I actually found this ruling to be something of a relief, not for what it did but for what it didn't do. And what it didn't do is rule the entire law unconstitutional. In fact, it didn't even halt its implementation, as the plaintiffs had requested. Until now, I had been worried by the lack of a so-called severability clause in the reform legislation--a provision saying that if part of the law should be struck down as unconstitutional, the rest of the law will still stand. I was afraid that a ruling against the individual mandate might necessarily mean all of the law has to go. But the judge who ruled on Monday severed the individual mandate from the rest of the law which demonstrated--much to my relief--that, hey, they can do that. So even if the individual mandate was ultimately struck down by the Supreme Court, they could at least preserve the rest of the law.
But what's really interesting is the treatment of the Necessary and Proper Clause in this ruling, which has come under criticism in some quarters. The Necessary and Proper Clause, of course, is the elastic banding in the underpants of the Constitution, the provision that says: "The Congress shall have Power - To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers, and all other Powers vested by this Constitution in the Government of the United States, or in any Department or Officer thereof."
What that means is that Congress can indeed do things that aren't explicitly written in the Constitution as long as those things are "necessary and proper" to carrying out one of the enumerated powers. And that isn't just me saying this, here's Madison in Federalist 44:
Had the convention attempted a positive enumeration of the powers necessary and proper for carrying their other powers into effect, the attempt would have involved a complete digest of laws on every subject to which the Constitution relates; accommodated too, not only to the existing state of things, but to all the possible changes which futurity may produce; for in every new application of a general power, the particular powers, which are the means of attaining the object of the general power, must always necessarily vary with that object, and be often properly varied whilst the object remains the same.
Shorter Madison: "We didn't write down every conceivable power needed in pursuance of the enumerated powers, but they're still in there. Use some common fucking sense, people."
One of the arguments the government used in defending its requirement that almost everyone either carry health insurance or pay a penalty was that this individual mandate is necessary and proper for executing its power to regulate health insurance under the Commerce Clause. This is a reference to the reason the individual mandate exists in the first place. The new law seeks to regulate the individual market for health insurance (i.e. the market in which you buy insurance if you're not getting it through your job) by eliminating unpopular practices like charging sick people higher premiums or even rejecting them entirely if they have a pre-existing condition.
But those practices exist for a reason. If 1) no insurer can turn you away for having a health condition when you want to buy insurance, and 2) that same insurer can't "penalize" you for being sicker than average by making you pay more for your insurance policy, there really isn't much reason to buy insurance if you're healthy. If you choose to go uninsured, you're not taking much of a risk if, should you get sick, insurers can't turn you down or charge you more to punish you for your irresponsibility. Take away the reasons a healthy person would pay for health insurance and lots of them are going to decide to drop out and stop paying premiums until they get sick, at which point they can just sign up again without any hassle. It just makes sense for healthy people to free ride in that situation. That will leave the insurance pools disproportionately full of sicker people and thus increasingly expensive. Bad news. Hence the individual mandate. It steps in to serve the function that was previously being served by medical underwriting. So if you want to regulate underwriting out of existence and you don't want premiums to explode, it seems you have to legislate an individual mandate into existence.
So you can argue that an individual mandate is necessary and proper to regulating the insurance market. And here's where it gets a little odd. At one point the ruling says:
The Commonwealth does not appear to challenge the aggregate effect of the many moving parts of the ACA on interstate commerce. Its lens is narrowly focused on the enforcement mechanism to which it is hinged, the Minimum Essential Coverage Provision.
The Commonwealth argues that the Necessary and Proper Clause cannot be employed as a vehicle to enforce an unconstitutional excercise of Commerce Clause power, no matter how well intentioned.
You can see in that first paragraph that Virginia wasn't challenging the federal government's authority to regulate insurance under the Commerce Clause. But then they argue that the Necessary and Proper Clause doesn't apply because, in their minds, it's being "employed as a vehicle to enforce an unconstitutional excercise of Commerce Clause power." Except they've already conceded that the Commerce Clause power being exercised--the regulation of insurance markets to eliminate pre-existing condition exclusions and the like--is constitutional. And since the individual mandate is instituted in furtherance of that power and its aims, one would think the Necessary and Proper Clause would indeed be relevant.
But get this bit of the ruling, where the judge is mulling whether or not to sever the individual mandate from the rest of the law:
Having found a portion of the Act to be invalid, the Section 1501 requirement to maintain minimum essential health care coverage, the Court's next task is to determine whether this Section is severable from the balance of the enactment. Predictably, the Secretary counsels severability, and the Commonwealth urges wholesale invalidation. The Commonwealth's position flows in part from the Secretary's frequent contention that Section 1501 is the linchpin of the entire health care regimen underlying the ACA.
Get that? The anti-reform plaintiffs argued that the whole law should be struck down if the individual mandate is unconstitutional because, of course, they accept that it's a "linchpin of the entire health care regimen." But this is a bit of a Catch-22 for them. As I already noted, they didn't actually challenge the "entire health care regimen." In their laser-like focus on taking down the mandate, they implicitly accepted that the insurance regulations in the law are constitutional. But if they're arguing that the mandate is the "linchpin" needed to make those insurance regulations work, they're making the "necessary and proper" argument. However, if they accept that argument, then the mandate should be valid. Bad news for them. If, on the other hand, they reject that argument (as they did), then there's no reason the individual mandate shouldn't be severable from the rest of the law. Also a bit of a defeat for them.
It's tough to see how they could get everything they want, in a logically consistent fashion, using these arguments.
Driving an hour to and an hour from work every day has caused me to become borderline obsessed with the fuel efficiency of my car. A few weeks ago I flipped through the manual, found the capacity of my gas tank, drove to and from work until it was nearly out of gas, filled it up again, and compared how much gas was left to how many miles I had driven (for the more science-y guys here, is that rigorous enough? I wasn't sure if I was leaving something out). Through all that I got a rough picture of the miles-per-gallon on my car: about 30 on a good day, not amazing considering it's a Honda Civic driving mostly on the highway; not horrible when you weigh in on the car's age ('93, with more problems than I have money to fix). It may be an unfair comparison, but just for fun the 2010 Prius or the Civic Hybrid got about 40-50 just on city driving. Sounds pretty nice right now...
However, through all that I was still worried that I wasn't being thorough enough. Maybe the gas station pump shuts the gas off before the tank is full, maybe there's more gas left than I think when the needle reaches E (or less than I think when it says full), maybe the air pressure in the tires isn't exactly where it needs to be, etc. Well, seems like a few of my concerns were justified when I stumbled on to this today. Even though everything else on our cars has been computerized and improved over the years, it seems that people like the illusion and comfort of knowing that our tanks have a little extra fuel in them than what the gauge tells us despite the fact that it messes with just how fuel efficient your car really is (kind of like the illusion of more safety on airplanes by adding more and more inefficient security). Things apparently get even more confusing if you top off at the gas station, something I don't do but according to the article can add almost another full gallon of gasoline. All-in-all it's not that big of a deal, but I always wondered why they didn't just put a digital number there that tells you how much gas is left. I guess nobody likes to hear the truth.
I don't know if this actually ends up improving my car's fuel efficiency or not. I just don't know what to think knowing that my fuel gauge is lying to me. I thought we were cool, gas tank...
TJ and I spend a lot of time hunting down a certain kind of art and it's time we shared some of it with you guys, assuming you're not already familiar with it. YouTube has enabled some talented folks to distribute a new class of amateur video that, when done well, can really leave you breathless. And your sides aching. As I am wont to do, I'll try and fit these videos within a loose classification scheme. They tend to fall into one of three broad categories: Recuts, Overdubs, and Splices.
Recuts
Recuts reshape what's already there, crafting a new story out of the ingredients of the old one. The new story is itself likely to be pretty funny but often the true hilarity comes primarily from the contrast with the source material. I started writing this post a long time ago and inserted here the absolute, hands down best example in existence, a Jaws recut called "Nobody Cares About Quint" in which the Orca crew's indifferent reactions to Quint's violent death are on display. I think TJ will vouch for the fact that this video was simply amazing. I'm leaving the embed in here even though, as you can see, it's been taken down. Maybe someday it will come back.
Overdubs leave the action of a movie scene unaltered but radically alter the character of it with some fun sound editing. These are a way of inserting another film into an existing scene without altering the action of the existing scene in any way (no recut necessary). The juxtaposition of old action with new dialogue can be great fun. Probably the best example around today is Dude Vader:
Other Vader overdubs, like Darth Schwarzenegger, also exist since he's an easy target, given that you can't see his lips moving. The classic HAL Pacino also falls into this category, as does Reservoir Turtles. And of course, the Ninja Lebowski series qualifies:
Lastly, as a general rule, overdubs that use original dialogue (i.e. instead of just inserting sound from another movie) are usually not very good. The most notable exception is the overdubbed (and sometimes recut) series of G.I. Joe public service announcements, known for such classics as Porkchop Sandwiches!
Splices
Splices take two different (often radically so) movies and find a way to make them interact in a way that not only sort of makes sense but is hilarious. Exhibits A and B are two Back to the Future-themed splices:
There are also a few sub-classes of YouTube Funnies. While these aren't anything we haven't covered, these don't easily fit under just one of the above three categories because they tend to wander between them (they choose not to respect my careful classification scheme). These include:
Alternate Endings
Alternate endings, of course, take the movies we love and resolve them in an entirely new way. Some alternate endings are recuts, like this one:
Other alternate endings are splices, like this Matrix-Crocodile Dundee scene:
There are probably hundreds of alternate movie endings on YouTube (although many of them aren't very good). Most notable is the series of Indiana Jones alternate endings (like this one) and the many, many Star Wars alternate endings (like this one), though again the quality varies. As a general (though not absolute) rule of thumb, if an alternate ending is longer than two or three minutes, the payoff probably isn't enough to warrant spending the time watching it.
Fake Trailers
These are exactly what the name suggests: trailers for movies that, tragically, don't exist.
They can be silly splices like A Hard Day's Night of the Living Dead:
Or they can be recut overdubs like Must Love Jaws:
I'm probably killing the bandwidth so I'll stop there. I have to say, I'd really love to develop some video editing skills so I can start making some YouTube Funnies of my own. But we'll see.
If I've left out anything noteworthy or you've got more you want to share, put some links in the comments.
Can you break the unbreakable? Truncate the infinite? End the perpetual?
I ask because I want to briefly wade into history (I'm pretty confident I'll be revealing some serious ignorance in this one). Some time ago, our Confederate friends believed that states could choose to leave the Union and, apparently, some states' rights folks still think this. The Civil War, then, apparently decided only that if your state wants to leave, it better be packing more firepower than the states that want it to stay.
We know that the Articles of Confederation was the first real governing document for the United States. But if you read the Articles, you'll notice repeated references to itself as the "Articles of Confederation and perpetual Union." In fact, the Articles stressed no less than six times that the union it was establishing between the states was to be perpetual.
I'm compelled to raise the questions in this post because one day while looking at the wiki page on the Constitution, I saw this:
On September 17, 1787, the Constitution was completed, followed by a speech given by Benjamin Franklin, who urged unanimity, although the Convention decided that only nine states were needed to ratify. The Convention submitted the Constitution to the Congress of the Confederation, where it received approval according to Article 13 of the Articles of Confederation.[10]
I didn't remember that bit about receiving approval from the Congress of the Confederation from history class (should I? perhaps this is an embarrassing admission) and the reference they give for that assertion is the National Archives page on the Constitution; it wasn't immediately obvious during a brief browse where on the site that factoid could be found.
But, assuming it's true, it seems to raise an interesting philosophical question. Though the Constitution didn't require unanimity for ratification and the Articles did require unanimity for the adoption of amendments (as you can see from Article 13 below), it's worth noting that the Constitution did ultimately receive unanimous ratification so at least in practice that discrepancy is without consequence.
Article XIII. Every State shall abide by the determination of the united States in congress assembled, on all questions which by this confederation are submitted to them. And the Articles of this confederation shall be inviolably observed by every State, and the union shall be perpetual; nor shall any alteration at any time hereafter be made in any of them; unless such alteration be agreed to in a congress of the united States, and be afterwards confirmed by the legislatures of every State.
The first question that occurs to me is pretty straightforward. If the Constitution was indeed adopted in accordance with Article 13 of the Articles of Confederation (right down to actually being submitted to the Congress of the Confederation), then is it indeed what it was originally supposed to be: an amendment to the Articles of Confederation? Perhaps I was zoning out during this bit of American history but I had always thought that the Constitution was written only after the Framers decided that amending the Articles was a lost cause and an entirely new document, written outside the context of the Articles, was needed. But if the Constitution is itself only a legitimately passed amendment to the Articles--granted, an entire overhaul but one done within the context and conceptual framework of the original document--then it is part of an unbroken chain that started with the writing of the original Articles.
And that leads to my second question. Is the "perpetual union" bit not still in full force? I ask because the Articles contained a very odd thing: An Infinity. A perpetual union is one that will exist for all time and presumably cannot be undone. The only way, then, to overcome that would be to deny the legitimacy of the Articles and supplant them with something entirely different. Which is what I had always thought is what happened.
But if the Constitution is technically just an amendment to the Articles, then it still acknowledges the legitimacy of the original document; again, this hinges on whether its passage was actually done in compliance with amendment rules set forth in Article 13 of the Articles but for the purposes of this post I'm assuming that's true. And since that document contained An Infinity, I would think that even a complete re-write couldn't scrub that Infinity out of existence. That is, it seems to me that under the original Articles, you couldn't have an amendment passed under Article 13 that said "oh, about that perpetual union thing? nevermind." The reason being that you can't create An Infinity and then later decide that you want to cap it, even retroactively. If the original document is valid and it creates An Infinity, then I would think that Infinity will persist for as long as the validity of the document is recognized. Even the full power of the document can't undo what it has done. You can't close Pandora's Box.
And if that's true then even under the current Constitution its parent's commitment to a perpetual union of states must still be in effect. Because you can't uncreate The Infinity contained within the Articles without rejecting the Articles, which the Constitution doesn't seem to have done (again, assuming its ratification was done with the assumption of the Articles' validity, i.e. as an amendment to the Articles). The reason being, quite simply, that if you could end something with a simple amendment, then it couldn't have been perpetual in the first place. Similarly, if you could simply cap the infinite whenever you felt like it, it couldn't have really been infinite to begin with. "Perpetual" means a very specific thing and, I think, implicit in that definition is that nothing at all can end it. And if the Constitution is cut from the same cloth as its predecessor, then even though the words "perpetual union" are no longer in the governing document they must still be operative anyway.
Does any of this make sense? Am I way off base here?
Not too long ago, Republicans were complaining that billions were being taken out of Medicare to pay for a new entitlement (subsidies for low income people buying insurance in new health insurance exchanges).
Today we learn that Senate Republicans and Democrats have agreed on a novel way to deal with the perennial problem of finding money to prevent Medicare physician reimbursements from going down next year: by taking billions out of that new entitlement and funneling it back into Medicare.
I went with the Escher "Drawing Hands" analogy because it comes with a nice visual but truly the first reference that came to mind was Milo Minderbinder's economics. That said, in its strange way, this all does make sense.
I'm a Time Warner subscriber and it seems like every few weeks they run a commercial (or, occasionally, send an email) exhorting me to lend my voice and help them stand up to some particular channel offerer. At the moment, it seems they're having trouble with at least two companies that offer some particular set of channels and, if an arrangement can't be worked out, subscribers (like me!) face a blackout of those channels. Here's part of their explanation about what's happening with one of those companies right now:
We are currently negotiating with the parent company of those channels, ______. And if we don’t reach a new agreement before December 15, ______ is threatening to stop allowing Time Warner Cable to continue carrying its stations. We’re working hard to reach an agreement that will prevent any interruptions in these channels, and are optimistic that we can do so. [...]
We’re talking about it because the single largest expense we have in delivering you video service is the price we must pay to the companies that own the programming. And customers have told us they don’t understand why the price they pay each month continues to rise. We want to give you the information that helps you make informed decisions about programming. Time Warner Cable buys programming from hundreds of different companies that run TV stations and cable networks. The contracts to buy that programming come up for renewal from time to time, with dozens up for renegotiation every year. Most are negotiated in private between the companies, without event. But sometimes some of those negotiations become public.
So I pay a monthly fee to this particular company (Time Warner), which then has to negotiate contracts with various companies that are actually providing the thing I want: TV channels. This sounds just like something else... (he said thoughtfully, stroking his beard and staring off into the distance).
Indeed, the superficial similarity I'm noting is to the dance that your health insurance company does with health care providers. And just as, sometimes, Time Warner's negotiations with the companies offering TV content spill into the public sphere, sometimes the negotiations between health insurers and health care providers become ugly public pissing matches. There was a story out of North Texas just last week about Blue Cross Blue Shield and a provider network called Texas Health Resources airing their dirty laundry in public. It seems if Texas Health Resources doesn't get the contract it wants from Blue Cross, its hospitals will charge patients/Blue Cross the much higher out-of-network fees (blackout!) and the hapless doctors caught in the crossfire "have sent letters to their patients encouraging them to contact Blue Cross" ("If you think it’s unfair for your local stations to black out your programs from Time Warner Cable customers while demanding significant increases that will eventually impact the price you pay for cable, let them know!" says Time Warner).
Instead of cooperating, the region's largest insurer and hospital system are taking jabs at each other.
Blue Cross says Texas Health is demanding an additional $120 million over three years to cover cost increases. The insurer has declined to say how much it is currently paying Texas Health.
The insurer says it contributes $178 million to Texas Health's annual profits. It also says the hospital system makes a 30 percent profit margin from Blue Cross members.
"This kind of runaway spending on medical care is one of the main causes of higher health insurance premiums for our members," Blue Cross said in a recent letter to members.
For its part, Texas Health says Blue Cross wants to pay its millions upfront in a lump sum. Instead, Texas Health wants its money reimbursed traditionally, after a claim is filed. The hospital system also points to the insurer's accumulated wealth.
"Blue Cross Blue Shield of Texas is sitting with about $7 billion in reserves. And they don't provide any patient care," said Wendell Watson, spokesman for Texas Health. "In fact for many of their customers – the self-insured ones – they don't do much more than manage the paperwork on claims."
Both are nonprofit companies. Texas Health had $2 billion in assets at the end of 2008, according to its latest financial reports.
The power struggle between insurers and hospitals has intensified in recent years as hospital consolidations created mega-health systems. These companies, emboldened with leverage, began going head-to-head with insurance companies for better rates.
"As we've grown we've gained a larger network of providers that provide care in a variety of settings," said Barclay Berdan, Texas Health's vice president for system alignment. "We get some economies of scale because of that."
Blue Cross' vice president for network management, Shannon Stansbury, said the company negotiates with smaller health providers across the state every day. Blue Cross has contracts with more than 400 hospitals in the state. [...]
It's tough to find much redeeming content in Thursday's Cavs-Heat game but I think my favorite part was seeing Z's reception when the Heat starting line-up was being announced. Deafening boos were momentarily replaced by thunderous applause.
Sucks that Z chose the Heat but at least he said goodbye with a nice Sunday ad in the Plain Dealer and not a nationally televised middle finger to the city.
Dear Cleveland,
When I came to this country 14 years ago, I was a young man who barely spoke the language and had no idea what to expect of this great country.
As I look back on those early days, I realize how lucky I was to have grown up in a place like Cleveland. All of you have taught me the importance of family and friends; of pulling together to get things done; of loving your country.
I’ve never felt as proud as when I’ve pulled on the wine and gold and stepped onto the court.
I’ve tried my best to return that support by playing as hard as I could each and every game.
The decision to play for Miami was not an easy one to make for either myself or my family.
But as I enter the last few years of my career, I felt I owed it to myself and my family to chase my dream of winning an NBA championship.
I hope you understand.
I also hope you realize that Cleveland will always be home to me.
Back to musing about health care. The issue of rising costs comes up again and again whenever health care is the topic of discussion. But the word "costs" is, confusingly, often used to mean two fairly different things (often simultaneously) so it's worth thinking about the difference. They are:
1. Costs are the prices we pay for procedures or devices. They're a measure of how expensive the units of health care we're buying are. 2. Costs reflect total (national) spending on health care. This is the aggregate amount (>$2 trillion) we're spending every year, or the percent of GDP we put toward health care services. This number, however, depends both on how much individual units of health care cost and how many of those units we buy (volume).
To illustrate the difference, I'll use a mundane example from my weekly routine. I live in an urban area and don't own a car. As such, I shop in a nearby urban grocery store. If I had a car, I could shop slightly further from home at one of the larger grocery chains prevalent in this area.
Given that when I do my weekly grocery shopping I do so on foot, there is a natural limit to how many groceries I can buy. Even if I wanted to buy more than 3 or 4 bags of groceries (not that I do), I wouldn't be able to carry them all home. At the same time, it's worth noting that as a small, independent grocery store, the prices at my grocery store are in fact a bit higher than the prices across town at the larger chain grocery stores.
So let's consider two scenarios. The first is my current routine, in which the amount of groceries I can buy at one time is limited but the prices of individual items is higher than the alternative. In the second scenario I have a car and can load up my trunk as full of groceries as I please. As such, I start shopping at one of the larger chains or even a Costco and give in to the urge to buy in (greater) bulk. What's the cost of my groceries? Or, as a separate question, what are my groceries costing me? If I wanted to answer the first question, I'd probably check my receipt to see item-by-item what everything costs. On that kind of per-unit analysis, the bigger stories with lower unit prices will look better than my independent grocer. But if you ask what groceries are costing me, say per year, I might be spending more money if I'm shopping at the chain stores, simply because I can (and thus am tempted to) buy more every time I go shopping. When I'm not limited to buying only what I can carry home, I might buy lots of extraneous goodies.
The point here, of course, is that while these are very different questions, when it comes to health care people tend to conflate "how much does this cost" (unit price) with "how much is this costing me" (unit prices x volume). I myself am guilty of not specifying what I'm talking about and bouncing between meanings in different posts. As such, alarm over health care costs sometimes manifests itself as disbelief at an outrageous bill for a given procedure, and sometimes as alarm bells sounded over an uptick in national spending and increases in the fraction of our national income we're directing into the health care market.
When I wrote The Case Against Providers back in the summer, I was talking mostly about the component of the cost issue that stems from providers bargaining up the reimbursements (prices) they get for procedures from payers. The Demi-Decade of Coverage, on the other hand, discussed some of the long-term cost containment potential of the reform law and that touches more on the "how much is this costing me" issue. And that's because the tools offered by the Affordable Care Act--the scalpels and chainsaws I mentioned--are aimed largely at reducing unnecessary volume: comparative effectiveness research, payment reforms, more efficient and effective delivery models, efforts to reduce medical errors, and the like are all aimed at streamlining the health care system and make it better at doing what it does (read: achieve good results without flushing huge amounts of money down the toilet for no reason). What the scalpels and chainsaws "cut" for the most part is unnecessary volume. By and large, however, those reforms don't lower the unit costs of procedures. That doesn't mean they're not important steps to slowing our national cost growth, since total spending will equal the prices of our procedures multiplied by the volume of them we consume very year. But still, room for improvement.
The 2010 law does little to address this. Its many cost-control provisions are geared toward reducing the amount of care we consume, not the price we pay. The law encourages doctors and hospitals to join "accountable care organizations" that have financial incentives to limit unnecessary care; it beefs up "comparative effectiveness research" to weed out inefficient treatments; and it will eventually tax the most expensive insurance plans to restrain consumers' superfluous use of health care.
Such measures could reduce redundant tests, emergency room visits and hospital readmissions, which would help control the costs of Medicare, where the government sets rates. But they are less likely to lower prices outside Medicare and stem the growth of private insurance rates.
The author astutely points out something I've noted before: the robust public option that was proposed in early incarnations of the health care bill (but ultimately was dropped) was targeted at bringing down the actual prices of procedures charged by providers. This is something liberal supporters and conservative opponents alike failed to recognize, with the two camps wrangling over whether this would put the fear of God into insurers or drive them out of business with nary a word about providers.
And make no mistake, the prices of the medical services we buy from providers in this country can be substantial (relative to our counterparts in the rest of the developed world). The International Federal of Health Plans' Annual Comparative Price Report came out a week or two ago and it's full of charts like this one:
The average price for something here is generally more than almost anywhere else but not by a ridiculous amount; it's the huge variation in prices we experience/allow here--where prices are often a jealously guarded trade secret and vary depending on who's buying (the same hospital can charge two different insurance companies different prices for the same procedure in every state except Maryland)--that allows some of what we spend to stretch into the stratosphere.
And while I expressed optimism that the reform law provides the tools to get serious about cost containment--particularly after the first "demi-decade"--the actual prices of services are something we still have to address. And to leave this post with a cliffhanger, I'll note that in some future post I'm going to mention one possible tool for doing that.
I'm not sure I know what to make of Jon Stewart anymore.
His message of restoring "sanity," which I took to mean restoring civility and fact-based argumentation, resonated with me and clearly hit a chord with plenty of others. And anyone who has watched his show and followed some of his extracurriculars knows Jon as something of a media critic. His most famous moment was the day he went on CNN's Crossfire in 2004, ostensibly to promote America: The Book, and tore into what he viewed as the triviality and partisanship of the way the program was run ("You're hurting America," he told them):
At the time, and to some extent still today, I agreed with his underlying message that Crossfire utterly failed in getting its guests off their prepared talking points and thus arguably there was no "real" dialogue. Certainly I agree that it would be nice if people--important people, no less--could sit and have a genuine discussion. And to some extent Crossfire's hosts were guilty of not holding the feet of politicians who appeared on the show to the fire, as the hosts themselves traded partisan barbs. But the reality, it seems to me, is that even if you have a relatively adversarial host who explicitly calls out a politician for sticking to talking points like a broken record, it doesn't matter.
For example, on election night a few weeks ago, Chris Matthews checked in on uberpartisan Republican Congresswoman Michelle Bachmann, who had just been re-elected. In a previous appearance on Matthews' show Hardball, Bachmann had suggested that someone (the media?) ought to investigate Congressional Democrats for anti-Americanism, an idea that many thought came dangerously close to outright McCarthyism. So when Matthews talked to Bachmann on election night, he came right out and asked her if she intended to launch investigations into anti-Americanism now that Republicans had taken control of the House. Her canned answers were completely unrelated to his questions, to the point that it didn't feel like an interview at all. Which led to this amusing question from Matthews:
But back to the point. When Jon Stewart and Stephen Colbert held the Rally to Restore Sanity and/or Fear a few weeks ago, the response from many left-leaning media personalities wasn't particularly positive. The hosts of MSNBC's primetime shows bristled at being compared to their counterparts at Fox News, viewing the juxtaposition as a false equivalence. And Bill Maher used part of the "New Rules" segment of his HBO show to say what I think many people were feeling about the rally:
Stung by the criticism from the left, Jon asked for some time last week to sit down and explain himself in an interview with MSNBC's Rachel Maddow. The uncut interview (50 minutes long) can be viewed here: The Interview. It's worth watching if you have the time because it's both interesting and surprising.
He says a lot of things in this interview that make very little sense to me. And some that outright contradict each other. As an example, Maddow and Stewart discuss an issue that has sprung back into the spotlight with the publication of Bush's new book: did the former President authorize torture, sometimes phrased as "is Bush a war criminal?" This is back in the news because in his book Bush explicitly admits to personally and enthusiastically authorizing waterboarding:
In George W. Bush's new memoir, Decision Points, the former president explains that the CIA approached him about the possibility of waterboarding Khalid Sheikh Mohammed, the al-Qaeda operative often called "the architect of 9/11." In his memoir, Bush writes that his response was "Damn right." This seems to be a straightforward admission that Bush approved the use of waterboarding on a detainee--even though this technique is widely regarded as inhumane, and its use is thought by many to violate the United Nations Convention Against Torture, of which the United States is a signatory. (In media outside the U.S., waterboarding is almost always referred to as torture.)
I'm actually not sure why this is being viewed as a revelation; everyone knew that the U.S. has waterboarded detainees. I suppose we didn't know for sure that Bush had personally signed off on it? Well, if we didn't know before, we know now. And so the issue seems to have become very simple: is waterboarding torture? If yes, then a crime was committed here. The current Attorney General has said that waterboarding is torture, it does seem to be a fact that the U.S. charged at least one WWII-era Japanese officer as a war criminal for waterboarding someone, a great many experts inside and outside the U.S. seem to feel it constitutes torture, and prior to 2002 the prevailing opinion in America seemed to be that waterboarding is torture. So with that background established, I've clipped the relevant portion of the interview:
The first thing that sort of made me do a double-take was Jon's statement to Rachel "You've said Bush is a war criminal. Now that may be technically true...". He starts off by conceding her point but chastises her for having the audacity to make it because it "feels like a conversation stopper." I fully agree with him that such a statement sounds incendiary. But this is where I think Jon's message gets a bit hazy. Does restoring sanity and civility mean ignoring the truth content of a statement? A statement like "Obama is a Marxist" doesn't satisfy the definitions of sanity and civility because it's nonsensical: there is no valid argument you can make in support of that statement. Put simply, you have to either 1) be unfamiliar with the tenets of Marxism or 2) be unfamiliar with the policies Obama has pursued or is pursuing to believe it. Either way, making that statement constitutes a massive breach of what one might consider to be the requirements of civilized discourse. It's not the style, it's the substance that sinks it.
In the case of "Bush is a war criminal," you have to believe three things: 1) Bush authorized waterboarding, 2) waterboarding is a form of torture, and 3) torture constitutes a war crime. The first one is not in doubt, since the man wrote a book boasting about that very thing. Regarding the third, I'm certainly not a lawyer so I'm not sure what domestic federal law says on the subject, but as signatories to things like the Geneva Conventions and the United Nations Convention Against Torture, I believe the U.S. (and, ultimately, the world community) has made its feelings clear on this issue. So it really hinges on the second point, which as I've indicated has lots of evidence in its corner that waterboarding is indeed a form of torture. And, just as an aside, if you're having trouble remembering exactly what it is that the former President signed off on:
Interrogators pumped detainees full of so much water that the CIA turned to a special saline solution to minimize the risk of death, the documents show. The agency used a gurney "specially designed" to tilt backwards at a perfect angle to maximize the water entering the prisoner's nose and mouth, intensifying the sense of choking – and to be lifted upright quickly in the event that a prisoner stopped breathing.
The documents also lay out, in chilling detail, exactly what should occur in each two-hour waterboarding "session." Interrogators were instructed to start pouring water right after a detainee exhaled, to ensure he inhaled water, not air, in his next breath. They could use their hands to "dam the runoff" and prevent water from spilling out of a detainee's mouth. They were allowed six separate 40-second "applications" of liquid in each two-hour session – and could dump water over a detainee's nose and mouth for a total of 12 minutes a day. Finally, to keep detainees alive even if they inhaled their own vomit during a session – a not-uncommon side effect of waterboarding – the prisoners were kept on a liquid diet. The agency recommended Ensure Plus.
So while Jon's right that the charge is incendiary, accusations that Bush is a war criminal don't seem to be based on false premises, nor are the arguments particularly weak. And while this seems to have emerged as a partisan issue, I don't think the fundamentals of the debate itself are partisan. Certainly the current President took a very Gerald Ford-ian approach of letting bygones be bygones. Did the last guy do something illegal? Eh, better not to ask the question, let's move on.
But let's get back to Jon's point. And I'm torn because I'm sympathetic to his "you're not helping" views. He seems to have in mind groups like Code Pink, which engage in silly publicity stunts to make their point. Certainly I agree that getting thrown out of a Congressional committee room by shouting about Bush's potential war crimes is a waste of time. In college, I was frequently annoyed by the antics of liberal student groups. When a group trying to force the university to divest any holdings that might somehow make it into Darfur crashed a university Board of Trustees meeting I took a Stewartian "you're not helping" point of view. Efforts to bar Coke products from campus in order to make some point about labor conditions in South America seemed pointless to me. Causes for the sake of causes never appealed to me, nor have antics for the sake of antics. So in that sense, Jon is right about the importance of style and certainly the effort to restore sanity entails stylistic changes to the way arguments are presented.
But this is exactly where many on the left took issue with him (and you can see this in Bill Maher's clip above). He conflates statements that are incendiary on the basis of their substance (e.g. that Obama is a socialist or Marxist or whatever) and pushed by a wide range of leaders in modern conservative/Republican thought (including political leaders), with arguments that are not incendiary--in the sense of "we don't have an argument here but are just trying to egg on the other side"--on the substance (e.g. by authorizing an apparent torture technique, Bush may well have committed war crimes) and have been suggested by all manner of sober legal scholars and relatively civil voices on the left (like Maddow). And he does this because a handful of groups on the left have chosen to make the point in an obnoxious way. And whether or not he wants to admit it, Jon is pushing a very serious false equivalence with that kind of thinking.
And he brushes off the accusation against the former President--after suggesting it "may technically be true"--by saying that, to him, a war criminal is Pol Pot or the guys convicted in the Nuremburg Trials. In other words, a war criminal isn't someone who knowingly and purposefully engages in actions that violate the established rules of war, it's someone who commits genocide. I can't get behind that, Jon. He suggests that if we're going to go down that road, we might have to ask whether Obama is some kind of war criminal for continuing the Bush-era policies of "extraordinary rendition," i.e. knowingly shipping prisoners off to more torture-friendly countries. And while I think there's a much less straight line case for actual criminality there, by all means let's talk about it. It seems a bit disingenuous to push the idea that we're in trouble because "tribal" politics colors everyone's perceptions, and then make that kind of argument in support his case--"well, we can't pursue that thread because then we'd have to consider the possibility that Obama has done something wrong." Sorry, Jon, that's not an argument against going down that road. Not to someone who can see--as you claim to want people to do--beyond red and blue.
I realize I've spent an inordinate amount of time on that one issue. There's a lot more in there that I find a bit off, such as his holier-than-thou attitude on his own role in the media. When I say Jon's a "media critic," I mean he's a very specific kind of media critic: a critic of cable news. Fox News, CNN, and MSNBC are frequently the target of his ire but I don't believe he ever criticizes network news or newspapers. In general, he goes after shows based on commentary--what I think are the TV equivalent of newspaper columnists or editorialists. And that's fine, those people deserve to be skewered. But we shouldn't confuse them with "the news." Bill O'Reilly is not the news. Keith Olbermann is not the news. They report stories, sure, but they do so with their characteristically ideological bent. Bill O'Reilly actually puts up his thoughts on the screen in bullet points, a practice lampooned by Colbert in The Word.
No one tunes into these people expecting a straight news broadcast any more than they tune into The Daily Show for a straight news broadcast. They tune in for the show's particular bent. In the case of The Daily Show, we watch because Jon makes fun of the news, he puts his unique comedic spin on it. Liberals watch Olbermann for his liberal bent and O'Reilly for his conservative bent. Everyone knows what they're getting: a certain kind of commentary on the news. In that sense, The Daily Show is no different than that which it mocks. It's just that the mockery itself is the bent its viewers want to see.
Here's Jon (somewhat incoherently, I think) trying to argue that his show is special and he has "leeway" that others lack:
I don't buy it, in part because I'm not sure what he's trying to argue. None of them are "on the field" in the sense he seems to be using it, which roughly seems to be "actively working as an arm of a party." I don't even think Fox News generally meets that definition, though some of the folks over there came awfully close in the first half of 2009 with the way they promoted Tea Party meet-ups. They all clearly have preferences (this includes Jon) and they all approach the news with a point of view that they wear on their sleeves. But again, that's not a bug, that's a feature: that's why people tune in. It's not "what happened today?" it's "how is ___ going to handle what happened today?" People getting some of their primary news from those programs is undoubtedly happening but that's not the fundamental point.
What becomes clear at a certain point of this interview is that Jon takes issue with what he views as a motive-driven narrative: viewing the actions of politicians through the lens of what you perceive their motives to be. Thus the criticism of Bush as a possible war criminal becomes invalid because many adherents to that view are undoubtedly fitting it into their core belief that Bush is a bad or evil man. And while I don't think there's any way to get rid of that kind of thinking, I don't think it's particularly relevant here. It doesn't matter if Bush's motives were relatively pure, as he suggests they were: everything he did, he did to protect American citizens. Invading Iraq, authorizing waterboarding, tapping phones, and so on. But to pretend that opposition to those policies is somehow invalid because the dissent has in some instances been overly shrill or rooted in an odd belief that Bush is some kind of second coming of Hitler is disingenuous. And by that I mean that the claim that these policies are bad for American has merit, regardless of whether the person making that argument believes it simply because he believes in his heart that Bush is a bad man. You can believe he was wrong, even criminally so, and still accept his claim that his motives were pure.
Let me illustrate this with a contrast. I have a good friend who, during the 2008 election season, took issue with some of candidate Obama's policy preferences because of some deep-seated suspicion of the years Obama spent overseas as a child. In the same vein, I've seen opposition to the Affordable Care Act that's rooted in the fact that in 2003 Obama told a room of union folks that he's a proponent of single-payer. These are part of a larger pattern that I would characterize thusly: Obama is different somehow, he's some kind of "other," either due to one's suspicion about the church he went to, or his "real" religious beliefs, or his years overseas, or his racial background, or the way these intersect with his alleged closet socialist or even Marxist beliefs. And because one believes that in his heart Obama has an unacceptable world view (be it in terms of religion, or economics, or culture, or all of the above), every policy he supports must be viewed through that prism, regardless of the independent merits or failings of the policy itself. Thus it's irrelevant that a dispassionate look at the ACA--er, "ObamaCare"--would confirm that its design does not lead anywhere close to single-payer health care (indeed, as I've pointed out, the design itself came from 1990s era Republicans)--since we "know" that Obama wants to take over every aspect of your life, it stands to reason that a health care law he supported must pave the way to whatever your worst nightmare happens to be.
In the war criminal example, believing that Bush is inherently a bad man with bad motives isn't necessary to make the argument, it will simply reinforce the conclusions that I believe a dispassionate analysis yields: these policies are not a good idea and quite possibly criminal. But when it comes to Obama, a deep-seated paranoia about the man himself is necessary to buy the arguments being presented because the facts themselves don't lead to those conclusions. These are not equivalent situations, no matter how hard Jon wants to strive to appear "fair." So when he makes these arguments, as well as arguments that it's just a "belief" that Saddam Hussein wasn't actually creating weapons of mass destruction, he leaves me scratching my head. Perhaps I'm missing the point he's trying to make because, as I said at the start, I don't know what to make of the guy anymore. Civility does not mean--as it does in the non-partisan, non-opinionated media that Jon doesn't attack--presenting bullshit as being on par with rational, fact-based analysis. If the failing of cable news personalities is that they have too much of a point of view, the failing of the dispassionate media is that it doesn't have enough of one. Instead we have news articles telling us that critics say X, while the White House or whoever responds with Y. Well, that's nice but it doesn't leave the average citizen with any means by which to evaluate the truth of X or Y. And thus they're forced to rely on partisan affiliations or their gut or chicken bones to pick a side. I don't know how to reconcile my own view that some statements, some points of view are just laughably devoid of facts or content--a view I feel is implicitly shared by The Daily Show in much of their tongue-in-cheek humor--with Jon's statements here.
And that's part of the enigma of Jon Stewart: what is he trying to do? What point is he trying to make? If it's just satire, I have to admit I think Colbert's show has been light years ahead of The Daily Show for years (virtually since Stephen left). If, as Wiki says, "In satire, vices, follies, abuses, and shortcomings are held up to ridicule, ideally with the intent of shaming individuals, and society itself, into improvement" then Colbert, by doing each and every show in character, as a false persona representing an amalgam of right-wing blowhards, takes the cake here. His humor is more biting, the heights of ridiculousness he reaches using conservative arguments and tactics are well beyond anything The Daily Show does these days, and just in terms of entertainment value Colbert has always been a better performer than Jon himself (Colbert's roots in Second City's brand of improv comedy serve him much better in this respect than Jon's background in stand-up serve him). In terms of sheer hilarious comedy with biting points to make about society, Colbert wins.
The Daily Show, I think, has to be viewed more as another version of that which it claims to parody: news shows with a point of view. Their point of view is expressed through comedy, but then many times so is Rachel Maddow's (in fact, in the interview she laments that now her attempts to use comedy to talk about politics come across now as a poor rendition of Jon Stewart's shtick). Despite Jon's protestations in this interview that even his own term for his show--fake news--isn't correct and that he's really just attempting to pull of his own version off a Jerry Seinfeld routine, it seems clear that his goal is to comment on the news in his unique style, which as a comedian obviously revolves around humor. This differs a bit from Colbert, I think, who is so dedicated to his satirical craft that he not only spoke at the 2006 White House Correspondents dinner in character to make fun of both the media and the President (to his face) but actually testified in front of a Congressional committee in character a few weeks ago. Again, if it's a question of which one is the kid blowing spitballs at the powerful for the sheer fun and comedy of it all, Colbert wins hands down (particularly when one reflects on the interviews--with a few exceptions--Jon has done with the people he lambasts).
Anyway, I found that interview perplexing. Take from it what you will.
edit// I realize I wanted to make some point about the history of partisan newspapers and the like in America to push back on Jon's implicit suggestion that the Era of Good Feelings lasted up until a few years ago when red-and-blue maps and nasty partisanship re-emerged from the dustbin of history. But maybe TJ or one of you can somehow relate those kinds of things to the topic at hand.
Historically the three-body problem was a very prominent (and difficult) challenge in physics: calculating the paths taken by three bodies interacting with each other gravitationally. Since each body is affecting the other two and those effects in turn influence how the other two bodies interact with each other and the first body, it's tricky.
But I'm using the phrase a little differently here. A week and a half ago I brought up the gubernatorial race in Maine, effectively a three-way race. And I posted this graph showing the shifting dynamics of the race in its closing days:
By the very end of the race the independent candidate, Eliot Cutler, had surged into a very close third behind Democrat Libby Mitchell and was clearly on the upswing. How did things turn out on election day? As Wiki attests:
That's right, it almost turned into the biggest upset of this gubernatorial election cycle. For most of election night, Cutler was leading as the election returns trickled in. So what happened?
My best guess is that the polls themselves altered the outcome of the race. Regardless of what triggered Cutler's momentum in the closing weeks, it was clear that he had it. It was also clear the Libby Mitchell was not going to be the next governor of Maine. And the fact is that Cutler, despite the Maine Democratic Party's idiotic decision to run negative ads against him in the final days of the campaign, was acceptable to most of the Democrats and other center-and-left-leaning residents of Maine. I mentioned his background in the other post so I won't repeat it here.
So it stands to reason that the average Democrat/non-right-leaning voter saw Libby Mitchell treading water--or even sinking--as the campaign wrapped up and, mortified by the thought of Tea Partier Paul LePage becoming governor, decided to vote strategically: withdraw support from Mitchell and throw it to Cutler, who was trending upwards. That's the kind of swing that takes a guy from third place to (almost) first. There are undoubtedly also voters like me--people who didn't intend to vote but impulsively decided on election day to take advantage of Maine's same day registration laws and turn out to vote for Cutler (who was my first choice even before I decided to vote).
In the end, the candidate formerly running 2nd in the polls--Democrat Mitchell--didn't finish first or second in any county in the state. That suggests those late interactions between her, Cutler, and certain voters' revulsion at the thought of a LePage victory had a significant impact on the race. In the end LePage eked out a victory, a victory I suspect wouldn't have happened if the remaining Mitchell voters had known how close Cutler would run with him. But dem's da breaks.
As for what the state can look forward to: ... Though Massachusetts gets credit for being reform-minded, Maine actually enacted comprehensive health reform in 2003. The state created the Dirigo Health program to expand coverage to the uninsured. And while the program has faced its ups and downs and is certainly in need of some work, Maine now has the fourth-lowest uninsurance rate in the country. But if Republicans are good for one thing, it's unmaking that which has been made.
Tarren Bragdon, a co-chairman of Mr. LePage’s transition team, said the new governor would probably also scale back the social safety net to focus on the “truly needy” in programs like food stamps, Medicaid and cash assistance, and look to remake the state’s health system.
That system, known as “Dirigo,” (Maine’s motto, which means “I lead“ in Latin), was enacted several years ago in an effort to provide universal health care coverage for residents.
“Dirigo,“ Mr. Bragdon said, “will be Diri-gone.”
And all because 38% of voters wanted this guy to be governor.
History is full of instances that at the time, and when viewed alone, seem to be innocent enough but end up dramatically changing the course of events when you look beyond that isolated moment. Often we stray into the somewhat treacherous realm of "What If" history while considering these events, where one can draw just about any conclusion they want if they stack the historic dominoes the right way. While it's interesting to consider how things could have changed in a different situation, I'm not arguing that historic figures should have had a clear view of what the end result of their choices would be. Rather, in most cases I argue the exact opposite: that we generally can not possibly know what the long term results of present actions will be until after the fact (sometimes not until decades or even centuries later), and even then it is a confused and muddled picture that we may never be able to grasp completely.
There are few spheres of history more rife with contingency than military history, and the fact that debates still rage on the consequences of certain actions shows that it is impossible to determine even hundreds of years later how much of history changes with a few different flips of the coin. Battles and even entire wars can be won or lost by a single decision or random event, whether it's made by the commanding officer, a conscript on the battlefield, or nature itself. One war that has contingency bursting from the seams is the American Revolution and there are entire books on some of the lucky breaks the Americans got during the war. And while most of these lucky breaks have fairly reasonable explanations for them, there are a few that are interesting to consider how close things really were. The most famous is probably Washington's retreat from Brooklyn Heights on August 29th-30th, 1776. Completely surrounded with the East River to their backs, Washington decided that to live to fight another day was better than a last stand and he organized for boats to ferry what was left of his army across the river. The winds stayed perfect for preventing the British ships from sailing up the river to cut off the retreat and General Howe oddly told his men to hold off the final attack and dig in, both of which bought the Americans some time. But the clincher was probably the heavy fog that settled along Long Island which prevented British sentries from seeing the American withdrawal and hitting them while they were vulnerable. The retreat succeeded and Washington slipped away with the remainder of his army to continue the fight.
Another fateful choice came later in the war, this time from the British navy. In 1781 the usually aggressive Admiral Rodney of the British Navy decided, for a multitude of reasons, not to engage a French convoy led by Admiral de Grasse, the same Admiral that was on his way to seal General Cornwallis in at Yorktown (and, interestingly, the same Admiral who was soundly thrashed by Rodney at the Battle of the Saintes one year later). The author Barbara Tuchman argues in The First Salute that in this case the British were actually aware of the possible result of their actions and yet failed to prevent it. Whether or not they fully grasped the contingency involved is impossible for me to say, but it does illustrate how one decision can have a large influence on world history.
There are plenty more I would like to include here, but I'll only choose one to expand on. Charles Guiteau was an American "lawyer" who obtained his law license under questionable circumstances at best, which later in life helped give rise to political aspirations. He spent some time in a New York jail, was nearly committed to an insane asylum but escaped to a neighboring state, and apparently narrowly avoided death in a steam boat collision in 1881. After hounding the White House for months and being politely refused for a political appointment he had absolutely no qualifications for, Guiteau decided to shoot President James A. Garfield as his plan to cure the Republican Party of its "problems" (mainly him not receiving his appointment). If any one of those circumstances had changed for the opposite, perhaps Garfield would have fulfilled his term and drastically changed the list of presidents? Regardless of how the eventual domino effect plays out, had he been removed from the picture at any one of those earlier moments it is unlikely that someone else as insane as Guiteau would have come along to assassinate President Garfield.
Whether or not history would have changed with any of these events and to what extent is impossible to say and indeed irrelevant to my point. The point is that any chance occurrence that happens today can have a butterfly effect tomorrow. It is both exciting and terrifying to think about what happens based on our actions each day. Perhaps you throw out that old sandwich which causes you to not die of food poisoning and eventually go on to cure cancer? Maybe your party losing in a disastrous midterm election *ahem* causes it to rethink its strategy and win big two years from now? Or the opposite? We know just as much about the results of our actions as Admiral Rodney did by choosing not to pursue de Grasse in 1781. I can't wait to see how it pans out.
And when two like-minded people both decide to run instead of consolidating under one banner and party apparatus, they tend to split the vote of like-minded voters. And in those circumstances, a candidate the majority of the electorate doesn't want in office can sneak through. As you can see from FiveThirtyEight's forecast for the Maine gubernatorial race, the Independent Cutler has surged in recent weeks while the Democrat Mitchell has slipped into a bit of a freefall. The result is that they've converged in the mid-to-high 20s and the Republican LePage is sitting pretty and heading for a win with only 41.7% of the vote.
Shitty situation. But, for the record, were I voting, I'd be voting for the independent, Eliot Cutler.
Half of primary care practices in Massachusetts are closed to new patients and wait times for appointments continue to be long, according to a new survey released today by a statewide physicians' association.
The Massachusetts Medical Society, which has been polling doctors, hospital executives, and medical educators for nine years, reports that primary care doctors are in short supply for the fifth year in a row, citing pressure from the state’s 2006 law mandating near-universal insurance coverage. Other doctors are not immune. All told, 10 of 18 specialties also have shortages and all of the state’s community hospitals say they are having a hard time filing vacancies.
But a visit to the Kaiser Family Foundation's tremendously awesome statehealthfacts.og resource reveals that, at least in raw numbers, Massachusetts doesn't seem to be in bad shape. Relatively speaking. If we look at "Nonfederal Primary Care Physicians per 1,000 Population" we see that in 2008 Massachusetts had the highest number of primary care physicians (PCPs) per 1,000 people of any state (it tied with Vermont).* Massachusetts and Vermont both had 1.8 PCPs per 1,000 people.
"But," you say indignantly, "Massachusetts has near-universal coverage! You can't just compare it to every other state like that!" And that's true. Assuming people without insurance are very unlikely to see a PCP, it seems Massachusetts probably has more primary care patients per 1,000 people than other states, too. But suppose we were to take the uninsured segment of each state's population and cut them out of the equation. That is, let's just look at the number of PCPs per 1,000 insured people. That should knock Massachusetts down a few pegs, right?
And it does. Almost. When we adjust for all the states' insurance rates, we find that Massachusetts is no longer tied for first place. It's now tied for second (with 1.9 PCPs per 1,000 insured people). Still not too shabby. How do we explain this apparent discrepancy between the numbers and the reality? How can Massachusetts have more doctors per capita than (almost) anybody but still be facing such a severe shortage?
We believe that the perception of a physician shortage, both nationally and in Massachusetts, is just one symptom of the underlying problems in our health care system. The current delivery and payment systems often make it more “efficient” for primary care physicians to see patients they already know (diminishing others’ access to primary care) and for all physicians to narrow their scope of practice (increasing referrals to specialists) and to admit patients to the hospital (where hospitalists manage their care). Data showing that physicians in high-supply regions are more likely to report difficulty gaining both hospital admissions and specialist referrals are consistent with this hypothesis. In the absence of reform of the delivery system, additional growth will lead to further fragmentation of care that will exacerbate the problem of access and worsen the apparent scarcity it is intended to remedy.
Rather than treat the symptoms, we should focus on the underlying disease — a largely disorganized and fragmented delivery system characterized by lack of coordination, incomplete patient information, poor communication, uneven quality, and rising costs. Pilot projects intended to address these problems are under way in both the private and public sectors, with growing interest in primary care–based medical homes, enhanced care coordination, programs for chronic-disease management, and payment reform.
Food for thought.
*Not counting the District of Columbia as a state--D.C. is far and away the winner in this category.
The latest latest CNN/Time poll has Ted Strickland up 1 point. This after having been down 10-11 in other polls in the not-too-distant past. I should note that this is the only poll that's shown him up recently.
But it's possible that after sustaining a very long, extended barrage from his opponents, Governor Ted is fighting back. Here's a dramatization:
Well, the demagogue from Michigan held me personally responsible for causing 10.1 percent of our work force to be unemployed. But 7.4 percent of them were unemployed when we got here. By my figures, we're only responsible for 2.7 percent.
It's October. A first-term president warily stares down the approaching midterm elections, cognizant of the fact that his party is heading for losses. The unemployment rate is persistently high and the economy is in poor shape. The year, of course, is 1982.
Some folks feel the need to suggest that Obama's economic performance, particularly when it comes to the unemployment rate, doesn't compare favorably to Reagan's. Yet at this point in his presidency, Reagan was facing a 10.4% unemployment rate. And it was rising, on its way to hitting 10.8% in November and December of 1982. The month he took office it had been 7.5%.
By comparison, when Obama took office the unemployment rate was already higher, 7.7%. But last month and the month before that it hovered at 9.6%. If we use Reagan's logic from the opening quote, that means Obama "owns" a 1.9% increase in the unemployment rate. Not too bad, considering.
But this misses the real story. Just looking at the instantaneous unemployment rate when Reagan or Obama walked into office--7.5 and 7.7 percent respectively--doesn't give us an idea of the magnitude of the problem. What we really need to consider here is the derivative: how fast was unemployment changing?
And while this fact seems to have been rather quickly forgotten, the economy really was in free fall 21 months ago; we were hemorrhaging jobs at an alarming rate. Take it from this February 2009 CNN article:
The latest job loss is the worst since December 1974, and brings job losses to 1.8 million in just the last three months, or half of the 3.6 million jobs that have been lost since the beginning of 2008.
The loss since November is the biggest 3-month drop since immediately after the end of World War II, when the defense industry was shutting down for conversion to civilian production.
Got that? We hadn't lost so many jobs that quickly for a sustained period of time since we demobilized the war machine after V-E and V-J day. Let that sink in for a second.
You can see the monthly unemployment rates going all the way back to Truman here. Since it often helps to make a point visually, I stuck some numbers into an Excel chart: the unemployment rates under Obama and Reagan in their first two years in office. However, to give that perspective on how that rate was changing when they showed up, I've also included the numbers for the 12 months before they came into office (i.e. 1980 for Reagan and 2008 for Obama). Go ahead, click it.
You can see that for Reagan the unemployment rate was mostly hovering around that mid-7% range when he took office, whereas for Obama the unemployment rate was riding a rocket to the moon. But not too long after Obama's Hundred Days ended the unemployment rate began to level out and eventually came down a bit. Today it hovers in the mid-9% range. This understates the pain, as that number doesn't tell us how many people have gotten discouraged and given up looking for work or who are stuck working part-time when they really want to be working full-time. But it certainly beats an unemployment rate of 14% or 18%.
I don't mean to suggest the current situation is acceptable; it isn't. Obviously that unemployment rate needs to come down. But it helps to stop once in a while and remember that things were downright terrifying at the start of 2009 and at the time the possibility of Great Depression II didn't seem all that remote. And despite the vast differences between the economic situation today and that of the early 1980s, remember that the unemployment rate right now is a full 0.8 points lower than it was in October 1982 and, as far as I can tell, it's not on its way up. So based only on the first two years of their first terms, I'd have to say Obama outperformed Reagan, getting a (comparatively) better outcome despite facing a decidedly worse situation.
Like many people, sometimes I'm conflicted on federalism. That is, I find it difficult to sort out an entirely consistent picture of the role I see for the states and the federal government. I was dismayed when Missouri voters passed Proposition C earlier this year, effectively instituting a state law that insulated them from the federal mandate to carry health insurance. "The Supremacy Clause is clear," I said indignantly, "this is purely symbolic because states don't have the authority to overturn federal laws." I reject the notion that states can nullify federal law.
And yet I'm secretly rooting for California's Proposition 19 this year, the state's ballot initiative to legalize marijuana. And what's the difference? Is it simply that I don't like federal drug laws--particularly with regard to marijuana--but favor health care reform? Perhaps. Everyone's a hypocrite sometimes. This hypocrisy occurred to me today when I found myself disappointed that the Attorney General announced his intent to crack down on pot if Prop 19 passes:
SAN FRANCISCO — The U.S. government will "vigorously enforce" federal laws against marijuana even if voters next month make California the first state to legalize pot, Attorney General Eric Holder says.
Holder's warning, contained in a letter to ex-federal drug enforcement chiefs, was his most direct statement yet against Proposition 19, and it sets up another showdown with California over marijuana if the measure passes.
Let me return briefly to the example I brought up in "Happy (Belated) Constitution Day": Thomas Jefferson and his Democratic-Republicans approving the Louisiana Purchase, an action not explicitly authorized in the Constitution. An allegedly strict constructionist made a funny argument to me in favor of Jefferson's decision. Jefferson's decision was plainly constitutional, I was told, because the Louisiana Purchase was the result of a treaty with France. And since the Constitution does grant the federal government the treaty power, there is no issue here. In practice, land acquisitions are often part of treaties, after all. Of course, this is true; Article II, Section 2 does tell us the President has that power:
He shall have Power, by and with the Advice and Consent of the Senate, to make Treaties, provided two thirds of the Senators present concur;
But it seems to me that there's something odd about this. Accepting it requires acknowledging that enumerated powers of the government come with various, potentially wide-ranging, implied powers that are not explicitly written down. And this is a very Hamiltonian sort of view--he used it to win the argument that a National Bank (not explicitly authorized in the Constitution) was constitutionally acceptable, a position Jefferson and Madison didn't share. One might think that conceding that the Constitution allows for actions not enumerated in it completely undermines the strict constructionist position. After all, the philosophy that the Constitution allows for actions not explicitly inked on the page is what loose construction is all about.
But let's step back to Proposition 19. Drug policy isn't my forte so I found myself wondering wherefrom Congress derived its authority to regulate and outlaw drugs. Now, usually I'm fairly sympathetic to federal power. But it's well-known that the Prohibition on alcohol required the Eighteenth Amendment to the Constitution so I was curious as to how Congress was able to prohibit other drugs without something similar. Naturally, I started with a trip to the Wikipedia article on the Controlled Substances Act to get my bearings on the subject. And I was surprised to find the justification for that law:
The Congressional findings in 21 U.S.C. §§ 801(7), 801a(2), and 801a(3) state that a major purpose of the CSA is to "enable the United States to meet all of its obligations" under international treaties - specifically, the 1961 Single Convention on Narcotic Drugs and the 1971 Convention on Psychotropic Substances. The CSA bears many resemblances to these Conventions. Both the CSA and the treaties set out a system for classifying controlled substances in several Schedules in accordance with the binding scientific and medical findings of a public health authority.
The feds can regulate drugs because we agreed to in a treaty? Now that's fascinating. Very reminiscent of the argument that Jefferson could double the size of the United States because a treaty was the vehicle for doing so.
But wait a minute. Does this imply that the federal government can do absolutely anything as long as its actions are in pursuance of treaty obligations? For example, the U.S. is a signatory to the Universal Declaration of Human Rights. This isn't a treaty. But suppose some administration took that language and stuck it into a "treaty" with, say, Canada. Both nations pledge to each other that they'll abide by those principles. Of course, treaties require approval by 2/3 of the Senate so adopting that faux treaty would be only slightly easier than simply passing a constitutional amendment. But this is a thought experiment so let's suppose that this U.S.-Canada treaty is ratified by the Senate and compliance with the Universal Declaration of Human Rights becomes a cornerstone of our relationship with Canada. That means, for example, our treaty obligations would require us to match policy action to words like these:
Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.
Presumably the federal government would then have carte blanche to regulate and/or provide health care in any way it chose, no (constitutional) questions asked. All because the treaty power is written into the Constitution. If strict constructionists buy that, then isn't the treaty power essentially an infinitely elastic clause (much more so than the actual Elastic Clause)?
For the most part, treaties don't seem to be used this way (perhaps in no small part due to the Senate supermajority approval stipulation) but that sure opens some doors, doesn't it? Anyway, anyone want to help me reconcile my revulsion to state nullification of the health reform law with my secret affection for California's attempt to locally overturn federal prohibitions on pot?
