You must insure your vehicle (of life)

In  arguments about the Constitutionality of the individual mandate in the Affordable Care Act, proponents have pointed out that the law obligates car owners to buy auto insurance, because the costs incurred and inflicted by uninsured drivers would be absorbed by the state.  Opponents have countered that no one is forced to own a car, and hence the state does not force us to buy car insurance. The ACA, by contrast, mandates that everyone buy health insurance, regardless of any prior economic decision.

There is a "vehicle" that each of us owns, however: our bodies. And while we don't "choose" to own them, we do choose to maintain them.  If we don't insure, we self-insure -- that is, make what provision we can to pay for the health care that we will inevitably consume.  But the self-insured rely on a massive reinsurer or stop-loss insurer whom they don't pay: the state. Federal and state law decree that no one may be denied care.  Hence failure to carry health insurance is an economic decision that affects the larger community. "Self-insuring" constitutes economic activity that may be regulated by Congress.

That is the thrust of the 2-1 majority decision in the U.S. Court of Appeals, 6th Circuit, upholding the individual mandate in Thomas More Law Center v. Obama.  Timothy Jost explains that Judge Boyce Martin, writing the majority opinion, redefined the question of whether the mandate regulates "inactivity" as opposed to economic activity:

Judge Martin contends that nearly every individual in the United States consumes health care, and thus must decide whether to purchase insurance or to self-insure.  Self-insuring is no less an economic activity than purchasing insurance.  Self-insuring results, however, in a substantial cost-shift when those who choose to self-insure cannot in fact cover the cost of their care.  For 2008, $43 billion dollars worth of care was passed on by those who chose to self-insure to others.  Thus self-insuring has a substantial impact on interstate commerce.

In fact Judge Martin also asserted that there is nothing in the Constitution or case law to prevent Congress from regulating 'inactivity" if the so-called "inactivity" affects interstate commerce:  "the text of the Commerce Clause does not acknowledge a constitutional distinction between activity and inactivity, and neither does the Supreme Court" (p. 23).    

That said, Martin also argued positively that the individual mandate "regulates active participation in the health care market" (p. 26, my emphasis).  Here again, the concept that those who do not buy health insurance effective self-insure is key: no one, insured or not, is inactive in the health care market; insurance determines who pays; and those who self-insure in aggregate pass their costs on to the insured.  Those who self-insure do so "cognizant of the backstop of free services required by law" (p. 19).

Is Obama exiting placatory mode again?

UPDATE: It was probably foolish to write the post below having read just one extended excerpt of what Obama said in today's press conference. The Journal, in a fuller account, says that Obama stated that the debt ceiling negotiations are aiming at a full-Monty $4 trillion in deficit reduction over 10-12 years. If Obama is really only demanding $400 billion in tax cuts to get there, that is terrible. How can they do $4 trillion without full-scale tax reform  that raises at least $1 trillion in new revenue over the 10-12 year period?  I had assumed that they were working on a kind of halfway-there deal, for which the proposed $400 billion in tax hikes would be proportionate.
     Ezra Klein thinks that the fact that Obama is picking a fight with Republicans over taxes means that he's given up on negotiations. This is actually a point I've made several times, particularly when Sullivan goes on about Obama "leading" on the deficit: when he starts staking out specifics in public and hammering the GOP, you'll know he's given up. Still, I must say, Obama did not sound today like someone who has given up on negotiations.
    Another idea I've been toying with, though, is that Obama's blowing off Congress regarding his Libyan adventure may have been a warmup for blowing off Congress on the debt ceiling. At TNR, Matthew Zeitlin recently recounted several lawyers' arguments that the executive branch could continue to pay debts, ignoring the debt ceiling.  Also in this category: making recess appointments, even if Congress doesn't recess.
    Guess I don't know what the hell Obama is thinking, or what's going to happen...
    Anyway, for what it's worth, here is this morning's post-haste post:
------------
I go back and forth on the question of whether Obama is unduly "passive," whether he cedes too much ground to the GOP, whether he fails as public advocate for his own policies...or whether it inevitably seems that way when you're presiding over 9% unemployment.

In any case, there have been moments when he's reshaped a debate or bid to decisively close one off -- e.g., his healthcare speech in Sept. '09, and his peroration to the healthcare summit in late Feb. '10.

Today's press conference delivered up what could be another such moment re the debt ceiling:

If everybody else is willing to take on their sacred cows and do tough things in order to achieve the goal of real deficit reduction, then I think it would be hard for the Republicans to stand there and say that, ‘The tax break for corporate jets is sufficiently important that we’re not willing to come to the table and get a deal done,’ or, ‘We’re so concerned about protecting oil and gas subsidies for oil companies that are making money hand over fist, that’s the reason we’re not going to come to a deal,’” he said. “I don’t think that’s a sustainable position.”

The weight of (recent) history

Ryan Avent quantifies a thought that's been kicking around in my head in one form or another for decades:

If people do make history, as this democratic view suggests, then two people make twice as much history as one. Since there are almost 7 billion people alive today, it follows that they are making seven times as much history as the 1 billion alive in 1811. The chart below shows a population-weighted history of the past two millennia. By this reckoning, over 28% of all the history made since the birth of Christ was made in the 20th century. [There's more, and a great chart.]

Some version of this reality first struck me when as a teen I read this dictum from Arthur C. Clarke: "Behind every man now alive stand 30 ghosts, for that is the ratio by which the dead outnumber the living."  My response (as I remember it, anyway): is that all?  After all these millennia? It jibed with some museum display of human population growth expoding in the last few centuries.

Where this came home to me is in education.  The sheer volume of discovery, thinking and writing produced in the last two hundred years -- always accelerating across even that span -- justifies because it necessitates the thinning out of students' exposure to the literature and history of the west from ancient times to the near present.

The slippage in Obama's "days, not weeks" promise

James Fallows, soberly upbraiding Obama for blowing off Congress in his prosecution of the isn't-war in Libya, repeats a quasi-misconception that in an odd way illustrates his point.  Arguing that Obama set himself up for Congressional rebuke by not seeking Congressional buy-in from the start, he writes:

This was a problem foreseeable from the very start* -- more than three months ago, when we were told that this would be a campaign of "days, not weeks."

Obama did not quite say that -- though there is some ambiguity in reports of what he did say on the two occasions when he used the phrase "days, not weeks."

First, on March 18, ABC's Jake Tapper relayed second hand what Obama reputedly said behind closed doors to Members of Congress.  The headline of the short item misrepresents the body content:

Another rough beast slouching

Lenin. Bin Laden. Palin. Stuxnet. Weapons that returned (or will return) to plague those who deploy them.

Thomas Wright of the Chicago Council on Global Affairs warns that Obama cannot have it both ways on cyberattacks: "It cannot on the one hand treat cyber-destruction by others as an act of war but then say that US cyber-destruction is a routine covert action":

What would Nixon do in Afghanistan? Kill a million more

The Times' inaugural revamped Sunday Review section is garnished with an extraordinarily perverse argument by Gideon Rose, editor of Foreign Affairs, regarding Obama's course in Afghanistan.  Rose asserts a) that in Afghanistan Obama should emulate Nixon's withdrawal strategy in Vietnam; b) that he is failing to do so; c) that Nixon's strategy was smart and could have worked; and d) that a similar strategy could work in Afghanistan.

Points a) and d) arguably have some truth to them; b) is largely refuted by Rose himself; and c) is factually wrong and morally objectionable.

Let's start with the deliberately provocative founding premise: that Nixon's "Vietnamization" and phased U.S. withdrawal could have worked.  Emphasizing the outré nature of this claim, Rose boldly quotes Nixon himself (and Kissinger) in seeming refutation:

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:

Nut-cutting time

Those who think that Obama will be placatory forever, let's see how he reacts to this joint statement (h/t E. Klein) from Sens. Mitch McConnell and Jon Kyl:

“The White House and Democrats are insisting on job-killing tax hikes and new spending. That proposal won’t address our fiscal crisis, our jobs crisis, or protect and reform entitlements. And a bill with new spending and higher taxes would fail with bipartisan opposition — as it should. President Obama needs to decide between his goal of higher taxes, or a bipartisan plan to address our deficit. He can’t have both. But we need to hear from him.”

Maybe it's wishful thinking, or the residue from last night's steely Afghanistan speech, or the memory from last November that Obama has absorbed The Clinton Tapes...but I think he's going to win this high stakes round.

Half a good prediction?

As the economic recovery continues to sputter in this second quarter, my thoughts have strayed from time to time to a February 2011 forecast by Goldman Sachs economist Alec Phillips. At the time, the shutdown loomed and the House GOP was demanding $61 billion in cuts to FY 2011:

Federal spending cuts deserve the most attention. They are the most likely of these issues to occur, and could have the largest magnitude. The assumption we incorporated into our recently revised budget estimates—discretionary spending cuts of $25bn and $50bn below the CBO baseline for FY2011 and FY2012 respectively—would shave nearly one percentage point off of the annualized rate of real GDP growth in Q2, but would fade quickly with a negligible effect on growth by year-end.

A ringing call to pragmatism

Not to presume to judge the wisdom of Obama's chosen course in Afghanistan, I just want to note how Obama himself understands his task as commander in chief of a country that has endured ten years of war, 6,000 lives lost and over a trillion dollars spent.  Here is the core:

We must chart a more centered course. Like generations before, we must embrace America's singular role in the course of human events. But we must be as pragmatic as we are passionate; as strategic as we are resolute.

He is about to pivot here to the highly leveraged U.S. effort in Libya. But this exhortation to pragmatism also describes his approach to Afghanistan -- indeed, to all overseas commitments. He is cerebral and cold-bloodedly minimalist about the AfPak mission. He wants just enough force to continue al Qaeda's degradation and the Taliban's containment -- and get out on sustainable terms.  With what sounds like a relatively modest troop withdrawal, he is marking, against his generals' will, the high tide of counterinsurgency -- beginning the transition to counterterrorism and handoff to the Afghans.

The war efforts must be triaged because the economic base of U.S. power is in peril:

Bed-wetting time again...

Chait complains, once again, that once again Obama is letting the Republicans run him off the negotiating field by getting drawn into negotiating what should be non-negotiable, the raising of the debt ceiling. Below, a comment I tacked on to Chait's post:

I feel the force of these by-now-longstanding laments about Obama's lack of negotiating skills. I feel them every time we go through this ritual - over Bush tax cuts in Dec., over 2011 budget. Thing is, each time he has come away with a somewhat hard to absorb but arguably surprisingly good deal. Perhaps we'll be surprised again by the debt ceiling negotiations - though all reports suggest otherwise.

Looks like there will be no significant concessions from GOP on raising tax revenue. That leaves a final backdoor stimulus, traded off of long-term cuts and spending targets. Perhaps, as in the 2011 negotiation, O will settle on spending cuts that look big but are structured the way he wants them and in line with his own proposals -- along with payroll tax cut extensions and maybe a surprise or two.

To widen the perspective a bit: Kevin Drum recasts an argument he made when Obama was negotiating the 2011 budget -- and once again, I think he's on point:

The Atlantic's slough of despond

Some time ago, The Atlantic's James Fallows wrote a reasoned, detailed and agnostic-to-hopeful assessment of the perception that the United States might be entering its long-anticipated decline.  Fallows concluded that the country has ample economic and cultural resources; that its fatal flaw might be the clunky democratic machinery bequeathed by the too-hard-to-amend Constitution; but that we had muddled through that difficulty in the past and might continue to do so (my take here).

A grimmer collective assessment is implicit in this month's Atlantic's dystopian take on the standard "year in ideas" feature.  This dyspeptic compendium may not reflect decline -- it's just fourteen journalists' perceptions -- but it does bespeak contagious pessimism begat by an anemic recovery.

The 14 biggest ideas of the year can mostly be placed three categories: no change, trivial change, and malign change. Or, sliced another way: lack of progress, useless diversion, and loss. Some of the changes -- the Arab Spring, wave elections, the rise of large middle classes in Asia -- are presented as at least potential positives -- but with a good deal of ambivalence. And in fact, those "ideas" in the "no change" and "trivial change" categories are mostly pretty malign too. Let's have a look:

Quick trip to Tralfamadore

Lightning round: trying to catch a quick chain of thought/association:

a) Read:  "Mayor Bloomberg, who just lost his beloved mother, also used his influence with Republicans to move the needle."
b)  Thought: strange, to lose your mother when you're yourself pushing 70...must concentrate the mind on mortality.  Then thought....

The empire pares back

In occasional posts about Robert Gates' speeches, I've noted that he takes a risk management approach to military spending.  In Pentagon debates regarding how to much focus on building conventional military capabilities to counter strong rival nation-states (i.e., China in 10-20 years) versus asymmetric conflict in failed and failing states, he has worked to weight the scales in favor of the latter, arguing that "the most likely catastrophic threats to the U.S. homeland -- for example, that of a U.S. city being poisoned or reduced to rubble by a terrorist attack -- are more likely to emanate from failing states than from aggressor states." He has served as a kind of antidote to Rumsfeld's "you go to war with the army you have"; his mantra might be have the army you're going to war with. And war, for the foreseeable future, is asymmetric conflict in failed/failing states.

Last week, in his final testimony before Congress, Gates adjusted this approach to deal with the new reality of long-term deficit reduction pressure -- in particular, Obama's proposal to save $400 billion from currently projected military spending over twelve years.  Since personnel costs account for the bulk of military spending, cuts of that magnitude mean reductions in troop levels, which in turn means reduced ability to fight Iraq/Afghanistan-type wars -- which from a certain (probably wrong) perspective means reduced focus on the risks Gates has defined as primary.

The new budgetary pressure requires a different kind of triage from the counterinsurgency-versus-big-ticket-weapons emphasis Gates has pushed for in recent years. The budget-cutting imperative means doing less (military) counterinsurgency -- which means, according to Gates, accepting additional risk. That means that the U.S. must be prepared to do less militarily -- and focus on doing it well:

A GOP oath best kept in the breaking?

Grover Norquist continues to insist loudly that Republicans violate his "no new taxes ever" pledge when they vote to close out any given tax loophole without instituting a fresh tax cut to offset the extra revenue. The response below is emotionally satisfying but misleading in one important regard:

“Grover is embarrassed that 34 Republicans essentially told him to take a hike [by voting to end the ethanol tax subsidy] and rejected his narrow and ridiculous interpretation of what the pledge means,” one aide says. “He’s made a calculation that this is an existential threat to his lobbying livelihood. That’s what this is about, one desperate lobbyist.”

The problem is, Norquist's "interpretation" of his tax pledge, which almost every Republican in the House and Senate has signed, is not "ridiculous." It's not even an interpretation.  He is simply holding the GOP to the letter of the pledge:

Unemployment and the incumbent president: look at the last 16 months

Binyamin Appelbaum recently warned in the New York Times:

No American president since Franklin Delano Roosevelt has won a second term in office when the unemployment rate on Election Day topped 7.2 percent. 

In response, political scientist Seth Masket plotted out presidential elections since 1948 and concluded, "the unemployment rate does not predict presidential elections at all." Carlisle Rainey dug deeper into the data and found that there does seem to be some relationship when incumbent presidents are up for re-election. Analyzing a massive series of data subsets, Rainey concludes more broadly, "the data are consistent with both very small and moderately large effects."  Nate Silver, similarly, dives deep and comes up agnostic, concluding that the unemployment rate does reflect (if not drive) the incumbent's fortunes,but that the relationship between the unemployment rate and electoral fortunes is too entwined with a host of other factors to map out with any confidence.

Silver also looks at the direction unemployment moves over an incumbent's term. Here I think he is getting warm. But as he looks over the whole four years, he finds little correlation.

I have for some time been (nervously) tracking Obama's political fortunes against Reagan's, since it's often pointed out that both inherited a vicious recession; at Obama's low moments I've taken some comfort in the fact that Reagan's approval rating reached a nadir of 35% in January 1983, shortly after the unemployment rate peaked at 10.8%.  The impression I've soaked up is that the unemployment rate really matters in the 16-odd months before a president stands for re-election, when the electorate starts to tune in and measure him against the opposing party's candidates.  For Reagan, I've noted, a decisive turn came in July 1983, when the unemployment rate dipped to 9.4% from 10.1% the prior month. From there he had the wind at his back to October 1984, when the rate was 7.4%. Hence Reagan's landslide.  He asked us to stay the course, and the course started running downhill run when it counted.

Coburn: ending the ethanol subsidy is (half?) a tax cut

I have been intrigued in the past to note that some conservatives characterize reductions in "tax expenditures" -- targeted tax breaks, such as for ethanol production or mortgage interest -- as "spending cuts" rather than as "tax hikes."  But Tom Coburn has gotten even more creative. Yesterday, Coburn won the support of 34 GOP senators for an amendment that would end the ethanol subsidy -- a vote he staged as a refutation of Grover Norquist's insistence that every closed-out tax break has to be offset with an equal tax cut.  Last week, ratcheting up his months-long feud with Norquist, cast ending a wasteful tax subsidy like this:

Are doctors more "defensive" than studies show?

Aaron Carroll takes a whack at the alleged myth that medical tort reform has the potential to significantly reduce healthcare costs. Citing two studies published in the September 2010 issue of Health Affairs, he reports findings from the first that our medical liability system accounts for only an estimated 2.4% of total U.S. healthcare costs (a nontrivial $55.6 billion), and from the second that tort reform would reduce costs by a mere one tenth of one percent.

Carroll originally published this post as a guest blogger for Ezra Klein, who has often cited similar findings -- as did Obama, in the bipartisan healthcare summit he called in February 2010.  Personally, I am deeply suspicious of the Republican passion for tort reform, medical and otherwise, which is part and parcel of their aversion to holding any industry accountable for any damages it causes.  Nonetheless, claims that the medical liability system has only a modest effect of doctors' behavior always arouses my skepticism.  This skepticism comes in large part from listening to my wife, a nurse-midwife at an inner city hospital, who is forever frustrated by the obstetricians' hair-trigger for Caesarian sections. Her colleagues are plainly strung taut by the constant threat of lawsuits; whenever anything goes wrong everyone anticipates a suit. I strongly suspect that the threat of liability affects caregivers' behavior in ways that do not show up in the research.  And I have questions about both of the studies Carroll cites, and about Carroll's presentation of them.

First, the two studies are to a certain extent at cross-purposes.  Carroll as noted above, reports that the first study [purchase required], led by Michelle M. Mello in a team including Atul Gawande, pegs the cost of our "medical liability system" at 2.4% of total healthcare costs and finds that the vast majority of that cost comes from the practice of defensive medicine.  Carrol then notes that the second study, led by J. William Thomas, pegs the potential savings from tort reform at just .1% of total costs.  But in the Mello study, defensive medicine costs and tort reform savings are presented as one and the same thing. The authors estimate of total, system-wide costs is based entirely on a series of studies by Kessler and McClellan conducted from 1984--1994. All the results, and the Mello authors' extrapolations from them, use those two terms interchangeably (my emphasis):

Kessler and McClellan examined the effect of tort reforms that directly reduce expected malpractice awards—such as caps on noneconomic damages—on Medicare hospital spending for acute myocardial infarction and ischemic heart disease from 1984 to 1990.⁷ The reforms lowered hospital spending by 5.3 percent for myocardial infarction and 9.0 percent for heart disease....

If I could poll Congress...

I wish I had the means to get every senator and House representative to answer this question anonymously:

If you were granted the power to personally appoint the next President, but it had to be a member of the party opposing your own, whom would you pick?

I wonder how many would pick the person they thought would be best for the country; whether some would pick someone they hoped would fail, but not so catastrophically as to destroy the country -- and what in fact those choices even mean. Someone of sincere ideological conviction would have to hope that his or her pick "failed" in some senses, i.e. in getting preferred policies enacted, while succeeding in others, perhaps mainly on the foreign policy front. 

Though I'm not in Congress, I have a preferred Republican, but my choice is a kind of cheat: Michael Bloomberg, a genuine RINO. Beyond that, I'm kind of clueless.  Huntsman seems able and sane, but I honestly probably just vacuumed that impression up from Fallows.  Bush Sr., I guess, is a little old for the job.

P.S. I wonder how many Republicans would choose Barack Obama.

Decay...decline...yada...we're fine (?)

Taking a cue from E.J. Dionne, Andrew Sullivan asks his readers to weigh in as to moments when they "realized we were late imperial Rome," adding, "Personally, I think it was some moment between the Congress's assent to torture in 2006 and when Sarah Palin was selected as a serious vice-presidential nominee in 2008."  The results are (by definition) impressionist:

The Clinton impeachment, hands down.  The long list of ridiculous investigations leading up to it were bad enough, but taking a step designed to remove an elected President over a personal affair showed that the view of politics over country now ruled the day.  The proceedings were political Kabuki Theater at its basest.

Well, maybe -- though I also must admit, net admirer of Clinton though I am, that I feel the force of Sandy Levinson's assertion that Clinton's "cold-blooded lying" (ultimately admitted) to constituents and Cabinet set an perhaps equally troubling precedent.


I am wary, though, of the decline narrative. It's hard to take the measure of an era, or put bounds around a given set of years as an "era," and harder yet to peg that era within a longer narrative. "You are too shallow, Hastings, much too shallow,/To sound the bottom of the after-times" (Henry IV, Part 2, IV ii). That's true for all of us.

I do fear that the U.S. has lost political functionality in two waves, one coming in with the Gingrich Congress in 1994 and the second with the Bush torture crew. The first destroyed norms that enabled the parties to work together, however adversarially; the second severely weakened our civil liberties and abused the powers of the executive branch.  Still, U.S. politics has probably been in dysfunctional mode more often than not since founding; the one virtue of our democracy is self-correction, and I'm hopeful for another round of that under Obama's stewardship. (I admit though that there too my faith goes wobbly; I am susceptible to the Krugman view of the Obama administration, damned repeatedly by half measures and failure to strongly rebuff GOP lunacy. See, for example, Joe Nocera's frustration today with Obama's failure thus to take a stand for Elizabeth Warren to head the fledgling Consumer Financial Protection Bureau.)

Tim Pawlenty, President of the United States of Gurgaon

Tim Pawlenty wants to privatize as many federal government functions as possible:

There’s some obvious targets. We can start by applying what I call “The Google Test.” 

If you can find a good or service on the Internet.     Then the federal government probably doesn’t need to be doing it. 

Perhaps, then, we should look to India for inspiration. Today, the Times' Jim Yardley portrays a country and city where economic dynamism wrestles with government dysfunction:

In Gurgaon and elsewhere in India, the answer is that growth usually occurs despite the government rather than because of it....

In Gurgaon, economic growth is often the product of a private sector improvising to overcome the inadequacies of the government.

To compensate for electricity blackouts, Gurgaon’s companies and real estate developers operate massive diesel generators capable of powering small towns. No water? Drill private borewells. No public transportation? Companies employ hundreds of private buses and taxis. Worried about crime? Gurgaon has almost four times as many private security guards as police officers.

The real Ezekiel Emanuel, revisited

Thanks to Ezra Klein for bringing into the current debate about euthanasia and assisted suicide Ezekiel Emanuel's humane argument against legalizing those practices, expressed in a 1997 Atlantic article.  Emanuel's chief concern was that once assisted suicide and euthanasia become common and accepted, subtle (or not-so-subtle) pressure would be exerted on some very sick patients to end their lives to ease the burden on their caregivers and loved ones:

Broad legalization of physician-assisted suicide and euthanasia would have the paradoxical effect of making patients seem to be responsible for their own suffering. Rather than being seen primarily as the victims of pain and suffering caused by disease, patients would be seen as having the power to end their suffering by agreeing to an injection or taking some pills; refusing would mean that living through the pain was the patient's decision, the patient's responsibility. Placing the blame on the patient would reduce the motivation of caregivers to provide the extra care that might be required, and would ease guilt if the care fell short. Such an easy, thoughtless shift of responsibility is probably what makes most hospice workers so deeply opposed to physician-assisted suicide and euthanasia.

That pressure, Emanuel warned, could also be financial, particularly in the United States:

Niall Ferguson goes all Götterdämmerung on us again...

Niall Ferguson issues a timely warning about the intense economic hardship following in the wake of the Egyptian revolution (recession, capital flight, inflation, unemployment). But having effectively demonstrated that hard times are at hand for Egypt, Ferguson goes into costume (melo)drama mode:

None of this should surprise us. Such is the life cycle of revolutions. What begins with euphoric crowds soon slides into a second phase of economic paralysis. The same happened in France after the initial “bliss” of 1789 and in Russia after 1917. In each case, exuberance at the overthrow of the old regime was swiftly succeeded by exasperation at the decline in living standards. And that was what gave the political extremists their opportunity to peddle their radical ideology of war against internal and external foes. Yesterday, the Jacobins and Bolsheviks. Tomorrow, I fear, the Muslim Brotherhood and Al Qaeda.

Well, maybe. But that is what I call a loose analogy (or pair of analogies).  A lot of countries have overthrown dictators since 1789; most have probably experienced economic hardship in the aftermath.  Not all have devolved into terror and tyranny.  In fact, the Egyptians of all stripes who participated in the ovethrow of Mubarak  have displayed intense awareness of a revolution-gone-wrong much nearer at hand: Iran's in 1979.  All, including the Muslim Brotherhood, publicly rejected that model:

GVF [2/4/11] — Egypt’s main opposition party, the Muslim Brotherhood have rejected calls by Iran’s Supreme Leader Ali Khamenei for an Islamic Revolution similar to the Iranian revolution of 1979 to be established in Egypt.

“The MB regards the revolution as the Egyptian People’s Revolution not an Islamic Revolution” said a statement published on the Muslim Brotherhood’s official website just hours after Khamenei's remarks on Friday, while “asserting that the Egyptian People’s Revolution includes Muslims, Christians, from all sects and political.”

Of course, Ayatollah Khomeini made noises about democracy too in 1979. Egypt's revolution could be betrayed (Elliott Abrams sees economic populism as a more likely wrong turn). But if Ferguson has any evidence that full-blown theocracy is around the corner, he doesn't cite it.

Back in February, a Bulgarian novelist, Nikolai Grozni, sketched out a very different analogy between a past revolution and Egypt's. His was offered as a hope, though not unleavened with warning:

Christopher Caldwell slips into the Fallows Fallacy on China

Noting that toilet maker Kohler has a global hit with an ultraluxury $6,400 toilet that was designed in large part to cater to Chinese tastes, Christopher Caldwell sees "a harbinger of trouble for the U.S":

A stubborn myth, in fact, holds that US creative exports are a more robust foundation for prosperity in the global economy than heavy industry ever was. Anyone can build a car, but Americans’ gift for innovation is ineffable. It is a kind of creative magic that is hard for the country’s sclerotic, overly bureaucratised trading rivals to match. How can you fight what you can’t fathom? Who can compete with a je-ne-sais-quoi?

America’s rivals are much less backward than its cheerleaders assume, however, and the country’s creative dynamism is much less mysterious. Taste tends to follow wealth. It should not surprise us if it turns out that people want US design only so long as the US is perceived as the richest, the best, the hegemon. True, there will always be American products that mix glamour and craftsmanship. But certain US exports are based on glamour alone, and will collapse as US prestige does.

At first read I thought that Caldwell was onto something profound here. And maybe he is, long term.  But I think he's overselling the troublesome toilet as a signifier that we're in deep shit now on the design-and-style front. This may well be an episode of what James Fallows calls the " "I just rode the bullet train to Tianjin, and holy shit, we're doomed!" approach to China's rise:

Against false equivalence on Medicare

Last week, the Times' Joe Nocera wrote that he finds it “discouraging” that “Democrats are going to make hay over the very idea that Republicans were trying to mess with Medicare” in response to Representative Paul D. Ryan’s plan to voucherize the program.

One of the five letters published in response today is mine. Needless to say, I don't like the false equivalence.  And the five taken together are a classic full-spectrum set of responses.  Full-spectrum of Times readership, that is: not one is in favor of implementing the Ryan plan as designed.    And come to think of it, very few Americans -- very few Republicans -- are.

Moan...a Lizza warning on 2012

Before I got sidetracked by the sheer mendacity of Mitt Romney's campaign launch speech yesterday, I was going to point out that it mounted a powerful assault on Obama's obvious vulnerability -- the still-moribund economy.  Ryan Lizza adds some important context -- the difference between social-conservative Mitt in 2007 and economic Mr. Fixit Mitt today -- and clips the same set piece I had pasted up:

Barack Obama has failed America.

When he took office, the economy was in recession. He made it worse. And he made it last longer.

Three years later, over sixteen million Americans are out of work or have just quit looking. Millions more are underemployed.

Three years later, unemployment is still above 8%, a figure he said his stimulus would keep from happening.

Three years later, foreclosures are still at record levels.

Three years later, the prices of homes continue to fall.

Three years later, our national debt has grown nearly as large as our entire economy.

Families are buried under higher prices for food and higher prices for gasoline.

It breaks my heart to see what’s happening in this country.

These failing hopes make up President Obama’s own misery index. It’s never been higher. And what’s his answer? He says this: “I’m just getting started.”

No, Mr. President, you’ve had your chance. We, the people on this farm, and citizens across the country are the ones who are just getting started.

Leaving aside the lie that Obama made the recession worse, this is a perfectly fair, inevitable, obvious line of assault.  If unemployment does not soon drop significantly, as it did for Reagan beginning in July 1983, this line of attack will be effective whoever delivers it.  

The brief against a sitting president probably always has this rhythm - short declarative sentences laying out what went wrong.  Compare John Kerry on September 24, 2004:

Romney to drown government in bathtub?

As an earnest of  Mitt Romney's intellectual honesty, note the way he contrasts his future budgeting with Obama's in his campaign launch speech in Stratham, NH today:

Government under President Obama has grown to consume almost 40% of our economy. We are only inches away from ceasing to be a free market economy. I will cap federal spending at 20% or less of the GDP and finally, finally balance the budget.

Sounds like he'll cut spending in half, doesn't it? Except that he is, natch, comparing an apple and an orange.

Combined federal, state and local taxes have been pegged at 39.97% of  GDP in 2010 -- by what looks to me a  dubious source (albeit cited by wikipedia): a certain Christopher Chantrill at usgovernmentspending.com , a site devoted in large part to highlighting the wonders of the Ryan budget. The number includes a self-described guesstimate of state and local taxes.   Dubious or not, according to the same source, the figure stood at 36.94% in 2008 and at 34.73% in 1988, the last year of Reagan's term. Given that over 90% of economists accept the imperative to raise government spending during an economic downturn, the 2010 figure hardly represents a dramatic surge to within inches away from ceasing to be a free market economy. The last time total government spending was at Romney's implied target, 20% of GDP, was 1940, according to Chantrill. Guess Romney's going to drown government in the bathtub?

Not exactly.  Romney promises to cut federal spending to 20% of GDP -- echoing the Ryan plan, whose authors proudly contrast it to Obama's budget as follows: 

Brings government spending to below 20 percent of the economy, a sharp contrast to the President’s budget, in which spending never falls below 23 percent of GDP over the next decade.

And that's in contrast to Obama's 2012 budget, since superseded by the White House's long-term deficit reduction plan, which proposes some $2 trillion in spending reductions over ten years.  We're talking 20% vs. perhaps 21-22% here -- hardly a last-ditch rollback of the red tide. Never mind that balancing the budget within the course of a two-term presidency is essentially impossible.

That's not to say that the differences in proposed spending between the Obama and Ryan plans are not dramatic. But it's the Ryan plan that's truly radical, promising to end Medicare and Medicaid as we know them and reduce federal spending to 14% of GDP by 2050, a level not seen since the early 1950s. Does  Romney's short-term 20% target suggest a similar trajectory? If so, good luck wrapping the flag around a Ryanesque budget.

Greg Sargent puts his finger on the line of attack that Romney's budgetary sleight-of-hand serves:

Romney signaled early on that Obama’s cultural identity and understanding and appreciation of America would be central to the 2012 campaign, and here he’s suggesting that Obama has transformed our economy into something no longer recognizably American.

Creating the impression that Obama has raised spending to unAmerican levels is of course central to this disgusting scare narrative.

Learning to love the individual mandate

A pivotal moment in Boston Globe reporter Brian C. Mooney's in-depth retrospective on Mitt Romney's role in passing healthcare reform in Massachusetts centers on a qualified acceptance of the plan's most politically fraught element:

“I’ve never been one for individual mandates in the past, but I do think that the way this has been proposed, in that everybody will do their part, that’s a compromise...I can buy into that.’’

That's Ted Kennedy speaking.  Romney's commitment to the mandate came earlier (it was Romney's plan that Kennedy responded to above) and was much less guarded when it came.  The mandate was far more in accord with Romney's principles (at that point in his career it still appeared that he had some) and with the interests of his support base than it was with Kennedy's.