Ken White makes a pretty fair case that we should be dealing with occurrences of police violence much less tolerantly than we have turning the same strategy that has produced a sharp rise in the encounters between the police and the general public in on itself:
If tolerating broken windows leads to more broken windows and escalating crime, what impact does tolerating police misconduct have?
Under the Broken Windows Theory, what impact could it have but to signal to all police that scorn for rights, unjustified violence, and discrimination are acceptable norms? Under Broken Windows Theory, what could be the result but more scorn, more violence, and more discrimination?
So: Two broad theories address health spending’s slower growth. One highlights the economy. The other — though not ignoring the economy — emphasizes policy and behavioral changes. It matters which is more correct.
Health spending faces increases from three sources: Obamacare (more people will be insured); an aging population (older people use more health care); and expensive new medical technologies. If market and regulatory pressures don’t offset these gains, spending may again outpace the economy.
I’m inclined to think that the slowing is multi-factorial. I’ll propose another factor: healthcare costs don’t rise at the same rate all the time but in fits and starts. That’s been true for decades and it’s probably true now.
For me the more important question is what does “under control” mean? Right now healthcare prices are rising faster than prices in the non-healthcare part of the economy, faster than incomes, and faster than public revenues. That is by no stretch of the imagination under control.
My definition would be costs that rise at a rate we’re willing to pay while maintaining a reasonable level of public health. There are at least three things packed into that sentence and none of them is the case now.
A 15% increase in anything is pretty substantial and that’s how much Medicaid enrollment has increased since it was expanded under the auspices of the Affordable Care Act. Philip Klein offers several arguments that the system is broken:
Its size. Just about 20% of Americans are presently enrolled in Medicaid.
Its cost. When you combine the state and federal contributions it amount to about $460 billion per year. That’s before the increase in enrollment.
The drop in physicians who are willing to accept new Medicaid patients.
Its limited effectiveness.
I don’t see that these factors either separately or together point to a “broken” system. Rather I think they point to a system that is being put to a purpose for which it was not designed. It was intended as a relatively small program to subsidize the healthcare of people who were genuinely poor at a time when healthcare consisted largely of a few immunizations and acute care. It has expanded far beyond that, to people who by no reasonable definition genuinely poor and most of its spending today is for chronic care.
However, I won’t hesitate to say that Medicaid is broken in Illinois. It takes a full nine months after the date of service for a physician to get paid in Illinois. Illinois under Rod Blagojevich elected to expand its Medicaid rolls and benefits rather than pay into its public employee pension funds. Now we have Medicaid bills larger than the state can afford and a public employee pension system that can’t make good on its promises to boot. I can’t imagine what the state will do when the federal government reduces its share of the bill as it’s scheduled to do in 2016.
It’s fun and anyone can play! All you need to do is complain that such a such a policy wasn’t effective because it was too heavy. Or too light. Not enough money was spent. Too much force was used. Not enough. It’s an all-purpose response and can be used on foreign policy (the war in Afghanistan) or domestic policy (fiscal stimulus).
For some reason practitioners of the Goldilocks Game never seem to realize that in making such claims they have undertaken an intellectual obligation to present empirical evidence that their preferred strategy will work. I.e. that there is some level of application at which your preferred strategy is effective. In the absence of that it’s just another vapid, unprovable claim.
Speaking of time machines, after stumbling across this old post of Megan McArdle’s, musing over what would have happened if the Supreme Court had declined to hear Bush v. Gore, I began to think about what might have happened if Gore had become president.
Since I’ve beaten the subject of whether Gore would have invaded Iraq or not to death with Dan Nexon of The Duck of Minerva (I think yes; he thinks no), let’s just assume that he would not have. Let me offer a series of speculations of what might have happened. I’ll mark issues on which I have very high confidence VH and issues in which I have high confidence H.
9/11 would still have happened (VH)
We would still have invaded Afghanistan (VH)
Afghanistan would have drawn the attention of foreign jihadis rather than Iraq (H)
We would still have forces in Afghanistan and it would be in no better state than it is now (H)
President Gore would not have pushed for tax cuts in 2001-2002
He would have wanted to spend more but would have been rebuffed by the Congress
He would have pushed for environmental reform but he would have been rebuffed by the Congress on that, too
He would have been re-elected in 2004
The Congress would have remained in Republican control in 2006
There would still have been a financial crisis in 2007-2008 (VH)
Jeb Bush would have defeated Hillary Clinton for the presidency in 2008
He’d’ve pushed for tax cuts
He’d be in his second term as president now
Barack Obama would be the junior senator from Illinois (H)
He’d be thinking about running for the presidency (VH)
The PPACA would never have been enacted into law
People would be wondering if the Democrats would become a minority party permanently
Saddam Hussein, Moammar Gaddaffi, and Hosni Mubarak would all still be running their countries (H)
Putin would still have annexed Crimea (VH)
That’s a pretty fair start. What would have happened if Gore had become president in 2000?
For all the money we spend on health care, we are getting some dividends. From 1960 to 2011, the death rate from heart disease has dropped 69 percent; the decline for cancer is 13 percent.
Unfortunately for arguments like this healthcare is only one of the factors involved in either of those. For example, the rate at which Americans smoke cigarettes is half what it was in 1960. To be able to attribute the decline in heart disease or cancer to healthcare alone you must be able to prove that smoking cigarettes had nothing whatever to do with the death rates from heart disease or cancer. You must disaggregate care from smoking cessation and that’s actually a lot harder than it sounds.
And then, of course, the larger question is less what you die of than whether you die or what your quality of life is. The likelihood of mortality is 100%. We shouldn’t lose track of that. I also have a vague recollection that the mortality rate from many heart disease processes is unaltered by many pharmaceutical medical interventions. It’s possible that my memory is faulty here.
I for one don’t think that surviving a fatal heart attack at age 70 to continue in a vegetative state for the next decade is an improvement even though it would lower the stats for death due to heart disease.
Then there’s the difference in population between now and 1960. It’s pretty obvious to anyone who was alive then (and still alive now) that the genetic makeup of the United States population has changed over that period. To attribute the change in morbidity and mortality to care we’d need to be able to disaggregate care from genetic predisposition.
Not to mention differences in air and water quality, diet, and so on and so on.
There’s also the question of cost-benefit but I guess that’s an entirely different post.
I am continually astonished at how weak the moral judgments of most Americans are. I’ve mentioned Thomas Jefferson’s library before here. At the time of his death it consisted of more than 6,000 volume. As mentioned in the linked post, a good chunk of those were devoted to morals and ethics. Clearly, Jefferson thought it was an important subject. That conviction does not seem to have filtered down to the present day.
It used to be the case that professional training, i.e. for doctors, lawyers, etc., required training in professional ethics. I know that my alma mater’s journalism school still requires a full year course in media law and ethics for graduation. A quick perusal of the course catalog for Harvard Law and the University of Chicago medical school finds the offerings on professional ethics meager indeed. I’m sure it’s touched on peripherally here and there.
My impression is that here in the United States we rely on what people learn at their mother’s knee (which, sadly, isn’t much these days since mom must work to provide for the family), what they’ve learned in the few weeks’ worth of Sunday school they might have attended, pick up on the streets, or learn from watching television. I suppose they could do worse than learning from Sesame Street or Fred Rogers. I shudder to think at what they’ve learned from Power Rangers.
A majority of Americans believe that the use of torture in fighting terrorism is acceptable. When they have the moral educations of seven year olds, we probably shouldn’t be surprised.
In mulling over the question of whether the passage of the continuing resolution omnibus spending bill (shortened to “CRomnibus”) by the House was a good thing or not, something that caught my eye was the unanimity with which the amendment to Dodd-Frank in the bill was condemned. Being something of a contrarian I always wonder what the counter-argument might be.
It was darned hard to find one but I finally located an argument in favor of the amendment at Powerline of all places (not regular reading for me) in the form of a lengthy quote from an unnamed “expert on risk management in the banking industry”. It’s long and dry and has a number of digressions but having read it I have a much better understanding of the political contours of the issue.
The “expert” makes one other good point that is too frequently ignored: a good deal of the federal government’s attention in the financial crisis was devoted to bailing out government-sponsored enterprises (GSEs), the public-private hybrids which fulfill functions which in most developed countries would be performed by government agencies, e.g. Fannie Mae and Freddie Mac. From my point of view those are pretty good things to hate. I can’t figure out why political appointees doing the work of a federal bureaucrat should be paid the wages of a Wall Street Banker. Maybe it’s just me.
It’s a pretty sad state of affairs when the news media whether broadcast or print are in such lockstep on an issue that you can find hardly a mention of what the other side of the question might be. You can find positions arguing in favor of torture but not in favor of repealing an obscure provision of Dodd-Frank. What a strange world we live in!