Category Archives: Public Policy and Governance

Is This As Stupid And Worthless As It Looks?

There is a new federal rule requiring all hospitals to post a master list of prices online–enumerating the services they provide together with their prices, so that people can review them, and presumably “shop” for the best deal.

Think about that for a minute, then review the fine print on your health insurance, assuming you are fortunate enough to have health insurance. You will note that you have very little choice of what your insurer calls “provider networks.”

Think, too, about the last time you or someone in your family had a medical emergency. If you fell off a ladder, were in an auto accident, were having a heart attack or found yourself in any of a number of similar situations, your most urgent task was getting to the nearest hospital as soon as possible; I’m pretty confident you didn’t delay in order to review and compare hospitals’ charges.

There are other reasons to file this new requirement under “worthless.” Hospitals in America’s ridiculous healthcare industry don’t charge every patient the same price for the same service. Patients with insurance are actually charged less than those without, for one thing. For another, most hospitals don’t even have a good idea of what their services cost them to provide.

Some years ago, we had friends over for dinner; one of them was, at that time, vice-president of a local hospital, and I asked him to explain the infamous five-dollar aspirin. We’ve all seen those itemized bills after emergency room visits or hospital stays that include bizarre and frequently outrageous charges, including per pill pricing that vastly exceeds what the same pill would cost at the local drugstore.

Our friend’s response was honest, if not reassuring. Because hospitals must deal with multiple insurers as well as Medicare and Medicaid reimbursement rates and with uninsured patients, they engage in “innovative” and “creative” cost-accounting. In other words (although he didn’t put it quite this way), they play games with individual bills, depending upon the likely source and timing of payment.

The bottom line: unless things have changed rather dramatically since that dinner party, hospitals really don’t know what any given service actually costs them, and there is no “standard charge” for a given medical procedure.

As I have said many times, I am a believer in markets–in economic areas where markets can work. If I set out to buy a widget, I’ll shop around to see who makes the best widget for the best price. The market for widgets works, because it provides what is essential to a market transaction: a willing buyer and a willing seller, both of whom are in possession of all information relevant to the transaction.

I know what sort of widget I want, and pricing information–what widgets are going for–is easily available. The guy selling me that widget knows what his widget cost to manufacture, and how much he needs to get for it.

If I have a stomach ache, or measles, or a broken arm; if I am having a heart attack, all I know is that I need medical care. I don’t know what medical science has to say about appropriate medications and their dangers (I may not even know my diagnosis); I have no idea what my treatment options might be, which ones are least likely to manifest side effects, or what they should cost. I’m not even a “willing” buyer who can walk away if I think the price is too high. I lack the knowledge to evaluate the quality of the care I’m receiving, let alone the ability to walk away if I think that quality is substandard.

Markets simply don’t work in these situations, and knowing that a hospital has posted its “best guess” prices is irrelevant.

Every other advanced country has figured this out. I’m beginning to think that “American Exceptionalism” means “exceptionally dense.”

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Who Decides?

I’m a big fan of “connecting the dots.” Too often, We The People and the lawmakers we elect fail to recognize important connections; we treat issues in isolation, and often don’t understand why our “fixes” to those problems don’t work.

In all fairness, the connections are often obscure.

Recently, the Executive Director of  In the Public Interest pointed out a connection that I had totally missed, even though I study both privatization and democratic processes. He warned that privatization is part of the ongoing assault on democracy.

“It couldn’t be clearer that the fundamental democratic right to have our voices — and votes — heard is under attack. Just this week, Wisconsin’s Republican-dominated legislature slashed early voting…in the middle of the night…during a lame duck session. Bottom line: there are politicians, conservative think tanks, and corporate funders who don’t want people to be able to vote. But we’ve learned through our work that there’s another — and perhaps deeper — threat to democracy spreading nationwide, and that is privatization. When corporations take control of public goods like water, transit, and schools, we give them the ability to make decisions that should be made democratically by us, the public.”

I often tell my students that the Bill of Rights, properly understood, is America’s answer to a foundational governance question: who gets to decide? Who decides what political opinion you hold, what prayer you say (or whether you pray at all), what book you read, how many children you have, who you are permitted to publicly love?

The Bill of Rights answers those and other questions by affirming the individual’s right to make those decisions for him/herself, by guaranteeing that we each have a significant measure of personal autonomy (otherwise known as self-government). Liberty, to the Founders, meant limiting the power of government to dictate what the Supreme Court has called the “intimate” decisions of its citizens.

Democratic theory is less prescriptive than the Bill of Rights, but it rests on the assumption that citizens’ assent to important aspects of their governance is a necessary element. Politicians and political scientists can and do disagree on just what those decisions are, about what decisions must be made by the citizens in order for a system to be considered democratic, but there is unanimity on the principle that “the people” must have the final say on the issues that are properly before them.

When government contracts out, it is authorizing a private entity to make decisions relevant to the contracted function. In many cases, that’s not a problem. (Leaving the decision about how much asphalt should be put in a pothole is hardly an assault on democracy.) When government turns over control of public goods like water, transit, and especially schools, that’s a different matter, and much more troubling.

Most of the considerable criticism of privatization has revolved around management issues, cost accounting, and occasionally corruption and “pay to play.” I’ve raised constitutional concerns as well.

I think we need to add the effect on democracy to the list. Have we turned over to private enterprise an area of decision-making that ought rightfully be democratically decided? What are those areas? And what are the dangers of contracting them away?

The answers will vary, but we need to ask the questions.

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When We Don’t Ask The Right Questions….

According to Engineering News Record (yes, I know I read a lot of weird shit–blame this one on my spouse, who subscribes),

A congressionally mandated study is recommending a dramatic increase in current highway spending to launch an ambitious new program to upgrade and modernize the aging, sometimes congested, Interstate Highway System. The report also calls for a hike in the federal gas tax to help pay for the plan.

It’s hard to fault this conclusion; the Interstate Highway System, like most of America’s infrastructure, is in indefensible disrepair. But looking at only one element of an integrated transportation system is like blaming all the dysfunctions of our broken government on Trump, without reference to the broken political system that facilitated his emergence and election. (Yes, we need to “fix” the Presidency by getting rid of the current occupant ASAP, but we also need to address gerrymandering, vote suppression, the Electoral College, the filibuster…)

Transportation, like so much else in our rapidly changing world, is undergoing all sorts of changes. A report that focuses only on highways (and not all highways, at that) without considering the present and future operation of the entire transportation system– air, rail (freight & passenger), state roads, etc.–misses much of the picture.

What sorts of transportation should policies promote? (For that matter, have any policies demonstrated the ability to shift those preferences? How? And which ones?)

What would the evidence tell us if we were asking the  right (systemic) questions? What are the relative costs and benefits of shipping goods via rail versus truck, for example? (Data I’ve seen would suggest that we put more money into rail.) How do different modes of transit affect the environment? Which transportation methods are most energy efficient? What is the return on investment of repairs to highways versus repairs and upgrades to rail and air?

I am definitely not suggesting that we allow our Interstates to fall into further disrepair while we debate our approach to a more rational transportation policy, but America has a tendency to pay for mansions where cabins are all we need, especially when policymakers are hiring private contractors who can be expected to return the favor and support those policymakers when the next election comes around.

When lots of money has been spent on something, there’s a natural incentive to use it. (Ask any woman who bought an expensive dress that she subsequently realizes was a mistake.) It’s human nature to look for reasons justifying the original decisions–and to ignore alternatives that might be more cost-effective , convenient or make more economic sense.

If we want to base policy on sound evidence (which I’m not at all sure we do…),if we want good data gathered from sound research to inform our decision-making, it helps to start by asking the right question.

We desperately need a comprehensive analysis of America’s infrastructure. All of it.

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“Mad Dog” Departs

It’s disconcerting enough when the most level-headed and trusted member of an administration is nicknamed “Mad Dog.” It is positively terrifying when that individual concludes he can no longer restrain the actual madness of the President he serves. But that is where America finds itself today.

The full text of General Mattis’ resignation letter is eye-opening.

Mattis quit after the Child-In-Chief ignored his advice and that of the Pentagon and State Departments, and decided (evidently after consulting his “gut”) to pull American troops unilaterally out of Syria. This rash move leaves our Kurd allies at the mercy of the Turks who have threatened to eliminate them; it endangers Israel; and it plays directly into the hands of Iran and Russia.

A Washington Post column was one among the many pointing to the strategic consequences of Trump’s abrupt and foolhardy move, and Mattis’ departure:

From the day Jim Mattis took over the Pentagon, he was seen by Washington and the world as a safeguard against a president addicted to chaos and animated by a different moral code.

At home, he was the seasoned battlefield commander who was willing to check Trump’s often-impulsive instincts when it came to deploying force. As long as Mattis was at the helm of the Pentagon, Republicans and Democrats trusted there was someone who would fight to ensure military actions weren’t taken on a whim.

Overseas, Mattis was perhaps the only Trump administration official who had the unconditional trust of America’s closest allies.

In his resignation letter, Mattis described the “resolute and unambiguous” leadership style that he had tried to bring to his position, particularly when dealing with threats posed by countries such as Russia and China.

Unstated, but implied, was that Trump’s erratic and impetuous approach to foreign policy isn’t up to the threats America faces.

The implications of Mattis’ resignation, underscored by the unprecedented language he employed when he submitted it, are deeply worrisome. Mattis has been one of the very few members of Trump’s administration widely perceived to be competent and honorable. His departure will make it much more difficult for partisans to ignore the damage Trump is doing to America’s standing in the world community, and his constant, dangerous assaults on global stability.

In an administration that has seen unprecedented turnover, Mattis’s conclusion that he could no longer work with Trump is likely to alter the course of the administration’s foreign policy more than any other departure.

In Europe and Asia, Mattis often traveled in Trump’s wake and calmed allies who were unnerved by the president’s threats to abandon allies who didn’t pay more for their defense. His decades of service and commitment to alliances reassured allies who were put off by Trump’s tendency to kowtow to strongmen, such as Russia’s Vladi­mir Putin or Turkey’s Recep Tayyip Erdogan, and insult traditional partners in Canada and Great Britain.

It is highly unlikely Trump will find anyone even minimally qualified who is willing to replace Mattis. (As one of my favorite bloggers, Juanita Jean, noted in her inimitable way, “Trump, you have no Secretary of State, no Attorney General, no Chief of Staff, no Secretary Defense, no border wall, and you probably don’t have a winkie. All you have left is the little Nazi-guy with the spray on hair.”)

Most of the people who were willing to join this administration have proved to be grifters, incompetents and/or outright thieves. A few, like Mattis, evidently concluded that duty to the country required subordinating concerns about working for an ignorant and manifestly unfit President.

Republican politicians who justified their public support for Crazy Town by reassuring themselves that people like Mattis would control the nuclear button, and Congressional Republicans willing to go along with a loony-tunes President in order to get those deficit-ballooning tax cuts for their rich patrons need to face up to the facts: America is being endangered daily by a mentally-ill narcissist who knows absolutely nothing about government or foreign policy,  is uninterested in learning, and unwilling to listen to people who do actually know something.

Congressional Republicans have been consistently willing to put party above country, and  must be held equally culpable for the incredible damage being done by this rogue administration. History will not be kind to them.

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Not The Onion. Really.

A recent headline in the Washington Post read: “Taxing Churches to Help Corporations.” It really was the Post, and not the Onion.  It wasn’t Borowitz. (This assurance does prompt me to give credit to Donald Trump for providing consistent, excellent assistance to political satirists…)

E.J. Dionne explains:

You would be forgiven for thinking this is a headline from the Onion or the fantasy of some left-wing website. But it’s exactly what happenedin the big corporate tax cut the GOP passed last year.

Now — under pressure from churches, synagogues and other nonprofits — embarrassed leaders of a party that casts itself as religious liberty’s last line of defense are trying to fix a provision that is a monument to both their carelessness and their hypocrisy.

The authors of the measure apparently didn’t even understand what they were doing — or that’s their alibi to faith groups now. It’s not much of a defense. And the fact that Republicans increased the tax burden on nonprofits, including those tied to religion, so they could shower money on corporations and the wealthy shows where their priorities lie.

I do disagree with E.J. on one point. He dismisses legislators’ excuse that “they didn’t know what they were doing.” I don’t. No one who saw the recent hearing where a Congressional committee was “grilling” the CEO of Google could come away believing that our elected lawmakers have the slightest idea what they’re doing.

Evidently, the GOP’s slap-dash effort to relieve the rich from the rigors of taxation had a negative effect on houses of worship.

At stake is a provision in the $1.5 trillion Tax Cuts and Jobs Act of 2017 that directednot-for-profits of all kinds — houses of worship but also, for example, universities, museums and orchestras — to pay a 21 percent tax on certain fringe benefits for their employees, such as parking and meals.

The new levy on the “armies of compassion” former president George W. Bush liked to extol would raise an estimated $1.7 billion over a decade.

That’s a vanishingly small amount in the scheme of the GOP’s deficit-inflating tax extravaganza, but it’s revealing. To lower the price tag of their confection for the wealthy, Republicans effectively hiked taxes on all sorts of other people and entities — most controversially, by sharply curtailing deductibility of state and local taxes. This was another two-faced move from a party that regularly assails “unfunded federal mandates” and lauds the importance of state and local problem-solving.

This story provides critics with an abundance of riches: we might focus on the mounting evidence that the Grand Old Party is filled with doofuses who haven’t the faintest idea how to structure public policy. We might focus on the “bought and paid for” identity of today’s GOP, and the party’s willingness to throw its religious base under the bus if pandering to its corporate base requires that. Or we might agree with E.J.’s accusation that this was a deliberate, nasty, entirely partisan assault–yet another example of Republicans putting the interests of their party over the good of the nation.

GOP leaders have told representatives of religious organizations that they had no intention of taxing them. They were focused on what they saw as liberal bastions in the third sector: universities, foundations and the like.

But this excuse only makes the story worse. It shows how slipshod the architects of this tax bill were, and it demonstrates their deeply partisan motives. After all, limiting the state and local deduction raises taxes far more on middle-class and well-off taxpayers in Democratic states than on their counterparts in Republican states.

Calling these assholes slipshod is way too kind.

That said, I think a stronger case could be made for taxing churches than universities and non-profits….

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