Sunday, January 31, 2010

While Washington Dithers, Tony Judt Confronts Nightfall

As of now, Barack Obama and the Congressional Democrats have precisely nothing to show for their year-long healthcare effort. They had a vision of bureaucratic control that failed with the American people, and it will most likely crater completely in Congress this year. This failure was a loss for the Democrats, as recent elections make clear. But it was also a loss for the American people--because all of us would like live healthier and longer.

Such thoughts on mortality are stirred yet again by a new elegiac diary of illness, published by Tony Judt, a professor at NYU and a leading scholar of modern European history, who is now wasting away from ALS--Amyotrophic Lateral Sclerosis, also known as Lou Gehrig's Disease. Lou Gehrig, known as "The Iron Horse" for his steady playing and playmaking over a decade-and-a-half in major league baseball, died at the age of 37. That was back in 1941.

Seventy years after the disease became famous, it doesn't seem that much has changed for ALS sufferers; we have to wonder what we have done with these seven decades. Judt describes his health situation in The New York Review of Books, in a piece called, simply, "Night." He is now, he tell us, a quadriplegic:

In effect, ALS constitutes progressive imprisonment without parole. First you lose the use of a digit or two; then a limb; then and almost inevitably, all four. The muscles of the torso decline into near torpor, a practical problem from the digestive point of view but also life-threatening, in that breathing becomes at first difficult and eventually impossible without external assistance in the form of a tube-and-pump apparatus. In the more extreme variants of the disease, associated with dysfunction of the upper motor neurons (the rest of the body is driven by the so-called lower motor neurons), swallowing, speaking, and even controlling the jaw and head become impossible. I do not (yet) suffer from this aspect of the disease, or else I could not dictate this text.

Such a fate is a tragedy for anyone, but Judt is a great scholar, and we shall miss his intellectual voice. From his professorship at New York University, he earned a reputation as a humane observer of politics and culture. He was always on the left, but possessed an Isaiah Berlin-like awareness of the danger of absolutism and dogmatism of any kind, and so he was interesting and useful to all sides in a debate. Just four years ago, he completed a major work, Postwar: A History of Europe Since 1945, which I reviewed, favorably, here, for The American Conservative.

And Judt, born in 1948, is only in his early sixties. A Baby Boomer. How much will we all lose if his voice is finally stilled, way before his time?

If the US government really wanted to make America a better and healthier place, it would focus on curing diseases such as ALS. It would be working with the Chinese, and the Europeans, and the Arabs, and anyone else, on a grand project. A grand project for world health--because we all, everywhere, have a stake in cures.

But instead, as we all know, when the US government thinks about "health," it immediately slips a category--it immediately shifts to "health insurance reform," which is not the same thing. Thus a scientific project becomes a political project--even when the American people don't want it done to them. It's hard to think of a bigger lost opportunity. A new young president who campaigned on "hope," who seemed so eager to try new things, found himself sinking into the mire of unpopular bureaucratic programs. But of course, nobody made him do it--he did it to himself. That's the lost opportunity, to do something positive with all that energy. A lost opportunity to truly "bend the curve" on healthcare, by helping people live healthier and longer lives.

Truly a lose-lose. This failure was a loss for the Democrats, as recent elections show, but it was also a loss for the American people, because none of us have that long to wait. So there's a power struggle going on, between the American government and the American people. Neither side is winning, and so, as a result, we are all dying.

Saturday, January 30, 2010

A Tale of Three Cities: Davos, Washington DC, San Francisco. And Three Different Visions for People: Two Positive, One Negative.

"Vaccines are a miracle." So says Melinda Gates, wife of Bill Gates and his partner in one of the great philanthropic projects of all time, The Bill & Melinda Gates Foundation. "With just a few doses, [vaccines] can prevent deadly diseases for a lifetime," Mrs. Gates adds, according to Science Daily, one of many sources reporting from the World Economic Forum in Davos, Switzerland. Yes, vaccines are, indeed a "miracle." So why don't we have more of them? How could it be that the Gates Foundation wishes to expand health and medicine for the world, while the US government seeks to restrict and constrict health and medicine here at home?

The Gates Foundation has just announced that it will donate $10 billion to the cause of vaccine research. In the words of Margaret Chan, head of the World Health Organization, "An additional 2 million deaths in children under five could be prevented by 2015 through widespread use of new vaccines and a 10 percent increase in global vaccination coverage." Well put!

But now we might note a strange dichotomy, a vast chasm between the warm outpouring of humanitarianism that we see in Davos and the chilly "austeritarianism" that's crunching DC. Over in Switzerland, Bill and Melinda Gates are seeking to "bend the curve" on healthcare costs in the best possible way--by eliminating disease, including AIDS, malaria, and tuberculosis. So it should be pointed out that in addition to the profound compassion driving the Gates' efforts, what they are doing, by promoting vaccines, will actually save the world money. Children who grow up to be productive adults are, to be utilitarian about it, good investments. Now I don't think that utilitarianism is the motivation of Mr. and Mrs. Gates; such economic abundance-making is merely a happy byproduct--good begetting good. If economic activity is ultimately a function of "animal spirits," then the higher the spirits, the more healthy the energy, the better for the world economy.

Meanwhile, what's the discussion in Washington DC, as led by Barack Obama and the majority in Congress? It's over "health insurance policy" and various schemes to ration care, all in the name of reducing costs. These "less is more" ideas were never all that popular, and they grew less popular as a) the economy worsened, and b) people learned new details of the Obamacare plan. Indeed, it now appears that Obamacare is doomed; even its best friends say it is on "life support." One might think, especially after the Clintoncare debacle, that the liberal-left would rethink its approach, and maybe now, after two huge defeats, it will. Maybe the liberal-left will embrace the "more is more" approach of the Gates Foundation.

A few days ago, here at Serious Medicine Strategy, I drew the contrast between Obama and Steve Jobs, both of whom made big announcements on Wednesday. But Jobs' announcement, launching the iPad, was greeted mostly with applause, while Obama's announcement, that he still wanted a healthcare bill, was greeted mostly with skepticism, even derision.

So now, in one of life's ironies, Jobs' great rival over the last 30 years, Bill Gates, has stepped forward with a vision that is also radically at odds with Obama's. That is, Gates and Jobs are on the same side of the optimism vs. pessimism divide; the two historic rivals are now united in their faith in a better future. Jobs seeks transformation through high-tech. Gates seeks transformation through cures. Those two visions, Jobs' and Gates', are both popular and admirable in their own ways. Meanwhile, Obama seeks only to build a bigger bureaucracy; his healthcare plan is mundane transactionalism, oblivious to the transformational power of technology, and also to the transformational power of prevention and cures.

So, come to think of it, it's a tale of three cities: Davos, Washington, and San Francisco. Optimism in Davos and San Francisco, pessimism in DC.

But wasn't Obama supposed to be the candidate of "Hope"? Indeed he was, back in 2008. But all the techno-progressivism of his campaign seems to have been leached out of him by the bloodless bean-counters he surrounded himself with when entering the White House. So yes, historians will marvel at these strange choices made by Obama. The 44th President is, after all, younger than either Gates or Jobs--and as an elected official, he is the figure most directly dependent on the affection and good will of the American people. It's Obama who will likely go before the voters again in less than three years; one would think that he would seek to propose something popular, such as a Cure Strategy, as opposed to the same old bureaucracy. Or at least that he would want to clamber onto the Gates bandwagon, or the Jobs bandwagon, or both.

So far, of course, Obama shows no such interest. But as his 2012 re-election campaign looms closer, perhaps the President will rediscover the value of Hope.

Wednesday, January 27, 2010

Steve Jobs vs. Barack Obama

Just published for Fox News, some thoughts on a cooler way to do healthcare.

Tuesday, January 26, 2010

Why Obamacare is Doomed--The Hollywood Version

Just published for Fox Forum.

Serious Medicine Strategy When The Agenda Shifts to Economics and Jobs

"Democrats Slam Brakes on Health Care Overhaul"--that's the headline in The New York Times today. “We’re not on health care now,” said Senate Majority Leader Harry Reid. “We’ve talked a lot about it in the past.” He added, “There is no rush.”

Indeed, as the chart above, from the Pew Research Center for People and the Press, shows,"health insurance" ranks twelfth on the public's list of priorities. Although interestingly, "Medicare" ranks much higher, sixth, and "health care" ranks eighth. And thus the reminder: people care about health and those who are extremely dependent on healthcare--the elderly--are extremely focused on "their" issues." But the general public doesn't rate "health insurance" as a very high priority. No wonder Reid doesn't want to talk about it anymore

And in any case, as the Pew data show, the top priorities are "economy" and "jobs."

So does that leave healthcare out in the cold? Maybe. One certainly gets the feeling that Reid has moved on, and perhaps also the Obama administration.

So should Serious Medicine Strategy find some other topic to worry about? Become Serious Economic Strategy? Nope. The argument here at SMS, all along, has been that healthcare is a great driver for the economy. It's the biggest employer, and medicine--not "health insurance"--is a product that people want to consume, sometimes desperately, ravenously. And not just Americans, but people around the world. So if that's not an economic engine, what is? Isn't that what we want?

But the argument has to be made. And alas, since, 98 percent of the discussion over healthcare has been over controlling costs--that is, shrinking the healthcare sector, perhaps provoking a recession in one of the few vibrant sectors of the economy--then it's little wonder that the country doesn't think of healthcare and medicine as an economic driver.

Serious Medicine Strategy has always been an economic strategy--now is the time to make that case.

Monday, January 25, 2010

Bernanke Confirmation Fallout: Death of the "Med Fed" Idea

I wrote this for Politico's "Arena" section:

The consensus seems to be that Ben Bernanke will be confirmed for another Fed term. And thus the Ulysses Grant-ization of Barack Obama’s presidency--substitute Wall Street, now, for railroads, then, to complete the analogy--continues apace.

But along the way, one bad idea seems to have disappeared, crashed along with the market. Which bad idea was that? A “Med Fed,” as pushed, most notably, by former Sen. Tom Daschle. In his book, Critical: What We Can Do About The Health-Care Crisis, Daschle wrote, “I propose a Federal Health Board, modeled loosely on the Federal Reserve System.” Unfortunately for Daschle, that book was published early in 2008, before the various meltdowns and bailouts discredited both financial wizardry and Wall Street.

Amidst the controversy swirling around Bernanke and the policies that he has so closely coordinated with Larry Summers and Tim Geithner, it’s almost humorous to re-read Daschle’s idea, based as it was on the premise that the Fed was such a great success that we needed more Feds. But when the Fed was riding high, the Med-Fed idea made sense to many. As Daschle put it two years ago, “Like the Federal Reserve, the Federal Health Board would be composed of highly independent experts insulated from politics. Congress and the White House would relinquish some of their health-policy decisions to it.”

It’s hard to think of a policy proposal that better reflected the pro-financialist Zeitgeist of the Greenspan-influenced, pre-crash era. Indeed, it seems like only yesterday.

Wednesday, January 20, 2010

How Much is an Autism Cure Worth?

Business Week's Ellen Gibson reports on accelerating efforts to find a drug to effectively treat autism. As the charts from BW above show, the affliction is destined to grow to be hideously expensive--and that's just in dollars-and-cents terms, to say nothing of the enormous human costs.

So again, looking at those sorts of costs, is it cheaper to think about saving money by shaving a few points off the growth trajectory of autism treatment? Or by tackling the problem of autism itself? The answer is obvious.

But in the meantime, Washington DC is abuzz with proposals for reducing the deficit and debt. But the question is whether or not any such budget-cutting commissions will actually think through the best way to cut spending. Will they look, for example, at strategies that involve eliminating the disease--such as a cure for autism? Or will they seek, simply, to reduce the rate of growth on future spending? A look at those charts reminds us: A huge percentage cut in future spending would still be a huge increase from where we are now.

The cheapest treatment is a cure.

Tuesday, January 19, 2010

Martha Coakley, and the Democrats, Meet a "Taboo Trade-Off"

The Democrats were doomed as soon as it became clear to the American people that their goal in healthcare was to save money. And here, all along, the American people thought that their government had wanted them to live longer and better lives, not shorter and cheaper lives. The hapless and luckless Martha Coakley was simply the first Democratic to come before the voters since the deeply and grimly utilitarian calculus of the Democrats became blindingly obvious to the American people.

According to the Democratic orthodoxy of the last few years, "House" and Marcus Welby and the Hippocratic Oath go out the window, replaced by a cost-benefit analysis conducted by CBO, OMB--or perhaps a "death panel." But budgets aside, the true medical ethos is to do more, not less. Some in the Obama administration might wish to change that ethos--and have written of their desire to say change it--but the folks never signed on to that. And so saying that the American people are expendable, less worthy of spending than another bailout tranche for AIG or more money for Afghanistan or the mayor of Baltimore, was never going to fly.

That the government will do less, deliberately, to keep people alive was simply an affront--even if the Democrats claimed it was part of some egalitarian scheme, (But of course, any egalitarian premise was punctured by the palpable reality that the rich and the connected will still get more, not less.) Such cynical brokering of human lives on the slab of Kennedy School-ish public policy is a "taboo trade-off" in the minds of Americans. Democrats should have known better than to violate such a powerful taboo.

The term "taboo trade-off" was coined in the early 90s by academics Alan Fiske and Philip Tetlock; it refers to an idea which "shocks the conscience," to borrow an evocative phrase from Justice Frankfurter. Fiske and Tetlock defined "taboo trade-off" as "Any explicit mental comparison or social transaction that violates deeply held intuitions about the integrity, even sanctity, of individual-to-individual or individual-to-society relationships and the values that animate those relationships."

Those words pretty much sum up Obamacare as it has come to be regarded by the voters. So goodbye, Martha. Now, who wants to be next?

Friday, January 15, 2010

The Next Boston Tea Party--And What It Means for Healthcare, and Serious Medicine

“Poll shocker: Scott Brown surges ahead in Senate race”--that’s the headline in The Boston Herald this morning, showing Republican newbie Scott Brown ahead of Democratic establishmentarian Martha Coakley. Is it really possible that the Democrats could lose a Senate race in the Bay State for the first time since 1962? And lose the Senate seat held by a Kennedy for 54 of the last 57 years? We’ll know Tuesday.

We shouldn’t underestimate the power of determined Democrats to hang on to that seat, not only for the sake of Massachusetts, but also for the sake of the 60 votes that they need in the Senate to pass Obamacare. (Ben Nelson of Nebraska must be sick at the thought that maybe he threw away his career and still won’t even get the bill he sold his political soul for.) But even if Coakley wins in Massachusetts, the message is clear: The Democrats have misplayed their hand--they focused on healthcare, when they should have focused on the economy.
But don’t take my word for it. Here’s Rep. John Larson (D-CT), the fourth-ranking Democrat in the House, was surprisingly blunt in The Washington Post this morning:

Look, as important as health care is, and as front and center as it is in the Beltway, when I go home . . . they care about health care, but they're focused on jobs. They know without a job, there's not an awful lot of hope of them getting health care.

Hmmm. Could it be that some people in Washington care more about political power--the transformation of one-sixth of the US economy, at their behest--than about jobs for ordinary folks?

Indeed, the latest Fox News/Opinion Dynamics poll confirms a point that’s been obvious for the last year: The economy trumps everything else. When Americans were asked to choose the “ONE” issue that they want President Obama to focus on, “the economy and jobs” was ranked first, at 48 percent, as we can see from the screen-grab above. By contrast, “health care” was a distant second, at 12 percent. (“Terrorism and national security” came in third, at 11 percent, although that number would have spiked if the Christmas Day underwear bomber had succeeded in his deadly plot.)

And so the Obamans made a "collossal miscalculation," in the words of fair-minded  political analyst Charlie Cook, who added this:

The latest unemployment and housing numbers underscore the folly of their decision to pay so much attention to health care and climate change instead of focusing on the economy “like a laser beam,” as President Clinton pledged to do during his 1992 campaign. Although no one can fairly accuse Obama and his party's leaders of ignoring the economy, they certainly haven't focused on it like a laser beam.

We might add that Bill Clinton focused “like a laser beam” on the economy during the 1992 campaign, which he won in a landslide. And yet then, many of the same people guiding the Obama administration persuaded the 42nd President to focus instead on “healthcare policy” once he took office in 1993. And we all know what happened in 1994.

So does that mean that healthcare is unimportant? No. But it does mean that the current model of healthcare is unimportant, not only because it’s a bad model, but because it is profoundly unpopular. The Democrats would be better off without it. But common sense tells us that health is extremely important. For everyone who prays, or wishes, or hopes to find a job, there are 10 who are praying, or wishing, or hoping for good health and wellbeing. Health, as opposed to “healthcare policy” is central to everyone’s existence. One could say that health--defined, once again, as physical wellness--is the ideology at the base of all other ideologies. It’s as if Democrats, conscious of the importance of health, as we all are, journey into a policy funhouse, where some sharpy convinced them that the natural human interest in health should somehow be transmuted into an unnatural interest in bureaucratic control over health. It was a con game of monumental proportions.

The point is this: The American people, like all people, want more health, not less. And that means that they want more healthcare, which is a pretty good proxy for health. Those who say that “healthcare” is not always the same as health have a strong case to make--e.g. that good diet and exercise is a more important variable for most than the last medical treatment--but they can’t make that argument if such an argument is seen as a front for rationing schemes of one kind or another. That is, if experts wish to argue that people should live a healthier lifestyle, that’s a message that Americans will, over time, gratefully receive. But if that “eat your spinach” message is coupled with the message of “let’s put a bureaucrat between you and your doctor,” well, fuhgeddaboutit. Americans might pick up a copy of Men’s Health, or Women’s Health, but they won’t want to empower Uncle Sam to make decisions for them, especially when he makes it clear that he wants them to have less healthcare. Such rationing schemes, especially if they are run by the government, will soon enough be regarded as “death panels,” and so healthcare will sail off into a whole ‘nother darker direction. In a small “d” democratic country, voters will never vote for their own demise.

Moreover, properly considered, healthcare is not separate from the economy, healthcare is part of the economy--a crucial part. The healthcare sector is already the largest employer in the US. And for decades, it has been one of the fastest-growing sectors. Isn’t that what we need right now: fast-growing employment sectors? Especially fast-growing economic sectors that can attract sick people, and healthy capital, from around the world? Isn’t that the very definition of a win-win?

Instead, the Democrats’ argument has been that in order to grow the overall economy, we must first shrink the healthcare economy. That is, toss away the bird in the hand for the recovery in the bush. Or, to mix a metaphor, we must bail out the boat, but first we must knock another hole in the hull.

As a matter of economic strategy, the Obamans should have seen healthcare as the golden goose--a goose to be cherished and replicated, not throttled. But instead, 30s-style social democrats joined up with 70s-style neo-Malthusians to come up with a solidarity-and-scarcity plan that nobody wants. What the Democrats needed was another intellectual system from the 30s: Keynesianism. Don’t worry about National Recovery Act-type solidarity, which was a dud, anyway. Focus, laserlike, on productive economic activity. In the 30s, that meant roads and rural electrification. Today, it would mean medical technology. And then, lo and behold, not only would the economy revive, but people would be healthier. Once again, a win-win.
As noted here in the past, the American people want more, not less. And that includes the latest in technology: The Obamans are tight with Silicon Valley, but there is no sense, in the current plan, that they have learned any lessons about user-friendliness, or transparency, or all-around “coolness.” In a world of iPhones, Droids, and Nexus Ones, the Democrats have been offering rotary phones and landlines.

Most of us have no idea what a “Google” or “Apple” approach to healthcare would look like--because Google and Apple are working on phones and computers and many other areas. Nobody in power seems interested in how the visionaries who run those companies would approach the issue of getting everyone better health. Note: not “health insurance,” but health.

So of course the “Cadillac Tax” on healthcare plans, which would have fallen heavily on blue-collar workers--has been exiled to out-year oblivion. Labor chiefs might be locked into the 30s social-democrat model, but they are not locked into the Malthusian model. So even if Obamacare somehow gets through (and that looks less and less likely), the Cadillac Tax is a goner. To repeat, the American people want more, not less. And from a policy point of view, if you want to grow the economy, you don’t begin by shrinking it.

We can close with the distinct possibility of a grand cosmic joke--it’s possible that the election that sinks healthcare will be the special election to fill the seat of the late Teddy Kennedy. So Kennedy, who spent almost forty years pushing for healthcare legislation--after booting away the chance in 1971, some say, because he didn’t want Republican Richard Nixon to get the credit--might now be replaced by a Republican who has pledged to the tea-partiers that he will throw Obamacare into Boston Harbor. A joke that's funny to some, and not funny to others.

But that’s my Boston--when you least expect it, the patriots up there do something big that surprises you.

Tuesday, January 12, 2010

The Ghost of Gompers Stalks Obamacare. Or, Why Does A Democratic President Think Working People Have It Too Good?

AFL-CIO chief Rich Trumka put it well, yesterday, as reported by the AP:

"Politicians who think that working people have it too good — too much health care, too much Social Security and Medicare, too much power on the job — are inviting a repeat of 1994," Trumka said.

Trumka didn't say it, but the Obamans are trying to shrink healthcare after grossly expanding Wall Street bailouts--and now wants to keep it all secret. A strange turn of events, no? What strange idol are the current Democrats worshiping, following a weird dogma that has them bailing out billionaires, while raising taxes on working stiffs?

The issue, of course, is the "Cadillac Tax" on healthcare plans--which is to say, a tax increase. The AP's Erica Werner further quotes Harold A. Schaitberger, head of the firefighters:

"The president's support for the excise tax is a huge disappointment and cannot be ignored. If President Obama continues to support it and signs a bill that includes the excise tax on workers, we will hold him accountable."

Trumka and Schaitberger are both protesting the core presumption of Obamacare--that Americans consume too much healthcare, and that the place to start reducing is with the middle class--the working class.

Needless to say, this core presumption is not popular. The polls show that Americans want more healthcare, and polls also show that Americans are increasingly skeptical of Obamacare--latest headline from CBS: "Poll: Obama Health Care Marks Hit New Low."

And yet the Democrats trudge onward, pursuing an ideological vision that pleases ivory tower elites, even as it antagonizes blue collars and soccer moms. So how do the Democrats process this--this attack on their own base? Thought-leading Democrats have turned their likely coming whomping at the polls in 2010 into a kind of prospective badge of honor: to prove how brave they are. But bravery in pursuit of a policy that nobody wants is not bravery--it is folly.

Meanwhile, Trumka, in particular, seems to be channeling the spirit of one of his predecessors, the supremely pragmatic and practical Samuel L. Gompers, who became the first president of the American Federation of Labor, back in 1886. When he was asked what his union members wanted, Gompers answered: "More." And he continued with a rhetorical flourish that we could use right now:

“We do want more, and when it becomes more, we shall still want more. And we shall never cease to demand more until we have received the results of our labor. . . .What does labor want? We want more schoolhouses and less jails; more books and less arsenals; more learning and less vice; more leisure and less greed; more justice and less revenge; in fact, more of the opportunities to cultivate our better natures.”

Indeed. And it all begins with more, not less. And today, Democrats are offering less. And while less may be more in architecture--it is never more in politics.

Sunday, January 10, 2010

Friday, January 8, 2010

A Cartoon is Worth a Thousand Words... I'll stop with an acknowledgement to Chip Bok, who nailed it.

Wednesday, January 6, 2010

Let's Provoke a Recession In Healthcare So That We Can Get Out of the Recession!

The New Republic's Noam Scheiber comments on the debate over jumpstarting the economy, which, in this case, means criticizing a Wall Street Journal op-ed by three University of Chicago economists, by Gary Becker, Steven Davis, and Kevin Murphy. Fine. Scheiber is a liberal, and Becker et al. are free-marketeers. So of course they are going to disagree.

But it's interesting that Scheiber, in the course of disagreeing with Becker & Co., so that he can tout his own Obama-friendly neo-Keynesianism, overlooks the obvious big jobs program staring him--and all of us--in the face. What jobs program is that? Healthcare, of course, which is a sixth of the economy and accounts for about 13 million jobs now, and growing fast. Growing fast, unless, of course, the government squelches that growth--which seems to be the Obama administration's goal, a goal that Scheiber eagerly signs on to.

Here's how Scheiber ledes his piece, which is headlined, “Beware the Meme! Would our economy be in better shape if Obama were less ambitious?”:

My favorite moment from last month’s White House jobs summit came when the president asked if Washington had been doing something to discourage hiring. At this point, a man named Fred Lampropoulos, the CEO of a Utah-based medical device manufacturer, chimed in that yes, in fact, it had. “[T]here’s such an aggressive legislative agenda that businesspeople don’t really know what they ought to do,” Mr. Lampropoulos told the president, according to The New York Times. Political uncertainty, he said, “is really what’s holding back the jobs.”

Well, okay. Let’s stipulate that if you make MRI machines, or whatever, and Congress is threatening to pay a lot less for them (via health care reform), you’re probably not rushing out to hire more workers. 

The message seems to be: Let's kibosh the healthcare sector, so that we can get on with the job of growing the economy!   Any more questions?

And yet interestingly enough, it's Scheiber who argues that the government ought to get bigger, overall. In criticizing Becker, Davis, and Murphy, he writes: "They start from the ideological assumption that a bigger role for government is bad." And for his part, Scheiber starts from the ideological assumption that a bigger role for government is good. And he is for Obamacare, in one form or another, as part of that ideological belief. So healthcare "reform" is great, he seems to be saying, as an exercise in social-medical justice, or perhaps as a rationing plan to fight against waste--just don't think of it as a jobs program!

Saturday, January 2, 2010

The Twin Threads of Competence and Trust

Let’s talk about the twin threads--the thread of computerized silicon, the thread of personal trust--that connect two of the biggest public concerns of today: homeland security and healthcare.

The thread of computerized silicon requires government competence. And so we must wonder: Is the government competent enough to run a complex project? And the thread of personal trust requires public confidence: Are its employees honest enough to be trusted?

The strength of the twin threads is vital to both our physical safety and our medical wellbeing. And so if the threads were to break--and they are now fraying badly--not only would public acceptance for homeland security measures and healthcare reform be lost, but we would all be at greater risk from terror and from disease.

Let’s take up homeland security first. Should regular Americans trust the government to keep them safe from terrorism? That’s been a concern for years, but such concern has been greatly amplified by the attempted Christmas Day bombing of NWA flight 253. Homeland Security Secretary Janet Napolitano said, as we all recall, that “the system worked.” Does that inspire confidence in her--or in the system in which she is a prominent part?

As Maureen Dowd put it in The New York Times:

If we can’t catch a Nigerian with a powerful explosive powder in his oddly feminine-looking underpants and a syringe full of acid, a man whose own father had alerted the U.S. Embassy in Nigeria, a traveler whose ticket was paid for in cash and who didn’t check bags, whose visa renewal had been denied by the British, who had studied Arabic in Al Qaeda sanctuary Yemen, whose name was on a counterterrorism watch list, who can we catch?

Commenting on this debacle in The Washington Post, Thomas E. McNamara, a security appointee in both the Clinton and Bush 43 administrations, noted the continuing challenges to federal threat-information sharing, a key to effective counter-terrorism. Spreading blame widely, McNamara accused both the Bush and the Obama administrations, as well as Congress, of failing to provide “the high-priority attention required to reform how national security information is processed.”

That’s a damning point. And yet who would say that McNamara is wrong?

McNamara concluded, “While the rest of the nation marches into 21st-century information management, the federal government cannot remain mired in 20th-century practices.” So again, we must ask: How much confidence can we have in our homeland security system? How much real reform can we expect from the current crew?

Yet in addition to incompetence, a strain of malevolence seems to be running through the homeland security system. Recently we learned that Errol Southers, the Obama administration’s nominee for administrator of the Transportation Security Administration (TSA)--which oversees, among other functions, airport-passenger screening--has abused his public trust. Back in the 80s, while he was an FBI agent, Southers accessed a government database looking for damaging information about a romantic rival, an illegal action which at the time drew an official reprimand. And then, last year, he misled Congressional investigators about those past actions. When confronted with evidence of his past misdeed, Southers’ answer was that he had forgotten about it.

Yet not only is the Obama administration sticking by Southers; many US Senators are stepping forward to defend him as well. He should be confirmed, they say, even though he misled them.

We might ask: If Southers is confirmed and takes his post, what confidence can we have about the sanctity of private data at TSA? And looking ahead, we might also ask: What’s going to be the public reaction as the TSA installs more full body scanners--the kind that reveal people’s private parts--in airports? Such scanners might be essential to airline security, but who is going to trust TSA to respect people’s privacy and dignity? What credibility would TSA have in its assurances that embarrassing pictures won’t go circulating through the TSA bureaucracy--and from there to the Internet? And what about the next security intrusion after that?

For many reasons, Americans lack faith in the Department of Homeland Security, which spends $55 billion a year.

Next we come to healthcare, for which the government expects to oversee trillions in new federal spending. At the national level, the oversight and management of a healthcare system is ultimately an information issue; it’s all about computers and competence. Does the government know about upcoming public-health crises? Is it properly funding needed research? Does it know who has health insurance and who doesn’t? Does it have a solid system for reimbursing doctors and hospitals? And does it have the tools for ferreting out waste, fraud, and abuse?

To gain perspective on those questions, all of which require technical competence, we might think back to last year’s swine flu epidemic--during which the Department of Health and Human Services mispredicted vaccine production by 85 percent. And so we might ask: If the homeland security bureaucracy proved, during this past year, that it was incompetent and untrustworthy, should we assume that the healthcare bureaucracy is any better? Recalling the words of Thomas E. McNamara--that the feds “remain mired in 20th-century practices”--we might wonder why anybody would think that federal health databases are any better managed than federal homeland security databases.

Indeed, for further perspective on the federal government’s computer competence, we might recall the stimulus-data fiasco of November, in which the supposedly cyber-savvy White House’s own website was found to be shot full of errors. The site claimed, for example, that the Ninth Congressional district of Tennessee had gained “156.2” jobs, while the completely mythical “47th Congressional District” of the Volunteer State had gained a grand total of three jobs, thanks to $2.3 million in stimulus spending. Nearly $800,000 per job--would the White House really have wanted to brag about that achievement, even if it were true?

But on health, on homeland security, or on any other cyber-subject, we might further ask: Is Congress providing proper oversight and needed checking-and-balancing against incompetence and malfeasance?

If not, then executive-branch snafus and abuses are likely to continue. And so it will be impossible to snuff out the rumors and paranoia that sprout like nightshades when the government is seen as going rogue--fearful phantasms of coercive rationing, mandatory euthanasia, or “death panels.”

If Obama wished to restore confidence in his leadership, he would make major changes in homeland security. He would call in the CEOs of Google, Intel, Cisco, and Apple, and listen closely to their suggestions for ensuring effective and trustworthy data systems. If he were to do so, he would increase confidence in his homeland security apparatus; indeed, as a bonus, he might find that public confidence in his healthcare system, too, was on the rise.

Anyone who presumes to lead the federal government will find that support for homeland-security and health policies depends on the strength of those two threads--the silicon thread of competence and the personal thread of trust.

So what to do? The prime objective should be to demonstrate effectiveness and prudence. Is the federal government current demonstrating such qualities?

Friday, January 1, 2010

The Massachusetts Model

Let's watch this space, budgetarily as well as politically. Ezra Klein, writing in the WaPo:

The bill that just passed the Senate was effectively the Massachusetts reform plan brought to national scale. It had more cost control, and more delivery-system reforms, but those were the main differences, and none of them were the controversial differences.

Klein, of course, supports the current bill.

But here's another take on the legislation, from Sarah McIntosh, writing for the Heartland Institute, also drawing on the Massachusetts precedent:

The potential costs of the health care bills under consideration on Capitol Hill continue to rise as mandates, regulations, and subsidies boost the total cost to taxpayers.

Initial estimates by the Congressional Budget Office of the health care bill added up to $1.1 trillion over 10 years, but the version ultimately passed by the House of Representatives is now projected to total more than $1.7 trillion in costs.
Gregory Schneider, a policy analyst at the Flint Hills Center for Public Policy, a Kansas-based think tank, believes the total price tag could run even higher.

“The sticker price could be as much as $3.3 trillion,” said Schneider. “The accounting gimmicks in the bill are such that the great bulk of the costs come later.”

And then McIntosh continues, using this headline: "Mass. Disaster Instructive":

Schneider points to Massachusetts as an example of unanticipated costs and inaccurate estimates. When Massachusetts enacted its broad health care reform package in 2006, the cost was projected at around $1.6 billion per year. The Commonwealth Care subsidies, the largest part of the plan, were projected to cost about $725 million per year.

By 2008, projections rose for Commonwealth Care to about $869 million for the following fiscal year, a 20 percent increase. Projections increased to $880 million for FY2010.

“Now, officials are saying it could be even $100 million higher than these estimates,” said Schneider. “Massachusetts has exceeded its cost estimates, and now, while having more people insured, has longer waits, rationing, and higher health care costs, which has burdened the state budget.”

As noted, watch this space--watch the budget.