That Wizard's Just a Crazy Old Man

I don't know why, but at this moment I'm finding Uncle Owen's line about Ben Kenobi to be absolutely hilarious.

That Wizard's Just a Crazy Old Man (clipped) sound bite  Star Wars: Episode IV - A New Hope sound bites

Déjà vu all over again

Update: Today the Kaiser News Network has released a table that encapsulates most of this post. So check that out.

Some time ago, in trying to explain a bit of the philosophy behind public policy, I identified a certain brand of thinking I call political nihilism:

A participant in the policy process who becomes unmoored from ideological preferences and personal passions finds himself in a dire situation. The loss of faith leaves him with only the cold embrace of cynicism. He can be little more than a "hired gun," choosing a side and playing to win by any means necessary. Politics and policy-making become solely about the acquisition of power or a simple love of the game. The notion of identifying desirable social goals and using policy to launch us in the direction of the Utopian's dream becomes quaint and, if anything, simply a tool in the political manipulator's arsenal. This sense of purposelessly drifting through the political landscape is what I'll call political nihilism (a usage of the phrase that differs a bit from what Wiki tells me is usual). It isn't any more endemic to society than is religious agnosticism but I suspect--as with religious agnostics--there are many adherents among us.

I think it's time to present an example of what I'm talking about.

I've been reading various alternative health care bills lately to see if I can identify one that has some potential for bipartisan support (there's actually a current Republican proposal I rather like that I'll post about sometime). Yesterday, I came across a doozy. But first I want to offer a little background on the current Democratic proposals that passed out of the House and the Senate late last year. So let's walk through some of the key elements.

● Insurance market reforms and the individual mandate. The Democratic bills institute guaranteed issue and adjusted community rating rules in U.S. health insurance markets. This means that insurers can't turn someone away based on medical history or pre-existing conditions and they can only vary rates in the insurance pool based on age, geographic location, and familial status (and even then there are limits to the allowed variation). These kinds of reforms are popular among the public and with good reason: the ability of insurance companies to cherrypick their pools by turning people away or charging women, the sick, or the elderly significantly more than they charge others strikes most people as unfair.

But medical underwriting (the practice of deciding whether to accept somebody into your insurance pool and, if so, whether to charge them more than everybody else) serves a purpose, even if it seems douchey on the surface. It helps to mute the influence of what economists call adverse selection, a process by which the composition of health insurance pools could disproportionately contain sick people, threatening their financial viability. If insurance companies have to accept you when you go to them and they can't charge you more than anybody else once you're in their insurance pool, why pay premiums every month when you're healthy? If you get sick, you can always go buy insurance without fear of being turned away or punished financially for your irresponsibility. It's actually a pretty great scam. But it means that these high-minded, popular limits on the abilities of those evil insurance companies to play their medical underwriting games actually threatens to destroy (or at least make exorbitantly expensive) health insurance itself.

So we need another piece of the puzzle. Some way to keep people from dropping out of insurance pools until they need to draw resources from them. Some way to head off the obvious scam that most of us healthy people would be tempted to run. That's where the individual mandate comes in. You incentivize people to enter (or stay in) insurance by threatening them with a tax penalty if they go without insurance. Make it so that it's not cheaper to be uninsured and there's no reason for people to go without health insurance. Then healthy people pay premiums and health insurance pools stay solvent. The only issue is that libertarians freak the fuck out.

● Financial assistance to low-income people. The only problem with mandating that everyone buy health insurance is that a number of people are uninsured because they can't afford to buy insurance (that's part of the problem we're trying to address here, right?). So you have to provide financial assistance to help low-income families pay their premiums. That, of course, is where the costs of the Democratic bills stem from and why you'll hear conservatives weeping that the bills cost almost $1 trillion over the next decade. But this assistance, along with the insurance market reforms, pushes us close to universal coverage. The House bill, by the way, contains a mandate on employers to provide insurance to their employees.

● State-based health insurance exchanges. Right now there are a few different health insurance markets. There's the large group market for big employers. Large companies either self-insure (they have enough people to make their own health insurance pool) or, if they do go to an insurance company, have a great deal of leverage in bargaining for decent plans because they can offer the insurance company thousands of new customers. There's the small group market, in which small employers (like mine) go to insurance companies and try to get some kind of deal but have considerably less bargaining power than big employers. And then there's the individual market for people who don't get coverage through their employer. This last one is expensive, opaque, confusing, and just difficult to navigate.

The Democratic bills create health insurance exchanges in each state. In addition to being governed by the ground rules we covered above (guaranteed issue and community rating rules), they are meant to be a more transparent, competitive marketplace than the individual insurance market currently is. These exchanges are envisioned as being a bit like the market in which federal employees choose their plans (the Federal Employees Health Benefits Plan). Check out the website. Click your state, get a brochure for all available plans, along with the rates. Easy, transparent, one-stop shopping. As time goes on, the Democratic bills allow small employers of larger and larger sizes to enter the health insurance exchanges with their employees. This effectively gives these small employers bigger pools with which to bargain with insurance companies because a transparent marketplace with a level-playing field is a competitive marketplace.

In addition to the ground rules for insurance companies operating in the new health insurance exchanges, insurers will face benefit standards (i.e. they have to offer at least a minimum package of benefits). The House bill sets up a panel of experts to determine what kinds of things should be included in minimum benefits packages.

● Taxes. The Democratic bills cost north of $900 billion over the next decade, yet they're actually projected by the nonpartisan Congressional Budget Office to reduce the deficit. They do this, of course, by coming up with revenue streams to pay for their spending (and then some). The House bill does this through a progressive income tax on millionaires. Every dollar you make in excess of $1 million gets a nickel taken out of it. And poor people get to stay alive. The Senate bill goes a different route. Instead of an income tax, it relies primarily on a tax on "Cadillac" insurance plans. That means if you have a very expensive insurance plan (costing more than $9,000 if you're a single guy or more than $24,000 if it's a family plan), you'll pay a 40% tax on it above that threshold. So if you have an individual plan costing $10,000 a year, you'll pay a 40% tax on that excess $1,000 (i.e. you'll pay $400).

● Miscellaneous. As you may have heard, these bills are a bit long. That's because they contain lots and lots and lots of things. Additional money to fight waste, fraud, and abuse in federal health programs. Additional money to encourage medical students (I'm looking at you, Jim!) to go into primary care; this includes things like extra loan forgiveness and resources to create more residency programs, etc. Efforts to improve Medicare, including an end to the practice of subsidizing private companies to do things the government is doing more cheaply. Efforts to emphasis wellness programs to help shift the focus from treating sickness to maintaining health. A focus on collecting and compiling data to encourage comparative effectiveness research that will help doctors choose the most effective (in terms of health and cost) treatments. Numerous delivery system reforms that plant the seeds for the kind of fundamental changes that will ultimately help us control costs by changing the way we deliver care. Even incentive payments to states that come up with novel ways of reforming their medical liability laws (yes, Virginia, that's a flavor of tort reform).

That, in a nutshell, is what's in the Democratic bills that have consumed the national policy debate for the past eight months. These are the bills that were on the verge of being signed into law and which would've, obviously, led to an ultra-liberal dystopia in which freedom as we know it no longer exists and the government is in total control of 1/6 of the U.S. economy. At least, that's what one party told me would happen.

But let's rewind to the last Great Health Care Reform Debate: Bill Clinton's ill-fated 1993 reform effort. As we all know, "HillaryCare" went down in flames. At the time, Senate Republicans took the initiative in drawing up a bipartisan, centrist plan to counter President Clinton's proposal. In addition to having several Democratic co-sponsors, this bill (introduced by Republican John Chafee) counted Republican Senate Minority leader Bob Dole among its co-sponsors, as well as several Republican Senators who still serve today (Kit Bond, Bob Bennett, Orrin Hatch, Dick Lugar, and Chuck Grassley). I want to list some of the key provisions of this bill, the Health Equity and Access Reform Today Act of 1993:

● Universal access to health insurance coverage, in part through premium assistance to low-income individuals who don't quality for Medicaid (ultimately up to 240% of the federal poverty line)
● An individual mandate requiring all citizens to be covered by a health plan
● A mandate on employers to provide health insurance plans to employees
● Requirements for qualified heath plans to meet standards of: guaranteed eligibility, availability, and renewability of health insurance coverage; nondiscrimination based on health status (i.e. eliminating pre-existing conditions); benefits offered; insurer financial solvency; enrollment process; premium rating limitations (allowing variation in premiums based only on age and family); risk adjustment; and consumer protection
● The formation of individual and small employer purchasing groups
● Requirements that the Secretary of Health and Human Services, in consultation with the Secretary of Labor, establish standards for large employer plans similar to requirements applicable to small employer plans
● Formation of a Benefits Commission to develop a standard (minimum) benefits package that any qualified health benefits plan must offer
● Enumeration of state responsibilities in implementing state insurance market reforms
● Certain alterations to tax law, including an excise tax for excess contributions to medical care savings accounts and a tax on employee contributions to health care plans in excess of a certain "applicable dollar amount"
● Quality assurance programs, including the creation of a national health data system
● Medical liability reform, including a requirement that states adopt an alternative dispute resolution method for the resolution of health care malpractice claims
● Efforts to fight fraud and abuse in federal health programs
● Efforts to bolster the primary care workforce

Sound like any other proposals you've heard recently? Maybe some other one described in this very post? Premium assistance to the poor, insurance market reforms, new purchasing groups for individuals and small employers (a pre-cursor to the idea of the health insurance exchange), individual and employer mandates, even a tax on excess spending on health plans (think of it as a tax on Cadillac plans, except with a much lower threshold).

For ideological purposes, it's the same fucking plan. Proposed by Republicans 15 years ago and co-sponsored by 5 Republicans who are still sitting in the Senate and who all voted against the Democratic bills last year. An idea that Republicans now attack so viciously that President Obama correctly pointed out: "But if you were to listen to the debate, and, frankly, how some of you went after this bill, you'd think that this thing was some Bolshevik plot."

This, boys and girls, is political nihilism.

A nod's as good as a wink to a blind bat!

Remember the smiley face in Moon? Well check this out...

The nod is one of the most important signals a person can send. When made at the right time, it means “I am engaged in what you are saying” or “I understand”. For computer programs and robots that are designed to interact with people, being able to notice nods and respond with nods of their own (through an on-screen avatar in the case of a computer, and with actual nods in the case of robots) would be a boon. Unfortunately, nobody has yet been able to get it right.

All things in moderation

Link

The price of being cheap

A few months back (although it feels like a few years ago), I posted a bit about what's going to happen to Medicaid under these health reform proposals. The gist of it was that Medicaid is going to be expanded to cover more people. At the time, the House bill called for expansions of Medicaid to include people whose incomes are up to just over 133% of the poverty line. That was later changed to 150% of the poverty line in the final bill that passed out of the House.

What's the virtue of doing this (from a politician's perspective)? It's cheap. Medicaid pays peanuts for the services that its recipients utilize. The downside of this, of course, is that many doctors don't bother to accept Medicaid clients because it's not particularly profitable (and Medicaid recipients as a group are generally difficult to deal with for a variety of reasons). But if we cover more people with Medicaid, that's a lot cheaper than helping to subsidize the purchase of private insurance. So instead of helping some uninsured person at 140% of the poverty line pay for private insurance, we'll be sticking him on cheap government insurance. This brings down the price tag of the bill.

But as that older post I referenced discussed, Medicaid is both cheap and very expensive. States never pay more than half of the costs of it and yet it still consumes an enormous chunk of state budgets. In fact, it's generally one of the two biggest items in state budgets (the other is education). And a great many states are in very serious financial trouble right now. As incomes drop during recessions and state tax revenues fall, more people tend to become eligible for Medicaid just as states begin having more and more trouble paying for things they could afford during the good times. In fact, since there are federal programs that give you a bit of a health care grace period when you lose your job--allowing you to keep getting the health insurance you got through your employer for a few extra months as long as you pay for it (or, thanks to the stimulus, 35% of it, with the feds temporarily picking up the rest of the tab)--the swelling of the Medicaid rolls tends to lag the worst of the recession a bit. So states might be taking an even bigger financial hit on Medicaid this year than they did last year. So what happens when Congress tells the states "oh, by the way, you're now required to cover more people and incur even more expenses than you did before"?

Bad things.

I got to listen in on a interview call the other day with the director of a certain national non-profit organization. This director mentioned that she had recently talked with representatives from a handful of states who indicated that unless they received more stimulus money to pay for certain programs, they were going to very seriously consider withdrawing from Medicaid funding. And this isn't an ideological threat; she indicated that 75% of the states who told her this were Democratic states.

States face certain requirements when they receive matching funds for their Medicaid program but they aren't required to actually have a Medicaid program. Indeed, the last holdout, Arizona, didn't institute a Medicaid program until 1982. But now certain states seem to be giving very serious thought to ending their programs because they're simply too expensive.

As you may remember, Senator Ben Nelson of Nebraska took a lot of heat recently for inserting a little sweetheart deal into the Senate bill for his home state: the costs of expanding Medicaid in Nebraska are to be borne by the federal government indefinitely. That is, they'll accept more people into their Medicaid program but it won't cost Cornhuskers any additional money because Uncle Sam is writing the check. Certain other states were understandably peeved that they're not getting the same perks as Nebraska. In his State of the State address recently, California's Governor Schwarzenegger was blunt:

"California's congressional delegation should either vote against this bill that is a disaster for California or get in there and fight for the same sweetheart deal that Sen. Nelson of Nebraska got for the Cornhusker State," Schwarzenegger said in his state of the state address on Wednesday. Schwarzenegger said Nelson "got the corn and we got the husk."

(In case you're wondering about the state of that State: they're in deep shit.)

They want the deal, too. And maybe they'll get it. There were rumblings that the final, final, final bill (the all-important center box) that's being drawn up now (and should be out this week) might federalize the Medicaid expansion for every state indefinitely. I don't know how much that would cost the federal government or how it would bloat the price tag of the final bill. But it might keep some states from doing something nobody's ever done before: ending their state Medicaid programs as we know them.

Speakeasy Book Club

I just started re-reading a classic: Policy Paradox by Deborah Stone. Policy Paradox is the single most influential book (to me) I read as an undergraduate. At the time I was asked to read it, I was restructuring my understanding of the political and policy spheres and struggling to grasp the nature of their intersection. Having stumbled over to policy from physics, I initially brought the eye of the scientist: a single problem will more likely than not have a single solution, a correct answer that can be devised by the clever policy scientist. This viewpoint isn't far from what I called the Utopian perspective in an old post.

At the time Policy Paradox came into the picture, I was beginning to move beyond that mode of thinking and to see more shades of gray. This book was immeasurably helpful in moving me along that path. To give you a feel for the way this book approaches public policy (and the impact it had on me), here's a sample from the introduction:

This book has two aims. First, I argue that the rationality project [a "mission of rescuing public policy from the irrationalities and indignities of politics, hoping to make policy instead with rational, analytical, and scientific methods"] misses the point of politics. Moreover, it is an impossible dream. From inside the rationality project, politics looks messy, foolish, erratic, and inexplicable. Events, actions, and ideas in the political world seem to leap outside the categories that logic and rationality offer. In the rationality project, the categories of analysis are somehow above politics or outside it. Rationality purports to offer a correct vantage point, from which we can judge the goodness of the real world.

I argue, instead, that the very categories of thought underlying rational analysis are themselves a kind of paradox, defined in political struggle. They do not exist before or without politics, and because they are necessarily abstract (they are categories of thought, after all), they can have multiple meanings. Thus, analysis is itself a creature of politics; it is a strategically crafted argument, designed to create ambiguities and paradoxes and to resolve them in a particular direction. (This much is certainly awfully abstract for now, but each of the subsequent chapters is designed to show very concretely how one analytic category of politics and policy is a constantly evolving political creation).

Beyond demonstrating this central misconception of the rationality project, my second aim is to derive a kind of political analysis that makes sense of policy paradoxes such as the ones depicted above. I seek to create a framework in which such phenomena, the ordinary situations of politics, do not have to be explained away as extraordinary, written off as irrational, dismissed as folly, or disparaged as "pure politics." Unfortunately, much of the literature about public policy proceeds form the idea that policy making in practice deviates from such hypothetical standards of good policy making, and that there is thus something fundamentally wrong with politics. In creating an alternative mode of political analysis, I start from the belief that politics is a creative and valuable feature of social existence.

I also started re-reading my BA the other day (the paper they made me write to graduate); it's on the policy making process and the influence of Policy Paradox is clear. I'm kicking around the idea of putting up a post a week or so reacting to each of the chapters. But we'll see.

Meanwhile, if anyone else is interested in reading it, I highly recommend it: Policy Paradox.

You guys reading anything I should be reading?

Battle of Shiloh: Throwing Stones at the 'Hornet's Nest'

In the field of history there is a fairly new and increasingly popular method of research called ethnohistory, where researchers go beyond traditional sources (books and manuscripts) and use other tools such as oral traditions and archaeology in order to fill in gaps and create a more complete picture of an event. This method is particularly useful in areas such as Native American history, where written documents from the individuals and tribes themselves are usually completely absent, forcing past historians to rely on biased (and occasionally flat-out false) accounts from outsiders. However, ethnohistory can also contribute important information to events that have been more than adequately documented. Military engagements are often among the most documented events in history, since officers are often required to write post-battle reports or testify at military tribunals; yet the confusing and complicated nature of war (as well as the urge to stress one's own achievements and gloss over the failures) creates gaps in the historical record, gaps that ethnohistory can and has helped fill.

The Battle of Shiloh took place in Tennessee on April 6th and 7th, 1862 during the American Civil War, and at that point represented the bloodiest military engagement in United States history: altogether slightly less than 24,000 casualties, a figure that would be outdone in later battles and even dwarfed at Gettysburg and Chickamauga. Arguably the most famous aspect of this battle was the Hornet's Nest, where scattered regiments from two Union divisions somehow organized a defense that held off waves of Confederate attacks for approximately seven hours until, after becoming completely surrounded, finally surrendered late in the day on the 6th. This delay bought the Union army enough time to regroup and counterattack the next day, turning a retreat into a vitally important victory for the North.

My first encounter with a very different version of this story came from catching an episode of 'Battlefield Detectives' which discussed this very event (see, we can learn something from tv), and others have additionally argued against this conception of the battle (for instance, this individual from HistoryNet.com) - offhand, I do not know any specific historians who have argued against the traditional account of the Hornets Nest, although some undoubtedly have. Using archaeology around both the Union and Confederate lines at the Hornet's Nest, researchers have found some startling evidence that contradicts descriptions from the soldiers.

For one, after methodically searching the Union line they found a lack of unfired ammunition, which is odd considering that in the heat of battle soldiers always dropped bullets when reloading. They did, however, find a decent number of fired ammunition along the Union line, indicating that the yanks were probably taking more fire from the rebs than they were dishing out.

Additionally, in the immediate aftermath of the battle gravediggers reported burying a comparatively small number of dead soldiers in the vicinity of the Hornet's Nest - strange, considering the custom was to use mass graves where the heaviest fighting had taken place in order to clean up the area as fast as possible. Even stranger is that years later when the government paid to have Union soldiers relocated to the national cemetery, they found that very few at all had been buried at the Hornet's Nest.

A final strike against the popular conception of the Hornet's Nest was that the canister fire (artillery shells that worked like a shotgun) that the Union supposedly rained down onto the Confederates to drive each wave back would have proven largely ineffective in reality - the Confederate line was apparently along the crest of a nearby hill, which would have absorbed most of the Union canister fire. In fact, archaeological evidence suggests that the Northern soldiers probably received more artillery fire than they shot out.

Ethnohistory (in this case, archaeology) thus helped historians create a more accurate depiction of the Battle of Shiloh. The episode of 'Battlefield Detectives' drew two conclusions from this evidence. First, that the popular conception of the Hornet's Nest probably arose from the anniversary celebrations held by Union veterans of the battle, where they would increasingly exaggerate their roles in the engagement. This seems a plausible explanation, considering others have pointed out that General Prentiss, one of the division commanders at the Hornet's Nest, initially gave a humble report of his unit's actions during the battle that he seemed to embellish slightly as time went on.

The second conclusion, however, struck me as a step in the wrong direction. The researchers seemed to feel that the Hornet's Nest simply was not really that important of an event during the battle. This argument is something of an overstatement. Regardless of whether or not the Union soldiers mowed down Confederate waves with musket volleys and canister fire, the approximately 3,000 men in the center of the Confederate attack remained an issue that the rebels had to deal with, slowing down their advance and buying Grant some time (some argue that the South should have simply bypassed the area, a strategy that tends to ignore the problem of now having a sizable force behind Confederate lines). And even if it was not the hurricane of a fight it has been made out to be, clashes and skirmishes still took place at the location; the Confederates were not able to simply skirt by the location to advance on the main body of Union infantry. Even the act of surrendering must have helped the North - the Confederates now had 2,200+ prisoners that had to be brought to the rear and put under at least minimal guard, costing time and manpower. In this case, casualties on the field do not necessarily correlate to strategic importance.

Ethnohistory can contribute greatly to our understanding of an event, as the work done recently on the Battle of Shiloh shows. However, I think it is important not to get too carried away and make radical conclusions simply because new evidence arises. Ethnohistory should fill in the gaps and help correct mistakes, but it should not be an all-important piece of the puzzle that alone can change history. That can be as problematic as those who ignore enthohistory altogether.

(Anyone else find it fitting that the history buff seems to write the more long-winded posts here? Trunkely, let's hear an in depth, step-by-step description of how one discovers, charts, and draws conclusions from stratification in rock layers.)