The long argument

There seem to me to be a number of good arguments for a health care system not unlike one that works.  Ours it not one that works at its primary job–delivering health care.  It seems rather its primary job is restricting it and rationing it on the basis of employment, wealth, or oddly, extreme (and undesirable) poverty.  That leaves people in a bind, of sorts.  If they're extremely wealthy (against all misfortune), it doesn't matter; if they're extremely poor or above the age of 65, they're covered (partially);  If they get a job that pays enough, they go off medicaid, and so become poor in a different way again; if they aren't rich and old, they will still live with severely restrictive costs; for everyone else, the wheel of fortune (employment) turns round and round: don't even think about starting your own business (you'll lose your benefits!), getting fired, working for an innovative start-up company with no benefits, living in an area with no access to quality health care (it's true folks), or, worst of all, don't even think of getting sick, for you may still go bankrupt anyway.  So those are reasons–sufficient I think–to change our system.  Every other industrialized nation in the world has (1) better health care outcomes; (2) pays not nearly what we already pay per person; (3) covers everyone.  Those are fairly straightforward facts.  The level of direct government involvement in each of these systems varies: a lot in the case of Britain; little in the case of Germany and Switzerland.  It has been established by crushing, boring, Al Gore-style reality, that such systems exist, work, and few of the citizens in those countries would dream of switching them for what we have.  What does this mean?  It means that when folks like Tom Coburn, Senator of Oklahoma, say that it's false that government is the solution, it is right to wonder what the evidence for that view is.  The government has been the solution for everyone else.

Normally here we don't make arguments.  We criticism them.  That of course opens us to the (immature) objection: if you're so smart, etc.  This is not an answer to that criticism–which is too silly to be answered.  Rather, in light of the enormous weight of the evidence in favor of a health care system not unlike one that works (and there many examples of them), we in America have to have a conversation about things like the following:

Obamacare Version 1.0 is dead. The 1,000-page monstrosity that emerged in various editions from Congress was done in by widespread national revulsion not just at its expense and intrusiveness but also at the mendacity with which it is being sold. You don't need a PhD to see that the promise to expand coverage and reduce costs is a crude deception, or that cutting $500 billion from Medicare without affecting care is a fiction.  

Yes, a red herring.  Back in 1993–I remember it well–a criticism of the Clinton plan was that it involved "very long" and "complicated" legislation.  Here is James Fallows' comment (in 1995!) on this argument:

To say that the resulting package of proposals was "too complex" is like saying that an airplane's blueprint is too complicated. The Medicare system is complex. So is every competing health-care-reform plan. Most of the 1,342 pages of Clinton's Health Security Act (which I have read) are either pure legal boilerplate or amendments to existing law. Conventional wisdom now holds that the sheer bulk of the bill guaranteed its failure. The Nafta bill was just as long, and so was the crime bill that passed last summer. If the health bill had been shorter and had not passed, everyone would know that any proposal so sketchy and incomplete never had a chance.

As for the "long" argument:

So I did some number crunching. I threw all my old Technician newspaper columns into Word, removed all paragraph breaks and titles, 12pt. Times New Roman double-spaced and came out to be 342 words/page. I took some representative samples of reports with natural paragraph breaks and section titles, also 12pt. Times New Roman double-spaced, and got between 270 and 300 words/page. Online you’ll find that an average book has between 200 and 250 words/page. I even went and compiled some quick and dirty statistics on the Harry Potter books, which average 255 words/page [no, I didn't control for publishing format, just wanted some quick numbers].

For H.R. 3200, I went and found the number of words per page for 20 random pages throughout the bill. The numbers ranged from 104 word/page to 215 words/page, for an average of about 159 words/page for the 1,036 page health care bill.

If we take these figures for more commonly found page formatting (342, 300, 270, 255, 250 words/page) and translate that to the health care bill, we’d have a bill that is between 485 pages to 663 pages, for an average length of 592 pages.

The last five books in the Harry Potter series have page lengths of roughly 448, 752, 870, 652, and 784. Jared Diamond’s Guns, Germs, and Steel hardcover clocks in at 512 pages. War and Peace is over 1200. Atlas Shrugged is about 1200 pages too.

Take that Randians–Atlas Shrugged is longer than the health care bill!  Who could possibly be expected to read it?

In the end, I think it would be nice to have a conversation about reality, but perhaps in the meantime, we can avoid debating about whether a bill is "complicated" (of course it is to some degree, but geez), or "long".  Those are just silly red herrings.


Since George Will thought to write a eulogy for Kennedy which included the term "meretricious," we thought it might be entertaining to take a trip back in time.  Here, via Hullabaloo via Somerby, is an excerpt from a 1995 James Fallows' article about Bill Clinton's 1993 attempt at health care reform:

Much of the problem for the plan seemed, at least in Washington, to come not even from mandatory alliances but from an article by Elizabeth McCaughey, then of the Manhattan Institute, published in The New Republic last February. The article's working premise was that McCaughey, with no ax to grind and no preconceptions about health care, sat down for a careful reading of the whole Clinton bill. Appalled at the hidden provisions she found, she felt it her duty to warn people about what the bill might mean. The title of her article was "No Exit," and the message was that Bill and Hillary Clinton had proposed a system that would lock people in to government-run care. "The law will prevent you from going outside the system to buy basic health coverage you think is better," McCaughey wrote in the first paragraph. "The doctor can be paid only by the plan, not by you."

George Will immediately picked up this warning, writing in Newsweek that "it would be illegal for doctors to accept money directly from patients, and there would be 15-year jail terms for people driven to bribery for care they feel they need but the government does not deem 'necessary.'" The "doctors in jail" concept soon turned up on talk shows and was echoed for the rest of the year.

These claims, McCaughey's and Will's, were simply false. McCaughey's pose of impartiality was undermined by her campaign as the Republican nominee for lieutenant governor of New York soon after her article was published. I was less impressed with her scholarly precision after I compared her article with the text of the Clinton bill. Her shocked claim that coverage would be available only for "necessary" and "appropriate" treatment suggested that she had not looked at any of today's insurance policies. In claiming that the bill would make it impossible to go outside the health plan or pay doctors on one's own, she had apparently skipped past practically the first provision of the bill (Sec. 1003), which said,

"Nothing in this Act shall be construed as prohibiting the following: (1) An individual from purchasing any health care services."

It didn't matter. The White House issued a point-by-point rebuttal, which The New Republic did not run. Instead it published a long piece by McCaughey attacking the White House statement. The idea of health policemen stuck…

Through most of 1993 the Republicans believed that a health-reform bill was inevitable, and they wanted to be on the winning side. Bob Dole said he was eager to work with the Administration and appeared at events side by side with Hillary Clinton to endorse universal coverage. Twenty-three Republicans said that universal coverage was a given in a new bill.

In 1994 the Republicans became convinced that the President and his bill could be defeated. Their strategist, William Kristol, wrote a memo recommending a vote against any Administration health plan, "sight unseen." Three committees in the House and two in the Senate began considering the bill in earnest early in the year. Republicans on several committees had indicated that they would collaborate with Democrats on a bill; as the year wore on, Republicans dropped their support, one by one, for any health bill at all. Robert Packwood, who had supported employer mandates for twenty years, discovered that he opposed them in 1994. "[He] has assumed a prominent role in the campaign against a Democratic alternative that looks almost exactly like his own earlier policy prescriptions," the National Journal wrote. Early last summer conservative Democrats and moderate Republicans tried to put together a "mainstream coalition" supporting a plan without universal coverage, without employer mandates, and without other features that Republicans had opposed. In August, George Mitchell, the Democratic Party's Senate majority leader, announced a plan that was almost pure symbolism–no employer mandates, very little content except a long-term goal of universal coverage. Led by Bob Dole and Newt Gingrich, Republicans by September were opposing any plan. "Every time we moved toward them, they would move away," Hillary Clinton says.

Another demonstration of "the merely contingent connection between truth and rhetorical potency."

5 years

This blog has been in business for five years and a few days.  I remembered at the beginning of the month that the anniversary was coming up, then it skipped my mind.  Sorry, blog.  I used to, by the way, hate to call it a blog.  

The core idea of this blog has always remained a very simple one: apply the lessons of the most rudimentary skills (such as I have) in critical thinking to the big millionaire pundits and see what happens.  I think in five years of doing this, I can say with confidence that George Will, for example, does not make the occasional forgivable error in argument, but rather engages in a systematic and morally despicable kind of activity, that is to say, sophistry.  The same goes for the other frequent offenders–see the archives for them.

Sophistry, I think, is a very bad thing.  Too many well educated people simply cannot distinguish good arguments from bad ones.  They either don't have sufficient factual expertise or they simply don't know what makes a good argument.

For a discussion of one such person, see here.

Over there

I think the health care reform debate, if one can even call it that, ought to be grounded in reality.  One aspect of reality relevant to the debate regards what is empirically possible.  People seem to take it, for instance, that covering more people and having better outcomes necessarily entails either spending a lot more or getting a lot less.  Other countries succeed at it, so perhaps we should at least patiently and honestly discuss what they do.  Just a thought.


Few people could seriously claim the behavior of the Obama administration has been socialist by any stretch.  It is characterized, in the minds of many progressives, by its adherence to Bush-era policies, giveaways to the banking and credit industry, and its obvious reluctance to challenge the insurance industry in enacting health reform.  In a sign, however, of just how no amount of democratic caving will satisfy some people, George Will writes:

As memories of the Cold War fade, like photographs bleached by sunlight, few remember the Brezhnev Doctrine. It was enunciated by Leonid Brezhnev in Warsaw in November 1968 as a retrospective justification for the Soviet-led invasion of Prague the previous August by Warsaw Pact forces to halt Czechoslovakia's liberalization. The doctrine was supposed to guarantee that history would be directional, controlled by a leftward-clicking ratchet. It asserted a Soviet right to intervene to protect socialism wherever it was imposed.

We are already testing whether President Obama and other statists who have given his administration and this Congress their ideological cast have a doctrine analogous to Brezhnev's. Having aggressively, even promiscuously, blurred the distinction between public and private sectors with improvised and largely unauthorized interventions in the economy, will they ever countenance a retreat of the state? Or do they have an aspiration that they dare not speak? Do they hope that state capitalism will be irreversible — that wherever government has asserted the primacy of politics, the primacy will be permanent?

Not only is this comparison ridiculous, it lacks imagination.  There are probably a thousand plausible things one could say, from the right, about Obama.  Comparing him to long dead Soviet Premier Brezhnev–"who is that, by the way?" the young ones will ask–is just shy of Godwin territory.


I think right now we have a system that rations health care.  It denies it to  the 47 or so million people who don't have insurance; it restricts health care to the people who don't have enough insurance; it denies it those people who get sick or have a preexisting condition; and it limits it those people who can't afford the limits and co-pays.  The real worry, however, for Michael Gerson, is whether (1) somehow people can afford abortions–a  procedure which is legal; (2) whether there will be rationing.  To be fair, he admits–sort of–that there is rationing.  Rationing done by insurance companies. 

The same is likely to be true of end-of-life issues. Talk of "death panels" is the parody of the debate — hyperbolic and self-defeating. But a discussion about the prospect of rationing in a public health system is not only permissible but unavoidable. Every nation that has promised comprehensive, low-cost health coverage for all citizens has faced a similar dilemma. Eventually it is not enough to increase public spending or to reduce waste. More direct forms of cost control become an overwhelming priority. And because health expenditures are weighted toward the end of life, the rationing of health care often concerns older people most directly.

Keith Hennessey, former director of the National Economic Council, puts the dilemma simply: "Resources are constrained, and so someone has to make the cost-benefit decision, either by creating a rule or making decisions on a case-by-case basis. Many of those decisions are now made by insurers and employers. The House and Senate bills would move some of those decisions into the government. Changing the locus of the decision does not relax the resource constraint. It just changes who has power and control."

So he admits it.  It would be nice at this point to talk about the effectiveness or the fairness of the current program of rationing.  But no.  

Because no one likes to ration directly, nations such as Britain and Germany employ "comparative effectiveness research" to lend an air of science to the process of cost constraint. Are "quality-adjusted life years" worth the public expense of a new drug or technology?

This type of question is unavoidable when resources are scarce and planners take charge. They seek to rationalize the inefficient medical decisions of families, doctors and insurance companies. But the very process of imposing a rational structure gives government extraordinary power. And the approach taken by planners is, by necessity, utilitarian — considering the greatest good for the greatest number. Decisions cannot be made on a human scale.

On the rough ethical edges of life and death, American health care has adopted messy, inefficient, decentralized compromises that a nationalized system is likely to overturn. Particularly if that system is imposed on a "go-it-alone" Democratic strategy, the divisiveness is only beginning.

The weird thing about this argument is that the insurance company is now the victim–not the perpetrator–of rationing.  On the current system, they're the ones who decide who gets covered and who doesn't.  The basis of their choice is a very simple and efficient one: (1) who is not sick; (2) who can pay.  The very idea of alternative system, one which bases decisions on care on some kind of principle (and no for Pete's sake it doesn't have to be by necessity "utilitarian") to Gerson raises the specter of Soylent Green.  It's people folks, it's PEOPLE.

Insured by Smith and Wesson

I think bringing guns to a town hall meeting about health care makes no sense at all (unless you're on your way to Afghanistan or Iraq, or police duty, or something like that, and have no where to put your gun(s).).  The people bringing the guns, however, seem to do so to make a point about freedom–freedom for guns, I suppose.  But we were talking about health care, so I don't get it.  Despite the ravings of several enumerated lunatics, a system of universal health care derived from obligatory taxes is (1) clearly not unconstitutional and (2) it has nothing to do with guns (other than fixing the wounds caused by them).  Finally, few people want to argue with the guy with an assault rifle.  Maybe that's the point.  If it is, poo-poo on the gun toters for trying to intimidate people.    

Having said that, Now here's a crappy argument from E.J.Dionne against the bringing of guns:

The Obama White House purports to be open to the idea of guns outside the president's appearances. "There are laws that govern firearms that are done state or locally," Robert Gibbs, the White House spokesman, said on Tuesday. "Those laws don't change when the president comes to your state or locality."

Gibbs made you think of the old line about the liberal who is so open-minded he can't even take his own side in an argument.

What needs to be addressed is not the legal question but the message that the gun-toters are sending.

[For the record, I can't find the transcript of this remark, so I can't tell what question was asked]  Dionne mocks Gibbs' (political) answer in one paragraph, and then affirms it in the second one.  It's not a legal question, obviously; the people with the guns were not violating the law (it's up to local law enforcement to maintain order, etc.).  As another political matter, by the way, Gibbs knows (I guess) that had he said, "shame on the gun people," we would be talking about that, and not, for instance, health care.  I can think of an example of where someone said something about a white guy with a gun and our liberal media changed the subject from health care (any subject but that) to the white guy with a gun–care to guess what I'm talking about anyone?

Along those lines, Dionne wants to do the same thing:

On the contrary, violence and the threat of violence have always been used by those who wanted to bypass democratic procedures and the rule of law. Lynching was the act of those who refused to let the legal system do its work. Guns were used on election days in the Deep South during and after Reconstruction to intimidate black voters and take control of state governments.

Yes, I have raised the racial issue, and it is profoundly troubling that firearms should begin to appear with some frequency at a president's public events only now, when the president is black. Race is not the only thing at stake here, and I have no knowledge of the personal motivations of those carrying the weapons. But our country has a tortured history on these questions, and we need to be honest about it. Those with the guns should know what memories they are stirring.

I remember seeing a black guy with an AR-15 (that's an assault rifle of sorts).  Besides, I wouldn't expect someone inclined to bring a gun to a debate about health care had in mind the vaguely relevant question of civil rights.  As in the other case, this is not what it seems.

The gun guys and gals, I imagine, want to change the subject from the content of the debate inside of the hall, to the fact that someone had a gun outside of it.  They're as silly as the ravings of the "Obama wants to ration toilet paper set."  Let's ignore them.

Deny or disparage

This op-ed by John Mackey, CEO of whole foods, has caused somewhat of a stir.  A bunch of people decided to boycott his store (and use his website to do so).  I prefer the raw capitalism of buying from the actual grower–but I guess that makes me some kind of communist.  Anyway, this morning I ran across a couple of tepid defenses of Mackey's op-ed.  Here, Mary Schmich in the Chicago Tribune, and here the newly rejuvenated Kathleen Parker in the Washington Post.

Mackey lays out a series of proposals that address access to health insurance (but don't guarantee it); the only one aimed at reducing costs (aside from being healthy) is tort reform.  I think tort reform is a dubious strategy for a libertarian–if you have any rights at all, you have a right to sue people for contract breech or for failure to perform up to a certain standard.  There is empirical research of a kind on that point, however, which would at least address the question as to whether tort reform would have any effect on medical costs.  Once that question is resolved, however, one would have to balance one's right to sue an incompetent doctor against the communist benefits of lowering health care costs across the board.  

In addition to offering these and other points, he runs some counter arguments against "socialism."  Since no one is offering socialism, or even socialized medicine (if you don't know that, step away from the microphone at the town hall, go to the local library [for free!] and read some newspapers) I can hardly applaud his courage.  

He runs a version of the "rights" argument as well.  I don't know where people pick up these arguments, but it's really silly.  For some reason people have framed this discussion as one about rights–namely about the rights they're losing in having greater access to health care.  Perhaps this explains why people show up at town hall meetings with guns.  As Wyatt Cenac on the Daily Show indicated yesterday, that makes about as much sense as showing up drunk (which is another thing you have a right to do).

Here, in any case, is Mackey's right's argument:

Many promoters of health-care reform believe that people have an intrinsic ethical right to health care—to equal access to doctors, medicines and hospitals. While all of us empathize with those who are sick, how can we say that all people have more of an intrinsic right to health care than they have to food or shelter?

Health care is a service that we all need, but just like food and shelter it is best provided through voluntary and mutually beneficial market exchanges. A careful reading of both the Declaration of Independence and the Constitution will not reveal any intrinsic right to health care, food or shelter. That's because there isn't any. This "right" has never existed in America.

Even in countries like Canada and the U.K., there is no intrinsic right to health care. Rather, citizens in these countries are told by government bureaucrats what health-care treatments they are eligible to receive and when they can receive them. All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments.

The idea that the Constitution and the Declaration of Independence (again–not a ruling legal document!) enumerate all of our "intrinsic" rights is silly.  It's silly because, as people should never tire of pointing out, the Constitution, on a careful reading (slightly more careful than Mackey's) says:

Amendment 9 – Construction of Constitution. Ratified 12/15/1791.

The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.

There you have it folks.  A careful reading of the Constitution shows that you may have more rights than the Constitution says.

One more obvious point.  I think no one could seriously argue that the Constitution contains all intrinsic rights, such that their not being mentioned (see above, 9th Amendment) is evidence of their not existing.  That would be circular!

I can’t change my mind

Speaking of one of the weirdest op-eds I've ever seen, Bob Somerby (aka the Daily Howler) asks:

For years, we have asked why the professors don’t help us with our floundering discourse. When our journalists fail to serve, who don’t the professors step forward to help? Where are all the professors of logic, with their vast clarification skills? Why don’t the professors step in to straighten our broken logic?

The question is obviously rhetorical, but he continues to ask it, so here's an answer.  John Holbo, at Crooked Timber, is a professor of philosophy, and he has stepped up to the plate (as have many others).  Holbo recently addressed the very kind of argument Somerby was complaining about (here and here).  We talked about that here the other day.  But, just for fun, and because Bob wonders where the professors of logic are, and I'm one of those, let's have a look see at what he was talking about.  

The op-ed in question is by Danielle Allen, a professor at the Institute of Advanced Study (I'm not kidding).  She writes:

His administration now agrees with the analysts who argue that only by ensuring that no one games the system can reform be made to work. The mandate serves to ensure that individuals do not buy insurance only when they are ill. Other elements of the reform similarly serve to ensure that neither insurance companies nor employers will game the system. As Paul Krugman has argued in the New York Times, each of these strategies to prevent gaming is necessary to make the whole thing work. The point, though, is that the push for implementation has turned Obama's policies into something other than what he promised.

This change in Obama's position goes a long way toward explaining the objections to the new reforms that are being raised vociferously through grass-roots action by citizens on the right. The issue here is not that these citizens consider Obama untrustworthy — though they do. The issue, rather, is that they recognize that the stated goals and structure of a policy may not fully capture its full range of outcomes in practice. This is why these citizens, including professionally briefed participants such as Sarah Palin, can continue to maintain, in the face of a barrage of insistences to the contrary, that the reforms will (1) result in rationing and (2) establish "death panels."

Gee professor, as others have pointed out (here and here for examples), every one is justified in making the most outlandish slippery slope arguments since it is a fact of nature that the "stated goals and structure of a policy may not fully capture its full range of outcomes in practice."  And no, for the love of Mike, a change in a proposal does not open the door to that inference, as she suggests.  While perhaps not a fact of nature qua nature, I think moderate (or even extreme) changes in the positions one advocates are a normal reaction to the facts on the ground.

Think about this for a second.  Given the professor's argument, no policy maker (or person) can change a position without having her real motives stretched to include the most extreme and unlikely consequence.  So, take heed, policy people, if you change your mind ever so little then Danielle Allen will wonder whether you really want to turn old people into Soylent Green.

Preventive scare

Charles Krauthammer is a doctor, the kind of doctor an insurance company would love:

How can that be? If you prevent somebody from getting a heart attack, aren't you necessarily saving money? The fallacy here is confusing the individual with society. For the individual, catching something early generally reduces later spending for that condition. But, explains Elmendorf, we don't know in advance which patients are going to develop costly illnesses. To avert one case, "it is usually necessary to provide preventive care to many patients, most of whom would not have suffered that illness anyway." And this costs society money that would not have been spent otherwise.

Think of it this way. Assume that a screening test for disease X costs $500 and finding it early averts $10,000 of costly treatment at a later stage. Are you saving money? Well, if one in 10 of those who are screened tests positive, society is saving $5,000. But if only one in 100 would get that disease, society is shelling out $40,000 more than it would without the preventive care.

In the very abstract, of course, that's not a ridiculous claim.  I think he's right to make the claim that preventive care is not the high road to lower health care costs (no one he cites seems to argue for that particular claim). He is also right to grant (as he does, a few paragraphs later) that there is a moral reason for preventive care–to limit suffering.  Nonetheless, I think there are two objections one could make here.

First, the economic calculation is the very one the insurance company makes–which, if I am not mistaken, is the problem.

Second, while Krauthammer is not wrong to say that preventive care is economically different from any other medical procedure (he does have an MD after all), he's allowing you to think that preventive care means everyone gets a series of costly tests every year, no matter how irrelevant or unnecessary.  He writes:

That's a hypothetical case. What's the real-life actuality? In Obamaworld, as explained by the president in his Tuesday town hall, if we pour money into primary care for diabetics instead of giving surgeons "$30,000, $40,000, $50,000" for a later amputation — a whopper that misrepresents the surgeon's fee by a factor of at least 30 — "that will save us money." Back on Earth, a rigorous study in the journal Circulation found that for cardiovascular diseases and diabetes, "if all the recommended prevention activities were applied with 100 percent success," the prevention would cost almost 10 times as much as the savings, increasing the country's total medical bill by 162 percent. That's because prevention applied to large populations is very expensive, as shown by another report Elmendorf cites, a definitive review in the New England Journal of Medicine of hundreds of studies that found that more than 80 percent of preventive measures added to medical costs.  

On the cost of an amputation, I'd say the surgeon definitely does not make that, but I think Obama means the total cost–which has to be somewhere around there (but I could be mistaken). 

But the "large populations" claim strikes me as odd, because not everyone will be a candidate for every preventive measure.  Besides, not every preventive measure is a 500 dollar test (which seems to be the basic idea of preventive care in the CBO study):

During a press briefing Tuesday, Thorpe said “the CBO focuses on one type of prevention, which is trying to detect disease through screenings. And some of those types of disease screenings can actually reduce costs, as in the case of colorectal cancer. And a lot of it is really not designed to reduce cost, it’s designed to get people medical intervention earlier,” he said. “So the intent of disease detection is not to save money, it’s sort of a straw man.” [Sorry for the format, but the original is behind a pay wall].

Finally, he is also assuming the present (inflated) cost structure as a baseline.  Some have argued recently that the cost structure and the medical practice we are the problem.  Others have argued that the metric of the CBO study leaves out what really ought to be measured in the first place.  While neither of these demonstrates the cost-effectiveness of preventive care–they do at least point out that we should be minimally circumspect about the CBO's study.