Wednesday, July 10, 2019

Profit isn't the problem with US healthcare costs

(Note: the following is an informal Op-Ed I wrote for America's Future Foundation)

Healthcare was a major focus in last week’s Democratic primary debate, and for good reason: U.S. per-capita healthcare spending is highest in the world, and roughly double the OECD average.  Regrettably, several candidates misdiagnosed this problem as the fault of a favorite scapegoat.  Controlling healthcare costs successfully will require more serious accounting for what makes them high to begin with.

To hear Democrats in the debate tell it, the problem is simple greed.  Senator Cory Booker alleged “[t]here are too many people profiteering off of the pain of people in America, from pharmaceutical companies to insurers.”  Senator Elizabeth Warren lamented how insurance companies sucked $23 billion in profits out of the health care system” last year.  And Senator Bernie Sanders summed up the logic behind his plan’s ambitions to lower cost: “We will substantially lower the cost of healthcare because we stop the greed of the insurance companies.”

This is a familiar refrain from the progressive left: US healthcare is broken because it puts “
profits before people.”  By juxtaposing financial success with suffering, they imply the former causes the latter, and convert sympathy for the sick into anger at the affluent.

This doesn’t fit the facts, and it doesn’t make intuitive sense.

The $23 billion in insurance company profit that so dismays Senator Warren amounts to just 0.6% of the $3.65 trillion Americans spent on healthcare last year – hardly the driving factor.  And greed cannot explain why healthcare is so uniquely expensive in a broadly capitalist economy.  All corporations seek to maximize profit; surely pharmaceutical executives are no greedier than those at Nike or Amazon.  Indeed, the facts suggest they are not.  Biopharma’s profit margin is 16%, “significantly lower than Computer Sciences (31.6%), Beverages (27.4%), Aerospace/Defense (23.0%), and Trucking (19.1%)”.

Some argue sick people “can’t say no” to life-saving products, but most patients’ circumstances are not so dire.  Besides, this is not unique to healthcare either. Americans can hardly do without shoes, clothing, or food, and yet most are able to afford these things in abundance.

So why can’t they afford healthcare?  The answer may not fit in debate-stage soundbites, but it ultimately boils down to two factors: competition, and cost consciousness.  In a healthy market, these factors limit how high and quickly prices can climb.  But in the U.S. healthcare system, decades of piecemeal regulation have gradually eroded those limits, permitting healthcare suppliers to
charge almost whatever they like.

Patent law provides de jure monopoly to pharmaceutical giants for decades at a time.  Once that expires, the FDA maintains enormous barriers to market entry, ensuring only the wealthiest and best-connected firms are able to participate.  Asinine prohibitions against importing drugs from overseas further shield these companies from any need to price their products competitively.  Meanwhile, antiquated restrictions on medical licensure and Med School accreditation artificially narrow the supply of doctors, giving each more leverage to charge inflated fees.

Patients rarely mind, though, because they’re usually not the ones paying for their care (at least, not at the point of service).  Through Medicare, Medicaid, and Veterans Affairs, fully 65% of healthcare spending is taxpayer funded.  And thanks to minimum coverage requirements and decades of tax exemption for health benefits, even private health “insurance” has morphed from peace of mind for unlikely misfortune into camouflaged prepayment for likely expenses.  In both cases, Americans have little incentive to economize on what they’ve already paid for.  Consequently, roughly a third of healthcare spending is wasteful or medically unnecessary.

Such frivolous spending may increase profits, but it’s not caused by the profits – it’s caused by the government distorting market incentives.  This is why most studies indicate Medicare for All would increase healthcare costs even further.  By offering more people access to more services at other people’s expense, Senator Sanders’ would greatly exacerbate the cost-consciousness problem.

Of course, the merits of healthcare reforms pertain to more than just overall cost.  Values questions of who should bear the cost also warrant careful reflection.  But blaming the profit boogeyman only mires such discussions with misaimed vitriol and disingenuous demagoguery.  Americans deciding whether government should manage more healthcare payments deserve to know it was government – not profit motive – which made the payments so high.

Thursday, March 7, 2019

Is driving 5 mph over the speed limit ‘reckless’ ?

An online acquaintance from Great Britain posted this article, titled “Retired village couple catch 130,000 speeding drivers in just a week,” with the caption, “Should motor-vehicle offenses be higher up the law enforcement agenda?  A long debate thread ensued, which I will not reproduce in full.  Instead, I’ll highlight a specific exchange I had with one reasonable commenter, and let you be the judge.  All names are changed as usual.

Kevin: That's approx 1 driver every 5 seconds speeding, 24 hours a day, 7 days a week. I somehow doubt this.

Me: They are plainly lying, just mathematically speaking. Even if they weren't, they're wasting their time and energy without performing any important public service at all. Speed limits are too low, more like guidelines than actual limits, and everyone in every developed country on Earth seems to know that except these two.

Kate:  lmao at the extraordinary defense of reckless driving practices in this thread…People who don't get the difference a couple of miles p/h can make to vehicle accidents honestly need to go back to school and pay attention. Makes me so fucking angry.

Me: if you think driving 5mph over the speed limit is reckless driving you're just amazingly out of touch with how ordinary people drive. 5mph over is the *norm* - the speed of traffic. Going considerably slower than the speed of traffic poses more safety risks than it does to just keep pace; it's oftentimes safer to go 5 over than it is to go 5 under. And in any case, that norm evolved because cops everywhere realize speed limits are drawn arbitrarily along a spectrum of risk (as opposed to some objectively correct cutoff point) in a way slightly more risk-averse than the average person's risk tolerance, including theirs, which makes those laws particularly lacking in moral authority at the margins. This universal speed limit fudge factor is not a consequence of individual moral failings; it's a direct and predictable consequence of arbitrary, out-of-touch, overly restrictive regulations, which is replicated in other areas.

If you want the moral authority to finger-wag at people who go a tiny bit over the limit, you need to boost the limit to something approaching popular consensus on what actually constitutes unsafe driving. We can either a) boost all speed limits by 10-15mph if you want them rigidly enforced, or b) keep the status quo of "unwritten rules" in which you're only pulled over for speeding if you're going more than 10 over (unless the cop's in a particularly bad mood!)

Kate: I'm actually really glad you used 5 mph as an example. Here's a video that pretty acutely explains the difference between car accidents just 5kmph in difference. If this is the damge 5kms can do, imagine how much worse 5 miles is. 

Me: There are a few reasons that video makes for an unconvincing rebuttal to my argument:

1. Determining whether something is reckless (aka "unacceptably risky") requires not just an analysis of how bad the event would be were it to happen, but also of how likely it is to happen in the first place. Yes, if a truck unexpectedly pulls out in front of you, it'd be better to be going 60. But the likelihood that this will happen is very low, and also variable based on circumstance (are you near an intersection? are the roads crowded or empty? is it night time so you'd see the headlights? etc.) in ways fixed speed limits do not account for.

2. In this video, the distance between the braking car and the truck was reverse engineered to maximize the difference in speed at impact (or at least inflate it beyond what it would usually be) for the purpose of making a more powerful commercial.

The video's core insight is that "in the last five meters of braking, you wipe off half your speed." Logically, this exponential speed decrease will only occur in one instance without occurring in the other under a narrow subset of real-world braking distances. Suppose it takes 45 meters to brake at 60kph, and 56 meters to brake at 65kph (reasonable because I looked it up: In both cases, you wipe off half your speed in the last five meters, fine - but that only makes a big difference in velocity at impact if your vehicle happens to be between 40-56 meters away at the moment you see the obstacle. Beneath 40m it makes little difference, and above 56m it makes no difference at all. Drivers already intuitively realize that the risk of *any* need to brake to a full stop is pretty low. The risk of encountering an obstacle exactly 40-56 meters away is lower still.

3. However important 5 kph/mph may be, speed limits are still an arbitrary cutoff, making them largely lacking in any real moral authority. The difference between 60 and 65 may be important, but it's not any MORE important than the gap between 60 and 55, or between 65 and 70, etc. Somebody still has to draw a line saying "this level of risk is acceptable, while this level is not" - and reasonable people can disagree about where that is! The reason speeding is so prevalent is not because average people are morons, incapable of grasping the gradual but intuitively obvious relationship between speed and risk, who need stern government technocrats to protect them from themselves. It's because speed limits were set by people from bygone eras, in which modern ABS and car safety features were not available, who faced political incentive to prioritize safety over competing values like tolerance and time efficiency, and were consequently much more risk-averse than the population is today.

4. Drivers do not drive in a vacuum, and the optimally safe speed is dependent on the speed of cars around you. Stop-times are not the only factor in driving safety; others include safe merging, or changing lanes on a busy highway, which are much more easily accomplished if your position in relation to other cars remains relatively constant. The fact of the matter is that most people speed whether you like it or not, and responding to this by being that one puritan asshole going way slower than everyone else ENDANGERS those who must now react to the unexpected, feel compelled to pass, or get over to the side in order to make their exit.

Monday, February 11, 2019

A brief analogy on Ilhan Omar's tweets

Imagine Bernie Sanders tweeted a story of a black Wall Street banker caught using illegal offshore tax havens to minimize his tax burden, alongside the caption, "What a crook!  We have to ensure these people are paying their fair share." Would that be racist? It is true that black people are often stereotyped as criminals.  And, it is true that "othering" a whole class of people is a common racism red flag.  In another context, referring to a black person as a crook and then following it with "these people" could certainly be racist.  But in this (hypothetical) context, there would excellent reason to suspect - from everything we know about Bernie and the issues important to him - that "those people" to which Bernie referred were not blacks as a class, but the class of millionaires and billionaires in the 1%.  That's because Bernie talks about how important it is to make the 1% pay their fair share *all the damn time.* (In fact, he criticizes Wall Street bankers so much that were he not Jewish himself, he would almost certainly be accused of anti-Semitism...but I digress). So it is with Ilhan Omar.  As a rising figure on the political left, she criticizes the corrupting influence of money in politics *all the damn time.* She made it a prominent pillar of her campaign by refusing to accept any money from Super PACs.  She criticizes the NRA's lobbying efforts.  She criticizes Citizens United as a common talking point.  So although "rich Jewish puppeteers using dark money to control the government behind the scenes" is most certainly an anti-Semitic trope, in this context it seems very likely that the reason she criticized AIPAC for throwing big money around was not that they happen to be Jewish.  In fact, it would be quite odd if Representative Omar took it easy on AIPAC's lobbying when she so uniformly opposes both a) the policy positions AIPAC endorses and b) the outsized influence of powerful special interest groups writ large. Ergo, that she criticizes their use of money to influence politics is not at all anti-Semitic. Things can still have a racist effect without racist intent, and she probably should have used more cautious wording. But the bipartisan pile-on excoriating her was a bunch of disingenuous pearl-clutching. Everyone knew what she meant.

Tuesday, October 16, 2018

Elizabeth Warren: 1% Native American, 100% foolish

Elizabeth Warren made headlines yesterday by releasing a DNA report showing she is somewhere between 1/1024th and 1/64th Native American – and then calling on Trump to follow through on his 2017 promise to pay $1 million to a charity of her choosing if she took a DNA test “and it shows you’re an Indian.”

…That was an astoundingly stupid thing for her to do.  In fact, it’s a perfect example of how foolishly progressives and the media play into Trump's hands.  

Here's a recap for those not tracking the context behind this.  Elizabeth Warren is a left-wing Senator from Massachusetts who grew up in Oklahoma, one of the states most heavily populated by Native Americans. Like many white Americans (myself included), her family taught her a legend of Native American ancestry on her mother's side, without really specifying how much or how far back.  Like many white Americans, she accepted this as true without caring to verify it.

Warren went on to launch a brilliant law career that included professorships at both UPenn and Harvard during the 80's, 90’s and 2000's. During this time, elite universities were particularly eager to promote diversity among their students and faculty, in order to combat the impression that they were a pay-to-play club of white Good-Ol’-Boys. And during this time, for reasons known only to her, Warren used her family lore of Native American ancestry to identify herself as a racial minority on multiple occasions.

In 1984, she submitted five recipes to a Native American cookbook titled Pow Wow Chow, identifying herself as Cherokee.  From 1986-1995, she listed herself as a “minority” in the Association of American Law Schools Directory of Faculty.  In 1996, a Harvard Spokesman identified her as Native American professor, as did a Crimson editorial three years later.  And in both 1994 and 2005, the University of Pennsylvania listed her as a “minority” professor in its Minority Equity Report.  None of this would have been possible had Warren not spoken up to promote her Native American ancestry to on multiple occasions, to professional peers and superiors who would have been much more eager to gobble up that claim than to verify it.

In 2012, Warren ran for Senator of Massachusetts, and the story finally caught up with her.  She was challenged to verify her ancestry by her Republican opponent, and was unable to, admitting honestly that she believed it solely because it had been passed down through family lore. A team of New England genealogists wasn’t able to conclusively trace any ancestry either, which made for a media embarrassment.  And although she won that race anyway, the issue resurfaced in 2017 when Trump brought it back up, calling her “Pocahontas” and making his $1 million pledge. His exact words were these:

“I will give you a million dollars, paid for by Trump, to your favorite charity if you take the test and it shows you’re an Indian.”

That’s it.  That’s the context.  That was the end of the story, until yesterday.

Yesterday, Warren released this video, three weeks before the crucial primary elections, “proving” that she had a Native American ancestor 6 to 10 generations ago.  With a smile!  Not with an apology…not with a “this is a distraction from the issues that matter” change-of-subject…but with an “I told you so” smirk as if she’d been vindicated – proven right! – after all this time.

The left-wing media played right along.  CNN broke the news with the headline “Elizabeth Warren releases DNA test with 'strong evidence' of Native American ancestry.”  Six generations would be 1/64th native, or 1.5%.  10 generations would be 1/1024th native, or 0.09%.  This is “strong evidence”?

The Washington Post article was titled, “Trump promised $1 million to charity if Warren proved her Native American DNA. Now he’s waffling.”  The Young Turks did the same, of course.  They really tried, for a whole day, to make this into a story that made Trump look bad.  Their political instincts are so off – their finger so hopelessly far removed from the pulse of the American electorate – that they still think reeaaaaaaaaching to show Trump plausibly reneging on another promise would make this into a story that hurt him.

Holy SHIT these people are thick!!!

Elizabeth Warren had an out here, people.  She could have just apologized, and it would have been totally forgivable.  We all tend to trust our family elders when they tell us things we’d already like to believe about ourselves, and romanticizing our Native American roots is part of white America’s founding mythology.  It’s sort of fun and mysterious to imagine we have some biological connection to the country’s original inhabitants (rather than just to the people who slaughtered them).  It might have even felt vindicating for a woman who fancied herself so progressive.  So she rolled with it, and subsumed it into her identity until the scrutiny of political prominence dug deeper than her pride had been inclined to dig.  Perhaps some UPenn administrator had sent out an email asking if anyone had Native Ancestry so they could play it up for their Minority Report, and she’d replied in the affirmative out of sincere misconception as to how it would be portrayed.  In comparison to all of Trump’s scandals, she could totally shake that off.

But she didn’t take the out.  Instead, she doubled down.  She took Trump’s bait, and made a professionally produced video arguing that a maximum of 1.5% Native ancestry was enough to justify identifying oneself as a “racial minority.”  She went full Rachael Dolezal three weeks before the primaries, on the apparent belief that reigniting this story would help her make political inroads in 2020 by enabling jokes bout Donald Trump’s “memory problems.”

Let’s ignore, for the moment, that Senator Warren’s DNA test literally proves Donald Trump right: she has barely any Native Ancestry, and was disingenuous to pretend otherwise for job security and social kudos.  Let’s pretend you’re partisan enough to think Warren really is vindicated and Trump really does owe her $1 million. 

What I wanna focus on is this: Elizabeth Warren wants to unseat Donald Trump as president in 2020.  How on God’s green Earth does she think this move will help her do that?

Donald Trump won the 2016 election because he won a series of crucial Rust Belt swing-states full of mostly white, blue-collar people.  White, blue-collar people who live in Rust Belt swing-states feel ignored, alienated, scorned and looked-down-upon by each of the following types of people:

1.     Liberal people
2.     Wealthy people
3.     Famous people
4.     People who live in cities
5.     People who live on the coast
6.     People with a college education

What they hate MOST of all are people who are all of these things at once, and then tell them that THEY – the relatively poor, uneducated, simple country flyover-folk farmers and truck drivers in the Midwest – are privileged because they are white.  This is why they hate Colin Kaepernick.  This is why they hated Barack Obama.  They hate anyone – from Hollywood actors to pretentious policy “wonks” at – who uses their distant, detached, lofty positions of relative social power to lecture them about how racist and ignorant they are, and how really THEY (the powerful coastal celebrities) are the victims on account of their race.

You don’t have to agree with these white people on racial issues (and I certainly don’t) to realize that nothing rouses their political ire more than a story about a rich, educated, powerful white Senator from a coastal Yankee state pretending to belong to an oppressed minority!

How long will it take for the left to figure this out?   How many think pieces have been written since 2016 about this exact phenomenon?  How many autopsies of Clinton’s failed campaign against the least popular man in modern political history have to be conducted before the Washington Post stops fanning the flames of that resentment?

If you think this DNA test makes Warren look good, you are out of your fucking mind.  If you think it catches Trump “waffling” and makes him look bad, you are completely out of touch with reality. If you’re so wrapped up in the literal veracity of the unscripted sentences that Trump says that you ignore the broader themes he’s messaging on, and the latent sentiments they resonate with, you’re missing the forest for the trees.

The longer the story of white-as-paper Elizabeth Warren claiming to be a racial minority at all remains in the press, the more the right wing is going to gobble it up, and the more popular Donald Trump is going to become in the states that matter in 2020.  If I were Donald Trump’s strategist, I would very publicly write her a check for $976.56 – exactly 1/1024th of a million dollars – just to keep it in the news.  Most of the country would rightfully laugh their asses off and he would emerge as the clear winner of the exchange.

I didn’t think Elizabeth Warren had a great chance to be President in 2020 anyway.  But if Democrats know what’s best for them (and they don’t), they won’t touch her with a ten foot poll now that she's revealed such awful political instincts.

Wednesday, September 26, 2018

Constitutional conservatives should hope Brett Kavanaugh is not confirmed

I don’t know if Brett Kavanaugh once tried to rape somebody.  Only a few people can know, and unfortunately, I can’t trust any of them blindly.  We can support and defend women who come forward about rape allegations in a general sense without being na├»ve as to the highly unique political circumstances of this allegation in particular.  Enough is at stake that everyone involved has plausible motive to lie or exaggerate.  What’s more, 37 years is enough time that any of those people might sincerely misremember the faces or names or details of what took place.  Kavanaugh is not entitled to a presumption of innocence; likewise, his accuser is not entitled to a presumption of his guilt.  I don’t believe either of them, as I have no reliable information to substantiate either’s testimony. Neither do you.

All I know is that the allegation that Brett Kavanaugh once tried to rape somebody is enough, in the eyes of tens of millions of Americans, to delegitimize his rulings on polarizing legal issues the Supreme Court has to address.  And that’s all I need to know to see that Congress ought not confirm him to that Court.

Constitutional Law is one of the few sets of issues on which I retain conservative sympathies.  I interned for The Federalist Society in college, and the Volokh Conspiracy is on my favorites bar.  I think Citizens United was rightly decided.  I find originalism compelling.  I detest Donald Trump, but I love Neil Gorsuch – that Trump gets to nominate multiple Supreme Court Justices strikes me as the silver lining of his otherwise despicable presidency.  Ideologically, I would probably agree with most of Brett Kavanaugh’s legal rulings.

But more than constitutional conservatism, I care about constitutionalism generally.  The constitution is the only structural restraint on government power.  That makes it pretty dear to my heart, considering I want government to have as little power as possible!  And the Supreme Court is easily the largest of these restraints, with the clearest track record of striking down oppressive laws instead of adding more.  An independent judiciary plays a crucial role in constraining the vices of democracy; in checking the abuses of ambitious leaders; in preventing mob rule; in protecting individuals from the whims of their neighbors; in articulating and enforcing rights.  To me, the constitution is the proudest and most defining feature of American government, and the Supreme Court is the only body capable of keeping it alive.

This urgently important job can only be done under certain conditions.  The Supreme Court has no Army; it relies on the good-faith compliance of the executive branch, in the spirit of respect for longstanding constitutional norms.  Over the course of our nation’s history, the President’s boldness in pushing the limits of Supreme Court rulings has waxed and waned according to circumstance - but ultimately, no President has openly defied a Supreme Court ruling.  For at least the past 80 years or so, the executive has deferred to the Supreme Court’s ultimate authority on legal questions – making it perhaps the only remaining area in which Presidential power is effectively constrained.

But if a President chose to ignore the Supreme Court one day, or Congress or a state government threw down the gauntlet of defiance, nobody quite knows what would happen.  At the very least, it would spark a showdown that disrupts this tepid status quo of executive obedience, and imperiled the legitimacy of the Supreme Court as a constraining body.  Which side prevailed would likely rely in part on the public’s opinion of the institutions competing: elected officials would only back down if the confrontation was making them look bad.

All of this is a roundabout way of saying "like it or not, appearances matter."  The Supreme Court’s ability to effectively constrain the other branches of government depends in part on its reputation as an independent, impartial, above-the-fray panel of experts, who command respect as men and women of intellect and character.

Unfortunately for Brett Kavanaugh, the allegations against him would significantly tarnish that reputation – and therefore degrade the Court’s ability to do its job effectively – whether they’re true or not.

If you doubt me, consider the following hypothetical.  Ruth Bader Ginsberg is 85 years old.  It’s entirely possible she dies before 2020.  It’s also entirely possible Trump wins again in 2020.  If either occurs, conservatives will probably secure a 6-3 edge on the Supreme Court.  That court would not include Merrick Garland – but it would include three justices nominated by a president who lost the popular vote, and (if Kavanaugh were confirmed) two justices accused of sexual impropriety against women (remember the Clarence Thomas/Anita Hill allegations).  And at some point in the next few decades, that court may be asked to relitigate Roe v. Wade – or, short of that, the constitutionality of funding for Planned Parenthood, or on whether the ACA covers birth control, etc.

I don’t use the term “constitutional crisis” lightly, because it’s sensationalist and our country has weathered a lot.  But I don’t think conservatives quite appreciate how scathing the Democrat pushback will be, or how disruptive it will be to the constitutional norms on which the SCOTUS relies, if a court of old conservative dudes accused of rape who the left thinks got there via Republican gamesmanship sides “against women” along party lines on those issues.  The left would literally revolt.  They would not shake hands and say “good game” and just wait 20 years until the Court goes left again; they will launch an attack on the legitimacy of the court that stretches the seams of our constitutional system much further than I’m confident they can hold.  I don’t think the Court will ever overturn Roe – but if they did, a President Kamala Harris might just ignore those rulings and dare the court to do something about it.  Alternatively, she might just pack the Court with 15 justices like Roosevelt tried before. And when that happens, the SCOTUS is officially dead, and so is the constitution I cherish.

The bottom line is that if Republicans care about using the Supreme Court to restrict government power moving forward, they need to tread lightly around the growing hostility my generation seems to have for it.  That Kavanaugh appears, to many, to have a history of violence or disrespect towards women impacts his ability to announce and author court rulings that will be taken seriously by the people of our country. If he is innocent, and this entirely falsified accusation denies him the pinnacle of his professional achievement, that wouldn’t be fair; I’d feel bad for him.  But ultimately, I care much more about the long-term legitimacy of the court that I do about which highly qualified person gets the privilege of serving on it.  There are better, no-less-conservative options that would be healthier for our Republic, and Republicans should pick one of them instead.