An ACA Reform in the Details

If we look at the cost of medical care (rather than the cost of insurance, which affects about 1/7 of the bill the patient pays) we can identify several huge problems, and we have done so here many times.

To recap: we have identified non-exigent care for the poor in ERs, fee-for-service rather than for results, end-of-life care, nursing home care, shortage of providers, malpractice (both the huge cost of bad medicine and the lesser but real cost of defensive medicine), the monopoly pricing of “new” pharmaceuticals in the USA and the closing of foreign markets to us,  and the failure to integrate and computerize record keeping, thus requiring the patient to reinvent her history from time-to-time with every provider.  Forgive me if I left out a biggie.

While ACA is primarily an insurance “reform”, it contained some provisions that were pilots aimed at some of these fundamental medical costs.  Here is a report on one aimed at moving to fee-for-results, and also reducing actual malpractices, and what it looks like.  It is a hopeful report.

 Why Health Care Will Not be the Same

Youth Sentencing

Should the juvenile offender, charged as an adult, be susceptible to life without parole sentencing?  Two cases were before the Court.  Read Lyle Denniston’s review and you will see that the various Justices likely raised every argument you would have raised, among you, among them.

Argument recap: Compromise on youth sentences?

A paragraph to chew upon if you do not read the link:

In the cases of Miller v. Alabama (10-9646) and Jackson v. Hobbs (10-9647), most of the Justices appeared to share the sentiment expressed early by Justice Anthony M. Kennedy that the Court did not want to be forced to choose between two opposite choices: no life-without-parole sentences for any minor, or no limit on the sentence for anyone no matter how young.  And there also seemed to be considerable support for Kennedy’s apparent willingness to focus mainly on the question of whether such a sentence should be mandatory and, if so, whether that should be keyed to a specific age.   Kennedy’s views may be crucial, since he has been the author of the Court’s key rulings on youths’ sentencing.

I am willing to accept that the concept of what constitutes “cruel and unusual” punishment changes over time based on neuroscience.  For an originalist, “cruel and unusual” does not change over time and this case presents no difficulties.  For me it presents difficulties.  However, I am a bit calloused in these particular cases.  In short, once we choose to prosecute a youth as an adult, we place him in the penitentiary system for the term of his sentence.  We do not place him in a home where he is wanted, or in a juvenile justice facility with serious pretensions for education, training, and reconstruction of a life.  In short, once we choose to treat them as adults, I think the die is cast.  I think they are less likely to reform than adult first time offenders, given the reality of the penitentiary as a high school, a college, and a career.  So for me, while the world could be a better and more forgiving place, in our everyday reality, it is not.

I would be more inclined to say that treating any juvenile as an adult offender before the age of 16 is cruel and unusual than I would be to say the life sentence without parole is cruel and unusual.  These are my own musings, not those of any of the Justices, according to Denniston.

 

 

Sunday Morning Open Thread

Did you turn your clock forward?

Before conference tournament play began these were your top 12:

1 Kentucky (31) 30-1 775
2 Syracuse 30-1 744
3 Kansas 26-5 703
4 North Carolina 27-4 690
5 Missouri 27-4 620
6 Duke 26-5 604
7 Ohio State 25-6 568
8 Michigan State 24-7 540
9 Marquette 25-6 537
10 Murray State 30-1 526
11 Baylor 25-6 422
12 Wisconsin 23-8 417

So far, KY, agreed to be the best team in the nation, barely squeaked out a win in the SEC semifinal, Syracuse, Kansas, Duke and Marquette did not make it to their conference finals, and MO and Baylor exceeded expectations.  The remaining teams have performed as expected – the Big 10 final result will not be an upset; however, if UNC loses in the ACC final, or if KY loses in the SEC final, that will be a surprise.  There is no qualitative difference worth mentioning between being a one seed or a two seed in the NCAA Tournament – if form follows, you get easy sledding for the first two games.  Everybody then is on even ground in the Sweet 16, because we have just seen that top 16 teams can all beat each other on a given night.

Match-ups matter.  Baylor is big and fast, but has defensive lapses that a team consistent in spreading the court with good three point shooters and good passing to take advantage of spacing will exploit.  Baylor cannot beat a Missouri or a Duke.  Syracuse can beat anyone if they are shooting well.  But they have the most trouble with a Missouri or a Duke, too, because they play zone.  KY, UNC, and Kansas all play like NBA teams, although not quite as talented.  Ohio St. is almost in that crowd with KY, UNC, and Kansas.  Michigan State is a testament to the best coach in America, Izzo, who has good but not great talent and makes them tournament tough by the end of the year.

On another note, about human capital:  http://www.nytimes.com/2012/03/11/opinion/sunday/friedman-pass-the-books-hold-the-oil.html?src=me&ref=general

My sis was graduated from Mich. St., PhD from UNC.  Good luck to UNC and Mich. St. today!

Addendum: KY and UNC lost their conference finals.  UNC benched one of its stars as a health precaution.  Both teams are probably still “ones”.  The Big Ten gives us its two premiere teams in the conference final, next.

SAVE CATO

A few of you are strong economic libertarians.  A few of you are strong social libertarians.  I maintain many libertarian positions as do most of the rest of us here, and I have always found Cato’s web page worth the read.  I think all of us should read this:

http://www.cato.org/SaveCato/

and this:

http://volokh.com/2012/03/09/koch-v-cato-skip-olivas-observations/

Some of us will also find this worthy as background material, because it centers on the kind of important philosophical matters Cato raises that could indeed be silenced:

http://baselinescenario.com/2012/03/08/the-koch-brothers-the-cato-institute-and-why-nations-fail/#more-9955

Partisan Democrats may think Cato is already a tool of Republicans, so I would not bother to recommend these articles at PL.   I think that any of you here from “left” to “right” who have ever gone to Volokh or to Libertarianism 101 recognize the difference.  When we argue policy, we may line up with the “platform” of one party far more than another, but political parties live first for self perpetuation by getting elected, which means raising money and votes, not to have true discussions of why policies make sense from a philosophical perspective.  We have some well established strains of political philosophy.  Libertarianism is one of them.  I want Cato to survive.

Syria – from Stratfor

 

Syria: What Prevents U.S. Military Involvement

March 7, 2012

 

 

Summary

 

The United States is not eager to launch an air campaign against the Syrian regime that would be similar to the NATO campaign in Libya even though numerous U.S. lawmakers have called for such a campaign. Not only did Libya not have the formidable air defense systems that Russia has provided to Syria, but Syria’s rebels have not been able to control large areas of territory. These factors would complicate any air campaign against the al Assad regime, but Washington’s reluctance to get involved militarily is based on the fear that it could slip into a much messier conflict than it did in Libya.

 

Analysis

 

Amid increasing calls from some U.S. lawmakers for an air campaign against the Syrian regime, the U.S. administration appears to be making a concerted effort to explain to the public why this is not a preferred course of action. Beyond the significant regional implications of such an action, Washington does not want to get involved in a conflict with Syria that likely would pose credible threats to U.S. air forces and risk involving ground forces as well.

 

The Rationale in Washington

 

When U.S. Central Command chief Gen. James Mattis briefed the U.S. Senate Armed Services Committee on Syria on March 6, his overarching message was that any military action in the country would not be easy. Mattis noted that the lack of any safe zones in Syria would mean deploying a significant number of ground troops to create such zones and warned that the United States believes the Syrian government possesses chemical and biological weapons. When asked about the possibility of imposing a no-fly zone in Syria, as NATO forces did in Libya, Mattis warned of the potential dangers posed by the advanced air defense systems Syria has received from Russia.

 

Mattis’ remarks were a subtle rebuttal to calls made in recent days by Sen. John McCain, one of the committee leaders, to launch airstrikes in Syria. On the same day as Mattis’ briefing, Foreign Policy published an article citing two anonymous Obama administration officials discussing what the White House is planning for the next phase in the Syrian conflict. One official referred to the same danger posed by Russian-supplied air defense systems, adding that a recent Russian shipment to Syria contained large amounts of advanced anti-aircraft missile systems, presumably intended to defend Syria should the conflict become international.

 

Washington seeks to dampen the expectation that it intends to do in Syria what it did in Libya. An air campaign is not on the horizon, and the United States is also hesitant to publicize any of its attempts to arm the opposition, though remarks from the officials cited by Foreign Policy seem to indicate that Washington is giving other countries (likely Saudi Arabia and Qatar) approval to do so. Public discussions of arming the opposition forces are, however, more for public relations to show that something is being done to assist an opposition under siege. If the United States were actively engaged in such activities, it would manage the operation covertly.

 

Syria’s Defenses Compared To Libya’s

 

The United States has a strategic interest in seeing the fall of the al Assad regime because of the effect it would have on Iran’s influence in the Levant. Aside from levying sanctions and a public acquiescence to other countries sending in weapons, Washington does not appear to be publicly doing much to hasten al Assad’s downfall. The United States is wary of entering the fray due to its fears that it would get dragged into a much messier conflict than those calling for an air campaign are anticipating. Pointing to the potential dangers posed by Syria’s air defense network is one way of discouraging calls for military intervention.

 

This is not to say that the Syrian Air Defense Command (ADC) is not formidable, especially in comparison to what NATO forces went up against in Libya. With an estimated 54,000 personnel, it is twice the size of former Libyan leader Moammar Gadhafi’s air force and air defense command combined at the start of the NATO campaign. Syria’s ADC consists of the 24th and 26th anti-aircraft divisions comprising thousands of anti-aircraft guns and more than 130 surface-to-air missile (SAM) batteries. The bulk of Syria’s ADC SAM weaponry is the SA-2, SA-3, SA-5, SA-6, and SA-8 SAM systems that were also operated by Gadhafi’s forces. However, the Syrians operate these systems in far greater numbers, have devoted significant resources to the maintenance and upgrade of these missile batteries and have also successfully deployed their SAM systems in a dense and overlapping layout that would complicate potential Suppression of Enemy Air Defenses operations.

 

Though also a Russian ally, Gadhafi did not have the more advanced Russian air defense systems that the al Assad regime possesses. For instance, Iran reportedly financed Syria’s acquisition of 50 SA-22 systems first delivered in 2007 — 10 of which allegedly ended up in Iranian hands. The Syrians are also thought to operate several SA-11 systems, which the Libyans did not have. Furthermore, reports emerged in November 2011 that the Russians upgraded numerous Syrian radar sites and transferred a number of advanced S-300 systems to Syria and that a Russian naval mission to Syria that month also served to transport several Russian missile technicians who were to assist the Syrians in operating the S-300s.

 

Syria’s defenses against an air campaign are not restricted to the ground. Its air force can contribute dozens of fighter aircraft and interceptors, the most advanced of which are the MiG-25 and MiG-29. But while the Syrian air force is both quantitatively and qualitatively superior to Gadhafi’s air force, which was just starting to re-equip and modernize itself after years of sanctions, it has neither played a meaningful role in managing the unrest in the country nor would it play a meaningful role in defending the country from an air campaign.

 

Perhaps the biggest difference between Libya and Syria is that the Syrian rebels have not yet been able to hold significant territory. This matters not just for their ability to have safe areas from which to launch attacks, but also for the air defense network’s ability to function properly. Air defense systems typically are designed to provide cover through overlapping areas of coverage. When eastern Libya fell into rebel hands early on during the revolution, that overlap was severely damaged, which in turn degraded the Gadhafi regime’s overall air defense network. The Syrians are not facing this difficulty.

 

A Feb. 28 CNN report said that the Pentagon had drawn up detailed plans for military action against the Syrian regime. The U.S. military indeed has updated its order of battle (orbat) for Syria in preparation for any contingency operations, and this work allegedly produced the best orbat the United States has had on Syria since 2001. However, contingency plans exist for numerous countries with which war is unlikely. The situation in Syria — whether through the loss of territory, massive defections from the regime or the loss of Russian support — will have to change before Washington implements any of the plans it has prepared.

 

 


RIGHTS

The word “rights” has been used to describe both liberties and claims against others (including “entitlements”). We rebelled against a monarchy that made broad claims of entitlement for itself, and we had run away from established churches that made claims of entitlement for themselves. We understood the limits of government to require the establishment of liberties, and not entitlements, as a natural result of our seminal experience(s).

 
We have attempted to expand liberties and encroach on entitlements by increments, notably including the freeing of the slaves and the expansion of the voting franchise.

 
We have also created entitlements, most notably SS and Medicare. To the extent these were modeled on insurance schemes, they were either intended to, or disguised to appear to, create common quid pro quo legal claims. Common quid pro quo legal claims are often spoken of as “rights”, as well. When I provide you a legal service that you requested, typically I am “entitled” to be paid for it. Thus we have words with mixed usages and should be careful in this conversation to be clear.

 
I concede that a society could adopt a quid pro quo entitlement in which all were charged for a service through a tax and all were entitled to receive it upon reasonable demand.  We have certainly done so in our nation’s history and I think we would find that all free countries have done so in modern times.

 
At this point in my monologue I pause to say that while I understand and can accept “entitlements” of various sorts, I do not place these on the same plane as liberties. I consider entitlements and claims to be less worthy than liberties, although we often permit entitlements to trump liberties. Life, liberty, and property can actually be taken by the state – with due process. The fact that Congress is “entitled” to tax, and the understanding that a government can levy taxes as an inherent power, limits our property rights. That Congress is “entitled” to call us to serve in time of war or national emergency limits our liberty rights. Examples abound.

 
Phrased in the rough manner that I have laid out, “liberties” and “entitlements” are always bound to be in conflict. I accept more in the way of “entitlements” than QB would and I may claim more in the way of “liberties” than he would, based on my reading of QB over time. But I would be just as adamant as he on the general proposition that “liberty” is the higher form of “right”, and while I am comfortable with calling many statutory claims “entitlements”, and many legal claims “claims of right”, I personally have reserved the word “rights” to describe our claims as citizens of a free state to life, liberty, and property.  Recognizing that these rights are bounded and that we can choose to limit them in other ways by creating entitlements is linguistically clearer to me than trying to equate entitlements with liberties.

 

I believe the UN Declaration cited by Yjkt incorporates aspirations for a post WW2 world in ruins.  It is an attempt to invoke the myth of Phoenix rising from the ashes.  As such, it is beautiful.  There is no form of government possible that could deliver on that entire Declaration because of the internal conflicts, and because of the fact of scarcity.  It is better to preserve the liberty rights while attempting whatever limited aspirations we can afford, in the world of limited resources.  Or so Mark opines.

 

I anticipate some here may argue that there are entitlements that are as important as liberty interests, and that some may argue that liberty interests must trump aspirations at every turn.  That debate would be more productive than trying to call everything we might want a “right”.

Sequestering CO2 to get more Oil!

This could be cool.  Clean coal, more oil.

Of course, the coal is filthy, but NRG in TX has a plan to pump the CO2 deep into an old abandoned oil field in S. Texas.  Pump it deep enough, the theory goes, and it won’t come back into the atmosphere.  Here, the greenhouse gas, pumped into the oil bearing formation, will force the remaining oil out of the rock, making it recoverable.

The story also presents the critics, of course – but I thought I would post a “good news” story to begin the week.

And here’s the written story:

http://stateimpact.npr.org/texas/2012/02/21/how-biggest-power-plant-in-texas-will-use-pollution-to-pump-oil/

The two best “Funny Valentines”

IIRC, this song first became popular when the great, then young, west coast jazz trumpeter, Chet Baker, sang it.

A couple of years later, it was made popular again when Ella sang it on the Rodgers and Hart Songbook.

Still later in the 50s, Frank Sinatra sang it.  But for reasons that are part of a funny story I will tell here someday, I do not play Sinatra.

Sting butchered it in a live concert.

Chet Baker and Gerry Mulligan, along with Brubeck and Desmond, defined west coast “cool” jazz.  When we were in high school, we really loved that stuff.  Baker did not often sing, but until he died in the 80s, whenever he played he would be asked to sing this.  Like any jazz guy, he never sang it the same way twice.  This first rendition was my favorite, and the one that put the song on the map as a “standard”.

And Ella was Ella.  I met her once.  I was 14.  She was gracious, as if it mattered to her that I knew who she was.  She was with the blind singer, Al Hibbler, at the time, and although I did not recognize him, when she introduced us, I knew who he was – he had made a hit of “Unchained Melody”.  I fumbled in embarrassment, but Ella made it AOK.

Happy Valentine’s Day, all.

NOT ENOUGH MDs

We here have been educated to understand the supply problem in American health care, thanks to NoVAH, Mike, and Michigoose, although many, if not all, of us understood the general outlines of this basic issue before we got here. This morning we read this:

http://www.washingtonpost.com/blogs/ezra-klein/post/the-health-reform-laws-biggest-threat-30000-too-few-doctors/2012/02/10/gIQALEQp4Q_blog.html?wpisrc=nl_wonk

What I did not know, until I read this article, is that Medicare covers the lion’s share of the cost of training medical residents.  Further, in order to make ACA’s package politically marketable, in the negotiations, there was no increase in the funding for residents.  Thus ACA built into itself the seeds of its own failure, and this is what NoVAH has been saying to us, although I don’t recall his having pointed to the failure to increase funding for residents.

When I read ACA in detail for my clients, I looked at it from the POV of the effect on small biz, which I decided was actually nil, for my clients.  A myopic view, I admit, but it fit my assignment.  A shortfall of 30000 new doctors in a near time frame will greatly increase health care costs above what they would have been if 30000 new docs had been trained.

The political compass

The political compass attempts to isolate two different axes of thought.  One ranges from “radical” to “reactionary” and one from “libertarian” to “authoritarian”.  The questions allow for shaded answers rather than “yes” or “no”.  I have found the website.

http://www.politicalcompass.org/

Here is the test.

http://www.politicalcompass.org/test

 

As I said, I was 3/10 libertarian and exactly on the midline between “rad” and “reac”.  My 100% R voting friend, no ticket splitter he, was 2/10 libertarian and 1/10 reactionary.  We were too close to even shake a stick at, but I am an inveterate ticket splitter.  So I think it’s more fun and less demeaning than a pigeonholed test that puts the enlightened at one end [lib, if a liberal wrote it, conservative, if a conservative wrote it].  If any of you take it, I don’t care how you score, but I would like to know afterward if you think it was relatively fair and/or relatively surprising to you.  In my case, my old friend and I were surprised we were so close.  But on reflection, we noted that we had been friends for 50 years at the time and always were able to pick up where we left off.  So maybe not so surprising.