Bending the Curve

Brad DeLong tries to figure out why the Congressional Budget Office has been so pessimistic about the potential for healthcare reform to reduce long-term costs:

The problem, I think, is that the CBO has a category for cost control but no category for getting system incentives right. It is a budget office, after all, not a philosopher-king office. The problem, however, is that it is the only arbiter out there. And there appear to be a lot of members of congress who think controlling costs = getting system incentives right.

I don't think we should care much about costs: it might be in the future we want to spend a lot on health; it might be that in the future we develop magic treatments and so want to spend a lot less. If we get the system incentives right, then whatever we spend on health will turn out to be the right thing to do.

There are useful things we can do that will help control costs.  Better IT, for example.  Lower administrative overhead.  Comparative effectiveness research.  For the most part, though, these are one-shot deals.  They're worth doing, but you only get to do them once.  And once they're done, costs keep going up.  They go up from a lower base, but they still go up.

Then, as Brad says, there are things that help align incentives better and (maybe, possibly) bend the curve of rising healthcare costs downward.  Moderate copays, for example, can help reduce unnecessary doctor visits.  Cheap (or free) access to preventive medicine can keep chronic ailments from turning into expensive acute crises.  Paying doctors straight salaries probably promotes more efficient use of expensive services than either capitation or fee-for-service. Universal coverage can prevent overuse of expensive emergency room services.  A more sensible malpractice regime might reduce defensive medicine (and more fairly compensate victims of genuine malpractice in the bargain).

But in the end, both as individuals and as a society, we're going to spend as much on healthcare as we feel like spending.  And why not?  We should spend our incomes on whatever we value the most, and for a lot of us that's healthcare.  If that turns out to be 30% of GDP, then it's 30% of GDP.

And that's what will eventually bend the curve in healthcare costs: when we all finally decide that we're spending enough.  Whether we're doing it as individuals, as employees with healthcare insurance, or via tax dollars, we'll get serious about controlling costs when we decide that costs have gotten too high.  Until that happens, though, well-designed incentives may make things more efficient but won't appreciably reduce the rise in total spending.  I don't think politicians can afford to say that in public, but it's probably true.

Geoengineering received a big boost this week. The American Meteorological Society released a major statement Monday on the topic, making these recommendations:

1. Enhanced research on the scientific and technological potential for geoengineering the climate system, including research on intended and unintended environmental responses.
2. Coordinated study of historical, ethical, legal, and social implications of geoengineering that integrates international, interdisciplinary, and intergenerational issues and perspectives and includes lessons from past efforts to modify weather and climate.
3. Development and analysis of policy options to promote transparency and international cooperation in exploring geoengineering options along with restrictions on reckless efforts to manipulate the climate system.

The AMS is a respected scientific body here in the US, and a statement of this kind certainly gives credence to the possibility of a major, well-funded, possibly federal geoengineering research program. It also comes on the heels of a National Academy of Sciences workshop in which leading experts debated the merits of such a research program.

Some geoengineering critics (and there are plenty of them) say investment in this kind of research will only distract from mitigation efforts. I disagree, and now, so does AMS. And I think the Society responds well to that argument with this point:

Geoengineering will not substitute for either aggressive mitigation or proactive adaptation, but it could contribute to a comprehensive risk management strategy to slow climate change and alleviate some of its negative impacts. The potential to help society cope with climate change and the risks of adverse consequences imply a need for adequate research, appropriate regulation, and transparent deliberation.

Some devil's advocacy for people who think Jose Padilla was treated fairly: Former Long Island car wash employee Bryant Neal Vinas, 26, has been charged with participating in a rocket attack on US forces in Afghanistan. According to the charges, he's a dangerous terrorist who trained with Al Qaeda and passed on information about the Long Island Rail Road and the New York City transit system. He is apparently cooperating with authorities.

If torture is such an effective tool, why didn't we torture Vinas? How do we know he's not holding something back? Padilla, another American citizen who was accused of conspiring with terrorists, had his mind essentially "destroyed" by sensory deprivation and solitary confinement. Padilla was held without a lawyer for nearly two years. He was allegedly forced to take LSD and PCP as "truth serums." Does Vinas deserve better treatment than Padilla? If so, why? If Padilla did deserve to be treated as well as Vinas, why wasn't he? Isn't Vinas just as much an "enemy combatant" as Padilla was? Why does he deserve rights that Padilla wasn't afforded? Who makes these decisions? Why do they seem so arbitrary?

Rich Miller of Bloomberg reports:

Global investors give Federal Reserve Chairman Ben S. Bernanke top marks for combating the worst financial crisis since the Great Depression and overwhelmingly favor his reappointment amid optimism that the world economy is on the mend.

Well, I don't favor it — and this has nothing to do with whether Bernanke has done a good job or not.  Just look at a couple of the quotes Miller dug up.  "He's the best, maybe around the world," says one guy.  "If he weren't renominated, it could have potentially very serious and severe repercussions on the stock market and the economy," says another.  Spare me.

Look: Bernanke isn't indispensable, any more than Alan Greenspan or Paul Volcker or William McChesney Martin were.  But everyone thought they were indispensable at the time, and that's a dangerous way to think about these guys.  Putting Fed chairmen on a pedestal, as the financial community does routinely, breeds both complacency and insularity.  In the long run, it's bad for business.

Wall Street needs to calm down and learn that being Fed chairman for a few years doesn't make someone superhuman.  The world won't end if Bernanke is replaced by one of the other dozen or so highly qualified candidates available, and Obama should take the chance to demonstrate this when he chooses Bernanke's replacement.

Earlier today, I wondered whether Sen. Sherrod Brown's mention of working through August and Nancy Pelosi's promise to do the same meant the Democrats were going to try playing the vacation card against the Republicans. It's a great political tool: if your opponents want to delay something (health care, in this instance) until after recess, express your willingness to work through vacation and paint your opponents as lazy. Congressional majorities do it all the time. If that really is the Dems' new strategy, Jane Hamsher at FireDogLake is helping to set them up:

The Republicans, the Blue Dogs and Joe Lieberman want to stall passing a health care bill, because they know that if members go back to their districts in August it gives the health insurance lobby a chance to hammer them with millions in advertising. There's one word for that:  unacceptable.  The House should keep working until they pass a health reform bill - health care is more important than vacation.

FDL has a petition asking the House to stay in session to pass health reform. They've also put together some facts about what three weeks without health care means for Americans: 

  • 143,250 people will lose their health insurance coverage
  • 53,507 people will file for bankruptcy because they can't pay their medical bills
  • 1,265 people will die because they lack coverage

Of course, even if a health care bill is passed, many of the most important reforms won't take affect for years. But talking about the costs of inaction is still important, because they're real. Not passing a health care bill doesn't mean things will stay the same. It means things will get worse. That's probably what President Obama is going to focus on in his press conference tonight: convincing Americans that the status quo is unacceptable. If he can convince Americans that reform has to happen now, he'll have half the battle won. Then he'll just have to convince people that his reforms are the right ones.

Brian Beutler reports that Sen. Orrin Hatch (R-Utah) has left the bipartisan "coalition of the willing" that's trying to negotiate a deal on health care. The real question is why it's considered necessary for a Democratic health care bill to have the vote of someone like Orrin Hatch in the first place. Eleven Senate Republicans in had more liberal voting records than Hatch during the last Congress (according to DW-NOMINATE scores). There are sixty Democrats. Surely no one expects incredibly conservative Republicans to vote for the Democrats' vision of health care reform. After all, the parties are supposed to disagree.

Dreamliner Down?

The Seattle Times has the scoop that the Boeing Dreamliner "may not fly this year." The problem is pretty serious: its wings don't attach to its body safely. The New York Times' Seattle correspondent, Timothy Egan, explains (in Slate) why this matters:

[A] big story about the future of American industry, such as it is: a Seattle Times story that the 787 Dreamliner may not fly this year and could have serious troubles down the road. The implication is that it may not fly at all. One caveat: My wife works at the Seattle Times, on the editorial side, so this could sound like a homer. But it's a big deal. Why? With the auto industry in bankruptcy, people oft say: We don't make anything in this country anymore. In fact, we do. We make airlines for the world, at some of the best wages in the world. If the Dreamliner, Boeing's next edition, doesn't fly, it's a huge blow to American industrial might, or what's left of it. And it shows, perhaps, that you can't build a plane by outsourcing all its parts to factories and engineers around the world, as Boeing has tried to do.

Our own Jim Ridgeway has already raised questions about the safety of composite aircraft like the Dreamliner. If Jim's worst fears about composites are realized, Boeing could be in big trouble.

Yesterday, the world's biggest business asociation, the U.S. Chamber of Commerce, launched a $2 million ad campaign designed to "protect employer-sponsored health care." The campaign, aimed at fending off any proposal to create a "public option" for insurance coverage, represents the opening salvo in the business community's attack on health care reform. (See one ad below.)

Until now, most of corporate America has remained on the sidelines while liberal groups and unions have jammed the airwaves with ads attacking conservative Democrats opposed to the public plan option. Virtually the only ads opposing the public option so far have come from  Rick Scott, a rich guy who made his money running a hospital chain guilty of epic fraud. Part of the business groups' reticence has come from disagreement on the various reform proposals, but also from an admonition from the White House and Sen. Max Baucus threatening to ban them from the bargaining table should they run attack ads before any bills were even in play. Now that the bills are on the House floor, the advertising floodgates are apparently swinging open.

Citizens for Responsibility and Ethics in Washington (CREW), a DC non profit, announced Wednesday that it is suing the Secret Service because the Obama administration is following Bush-era practice and refusing to release White House visitor logs. CREW wants to know which health care executives were visiting the White House, and when. The Most Transparent Administration EverTM doesn't want to tell. So now we get a lawsuit. The White House doesn't really have a leg to stand on here: even if it could make the legal case that it should be able to withhold the visitor logs, there's no way it can make the good government case. The president serves the public; the public should know who has his ear. The only reason the White House is getting away with withholding these records for now is that the media (and Congress) don't seem to care enough to draw attention to it.

A co-worker's tweet this morning drew my attention to a blog post on how to respond to rape jokes. The author of the blog post lays out 5 possible responses when someone jokes that a woman wanted it, or was so unattractive she should be glad to get raped:

1. Keep quiet and feel uncomfortable.

2. Try to top the joke with a more offensive one.

3. Initiate a Very Serious Conversation in which you state rape is never funny.

4. Initiate a Very Serious Conversation II in which you disclose your own rape, and mention that you were definitely NOT laughing during it.

5. Talk outside the box. As in, "I knew this guy in college, and he totally got raped during rush and had to go to the doctor! He's in therapy now! It was hilarious!"