro New York this year, it's also all about glorious sunshine and refreshingly cool breezes.  So here's to worshiping outside.

Wednesday, April 16, 2014

Racism in service of plutocracy: Beutler's response to Chait

Jonathan Chait's two-front argument that 1) the Republican policy platform has deep roots in slavery and racism, but 2) Democrats are too quick to ascribe racism to individual conservatives, their policy positions and utterances, angered a lot of progressives, who see false equivalence as well as neglect of the real effects of conservative policies on African Americans and other minorities.

On the false equivalence front, Brian Beutler argues that Chait has mischaracterized progressives' case that the Republican gestalt is racist:

Tuesday, April 15, 2014

Tell me your ACA-shopping story

Always fair-minded, Jonathan Cohn pauses in his celebration of lower-than-forecast ACA premiums (as highlighted by the latest CBO update) to acknowledge:

In the transition from the old system, in which insurers could charge higher prices to the sick or avoid them altogether, to a new system, in which everybody pays the same price regardless of pre-existing condition, some young and healthy people must now pay more for their individual policies
The "and" in "young and healthy" is interesting, because, as the conjunction suggests if you look twice, it's not just the young who are paying more under ACA rules. Some if not most healthy older buyers who were in the individual market in 2013 are now paying more -- that is, if no one sharing the insurance has a preexisting condition.*

If you're in the individual market and you're paying more for your insurance in 2014 than you did in 2013, I'd like to speak to you (or, for that matter, if you're unsubsidized and paying less or about the same).  I'd like some detail about what your prior policy covered vs. what your current one does -- what were the tradeoffs. (I wrote up two such stories last month, and I'd like to do more.)

Cognitive dissonance on Passover

I suffer from it, as recounted in this June 2011 post:

Jeffrey Goldberg, Excommunicator

Jeffrey Goldberg has ignited a blog conflagration with an attack on Allison Benedikt's coming-of-age tale of her progressive disillusionment with the gung-ho Zionism she sucked up in summer camp. I found Benedikt's  narrative riveting, and Goldberg's critique smotheringly self-righteous.

Goldberg asks of Benedikt: "Does she ever try to answer for herself why Israel exists? Or is she happy to subcontract out her thinking about the most important questions facing Jews first to her camp counselors, and then to her husband?"  It's true that Benedikt's stances on the issues are barely sketched in, but that in itself suggests neither a lack of thought nor of due diligence. Her focus is on how her changing perceptions registered emotionally, not on the data points that caused them. Hers is not a policy piece; it's a chronicle about how she navigated the family mania for Israel -- and later, her husband's antipathy toward the country -- over the course of a decade and a half or so. Benedikt's response to Goldberg makes this point better than I can.

I want to focus on Goldberg's most poisonous charge -- which he saves for last. I think it reveals more about him than about Benedikt:
And then there is a whole set of other questions:  Does she ask herself whether she has a responsibility to make Israel a better, more humane, place? Does she question herself about the consequences of abandoning Israel? Does she think about the sin of the wicked son in the Passover story, and how that sin might echo in her own life? 
Abandoning Israel? Goldberg seems to have derived that idea from Benedikt's kicker at the close. Let's take a look:

Monday, April 14, 2014

Why the South doth prevail (and why to some extent it didn't)

A 1957 essay by William F. Buckley, Why the South Must Prevail, was making the rounds on Twitter last night (thanks to Erik Kleefeld). In it, Buckley pretends to some regard for the ultimate welfare of Southern "negroes" but asserts that Southern whites have the right to preserve their cultural superiority by denying their black neighbors the right to vote --because  "the claims of civilization supersede those of universal suffrage."

That is, southern whites don't want to integrate and so pollute their...culture, so they have the right to keep "negroes" from voting to force them to do.  How can a minority claim to speak for "civilization"? "[T]he White community is so entitled because, for the time being, it is the advanced race."

People well-versed in Buckley's oeuvre and career, and in the legislative civil rights battles of the of the late 50s, will doubtless weigh in with appropriate context and analysis. Lacking more than passing familiarity with the latter and interest in the former, I still think it's worthwhile to note a couple of points that struck me, coming to this cold.