How's That Health Reform Implementation Going?

TJ's comment to his post the other day reminded me that we haven't really discussed implementation of the new health reform law yet. There were a number of posts in the run-up to its passage last March but I suppose at some point we should talk about what's happened since then and what happens next. But it would take days to recount all we've witnessed! So, settle in.

There are lots of graphics out there to illustrate how public policy gets made and put into action. I rather like this one:



Many years were spent forming most of the ideas that went into the reform legislation and almost 9 months was spent hammering it into a shape that could pass through Congress (the first of the reform bills was introduced in Congress at the beginning of the summer of 2009 and Obama signed the final law last spring). We are, happily, out of the main part of the formulation phase. We've now proceeded into the realization phase with implementation in full swing. I believe most observers would agree that implementation is the hardest stage on that chart--taking the policy as passed by Congress and making it work on the ground, out in the states is going to be tough. Unintended consequences are going to crop up, mistakes are going to be made, some implementation decisions are going to turn out to have been the wrong ones. So while this is the most challenging and exciting part of the whole process, it's also the one most easily attacked. TJ had asked about the griping that's been going on and we're going to go through that as we look at each piece of the law that's been implemented so far. (What I do, by the way, mostly falls under dissemination with the aim of furthering implementation. But most of it is only incidentally related to reform.)

But first I think it's important to note that, though lost in the sharply defined color scheme of that chart, the distinctions between different stages of phases of the policy process are generally a little murky. The implementation phase we're in right now actually involves quite a bit of policy formulation: in this case, it's called administrative rulemaking.

Legislation is often vague. It knows, in general, what it wants but the nitpicky details are left to someone else: experts in the the executive branch. Let's take an example. I'm sure you know that the legislation allows dependents to stay on their parents' insurance up to the age of 26, so people aren't (as I was and I'm sure some of you were) thrown off their parents' insurance shortly after graduating from college. But what does the law actually say about who counts as a "dependent" (a definition one would think is pretty important to this particular provision)? Nothing:

`(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage.

`(b) Regulations- The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a).

The legislation is full of "the Secretary shall"s. Who is the Secretary? It can vary depending on which part of the law we're talking about but for most things it refers to the Secretary of Health and Human Services, Kathleen Sebelius. Sebelius, formerly the governor of Kansas (and daughter of Ohio's 62nd governor, John Gilligan), isn't actually going to sit down and write the definition herself. "The Secretary shall" is just another way of saying "somebody at HHS shall" because this task falls to experts employed by the Department of Heath and Human Services: that's right, bureaucrats!



This is a theme we'll keep coming back to: definitions are hugely important and, as we'll see, it's not just HHS that's formulating them right now. When you control the definition, you can dictate the outcome of the policy you're implementing. And the shape of the dreaded unintended consequence will depend in large part on what the definitions and regulations turn out to be.

The shaping of regulations generally follow a certain formula. First, the relevant agency (for the purposes of this law, usually a subdivision of HHS) writes a proposed rule. This is then publicly posted for some period of time--usually 60 days--and public comments are accepted. That's right, you can weigh in on these proposed rules if you so desire. Once the comment period closes, the agency will review all of the comments, make revisions to the proposed rule as needed, and then release a final rule that then has the weight of law (sometimes they start off by releasing an "interim final rule" which goes into effect and has the weight of law immediately; these rules still have a comment period and are revised, they just happen to be in effect while they're being commented on and revised). If you find all of this as fascinating as Hermes and I do, I encourage you to take a look at the Reg Map, which summarizes the process with a handy graphic.

So let's jump into the specifics of implementing this law. As you can imagine, states and feds alike are very, very busy at this point. Though the biggest parts of the law don't kick in until 2014, lots of things are happening between now and then (not to mention that states need to get prepared for the big ticket 2014 items). You can see many of those things on this timeline. We'll walk through some of the things that have happened so far and look at what certain folks have bitched about with regard to them.

What has happened so far?

Before we get into the meat of this, I'll note one thing: state Medicaid programs (i.e. the government health insurance program for the poor) will be expanding to cover lots more people starting in 2014. States have the option to start expanding now if they so choose. Connecticut is the only state I know that's done so this year. So that's one thing. On to the required stuff.

HealthCare.gov. We'll start with my favorite, HealthCare.gov. The law directs HHS to get a website up and running that allows shoppers to see all the health insurance options to them in every state. This will connect you to a high-risk pool if you're eligible, or Medicaid, or show you all of the private insurance options available to you. Right now it lists all the plans available in your area but it's a work in progress--comparative price information is supposed to be added to it by October so you can see side by side what each insurer will charge you for a policy. The website has much more than that, however. It has all sorts of information on the law itself (the timeline I linked to above is from there) and federal health care improvement efforts in general. And it keeps improving. This week they released a widget that allows you to embed the insurance search feature anywhere on the web you want:



Give it a go. I don't actually think I've heard much griping about this website (a step toward making a more transparent marketplace for health insurance), other than that some conservatives don't think it's necessary. But that's a bit of a half-hearted criticism.

The Pre-existing Condition Insurance Plan. Quite a few people aren't able to buy insurance because they have a pre-existing condition or an otherwise blemished medical history. Some states have historically tried to deal with this population by forming special, heavily subsidized insurance pools for these high-risk populations. Under the reform law, every state is receiving funding to set up high-risk pools which means that states which didn't have high-risk pools (like Ohio) now have one for the first time. States had a choice of whether they wanted to run their state's pool or have the Department of Health and Human Services run it for them. Around 20 states are letting HHS run their high-risk pools and, in those states, applications for the pool started going out at the beginning of July. The states running their own pools were often a little behind schedule; for example Ohio's high-risk pool started accepting applications at the beginning of August. But the bottom line is that these pools are now up and running and formerly uninsurable people are starting to get coverage through them.

Are there gripes to go along with this? Oh my, yes. First, it's important to understand that these pools are temporary. They exist only through the end of 2013. On January 1, 2014 every state will have a new health insurance exchange in which every participating plan will be required to offer coverage to anyone who applies, without any variation of the premium based on medical history. At that point, "uninsurable" people with pre-existing conditions will be able to buy the exact same coverage--at the exact same price--as you and me. In the original health care bills introduced last summer, that was it. Nothing happened between now and the opening of the exchanges (which was in 2013 in the House bill and 2014 in the Senate bill; a version of the latter eventually became law). In order to ease the suffering between now and then (the suffering of both the uninsurable and the Democrats in the two elections that occur before the law goes into full effect), the high-risk pools were funded to exist from last month through the end of 2013.

The problem is that they were given $5 billion to last through 2013. Several experts have suggested that if these pools are to last that long, they should've been given at least three times as much money. As such, the pools have to try and conserve money. At a practical level that means two things: 1) insurance through them isn't cheap (though insurance through a high-risk pool never is), and 2) some people are probably going to have to be turned away. Those were the predictions anyway. Now that the pools are up-and-running (albeit only for a very short time), it looks like (1) might be taking care of (2). New plans for the uninsured are off to a slow start:

About 3,600 people have applied and about 1,200 have been approved so far in state plans that started in the beginning of July, according to data from the states and federal government. Officials say the new plans, although a better deal than anything comparable on the private market, still may be unaffordable for many people. Eligibility requirements are another possible barrier. And states have had little time to publicize the plans.

It’s too soon to gauge the program’s impact. The plans won’t be up and running in all the states until September. But some officials are surprised.

"It’s early, but thus far interest in the program is lower than we expected," said Michael Keough, executive director of the North Carolina Health Insurance Risk Pool, which started July 1. As of Tuesday, 314 people had applied and 158 had been approved.

GettingUSCovered, Colorado’s program, has received 204 applications; 108 people are enrolled. It’s a “very low number given that there are hundreds of thousands of uninsured in the state,” said Suzanne Bragg-Gamble, the executive director.

Are the criticisms justified? Well, ideally the programs would have more money to work with so the coverage could be more affordable and cover more people. They are, however, only a stopgap (and one that originally wasn't even in the laws) to hold us over until the main attraction arrives in 2014 so it's hard to be too down on these programs. But it's not easy to take seriously the people pre-emptively declaring the program a failure, at least if they're Republicans. They forget that in this law, high-risk pools are not a long-term solution for the problem of the uninsured. Yet in the Republican repeal-and-replace law, they are the solution: high-risk pools are set up in perpetuity to deal with the uninsured. Fun fact: the Republican bill would allocate $3 billion to the high-risk pools through the end of 2013, or 40% less than the actual law allocates to them over the same time period (though funding does ramp up a little bit later on in the Republican bill; obviously in the real law these pools won't exist later on because they won't be necessary).

The other gripe leveled at the high-risk pools is that when New Mexico and Pennsylvania were writing their proposals, it looked like both states would potentially allow elective abortions to be funded through their pools. Since the pools are being funded with federal money, this is a big problem. Federal funding--your taxes!--should never go to pay for such morally reprehensible things (on an unrelated note, taxpayers who question the morality of using taxpayer money to kill Afghans are shit out of luck). Of course, this turned out to be a non-story as HHS worked quickly to roll out its regulations, which clarified that elective abortions wouldn't be covered in the federal high-risk pools.

Early retiree reinsurance program. The law also creates a program to help support the health costs of retirees who are older than 55 but not yet old enough for Medicare (i.e. they're under 65). They started collecting applications for it in July. Like the high-risk pools, this is just intended to last through the end of 2013. And, also like the high-risk pools, the primary gripe is that it didn't get allocated enough money and the funds won't last through 2013. We'll have to see.

Tax credits to small businesses. Businesses with less than 25 employees and average wages less than $50,000 are eligible for tax credits to help them pay for some of the costs of offering their employees health insurance (up to 35% of the employer's costs, in fact). The idea is that small businesses employing relatively low-wage workers often don't offer health insurance, so this will help them to do so.

The criticism from some has been that it doesn't target enough businesses (no word on if the people leveling this criticism are the same ones who think the law is too expensive). And here's where we get into dueling figures from business associations. A study commissioned by Small Business Majority (pro-reform) contained good news for small businesses:

Key findings

● More than 4 million (4,015,300) small businesses will be eligible to receive a tax credit for the purchase of employee health insurance in 2010. That’s 83.7 percent of all small businesses in the country (see Table 1 on page 3 of the PDF).
● In 11 states, more than 90 percent of small businesses will be eligible to receive a tax credit in 2010. These states are Arkansas (94.2 percent), Montana (94.0 percent), Nebraska (93.8 percent), South Dakota (93.6 percent), Mississippi (93.2 percent), Indiana (92.9 percent), North Dakota (91.9 percent), Missouri (91.8 percent), Iowa (90.8 percent), West Virginia (90.3 percent), and Maine (90.1 percent) (see Table 1 on page 3 of the PDF).
● Approximately 1,198,700 American small businesses will be eligible to receive the maximum tax credit in 2010 (see Table 2 on page 4 of the PDF).

But the National Federation of Independent Business (not so hot on this law) says the number of eligible small businesses is actually much lower (that link has side by side comparisons of the NFIB and SMB estimates of what percentage of small businesses in each state qualify). Why the disparity? Well, NFIB has a funny (very restrictive) definition of "eligibility." They astutely point out that a small business that satisfies all of the criteria but doesn't offer health care won't be eligible for the tax credit to cover part of its health care expenses. They thus move such a business into the ineligibility column.

But, as I said, one of the aims of the tax credit is to get small businesses that don't offer coverage now, whether due to costs or some other reason, to start. So a huge chunk of the target businesses are just dropped out of NFIB's calculations because they don't offer coverage today. That's a bit like saying a high school senior is "ineligible" for a Stafford Loan because he isn't in college today. Well, sure, I suppose that's technically true. But he will be eligible for a federal student loan the moment he decides to go to college--and you could say that, in part, such loans are intended to help him make the decision to attend college. If you were to use NFIB's understanding of eligibility, the federal student loan program is a complete disaster because every graduating high school senior is ineligible for participation. Makes you wonder how anyone ever manages to afford college...

NFIB also focuses on the requirement that the employer pay at least half of the cost of the employee's health plan in order to qualify for the tax credit. Businesses that don't do so today are considered ineligible for the tax credit. But, again, one of the goals of the tax credit is to alter employers' behavior and give them a reason to shoulder more of the burden of the company's health plan. If you're a small business owner who's otherwise eligible for the tax credit but you only pay 45% of your company plan's health costs today and let your employees pay 55%, are you really not going to increase your share to 50% (or more) in order to have the government pick up 35% of your tab? Small Business Majority would count such a business owner as eligible for the tax credit (even though he has to alter his behavior/practices to claim it), while the National Federation of Independent Business would not. Personally, I think NFIB is trying to pull a fast one with these numbers by playing dumb. Because their argument is dumb.



Gradual closure of the Medicare donut hole. Medicare started paying for prescription drugs a few years ago. But it does a funny thing. If you have medication expenses, you'll pay your deductible and then up to $2,700 Medicare will pay 75% of your medication bill. But then between $2,700-$6,154 they pay nothing. If your expenses go higher than that, they'll meet you on the other side: for expenses above $6,154 they'll pay 95% of your medication costs. But there's a big chunk in the middle where the elderly are on their own. This law will slowly close that hole over the next decade. They started in June by mailing out $250 rebate checks to Medicare recipients who are in the donut hole. That's not much compared to the $3,400 hole but it's something.

The criticism from some has been political: mailing checks to old people in an election year is an attempt to "buy" the election. I wouldn't go quite that far but certainly the Democrats are targeting the elderly, who remain the demographic most suspicious of the reform law. Medicare even put together an ad with Andy Griffith trumpeting the benefits of the new law, which I find kind of funny. Are old people really so stereotypical that all it takes to sway them is the assurances of Matlock?

Premium oversight. A common charge made against this law was that it would (and now the charge is that is already has) send health insurance premiums skyrocketing. But an insurer can't just raise premiums for no reason, or in anticipation of someday having a reason. The law requires insurers to justify "unreasonable premium increases" to the state and the feds (this is one of those key terms that will have to defined by HHS through a rulemaking process). Insurers can be excluded from the health insurance exchanges--i.e. the new individual marketplace in which everyone receiving a federal subsidy to buy health insurance will be--"based on a pattern or practice of excessive or unjustified premium increases."

Various states already have some kind of premium oversight system in place: 26 states and Washington, D.C. can actually reject proposed rate hikes from insurers. Other states at least require advance notice and review, even if they can't actually stop the premium increases. The law offers grants to states to beef up their premium oversight structures in order to keep an eye out for "unreasonable premium increases" (whatever the definition of those turns out to be). HHS awarded the first of these grants to 45 states and D.C. just over a week ago:

States have proposed to use this funding in a variety of ways.

● Additional Legislative Authority: 15 States and the District of Columbia will pursue additional legislative authority to create a more robust program for reviewing or requiring advanced approval of proposed health insurance premium increases to ensure that they are reasonable;
● Expand the Scope of Health Insurance Premium Review: 21 States and the District of Columbia will expand the scope of their current health insurance review, for example by reviewing and requiring pre-approval of rate increases for additional health insurance products in their State.
● Improve the Health Insurance Premium Review Process: All 46 State grantees will require insurance companies to report more extensive information through a new, standardized process to better evaluate proposed premium increases and increase transparency across the marketplace;
● Make More Information Publicly Available: 42 States and the District of Columbia will increase the transparency of the health insurance premium review process and provide easy-to-understand, consumer friendly information to the public about changes to their premiums; and
● Develop and Upgrade Technology: All State grantees will develop and upgrade existing technology to streamline data sharing and put information in the hands of consumers more quickly.

You can get the state-by-state specifics of what states already do and what they're going to do with this grant here (there's that HealthCare.gov again!). I'm not familiar with any gripes about this, other than the standard "big government takeover" thing, generally from people who also complain about unreasonable premium increases.

What's About to Happen?

Lots of provisions are about to kick in for plan years starting after September 23 of this year. That means whenever your health insurance plan renews after that date, the provisions are in effect for it.

Extension of dependent coverage. This is the bit about staying on your parents' plan until you're 26. I don't think the rules for this provision we talked about above are out yet. The gripe is that this makes a mockery of the notion of personal responsibility and extends adolescence into one's late twenties. Note that the Republican repeal-and-replace bill has the same provision.

Free preventive care. After September, certain kinds of preventive care must be free at the point of care (i.e no co-pay). These are evidence-based preventive measures: things with high ratings ('A' or 'B') from the United States Preventive Services Task Force and immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

The gripes on this one are that this is not cost effective and will raise costs and increase utilization. This is true, premiums are estimated to rise about 1% because of this feature.

Ending rescissions. Rescissions are when an insurance company comes us with a clever reason to cancel coverage and get rid of a potentially expensive individual. This will not be allowed starting in September. I don't believe anyone opposes this (even the Republican repeal-and-replace law ends rescissions).

Eliminating lifetime benefit caps, regulating annual benefit caps. Starting in September, plans can't set a lifetime limit to what they'll spend on you, nor can they put unreasonable caps on annual benefits. Like several of the things we've discussed so far, these are bipartisan ideas and are included in the Republican repeal-and-replace bill.

But the gripes are plentiful on this one. Health plans offered by colleges may be threatened by this provision (and a few other provisions, like the medical loss ratio requirements discussed below), as may limited-benefit "mini-med" plans sometimes offered to low-wage workers.

Coverage for kids with pre-existing conditions. Adults with pre-existing conditions can't be turned away by insurers starting in 2014; until then, they'll have to make due with the high-risk pools. Kids (really, anyone under the age of 19), on the other hand, were protected by so-called "guaranteed issue" rules starting this year. Or at least they were supposed to be. In an embarrassing turn of events, it turned out that the staff lawyers who wrote the text of the bill made a little error so that law, if taken literally, only requires insurers to cover pre-existing conditions for kids they're covering. That's not a real guaranteed issue rule, as it doesn't require them to accept children with pre-existing conditions who are applying for insurance; legally, it seemed, they could still turn children away (until 2014). HHS worked to resolve this, partly through regulations, and largely got agreements from insurers to play ball.

Still, some insurers in Florida announced a month ago they wouldn't be issuing new coverage to kids--any kids. That's a bad unintended consequence (gripe! gripe!). Within a week HHS had issued guidance clarifying that insurers are free to set up open enrollment periods (i.e. issuing new policies for only one month a year and not allowing people to get new policies any time they like). Insurers announced they'd resume the sale of child-only policies.

There are other, slightly smaller provisions rolling out this year and next but there's one more major one I want to hit on:

Medical loss ratios. Under the new law, health insurers will have to spend at least a certain percentage of the money they take in through insurance premiums on actual care (this will be starting next year). This percentage--known as medical loss because premium money that goes toward providing care is considered a loss in the insurance world--will be 85% for the large group market and 80% for the small group and individual markets. If insurers spend less than that percentage of premium revenue on care, they have to send the difference back to their customers through a rebate.

But definitions are everything. HHS ultimately gets to decide, through the rulemaking process, on what counts as care but they're directed to take advice from the National Association of Insurance Commissioners, who are doing the heavy lifting on sorting this one out. Just over a week ago, NAIC approved a definition for what sorts of things will count as medical care. They came out with drafts of the actual forms insurers would have to fill out--known as blanks--to show they're meeting the law's requirements. I think it's actually too soon for anyone to have gotten many gripes in.



Anyway, that should give you a good idea of how implementation has been rolling out. In addition to the more immediate things we've been considering here, states are starting to get going on planning for the big items down the road (namely, the construction of health insurance exchanges and the expansion of their Medicaid programs). Tough stuff but they're working on it.

How not to look up a bill

You may remember that at the beginning of this month the House and Senate passed a $26 billion bill to 1) prop up state Medicaid programs ($16 billion) and 2) shore up state education budgets to prevent teacher layoffs ($10 billion).

At the time, I noticed a silly mistake around the internets that, while annoying, offers a teachable moment. Information is readily available in this day and age but it's important to know how to interpret it once you've found it. The mistake I'm talking about is exemplified by this entry on this site:

P.L. 111-226, The XXXXXX Act of XXXX

H.R. 1586 would impose an additional tax on bonuses received from certain TARP recipients.

H.R. 1586 is the bill number of the bill that I mentioned above--the aid to states for education and Medicaid (now signed by the President and thus a public law: P.L. 111-126). You might notice right away that those things have nothing to do with TARP (the financial bailout bill from 2008). But some folks, trying to look up this Medicaid/education bill they'd heard about, went to sites like that and thought that somehow the Democrats had pulled a fast one: this was all just a ruse to tax bonuses! Actually, no. These are the wrong trousers, Gromit!

It's possible to look up the right bill and still get the wrong bill. As you undoubtedly know, bills that get introduced in either chamber of Congress get a unique number: H.R. ## for House bills, S. ## for Senate bills. The numbers start over at the beginning of each session of Congress--i.e. every 2 years--but if you look up a specific bill number, you're unlikely to stumble across that bill from a previous Congress unless you're really trying to. So what happened?

First, always go to the authoritative source for the text of Congressional bills: the Library of Congress's THOMAS (Thomas, like the groundhog third President). There are others that are decent--OpenCongress is making a nice attempt at getting a community thing going--but this is the one you know is bulletproof. Now, if you went to THOMAS and looked up this education and Medicaid funding bill by typing its unique number, H.R. 1586, into the search field, you'd find that it comes in seven versions, all from the current Congressional session:

1 . To impose an additional tax on bonuses received from certain TARP recipients. (Introduced in House - IH)[H.R.1586.IH][PDF]
2 . FAA Air Transportation Modernization and Safety Improvement Act (Engrossed Amendment Senate - EAS)[H.R.1586.EAS][PDF]
3 . To impose an additional tax on bonuses received from certain TARP recipients. (Engrossed in House [Passed House] - EH)[H.R.1586.EH][PDF]
4 . XXXXXXAct ofXXXX (Engrossed Amendment Senate - EAS)[H.R.1586.EAS2][PDF]
5 . Aviation Safety and Investment Act of 2010 (Engrossed Amendment House - EAH)[H.R.1586.EAH][PDF]
6 . To impose an additional tax on bonuses received from certain TARP recipients. (Placed on Calendar Senate - PCS)[H.R.1586.PCS][PDF]
7 . XXXXXXAct ofXXXX (Enrolled Bill [Final as Passed Both House and Senate] - ENR)[H.R.1586.ENR][PDF]

Now, usually when you see a list like that on THOMAS, those versions are in chronological order. That's not quite true of this list. So let's trace the life of this particular bill.

This one started out as the "H.R. 1586--To impose an additional tax on bonuses received from certain TARP recipients," introduced in the House on March 18, 2009. That's the first item on the list (the ".IH" means it was introduced in the House but didn't pass in that form). The next day it passed the House with the text listed at number 3 in the list (the ".EH" means it was engrossed in the House, i.e. passed out of that chamber and sent to the Senate), which is also the text of version 6--the bill placed on the calendar of the Senate (".PSC"). There it sat, a bill taxing the TARP bonus money that passed the House in March 2009.

Fast forward a year. The Senate "took up" the legislation, by which I mean they pulled the text of the bill the House had sent them out of the drawer, blew the dust off, and stuck in--via an amendment--the text of a completely unrelated bill they wanted to pass, entitled " FAA Air Transportation Modernization and Safety Improvement Act." What's the deal there? Why not just write a new bill--"S. ##"--instead of usurping H.R. 1586? Well, if you look at this version of the text of the bill, you'll notice one of the titles is "TITLE VIII--AIRPORT AND AIRWAY TRUST FUND PROVISIONS AND RELATED TAXES." Article 1, Section VII tells us that "All bills for raising Revenue shall originate in the House of Representatives; but the Senate may propose or concur with Amendments as on other Bills." So when the Senate wants to start the ball rolling on legislation that will raise revenue, they'll often take a bill that's passed the House, completely scrap its text and replace it with an amendment containing the full text of their own new bill. So the revenue-raising bill starts with "H.R. ##" as required by the Constitution but the Senate still gets to introduce a revenue bill with a wink and a nod. This is why the health care bill that became law in March was numbered H.R. 3590 even though it was actually the Senate's health care bill (and thus one might naively have thought it should have been numbered S. ##).

So this transportation bill, number 2 in the list, was engrossed in the Senate and sent back to the House on March 22, 2010. The House then amended the Senate amendment to produce yet another iteration of the bill--now called the " Aviation Safety and Investment Act of 2010"--which it passed and sent back to the Senate on March 25, 2010. Since both chambers have to pass the same piece of legislation before it goes to the President, it can ping pong back and forth like this for a while.

This one, however, didn't. It sat in the Senate until the beginning of this month, at which point yet another amendment ("SENATE AMENDMENT TO HOUSE AMENDMENT TO SENATE AMENDMENT") was used to strip out all the text and put in a completely new bill. This is the one they didn't bother titling that extends Medicaid and education funds to states. That's number 4 on the list, " XXXXXXAct ofXXXX." The Senate passed this, at which point it went to the House which passed it unaltered (that's number 7 on the list: "Enrolled Bill [Final as Passed Both House and Senate]").

This bill--the sixth or seventh iteration of H.R. 1586 and the third completely different bill bearing that number--is what the House came back to Washington to pass earlier this month. They did so and the President signed it. But this isn't the TARP bonuses bill and it isn't the Aviation Safety bill. The text of those bills was each thrown out as this thing ping ponged back and forth between the two chambers until, finally, they both agreed to the same text.

Kind of reminds you of the Ship of Theseus, doesn't it? If you dismantle a bill piece by piece and replace it with something else, is it still the same bill? That's one for the philosophers but it certainly does keep the same bill number. So don't get confused.

A recent poll showed that approximately 1 in 5 Americans believe President Obama is a Muslim. I don't usually agree with the phrase "history repeats itself", but having studied 19th century American history this is a little too eerily familiar. We've certainly come a long way as a people from fearing Catholic plots to overthrow the government, Zionist movements to control the world, and freed African Americans running away with white women (for any of you 1 in 5 out there who by some long shot read this, I'll explain because I am sure it is necessary: that was sarcasm).

More on Paths

I introduced the notion of the Path in "A bit more introspection." This is an idea that, in some form, influences areas of physics, philosophy, policy, and — sometimes — more personal issues. This is going to be a bit of a meandering post that winds through all of those things.

I’ll start, as I sometimes do, with physics. I mentioned in "A bit of introspection" that I have a certain fascination with variational principles, the most famous of which is the principle of least action. This is a physical principle that allows us to figure out what the motion of a particle—its path through space and time—is going to look like. If you want to do something like that using Newton’s laws (e.g. Force = mass x acceleration) you’d look at all the forces on the particle at any given time and see that “oh, it’s getting nudged this way, and then it’s going to get nudged that way…” and so on. It can get a bit clumsy and you have to add up all kinds of forces—you have to deal with vectors and things can get very messy depending on your coordinate system.

The principle of least action gives you another way to figure out how a particle’s going to move and this way turns out to be completely equivalent to doing things Newton’s way. But the calculation is very different. Instead of figuring out the net results of all the pushes and pulls acting on the particle, we instead focus on the path. We take the starting point and the ending point of the particle’s path and we find that the real path it takes between those two points is the path for which a certain quantity that we know how to calculate—“action”—is the smallest. If you think about it, conceptually that seems like a big difference. As Richard Feynman put it in his Lectures on Physics:

There is quite a difference in the characteristic of a law which says a certain integral from one place to another is a minimum—which tells something about the whole path—and of a law which says that as you go along, there is a force that makes it accelerate. The second way tells how you inch your way along the path, and the other is a grand statement about the whole path.

One of the philosophical points raised in response to this, historically, was that it seemed to introduce teleology into the universe. Telos (“the end term of a goal-directed process”) assumes a certain underlying purpose, some kind of meaningful connection between a beginning and an associated end. If our physical calculations involve knowing a certain starting and ending point for a particle to determine the path it will take between them, does that mean the particle “knows” where it will end up when it starts out? As Wikipedia notes in the “apparent teleology” section of its page on least action :

In particular, the fixing of the final state appears to give the action principle a teleological character which has been controversial historically. This apparent teleology is eliminated in the quantum mechanical version of the action principle.

The quantum mechanical version they mention—invented by Feynman—is called the path integral formulation and resolves the question by essentially postulating that the particle takes all possible paths to all possible endpoints and things just sort of average out to reflect the classical picture of a set path between set points:

Classical action principles are puzzling because of their seemingly teleological quality: given a set of initial and final conditions one is able to find a unique path connecting them, as if the system somehow knows where it's going to end up and how it's going to get there. The path integral explains why this works in terms of quantum superposition. The system doesn't have to know in advance where it's going or what path it'll take: the path integral simply calculates the probability amplitude for any given process, and the path goes everywhere. After a long enough time, interference effects guarantee that only the contributions from the stationary points of the action give histories with appreciable probabilities.

That may explain the source of the apparent teleology but I’m not convinced it eliminates it. But teleology as a concept isn’t limited to this physical example, it (or the lack thereof) also has implications for society as a whole. Teleology plays a key role in Alasdair MacIntyre's arguments in his book After Virtue.

MacIntyre, in exploring questions of ethics and the virtues, points to the centrality of telos to the Aristotelian conception of ethics and morality. Man has a proper end toward which the path of his life winds and only by living a virtuous life can man satisfy that telos and reach that intended end. But the concept is even broader than that. Far from simply informing ethical choices and shaping a person’s actions, telos actually defines one’s social role (and all interactions between the individual and society) and one’s personal identity. Consider this bit from the book in which MacIntyre discusses the concept of ancient heroic societies (the sort you read about in the Illiad or Beowulf):

What I hope this account makes clear already is the way in which any adequate account of the virtues in heroic society would be impossible which divorced them from their context in its social structure, just as no adequate account of the social structure of heroic society would be possible which did not include an account of the heroic virtues...For the given rules which assign men their place in the social order and with it their identity also prescribe what they owe and what is owed them and how they are to be treated and regarded if they fail and how they are to treat and regard others if those others fail.

Without such a place in the social order, a man would not only be incapable of receiving recognition and response from others, not only would others not know, but he would not himself know who he was. It is precisely because of this that heroic societies commonly have a well-defined status to which any stranger who arrives in the society from outside can be assigned.

In such a society, whether they actually ever existed or not, a person has a set role to play. They have an end toward which they are striving (recognized and decided not just by them but by everyone) and, as such, their social and personal lives have purpose (and, I daresay, some sort of meaning). Ethical principles by which to live one’s life—the virtues—thus emerge from this teleology-oriented cosmology fairly naturally. Ethics and morality are those principles that will best enable the individual to fulfill his social role and arrive at the destination intended for him.

In our own post-Enlightenment Western society, the emphasis is on the supremacy of the individual. Individuals do not derive their identify from society, they carry it with them into society, which is itself an emergent structure that arises from the myriad interactions of countless individuals. No one is fulfilling a telos that determines his position or role in society, no one really has any particular reason (beyond a personal preference) to live by a given set of ethical or moral principles, and many of us face a recurring—and sometimes debilitating—sense of purposelessness. To the extent that our intense focus on individuality prompts us to attempt to define ourselves, our reality, our values, etc (i.e. to the extent we don’t get these definitions from religious, cultural, or familial cues), it robs us of the possibility of some external driver shaping our paths with some endgame—some telos—in mind.

And so we fit into society awkwardly, with an oft-shifting and meaningless role that invites and requires few ethical principles to sustain it and anchor our metaphysical selves. We stagger haphazardly through the wilderness instead of following a path. There is no destination, there is no purpose, there is no path. This is the state in which our listless society finds itself today. Or at least, this is the philosophical view of existence that has come with with our self-centric cosmologies, whether we intended for it to or not. But as I mentioned in "A bit more introspection," my philosophical/physical understanding of the nature of time suggests to me that our lives are not being written but in fact are written, with a defined end point out there waiting for us. Yet this doesn’t necessarily suggest purpose and an end goal (although I don’t think it can be said to preclude that possibility either). Rather, it’s a statement about limitations. If tomorrow has already happened, I can no more deviate from the path I took through it than I can deviate from the path I took through yesterday. What happened yesterday has happened and what happens tomorrow will happen and I experience events at least as much as I shape them.

This notion of limitations brings us to another manifestation of paths: the policy (or, more generally, social scientific) concept of path dependence. Where you can go is constrained by where you’ve been. That’s why, for example, the current political and policy climate is generally assumed to preclude an abrupt shift to a single-payer health care system. Certainly this is the way Obama has approached the question:

“If you’re starting from scratch,” he says, “then a single-payer system”—a government-managed system like Canada’s, which disconnects health insurance from employment—“would probably make sense. But we’ve got all these legacy systems in place, and managing the transition, as well as adjusting the culture to a different system, would be difficult to pull off. So we may need a system that’s not so disruptive that people feel like suddenly what they’ve known for most of their lives is thrown by the wayside.”

All this serves as an exclamation point on the suggestion that the past and future of the path can’t be viewed in isolation but must be viewed as a seamless whole. Or, to borrow the phrase Feynman used in discussing least action principles, we should be prepared to make “a grand statement about the whole path.” If we try and take that whole-path perspective, we might stumble over some interesting thoughts about the physical universe, the social universe, political developments, and even our own lives. But as the Oracle once said, everything that has a beginning has an end. And since I'm getting tired, I think this post has just about fulfilled its telos. May we all be so fortunate.

Unregistered

First national election in which I'm of age but have no desire to vote. Wake me up when November ends.

A bit more introspection

I'm a fatalist. When I wore my physics cap, I tended to favor a Minkowski block universe (i.e. eternalist) model and a many worlds interpretation of quantum phenomena. In this understanding of things, it's really true that, as Einstein said, "the distinction between past, present, and future is only a stubbornly persistent illusion." The future is as real as the past. There's no cathartic Doc Brown-esque "your future hasn't been written yet...your future is whatever you make it!" moment. The future is written.



And let me briefly touch on one of my favorite examples to make this point. As you probably know, every particle in the universe has an antiparticle twin. Antiparticles are exactly like their matter counterparts except they have the opposite charge. So the negatively-charged electron has a positively-charged counterpart (the aptly named positron). And as you may also know, when a particle meets its antiparticle, they annihilate and essentially convert their masses into energy, leaving behind only a barrage of photons (with a total energy equal to twice the energy equivalent of the electron mass, accounting for the fact that there are two electron-mass particles disappearing). What does it look like when that happens? Pretty much as you might expect--an electron and a positron wander towards each other, getting closer and closer as time goes on until they converge and vanish.

The physicist Richard Feynman developed a simple pictorial representation of these kinds of interactions called a Feynman diagram. The Feynman diagram below shows an electron and positron converging as time goes on until they annihilate in a flash of gamma rays (and, in that diagram, the blue squiggle gamma rays at some later point in time go through the reverse process and spontaneously convert into a new particle-antiparticle pair, a process known as pair production--but we'll just focus on the electron-positron interaction on the left, i.e. earlier in time).



One way to read this diagram is to say it shows two different particles, an electron (e-) and a positron (e+), getting closer as time moves forward and eventually crashing into each other and annihilating. Certainly that's what things would look like if you were actually watching this process in real life. But there is an alternate interpretation that's equally valid, known as the Feynman-Stueckelberg interpretation.

In this interpretation we can imagine an electron going on its merry way forward through time. At some point it emits a photon with twice its mass equivalent of energy, leaving it with a negative energy equal in magnitude to its regular mass-energy (kind of like how if you were to spend twice the amount you have in your back account, you'd end up with a negative balance equal in magnitude to whatever amount you had in there before). At the same time, the electron does a U-turn in time, now proceeding on its merry way backwards through time, passing itself along the way. To someone observing at any one slice of time, it would look like there were two distinct particles, identical in every way except with opposite charge. Feynman once explained it in terms of an aerial view of roads:

A bombardier watching a single road through the bomb-sight of a low flying plane suddenly sees three roads, the confusion only resolving itself when two of them move together and disappear and he realizes he has only passed over a long reverse switchback of a single road. The reversed section represents the positron in analogy, which is first created along with an electron and then moves about and annihilates another electron.

The "roads" here are the paths traced by the single particle as it goes forward through time, then backwards, then forwards again. Someone watching at a given point in time would apparently see three distinct particles, not realizing it was one that kept doubling back on itself. So a particle-antiparticle annihilation event is, according to Feynman-Stueckelberg, just a single particle that makes a U-turn in time at some point (which, to our untrained eyes, looks like an annihilation event). How do we interpret this? Feynman, never one for philosophy, made a seemingly utilitarian suggestion for wrapping one's mind around this kind of thing: "It may prove useful in physics to consider events in all of time at once and to imagine that we at each instant are only aware of those that lie behind us."

Indeed. But this view of particle-antiparticle annihilation is decidedly fatalistic. When the electron catches sight of its future positron self heading the opposite way in time, it knows that the annihilation/U-turn event lies in its future. In the same way, when (sometime prior to October 1985) Doc Brown taped together Marty's letter about the Libyan terrorists shooting him, he knew that event lay in his future, his bullshit about the future not being written notwithstanding. The future already exists and nothing can be done to change it. Have I mentioned that 12 Monkeys is my favorite time travel movie? Cole's recurring dreams about his own death, witnessed by his nine-year-old self, are exactly the same sort of deal. The future is inescapable precisely because it's not being written, it's out there and only vagaries of human perception keep us from experiencing it (and all time, for that matter) at once. I have another physical model (also from Feynman) demonstrating similar principles that I like even more than Feynman-Stueckelberg but I'll save it, this post is getting long enough.

As I said, I'm a fatalist. My own philosophical thoughts about the universe, my insights stolen from physical theory, lead me to believe in a universe in which tomorrow is no more special than yesterday and my death has already occurred just as surely as my birth has. It's been remarked to me that I take something of a passive approach to life, in that I let things happen to me instead of seeking to shape events. To some extent this is true, in part because I rely on Fate to steer my ship. Believing in Fate is not the same as believing in a god (I'm an agnostic). Rather, it's a sense that the path is there to be discovered, not yours to create. I don't know if that implies a Cosmic Writer, I don't even know if that means free will doesn't exist.

My sense, however, (since I'm sure you asked) is that free will and choice are, like distinctions between the past and future, stubbornly persistent illusions. When I choose a calzone over a taco it's a conscious choice, but based on an innate preference ("I have a taste for a calzone" or "I'm sick of tacos") over which I have no conscious control. Thus it seems to me that ultimately every choice is a Hobson's choice of some form, a bit like a parent allowing a child to "choose" some activity or food or whatever only as long as the child makes the "right" choice. Everyone wins: the parent's (the analogue of Fate) wishes are fulfilled and the child believes he was able to freely make a decision, never knowing the alternative was never a real possibility.

When I was younger, I had a (professional) path in mind. Since I knew the end point, it was easy to determine the path because there was very little leeway in the path that would lead me to the desired endpoint. I liked the concepts and practices of physics, I enjoyed conveying them to others, and I believed I wanted to do research in that area. The obvious conclusion was that I should be a physics professor and the path to that is fairly straight foward: an undergrad physics degree followed by a Ph.D followed by a few postdocs followed by an assistant professor gig and eventually the endgame. The exact path (where? and when?) were mysterious but the contours were clear.

This is where things stood my freshman year of college. But deep down I hoped that in five years I'd be somewhere I would have never imagined at the time (note: five years later, I am in about a dozen ways, including philosophically, mentally, professionally, geographically, and so on--not to imply that all these changes are good things). My inner fatalist seeks to rebel, to know in its heart of hearts that the path is already laid down but that it still holds surprises. I loved physics but remained unhappy in it, in part for reasons revealed in the first installment of these introspective posts. It seems like every week I was thumbing through the course guide waiting for Fate to reach out its hand and show me something new. And it did. When the path turned, I followed it. I explored the places it took me and the ideas it showed me.

And there were a handful of times--terrible, dark, terrifying times--when I lost sight of it. I firmly believe that there isn't a scarier feeling a person can experience than feeling lost, from a child who loses sight of his parents in some public place to a recent college graduate with little idea where or why he is. I think I've only been truly lost--really, truly lost--once in my life, a few years ago, and if I never go back to that place for the rest of eternity it will still be too soon. But I've been quasi-lost a number of times and in those times the path has always eventually reappeared to me.

When I graduated the job market was weak, my credentials could have used a little beefing up, and I wasn't sure I knew what I wanted (I didn't realize it then, but I did have a pretty good idea of the kind of place I wanted to go to and the kind of work I wanted to do). And after a long and laborious job search, I finally go an offer--from the 90th place I applied to--that turned out, fortuitously, to be exactly what I was looking for. The nature of the work, the subject matter (particularly given current events), even the geography turned out to be exactly what I needed and, I realize now, wanted. And this all happened seemingly by accident--there was no planning for this on my part or this wouldn't have been Option 90. The path had reappeared.

That isn't to say that a fatalistic philosophy has worked out perfectly well up to this point. My personal life--conducted by the same principles as my professional life--is nowhere near where I'd like it to be, though much of that can, I believe, be attributed to innate factors beyond control that won't be changing (there's that strand of fatalism again). Time will tell if the path will produce answers to those questions or merely terminate ingloriously. I have no idea what it holds, just suspicions, though I do believe its windings and end have never been in doubt.

And so I'll continue on because the choice to adhere or deviate isn't really mine.

A bit of introspection

I like knowing how things work. But there are some nuances in there. I realized as an undergrad that I didn't really care all that much how various machines and mechanisms worked, and circuit diagrams just bugged me. I wasn't particularly tech-minded like other physics majors. The thing I enjoyed most about doing physics was getting glimpses of how the universe worked, little peeks at a very broad existential reality that transcended everything else. My favorite day in any physics class remains the day that one of my professors took Maxwell's equations and made light. I knew it would happen, certainly I knew that the fundamental equations governing electromagnetism could, when solved, produce electromagnetic radiation. But I was still absolutely floored by the majesty of it all. The handful of people on earth who knew my obsessions in physics know they often centered on Mach's principle and variational principles (often known as least action principles)--simple, fundamental ideas that govern (or, in the case of Mach's principle, might govern) the basic processes underlying the universe.

But I came to find that my future doesn't lie in physics. I still love the ideas but I became far too much of a relativist to retain the simple idea that attracted me to physics in the first place: that it was the closest thing to a window on Truth that mankind would ever have. There's a scene in Inception--which you should see (TJ)--where Leonardo DiCaprio's character draws a diagram of two sides of a circle eating each other, explaining that while we sleep our mind perceives a certain reality at the same time it's creating that reality. The truth is, the same could be said about the waking world. We never touch Reality (Reality being, in my young mind, the Holy Grail of physical inquiry), we touch the manifestation--informed, one assumes, by interaction with Reality--created by our minds. We see relations, which seem to be true enough, but we don't see what's being related. We've created an intricate web of concepts to connect things and make (accurate) quantitative predictions, but what the concepts map to in the world outside our minds (assuming, as most of us do, such a thing exists) will forever be a mystery to us. Thus physics could offer me only statements that seemed true, in that the linkages between concepts made predictions that seemed to be borne out by experimentation, but it couldn't give me Truth.

So I wandered over to my other great interest: the workings of human society. Here there was never any promise of Truth; knowing how society works or people tend to interact has no grand metaphysical implications, no existential ramifications. It's just how things work here, in this place in the universe and perhaps this time in global history, among these people. And since I like to know how things work, for me that's enough. Unlike technical devices, I desperately want to know the nuts and bolts of how social institutions work. How does government make things go? How do movements of people shape government? How do programs actually work in practice, what does implementation of ideas look like?

A year ago + a few months I knew very little about health care. I knew the basics of Medicare and Medicaid (extending only slightly beyond simply what they are). About a year ago, finding myself with some free time and interested in a national debate that was heating up, I began learning everything I could about health policy, particularly so I could make sense of the reform bills I was reading. Then I got a job in health policy and became exposed to a much more in-depth view of how things work (indeed, my boss used to run a state's Medicaid managed care program). I love where I am.

My fear around the time I graduated from college was irrelevancy. Ending up at a place that played no role in the way things work, that had things to say that important ears never heard. That isn't the case with the place I am now. They provide guidance to the people who make things work, which is about as relevant as it gets. I remember the difficulty I had even getting people from relatively insignificant non-profits in Chicago on the phone while trying to write my senior thesis (a difficulty that led to me scrapping my first topic) and now it's not particularly strange to get a state's Medicaid director on the phone--and that makes me think I'm right where I want to be right now.

God I love margaritas. What makes you tick? Where do you want to be? Or where do you want to go?