Category Archives: Public Policy and Governance

The State of the Governor

So–I poured a stiff drink and listened to Mike Pence deliver (his version of) the “State of the State.”

The word “smarmy” comes to mind.

There is much that might be said about this particular effort to put lipstick on a pig–the state he described is not one I recognized, nor the state that widely available data describes.  (My son, with whom I was watching, asked what grade I would give a student whose assignment was to deliver an accurate assessment of Indiana’s economic and social well-being and utterly failed to do so.)

There were some truly cringeworthy moments. The Governor, you may be surprised to learn, is “honored to be the Commander in Chief” of Indiana’s National Guard. At the conclusion of the forced, wooden speech—a pastiche of talking points and trite adages that met with dutiful but definitely not enthusiastic applause—he declaimed several lines from  “On the Banks of the Wabash.”

The part of the speech that the entire state was waiting for—the Governor’s position on extending state civil rights protections to LGBT Hoosiers—came at the end, and the Governor’s discomfort was palpable.

Pence assured everyone that he had “prayed” about the issue. (Clearly he hadn’t thought about it—but then, nothing in the speech gave evidence of much thought.) He reprised his “Hoosiers are good people who don’t discriminate” mantra and then engaged in a rambling discourse about the importance of religious liberty.

Bottom line: he won’t sign a bill that deprives religious folks of their ability to act on their beliefs everywhere—including at work.

There are two rather obvious responses to that declaration, one legal and one political.

First, the Constitution protects citizens’ right to believe anything. Full stop. It does not, however, protect an untrammeled right to act on the basis of religious doctrine. If my sincerely held religious belief requires me to sacrifice my first-born, or take drugs, or murder abortion doctors, or cheat nonbelievers, the government has the right to step in and say “too far.”

People of good will can disagree about the specific rules that are necessary to a fair and functioning society, but the Constitutions of the United States and Indiana have never been interpreted to privilege socially harmful behaviors simply because those behaviors are religiously motivated.

Second—and here, I admit to more than a bit of shadenfreude—Governor Pence has wedged himself firmly between a political rock and hard place.

The religious extremists who have always been his base will desert him in a heartbeat if he signs any bill that, in their eyes, “legitimizes” LGBT Hoosiers. Meanwhile, polls confirm that a solid majority of Indiana voters support adding “four words and a comma” to the state’s civil rights statute. And given this administration’s other blunders—its unremitting war on public education and  Glenda Ritz, the proposed “news bureau,” the lack of attention to Indiana’s crumbling infrastructure, etcetera etcetera—Pence simply does not have political capital sufficient to weather widespread disapproval of this particular culture war battle.

The wooden and forced delivery of last night’s platitudes suggests that the reality of his position is beginning to dawn on our “Christian soldier” Governor.

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Medicare for All

I’ve been interested to see how frequently the comments to this blog end up discussing (and debating) America’s health care system–even when the ostensible subject of that day’s post is something entirely different.

(As I was typing the phrase “healthcare system,” I was reminded of a graduate student—a hospital administrator—who corrected my use of that term. “America doesn’t have a healhcare system,” he said. “We have a healthcare industry” and it’s not the same thing.)

I often share insights from my cousin, a respected cardiologist who also spent many years teaching medicine. He recently sent me a thoughtful analysis of that healthcare industry, and the prospects for fixing what everyone realizes is unsustainable. I particularly like his introduction to the issue:

When considering the best way to solve our country’s medical care woes, I am reminded of Churchill’s famous statement about democracy as a form of government, in which he stated in effect: It’s a terrible system, but everything else is worse. This same statement might apply to a single payer system in medical care, for it probably beats everything else, as I explain below.

He noted that a truly effective system will require cost controls, including tort reform, the excessively high cost of drugs, inappropriate use of expensive tests and treatments, and several others. He is convinced that these issues can be resolved, and that a single-payer system (for example, “Medicare for All”) is both inevitable and the best solution:

In an article on why a single-payer system would be our best solution, Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and an architect of the Affordable Care Act (ACA), contended that although the ACA has been “a step forward for the country,” it “does not deal with the problem of waste and complexity in the system,” as he feels a single-payer system would. I can personally attest to the complexity of the system with the many headaches provided by a dizzying array of differing insurance forms pertaining to treatments, hospital admissions and a multitude of other issues.

And James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of the forthcoming book Talking About SINGLE PAYER!, argued that a single-payer system is “a more economical way to use healthcare resources. You could reduce expenses and still improve quality. That’s a tremendous opportunity that you don’t have in many other fields.” Of course, as he pointed out, this would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000. (Maybe these same workers could be involved in more productive work such as restoring our nation’s wobbly infrastructure!) But Dr Burdick also maintains that a single payer system would likely restore doctors’ authority. And those who favor this system say that for all practices, administrative costs would plummet because there would be only one set of payment rules and forms, with the result that prior authorizations, narrow networks, and out-of-pocket payments would be eliminated.

He also reports that there is growing physician support for a single-payer system. For example, a 2014 survey of Maine physicians conducted found that nearly 65% of respondents preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey.

Interestingly, a majority of the population (51%) now supports Medicare for all, according to a national poll released this past year.

In reality, a government-run single-payer system is the only way to provide effective basic medical health therapy and management, but for those who desire a higher level of care—and can afford it—there should be a private-pay system, contrast with the Canadian system. This would, de facto, constitute a two-tiered system. This might be objectionable to egalitarians that wish to have a “one size fits all” system, but would be the most pragmatic approach.

Usually those against single payer system trot out the usual vague objections that we are becoming “socialistic.” But what about our current Medicare system, is that not socialistic? I might add further that I personally have worked at a VA hospital, and, despite all the current noise, found that once patients were able to access the system, the care is quite good. Its main problem seems to be gaining initial entry into an overburdened system in a timely manner. By contrast, it is highly unlikely that a random assortment of for-profit HMOs would do a better job serving the high-utilization health needs of our veterans.

His conclusion–with which I concur:

Whether we like it or not, basic healthcare is like a utility—something everyone needs, and, in the best interest of our society, everyone should receive. Although there are many variations of the general theme as I have enumerated above, we are moving inevitably toward a single payer system. When it finally arrives, I believe everyone will be relieved, if not pleased, even including the Republicans!

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Don’t Confuse Me with the Facts!

Just how depressing have America’s policy debates become? What is the extent to which emotion and ideology have replaced reliance on facts, evidence and data–and what are the consequences of our refusal to confront unpleasant realities?

Permit me to offer just two examples.

In Florida, as you have probably heard, state workers are not permitted to use the phrase “climate change.” As the Guardian wryly noted,

You might have missed it, but Florida has solved climate change. Our state, with 1,300 miles of coastline and a mean elevation of 100 feet, did not, however, limit greenhouse emissions. Instead, the state’s Department of Environmental Protection (DEP), under Republican governor Rick Scott, forbade employees from using terms like “climate change,” “global warming” or “sea-level rise”. They’re all gone now. You’re welcome, by the way.

It’s pointless to call linguistic distortions of reality like this Orwellian: people tune you out when you use that word and, besides, Big Brother at least had wit. These are just the foot-stamping insistent lies of intellectual toddlers on the grift. It is “nuh-uh” as public policy. This is an elected official saying, “I put a bag over your head, so that means now I’m invisible” and then going out looting.

It isn’t only Florida; Scott Walker’s Wisconsin has a similar rule.

North Carolina went them one better:

In North Carolina, the legislature passed a ruling after the state’s Coastal Resources Commission released an estimate predicting the sea will rise 39 inches along the state’s coast in a century, ABC News reported.

The estimation alarmed developers and seaside residents. If the state was to take action, it would cost hundreds of millions of dollars, said ABC. North Carolina would need to draw new flood zones, build waste-treatment plants and elevate roads, and several permits of planned development projects would be in jeopardy.

So the state’s legislature promptly addressed the problem–with a bill banning the actual measurement of sea levels; henceforth, sea-level rise “may be predicted based only on historical data.”

It isn’t only climate change. For a number of years, Congress has banned federal research by the CDC on gun violence–a ban it extended in the immediate aftermath of the Charleston church shooting that left 9 people dead.

The ban began with the 1996 Dickey Amendment, which barred the CDC from involvement in any research that could be interpreted as advocating tougher gun laws. Jack Dickey, a Republican Congressman from Pine Bluff, Arkansas, who was then a junior member of the House Appropriations Committee, authored a rider to a spending bill that also slashed $2.6 million from the CDC’s budget— the precise amount that the organization had dedicated to studying gun violence the year before.

Ever since, CDC studies on guns and public health have been virtually non-existent. Dickey has since expressed regret over sponsoring the measure.

Every single day, 89 Americans die from gun violence, and yet we refuse to support research on the causes, effects and consequences of those deaths.

Representative David Price, vice chair of the House Gun Violence Prevention Task Force, recently argued that

“Regardless of where we stand in the debate over gun violence, we should all be able to agree that this debate should be informed by objective data and robust scientific research.”

Representative Price is wrong. There is nothing that ideologues and interest groups fear more than “objective data and robust scientific research.” Their most fervent hope is that public policy debates continue to be conducted in the absence of evidence. Their motto is: don’t confuse me with science or fact.

Problem is, as Neil DeGrasse Tyson is fond of noting, science is true whether or not you believe in it. Facts exist whether we accept them or not.

Ignoring reality is ultimately unsustainable.

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That Quaint Thing Called “Ethics”…

A recent article in New America Weekly argues that we Americans need to clean up our understanding of corruption. We tend to think of corruption as the sorts of outright bribery encountered in many other countries, where “doing business” has often required greasing the hands of public servants. If no money has changed hands, Americans tend not to see an ethical problem.

The author of the article—a social anthropologist— argues that we need to expand our definition of corruption to include “rigged systems.”

According to Gallup, the notion that corruption is widespread has gained enormous traction in recent years. With results like this, it’s not hard to see why Donald Trump and Bernie Sanders have so much appeal. When so many people see the system as rigged and corruption as endemic, citizens are naturally attracted to outsiders, because they themselves feel like outsiders in a game they were set up to lose.

This state of affairs—with so many people self-defining as outsiders in a democratic society—makes it all the more urgent that we redefine corruption. Because unlike communist and many post-communist countries, where few believe(d) in either the system’s version of itself or its ability to deliver on it, the United States has traditionally been a country of believers—where people largely bought into the promise of their system. That is how it should be in democratic society.

The article lists several examples of systemic corruption—from the banking practices that cratered the economy, to the conflicts of interest of military figures who sit on corporate boards while advising the Pentagon on procurement—and the failure of mechanisms to insure accountability.

We need to understand how corruption manifests itself in America in 2015. We need to ground accountability in the ethics of the broader society. Democratic societies run on trust. A civic society can flourish only when the public believes the system is accountable in a real, not performative, way. Without that trust, perception of corruption will only worsen and the ranks of outsiders will swell.

As I have repeatedly noted, a major contributor to this lack of accountability is the current absence of genuine journalism, especially what we used to call “investigative journalism,” and particularly at the local level.

When local media report only on the “what” (new parking meters, new development projects, new public purchases) and ignore the “who” and “how” (dealmaking, cronyism, procedural shortcuts)—when columnists and reporters dismiss legitimate concerns about the “how” as partisan bickering unworthy of investigation—we fail to hold our elected officials accountable, and we feed the growing distrust that acts like sand in government’s gears.

Rigged systems are complicated, and a lot more difficult to combat than bribery and other, more blatant forms of self-dealing. It’s easy to shrug and conclude that “this is just how things get done.” But the integrity of the democratic system is ultimately far more important —and its absence far more consequential—than individual acts of dishonesty.

Quaint as it may sound, ethics matter. And ethical public behavior requires a culture of ethical accountability. “Trust me” doesn’t cut it.

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The Problem Isn’t Capitalism

‘Tis the season to bemoan crass capitalism. But we should think before joining that chorus.

Markets are wonderful things; as Adam Smith explained many years ago, the “invisible hand” channels self-interest toward socially desirable ends. Market competition has given us better goods at lower prices, and has demonstrably been a “rising tide” lifting many boats.

Why, then, is America’s capitalist economy generating so much criticism? What is the cause of the country’s growing and very worrisome inequality?

Two reasons are pretty apparent.

First, the system we currently have in the U.S. is not market capitalism. It is corporatism. Corporatism has been defined as the organization of society by major interest groups, specifically corporations. It isn’t exactly a secret that the last thing many of our captains of industry want is genuine competition. The legions of lobbyists sent to Washington and state capitals are not arguing for open markets; they are vying for competitive advantages and taxpayer subsidies.

The second reason is less obvious, but no less consequential. Markets don’t work for everything.

In the areas of the economy where market competition is appropriate—in the production of consumer goods and services, most obviously—markets operate as Smith’s theory suggests. But as every student of economics learns, there are areas where competition is unworkable.

Historically, for example, America has regulated utilities, and (at least since Teddy Roosevelt) tried to prevent domination of a market through monopolistic practices. (As technologies and markets change over time, these categories may shift, and it isn’t always clear that our governing institutions keep pace, but that is a subject for another day.)

What doesn’t change, however, is a foundational premise: In order for a market to function, there must be a willing buyer and a willing seller, both of whom are in possession of the necessary relevant information. When there is a significant and unavoidable asymmetry of knowledge or information, a true market cannot exist.

Health care is the poster child for that asymmetry. Not only does the consumer lack the information and expertise necessary to “shop” for a seller/provider, the realities of illness make it likely that she will lack the time needed to evaluate her options. Add to that the way in which the health insurance industry has developed, with “in network” and “out of network” providers, and you don’t have to be an economist to recognize that market principles are simply inapplicable.

Most Western nations came to that conclusion many years ago, and most have national health care systems. Here in the U.S., even the modest movement toward government-insured access to health insurance has met with hysterical resistance—and lots of rhetoric about creeping socialism and the superiority of markets.

The immorality of this refusal to make important distinctions was most recently highlighted by the actions of one Martin Shkreli, who bought the rights to a drug and raised its price 5500%. As several commentators noted, America is the only developed nation that lets drug-makers set their own prices — maximizing profits the same way that sellers of chairs, mugs, shoes, or any other seller of manufactured goods would.

Shkreli’s behavior underscores the irrationality—and yes, the immorality—of America’s healthcare system, where corporations set our public policies and insist upon market principles in an area where, by definition, genuine markets cannot function.

The moral of this story: don’t blame capitalism. This isn’t it.

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