Kevin Drum

Here's Why Phoenix Is Ground Zero for the VA Health Care Scandal

| Tue Jun. 3, 2014 2:18 PM EDT

I've steered clear of the VA story for the past few days, though not for the obvious reason. Basically, I got to the point where the collective hypocrisy over the whole thing became too much to take. Rather than write an epic rant I might later regret, I decided to just shut up.

However, in one of my last posts on the topic, I urged everyone to keep at least two things in mind. First, there's a difference between the backlog of vets trying to establish eligibility for VA health care and wait times for vets who are already in the system. Second, always ask: "compared to what?" If you're claiming that VA health care is terrible on some metric or another, tell us how that compares to private sector health care.

Today, Phil Longman comes along to write knowledgeably about both topics. In particular, he takes on the second one. Here's Longman on wait-times:

Here’s a key relevant fact that is just the opposite of what most people think. For all the wars we’ve been fighting, the veterans population has been falling sharply....I have visited VA hospitals around the county and often been unnerved by how empty they are. When I visited two of the VA’s four state-of-the-art, breathtakingly advanced polytrauma units, in Palo Alto and Minneapolis, there was hardly a patient to be found.

But at the same time there is a comparatively small countertrend that results from large migrations of aging veterans from the Rust Belt and California to lower-cost retirement centers in the Sun Belt. And this flow, combined with more liberal eligibility standards that allow more Vietnam vets to receive VA treatment for such chronic conditions as ischemic heart disease and Parkinson’s, means that in some of these areas, such as Phoenix, VA capacity is indeed under significant strain.

This regional imbalance in capacity relatively to demand makes it very difficult to manage the VA with system-wide performance metrics. Setting a benchmark of 14 days to see a new primary care doc at a VA hospital or clinic in Boston or Northern California may be completely reasonable. But trying to do the same in Phoenix and in a handful of other sunbelt retirement meccas is not workable without Congress ponying up for building more capacity there.

VA managers have known for years that some of their facilities were gaming the system by using paper lists and other tactics to mask long wait times. Mariah Blake has the whole story here. In other words, contrary to the legion of pundits who seem to have discovered the phrase "perverse incentives" just last week, VA managers aren't drooling idiots who didn't realize that incentive systems can be gamed. They knew it perfectly well and were trying to fix it. Rather, the problem was that (a) they failed to set different goals for different facilities, and (b) they're apparently lousy at oversight.

Regional imbalances also explain why these problems show up only in some facilities and not in others. And it also explains why, on average, VA wait times are actually pretty good and why VA patients generally rate their care higher than private-sector patients. It helps you get a handle on the "compared to what?" question.

Longman's piece isn't an apology for the managers who gamed the system in order to spike their bonuses—or for their higher-ups who failed for years to get this under control—but it does explain why it's happening in some places and not in others. And there's more to come:

As I’ll argue further in future posts, the key question to ask when confronting the real deficiencies of the VA is “compared to what?” Once that context is established, it becomes clear that VA as a whole continues to outperform the rest of the American health system, making its true lessons extremely important to learn.

Longman is well worth reading if you genuinely want to understand more about how the VA works and how it compares to health care elsewhere. He'll make you smarter, not dumber.

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Courts Should Be More Willing to Weigh in on "Political" Disputes

| Tue Jun. 3, 2014 12:34 PM EDT

Does the Bowe Bergdahl outrage on the right have legs? Yesterday I didn't think so. Today I'm not so sure. We'll see.

I want to steer clear of the fever swamp stuff for now,1 but one aspect of all this prompts me to finally get around to writing something that's been on my mind for a while. One of the questions surrounding the Bergdahl prisoner swap is whether President Obama broke the law by releasing five Taliban prisoners from Guantanamo without giving Congress its required 30-day notice. Republicans says it's a clear violation of the law. Obama says the law is an unconstitutional infringement of his Article II authority as commander-in-chief. Who's right?

Here's the thing: these kinds of disputes happen all the time in various contexts. Federal and state agencies take various actions and then go to court to defend them. Sometimes they win, sometimes they lose. It's pretty routine stuff.

And that's what should happen here. Congressional Republicans should challenge Obama in court and get a ruling. This would be useful for a couple of reasons. First, it would be a sign of whether Republican outrage is serious. If it is, they'll file suit. If they don't file, then we'll all know that it's just partisan preening. Second, we'd get a ruling. The scope of the president's authority would become clear. (Or at least clearer.)

But this doesn't happen very often. Sometime problems with standing are at issue, but not usually. Congress has standing to challenge this. No, the more usual reason is that it's hopeless. Courts traditionally treat disputes between the president and Congress as political, and decline to weigh in.

This is fine if a dispute truly is political. But this, like many other so-called political disputes, isn't. It's a clear question of how far the president's commander-in-chief authority extends and what authority Congress has to limit it. If Republicans truly believe Obama violated the law, they should be willing to go to court to prove it. And courts should be willing to hand down a ruling. It's a mistake to simply wash their hands of these kinds of things.

1Speaking of which, you should have seen my Twitter feed after yesterday's Bergdahl post. Hoo boy.

Good News for August

| Tue Jun. 3, 2014 12:09 PM EDT

Hey! Rick Perlstein's final (?) volume in his account of the rise of the modern conservative movement, The Invisible Bridge, is coming out on August 5. How did I not know this until now?

In any case, this is good news. I'll have something good to read in August. And so will you.

UPDATE: I just got an email from Rick:

not final....

Just signed contract to write fourth and final volume taking story through 1980 election.

Hmmm. This is sounding very Game-of-Thrones-ish. It keeps expanding. When volume 4 is released, will we learn that Rick decided the 1980 election really deserved a book 5 all of its own?

In any case, I've long felt that that the 70s are one of the most underrated decades. An awful lot of what's happened since was germinated in the froth of the 70s. It was a decade in which a lot of things—political, cultural, and economic—were in flux; and whether we knew it or not, we were making choices that determined which direction we were going to take over the next few decades. I'm looking forward to Rick's take on this.

Sorry, "Daily Show": Anti-Vax Nuts Come From Both Sides of the Aisle

| Tue Jun. 3, 2014 11:45 AM EDT

The Daily Show did a segment last night propagating the meme that anti-vaccine hysteria is mostly a pathology of the granola-crunching, hippie-dippie left. However, just in case anyone cares about the actual truth,1 here's the truth: anti-vaccine lunacy has no special ideological valence. Liberals and conservatives share it in approximately equal numbers.

The basic chart is on the right. The black line represents how risky various groups think vaccines are, and it's pretty flat: it starts at around 1.8 among the very liberal and ends at about 2.0 for the very conservative. That's as bipartisan as it gets. I suppose it's possible that if you broke out the tiny minority who think vaccines are extremely risky, you might find more hippie-dippie lefties than gun-toting righties. I don't know. But it's a minuscule fringe belief in any case: Fewer than 1 percent of parents refuse to allow their children to receive any vaccines at all.

1A quaint notion, to be sure.

Chart of the Day: Eurozone Inflation Edging Close to Zero

| Tue Jun. 3, 2014 10:40 AM EDT

Hyperinflation is right around the corner! Oh, wait:

Consumer prices in the euro zone ticked ever closer to outright deflation, official data showed Tuesday, making it almost certain that the European Central Bank will move to ease monetary policy this week....Many economists say that inflation is already well below the danger zone for tipping into deflation, and some analysts have taken to calling the condition “lowflation.”

....The Governing Council of the European Central Bank, which meets Thursday, targets an inflation rate of just below 2 percent, a level that it has been undershooting for months. Adding to the pressure, a separate report showed the European labor market continuing to stagnate. The euro zone jobless rate came in at 11.7 percent in April, ticking down marginally from 11.8 percent in March, Eurostat said.

And what is the ECB planning to do about this? According to Gilles Moëc, the chief Europe economist for Deutsche Bank, "investors might be surprised to find that the scale of the central bank’s actions would probably be significantly smaller than those taken by other central banks, including the Federal Reserve in the United States." That makes sense. After all, with unemployment at 11.8 percent and inflation close to zero, you can't be too careful. One wrong move and inflation might skyrocket to 1 percent. And then where would we be?

Yes, Let's Gid Rid of the White House Press Secretary

| Mon Jun. 2, 2014 3:35 PM EDT

After President Obama announced Jay Carney's resignation as White House press secretary last Friday, a number of people suggested we just do away with the position. Dave Weigel's take was typical:

The tragedy of the White House beat, as hacks like me keep pointing out, is that the White House is forever innovating ways to make it useless. A specific question about the administration? Why, there's another department you can direct your questions to. What news there is gets generated by reporters acting on their own, not by anything pulled from the White House press secretary. Jay Carney's role, and Josh Earnest's role, is to dodge....

Why do we need this particular public official? As the White House pioneers ways to avoid questions, what's the point of the job Jay Carney's now leaving?

This is all true. And yet....I wonder if this lets reporters off too easily? Every once in a while I happen to catch a White House press briefing, either live or on YouTube, and what strikes me is that reporters are less interested in gaining actual information than in simply playing gotcha. Do press secretaries dodge? Sure. But then again, if you ask whether the president still has confidence in Eric Shinseki (this is Weigel's example), what do you expect? It's a dumb question, designed to produce theater, not information. Everyone knows perfectly well that you have to express confidence in your deputies until the day you don't. If you ask about it, you're just going to get mush.

Ditto for lots of other press room fodder. White House reporters seem to be in love with asking questions that they know perfectly well aren't going to be answered, for no reason except that it provides a soundbite for the evening news that shows them being "tough."

If I had to guess, I'd say this culture started with Ron Ziegler and Watergate. In that case, tough, relentless questioning was legitimate. In general, it's legitimate whenever you're probing a genuine scandal of some kind. But after Watergate was over, White House reporters somehow got in the habit of treating everything like a scandal, and press secretaries got in the habit of treating every question as an attack. After 40 years of this, it's become a dysfunctional relationship that does no one any good.

So yeah, get rid of the press secretary. Get rid of the televised daily briefing. Maybe the president should just have a low-level staff that distributes schedules, answers basic questions about presidential actions, and coordinates interview requests. Since these would be low-level aides, nobody would expect them to have direct access to the president, and therefore there'd be no point in badgering them.

And then, everyone could go back to doing actual reporting, instead of pretending that either the press secretary or the president himself will ever produce real news. Tough questioning hasn't produced any real news from either one of them for years, and that's unlikely to change.

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Don't Believe the Doom Mongering About Obama's New Carbon Regs

| Mon Jun. 2, 2014 1:46 PM EDT

For deep coverage of President Obama's decision to roll out new limits on CO2 emissions from power plants, I commend to you the fine folks who cover the environment for us. Their real-time reporting on today's events is here.

For now, I'll just make a couple of points. First, EPA administrator Gina McCarthy sure is right about this:

McCarthy said critics who warn of severe economic consequences of the rules have historically decried all environmental protections. She described them as “ special interests” who “cried wolf to protect their own agenda. And time after time, we followed the science, protected the American people, and the doomsday predictions never came true. Now, climate change is calling our number. And right on cue, those same critics once again will flaunt manufactured facts and scare tactics.”

Before the rules came out, the U.S. Chamber of Commerce said it would cost the economy $50 billion annually and hundreds of thousands of jobs. Senate minority leader Mitch McConnell, from the coal-heavy state of Kentucky, called it “a dagger in the heart of the American middle class.”

You should basically ignore cries of doom from conservatives and business interests. They'll be producing reams of data showing that the new EPA regs will cost untold billions of dollars, millions of jobs, and thousands of plant closures. This is what they've done with every environmental regulation ever proposed. In virtually every case, they've been wrong. The cost of compliance turns out to be a lot lower than we expect, as does the impact on jobs and energy prices. Roughly speaking, this is because capitalism really does work, something these fans of capitalism always forget whenever it becomes inconvenient. But work it does: we invent new ways of compliance and new ways of generating energy, and it all turns out far better than the doom-mongers expect.

But you probably knew that already. So here's something else to ponder: What is Obama's real goal in announcing these new regulations? The reason I ask is that today's announcement is just the first step. We now have to go through the normal drafting and public comment phase, and this is a lengthy process—even if the courts don't get involved, something I wouldn't bet on. Obama may have directed the EPA to issue the final rule by June 2015, but that seems hopelessly optimistic to me. At a minimum, for a complex and powerful regulation like this one, I'd expect a minimum of two or three years.

In other words, it probably won't go into effect during Obama's presidency. And that makes me wonder if it's as much a bargaining chip as anything else. Back in 2010, when cap-and-trade was being considered in the Senate, Obama warned that if it didn't pass, he'd take executive action on his own. That wasn't enough to scare Republicans into supporting the bill, but now he's actually doing it, which means there's a concrete regulation to compare alternatives to. And I wonder if that isn't the main point: Produce something specific enough that it's possible to get some Republican support for an alternative. Even now, I suspect that Obama would be much happier with congressional legislation than with an executive action.

I'm just noodling here, and I might be entirely off base. God knows Obama has no reason to think that anything short of Armageddon will provoke any serious compromising from Republicans in Congress. Still, the timing certainly seems a bit peculiar. It's been four years since cap-and-trade failed. Why did it take this long to produce the EPA regs that he had threatened as the price of failure?

Surprise! Democrats Benefit More From Obamacare Than Republicans.

| Mon Jun. 2, 2014 12:46 PM EDT

Sarah Kliff points today to an interesting new Kaiser poll about Obamacare. The question is whether Obamacare has directly helped or hurt your family. It turns out that far more Democrats think it's helped them than Republicans.

Now, there are some reasons to think this is objectively true. Obamacare exchanges have generally been more effective in blue states, signing up more people. Medicaid expansion has been almost entirely limited to blue states. And Obamacare is directed primarily at those with low incomes, who lean heavily Democratic. Put all this together, and you'd expect that a lot more Democrats have benefited from Obamacare than Republicans.

However, Kliff thinks this doesn't explain the entire gap. A lot of it is just plain partisanship: "Democrats likely overestimate the health law's reach, Republicans underestimate and the truth is probably somewhere in the middle." I suspect that's true, and it's the chart on the right that demonstrates it most clearly. Take a look at the question in the middle. A full 34 percent of Republicans say they personally know someone who lost their insurance thanks to Obamacare. Given the rather small number of people who actually fall into this category, it's vanishingly unlikely that 34 percent of Republicans truly know someone who lost coverage. But since they don't like Obamacare, I suppose they're more likely to count friends of friends, or someone that Aunt Millie told them about, or someone they heard about at that party last Christmas. Democrats probably act the opposite.

On the other hand, the results of the question about gaining coverage actually seem fairly reasonable to me. I'd expect about a 2:1 difference between Republicans and Democrats, and that's what we see. For some reason, I suspect that people are answering questions about gaining coverage fairly honestly. It's only on the issue of losing coverage that partisan loyalties are skewing the results.

Low Interest Rates May Be the New Normal

| Mon Jun. 2, 2014 11:46 AM EDT

Paul Krugman says that low interest rates are likely to be with us for a long time:

Structural change is happening fast — just not the kind of structural change people like to talk about. Never mind the stuff about skill mismatches and all that. What’s really happening fast is the demographic transition [i.e., an aging population], with Europe very quickly turning Japanese. And the US, although growing faster, also turning down sharply.

Add to this the fact that what we thought was normal actually depended on ever-growing household debt, and it becomes clear that historical expectations about normal interest rates are likely to be way off. You don’t have to believe in secular stagnation (although you should take it very seriously) to accept that low rates are very likely the new normal.

If this is true, is it another reason to think that Thomas Piketty might be wrong about returns to capital staying high over the next century even as economic growth slows down?

Yep, Republicans Are Even Outraged Over the Release of a POW

| Mon Jun. 2, 2014 10:52 AM EDT

Republicans are upset over the release of Sgt. Bowe Bergdahl in exchange for the release of five Taliban prisoners. They have several complaints: the president "negotiated with terrorists"; the president broke a law requiring 30-day notice before prisoners are transferred out of Guantanamo; and among a few fringe types, a belief that perhaps Bergdahl was actually a deserter not worth rescuing.

Is there anything to any of this? Probably not. But it's pretty much impossible to tell for sure. Republicans these days are so hellbent on finding reasons to be outraged over everything President Obama does, there's no longer any way to tell whether their outrage over any specific incident is real or manufactured. And in this case, it's probably not worth trying to find out.

As a rough rule of thumb, I figure that if there's anything to these Republican complaints, there will be at least one or two Democrats from red states who join in. So far I don't think there have been any, which is probably a good sign that this is just random partisan fulminating, not genuine outrage.

UPDATE: On a historical note, I guess it's worth pointing out that prisoner exchanges—and the issues surrounding them—at the ends of wars have often been contentious, leading to partisan sniping. This is a tiny prisoner exchange, so maybe it's normal that it's leading to a tiny amount of partisan sniping.