Wednesday, September 30, 2009

If you read one post on health care reform...

let it be Paul Starr's brief history, showing the extent to which the Dems' bills have incorporated Republican ideas floated over the past half century:
...the Democratic proposals are built around the ideas that Republicans used to favor -- those proposals already are bipartisan compromises. Unfortunately, they are compromises with a Republican Party that no longer exists.
This fundamental truth is not only sad but dangerous. It's no particular compliment to the Democrats to note that this country currently has only one viable political party. The Republican Party is right now neither fringe nor mainstream. It's in some volatile liminal zone between the two, a nativist, militarist, authoritarian, Social Darwinian dreamland.

Monday, September 28, 2009

Dispelling dystopian dyspepsia

Gideon Rachman goes dystopian on us with a forecast of international failure on the Iranian front backlit with back-to-the-future foreboding of a new era of blood and iron. In a comment, I try to clear the air via Gary Sick and Roger Cohen's congruent glimpses of a route to a negotiated solution with Iran.

Sunday, September 27, 2009

How to call out a President

The blog Letters of Note posts a 1958 letter from Jackie Robinson to President Eisenhower, calling him out for suggesting for the umpteenth time that negroes be "patient" in the face of discrimination and oppression (h/t Andrew Sullivan).

Whose impulsive reaction to a President's speech does the letter's opening call to mind -- by way of contrast?
My dear Mr. President:

I was sitting in the audience at the Summit Meeting of Negro Leaders yesterday when you said we must have patience. On hearing you say this, I felt like standing up and saying, "Oh no! Not again."
No, Jackie Robinson, who broke baseball's color barrier by dint of superhuman self-restraint, did not leap up on the spot to impugn the President's honor. After the fact, "respectfully," he simply made clear in no uncertain terms (dangling modifier notwithstanding) the pusillanimity, hypocrisy, disingenuity and untenability of Eisenhower's patronizing position:
As the chief executive of our nation, I respectfully suggest that you unwittingly crush the spirit of freedom in Negroes by constantly urging forbrearance and give hope to those pro-segregation leaders like Governor Faubus who would take from us even those freedoms we now enjoy. Your own experience with Governor Faubus is proof enough that forbearance and not eventual integration is the goal that the pro-segregation leaders seek.

How generous that "unwittingly." How incontrovertible the logic. Here's to you, Mr. Robinson.

C.S. Lewis on Matt Latimer

Love or hate his theology or his cultural preferences and prejudices, C.S. Lewis remains worth reading because of his imaginative grasp of human motive. Among the "multiple intelligences" classified by Howard Gardner he had in spades the type that observes its own internal working and extrapolates from self knowledge to psychological and sometimes sociological. Lewis was especially (you might say viscerally, personally) insightful about what he archaically deemed the temptations of 'the world'--the lust to be part of an 'inner ring,' to cede one's moral judgment for a place in the councils of power.

He was particularly scathing about the type of person who's often best adapted to penetrate such circles. This persistent type in his writings came to mind as I read an excerpt and various snippets of the newly published memoir of Bush speechwriter Matt Latimer. Latimer seems to cast himself as the sort tempted into but standing apart from an "inner ring" of ethically and intellectually bankrupt power players -- a disillusioned idealist. But his sneering, trash-heaping tone reminds me of that type itself. Here's a Lewis description from Out of the Silent Planet, of a character who ripens into a primary protagonist of evil:
Devine had learned just half a term earlier than anyone else that kind of humour which consists in a perpetual parody of the sentimental or idealistic cliches of one's elders. For a few weeks his references to the Dear Old Place and to Playing the Game, to the White Man's Burden and a Straight Bat, had swept everyone, Ransom included, off their feet. But before he left Wedenshaw Ransom had already begun to find Devine a bore, and at Cambridge he had avoided him, wondering from afar how anyone so flashy and, as it were, ready-made, could be so successful.
Compare Latimer:
Ed said the president wanted to see us in the Oval Office. The president looked relaxed and was sitting behind the Resolute desk. He felt he’d made the major decision that everyone had been asking for. That always seemed to relax him. He liked being decisive. Excuse me, boldly decisive. The president seemed to be thinking of his memoirs. “This might go in as a big decision,” he mused.

“Definitely, Mr. President,” someone else observed. “This is a large decision."
At one point, during another of our marathon speechwriting sessions, Steve Hadley and Fred Fielding, the White House counsel, let us know that the president needed an FDR line—like “We have nothing to fear but fear itself.” The president had his own suggestion for such a line, however: “Anxiety can feed anxiety.” So we produced a speech with no real information and our FDR knockoff line. Here were some of the kinder reviews: “lackluster”; “there is no news here”; “the president should go away for a while.” The stock market dipped further.
As Treasury started to use the bailout funds to invest directly in financial institutions, Ed wanted to come up with a name for the plan that made it sound better to the public, particularly conservatives who thought this was nothing more than warmed-over socialism. Yes, a catchphrase would solve everything. As we were working on this, Ed called a few of the writers on speakerphone with the idea he’d come up with: the Imperative Investment Intervention. “Oh, that sounds good,” one of us remarked, as the rest of us tried not to laugh. We decided that if a catchphrase must be deployed, surely we could come up with something better than a tongue twister with the acronym III. We started out with dark humor: the “I Can’t Believe It’s Not Capitalism” Plan; the MARX Plan. I suggested that we also apologize to the former Soviet Union and retroactively concede the Cold War.
This is not to suggest that Latimer's characterizations of chaos, off-the-cuff policymaking and cavalier message-crafting in the Bush administration is not accurate in many or even most particulars. But someone who trashes in humiliating detail the majority of colleagues he portrays in an account of 22 months of ultra high stakes work is not what I would call a a reliable narrator -- however emotionally gratifying his judgments may be to outraged progressives, disillusioned conservatives, aggrieved insiders, and other constituencies who recognize the Bush presidency as a disaster.

Thursday, September 24, 2009

We are all boiling frogs

James Fallows objects noisily to the ubiquitous metaphor of the frog that boils to death in a pot of water when the heat is turned up gradually; he calls for alternatives. Andrew Sullivan seconds. Many submissions have to do with smell or noise to which we grow acclimated, and some with gradually increasing one's capacity for pain or discomfort or with gradually deteriorating capacities.

None of these quite wash. What gives the boiling frog metaphor its bite (and it's a good metaphor - that's how it got to be a cliche) is that the frog ends up dead. Unfortunately, the best analogues may be the things that really kill us: clogging arteries, growing cancers. In fact the boiling water is mortality. Every year is a degree.

Battle of the Bush surrogates: Burt trumps Bolton in WSJ

I like this quote selection by the WSJ's Jonathan Weisman, covering the U.N. Security Counsel's unanimous passage of "a nuclear-safeguards resolution drafted by the Obama administration to lay the legal framework for military and diplomatic action against nations that use civilian nuclear technology for military purposes." It captures the whole difference in worldview between the administrations of Bush Sr. and W.

First, John Bolton, Bush Jr.'s never-confirmed "ambassador" to the U.N., fulminates:
It's passing a resolution that doesn't have any impact on the real world that undercuts the credibility of the Security Council.
Next, Richard Burt, arms-control negotiator for Bush Sr., now with arms control group Global Zero. Burt
said similar proposals were put forward by the administration of George W. Bush. But they went nowhere.

"What the administration is trying to do is lay the groundwork for proposals that are formally adopted at the NPT conference next year," he said. "The administration views all this as part of the process of establishing a real international consensus against proliferation."

End of article. Way to frame it, Weisman.

Swallowing the fly in Afghanistan

A moment of illumination in George Packer's profile (subscription required for whole) of Richard Holbrooke and the conundrum he's trying to manage in "AfPak":
James Dobbins, now with the RAND Corporation, couches the problem this way: "There is a gap between the reason we're there and what we're doing. The rational is counterterrorism. the strategy is counter-insurgency."
I'm reminded of the old song:
She swallowed the cat, to catch the bird,
She swallowed the bird to catch the spider...,
She swallowed the spider to catch the fly...
The problem is that the "fly" does need to be swallowed, and there may be no viable direct path, in an environment that breeds flies.

Then too, this conundrum is really always true of counterinsurgency, or rather of an outside power's support/control of a counterinsurgency. You're not there out of benevolence, but to check the empowerment of a force you perceive as malign and a threat to your own security.

DeLay of de land in Congress

Tom DeLay may be a mean, corrupt extremist thug whose chief mission while in power was to sell sell legislation to lobbyists. But that doesn't mean he doesn't know the legislative process:
"The Democrats will do exactly what we always did, rewrite the bill over and over until they give all the members what they need to get to 218 votes. The Senate will do the same thing." It will, he predicts, be a straight party-line vote, and "maybe a few Republicans voting for it, but not many."
Right on cue, the Times today reports that Senator Bill Nelson, Democrat of Florida, is getting hammered by seniors up in arms about planned cuts in subsidies to Medicare Advantage providers, and is in turn holding out to have those cuts eliminated or scaled back. The Times' Robert Pear notes the likely effect if Nelson succeeds:
Approval of the amendment could invite other Democrats to ask for similar deals that might make the bill more palatable to their constituents, but more costly as well.
So we'll see what happens to all those lovely cost-saving measures in the Baucus bill that led the CBO to score it better than deficit-neutral.

The Times article also highlights the many channels of corporate influence. Nelson has received substantial contributions from the insurance industry, health professionals and pharmaceuticals -- a total of over $1.6 million, putting him at about #14 among Democratic senators. But he's being pressured also by seniors in Medicare Advantage programs (remember, he represents Florida), put up to it by their insurers (e.g., Humana), who are scaring them with letters that the Obama administrations calls "misleading and confusing." Ah, democracy...

As a footnote, one under-reported element of the health care debate is the performance and value (or lack thereof) offered by Medicare Advantage programs. The subsidies paid to Advantage providers have been targeted and denounced. Some programs have been flagged for misleading representations of benefits. Obama has implied that Advantage programs provide nothing of substance that seniors can't get from traditional, fee-for-service Medicare. At the same time, the programs should at least have the potential to implement many of the cost-saving measures touted by the Administration - global payment systems, preventive and wellness care, teams of doctors that communicate with each other. I'm going to see what I can scare up on the topic.

Tuesday, September 22, 2009

Is Obama trying to force a unity government in Afghanistan?

On Sunday night, I noted that in his Sunday talk show blitz Obama seemed to offer a new rationale -- or a new emphasis in that rationale, at least -- for why he ordered fresh troops to Afghanistan in March:
I did order 21,000 additional troops there to make sure that we could secure the election, because I thought that was important. That was before the review was completed. I also said after the election I want to do another review (my emphasis).
Is Obama hesitating at the brink of escalation, holding back General McChrystal's report and request for additional troops, because the Afghan election was such a balls-up? Note that Obama not only tied his March decision to securing the election but implied that the subsequent review would be focused in large part on the election results.

Could the pause be an act of brinkmanship against Karzai? Will there be a sequence in which an Afghan unity government is announced, and then the administration announces a troop increase? Or is Obama simply preparing to cut bait?

Monday, September 21, 2009

Three legs of financial reform

Today, two columnists tout two pillars of bank reform, each worrying that fearsome bank lobbying will bend the Obama administration's resolve.

In this corner, Clive Crook urges the G20 to follow Geithner's proposals and act in concert -- so that banks cannot forum shop -- in raising capital ratio requirements and a cap on total leverage for systemically important banks:
The global finance industry is in no position, yet, to mount a vigorous campaign against changes which, if they are adequate, will implicitly tax its growth. That is what higher capital requirements would do, and is precisely why they are needed. Checking the industry’s expansion must be seen as an aim of policy, not an unintended consequence.
And over at the New York Times, Paul Krugman insists that the sine qua non of true bank reform is compensation reform (as proposed back in January 2008 by Raghuram Rajan) -- retooling the current massive incentives for bankers and traders to take excessive risks :
According to recent reports, the Fed’s board is considering imposing new rules on financial-firm compensation, requiring that banks “claw back” bonuses in the face of losses and link pay to long-term rather than short-term performance. The Fed argues that it has the authority to do this as part of its general mandate to oversee banks’ soundness.
I wonder whether a third leg of the stool -- Obama's proposed banking consumer protection agency -- may not be the most important of all. No one seems to be paying much attention to this -- except the banks, which are vociferously opposed. Krugman nods toward this proposal, but also dismisses it as only "the beginning of reform."

Hmm. Notwithstanding the complexities of securitzation, credit default swaps, and capital ratios, it was a simple failure of consumer protection -- tolerance of massive underwriting fraud, abusive loan products like negative principal loans, incentives for loan officers to put people into higher-interest loans than they qualified for -- that blew up the credit bubble and provided the toxic material for all those toxic securities that brought the banks low and triggered the credit default swap obligations that threatened to bring the whole financial system to its knees.

That's not to say that banks could not find other stupid risks if they were prevented from deceiving retail customers and offering them excessive credit. Pay incentives and capital ratios are crucial, too. But if consumer protection is merely a "first step," it's also a first priority.

Sunday, September 20, 2009

Is Obama signalling no more troops to Afghanistan?

Slightly distorting Obama's words in the retelling, George Stephanopoulos headlines a blog post about his interview with Obama aired this morning:

President Obama: "Skeptical" on More Troops for Afghanistan

That's almost but not quite true. Per the exchange below, I think Obama was characterizing himself generally as "skeptical" when fielding military requests for more troops - skeptical as a matter of principle and habitual procedure.

Which is not to say that Stephanopoulos was not picking up a genuine signal. What struck me, below, was the way Obama characterized his March decision to send 21,000 more troops to Afghanistan:

STEPHANOPOULOS: You were for a flexible time line in Iraq. Some people now are saying that's exactly what should happen in Afghanistan if the same conditions hold. Do you agree with that?

OBAMA: Here's what I think. When we came in, basically, there had been drift in our Afghan strategy. Everybody acknowledges that. And I ordered a top to bottom review. The most important thing I wanted was us to refocus on why we're there. We're there because al Qaeda killed 3,000 Americans and we cannot allow extremists who want to do violence to the United States to be able to operate with impunity.

Now, I think we've lost -- we lost that focus for a while and you started seeing a -- a classic case of mission creep where we're just there and we start taking on a whole bunch of different missions.

I wanted to narrow it. I did order 21,000 additional troops there to make sure that we could secure the election, because I thought that was important. That was before the review was completed. I also said after the election I want to do another review. We've just gotten those 21,000 in. General McChrystal, who's only been there a few months, has done his own assessment.

I am now going to take all this information and we're going to test whatever resources we have against our strategy, which is if by sending young men and women into harm's way, we are defeating al Qaeda and -- and that can be shown to a skeptical audience, namely me -- somebody who is always asking hard questions about deploying troops, then we will do what's required to keep the American people safe.

Those troops were sent "to secure the election"? I don't believe that the stated rationale was that circumscribed when the deployment was announced. The reinforcements were sent to staunch an acknowledged deterioration in the fight to contain Taliban influence. Moreover, the effort to "stabilize" the election is universally acknowledged to have failed to prevent massive election fraud.

Does that retroactive mission-tightening suggest a current reluctance to commit more troops?

Political fantasy hour

This Sunday's op-ed section in the Times includes two well-informed proposals for radical reform that will never happen, at least not any time soon. One is Tom Friedman's endlessly-reiterated call for a $1/gallon Federal tax on gasoline - an idea so eminently sensible that he's right to have spent decades rolling that stone up the hill. The other is economists Peter Boone and Simon Johnson's proposed five-year revolving door ban between Wall Street and the Federal government -- a ban not just on lobbyists moving back and forth, but financial executives too. This strikes me as a bit extreme, not to say Utopian -- some foxes do make good henhouse guards.

Reading the two policy wishes in tandem set me off on an "if I were king of the forest" fantasy. If I could change U.S. policy by fiat, what would I do? What's politically impossible but eminently sensible? For starters, I think Freidman is dead right -- taxing gasoline has made sense to me ever since Rep. John Anderson proposed it in the 1980 presidential campaign. A few other strays:
  • Ban political advertising. I've always thought the free speech defense was bullshit. The Constitution guarantees free speech, not the right to pay to broadcast your speech. e. I realize there's a long line of legal precedent on this issue, but I think it went in the wrong direction. Political advertising undermines real political discourse.

  • Single payer health insurance: all of the planned reforms to "bend the curve" on health care inflation would be more effective if the government were the only payer. The health insurance industry is parasitic -- it adds nothing constructive to health care delivery. Whatever Rube Goldberg system we patch together will be inferior to Canada's "Medicare for all."

  • End the subsidized private student loan industry: this is one more financial sub-industry that's purely parasitic - subsidized to exploit the young and squeeze profits out of government money directed to a social end.

  • Tear up the college "529" savings programs: I'd love to see the legislative/lobbying history of this boondoggle, in which each state hands a captive market over to a particular mutual fund company or handful of mutual fund companies, which offer a limited menu of investment options offered tax protection in that state. Who can tell me why college savings accounts are not structured like IRAs, allowing investors to qualify for the tax break while investing in whatever vehicles they choose?
This list should be far longer, but I'm sticking to pet peeves and no-brainers. So much for my shallow Sunday morning thinking for a Sunday morning.

Saturday, September 19, 2009

The crown jewels of health care cost-cutting

Ron Brownstein has an important post that details the substantial cost-control measures in the Baucus bill that led CBO to score it as a deficit reducer over the long term. The measures, Brownstein notes, center on two themes: "shifting the reimbursement model away from volume to value, and encouraging physicians to work more closely in teams to manage the overall health of patients, particularly those with expensive chronic conditions."

The Baucus bill would also create an empowered oversight commission, the "MedPAC on steroids" that Obama has emphasized as the chief mechanism for sifting, improving and expanding the cost control measures seeded in the bill. Brownstein:
The bill creates a second new institution that could be even more important: an independent Medicare Commission, as Obama has proposed. The commission would be required to offer proposals for cost-savings whenever Medicare spending rises too fast and Congress would be required to give their proposals fast-track consideration. The commission would likely become a vehicle to move into law the most promising payment and coordinated care reforms that emerge from the tests and pilot programs that the bill's other provisions set in motion. "If it develops into a respected independent body it could be one of the most significant parts of this legislation," said the senior administration officials. "I think that's the most auspicious path forward for promoting fundamental reform."
Compare Obama, speaking to Washington Post editor Fred Hiatt in July:
At this point, I am confident that both the House and the Senate bills will contain what we've been calling MedPAC on steroids, the idea that you continually present new ideas to change incentives, change the delivery system, understanding that because this is such a complex system we're not always going to get it exactly right the first time, and that there have to be a series of modifications over the course of a series of years, and we have to take that out of politics and make sure that an independent board of medical experts and health economists are providing packages that are continually improving the system. So I think there's general consensus that that is one of two very powerful levers to bend the cost curve.
Note the gradualism. That's not pusillanimity; it's recognition that our current payment system is a huge battleship that can only be turned by degrees. Compare Atul Gawande, who did so much to spotlight payment incentives as a core driver of health care inflation:
McAllen and other cities like it have to be weaned away from their untenably fragmented, quantity-driven systems of health care, step by step. And that will mean rewarding doctors and hospitals if they band together to form Grand Junction-like accountable-care organizations, in which doctors collaborate to increase prevention and the quality of care, while discouraging overtreatment, undertreatment, and sheer profiteering. Under one approach, insurers—whether public or private—would allow clinicians who formed such organizations and met quality goals to keep half the savings they generate. Government could also shift regulatory burdens, and even malpractice liability, from the doctors to the organization. Other, sterner, approaches would penalize those who don’t form these organizations.

This will by necessity be an experiment. We will need to do in-depth research on what makes the best systems successful—the peer-review committees? recruiting more primary-care doctors and nurses? putting doctors on salary?—and disseminate what we learn. Congress has provided vital funding for research that compares the effectiveness of different treatments, and this should help reduce uncertainty about which treatments are best. But we also need to fund research that compares the effectiveness of different systems of care—to reduce our uncertainty about which systems work best for communities. These are empirical, not ideological, questions. And we would do well to form a national institute for health-care delivery, bringing together clinicians, hospitals, insurers, employers, and citizens to assess, regularly, the quality and the cost of our care, review the strategies that produce good results, and make clear recommendations for local systems.

Dramatic improvements and savings will take at least a decade...

Bending the health care cost curve is not the work of a day, or a single bill. There is a fair amount of consensus among Democrats about how to get the process started. Will the lobbyist-ridden legislative process gut the promising provisions drafted in Baucus's and other bills? Will Obama take a stand on these, as he didn't on the public option? Did he decide long ago that payment mechanisms were more important than insuring mechanisms?

Friday, September 18, 2009

Boehner gives the game away on missile shield in Eastern Europe

John Boehner's denunciation of Obama's cancellation of the missile shield deployments in Poland and the Czech Republic shows what the plan was always really about:
“Scrapping the U.S. missile defense system in Poland and the Czech Republic does little more than empower Russia and Iran at the expense of our allies in Europe,” said Representative John A. Boehner of Ohio, the House Republican leader. “It shows a willful determination to continue ignoring the threat posed by some of the most dangerous regimes in the world.”
Note the sequencing of threats in this knee-jerk reaction. What does that say about Bush's repeated protestations that the shield had nothing to do with Russia?

And don't expect any subtlety from John McCain, enabler-in-chief of that Georgian fool's Saakashvili's furnishing of a pretext for Russian intervention in 2008:
“I fear the administration’s decision will do just that [undercut allies],” Senator John McCain, Mr. Obama’s Republican rival in last year’s presidential election, said Thursday, adding that the decision came “at a time when Eastern European nations are increasingly wary of renewed Russian adventurism.”
The Poles and Czechs, meanwhile, seem to have been concerned mainly to get American boots on their soil, whatever the pretext. They're about as worried about Iran as we are over incoming meteoroids.

The decision's possible downside -- raising Polish and Czech anxieties, perhaps emboldening Russia with an unforced 'concession' over a program that allegedly had nothing to do with them--does highlight what may be the signature challenge of the Obama Administration: unraveling bad policies that entail real commitments to various parties.

Thursday, September 17, 2009

Wydening the insurance exchange

Senator Ron Wyden has taken a slice out of the widely respected but off-the-table Wyden-Bennett health care reform bill, which would put all Americans in a national insurance exchange, to propose now that all Americans share the opportunity to opt into an insurance exchange:

I believe there is a way to work with the present employer-based system to guarantee that all Americans have choices, and I am proposing it in an amendment to the latest Senate health care bill. My amendment, called Free Choice, would let everyone choose his health insurance plan.

It would impose only one requirement on employers — that they offer their employees a choice of at least two insurance plans, one of them a low-cost, high-value plan. Employers could meet this requirement by offering their own choices. Or they could let their employees choose either the company plan or a voucher that could be used to buy a plan on the exchange. They could also simply insure all of their employees though the exchange, at a discounted rate.

Could this widening of the exchange pool serve some of the purpose of a public option, e.g., by providing critical mass to health care co-ops? And shouldn't that partial individualizing of the health care market appeal to Republicans?

Ezra Klein reports that Obama met with Wyden and Bennett as well as with Jay Rockefeller. Could a final bill staple together Baucus's deficit-reducing funding mechanism, the bigger subsidies that Rockefeller wants (as do liberal Democrats generally), and Bennett's "privatizing" amendment? Could compromise actually improve the bill that becomes law? We can dream, can't we?

Tuesday, September 15, 2009

Is a specter haunting Chinese communism?

Back in May, I humbly questioned the conclusions drawn by the authors of an intense statistical study* of the factors contributing to nations' transitions to democracy (humbly, because the researchers' numbers crunching is way beyond me; I was only looking at the conclusions they drew from statistical patterns they themselves identified). The authors concluded that economic growth in non-democratic states does not foster democracy, because their data showed that states experiencing strong GDP growth generally do not make the transition.

But while growth may not trigger a change in government while it's happening, perhaps change tends to come after a period of rapid growth, during a sudden onset of economic stress. People whose standard of living has risen and whose expectations have risen faster may be more inclined than their poorer forbears to hold an autocratic government accountable when it fails (or seems to fail) to deliver the goods.

China's rulers seem to live under the shadow of this possibility. Gideon Rachman, assessing the pace at which China may be moving toward world leadership, notes:
The government’s neurotic obsession with achieving its totemic figure of 8 per cent growth a year hints at the country’s continuing political fragility. Without a democratic mandate, the Communist party relies on rapid growth to keep the system stable. Somehow the country needs to make the transition to a system in which the government can draw upon alternative sources of legitimacy. Twenty years after the Tiananmen massacre, the Communist party shows no outward sign of contemplating a transition to a more democratic system. Meanwhile, the Chinese media speculate openly that social unrest could rise to dangerous levels, if economic growth slackens.
Over time, China may yet prove the much-maligned Francis Fukuyama right in his contention that competitive economic pressure is pushing all countries toward liberal democracy. Fukuyama hedged that hypothesis in various ways and never suggested that the "end of history" was at hand as he wrote. It seems to me that the jury is still very much out.

*Extreme Bounds of Democracy, by Martin Gassebener, Michael J. Lamia and James Raymond Vreeland

David Frum is making sense

David Frum has a simple syllogism for Republicans on health care:

a) If you succeed in killing health care reform this time around, health care costs will spiral out of control
b) If health care inflation is not curbed, the United States will never see another tax cut
c) What are Republicans for, anyway?

Frum is in sustained combat with the wackos that have taken over his party. And he's serenely confident that he will win:
We have been besieged but this is a fight worth doing. And I have to say I'm thinking of changing our slogan. I'm adapting something from the old Panasonic folks, our new motto's going to be "just slightly ahead of our time." I know the conservatives of this country are not with me on these issues today. But I know equally well they will be with me on these issues in the future. They are just going to learn it, unfortunately, a harder way.
Let's hear it for good old-fashioned courage.

Monday, September 14, 2009

Osama's amended complaint

The latest alleged Osama bin Laden tape "reminds" Americans:
We have demonstrated and stated many times, for more than two-and-a-half-decades, that the cause of our disagreement with you is your support to your Israeli allies who occupy our land of Palestine.
Was not Osama's original causus belli the United States' "occupation" of the sacred soil of Saudi Arabia during and after the 1991 Gulf War?

Yes, Israel is always there as a stand-by, but in Osama's 1998 fatwa ordering Muslims to kill Americans wherever they can, U.S support of Israel is a paltry third justification, trailing 1) "occupying the lands of Islam in the holiest of places, the Arabian Peninsula, plundering its riches, dictating to its rulers, humiliating its people, terrorizing its neighbors, and turning its bases in the Peninsula into a spearhead through which to fight the neighboring Muslim peoples" and 2) "Americans' continuing aggression against the Iraqi people using the Peninsula as a staging post."

In the latest tape, Osama (if the tape is authentic) asserted that Obama is "powerless" to stop the war in Afghanistan and in the grip of the "pro-Israel lobby." But surely Osama's intended audience is aware that Obama is mistrusted and unpopular in Israel. If this tape is authentic, it seems a particularly lame indictment, even from a violent Jihadist's point of view.

Sunday, September 13, 2009

On "catching" happiness

According to the research team Nicholas Christakis and James Fowler, pioneers in the study of "social contagion," happiness is a large social network. From Clive Thompson's long assessment of their research in the Times Magazine:

The subconscious nature of emotional mirroring might explain one of the more curious findings in their research: If you want to be happy, what’s most important is to have lots of friends. Historically, we have often thought that having a small cluster of tight, long-term friends is crucial to being happy. But Christakis and Fowler found that the happiest people in Framingham were those who had the most connections, even if the relationships weren’t necessarily deep ones.

The reason these people were the happiest, the duo theorize, is that happiness doesn’t come only from having deep, heart-to-heart talks. It also comes from having daily exposure to many small moments of contagious happiness. When you frequently see other people smile — at home, in the street, at your local bar — your spirits are repeatedly affected by your mirroring of their emotional state. Of course, the danger of being highly connected to lots of people is that you’re at risk of encountering many people when they are in bad moods. But Christakis and Fowler say their findings show that the gamble of increased sociability pays off, for a surprising reason: Happiness is more contagious than unhappiness. According to their statistical analysis, each additional happy friend boosts your good cheer by 9 percent, while each additional unhappy friend drags you down by only 7 percent. So by this logic, adding more links to your network should — mathematically — add to your store of happiness. “If you’re at the center of a network, you are going to be more susceptible to anything that spreads through it,” Fowler said. “And if happiness is spreading more reliably, then on average you’re going to be catching happy waves more often than you catch sad waves.”
This sweeping claim set off a series of free associations in me, an inveterate introvert. E.g.:

1) Walking to work in Manhattan, where I might pass 1,000 people on my mile-long route, I've noticed that people look a lot better when they're with someone else -- happier, more intelligent, more energetic.

2) As Atul Gawande documented ably some months ago, solitary confinement is torture. It has taken hold through what also might be a kind of social contagion in the U.S. over the past quarter century:

Prolonged isolation was used sparingly, if at all, by most American prisons for almost a century. Our first supermax—our first institution specifically designed for mass solitary confinement—was not established until 1983, in Marion, Illinois... In 1995, a federal court reviewing California’s first supermax admitted that the conditions “hover on the edge of what is humanly tolerable for those with normal resilience.” But it did not rule them to be unconstitutionally cruel or unusual...The ruling seemed to fit the public mood. By the end of the nineteen-nineties, some sixty supermax institutions had opened across the country. And new solitary-confinement units were established within nearly all of our ordinary maximum-security prisons.

The number of prisoners in these facilities has since risen to extraordinary levels. America now holds at least twenty-five thousand inmates in isolation in supermax prisons. An additional fifty to eighty thousand are kept in restrictive segregation units, many of them in isolation, too, although the government does not release these figures.
3) The former king of the Himalayan kingdom Bhutan, Jigme Singye Wangchuck, may have been onto something with his concept of Gross National Happiness as an aim of government policy. But perhaps instead of focusing on sustainable development, cultural values, environment conservation and good governance he should have focused on increasing social interaction.

4) I have often wondered whether people in countries that are poor but still organized around tight social networks, such as tribes, mightn't be happier on average than people in advanced industrial societies -- that is, if the country is not a failed state or ruled by a brute like Saddam, or by a regime that deeply intrudes upon and controls and distorts social and economic life, like Iran's.

5) On the other hand, the ancient pastoral ideal and classical dichotomy between the wholesome country life and the sordid, corrupt city is more or less a load of crap -- as are demagogues' paeans to the virtues of small town America. While cities can be places of both horrific isolation, human beings have at every opportunity voted with their feet -- and hearts, and minds - to place themselves in ever larger social hives.

6) Per items 4 and 5, I really have very little idea where human social life is most rewarding. I really should get out more. But it does seem that organizing ourselves in ways that maximize positive social interaction is the fundamental challenge of human collective effort. Perhaps Wangchuck's four pillars of "GNH" are at bottom means to that end.

Saturday, September 12, 2009

A Distant Mirror in Iran

Mohammad Sahimi at Tehran Bureau has a magisterial, level-headed, fact-crammed, on-the-on-hand-on-the-other-hand overview of the situation in Iran that should not be missed (h/t Gary Sick). It's a Rorschach test for those with hopes or fears or strong opinions about Iran, in that it details the weaknesses of the hardliners' position as well as the full implications of the fact that the ruling clique has all the guns and Mafioso-style control of the economy.

I would not presume to add my thinly informed two cents to this deeply informed analysis. But one free association is perhaps worth recording. It was triggered by one item in a list of challenges faced by the ruling hardliners:
Secondly, the Ahmadinejad group is totally devoid of intellectuals and deep thinkers who can lead or even show the way to improving the economy. Most moderate conservative experts have fled the Ahmadinejad camp. The composition of his new government, which is totally devoid of any “heavy weight” expert, is highly illustrative of that fact.
This gave me a flash image of the U.S. after a Palin-led or other extreme rump Republican takeover -- enabled perhaps after a nuclear terrorist attack (Joe the President, anyone?). Our system has stronger antibodies than Iran's, but who's to say it couldn't happen? The Bush Administration went a ways down this road, packing the Justice Department, EPA and countless other agencies with faith-based ideologues and industry shills; it went a long way toward bankrupting the country with a 1-2-3 punch of tax cuts for the wealthy, entitlement giveaways and unnecessary war; it further undermined institutional norms and taboos by cooking the intelligence-gathering process and instituting a torture regime; it stimulated and materially aided what Andrew Sullivan calls "movement conservatism, the business," i.e. the entertainment juggernaut of mainstreamed Father Coughlin-level demagoguery.

We're in partial remission at the moment. But the radicalization of the Republican rump is dangerous; demagogues are waiting in the wings. The country needs two parties capable of governing. As of now, we don't have that.

Friday, September 11, 2009

Obama "triggers" a recount of heath care bills' costs

David Brooks would have us believe that Obama's promise in Wednesday night's speech not to sign a health care bill if it "adds one dime to the deficit" "kills the kills the House health care bill," which allegedly would add $220 billion to the deficit over ten years.

But as Ezra Klein highlights for us, Obama's very next sentence indicates an intent to change the CBO scoring that determines each bill's alleged price tag. As several observers including John R. Gabel have pointed out, the CBO has a history of underestimating the savings from various enacted Congressional measures to reduce health care costs; it's difficult for lawmakers to get due credit for cost-cutting measures. Hence this proposal, immediately following the "dime" pledge:
And to prove that I’m serious, there will be a provision in this plan that requires us to come forward with more spending cuts if the savings we promised don’t materialize."
Klein, I believe, had already flagged this possibility prior to Obama's speech (it was either him or Cohn). Today, he's all over it:
The idea was recently explained in a paper David Cutler and Judy Feder wrote for the Center for American Progress, so I called Feder today to ask what, exactly, the president was talking about.

How does a fiscal trigger work?

The idea of a trigger is that one establishes in advance a target for savings in the system, agrees on measures that need to be achieved, track that progress as the program is implemented, and if shortfalls are found, then certain actions are automatically triggered in.

What are those actions? What happens when you pull the trigger?

David Cutler and I put forward a range of options and believe a menu should be specified in the legislation. That menu could include further reductions in Medicare or changes in the tax treatment of employer-based efficiency or a strengthening of a public plan to further competition with insurers.

And why do we need this? I thought the plan already had savings in it.

The reason that David Cutler and I have been so supportive of a trigger is that we are firmly behind the cost-saving measures that are in legislative proposals and on which there is enormous agreement to change the health-care delivery system. Payment reform, a value-based purchasing system, moving away from the overprovision of low-value and high-cost procedures, and rewarding providers for better care and management of chronic illness. There's work and experience showing those measures can achieve huge savings systemwide. David Cutler and Rand's Melinda Buntin estimated (pdf) the savings at $2 trillion over the next decade.

But CBO is very cautious about scoring those measures. So it's our belief that for scoring purposes, we can put underneath them a failsafe that guarantees CBO will score the savings.

So the idea is that those savings will appear, but since CBO won't score them, you basically give CBO something it can score that's of similar value?


Presto. That house bill might be scored differently. More importantly, it may really accelerate the imposition of serious cost controls, i.e. changes to the fee-for-service payment structure, which by their nature must be incremental. Read the whole of Klein's interview of Feder.

The invisible 1/3 of U.S. health care funding

Trickling through news reports and blogs are 2008 census figures showing an accelerating shift away from employer-based and toward government-supplied health insurance. Employers in 2008 covered just 58.5% of Americans, down from 59.3% in 2007 and 64.2% in 2000.

What's often not noted in the health care debate is a parallel shift by employers from providing traditional insurance, supplied by an insurance company, to providing self-funded health care plans, generally administered by an insurance company or other "third party administrator" (TPA) and backed by catastrophic "stop-loss" insurance.

More than half of Americans who get their health coverage from their employers are in self-insured plans (the last figure I remember seeing is 55%), which are not subject to state mandates. There are more people whose health care is funded directly by their employer than by government plans, and almost as many as are insured by private health insurers (whether employer-provided or purchased directly).

Per the numbers below, presented by the Council of Economic Advisor's Cecilia Rouse and flagged by Ben Smith, little more than one third of Americans are covered by traditional private, third-party health insurance plans (a bit less than half of the 58.5% with employer-based coverage, plus approximately 9% who buy insurance directly).

Some questions worth answering: how does employer-funded health care stack up against traditional private insurance? How successful are employers at controlling costs -- are they completely in the hands of their TPAs? What percentage of health insurers' income comes from administering companies' self-funded plans, or from providing stop-loss to self-funded companies? To what extent will new health care legislation regulate employer-funded benefits? In addition to providing health insurers with a new pool of subsidized shoppers, will health care legislation offer them new opportunities to act as administrators?

Thursday, September 10, 2009

The great myth about Obama's soaring rhetoric

Ezra Klein creates a compelling formula to frame the drama of Obama's health care speech. The only problem is, it's completely untrue:
Barack Obama is considered a great speaker. But he's not typically been great at giving this kind of nuts-and-bolts policy speech. He's good at handling grand, sweeping topics. He's better at talking about how the arc of history bends towards justice than how the provisions of health-care reform bend the curve. During the campaign, John Edwards and Hillary Clinton were both more effective policy communicators than Obama. Particularly on health care.
In this speech, in fact, Obama needed to do the precise opposite of what he's best at. He needed to bring health-care reform down to earth rather than launch it into orbit. He needed to make it seem less dramatic and unknown. He needed to cast it not as change, but as improvement.
All of which he did.
Klein is terrific on policy (including, later in the same post, the policy specifics of this speech), but he's all wet on rhetoric (here at least). It's true that during the campaign Obama sometimes did not debate the specifics of policy with as much command of nuance as Clinton. But Obama is vastly better than Clinton -- and every other politician in America -- at articulating a strategic and conceptual framework for a set of policy specifics (often a laundry list as long as Hillary's). That's why he won the election.

He did it in March 2008 while delineating the dynamics of the financial crisis: pain trickled up. He did it a few days earlier in articulating a global strategy for defanging Islamic fundamentalism: The central front in the war on terror is not Iraq, and it never was...It is not too late to prevail in Afghanistan. But we cannot prevail until we reduce our commitment in Iraq. He did it in spades in his remarkable (and it seems temporarily forgotten) speech on the economy this past April (explaining why he did not move swiftly to nationalize giant banks): Governments should practice the same principle as doctors: first do no harm. So rest assured – we will do whatever is necessary to get credit flowing again, but we will do so in ways that minimize risks to taxpayers and to the broader economy.

Where Obama really takes off is where, having built the case for a set of specific policies, he frames those policies as a continuation of the mainstream of American history, an articulation of core American values. That's where the "bend the arc of history" language comes in, generally in the peroration. It's true that at times in '08 that rhetoric was untethered from a lot of policy specifics. But it was a long campaign. Regularly, Obama got down to brass tacks. As he did again last night.

We elected Obama because he repeatedly demonstrated the power of mind to formulate policy specifics as means to an end (as he cast the public option last night). This was not simply a matter of idealizing American history. He has given us many arresting formulations of the specific goals of specific policies -- and tactics. Some examples:

On the uses of soft power:
What lies in the heart of a child in Pakistan matters as much as the airplanes we sell her government. What's in the head of a scientist from Russia can be as lethal as a plutonium reactor in Yongbyon. What's whispered in refugee camps in Chad can be as dangerous as a dictator's bluster. These are the neglected landscapes of the 21st century, where technology and extremism empower individuals just as they give governments the ability to repress them; where the ancient divides of region and religion wash into the swift currents of globalization.
On rebalancing the economy:
today, for far too many Americans, [the American] dream is slipping away. Wall Street has been gripped by increasing gloom over the last nine months. But for many American families, the economy has effectively been in recession for the past seven years. We have just come through the first sustained period of economic growth since World War II that was not accompanied by a growth in incomes for typical families. Americans are working harder for less. Costs are rising, and it's not clear that we'll leave a legacy of opportunity to our children and grandchildren. That's why, throughout this campaign, I've put forward a series of proposals that will foster economic growth from the bottom up, and not just from the top down....we need to pursue policies that once again recognize that we are in this together.
On rebalancing U.S. foreign policy (in debate):
Look, over the last eight years, this administration, along with Senator McCain, have been solely focused on Iraq. That has been their priority. That has been where all our resources have gone.In the meantime, bin Laden is still out there. He is not captured. He is not killed. Al Qaeda is resurgent. In the meantime, we've got challenges....We have weakened our capacity to project power around the world because we have viewed everything through this single lens, not to mention, look at our economy. We are now spending $10 billion or more every month.
On pushing major legislation forward during a financial crisis:
Just as a cash-strapped family may cut back on luxuries but will insist on spending money to get their children through college, so we as a country have to make current choices with an eye on the future. If we don't invest now in renewable energy or a skilled workforce or a more affordable health care system, this economy simply won't grow at the pace it needs to in two or five or ten years down the road.
On how to effect systemic change incrementally:
This metaphor has been used before, but this -- the ship of state is an ocean liner; it's not a speed boat. And so the way we are constantly thinking about this issue of how to bring about the changes that the American people need is to -- is to say, if we can move this big battleship a few degrees in a different direction, we may not see all the consequences of that change a week from now or three months from now, but 10 years from now, or 20 years from now, our kids will be able to look back and say that was when we started getting serious about clean energy, that's when health care started to become more efficient and affordable, that's when we became serious about raising our standards in education.
It is simply a canard that Obama bewitched Americans with empty, soaring rhetoric. Yes, he flatters us; yes, he idealizes American history while casting his policies as a course correction back to its mainstream after a 10-30 year hard right detour. But he uses that enchantment to good end. His rare gift is to set policy choices within a framework, first of the strategic ends specific to that policy, and second of the broader goal -- building sustainable shared prosperity.

Wednesday, September 09, 2009

Obama seizes the center on health care

Obama's speech before Congress laying out his health care plan doubtless made his core supporters' hearts soar -- those, at least, who don't consider a government-sponsored public option the indispensable heart and soul of reform. But what the speech needed to do politically was swing the center -- independents and the constituents of blue dog Democrats -- his way. That he set out to accomplish in at least four ways:
  1. He spelled out how reform would make those who already have insurance more secure, and reassured seniors that he was strengthening rather than hollowing out Medicare.
  2. He directly spelled out, denounced and debunked the lies and distortions that have dominated coverage of the issue all summer
  3. He positioned himself in the center between "those on the left" who would a) prefer a single payer system and b) insist on a public option or bust, and "those on the right" who would a) end employer-based health care and completely individualize or b) simply try to kill any reform bill that has a chance of passing.
  4. Returning to the theme that gave his rhetoric wings in the campaign, having carved out that center space for himself, he moved the center left by defining provision for the common weal as a central theme in American history albeit (balancing individualism and a healthy skepticism about government).
Let's take these one at a time.

1. Appealing to the insured: there are two parts to this: a) enumerating the risks that the currently insured face, and b) showing how the plan would alleviate them. Here's what Obama had to say on both counts:
a) But the problem that plagues the health care system is not just a problem of the uninsured. Those who do have insurance have never had less security and stability than they do today. More and more Americans worry that if you move, lose your job, or change your job, you'll lose your health insurance too. More and more Americans pay their premiums, only to discover that their insurance company has dropped their coverage when they get sick, or won't pay the full cost of care. It happens every day....

b) Here are the details that every American needs to know about this plan:

First, if you are among the hundreds of millions of Americans who already have health insurance through your job, Medicare, Medicaid, or the VA, nothing in this plan will require you or your employer to change the coverage or the doctor you have. Let me repeat this: nothing in our plan requires you to change what you have.

What this plan will do is to make the insurance you have work better for you. Under this plan, it will be against the law for insurance companies to deny you coverage because of a pre-existing condition. As soon as I sign this bill, it will be against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick. And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies – because there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.

That's what Americans who have health insurance can expect from this plan – more security and stability.

And on Medicare:

More than four decades ago, this nation stood up for the principle that after a lifetime of hard work, our seniors should not be left to struggle with a pile of medical bills in their later years. That is how Medicare was born. And it remains a sacred trust that must be passed down from one generation to the next. That is why not a dollar of the Medicare trust fund will be used to pay for this plan.

The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud, as well as unwarranted subsidies in Medicare that go to insurance companies – subsidies that do everything to pad their profits and nothing to improve your care. And we will also create an independent commission of doctors and medical experts charged with identifying more waste in the years ahead.

These steps will ensure that you – America's seniors – get the benefits you've been promised. They will ensure that Medicare is there for future generations. And we can use some of the savings to fill the gap in coverage that forces too many seniors to pay thousands of dollars a year out of their own pocket for prescription drugs. That's what this plan will do for you. So don't pay attention to those scary stories about how your benefits will be cut – especially since some of the same folks who are spreading these tall tales have fought against Medicare in the past, and just this year supported a budget that would have essentially turned Medicare into a privatized voucher program. That will never happen on my watch. I will protect Medicare.

2. Giving the lie to Palin and her ilk:

Still, given all the misinformation that's been spread over the past few months, I realize that many Americans have grown nervous about reform. So tonight I'd like to address some of the key controversies that are still out there.

Some of people's concerns have grown out of bogus claims spread by those whose only agenda is to kill reform at any cost. The best example is the claim, made not just by radio and cable talk show hosts, but prominent politicians, that we plan to set up panels of bureaucrats with the power to kill off senior citizens. Such a charge would be laughable if it weren't so cynical and irresponsible. It is a lie, plain and simple.

There are also those who claim that our reform effort will insure illegal immigrants. This, too, is false – the reforms I'm proposing would not apply to those who are here illegally. And one more misunderstanding I want to clear up – under our plan, no federal dollars will be used to fund abortions, and federal conscience laws will remain in place.

My health care proposal has also been attacked by some who oppose reform as a "government takeover" of the entire health care system. As proof, critics point to a provision in our plan that allows the uninsured and small businesses to choose a publicly-sponsored insurance option, administered by the government just like Medicaid or Medicare.

So let me set the record straight. My guiding principle is, and always has been, that consumers do better when there is choice and competition. Unfortunately, in 34 states, 75% of the insurance market is controlled by five or fewer companies. In Alabama, almost 90% is controlled by just one company. Without competition, the price of insurance goes up and the quality goes down....[defense of the public option follows]

3. Carving out the center:

There are those on the left who believe that the only way to fix the system is through a single-payer system like Canada's, where we would severely restrict the private insurance market and have the government provide coverage for everyone. On the right, there are those who argue that we should end the employer-based system and leave individuals to buy health insurance on their own.

I have to say that there are arguments to be made for both approaches. But either one would represent a radical shift that would disrupt the health care most people currently have. Since health care represents one-sixth of our economy, I believe it makes more sense to build on what works and fix what doesn't, rather than try to build an entirely new system from scratch. And that is precisely what those of you in Congress have tried to do over the past several months....

It's worth noting that a strong majority of Americans still favor a public insurance option of the sort I've proposed tonight. But its impact shouldn't be exaggerated – by the left, the right, or the media. It is only one part of my plan, and should not be used as a handy excuse for the usual Washington ideological battles. To my progressive friends, I would remind you that for decades, the driving idea behind reform has been to end insurance company abuses and make coverage affordable for those without it. The public option is only a means to that end – and we should remain open to other ideas that accomplish our ultimate goal. And to my Republican friends, I say that rather than making wild claims about a government takeover of health care, we should work together to address any legitimate concerns you may have.

4) Moving the center left and positioning government action for the common good as a core element of American identity: For this, Obama deployed the ghost of Teddy Kennedy:

He [Kennedy] repeated the truth that health care is decisive for our future prosperity, but he also reminded me that "it concerns more than material things." "What we face," he wrote, "is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country."

I've thought about that phrase quite a bit in recent days – the character of our country. One of the unique and wonderful things about America has always been our self-reliance, our rugged individualism, our fierce defense of freedom and our healthy skepticism of government. And figuring out the appropriate size and role of government has always been a source of rigorous and sometimes angry debate.

For some of Ted Kennedy's critics, his brand of liberalism represented an affront to American liberty. In their mind, his passion for universal health care was nothing more than a passion for big government.

But those of us who knew Teddy and worked with him here – people of both parties – know that what drove him was something more. His friend, Orrin Hatch, knows that. They worked together to provide children with health insurance. His friend John McCain knows that. They worked together on a Patient's Bill of Rights. His friend Chuck Grassley knows that. They worked together to provide health care to children with disabilities.

On issues like these, Ted Kennedy's passion was born not of some rigid ideology, but of his own experience. It was the experience of having two children stricken with cancer. He never forgot the sheer terror and helplessness that any parent feels when a child is badly sick; and he was able to imagine what it must be like for those without insurance; what it would be like to have to say to a wife or a child or an aging parent – there is something that could make you better, but I just can't afford it.

That large-heartedness – that concern and regard for the plight of others – is not a partisan feeling. It is not a Republican or a Democratic feeling. It, too, is part of the American character. Our ability to stand in other people's shoes. A recognition that we are all in this together; that when fortune turns against one of us, others are there to lend a helping hand. A belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgement that sometimes government has to step in to help deliver on that promise.

This has always been the history of our progress. In 1933, when over half of our seniors could not support themselves and millions had seen their savings wiped away, there were those who argued that Social Security would lead to socialism. But the men and women of Congress stood fast, and we are all the better for it. In 1965, when some argued that Medicare represented a government takeover of health care, members of Congress, Democrats and Republicans, did not back down. They joined together so that all of us could enter our golden years with some basic peace of mind.

You see, our predecessors understood that government could not, and should not, solve every problem. They understood that there are instances when the gains in security from government action are not worth the added constraints on our freedom. But they also understood that the danger of too much government is matched by the perils of too little; that without the leavening hand of wise policy, markets can crash, monopolies can stifle competition, and the vulnerable can be exploited. And they knew that when any government measure, no matter how carefully crafted or beneficial, is subject to scorn; when any efforts to help people in need are attacked as un-American; when facts and reason are thrown overboard and only timidity passes for wisdom, and we can no longer even engage in a civil conversation with each other over the things that truly matter – that at that point we don't merely lose our capacity to solve big challenges. We lose something essential about ourselves.

Here Obama not only managed to cast Ted Kennedy as a pragmatist of his own ilk; he cast core liberal values as a basis for consensus over the last seventy years. He echoed his 2004 Convention speech, and just about every major speech since, with his elision of the ideological divide between the parties: "That large-heartedness – that concern and regard for the plight of others – is not a partisan feeling. It is not a Republican or a Democratic feeling. It, too, is part of the American character." He has taken the ever-shrinking reality of Republican consent to the core institutions of the welfare state and used it to paint a consensus of American compassion. A bit of a stretch, but not entirely untrue, even in the recent shreds and patches of expanding SCHIP. And if the Republican party is to revitalize, it will be more true hereafter.

A mantra for Democrats

Andrew Sullivan flags a golden talking point for Democrats:

Somehow - thanks in part to dishonest partisan hacks like Glenn Reynolds and Sean Hannity - the Bush-Cheney debt is all Obama's fault and you need to get Republicans back to fix it. A commenter on Bruce Bartlett's Forbes column has the best response to that:

The last Republican who left the office of the presidency with the federal public debt as a percentage of GDP less than when he entered was Richard Nixon (FY 1975). The last Republican who left the office of the presidency with a federal deficit less than 2.7% of GDP was Dwight Eisenhower (FY 1961). Since WW II no Democratic president has ever left office with the federal public debt as a percentage of GDP more than when he entered. And since WW II no Democratic president has ever left office with a federal deficit more than 2.6% of GDP.

We already have at least one party of fiscal responsibility. It's called the Democratic Party.

Let's see, can we get this down to bumper sticker size? Democrats reduce Deficits?

Tuesday, September 08, 2009

The free market that ate conservatism

Andrew Sullivan, addressing a reader's question why the Republican Party has embraced the lunatic right, posits:
The only real explanation that I can come up with is that the interests of "movement conservatism, the business" trumps patriotic conservatism as a political philosophy in the GOP.

The power of the conservative industrial complex - utterly cynical enterprises like Eagle Publishing and Fox News, for example - is real and has done a huge amount to destroy an uncynical and constructive conservatism.
There's an irony here. There's long been a tension in American conservatism between defense of "traditional values" on one hand, which include deference to established authority as well as Biblically-based sexual morality, and free market fundamentalism on the other. The latter, with its hostility to regulation, undermines traditional values by removing all restraints on the entertainment and advertising industries. Those industries have eviscerated public discourse, swallowed much of the news industry, and now hold the free market party itself hostage to a cadre of quasi-fascist screamers.

Monday, September 07, 2009

His speech will be pretty good

Just a wee bit of pressure has built up on Obama in anticipation of his health care speech before Congress and a national audience on Wednesday. Here's how Peter Baker's pre-game show in the Times, "Obama Faces a Critical Moment in His Presidency," frames it:

Of all the challenges Mr. Obama faces this fall, health care has come to dominate so much that the fate of the rest of his domestic program, particularly climate change legislation and new regulations on the financial industry, may depend in part on whether he wins this fight.

“He’s gone all in,” said Matt Bennett, vice president of Third Way, a Democratic-oriented advocacy organization, using a poker term. “Everyone’s watching. The bets are all on the table. And we’re just waiting to see what the cards say.”

I am reminded af a vignette in Ryan Lizza's July '08 New Yorker portrait of Obama:
Obama has always had a healthy understanding of the reaction he elicits in others, and he learned to use it to his advantage a very long time ago. Marty Nesbitt remembers Obama’s utter calm the day he gave his celebrated speech at the 2004 Democratic National Convention, in Boston, which made him an international celebrity and a potential 2008 Presidential candidate. “We were walking down the street late in the afternoon,” Nesbitt told me. “And this crowd was building behind us, like it was Tiger Woods at the Masters.”

“Barack, man, you’re like a rock star,” Nesbitt said.

“Yeah, if you think it’s bad today, wait until tomorrow,” Obama replied.

“What do you mean?”

“My speech,” Obama said, “is pretty good.”
My bets are on the President pulling out a health care bill that will disappoint many followers but that will be recognized in later years to have "move[d] this big battleship a few degrees in a different direction."

My countries, tis of thee...

Some good news (and good reporting) from The Economist:

At a recent summit of the cold-war relic called the Non-Aligned Movement, Serbia’s president, Boris Tadic (above left), remarked that companies from former Yugoslav republics should join forces to bid on construction projects or specialised military-equipment contracts. His Croatian counterpart, Stipe Mesic (right), responded approvingly. Companies from “our countries”, he said, were too small to compete in other markets by themselves.

On the face of it, these comments were both obvious and inconsequential. The firms are indeed small by global standards. Yet the use of the term “our countries” by the leader of one ex-Yugoslav republic to refer to everyone in the group, enemies as well as friends, points to a bigger change. From Slovenia to the Macedonian border with Greece, most people in the region still have a lot in common, even if they do not talk about it much. Every day the bonds between them, snapped in the 1990s, are being quietly restored. Yugoslavia is long gone; in its place a Yugosphere is emerging.

I remember the cynical write-offs of the region in the nineties to the tune of "those hatreds have been festering for centuries." The ethnic tensions and nationalist ambitions exploited by unscrupulous and fanatical leaders, were real enough to tear Yugoslavia (and Bosnia, and Serbia) apart. But they weren't the only reality:

The Yugosphere has its roots in shared experience, in trade and in business. Most former Yugoslavs—Bosnians, Serbs, Montenegrins and Croats—speak the same language with minor variations. Many Macedonians and Slovenes still speak or understand what used to be called Serbo-Croat as a second language. Within most of the region, people can travel freely using just their identity cards.

They like the same music and the same food. Political, religious and ethnic differences persist of course. But every summer thousands of young people come together at the Exit music festival in Novi Sad in Serbia, and big stars from across the region have no trouble packing in audiences wherever they perform. Much to the irritation of Croatian music executives, the mobile phones of many young Croats hum with the latest Serbian tunes. Pan-Balkan opinion polls show a certain commonality of outlook: people have similar fears, worries and hopes. Gallup’s Balkan Monitor, for example, released a survey in June that showed a drop in those wanting to emigrate in every state in the west Balkans.

Almost a third of Montenegro’s trade is with Serbia. Bosnia is Serbia’s largest export market and Croatia’s second largest. Serbia is Macedonia’s largest trading partner. In small economies, expansion generally means doing more business with the neighbours. Delta from Serbia, Mercator from Slovenia and Konzum from Croatia all run supermarkets and have been opening new shops in each other’s backyards. Like more and more companies of the former Yugoslavia, they treat the region as one. Serbia’s leading daily, Politika, has a domestic edition and a slightly different “ex-Yu” one. A typical recent Serbian headline announced the planned “conquest” of Croatia, not by armed force but by Cipiripi, a Serbian chocolate spread.

Are supermarket chains the ties that bind? Can ethnic hatred be smoothed over by a chocolate revolution. And btw, what's up with the Czech Republic and Slovakia?

Sunday, September 06, 2009

Ali Soufan goes nuclear on Cheney

Four months ago Ali Soufan, the FBI interrogator who extracted reams of actionable intelligence from Abu Zubaydah using rapport-based techniques before the CIA took over and commenced torturing him, broke a seven-year silence to assert that the CIA's torture regimen interrupted and undercut effective noncoercive interrogation and never yielded any actionable intelligence that could not have been gleaned without coercion.

Today, in a second Times op-ed, Soufan goes further, suggesting that the U.S. failed to capture top al Qaeda leadership because it turned to ineffective torture:

It is surprising, as the eighth anniversary of 9/11 approaches, that none of Al Qaeda’s top leadership is in our custody. One damaging consequence of the harsh interrogation program was that the expert interrogators [e.g., Soufan] whose skills were deemed unnecessary to the new methods were forced out.

Mr. Mohammed knew the location of most, if not all, of the members of Al Qaeda’s leadership council, and possibly of every covert cell around the world. One can only imagine who else we could have captured, or what attacks we might have disrupted, if Mr. Mohammed had been questioned by the experts who knew the most about him.
There's a fearful symmetry here: Cheney claims that torture prevented further terrorist attacks on U.S. soil. Soufan suggests that torture prevented the capture of top Al Qaeda leadership.

This inflammatory claim follows a point-by-point demolition of the various claims made for torture-based interrogation: that it led to foiling a plot to fly a plane into the tallest building on the West Coast; that it led to the capture of Khalid Sheikh Mohammed; that torture induced KSM to give up new information about Al Qaeda's organizational structure. According to Soufan's parsing of the CIA inspector general's report of 2004 and the two CIA memos on intelligence gained from detainees, virtually all actionable intelligence cited by torture's defenders came from "pocket litter" and from captives' assumption that they were giving up information their questioners already had.

Soufan is plainly tormented by the conviction that he personally had what it took to get the highest-value information out of the top-level detainees, and that he and other informed and skilled interrogators were prevented from doing so by the thugs at the top who imposed the torture regime. Of course he can never prove what he might have accomplished -- just as torture's defenders can't prove that any info gained once the"program" commenced could not have been gained by other means. But Soufan does know a) what was gained in the interrogations he did conduct; what is false in most of the explicit claims about knowledge gained under torture; and c) a good deal about the psychology of the top detainees and the knowledge in their possession at the time of capture.

Philip Zelikow, who interviewed Soufan for the 9/11 Commission, says that he "seemed to us to be one of the more impressive intelligence agents -- from any agency -- that we encountered in our work." Soufan is a far more credible witness than Cheney and his henchmen.

Saturday, September 05, 2009

$27 million split how many ways?

This New York Times headline triggered some free association:

Teacher Bonuses Total $27 Million, Nearly Double Last Year’s

Those bonuses will be split among teachers and principals at 139 New York City elementary and middle schools that received As and Bs from the Dept. of Education, based on student test score improvement.

Not to think too hard about comparable worth -- or the wisdom of incenting teachers to teach to tests, or the cogency of the bonus criteria -- but how many New York traders and hedge fund managers will earn $27 million this year to keep for their own little selves?

While Rome burns

Gail Collins' "ghoulish" summer news quiz is amusing, with its reminiscences of people packing heat to town hall meetings, governors and state senators confessing to affairs and undergoing indictment for assaulting girlfriends, and demagogues screaming about death panels and babbling about dead fish. But it does make you wonder, however fleetingly, if we're in the last days of empire.

Friday, September 04, 2009

Of venal dentists and patients' incentives

Don't get my father, 81, started on the incompetence and venality of (some) dentists. Troubled with bad teeth -- most of which he's managed to keep -- all his life, he's had several bouts of long, painful, expensive bridge work, periodontry, implants, etc. He's learned always to get two or three opinions. He loves to tell of the guy who told him he needed $4,000 worth of bridge work -- which another dentist told him was totally unnecessary, proving it with effective, much more limited treatment.

It occurs to me that dentists are likely no more venal than doctors (or members of any other profession). The difference is that since most of us don't have dental insurance, we know how much dental treatments will cost, if we care to ask. While I disagree with health care free marketeer David Goldhill's solutions to our health care crisis (ultra-high deductible insurance for all; HSAs for all; substantial services paid out of pocket), he has a point that we're apt to spend like drunken soldiers on health care when doctors tell us to, because we don't know the cost and don't bear much of it -- if we have decent coverage.

It stands to reason that many specialists, e.g., surgeons, whether out of unabashed "entrepreneurialism" or a natural tendency to believe that most people suffering from the ailments they treat will benefit from the very expensive treatments they offer, are as apt to recommend unnecessary expensive treatment as the dentist villain of my father's tale. When the procedure is high risk, many patients are likely to seek at least a second opinion. When it's not -- when the procedures are diagnostic, or hold out what seems a reasonable chance of quick relief from pain, or seem likely to eliminate what may be a very low-odds but deadly risk -- most people will go for it.

It is quite difficult to figure out the appropriate mechanisms and agency and incentives for cost-benefit analysis. Much of our problem is cultural. In a paper (fee required) on the causes of Americans' "overutilization" of medical services, Ezekiel Emanuel and Victor Fuchs identified 7 factors -- "4 related to physicians and 3 related to patients." Doctors' factors, according to Emanuel and Fuchs, are 1) training that places a premium on "enumerating all possible diagnoses and tests that would confirm or exclude them"; 2) fee-for-service, which creates incentives for overtreatment; 3) pharmaceutical marketing to doctors; and 4) medical malpractice laws. On the patient side, there is 1) the American cultural tendency "to embrace technologic fixes for problems"; 2) direct-to-consumer pharmaceutical marketing ; and 3) third-party payment for services, as outlined in this post.

Changing doctors' incentives has been the focal point of most discussion of health care cost containment. But changing the maximalist culture that patients have imbibed -- which starts by at least making costs transparent -- must also be part of the mix. No politician is going to tell the American people that. "It's your fault too" has never been a winning political message -- except to a minority, when a majority is calculated to overhear.

UPDATE: Ezra Klein, referring to the employer tax break for health care that produced our current system and so hides their cost of health care from most of us, points a way to change patient incentives:
I would like to see the tax preferences eliminated, and I would like to see every worker get the money their employer pays for their health care put back into their wages. Then I would like them to purchase health insurance on their own, so they see the full cost of it, and can decide whether they're willing to support more radical efforts to bring those costs down, or whether they're willing to accept more care management in order to save some money. This is, basically, how the Wyden-Bennett bill works, and it's why it's such a gamechanger. It's also why it has so little legislative support: It tries to solve the full problem when people only feel a small fraction of the problem.
In agreement with Klein and contra Goldhill, I would add that it makes more sense to induce people to give up a degree of autonomy over treatment courses in advance than to force each of us to factor in cost when we're up against major treatment decisions, such as whether to undergo bypass surgery.

Wednesday, September 02, 2009

Ah, September: bedwetting season for Democrats

This time last year (okay, Sept. 12 '08), as McCain surged ahead of Obama in the polls in the wake of Sarah Palin's demagogic debut and a ghoulish supporting cast blasting away at the "community organizer" in the Republican Convention, David Plouffe was ruefully downplaying the panic of Democratic "bedwetters." Here we go again: after a month of gleeful lying about health care reform in town hall meetings, Republicans smell blood and Dems are wetting away as Obama's poll numbers sag.

I am confident that Obama will once again prove calmer, more focused, smarter than his critics. As Jonathan Chait and John Dickerson have pointed out, premature postmortems detailing his purported errors -- too uncompromisingly liberal, too focused rhetorically on reducing costs rather than increasing coverage, too passive in the legislative process -- are wrong where they're not mutually exclusive. In hindsight, again, we'll recognize that Obama was consistent and focused, and that he gave his adversaries space to hang themselves. Concessions and scaling back, as with the stimulus bill, will loom large and disappoint, but in hindsight it will be recognized that the legislation that passes constituted a giant step toward universal coverage.

Meanwhile, the dominant narrative comes across visually as much as verbally. Our radiant One has become the frowning, nonplussed, beleaguered One, per above. Let's see if the image changes after his speech on health care reform next Wednesday.