Kevin Drum

Quote of the Day

| Mon Nov. 23, 2009 1:03 PM EST

From Ezra Klein, on the likely course of healthcare reform:

I once heard an activist say that leadership is the process of managing your constituency's disappointment. If that's accurate, then the next few months are going to offer ample opportunities for leadership.

Yep.  The opt-out public option is almost certainly toast, and we'll end up instead with something closer to Olympia Snowe's trigger idea — assuming we even end up with that much.  And there's no telling what other amendments are going to get tacked on and then make it through the final conference report.  Whatever happens, though, it's not going to be pretty.  Watching sausage getting manufactured never is.

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Mass Production Heart Surgery

| Mon Nov. 23, 2009 12:40 PM EST

Over the weekend, the Wall Street Journal had an interesting piece about Devi Shetty, an Indian heart surgeon who is revolutionizing the practice of heart surgery:

Dr. Shetty, who entered the limelight in the early 1990s as Mother Teresa's cardiac surgeon, offers cutting-edge medical care in India at a fraction of what it costs elsewhere in the world. His flagship heart hospital charges $2,000, on average, for open-heart surgery, compared with hospitals in the U.S. that are paid between $20,000 and $100,000, depending on the complexity of the surgery.

....Then there are the Cayman Islands, where he plans to build and run a 2,000-bed general hospital an hour's plane ride from Miami. Procedures, both elective and necessary, will be priced at least 50% lower than what they cost in the U.S., says Dr. Shetty, who hopes to draw Americans who are uninsured or need surgery their plans don't cover.

A few notes: Shetty runs a for-profit business, not a charity.  He makes money at these prices.  And although a big part of his lower prices has to do with the generally low cost of living in India, his mass-production techniques have reduced prices more than 50% even compared to other Indian hospitals.

But although this may be cheap medicine, there's nothing cheap about his results: outcomes at his hospitals are at least as good as they are at the best American clinics, and probably even better.  It's the kind of thing someone ought to be trying here.  The whole story is worth a read.

Weatherizing Your House

| Mon Nov. 23, 2009 12:17 PM EST

"Using energy more efficiently in buildings may be the fastest, cheapest way to substantially reduce carbon emissions in the short-term," says David Roberts, and I think my only quibble there would be with the word may.  But how do we get people to do it?  Most people don't bother with this stuff even if it already makes economic sense, so putting a price on carbon and raising the price of energy will probably have only a minor impact on getting people off their butts to weatherize their houses and buildings:

Evidence indicates that the elasticity of energy demand is weirdly low.  The price signals that already exist aren’t getting a rational response. People can already save lots of money by investing in efficiency, but they aren’t doing it. They absorb a lot of price pain before they adjust their behavior....Which raises the question: why should price-based policies be our exclusive focus? Why not instead, or in tandem, try to increase elasticity of demand? If the federal government wants to get good job and economic results from its stimulus investments—and it surely does—it should not only spend the money, it should start attending seriously to the project of meliorating the market and behavioral failures in efficiency markets.

How do we remove the barriers? It turns out we know a decent amount about them but comparatively little about how to overcome them.....We’ve had three decades of cheap energy, so there’s been little reason to focus on accelerating efficiency; our know-how froze in the 1970s.

What’s clear is that getting the most out of efficiency will not only mean federal policy but state and local policy,  public-private partnerships, new financing models, new models of information sharing, and much more creative thinking. Because we know so little, there’s a lot we can learn quickly with an all-hands-on-deck effort.

Part of the problem here is simple: inertia.  Or call it laziness if you like.  It's like the difference between opt-in and opt-out: people are far more likely to accept the status quo, whatever it is, than they are to actively seek change.  Look at me: I accidentally ordered a bunch of extra channels from my cable company a couple of months ago, but I still haven't gotten around to cancelling them.  Maybe I never will.  Inertia is powerful.

But we also know that financing is a big part of the problem too.  Most of us don't have $10,000 to get our homes up to snuff, and if we finance the improvements via a loan, the payments need to be low enough that we see a net savings each month.  That might require government help.  Most of us also aren't willing to bother with this stuff if we think we might be selling our house in the next few years.  Creative financing that stays with the house, not the homeowner, can help here too.

But pure marketing is also part of the answer.  Many of us, I suspect, don't really believe all the claims about energy audits.  Even I don't.  Several years we bought a new refrigerator, and the energy savings on the model were plastered all over it.  What's more, the Energy Star program has gotten lots of publicity over the past decade.  And yet, I was still sort of surprised when we got the next month's electricity bill and it was about $20 lower than before.  In my heart, I guess I hadn't ever really believed that all the hype was true.  But the fact is that it really has paid for itself over the past five years.

So yes, this is low-hanging fruit from an economic point of view.  But to get the most out of it, we need a lot more work on quantifying the benefits, on marketing, on behavioral prods, and on financial programs.  Plus we need whatever stuff David is promising to share in a followup post tomorrow.  It'll probably be worth reading.

Dog Food Explained!

| Mon Nov. 23, 2009 11:04 AM EST

So how did the Senate's provision forcing members of Congress to buy health insurance through the exchange end up in the final bill?  A reader emails to explain:

The provision in the health care bill was added by Sen. Chuck Grassley. He originally wanted it to cover all federal workers — not just the Congressional ones — and obviously that created a bit of a stir. Baucus tried to placate him by adding language to say that federal employees may enter the exchanges, but that didn't work. So then Grassley offered his amendment saying, members of Congress and their staffs must use the exchanges. Perhaps he thought this would lead to an embarrasing fight, but Baucus said, "fine," and then that was that. As far as I know, the House version just says, members of Congress may enter the exchanges if they want to.

So there you have it.  More here.

Eating Their Own Dog Food

| Sun Nov. 22, 2009 5:53 PM EST

Last week I found myself talking about healthcare for a few minutes with a friend I hadn't seen in a while, and at one point she remarked sarcastically that if healthcare reform was such a great idea, why didn't Congress give itself whatever deal it was foisting on the rest of us?  I mumbled some kind of lame reply, but little did I know that the Senate bill actually does this.  Joe Klein explains:

My favorite provision requires that all members of Congress give up their federally-funded health care benefits and join the health care exchanges that will be set up by this bill. This is brilliant politics, addressing the tide of populist anger and fears of incipient socialism. But it also makes an important substantive point. The future of health care reform in this country will depend on how effectively the exchanges — health insurance super-stores — are working. If members of Congress have to participate in this system, you can bet they'll insist on a array of choices, similar to the system they currently use, the Federal Employees Health Benefits Plan.

There are actually a couple of ways you can look at this, and the pessimistic way is that if you make Congress buy insurance from the exchange then we'll never get any cost controls in place — because members of congress will never approve of anything that might infringe on their own perks of office.

But even I'm not quite that pessimistic.  I think Klein is right: if this survives the conference report, and gets the publicity it deserves (why is this the first time I'm hearing about it?), it will actually go a long way toward assuaging public cynicism about both Congress and healthcare reform.

(And hey — why is this the first time I've heard about this?  It's not as if I don't follow this stuff pretty closely.  Was it added in by Harry Reid at the last second?  Or what?)

UPDATE: Answer here!

Tricked Out

| Sun Nov. 22, 2009 1:46 PM EST

Compare and contrast.  Here is a math teacher describing a technique in algebra:

The trick to deriving the quadratic equation is remembering to complete the square.

You probably remember that from junior high school.  Now, here is climate scientist Phil Jones describing a statistical technique in an email to another climate scientist that was recently hacked and stolen from the University of East Anglia webmail server:

I've just completed Mike's Nature trick of adding in the real temps to each series for the last 20 years (ie from 1981 onwards) and from 1961 for Keith's to hide the decline.

Climate skeptics have gone gaga over this, of course, insisting that the word "trick" means something nefarious designed to pull the wool over the eyes of the world.  But it's not.  RealClimate explains:

The paper in question is the Mann, Bradley and Hughes (1998) Nature paper on the original multiproxy temperature reconstruction, and the ‘trick’ is just to plot the instrumental records along with reconstruction so that the context of the recent warming is clear. Scientists often use the term “trick” to refer to a “a good way to deal with a problem”, rather than something that is “secret”, and so there is nothing problematic in this at all. As for the ‘decline’, it is well known that Keith Briffa’s maximum latewood tree ring density proxy diverges from the temperature records after 1960 (this is more commonly known as the “divergence problem”–see e.g. the recent discussion in this paper) and has been discussed in the literature since Briffa et al in Nature in 1998 (Nature, 391, 678-682). Those authors have always recommend not using the post 1960 part of their reconstruction, and so while ‘hiding’ is probably a poor choice of words (since it is ‘hidden’ in plain sight), not using the data in the plot is completely appropriate, as is further research to understand why this happens.

This won't slow down the skeptics for a millisecond, of course, but there you have it.  The rest of the email stash contains plenty of examples of scientists being annoyed with skeptics and wishing them ill, but that's about it.  For the record, though, I also find skeptics annoying and wish them ill, so the only surprise to me is that the scientists managed to restrain themselves so well even in private.  I don't think I could have kept things so civil.

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Dissent of the Day

| Sat Nov. 21, 2009 5:26 PM EST

A regular reader emails to tell me to wake up and smell the mooseburgers:

It's easy as hell to laugh at Palin but I think Democrats are making a big mistake if they don't start taking her much more seriously as a credible challenger to Obama. People are in a sour-as-hell mood and if the economy doesn't pick up dramatically by 2012, Obama is going to be toast. Heaven help our Congressional majority next year.

Yes, Palin speaks in trite, childish platitudes but so do most Americans. Face it, the vast majority of our voters are not exactly rocket scientists and for many of them she will be a perfectly fine alternative to Obama.

Listen, I'm the guy who was convinced the American people would never choose the "amiable dunce" Reagan or the stupendously stupid Bush over Democrats who had IQ scores that couldn't possibly be any less than 30 or 40 points above their opponents'.

Given the state of today's Republican Party, I'd say Palin has an excellent shot at the nomination and if our economy still sucks in 2012 she'll have an excellent shot at beating Obama. So, let's take her for the more serious threat that she actually is and not as some poor joke. Remember, the dullest knife in the drawer is often the quickest to cut us.

I'm pretty sure I disagree.  But let's open up the floor for discussion.  Sarah Palin: joke or serious threat?  Vote in comments.

Reining in Healthcare Costs

| Sat Nov. 21, 2009 3:22 PM EST

Ronald Brownstein on the cost-control measures in the Senate healthcare reform bill:

[Jonathan] Gruber is a leading health economist at the Massachusetts Institute of Technology who is consulted by politicians in both parties. He was one of almost two dozen top economists who sent President Obama a letter earlier this month insisting that reform won't succeed unless it "bends the curve" in the long-term growth of health care costs. And, on that front, Gruber likes what he sees in the Reid proposal. Actually he likes it a lot.

"I'm sort of a known skeptic on this stuff," Gruber told me. "My summary is it's really hard to figure out how to bend the cost curve, but I can't think of a thing to try that they didn't try. They really make the best effort anyone has ever made. Everything is in here....I can't think of anything I'd do that they are not doing in the bill. You couldn't have done better than they are doing."

....In their November 17 letter to Obama, the group of economists led by Dr. Alan Garber of Stanford University, identified four pillars of fiscally-responsible health care reform....[Mark] McClellan, the former Bush official and current director of the Engleberg Center for Health Care Reform at the Brookings Institution, was one of the economists who signed the November letter. McClellan has some very practical ideas for improving the Reid bill (more on those below), but generally he echoes Orszag's assessment of it. "It has got all four of those elements in it," McClellan said in an interview. "They kept a lot of the key elements of the Finance bill that I like. It would be good if more could be done, but this is the right direction to go."

McClellan is being honest here: it would be nice if more could be done to rein in costs (it would always be nice if more could be done, wouldn't it?), but the Senate bill is still pretty good.  It includes all the primary elements of healthcare cost control and gets us moving in the right direction.

It's noteworthy how much support healthcare reform has from retired Republicans compared to the zero support it has from active Republicans.  The Senate measure is basically a pretty good bill considering the political environment it's being built in, and lots of Republicans who aren't running for office see that.  But Republicans who are running for office aren't allowed to admit any of this.  Not because the bill is bad, but because their political careers would be ruined by taking any of this stuff seriously.  Sad.

Via Ezra.  As he says, it's a very good, detailed column.  Worth a full read if you want to understand more about how the Senate bill gets the ball rolling on healthcare cost control.

Quote of the Day

| Sat Nov. 21, 2009 12:32 PM EST

From Sarah Palin, after Bill O'Reilly asked her if she thinks she's qualified to handle "the most powerful job in the world":

I believe that I am because I have common sense, and I have, I believe, the values that are reflective of so many other American values. And I believe that what Americans are seeking is not the elitism, the kind of a spinelessness that perhaps is made up for that with some kind of elite Ivy League education and a fact resume that's based on anything but hard work and private sector, free enterprise principles. Americans could be seeking something like that in positive change in their leadership. I'm not saying that has to be me.

I've been waiting for this transcript to appear ever since I heard this segment last night.  I started laughing halfway through and couldn't stop, which probably just proves that I'm one of those sneering coastal libertines Palin is talking about.  But there you have it: Palin is qualified to be president because she's got American values and she isn't a spineless elitist.

And yes, I know that I should probably pay less attention to Palin.  Sorry.  I can't help myself.  Her word-salad-straight-from-the-limbic-system approach to life is just too fascinating.  But as long as we're on the subject of elitist condescension toward Palin, check out this part of the O'Reilly interview about Iran:

PALIN: Let's start considering the sanctions that we should have been applying already, especially in this past year. Let's start looking at cutting off their imports of refined petroleum products.

O'REILLY: Does that mean a blockade, a naval blockade?

PALIN: We need to at least be willing to do such a thing and discuss it with our allies. And we need to be working closely with France and Britain, or other allies whom we can count on even.

O'REILLY: But they're already onboard. The primary...

PALIN: They're on board with what though? What were...

O'REILLY: They're onboard with economic sanctions against Iran. Do you know the country that isn't onboard, that's causing all the trouble here?

PALIN: Well, we have to question Russia's commitment to all this also.

O'REILLY: Excellent. Russia is the problem.

Palin was apparently unaware that Britain and France are already on board within beefing up sanctions on Iran, but that's par for the course with her.  Hardly worth mentioning.  But notice O'Reilly's reaction: he starts quizzing her like a big brother.  When she manages to pluck the right answer out her mental note file, he beams and almost pats her on the knee.  "Excellent.  Russia is the problem."

If Charlie Gibson or Katie Couric had pulled something like that, the conservosphere would be apoplectic with rage over their patronizing, elitist treatment of Palin.  Do you think O'Reilly will get the same treatment?  Me neither.

(BTW, I actually give O'Reilly some points for the way he conducted the interview.  Sure, it was basically friendly, but it wasn't fawning, and he did ask some tough questions and then fight back a bit when she delivered mangled platitudes instead of answers.  Overall, pretty good for a Fox host.)

Blame Democrats

| Sat Nov. 21, 2009 11:54 AM EST

Via Matt Yglesias, here is Gillian Tett arguing that a populist backlash against bankers could be headed our way when we have to start getting serious about cutting deficits in 2011-13:

Perhaps that will occur when income taxes are hiked above 50 per cent. Or maybe when hospital budgets are cut, or military spending slashed....“Don’t the bankers realise what could be coming?” I heard one senior western finance official tell a room full of bankers this week, as he argued — with passion and a sense of desperation — that it would be a mistake for banks to pay big bonuses.

Well, stranger things have happened, I suppose, but here's my guess about who will get the blame if we raise taxes or slash spending a couple of years from now: Democrats.  End of story.  By then, bankers will be yesterday's news, but Republicans and the media will still be eager to haul out the liberal-tax-and-spend narrative and lay into it with gusto.  The fact that the financial meltdown happened under a GOP president, the bank bailout was championed by a GOP treasury secretary, and monetary policy was controlled by a GOP Fed chairman won't matter a whit.  Democrats will be in power and Democrats will get the blame.

Does anyone seriously want to argue that this isn't how things will play out?