Public Policy and Governance – Page 321

Masson’s Home Run

I always read Masson’s Blog, and always find him insightful, but this morning’s post on the mis-named “Right to Work” proposal is an absolute home run.

In an era that elevates spin over accuracy, naming/framing all too often substitutes for describing. “Right to Work” is a wonderful example–who could be opposed to people’s right to work? It is phrasing that feeds into the American belief in individual rights. And as Doug Masson explains, it is a phrase that has very little relationship to the reality of the legislation.

As Masson writes,

The perniciously named “right to work” is a misnomer. What the law really does is use government authority to prohibit a certain kind of contract. As it stands now, employers and employees have the freedom to enter into a contract whereby one of the conditions of employment is that employees join a union or, at least, pay some equivalent of union dues so they are not tempted to be free riders, receiving union benefits without paying for them. So, it’s a contractual provision that is currently permitted but not required. “Right to work” is a limitation on this freedom to contract. The General Assembly tells employers that they are not permitted to make union membership a condition of employment.

This is typically dressed up as championing the rights of future employees who might not want to join a union as a condition of employment; but the oddity is that typically the advocates of this restriction on contracts are, in other contexts, champions of absolute freedom to contract and could rarely care less what a potential employee thinks about the conditions of employment set by an employer. (Don’t like that condition of employment? Fine, go work somewhere else.) But, when union membership comes up, horrors! Conditions that are pro-union or anti-gun are off the table, but pretty much anything else goes.”

Home run!

This post should be distributed far and wide.

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This is Not a Bill

I’ve been following the Sunday series in the New York Times in which Ezekiel Emanuel—vice-provost and Professor of Medical Ethics at the University of Pennsylvania, and former White House advisor—has been explaining high healthcare costs.

I particularly appreciated this week’s discussion, “Billions Wasted on Billing.” My husband and I are at the age when doctor’s visits become more frequent, and I have weekly opportunities to open envelopes to read incomprehensible jumbles of medical and financial jargon under the heading “this is not a bill.” Anyone having experience with mailings of any sort—bills, invoices, reminders—knows that it is impossible to generate and mail anything for less than $5-$7 dollars, once you account for clerical time, stationery and postage. I’ve never understood why the same not-so-informative information can’t be included when the actual bill is sent.

Emanuel’s column was not just about billing, but about all the other repetitive, duplicative paperwork that characterizes our current health care system. How many times do we fill out patient forms with the identical information? How many insurance claims must be completed in different formats by all those white-haired ladies in colorful smocks sitting behind the glass partitions in your doctor’s office?

What does all this cost, and how much of it is really necessary?

According to Harvard economist David Cutler, electronic billing and credentialing could save the system upwards of 32 billion dollars a year. Transitioning to electronic record-keeping would pay other dividends as well: it would allow medical providers to use existing anti-fraud detection methods currently used by credit card companies, and it would minimize the errors that are inevitable when data is manually entered. (No longer getting “this is not a bill” mailings would also have a salutary effect on my blood pressure.)

What Emanuel’s column did not address is the question why medical insurers and providers have been so slow to adapt to the electronic age. I think a part of the answer is the complexity of what passes for a medical system in the U.S.—a complexity that also bedevils efforts to conduct reasonable policy discussions about health care in general.

We’ve all joked about the senior citizen at the Town Hall meeting who shouted “keep government’s hands off my Medicare.” It’s true that most Americans do know Medicare and Medicaid are government programs. We know that taxpayers fund the (much-lauded) Veteran’s Administration. But how many of us understand the extent to which government currently funds pharmaceutical and medical research? Or how much state governments contribute to the cost of medical education? To public health programs? How many of us know what local government units spend for everything from ambulance service to charity care?

I like to think of myself as informed, but I certainly don’t know the answers to those questions. I was astounded a few years ago when, serving on an academic committee dominated by healthcare professionals, I learned that government at all levels currently funds between 60% and 70% of all healthcare costs.

The real question isn’t whether we should have a government system or a private one. We haven’t had a private, market-driven system for decades, and for good reason. Markets require a willing buyer and willing seller, each of whom has the necessary relevant information and the ability to exercise choice. The real question is how to identify the measures that will reduce healthcare costs and improve patient care and access. Right now, we pay 2 ½ times what the next most expensive country pays for a system that ranks 36^th in the world.

That’s a bill we shouldn’t have to pay.

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The Good Old Days

I have officially become one of those cranky old people who bemoan the passage of the “good old days.” Which is sad, since the good old days weren’t all that good.

Most of all, I miss the Republican Party I was a part of–a party that didn’t have an embarrassing slate of kooks for Presidential candidates, a party that had a platform rather than a religiously-held extremist ideology. It was genuinely pro-business, pro-family and pro-good-government.

How times–and definitions–have changed!

In Congress, the GOP has again defeated President Obama’s proposal to create jobs by repairing America’s deteriorating infrastructure. The party I used to belong to would have sponsored such a measure. Indiana’s two Senators participated in the Senate filibuster–something I would have expected of Dan Coats, but that constitutes one more shameful effort by Dick Lugar to ingratiate himself with the crazies who detest him for the sin of previously being thoughtful. But the GOP did offer an alternative to the President’s bill–they reaffirmed that America’s national motto is “In God We Trust.” Not that anyone had suggested otherwise.

A pro-business party understands that economic prosperity depends upon the creation of jobs that allow people to purchase goods from businesses. Whether they trust God or not, most businesses depend upon a well-maintained infrastructure, and a calm social order. Republicans used to understand that.

They also used to understand that responsible economic policies were the best way to be “pro family.” Today, we have the embarrassing spectacle of Rep. Joe Walsh, first-term Tea Partier, getting a “Pro Family” award from the Family Research Council, despite the fact that he owes over 100,000 in back child support for his own children. But he was “pro family” because he voted to repeal healthcare, defund Planned Parenthood and uphold DOMA. Words fail.

Good government? When I was in City Hall, in a Republican Administration, the party put a premium on professionalism and careful analysis. The people I worked with would never have been guilty of the gross incompetence that led to the Litebox blunder. They would never have relinquished control of the city’s parking infrastructure for 50 years, in order to enrich a well-connected vendor at taxpayer expense. (And the Mayor I worked for–who really wasn’t a “politician”- would never have stooped to accusing an opponent of responsibility for an increase in rapes that occurred during the time she served as Deputy Mayor for Economic Development.)

There was plenty wrong when I was politically active. The administration I served was far from perfect, and Republican politicians weren’t saints. But next to what we have today, they sure look good. I miss them–and America desperately needs them back.

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A Step in the Right Direction

The Supreme Court’s decision in Citizens United should have been a wake-up call for those of us who have been concerned over the growing power of corporate America. Corporations have their place–by shielding entrepreneurs from personal liability, they encourage risk-taking and innovation; I have no problem with the corporate form as a useful business mechanism. (Although I do find it ironic that the growth in corporate hegemony tends to be applauded by people who talk a lot about the need for poor people to exercise “personal responsibility.” Corporations were invented to allow people to escape personal responsibility.)

The problem isn’t with the existence of corporate entities, the problem is with confusing these artificial constructs with human beings, and awarding them rights. There’s a reason we call our individual liberties “human rights.” When the Supreme Court essentially ruled that corporations and labor unions could give unlimited amounts to political candidates and causes, and justified that ruling as “free speech,” most observers–certainly this one–considered the decision both ill-considered and extremely dangerous. When the Senate refused to pass a measure requiring disclosure of such contributions, the floodgates seemed permanently open. We are going to see unprecedented sums spent by the 1% to influence the 2012 elections, and distort the electoral process.

The influence of money on our government has been well documented, and the picture isn’t pretty, but I was heartened to see President Obama taking at least a small step toward limiting the wholesale purchase of policy.

It has been reported that the President is drafting an executive order that would require companies pursuing federal contracts to disclose political contributions that have been secret under the Citizen’s United ruling. Despite howls from the usual suspects, this is a modest “good government” measure that does not violate anyone’s free speech rights. If a company wants to do business with government, and receive payment from our tax dollars, we the people have a right to know whether that business has been contributing to lawmakers and/or government officials who will influence those contracting decisions.

It’s not enough–we need to reign in the increasingly common use of obscene amounts of corporate money to gain political advantage. But it’s a start.

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The Free Rider Problem

Yesterday I received my copy of PA Times–a publication that is admittedly unlikely to be on the bookshelves of those who read this blog. It’s issued by the Association for Public Administration, and it has articles that appeal primarily to geeks like me who study how governments work.

The article that caught my attention–and raised my ire–was all about “crowd-funding” government.

Crowd-funding, like crowd-sourcing, is a phenomenon of the internet. People wanting to raise funds for new businesses, or for charitable efforts, use the web to solicit many small investors or donors, rather than attempting to raise capital from banks (many would not be “bankable”) or large amounts from big donors. That’s creative, and I applaud the entrepreneurs and nonprofit organizations that are using that new tool.

But now, according to the article, the same approach is being taken by cash-strapped units of government to raise money for public projects. And I have a big problem with that.

Let me make one thing clear: I do not oppose efforts to trim government spending by revisiting what government does. Although citizens would passionately disagree over the propriety of having this or that task done by government, that is a discussion we should be having. (I would vote to discontinue the drug war in its current form, for example. Others might argue that local government ought not provide golf courses, or other recreational services.)

Once government at any level assumes responsibility for providing a service that benefits all its constituents, however, all of us need to pay our share to support those services. And let’s be honest about what constitutes “benefit.” My children aren’t in the public school system any more, but I benefit in numerous ways from living in a community where people are educated. I also share the disadvantages of a school system that is below par. A good school system adds value to my property, it helps my community attract good jobs, etc.

A government agency that inspects the chicken before my local Kroger can sell it, another that monitors air and water quality and yet another that keeps merchants from peddling unsafe devices all benefit me. I benefit from paved streets and traffic signals, from parks I can walk in, from zoning laws that keep someone from building a strip bar in my neighborhood…Well, you get the picture.

If these government functions are financed by contributions, rather than taxes, we have the classic “free rider” problem. The people who are unwilling to pay their fair share benefit equally with those who do pay. This is the dirty little secret that the rabidly anti-tax folks want to ignore.

In a sane world, citizens would decide by majority vote just what services government ought to provide. Then they would fund those services through a system of fair taxation. We can and should debate just what role government must play in our communities, and we can and should have robust arguments about the sort of tax system that is fair and equitable. We can and should demand efficient and businesslike management of our government agencies.

But when we reorder our common institutions to satisfy the selfish, when we burden those who care about their neighbors and neighborhoods in order that others can enjoy the benefits of government without bearing their fair share of the costs, we’ve truly lost any sense of what it means to build communities.

I don’t know about anyone else, but the last thing I want on my tombstone is the epitaph “free rider.”

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