Wednesday, September 12, 2007

Happy Birthday to me

I turn 40 today, and all I want for my birthday is intergalactic war:



Of course, it doesn't come out until Sept. 25, and I'd need to buy an Xbox 360 first -- it won't run on the Xbox already in my house.

But those are quibbles. I'm 40, dammit! Life's gettin' short!

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Some thoughts on health care

(Previous posts worth checking out are here and here.)

Health-care costs -- and whether to go to a government-run payment system -- is an issue that could dominate the 2008 elections. But as always, the debate could benefit from some decluttering.

First, let's be clear on what we're talking about. Opponents of any sort of national health care deride it as "socialized medicine". In fact, they use that label to describe any government involvement in the health-care system, however small.

But true socialized medicine is when the government is the health-care system -- it owns the hospitals, employs the doctors, and decides what procedures are included and what are not.

That's not generally what is under discussion here in the States. We're mostly talking about a "single-payer" system -- wherein the government pays for medical care, but it is provided by private hospitals, doctors and clinics.

But that's just the beginning.

Proponents of the current system warn of rationing -- as if care isn't rationed now, by ability to pay. Nor do they mention all the personal bankruptcies related to medical costs.

They warn about bureaucracy -- as if there isn't plenty of bureaucracy involved right now. The only advantage is that you get to choose among several private bureaucracies instead of being stuck with one big government bureaucracy.

They warn about lack of choice -- as if workers have much choice now. At a good-sized company, an employer might offer two or three health plans. But most workers are lucky to have health insurance at all -- and often, even when it's offered, it's expensive or has big coverage gaps.

They warn that people will stop trying to become doctors if salaries are squeezed. But doctor pay actually isn't a big factor in rising health-care costs, and so shouldn't be the primary focus of cost-control efforts. Even under a single-payer system, doctors should still be well-paid.

(And never mind that one of the reasons for high medical salaries is the staggering cost of medical school. If those costs could somehow be ameliorated -- say, by hospitals agreeing to shoulder some of that debt when they hire new MDs -- we could have lower salaries without discouraging new doctors).

PERVERSE INCENTIVES
The current system is also riddled with Catch-22s that might make sense individually but end up being senseless in aggregate.

My brother's a doctor. He's a family practitioner, which if you know anything about medicine means he's not primarily in it for the money. Yet for an FP he makes money hand over fist because he happens to have a patient base that is generally young and healthy -- meaning he can pack lots of appointments into an hour, the most profitable way to operate given his employer's payment system (which, in turn, is based on insurance reimbursement schedules.)

He has a colleague who is really detail-oriented, likes talking to patients and takes time with them. She ends up with all the hard cases -- and because those patients take a lot more time, she makes a lot less money. Yet the system would collapse without her -- she frees up the other doctors to see more patients.

Does that compensation system make sense?

Then there's the bureaucratic craziness caused by having to deal with dozens of different insurers, all of whom have their own coverage and reporting requirements.

My brother knows all this. He can rattle off a dozen perverse incentives caused by the current health-care system.

Would single payer solve some of those problems? Yes. Would it introduce other problems? Almost certainly. Whether the tradeoff is acceptable depends on how its structured.

COMPARING THE TWO
The biggest advantage of the current system is that if you've got the money you can get the care you want, when you want it.

The biggest advantages of a single-payer system would be universal coverage (no more "preexisting condition" exclusions) and an end to medical-related bankruptcy. It would also relieve businesses of the burden of providing health insurance, making them more competitive in the global marketplace.

One of the remaining big issues -- quality and availability of care -- comes down to details in the design and administration of the single-payer program.

The remaining big issue would be cost. It would make no sense to move to single-payer if, after subtracting the cost of providing universal coverage, it cost more than the system it was replacing, or provided far worse outcomes for the same price. But that, again, depends on the specific structure of the single-payer program.

I still think the simplest thing to do would be one of the following:

1. A mandatory insurance system like that being tried by Massachussetts;

2. Pass a law requiring insurance companies to treat the entire country as one giant risk pool, with discounts or surcharges allowed for measurable health risks like age, obesity, smoking, skydiving, etc. Then let individuals buy insurance themselves. It would take the burden off of businesses and let the market work while giving everyone access to group rates. One could combine this with a "must buy health insurance" law in order to avoid free-riders. Or one could simply let people take their chances.

If I were going to introduce a single-payer system of universal coverage, I'd simply introduce it without banning other systems -- an extension of Medicare, say but with higher compensation. Then I'd let employers choose whether to keep providing private insurance or offload their employees into the government system.

Or maybe they'd keep it as a cheap option. That would result in a health-system structured in tiers: basic coverage for everyone, with consumers having the option of buying private insurance to supplement it if they so desired. Providers, in turn, could charge what they wanted. If they charged more than the government plan paid, patients would have to pay the difference -- either out of pocket or through the supplemental private insurance they bought.

All these things should be on the table. If we were to approach this pragmatically we should try the more market-based approaches first, in order to avoid creating a self-sustaining government program that would be hard to kill if it proved a disaster. But a full-fledged single-payer system shouldn't be dismissed out of hand. If the middle paths fail, it remains the logical next step.

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Tuesday, September 11, 2007

Chuck Hagel won't run -- for anything


Sen. Chuck Hagel of Nebraska said yesterday that he won't run for re-election to the Senate in 2008 -- nor will he run for president.

There went just about any chance I would vote for a Republican presidential candidate next year, though it depends on whom the Dems end up nominating.

He's apparently quitting to fulfill a semipromise of a self-imposed term limit:

"I said after I was elected in 1996 that 12 years in the Senate would probably be enough," Hagel said. "It is."

Fair enough. But I'm sad that he's not tossing his hat in the presidential ring. A solidly conservative, principled, nonisolationist antiwar candidate would have made things interesting.

As the story notes, the pending retirements of Hagel, Wayne Allard, John Warner and probably Larry Craig give Republicans four tougher-than-expected races that they'll need to win simply to stay even in the Senate. With 22 GOP seats up for re-election versus only 12 Democratic seats, it seems likely that Democrats will strengthen their hold on the Senate regardless of how the presidential campaign turns out. The question is whether Democrats will end up with anywhere close to 60 seats, which would put them within striking distance of being able to pass legislation over the objections of minority Republicans. Which, in turn, would make life very pleasant for a Democratic president and very uncomfortable for a Republican.

Me, I don't mind the Democrats getting a shot at control of Congress and the presidency, if only to undo some of what Bush "accomplished" under Republican dominance. But if they get it and screw it up, I hope Republicans take over part of Congress in 2010 and save us with gridlock. Unless obvious good is being done, gridlock is our friend.

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Wednesday, September 05, 2007

Rep. Paul Gillmor found dead

It's a rough time to be a Republican. Resignations, criminal charges, and now this:

Rep. Paul Gillmor (R-Ohio), a 10-term congressman from northwest Ohio, has died at the age of 68.

Gillmor, who just returned to Washington after the monthlong recess, did not show up at his office today. His staff went to check in at his apartment and found that he had died. Capitol Police are currently investigating the cause of death.

Initial reports say the cause of death was a heart attack. He was 68 and overweight, so that's not surprising.

This has little bearing on control of the House, where Democrats already have a comfortable margin.

Condolences to his family.

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Iraqi security forces unprepared to take over

Another day, another Iraq report.

This one is a Congress-commissioned study on the readiness of Iraqi forces, led by retired Marine Gen. James Jones, former Supreme Commander in Europe and former Commandant of the Marine Corps -- both under Bush, so let's not hear criticisms of him as a "Clinton general" or anything like that.

The conclusion: Four years after our invasion, Iraqi security forces remain unready to take over the country's security, and won't be able to any time soon. Structural progress within the military itself has been confounded by political corruption.

Overall, Jones found that Iraqi military forces, particularly the Army, show "clear evidence of developing the baseline infrastructures that lead to the successful formation of a national defense capability." But Baghdad's police force and Ministry of Interior are plagued by "dysfunction."

"In any event, the ISF will be unable to fulfill their essential security responsibilities independently over the next 12-18 months," the report states.

That bears out what U.S. troops have experienced throughout our time in Iraq, up to and including the surge: American troops can clear an area of insurgents, but Iraqi units are incapable of holding the cleared terrain.

That, in turn, bodes badly for the upcoming progress report on Iraq, because it's an example of political problems stymying military efforts.

The actual Iraqi military gets reasonable marks, though it, too, is plagued by corruption and sectarian rifts. But the report is stinging in its criticism of the police force, which makes up the bulk of Iraqi security forces.

It describes the Iraqi police as fragile, ill-equipped and infiltrated by militia forces. And it is led by the Ministry of Interior, which is "a ministry in name only" that is "widely regarded as being dysfunctional and sectarian, and suffers from ineffective leadership."

In other words, not much has changed in the last nine months. Which does not meet any definition of "progress" that I'm aware of.

Jones testifies before Congress tomorrow. Maybe he'll flesh things out a little then.

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Data-mining program dropped

The Department of Homeland Security has dropped one of its most ambitious data-mining projects after determining that it was cumbersome and had violated privacy rules.

Known as ADVISE and begun in 2003, the Analysis, Dissemination, Visualization, Insight and Semantic Enhancement program was developed by the department and the Lawrence Livermore and Pacific Northwest national laboratories for use by many DHS components, including immigration, customs, border protection, biological defense and its intelligence office.

The problems: They tested it for two years with real data instead of made-up data, violating privacy rules; and analysts found it "cumbersome" to use. Translation: it didn't work as intended.

Which has always been my problem with data-mining. It's great in theory, and I have no philosophical problem with it if personally identifiable information is protected. But the privacy worries are real -- this was the second data-mining project to violate privacy rules -- and connecting the dots turns out to be far more difficult than envisioned.

We should keep working on such systems to perfect them. But there should be two caveats: a sort of "proof of concept" that data-mining actually works, and strict privacy protections so that ordinary people don't find their data being bandied about by government bureaucrats.

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Tuesday, September 04, 2007

Backfill


Geez, I leave town for a week and everyone goes nuts! What's up with that?

BUH-BYE, GONZO
The big news, of course, was that Alberto Gonzales finally resigned -- with little or no explanation, though various administration officials applied various spins to the decision.

Not that it really matters. I don't care if he wants to "pursue other options" or "spend more time with his family" or simply "make more money in the private sector." I don't care if he was forced out or jumped or fell. All I can say is, "at last." It was too long in coming.

His resignation won't bring an end to the myriad Congressional inquiries into his actions and those of his subordinates. But it might take some of the bite and energy out of them.

His temporary replacement will be Solicitor General Paul Clement. A permanent replacement will be hard to find, for several reasons: Bush's diminished influence, the mess Gonzales leaves behind, and the fact that "permanent" means a little more than a year at the end of a dying presidency. It would essentially be a caretaker role, not a platform for grand initiatives.

If Bush is smart, he'll find someone of impeccable integrity who can spend the year cleaning up the department and restoring its morale and reputation -- an endeavor that, if successful, might erase the memory of Gonzales in time for the 2008 elections. But it could take quite a sales job to persuade the right person to take on that task.


CRAIG'S RAP SHEET
Meanwhile, reporters discovered that Idaho Sen. Larry Craig was arrested in an airport bathroom here in Minnesota, and pleaded guilty to soliciting sex from an undercover cop.

(Tangentially, it must be just loads of fun to be an undercover vice cop, sitting in toilet stalls and waiting for someone to proposition you. I wonder if they get a lot of reading done.)

Craig, pressured by Republican leaders, said he would resign -- but is now reconsidering that decision.

Craig denies being gay or soliciting sex, saying he pleaded guilty in hopes of making an embarassing situation go away. And the evidence against him is circumstantial -- essentially, a series of actions that are traditionally used by gay men seeking sex. No direct request, no words spoken.

Still, the sequence of events is odd to say the least -- looking into the neighboring stall, placing his bag against the front of his own stall, tapping his foot, touching the undercover officer's foot and "swiping his hand under the stall divider."

Any one of those actions could be explained away -- though the last is somewhat difficult. But all of it in sequence makes little sense except as a come-on. He might claim police entrapment -- but the officer in question has a good reputation.

On the other hand, the transcript of his discussion with the officer shows sharp disagreement about what occurred. So there's room for doubt. Nothing Craig said in the transcript conflicts with his public claims. It comes down to who you believe -- and what weight you place on the unreliability of eyewitnesses, even trained eyewitnesses like undercover officers. Craig could well be telling the truth, and he might well have prevailed had he been willing to endure a public trial.

Still, for the sake of argument, let's assume Craig is guilty. What should be our reaction?

My basic take is that, in a perfect world, this should be a nonstory. Who cares about his sexual orientation or private sexual habits, as long as they're not illegal? But the hypocrisy -- of Republicans in general, and the strongly anti-gay Craig in particular -- is what drives these sort of things. Republicans have made an issue of homosexuality, and poking their nose in people's bedrooms; this is the flip side of that coming home to roost.

Which is why a Republican strategist, Michelle Laxalt, said the following about the Craig case on Larry King:

"I happened to have come into the Republican Party during the more civil libertarian era of Barry Goldwater, Bill Buckley, Paul Laxalt, Ronald Reagan. And in their philosophy, the view about judging people regarding their personal lives was a live and let live philosophy. And somehow during the ensuing years, there has been a faction who call themselves the Moral Majority. We all remember the bumper stickers many years ago floating around Washington, which read 'The Moral Majority is neither.' And here we find ourselves virtually every single time getting whacked because of what is perceived to be a hypocrisy factor. The Republican Party needs to have some very serious introspection and return to the values that started us out, and that is individual liberty and a live and let live policy when it comes to people's private lives."

Amen. The Dems figured that out years ago, which is why nobody cares if a Dem is gay. There's no hypocrisy. In cases like this, Republicans are merely reaping what they have sown in their embrace of the religious right and "family values" issues.


THEY'RE BAAACCKKK!!
Congress returns from their summer recess, and that means more hearings on Iraq. Today we got a look at a GAO report on the Iraqi benchmarks, which notes that the Iraqi government has met only three of the 18 goals it set for itself, and partially met four others. And the ones that were met were the small, easy ones. (click here for the full report (pdf))

Wednesday and Thursday we'll get Congressional reports on the Iraqi security forces and the administration's own assessment of progress on benchmarks. And next week we'll get the big surge update from Gen. Petraeus. Both sides are already jockeying for position, with the White House downplaying the importance of political benchmarks and Congressional Democrats downplaying the importance of military benchmarks. It appears that many minds are already made up, and won't be changed by anything as mundane as facts on the ground.

This is a bit depressing, though I must admit that it's funny to see the White House criticizing the GAO report as "lacking nuance" when back in 2004 President Bush famously said he "doesn't do nuance." Oh what a difference three years of plummeting popularity makes.

Me, I accept the argument that the political benchmarks are more important than the military ones. But both are important, because progress (or backsliding) in one sphere can foreshadow progress (or backsliding) in the other. And it won't be as simple as "have they been met yet?" Indeed, that is only one of two important questions to be answered about the benchmarks.

1. Have they been met yet? This question is important both as an assessment of where we stand and as a way to judge the credibility of the claimants on both sides of the war, which should have some bearing on whom we believe going forward.

2. Has there been progress? And if so, how much? If the strategy can be shown to be working -- if there is reasonable reason to believe that it will deliver the necessary results -- then it deserves more time. But if the political benchmarks remain out of reach despite battlefield successes, or the battlefield is not successful enough to sustain the political achievements, then it's time to pull the plug.

Time to pull out my crystal ball.

Assuming the predictions are correct, what we'll get is a report that shows modest battlefield advances but political paralysis. So the debate will move on to two subordinate questions: what are the prospects for political progress, and are the battlefield gains both real and sustainable?

For that, we must await the reports.

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Back in the saddle


I'm back from the Black Hills of South Dakota, having shaved my head, stood five feet from a (live) buffalo, poured a drink for Wild Bill Hickok, driven over a picnic table and sat outside the razor-wired fence of a Minuteman missile silo without being arrested.

I swear all of the above is true.

Four adults and four kids, we named ourselves the "Van Hellions" in honor of our trusty 15-passenger van -- and, of course, as a tribute to Eddie. Oddly enough, while we had an eclectic music selection -- ranging from Flock of Seagulls and Fleetwood Mac to Rush, Guns 'n' Roses and Nickelback -- Eddie was not among them. We mourned his absence.

We also attended the Corn Festival in Mitchell, S.D., eating dinner across the street from the Corn Palace while Weird Al Yankovic played inside. The weirdest thing about the Corn Festival is that it involved no actual corn.

Other highlights included a horseback ride through Custer State Park, touring a gold mine, driving the Needles highway, visiting Jewel Cave, Mt. Rushmore and Crazy Horse Mountain, and driving through the Badlands.

On the way back home we survived a night of overpacked horror at the Jellystone campground in Sioux Falls, jammed in cheek-by-jowl with hundreds of Labor Day weekend revelers. We thought the kids would like it; we'll never make that mistake again.

In the quiet hours I found time to read "The Kite Runner" by Khaled Hosseini -- a good-though-not-great novel that paints a vivid picture of pre- and post-Taliban Afghanistan, and life as part of the Afghan diaspora. Next on the list: "Thirteen Moons", the second book by "Cold Mountain" author Charles Frazier.

All in all it was a great time, and everyone got along great. We're already planning next year's trip -- probably a canoe-camping venture in the Boundary Waters.

While I enjoyed the time away from all forms of media, I'm glad to be back and will resume my regular blogging schedule soonest.

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