The Brass Tack

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Archive for August, 2009

Yes, we need to bring down health costs

Posted by srconstantin on August 5, 2009

There are those, like Kevin Drum, who think this compromise Senate health bill isn’t so bad after all. The point, says Ezra Klein, is that that at least it’s covering more uninsured people, even though there’s no public option. “What has kept health-care reform at the forefront of liberal politics for decades is moral outrage that 47 million of our friends and neighbors are uninsured. ”

Matt says something similar, that “On paper, and pretty much in reality, it will achieve universal coverage,” but “Besides IMAC, there won’t be any good price control or delivery reforms” and that it will still be the “greatest domestic policy accomplishment since the Johnson administration.”

I’m with Matt on his predictions, but I disagree with all of them on their positivity. After all, the moral case for health reform isn’t outrage that citizens aren’t insured on paper, but outrage that citizens can’t get medical care except at the emergency room. I don’t believe that poverty or pre-existing illness should, in the richest country in the world, bar so many people from getting medical treatment. But if we want to change that, we don’t just have to make sure everyone’s insured on paper, we have to make sure everyone gets adequate medical treatment. And for that, we’ll have to bring down prices, or health care will still be “rationed” in another way (if not by high insurance premiums, then by long waiting times.) Or, as Tyler Cowen says,if we don’t solve the costs problem, in egalitarian terms things will only get worse, no matter how many people we cover.

The cost-saving measures were my favorite part of the plan. Things like changing how doctors are paid to reduce unnecessary procedures; making unified electronic health records to reduce billing costs and duplications; and the public option itself, which probably would create some competition and lower insurance costs (though it’s better understood as undercutting insurance prices and thus being a public subsidy for health care.) I actually talked to someone the other day whose job is improving electronic health records with cloud computing; your internist would have a record of all the other specialists you see, and it would be possible to simultaneously pull data from all the doctors associated with one person, reducing duplication and the kinds of problems that arise when prescription medicines don’t go well with each other. If you reduce the cost of health care (and there’s a lot of fat in the system to reduce, since more spending often doesn’t correlate, state-to-state or country-to-country, with better health) then more people can get decent health care. If you don’t, then we might just have shortages (of things like supplies and family physicians).

Maybe Matt’s point is valid as a political one. If we can just change health care from a private good to a public one — if people can become as comfortable with publicly subsidized health care for all as they are with the idea of public schools — it will be a major political victory. But if costs keep rising as they are, the health plan as it sits now may wind up insolvent or toothless.

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GatesGate Too Late

Posted by srconstantin on August 5, 2009

I’m behind the news cycle — way behind. Partly because I like to give my thoughts time to simmer, and partly because I’m an amateur and I blog on my own schedule.

I’m a learner, not a ranter, when it comes to race, so I’ll leave racial thoughts about Henry Louis Gates’ recent arrest to people who are better at making them. Instead, I have two points that aren’t race-related.

First, whether or not it was a racial-profiling issue, it was certainly a police power issue. This is why, long after the fact and after mulling it over, I still disagree with Dan Strauss, who sympathizes with the “black response” that Gates was being an idiot by arguing with the police officer. My mom told me to be careful around policemen too (though perhaps not with the same force that a black mom would). But I’m not Gates’ mom, or his best friend, to give him personal advice. The role of a blogger or journalist is to comment on the political significance of what happened. And the political significance is that Gates was arrested on a charge meant to prevent people from inciting riots, which he evidently was not; that policemen are legally obligated to give their badge numbers upon request in his state; that verbally protesting arrest or alleging racial profiling is Constitutionally protected speech; that he was arrested though he did not commit a crime, as many, many Americans regularly are. Radley Balko is entirely right.

Perhaps on an individual level, this is sound advice. As a general rule, you ought not provoke someone carrying a gun, whether your criticism is justified or not. As a broader sentiment, however, it shows a dangerous level of deference to the government agents in whom we entrust a massive amount of power. And it comes awfully close to writing a blank check for police misconduct.

And he puts the dangers of police misconduct in context:

A week before the Gates incident, the NAACP launched a new website where users can upload video, photos, and text accounts of police misconduct from their cell phones. Just days before Gates was arrested, Philadelphia newspapers reported on a local cop who was captured by a convenience store’s security video brutally assaulting a woman who had been in a car accident with his son. He then arrested her and charged her with assaulting him. The officer then demanded the store clerk turn over surveillance video of his attack. The clerk says other officers made subsequent demands to turn over or destroy the video. To his credit, the clerk refused. The video vindicated the woman. The officer has since been suspended.

A major function of an active citizenry is to be aware of this sort of thing. “Don’t mess with cops” is a survival skill, but I hope that in the long run we can do better than just survival in a bad situation.

My second point is that I find it odd that it’s taken so much for granted that when a scandal like this arises, the President of the United States not only comments on it, but sits down with the participants themselves to resolve their dispute. It’s spooky, when you think about it — the president is so inextricably linked with “his” country that if anything is newsworthy, we want to know his opinion, and what he’s going to do about it. No. We are not the Borg, and Barack Obama is not a tan, manly version of Alice Krige.

Happy Birthday, Mister Pwesident.

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Hothouse conservatives

Posted by srconstantin on August 4, 2009

Friend of the blog, classmate, and fearless historian Emily (whose blog comes up as the first Google result for the search term “worthless drivel,” although it assuredly isn’t) has been booted out of the conservative Young America Foundation’s conference, which she intended to live-blog. As she commented:

Mattera explained that the problem was that I’m a Campus Progress intern, and that since I’ve been liveblogging the conference all morning, I wouldn’t be allowed in, since blogging isn’t allowed at YAF’s conference (despite the fact that attendees have been tweeting about the conference all day). I told Mattera that struck me as bizarre, and a little bit like censorship. He suggested that I tell this to my “friends in the White House, and maybe they’ll pass a law to make us let you in.” Mattara is, apparently, unaware of the fact that it is Congress, not the White House that passes laws. […]

Mattera laughed at me, and then replied, “Goodbye—oh wait, here, have an Obama fist bump.” I refused his proffered fist, and he added, “Why don’t you move to Canada?” He seemed to think this suggestion was hilarious.

Liberal conferences, like Campus Progress’s, are generally open to all, regardless of ideology. Apparently, though, the YAF would crumble at the first blog post from Emily’s mighty left-wing pen.

It’s a little thing, but it’s not totally isolated, in my opinion. I’m friends with a number of college conservatives, quite nice in general, but they have an antagonistic attitude towards the “mainstream,” as though they have to carve out sheltered niches to protect themselves from anti-conservative bigotry. They often sound aggrieved. Maybe, to some extent, they are, being a minority both in colleges and in policy/journalism circles, but it’s also partly self-perpetuated. That clubbishness, that us-against-the-world spirit, I think makes it hard for them to communicate (especially with young people) and hard to adapt to changes in society.

Insufficient contact with the less-zealous, internet-surfing youth is what leads to absurdities like the main organization against gay marriage choosing the acronym NOM, which makes most right-thinking people think of adorable hamsters.

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Yes, obesity matters. Freedom matters too.

Posted by srconstantin on August 4, 2009

Megan McArdle, who lately has done a lot of thinking about obesity and society, has a rambling and interesting piece on all things fat-related. I agree vehemently on some points, but not all. Here, she talks about a study showing the detrimental effects of yo-yo dieting on health:

Take this paper on weight cycling, which summarizes much of the literature regarding weight cycling, acknowledging both papers that say it adversely impacts mortality, and papers arguing that those papers suck. The paper says the evidence is equivocal, though it asserts that whatever effect weight cycling has on mortality probably comes because those who diet and regain end up gaining more weight than those who don’t.

To me, that screams “do more research!” But the researchers couldn’t . . . quite . . . bring themselves . . . to suggest that we might want to look into this further before continuing to recommend that people go on highly restrictive diets that they probably won’t stick to.

If 99% of the time the actual result of the course of action you recommend is that people diet, and then regain a bunch of weight, you need to take this into account before issuing further such recommendations. It doesn’t seem like simply proclaiming that they shouldn’t go and gain the weight back again is quite enough.

After all, people who have lost a bunch of weight are presumably aware of how they did it (and if not, they need to talk to an oncologist, not an obesity researcher). They are thus presumably also aware of what will cause them to gain it back. Nor are they usually uninterested in staying thin. They’ve usually worked very, very hard to lose all that weight, and are really quite desperate not to gain it back again. The idea that all that was missing was a doctor telling them that no, seriously, they should really keep that weight off–an incentive obviously far more powerful than, say, the horrific way that America treats fat people–has sailed beyond arrogant into fantasyland.

If I may go on a little nutritional rant, diets usually fail because people usually diet badly. They eat too little (especially protein), they skip meals, and they ruin their metabolisms so they can’t help gaining weight back. Kate Harding notes that in a recent New England Journal of Medicine, most participants on a diet gained weight at the two-year mark despite eating less than they did at the beginning. That sounds like a slowed metabolism to me. And what are these people eating? Let’s see. A 750-calorie deficit from baseline, which is fairly harsh, and nutrient breakdowns of 20% fat, 15% protein, and 65% carbohydrates (low-fat, average-protein); 20% fat, 25% protein, and 55% carbohydrates (low-fat, high-protein); 40% fat, 15% protein, and 45% carbohydrates (high-fat, average-protein); and 40% fat, 25% protein, and 35% carbohydrates (high-fat, high-protein). My idea of a high-protein diet (which is what I eat, though I’m not “dieting”) is 35% protein, 50% fat, 15% carbohydrates; that difference sounds like splitting hairs, but it makes a profound difference in what’s on your plate and how well you feel. And what are the participants doing for exercise? 90 minutes of moderate activity a week. That’s … one game of tennis. So to recap, these people are not eating very much, not eating much protein or fat, and barely exercising; doesn’t sound great. And, anecdotally, I think that’s how most people do diet. The medical establishment could be giving better advice on this.

Megan McArdle makes two points: one, that the rise in obesity is correlated with some things we like, such as women working outside the home (and thus having less time to cook meals or take their kids out to play) and two, there are pesky things like property rights and personal liberty that get in the way of preventing people from eating empty calories. I agree wholeheartedly.

I’m not for a war on obesity, for those reasons. I don’t want to make life difficult for those on tight schedules or budgets by making cheap, convenient food harder to get. And I don’t want, in the style of Michael Pollan, to privilege a time-consuming, virtuous lifestyle of home-cooked meals, where the burden frequently falls on working women. Amanda Marcotte has the feminist angle. (I try to cook for myself, but I do often wind up eating out or buying packaged food. As Amanda knows, a smooth eggplant salad is a rare delight, but you do need a broiler, time to salt and drain the eggplant on a foil-lined cookie sheet, and a good stick blender.)

I am, though, for giving people better opportunities to eat what they really want, and weigh what they really want. More bike lanes. More sidewalks. An end to the HCFS and sugar subsidies. More grocery stores in poor neighborhoods — including Walmart, which, because it has a produce section, causes weight loss when it moves into a neighborhood. If people were as dead set as Megan thinks against losing weight, why would they flock to the fruits and vegetables? The same libertarian reasoning that says we should assume people genuinely want to eat the foods they choose, the reasoning that (rightly) condemns government programs that try to know citizen’s desires better than they do themselves, should also acknowledge that people often eat cleaner when they have the opportunity, and many have an honest preference (not “false consciousness”) to be leaner than they are. Why shouldn’t we remove some of the impediments that make it unnecessarily difficult for people to make their own choices? (Some things that aren’t commonly recognized as “food policy”: anti-development laws meant to keep out “big box” stores that actually keep out cheap vegetables; housing policy that favors owners over renters, and therefore suburbs over cities.)

I’m on the fence about the calorie counts in New York restaurants. On philosophical grounds, they’re not a big deal — no more coercive a regulation than, say, liquor licenses. On a personal level, I’m ambivalent. They do signal “Uh-oh, you have now entered status-crazy Manhattanland.” But it is a convenience to know what’s in what I’m eating.

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From Russia with Love

Posted by srconstantin on August 4, 2009

Two wonderful things of the Russkie variety:

Lydia Kavina (a student of Leon Theremin himself) playing “Claire de Lune” on the theremin.

The full text of Ilf and Petrov’s classic The Twelve Chairs. For the uninitiated, Ilya Ilf and Evgeny Petrov were a pair of humorists, writing together from 1927 to 1937.
As they introduced themselves in their “autobiography”

t is very difficult to write together. It was easier for the
Goncourts, we suppose. After all, they were brothers, while we are not even
related to each other. We are not even of the same age. And even of
different nationalities; while one is a Russian (the enigmatic Russian
soul), the other is a Jew (the enigmatic Jewish soul).

The Twelve Chairs (later made into a fairly awful Mel Brooks movie) is the story of a down-on-his-luck aristocrat trying to recover the jewels that his mother-in-law sewed into a chair before the Revolution, and the irrepressible young con-man Ostap Bender who helps him on his quest. It was a daring book — there’s quite a bit of ribbing at the expense of the Communists — and the humor holds up through eighty years and a rather old English translation. Not only humor, but sweetness; in the sense that, no matter what happens, people will keep on complaining, eating, drinking, falling in love, and ridiculing the pompous.

The Little Golden Calf is also supposed to be good, and maybe I’ll read that next if I can find it. Skip Ilf and Petrov’s American Road Trip. It’s a Pravda project, and reads like one: stilted and pedantic. The power to make a writer not funny anymore — that’s a sad thought.

(Link thanks to mute.

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Penguin impersonators, or why you’ll never convince a gay marriage opponent

Posted by srconstantin on August 4, 2009

Contra Brad DeLong, I do think it’s uncontroversial that Robert George is very, very smart. He’s also wrong. But he makes intellectually honest and consistent arguments and knows far more philosophy than I do. (That’s what makes him satisfying to dispute; there’s actually an edifice to try to knock down.)

Here he is on gay marriage:

The definition of marriage was not at stake in Loving. Everyone agreed that interracial marriages were marriages. Racists just wanted to ban them as part of the evil regime of white supremacy that the equal protection clause was designed to destroy.

Opponents of racist laws in Loving did not question the idea, deeply embodied in our law and its shaping philosophical tradition, of marriage as a union that takes its distinctive character from being founded, unlike other friendships, on bodily unity of the kind that sometimes generates new life.

What George is saying here, and what becomes clear if you read more of his essays on natural law and marriage, is very strange and interesting.

It is physically possible, though not legal, to steal.
It is physically impossible to turn yourself into a penguin.

George thinks that interracial marriages have always been possible, though they were once illegal. The Lovings were legally prohibited from doing something they had the capacity to do, namely, to marry. But George thinks that two people of the same sex do not have the capacity to marry — that such a marriage is a physical impossibility. Whatever two men or two women do together, it isn’t marriage. Prohibiting gay marriage is then like prohibiting people from falsely claiming that they are penguins protected by the Endangered Species Act.

(A straight penguin, bien sur.)

(A straight penguin, bien sur.)

Liberals (like myself) tend to frame the gay marriage debate in terms of civil rights. Why shouldn’t gays have the same right to marry as anyone else? Denying them marriage denies them equal protection under the law.

But that only works if we agree on what “to marry” means. To me it means “to go to City Hall, get a marriage certificate, and receive the legal benefits of marriage.” It also means to enter a social institution with connotations of commitment, love, and sometimes childrearing. That is what the same-sex citizens of California are prohibited from doing. But to George and other natural lawyers, I think, “to marry” means something else; it means, fundamentally, to pledge to have vaginal intercourse with your spouse and only with your spouse, for the rest of your life, and to attempt to bear children. Marriage has a sort of independent, immutable reality, under this way of thinking, which its legal status only clothes and reinforces. For George, that reality is highly biological — he spends a lot of time talking about sperm and egg and physical union, the idea being that biology itself defines what kinds of relationships are “natural.” That’s why you’ll often hear conservatives say “The government can’t define marriage.”

But marriage changes, and should. As was pointed out to me in a recent conversation, in the Middle Ages there was no marriage without consummation and no consummation without marriage. In state marriages witnesses actually stood around the marriage bed (with curtains closed) waiting for proof of the deed. And if a woman spent the night in the same house “unchaperoned” with a man, that was grounds for requiring her to marry him. George, writing about “the norms—annulability for non-consummation, the pledge of permanence, monogamy, sexual exclusivity—that shape marriage as we know it” is writing in this tradition. Of course, the roots of this tradition lie in preventing the woman from bearing another man’s child. This is marriage as social control of women. It is not why committed couples, in general, marry today. It is not what marriage is today.

Matt Zeitlin gets at this in his post:

This seems like the insurmountable challenge for opponents of gay marriage. The institution has already changed into one that is no longer based around procreation. Also, we are approaching a societal consensus that discriminating against gay people just because of their sexuality is bigoted and wrong. Lots of gay people want to get married and abide by the standards, rules, regulations and expectations of married people. So, it’s going to take a lot more than a legalistic, nostalgic definition of marriage combined with a slippery slope argument about polyamory to deny a strong claim from fairness and equality about why a group of people should enjoy some rather basic rights.

What people don’t often realize, though, is that the difference between Robert George and people like Matt and me lies deeper than our differing views on marriage or sexuality or gay rights. It’s about the relationship between social institutions, social value, and government. Notice that Matt’s writing about the right to marry (implicitly, the “City Hall” definition of “to marry.”) For someone working in a roughly liberal framework, social institutions can change, social value comes from institutions that promote citizens’ welfare, and government can lend support to valuable social institutions, and must provide equal rights to such support.

When Robert George talks about social value, though, or the intrinsic value of marriage, he means something different than citizens’ welfare. He often writes of intrinsic human goods, an idea that comes from Aquinas; intrinsic goods are those that “perfect human nature.” Marriage (the heterosexual, monogamous kind) is an intrinsic good. Gay relationships are not. They do not have intrinsic value, no matter how much people may value them. Social institutions are good precisely if they promote intrinsic goods; government’s role is to support intrinsic goods. Matt is right — George isn’t concerned with the effect of marriage policy on gay citizens’ welfare. He actually, as I understand, isn’t all that concerned with anybody’s welfare, in the utilitarian sense of people getting the things they themselves want and value — he’s interested in intrinsic goods, those things which he asserts ought to be valued. It’s a strange philosophy to many, and in a way a pre-democratic philosophy; instead of being founded to establish justice and promote the general welfare, government is intended to promote a set of immutable “goods,” which are not up for debate.

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