The two great myths of health care - part 1

I'm returning from my self-imposed exile because I'm finally fed up with the rhetoric surrounding the endless and, almost certainly, failed bid to create a health care plan that will actually help Americans at a reasonable cost. Having read endless amounts of prose on the two sides over the past year, I don't need to articulate the very real concerns that the right has over these proposed plans (of course, 95% of everything they've said is garbage - death panels? - but worrying about future costs is perfectly reasonable), because they seem to be carrying the day.

No, I have a problem with the left, particularly that segment of the left which says, "We're not getting everything we wanted at the beginning, but it's still a good start; let's not make the perfect the enemy of the good." I'm with them up to a point. I think something should be done, and the bills that are on the table represent some progress toward treating health care, to some level, as a right of citizenship rather than just another consumer good.

But it is profoundly unhelpful to advance arguments that are wildly speculative and questionable as justification for passing such major legislation. And, as I've had the opportunity to read and ponder much of the rhetoric, I've identified two such arguments that are seen as "proof" that we must move ahead with what's on the table. In this post I'll take up the first: the idea that whatever is passed will inevitably be improved in the near term, so we better get the ball rolling.

Any number of bloggers and pundits have taken up this idea, this utopian vision of "It must get better, so let's get started." Matt Yglesias, Ezra Klein, et al seem honestly to believe that flawed legislation will inevitably be followed by better legislation ad infinitum, that somewhere in the future we will end up with a near-perfect system in which everyone gets what they deserve and no one has any problems. This viewpoint is exemplified by a Kevin Drum post from today:

In 20 years this bill will be entirely forgotten except as the first step toward broad national healthcare. The excise tax, the public option, the subsidy levels, the exchange — all forgotten because they will have been steadily replaced by an entirely different infrastructure. It's true that some of that infrastructure will be path dependent on the details of the current bill, but most will simply evolve as a result of technology and public demand. By 2030 arguments over the public option will seem as antiquated as rants against the tin trust.

Wow, that sounds great. But do these folks have any evidence to offer along this route to perfection? Well, they love to cite both Medicare and Social Security, which started out in limited ways, requiring years of pressure and legislation to achieve their current status.

And I will admit that these programs, each of which were thought wanting in their original creation, have been refined over the years and become closer to their original intent. And national health care kind of looks like those programs, so it is natural (if somewhat pat) to believe that the arc of development will be the same.

However, the rationalist must then look more broadly, across all government programs, and must ask: "Has that been the fate of all large-scale government programs? Do they inevitably start out small and limited, and grow to something wonderful over time?"

The answer must, alas, be no. I'm sure there were people who felt that our periodic stabs at creating better schools would eventually lead to, yes, better schools. And some of those people have been waiting for three generations to see those schools improve, and they're still waiting. The war on poverty was going to stamp out the injustices that prevent people from achieving their dreams, and it is a war as yet unwon.

There is very little evidence that there is political tide which inevitably makes bad or flawed legislation into good policy; there are numerous examples on both sides of that ledger. I'd like to see those who are willing to settle for whatever Washington may eventually pass to concede that it may not ever get a whole lot better than what we start with. If there are flaws in National Health Care 2010, they may well still be there in 2030 (and 2050...), and we had better be prepared to live with that. [The other myth later...]

Notes on being away

Not blogging for two months has its pros and cons, but there are two I'll mention briefly.

1) I've started to get comment spam, odd since there's been very little activity here, and I'm planning to clean it out. If you happen to be a spammer who's reading this (as if), don't bother to send it. My readership is not all that big, and it's pretty much non-existent from Japan, so it's really not worth it.

2) Back in July I wrote a post that was kind of a throwaway, about a radio commercial that had really bugged me (does "keeper of cool" resonate with anyone?). Why, I can't imagine, but my post continues to show up first (out of 433,000 hits) in a Google search for that phrase, and, as a result, it has become my most popular post by a wide margin, attracting (so far) 39 comments. I confess that I don't understand that at all.

Wait - what??

As you can see, it's been more than two months since I've blogged, and what's funny is that I really haven't missed it all that much. That said, it may be time to get out and drop a few insights on the world; also, I owe you, my readers, some promised posts (such as my guide to going Rim-River-Rim in the Grand Canyon in one day, NPS advice notwithstanding).

In my dedication to remaining logical and centrist, I'm finding plenty to criticize in the current scheme. Since I ripped conservatives pretty consistently in the runup and aftermath of the Obama election, you might think that I'd be in hog heaven right now. But I'm not, not that I expected much else (I'm actually pretty amused at the liberals who thought the system would change overnight, ignoring that Obama is a successful product of that very system, and apparently believes that tweaks are preferable to revolution).

But what really amuses me on either side of the political dichotomy is the raging inconsistency that people demonstrate. Let's just take one example from last month. Ezra Klein is a young man who writes for the Washington Post, and has taken a special interest in health care. A lot of what he writes is insightful and informative, and I recommend following him.

However, he can fall plague to the seduction of utopia. A favorite staple of people who want to advance some controversial notion is to let the states experiment with alternatives, at which point we can pick the best one for the country as a whole. This argument ignores differing situations - does the Massachusetts health care program, and we'll stipulate that it's been a success, really apply to Hawaii, Texas, and North Dakota? I can't say, but neither can anyone else.

But here's Klein on November 17:

Medicaid should be federalized, but so too should a lot more of school spending, along the line Matthew Miller has argued for. And these would both be good policies even outside of the context of state budgeting, as leaving school funding to local communities is a recipe for wild inequality and inconsistent standards, while leaving Medicaid eligibility to the states has left America with 51 different Medicaid programs with 51 different eligibility schemes and very little coherence.

I'm sorry, but why hasn't one really good Medicaid idea come to dominate others? You can't argue that the states can be used as laboratories for policy alternatives if real-world examples are hard to come by. I suspect we're seeing path dependence and special interests as impediments to change, and that's why I'm always mightily suspicious when anyone's pet theory is advanced as a candidate for dispersion. It's very possible that some new method of education, no matter how successful, will not be adopted wholesale by lesser-performing school districts. In the end, it will all come down to some kind of central coercion, and I don't have the sense that the United States is all that happy with that idea.

A blogging loss, at least for now

I would be remiss if I didn't mention that there has been a change in a blog I have mentioned often and have highlighted to the right, Decidedly. The main author, Greg Glockner, has left the company from which the blog emerges (he talks about his decision in a post here). and we shall be losing his insight on issues of decision-making. The blog continues with posts by Carol A. Burch, whom I have quoted from time to time, and I'll go on following it, but we'll miss Greg and hope he finds another outlet for his writing soon.

First the Cubs, now the Olympics

I'm going to admit upfront that I love the Olympics. The idea of athletes from all countries and all sports getting together and competing is easily over-sentimentalized, I know, and the problems of the world don't go away for 17 days every four years, but it still represents an ideal that is good and noble. Maybe it's become cluttered with commercialization and politics and greed and all the other human sins, but there remains a purity behind the intent that I appreciate and admire.

Perhaps that's why I, while leaning toward wanting the Games in my home city of Chicago, retained some very real ambivalence about the whole thing. The politics of Chicago and Illinois is so corrupt, so subject to cronyism and cheating, that I feared, I suppose, that the Olympics would be tainted by the sweetheart deals, the opportunities of resource diversion to cronies of Mayor Daley, the ram-it-through mentality that would make the actual people of Chicago an afterthought.

Yet...it still would have been really cool to see the Olympics come to Chicago, to be here for this oft-wonderful city to be highlighted on the world stage. Perhaps Bob Costas could do his show overlooking Daley Plaza with a big picture of Da Mare over his shoulder (having set the precedent of honoring local dictators by allowing us to spend 17 days appreciating the lovely mass murderer Chairman Mao).

Alas, it is not to be. Chicago got blown away in the first round of a competition that everyone in the city figured was in the bag. The media coverage was laughable, of course, including Olympics "experts" who, before the vote, confidently told us all the reasons Chicago was the front-runner, then did a 180 after the vote and confidently told us about the many flaws in the plan.

[To offer a minority-in-Chicago opinion: The voting results tell me that Chicago had no chance. Had we squeaked by Tokyo in the first round, I doubt things would have gotten any better. One has to suppose that the Asian bloc would have gone to Chicago instead of Rio, and I know no reason to think that would have been a lock.]

But here's the most important flaw, in my eyes. Chicago is simply not perceived as a world-class city by, well, anyone who doesn't live in Chicago. I wish it were true, certainly, because I love a lot of things about this town, but it simply isn't, and all the boosterism in the world isn't going to change that.

Look at a Chicago Tribune editorial from this past Monday:

No, Chicago doesn't need the Olympics. This is already a world-class city. Has been for decades. During its rich history, Chicago has scrapped its path to world-class stature in manufacturing, finance, retail, professional sports, academia -- on it goes. An Olympiad would be wonderful, but certainly isn't essential.

The paper cites five areas in which Chicago is world-class.

Manufacturing - largely gone to cheaper places in the country and out, and most of the headquarters of those companies have left for greener pastures.

Finance - guess the largest bank headquartered in Chicago. Go ahead, I'll wait. That's right, it's the Northern Trust, an institution that exists primarily to manage the assets of rich people. It has no place in the nation's top banks.

Retail - we need only look at the replacement of Marshall Field's with Macy's, but we can also walk down Michigan Avenue and see all the national chains to understand that retailing is no longer a primary industry.

Professional sports - even if we grant that field an influence it doesn't have, it's hard to make a case that we're any better at that than other world cities.

Academia - the tendency to overrate Northwestern, which comes from looking around newsrooms and seeing all the Northwestern grads, is irritating enough. When one looks at the deplorable condition of the once-proud economics faculty of the U of Chicago, one gets a sense that perhaps all is not rosy on the local quads.

The "on it goes" might include financial markets, but the Board of Trade and its ilk are rapidly moving to T1 and T3 lines coming in from all over the world, so they aren't the source of employment they once were. It might include tourism and conventions, but a lot of that business is being lost to cities with more to offer in the way of entertainment and food (it seems clear that any industry with a strong Asian presence is going to put their conventions in Seattle, San Francisco, or Vegas; Europe, New York or Orlando).

What Chicago has not done is establish any particular presence in anything with a future, in technology or bioengineering or alternative energy. That we aren't Detroit stems mainly from bigger size and greater diversity of industry, but it's not difficult to see us following that path eventually.

And Mayor Daley knows this, which is why he pushes tourism and splashy parks and big events, because those are the only ways he can think of to extract money from other places to prop up an obviously unsupportable infrastructure.

I hate to write this, hate to believe it, but it's hard for me to see a great future for Chicago. Getting the Olympics might have delayed the day of reckoning, but it wouldn't have changed the fundamentals. Not getting them, I don't know what's going to happen. But, at some point, the boosters and hucksters are going to have to realize that a very different Chicago is coming down the pike, and we're better off planning for that than we are trying to hit the big home run to "put us back on the map."

Back from the Southwest

Blogging (and responding to comments) has been even more sparse the past few weeks, as you may have noticed. I was away, picking up on more of the things that I missed from having a travel-averse mother. I finally made my first journey to both the Grand Canyon and Las Vegas, about which I'll probably have more to say in the coming days (of course, I said that about last year's trip to Utah, too, and you're still waiting for that).

I'll just enliven things with one comment: It is possible, no matter what the Park Service says, to hike from the rim of the Grand Canyon to the Colorado River and back in one day, though I am not minimizing it as a challenge. But the wife and I did it, it was not unbelievably difficult, and I'll write more about that for those who care at some point. Anyway, ho hum, I'm back to the quotidian, and none too thrilled about it.

They shoot, they score

CBO (Congressional Budget Office) scoring has become the hottest thing lately. CBO assessment of a health care plan, for example, is seen as definitive (at least until the results differ from what is desired, at which point the spin comes in - but the numbers themselves are rarely questioned).

So, and it seems to be a question day on the old blog, why can't the magic of CBO scoring be extended to a breakdown of costs and benefits by population segment? Why can't we put the wisdom of these analytic solons to the test of figuring out, for example, what a health care bill will really cost for different people, or anticipating how the market will change in response to passage of any of the myriad of bills we have?

The answer is probably that these matters are too difficult to forecast, that too many different things can happen. But can't that same argument be extended to the areas the CBO is willing to consider? Aren't all of their numbers, all of their revenue and deficit calculations, fraught with uncertainty? Perhaps we all need to take everything we're hearing with huge heaps of salt.

Software vs. finance

I've worked in software for quite a few years now, and I know that there are few more complex things that humans have created. To describe to anyone who hasn't worked in the field just how complicated an order entry system, for example, can be is almost impossible. You not only have thousands of lines of code, written by people of varying skill levels and experience responding to different requirements, but you also have interactions with the operating system, third-party software, external data stores, and so forth. Any moderately interesting application is orders more complex than the majority of the non-computer world.

So my question for the day is this:

Why do we need finance people to stay in place to unwind the crisis, when we let completely inexperienced people take over our software?

We're seeing our bankers making the big bucks again, and they were all kept in place through government bailouts. No matter what they had done to destabilize the world financial system, they were needed because "only they could understand these complicated financial instruments."

Now I have a master's in finance from a prominent school (FWIW), so I have some understanding of financial products, the misdirection, the assignment of risk (that theoretically reduces that risk, ha, ha), and I can tell you that there is no financial product, no matter how layered in legal jargon, that compares to a useful computer program in difficulty.

So, and I ask this in sincerity, why do we need to prop up the kings of Wall Street, restore them to their place in the universe, while every day we move some piece of software to an offshored company full of folks with meager training and experience? Why are we so comfortable taking applications away from the people who built them, giving them over to people who don't understand the business, the industry, the requirements of users?

Several answers present themselves, and at least one of them is right, but I still find it incongruous and unfortunate.

The final end to Camelot?

Ted Kennedy has, as pretty much everyone knows by now, passed away, and there is no end to the tributes for the great "liberal lion." A typical one comes from Robert Reich:

America has had a few precious individuals who are both passionate about social justice and also understand deep in their bones its practical meaning. And we have had a few who possess great political shrewdness and can make the clunky machinery of democratic governance actually work. But I have known but one person who combined all these traits and abilities. His passing is an inestimable loss.

Most Americans will never know how many things Ted Kennedy did to make their lives better, how many things he prevented that would have hurt them, and how tenaciously he fought on their behalf. In 1969, for example, he introduced a bill in the Senate calling for universal health insurance, and then, for the next forty years, pushed and prodded colleagues and presidents to get on with it. If and when we ever achieve that goal it will be in no small measure due to the dedication and perseverance of this one remarkable man. We owe it to him and his memory to do it soon and do it well.

I don't really have a lot to say about Ted Kennedy in particular. The whole Kennedy family mystique has always eluded me; I never found them as good-looking or effective or impressive as the common wisdom would tell us, but they seemed to fill some niche in America that people desired. We're starting to see some dispassionate looks at the legacy of JFK, finally, and it would appear that, whatever his potential may have been, the reality was somewhat more disappointing. RFK was a master of rhetoric, but he didn't really accomplish much either.

But Teddy, he's the one who rolled up his sleeves and did the work and stood as a beacon of hope. And that may all be true, at least to some people.

My point, actually, is about the expectations we have for people in politics and how different they are from those in any other walk of life. Look at the Reich quote above; we're supposed to commend Kennedy for fighting for universal health insurance for 40 years, for fighting the good fight.

But, bottom line, he didn't get it done. He spent 40 years under Democratic and Republican presidents, within Democratic and Republican Congresses, and it hasn't happened. He was undoubtedly sincere about wanting it to happen, he introduced bills and talked up the issue and cared about the people who needed it, I'm sure, but, in the end, we don't have it.

I can't think of another field of endeavor in which results are so severed from perception. If you worked in a company and spent 40 years never quite getting your product out the door - well, you wouldn't work in that company for 40 years. On the other hand, if you happened to be in a division that got lucky, you'd be lucky too. But it would all come down to what you had been perceived as accomplishing, not to the effort you had made, no matter how noble.

That's not true in politics. You can truck through 40 years, making speeches and showing you care, and, when you pass on, you'll be hailed as a success despite a lack of provable results. Whatever symbolic role Ted Kennedy filled (and symbols do matter, so I am not trying to deny the power of that), the reality is that very little of his effort in health care (and other issues) came to fruition. That doesn't mean he shouldn't be admired for trying; it does mean we should try to temper our awe, just a bit.

A shameless bid for Google attention

The Illinois Lottery is running a couple of commercials for their second chance lottery game, one of those things where people can win by saving their losing tickets. One of those commercials has a funny line, though I'm ignoring the fairly obvious implication that girls with accents are easy (leading the lottery-playing character to get a creepy smile on his face). One of the Vegas dancers is trotting down the street and says, "I'm a dancer. I can dance." The actress gives a good reading of the line.

I mention this only because I want to see what Google does with this post. Only one result currently comes up in a search with <"i'm a dancer i can dance" lottery>; this post should make two.