White swans and mass shootings

The term “black swan” refers to an event that has enormous impact and is rare and difficult to predict. The prime example used by Taleb is 9/11 — an event of outsize importance that typical risk analyses would have been unable to predict or identify. There’s a fair amount of focus now on black swans, how to predict and control for them.

Sometimes, though, we are looking for black swans when we should be looking for white ones — events that have enormous impact, but that are neither rare nor particularly difficult to predict. An event like the Newtown murders may feel like a black swan — who could have predicted? But the preconditions for the event make it more of a white swan than a black one. For one, mass gun violence is relatively common in America; about 80 people die every day from gun violence. Although it is tragic that 27 murders and 1 suicide occurred in one place, and that many of the dead are children, it is not extraordinary in a world where gun violence occurs with regularity.

As long as it is easier for a mentally disturbed young man to get a handgun than mental health treatment, President Obama’s exhortations that we will do more to protect children strike me as hollow. Gun control laws have been eviscerated by the Supreme Court, and the gun lobby’s loud voice in the public conversation make movement on that front almost unimaginable. Mental health treatment is only slightly more likely, and my guess is that such laws would be targeted at committing people to quasi-incarceration rather than actually providing therapeutic treatment.

We cannot predict mass murder with precision, of course, but we can say with some probability that murders with guns will occur regularly through the day, week, month, year, etc. Without concerted efforts to either reduce the availability of firearms or increase the availability and reduce the stigma of mental health services, mass murder will continue to be a white swan rather than a black one.

(On the gun control topic for a second, I get all the 2nd Amendment stuff — we need to have firearms in case we need to overthrow the government. Sure. But a state monopoly on violence goes a long way to reducing violence among the populace. If this is an explicit trade-off being made, then fine, but I don’t think we have properly costed in the price of lost lives and mental/physical trauma.)

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Health care predictions

Like the saying goes, “It’s hard to make predictions, especially about the future.”

I am in the minority view here, but I think the Court still upholds the whole law in a quite narrow opinion in a 6-3 decision authored by Chief Justice Roberts. Maybe I am naive in my belief that laws matter, but I just don’t believe that the Court is willing to limit the Commerce Clause on some made-up wacky distinction like “action” vs. “inaction.”

I’d also give about 20% odds that the Court punts entirely, either by ruling on the Anti-Injunction Act provision (rendering all the lawsuits invalid) or by delaying the decision entirely by another year.

Predicting the Supreme Court is tough, but the ones who would know think it’s looking rough for the individual mandate. I’m hoping that the judges remember that law matters.

We’ll find out Thursday, along with everyone else.

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On defeatism and getting nothing

Unlike many (including Howard Dean and the Great Orange Satan and probably Linus) who say that we should “kill the Senate bill,” I believe that a flawed bill is better than nothing.

Let’s take a trip down memory lane to, oh let’s say, 2004. Some left-wing New England governor, who was something of a health care wonk and touted as a viable progressive alternative to John Kerry, proposed a daring health care overhaul. His plan would increase coverage to 26 million more Americans, but it had no public plan, co-op or anything similar. It did have a federal employees health plan, similar to the one currently in the Senate bill. It did not eliminate rescission or regulate insurers’ ability to refuse patients with pre-existing conditions.

This plan belonged, of course, to lefty progressive hero Howard Dean.

The current Senate health care bill would pay for more people’s coverage, would cover more people, and would regulate insurers to force them to stop their most egregious cost-cutting tactics. Instead of a tax increase, it has an individual mandate, which in the end will function the same way.

(For a more comprehensive list of what we still get, check Kevin Drum.)

Put another way, the current Senate health care bill is arguably to the left of the Howard Dean health care plan of 2004.

Yes, we are in a more progressive moment. Yes, we should have a better chance than we did in 2004. But a setback here will be a setback for another generation. If this bill fails to pass, 40 million Americans still won’t have health insurance, no matter how much pride the progressive wing of the Democratic party has saved. I am pissed at Joe Lieberman, Ben Nelson, and the rest. I’m pissed at the filibuster. I’m pissed at the horse-race-obsessed media. I’m pissed at Obama for not taking a more progressive stance. The fact that I am pissed will not make anyone get health insurance. This bill will.

When a student talks during a test, I give the student automatically half-off. Usually, the student pouts and throws his/her test on the floor, exclaiming “If all I can get is half, I don’t want to take your stupid test!”

I pick up the paper off the floor, and gently ask the student, “You still have 25 minutes left. If you choose not to finish, that’s your choice. But think about this one question: Is something better than nothing?”

The student sits there, thinking. Eventually, the student finishes.

Something is better than nothing.

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Re: Baucus

Having now actually taken the time to read large parts of the Baucus bill, which you can read here, I have fewer reservations about it than I used to, and I believe its major shortcomings (free rider provision, lower subsidies) can be hammered out in conference.

Now, I’m aware of Linus’ distaste for the bill, particularly its kowtowing to Republicans without getting any actual Republican support, but like it or not, this is the bill that counts. There’s no public option, but the cost controls appear to be solid (the CBO loves it), which was the justification behind the public option in the first place. The major reforms controlling the actions of insurers (preexisting conditions, rescission, etc.) as well as the subsidies (however neutered they are, although again, this could be restored in conference) remain intact.

Again, Linus’ concerns about Republican support are real, but the bill is very much a reflection of Obama-style bipartisanship: listen to the other side, take some of their ideas, even if they refuse to support it.

I also don’t buy the momentum argument, as if passing it quickly would have necessarily been better. Most major American legislation needed a long time to reach its best state (see: Social Security). As much hay as has been made about Obama’s approval rating, his job approval has stabilized after a dip in August, and a guy who won 53% of the vote has about a 52% approval rating. Not insane.

One part of this, however, is that Obama has not done well enough in selling that the plan will just make your health care easier to manage. At every stage of this bill, the government is introducing regulation that streamlines the process or puts you in more control of your own health care, rather than the hands of your insurance company. The bill covers improvements to almost every facet of federal regulation of health care, from requiring more coverage of rural self-employed Americans to ensuring family-to-family health information centers continue to get federal funding. Instead of saying “your health care won’t change at all,” Obama should be saying “your health care will become more awesome!”

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Chopped and screwed

One part of T.R. Reid’s recent piece talking up his new book stuck out to me as a point often missed in the health care debate.

American health care is not any more “free-market” than, say, America’s telecommunications networks (another problem entirely), but both left and right often treat the system as a cruel and brutal affair run with market principles and pure laissez faire in mind. In fact, the system is much more a hodgepodge than we sometimes think.

Reid:

In many ways, foreign health-care models are not really “foreign” to America, because our crazy-quilt health-care system uses elements of all of them. For Native Americans or veterans, we’re Britain: The government provides health care, funding it through general taxes, and patients get no bills. For people who get insurance through their jobs, we’re Germany: Premiums are split between workers and employers, and private insurance plans pay private doctors and hospitals. For people over 65, we’re Canada: Everyone pays premiums for an insurance plan run by the government, and the public plan pays private doctors and hospitals according to a set fee schedule. And for the tens of millions without insurance coverage, we’re Burundi or Burma: In the world’s poor nations, sick people pay out of pocket for medical care; those who can’t pay stay sick or die.

This fragmentation is another reason that we spend more than anybody else and still leave millions without coverage. All the other developed countries have settled on one model for health-care delivery and finance; we’ve blended them all into a costly, confusing bureaucratic mess.

To use current right-wing vernacular, we do have the “greatest medical care in the history of the world,” but we only provide it for a limited majority of our population. For everyone else, we provide nothing at all.

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The middle finger rises…

Here comes Rahm-bo!

The Republican leadership,” Mr. Emanuel said, “has made a strategic decision that defeating President Obama’s health care proposal is more important for their political goals than solving the health insurance problems that Americans face every day.

To be fair, the White House has been unable to stick to a script, largely because there wasn’t exactly something to sell. So this tack could change quickly if there’s pushback.

Still, it’s good to see the White House refocusing the messaging on “solving the health insurance problems that Americans face every day” while whacking obstructionists with a two-by-four. This doesn’t counteract the biggest problem, though… some of the biggest obstructionists are Democrats! How much Rahm is willing to chase after the centrists, or at least guarantee a non-filibuster, is up to Obama.

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There is no penalty for lying, so why stop?

Greg Sargent has a new post up about Sen. Chuck Grassley’s retraction of his lie about the government “pulling the plug on grandma.” The retraction was done through a spokesman and buried in a Washington Post profile, sure to be ignored by the media, whereas his initial lie was trumpeted everywhere.

The key graf:

So, either Grassley made his claim about “grandma” to a crowd in his home state last week and didn’t believe it; or he changed his mind since then.

Grassley’s retraction will get nowhere near the coverage his initial statement did. False or outlandish claims are “controversial,” so they get rewarded with media attention; their subsequent retractions tend to pass unnoticed, because the press has moved on to the next false or outlandish claim. The big news orgs blared Grassley’s initial assertion at the electorate for days, but almost no one will ever learn that Grassley didn’t really mean it.

If there’s no penalty for lying, people will continue to lie. If Chuck Grassley can feed the red meat to the conservative base without sacrificing any of his “moderate” status, he will continue to do so. The worst part of the “death panels” hysteria is that the Republican lawmakers standing up lying about them actually think they are a good idea. Sarah Palin, John Boehner, Newt Gingrich — they all supported some form of end-of-life planning. They are disingenuously lying to weaken the bill and weaken the President.

If no one really calls them on it, they will continue to lie unabated.

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The plural of anecdote is not data

In the health care debate (and almost all public policy debates), personal stories become quite moving and important in defining the narrative of the debate. Anecdotes are used to support a point, however divorced they are from general trends.

For example, consider the case of physicist Stephen Hawking — first held up by Investor’s Business Daily erroneously (and comically) as an example of someone who would die under Britain’s nationalized health care system (despite his being British and alive) — who has now become a semi-poster child for the left’s claim of national health care’s efficacy in caring for citizens with debilitating illnesses.

Hawking’s case is just one in a series of cases of anecdote as data, such as Britain’s Twitter campaign “We Love The NHS.” I have nothing against this club, nor do I think people should stop telling their personal stories. I would like to note, however, that looking at broader data is far more accurate than looking at specific cases. Britain’s system has its problems, although it is freakishly cheaper than the American system. If we allow anecdote to take the place of systemic analysis, we will find ourselves with patchwork and counterproductive solutions (see: Medicare prescription drug coverage).

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Do I want my medical care to be like the post office? Hell, yes!

Recently, liberal commentators have expressed bafflement at conservative contentions that government-run health care (which the current Finance Committee plan is not, but lies are par for the course) will be run as inefficiently as the Post Office, with at least one libertarian commentator referring to the plan as “Post Office health care.” There’s ample commentary as to whether this is a good political argument to make, but I’m wondering whether the Post Office is actually a good analogy for health care reform.

The Post Office is deficit-neutral and has high approval ratings (58% in the above survey). But the Post Office may be the best analogy for the “public option.” It’s not great; it has bureaucratic hoops to jump through; its expenditures are high, but not exorbitant. It is, however, low-cost to the consumer, relatively efficient (a letter you send will arrive at its destination sometime), and equal based on vastly different areas of cost to the organization.

Consider that it costs the same 44 cents to send a piece of mail from Florida to Alaska as it does to send the same piece of mail from Ohio to Indiana. It hardly seems fair — after all, the cost of sending a letter several thousands of miles is much more than the cost of sending the letter to a much nearer destination. This is not unlike the problem of preexisting conditions in health care — a child with leukemia will require much more care and money than a twenty-something non-smoking female, but under a public plan, the premiums they paid would be similar.

The Post Office provides the basics: you can mail a letter or send a package. They have various premium services, if you so desire, but these are often done better by competitors (FedEx, UPS, etc.). I think this is essential, however; the basics are just basic. You can upgrade your service using a supplementary company at any time.

The Post Office is also required by Congress to be deficit-neutral, which is why stamp prices keep going up. Yet, this does not mean that the post office is wholly independent of the government or its revenues. On the contrary, the Post Office had to be set up by the government originally and organized/expanded by government funds. It’s not as if the Post Office just magically came into existence.

If all you want to do is send a letter, then the Post Office is your best bet. If you have an urgent or important decision, you can still use the Post Office, but other organizations exist if you want higher levels of performance.

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More doctors in more places

Physicians per 1000 people, OECD countries

One part of the health care debate that has gone under-mentioned is the fact that this debate is necessary at all. One of the biggest problems with health care is that it is a scarce commodity — doctors have little time to actually see patients (15-20 minute appointments being the norm across the industry) and the fear of “rationing care” only becomes a problem when good doctors are simply in too high demand.

Furthermore, when there are fewer doctors, they are compensated more highly (the average US doctor makes roughly double the average OECD industrialized nation’s doctor).

America actually has relatively few doctors per capita, and the government could frankly do much more to alleviate cost, particularly the costs of medical school for primary care physicians. The average educational debt for med school graduates is around $140,000. If the government did more to pay for these costs, the financial dynamics for doctors could be changed dramatically. More doctors should be a necessary component of any national health care reform.

It won’t matter how you pay for them if there aren’t enough of them.

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