Smarter Healthcare, Part 2

Quite some time ago, I proposed a solution to healthcare that looked very different from other plans I had seen in the past^[1]. Since that time, a great deal has happened on the healthcare front: the House passed the AHCA and narrowly passed it after a false start, and the Senate tried to rush through the BRCA but currently does not have the necessary support. Both bills achieve two primary objectives: they roll back tax increases that were part of the Affordable Care Act, and they dramatically reduce Medicaid spending. Both are projected by the Congressional Budget Office to have a modest deficit reducing effect (which, for technical reasons, is necessary to avoid a Democratic filibuster) and both are projected to dramatically increase the number of uninsured persons in the United States by about 22 million ^[2]. Such forecasts should be understood to have large uncertainty, but the uncertainty could go in either direction; don't mistake uncertainty in a forecast for a guess with no basis. The CBO is almost certainly right that tens of millions of people would lose insurance under the AHCA and BRCA, and it could just as easily wind up being more than 22 million as less.

 The bill is quite unpopular^[3], although understandably many people don't feel they know enough about the bill to have an opinion. My own opinion is staunchly negative. I have always been tepid in my support of the Affordable Care Act (I refuse to call it by its more popular moniker because the idea of making health care reform a referendum on a previous president is madness to me), mostly because I have always felt it was wildly insufficient to solve the problem of U.S. health care and did not, despite its billing, come close to solving our need for long term health care reform. But returning to the broken system we had before cannot be the answer.

So instead, my proposal puts negotiating power in the hands of health care consumers by allowing them to pay medical expenses directly with federal loans. They can negotiate upfront pricing with providers. Currently, the majority of Americans have almost no bargaining power in health care: their insurance is decided by their employer, and their providers negotiate with their insurers. Most consumers are left basically forced to spend a certain amount of health insurance and forced to accept a certain among of coverage. This bears some similarity to health savings accounts favored by many conservatives, but it does not require that savings be stockpiled in advance in case of a medical emergency.

Today, I'd like to compare my system to a favored option on the left and used relatively successfully in many other countries: single-payer. Single-payer basically means that you get health insurance from the government, and it is paid for by tax dollars. Like the current system, consumers have little direct negotiating power, but the entire insurance process could be streamlined. Advocates point out, correctly, that every single-payer system in the world costs a lot less per capita than the U.S. system.

However, as the Washington Post notes, there is little reason to believe that a single-payer system in the U.S. would drive down costs without other massive overhauls ^[4]. After all, we have two large government health insurers (Medicare and Medicaid) and both come with exorbitant costs. In fact, as you can see in the image below, in spite of having more private spending on health care than any other nation, the U.S. already manages to also spend more on public or compulsory healthcare than almost all other nations. We have ended up with the worst of both worlds: a sprawling, expensive public health care system while still forcing most citizens to pay massive private costs for health care.

One advantage of my proposal is that I think it could legitimately bring down costs. In the current system, if you have insurance, your decisions to consume health care are almost wholly divorced from the actual cost of health care. Instead, if you have coverage, either you or taxpayers have already paid a lot for your healthcare and you might as well take advantage of services offered to you, or at the very least your decision to take advantages of those services has more to do with time and desire to see the doctor than it does the cost. Also, the costs are opaque and confusing, negotiated by insurers in such a way that when we receive our bills, the average American has little chance of deciphering what the charges even mean. We write a check and move on. Because doctors negotiate with insurers rather than patients, there is no incentive for transparent or upfront pricing.

However, once consumers are in charge of purse strings, it suddenly becomes easy to demand upfront pricing, as you can with an (uninsured) eye exam or dental exam, or a car repair shop. Certainly, some providers will try and talk their patients into costly, unnecessary procedures, but patients will have the ability to walk away and find someone else if they don't believe their provider is behaving ethically. It allows patients to see the value of nurse practitioners and physicians assistants, both of which can provide quality patient-centric care cheaper than medical doctors in many instances.

Also, I believe this idea will prove more politically palatable that the single-payer option. Observers are right to note that support for single-payer is growing, but it is still not the preferred choice of most Americans ^[5]. I believe options that give Americans more direct control while still having protections for worst-case scenario medical needs, on the other hand, could prove very popular. As always, comments and questions are welcome.

A Win I Want For America

In the midst of the unbelievable chaos that was last news cycle, I was heartened to read that legislation fighting back against mandatory sentencing was again being introduced by Sen Leahy (D-VT), Sen Paul (R-KY), Sen Merkley (D-OR), Rep Scott (D-VA), and Rep Massie (R-KY). I am not very familiar with the others, but my impression of Paul and Leahy is that for all their differences in ideology and temperament, they are both tenacious and intelligent lawmakers. They are excellent people to be leading the charge.

Of course, this effort is unlikely to be met kindly by the White House, who appear to be fully committed to locking up as many people as possible. It will be a very hard fight, even if we have the right people leading the charge. One would almost have to imagine congress being able to muster a bipartisan veto-proof consensus. I cannot recall when such a thing last happened.

But it has happened, if not recently. And maybe, with a lot of help from the people, it can happen again.

If you believe in criminal justice reform (and I will not attempt to make the case here, except to say I am passionate about it), this is a moment where something really special can happen, in terms of policy, politics, and national morale. This is a moment where a bipartisan movement can get something really important and really difficult done.

I cannot imagine anything that would make me prouder than one day saying to my children than saying, when I describe 2017, "Well, no one understood each other and people were frightened and angry and the presidency was embroiled in a dangerous scandal and people seriously doubted the congress could pass any meaningful legislation. And in the midst of that, Americans came together and fought against one of the greatest injustices of their time."

I want to fight for this. I want to fight hard for this. I want to do whatever I can to help bring home a giant, inspiring win for America. I want to prove we can make smarter laws and fairer laws, and we can do it for our country alone without needing our partisan teams to get the credit.

I haven't had time yet to start to formulate a strategy. But I want to start, and soon, and I will appreciate as many ideas and input as I can get. And I would very much like some allies to fight with.

Smarter Health Care, Part 1

If the events of the past few weeks have proved anything, it is that the United States is not close to passing significant health care reform. To an alien landing on planet Earth who knows nothing of our politics, this would make little sense. Check out these statistics from the OECD:

You might already be aware that the United States spends far, far more per capita on health care than any other nation on earth. But check out the bars in blue for an even more staggering statistic. The United States is behind only Norway in public and compulsory spending on health care. Think about that for a moment: already, the government of United States mandates more spending on health care than all but one nation on earth, and yet somehow we also manage to pay more out of our own pockets than any other country. A lot more. Meanwhile, we lack universal coverage (unlike every other wealthy nation on the planet).

This situation constitutes an obvious crisis. You would think that fixing this problem would unite big government skeptics, economic pragmatists, and progressives. Instead we have nothing but finger-pointing. In the meantime, costs continue to balloon (if you'd like to get US health care expenditures in 2015, tack an extra $400 on to the already absurd 2014 figure). We need to find a true, long term solution as soon as possible.

I want to float an innovative solution to our particular challenges, an approach that is market driven, focused on patients and doctors having freedom to make their own decisions, and makes sure that no one is unable to afford treatment when they need it.

The idea is simple. When you go to the doctor, you can chose to pay however you like, but one option will be that you can borrow money to pay the bills from the government, much like how the Department of Education offers student loans. Interest rates can be calibrated so that any such loans don't increase our debt or deficit over the long term.

Based on financial situation, every person will have an expected contribution to their health care each year. Up to that point, if people want health care they must pay for it out of pocket, with private insurance, or by taking advantage of government loans. After that point, however, their expenses are covered, so that the poorest and sickest Americans are able to get care without wracking up so much debt that bankruptcy is inevitable.

If you want to use private insurance, you can. You won't be able to borrow to pay insurance premiums, but money that comes out of pocket for insurance premiums will count toward meeting your expected annual contribution for health care and you can borrow to cover co-pays, deductibles and coinsurance.

But if you don't want insurance at all, that's fine too. You can go without insurance and have a real choice about how much health care you want to consume. Want a regular check up? You can go to any doctor you like, and you have the leverage to get upfront pricing. If the doctor recommends an expensive test or an elective surgery, you can have those procedures done if they are worth it to you, regardless of how much money is sitting in your bank account that day. And you aren't restricted in which doctors or hospitals you go to, because everyone takes cash.

This option puts control back in the hands of doctors and patients. It lets individuals decide what services they want and how much they are willing to pay for those services, but without leaving the most vulnerable with few good options for care. It encourages entrepreneurship by not tying affordable health care to a job. It lets people purchase health care plans tailored to their specific needs, knowing they even if they decide to go with a cheaper premiums and less coverage, they are still protected in a worst case scenario. And it frees doctors up to use their medical judgement when making decisions rather than having to ask insurance companies for permission.

In future posts, I will be comparing this option to some other popular suggestions, and if you have any specific comments, questions, or criticisms about this idea, I would be happy to discuss them. 

Racial Biases Are Pretty Normal

Let’s talk about race in America. It's okay if that subject makes you uncomfortable. Me too! My anxiety has been going through the roof even thinking about this post. But there is a very important point I want to drive home: racial biases are normal and common.

You may be familiar with the term “systemic racism,” which attributes the wide disparity in education levels, incarceration rates, income, etc. to racial biases that are ingrained into our society and our laws. I personally find this theory compelling, but in the social sciences, an observation about outcomes alone is not sufficient to establish the cause of those outcomes. So systemic inequality doesn't, on its own, tell us much about how widespread racial biases are.

On the other hand, experimental evidence clearly establishes the pervasiveness of racial biases. For instance, in 2004 Bertrand and Mullainathan showed that when people where shown resumes with first names that were strongly associated with a certain race, people responded more favorably to names that were common among whites than names that were common among blacks (a more recent study could not replicate the result with last names, but frankly, I think last names are a pretty weak signal of race. Apparently "Jefferson" and "Washington" are more common among blacks, which I suppose sounds right if I think about it carefully, but I seriously doubt that thought would occur to me if I was glancing at a resume). The racial biases also show up clearly in computer based tests: for instance, most white people, it turns out, do much better on tasks that require sorting "bad" words with blacks and "good" words with whites than the other way around.

It is important to establish that racial bias is normal and common because our society has an unhealthy culture of shame and silence when it comes race. Yes, this nation engaged in codified slavery and segregation, and both are morally indefensible. Yes, I believe continuing racial inequality is a very real problem. But people don't have racial biases because they chose to have them. People develop racial biases because as children we watch role models such as parents and teachers act out such biases. In most cases, those adults never intended to teach to pass that lesson on and may not have been aware of their own biases, but children have an incredible capacity to pick up on and emulate subtle behaviors: it's how we learn to construct sentences, tell jokes, make friends, and any other of a myriad of complex social behaviors.

Having biases does not make us bad people. To the contrary, some of the bravest, best people I know will admit to their own biases in public. However, racial biases will not go away by pretending they don't exist. We will pass them on to our children and our grandchildren unless we commit to fighting them.

We should be open to learning about our biases. Harvard has short, publicly available implicit bias tests. As long as you aren't afraid of the result, you might find the tests to be fun. And if you are surprised by the result you get, then know you are in the majority and it doesn't mean you have done anything wrong. What it does mean is that it will take awareness, courage, and effort to combat these biases. Changing ourselves and our culture will be an uphill battle every step of the way, but we must not shrink from the task.

Islam and I

This post is about my personal relationship with and my family history regarding Islam, and my viewpoints on Islam today. If you would like to know why I am writing such a post, I refer you to my previous post.

My mother and father raised me as a Baha'i, a religion that originated in Persia (now Iran) in the middle of the 19th century. Baha'is have been systematically persecuted by Muslim authorities since the origin of the religion. I heard stories from childhood about the torture and murder of Baha'is in an effort to get them to recant. Unsurprisingly, the current Islamic Revolutionary government of Iran is extremely hostile to the Baha'is. At present Baha'is are not allowed to attend schools and are frequently jailed on flimsy charges, and at various points have involved executions. The Baha'i Faith is still believed to be the largest religious minority in Iran, but there is no official headcount because the government does not officially recognize them as a religion.

My father was raised a Muslim in India. Sometime during his teenage or young adult years (I don't know the full story as well as I wish I did), he converted to the Baha'i Faith, as well as his younger sister. For that, they were effectively disowned by my grandfather, a very "conservative" Muslim. I got to meet him when I was about 7, very briefly. The only thing I remember about him personally is that he made me feel loved from the instant I first looked at him.

My mother was raised a Presbyterian but became a Baha'i as a teenager. She was interested primarily in religious studies, although she eventually pursued a Ph.D. in history, largely because history departments are better supported in academia than religious studies departments. She was going to go to Iran to research her dissertation, and right as she was set to go, the Iranian Revolution happened, and as an American Baha'i woman, there was no chance she would be safe there. Instead, she went to India and wrote her dissertation on the Zoroastrian diaspora in India. Zoroastrianism was, until the Muslim conquests, the state religion of Iran, and it is really impossible to tell the story of how Zoroastrians came to leave Iran without telling the story of the Muslim invasions that displaced them. Most of her published articles deal with the Baha'i Faith, which again is rather difficult to study without first understanding the Muslim societies from which it originated.

All of this is to say I am quite aware of the brutality that occurs in many Muslim majority countries. I am quite aware that Muslims are capable of being intolerant. But my basic impression, on the whole, of the many Muslims I've interacted with is that they are just people. Sometimes they do ordinary things. Sometimes they do admirable things. Sometimes they do shitty things. History, in my mind, provides no evidence that their morals are defective compared to the rest of the world. To the contrary, they have a history towards tolerance of Jewish and Christian minorities (much more so than the Christian world had towards religious minorities prior to the very recent past). Prior to the 20th century, the Muslim world's record on women's rights was superior to Europe's. I don't mean to downplay the serious depravity and danger posed by ISIS or the state mandated oppression of women in Saudi Arabia. I mean to say that apocalyptic death cults and oppressive dictatorships are hardly an invention of the Muslim world or confined to Muslim countries.

I also want to be clear about what I think about Muslim immigrants in particular. One of the most important things to remember about Muslim immigrants in Europe and America is that these people chose to live in a country where they were a minority because they thought they would have a better life there. These aren't people who are opposed to Western values. These are people who are embracing Western values and abandoning (or, as in the case of Syrian refugees, desperately fleeing) less free societies.

ISIS has had some alarming successes wooing European-born Muslims. So far, they have had very little success with American-born Muslims. A commonly cited explanation is that American Muslims feel much more integrated with their societies than European Muslims do. Personally, I'm proud that America can boast that. But if we persistently send American Muslims the message that they are unwelcome and we find their faith incompatible with American values, I think we will be making a grave mistake, both morally and in terms of the possible consequences.

Who We Are and How We Think

The other day a post from a blogger came up on my feed with a post arguing that there is a huge problem with rape in Sweden by Muslim refugees. The primary basis for this claim was that reported rapes and other sex crimes are higher dramatically today than they were in 2003 (as shown by official government sources). After looking at the data, I pointed out that the increase occurred almost entirely between 2007 and 2010, and therefore couldn't have been caused by refugees from the Syrian Civil War that began in 2011. No one on this comment thread seemed to be persuaded, which didn't surprise me. I engaged in conversation with people who replied to my comment, and despite the fact that absolutely no one there seemed to agree with anything I had to say, the conversation was generally polite and I enjoyed it.

At one point, though, someone said that my beliefs required "ignoring 1400 years of history." I considered not replying.

I happen to think I know an awful lot about the history of Islam, as it is both a casual interest of mine and my mother is a Ph.D. who specializes primarily in South Asian and Middle East history, and primarily focuses on religions in those regions. She has taught me a lot about different world religions. But I also recognized that the other person also felt very confident they had the correct impression of Islamic history, and I seriously doubted there was any hope of convincing this person otherwise. In fact, psychology tells us the opposite happens when two people argue. Instead, the most likely outcome is that both sides reinforce their own beliefs rather than coming closer together.

But reply I did, arguing that during the vast majority of those 1400 years, the Islamic world was more tolerant of other religions and treated women better than the Christian world. I was asked for sources, and at some point mentioned my mother. At which point I was asked this:

What has she published? Is she Muslim? Am I?

Asking what she's published is pretty fair game in my mind if I'm going to appeal to her expertise when I claim I really do know a good bit about Islam and its history. And you know what? I don't know what this stranger I've never met and never spoken to intended when he asked whether I or my mother were Muslim, but I actually think this is an important and totally fair question.

See, our backgrounds inform what we think of as obvious and true. Something very important was glossed over in the sarcastic mockery of the phrase "alternative facts." Sure, I believe there are things that are true and things that are not true. But for all of us, what we think is true and not true is determined nearly entirely because of our life experiences. For instance, I believe wholeheartedly that men have walked on the moon. But what's my basis for that? Sure, I saw some pictures and some grainy film, but by that measure, I've got better evidence that the Avengers saved New York City. Mostly, I believe men walked on the moon because people told me, because it's consistent with everything else I think I know, and because any story where men did not walk on the moon requires me to abandon not one but multiple things I believe about objective facts and reality.

Men walked on the moon. I'm certain it happened. But the fact of it happening did not create my certainty. Being told it happened by people I trust created my certainty.

Right now, there is a vast gulf between what some Americans think is true and is not true. We really are living in different realities. And I really don't have high hopes for our future as country if we don't start to understand each other.  The recent election really didn't cause this problem. Exacerbated it, maybe. But the truth is, the near complete disconnect between such large segments of our population is a crisis that has been with us for a long time, and it has only been getting worse.

So in my next post (which I need a little more time to work on), I'm going to answer that question and talk about my personal relationship with Islam. Because it matters. It matters not just what I believe, but how I came to believe it.

I Am a Republican

Today, I am declaring myself a Republican.

I wasn’t always a Republican. Quite the opposite, in fact. For most of my adult life, I've considered myself an independent but usually voted Democrat, though I’ve cast votes for both parties and for third parties. To be clear, I do not support the present administration. I am on record as having supported Ms. Clinton for the presidency, and today I have a lower opinion of the President than I did on election day.

This administration is an immediate, important concern. But even more frightening to me is how unequipped our government is to deal with this threat. Despite the fact that many Republican lawmakers publicly denounced Mr. Trump, they backed off when pro-Trump protesters showed up at their rallies, and rolled over entirely after his election. You may recall, back in October, congressional Republicans told us they would serve as a check on the President no matter who it was.Now, Speaker Ryan is content to just pretend he didn’t say, only months ago, that attempts to ban immigration on the basis of religion was immoral. Congressional Republicans, by and large, have proven to be cowards.

I certainly don’t mean to absolve the Democratic party of blame for this mess. The Democratic establishment linked arms and pushed everyone aside to nominate Hillary Clinton, even though it was clear she was a dangerously unpopular candidate. And when it was (or should have been) obvious that Mr. Trump was the presumptive Republican nominee, still the Democratic party actively colluded to put the weaker candidate on the ballot. Even before that, I already had acquired a distaste for their tactics. I have yet to see a fundraising email that wasn’t laced with shrill hyperbole about the awful things opposing candidates supposedly believe.

However, these parties are American institutions. You may think (and most Americans do) that it would be better if we had a third party. I have believed that at times myself. But the truth is that Americans cannot agree on what a third party should look like, and until they do, there will be none. In the meantime, let’s call the Republican and Democratic two-party system what it is: the way American government has operated for over 150 years.

Right now all our institutions are under siege. We have lost trust in our leaders, in our media, in our courts, in our scientists, and most importantly in each other. A lot of Americans are, understandably, in the mood to tear everything down. However, the lesson I take from history is that when the institutions that protect a free society are dismantled, more often than not, the new society that rises from the ashes is anything but free.

I believe the Republican Party can and must be reinvigorated with moral integrity. For myself, I believe in free markets. I believe that large, persistent deficits are going to catch up with us if we don’t get smarter about our budgets. I believe (like most mainstream economists) that infrastructure development pays long-term dividends. I believe education is incredibly important but that we have to stop trying to protect an industrial-era vision of school and learning. I believe taxes and regulations work best when they are simple and streamlined.

However, I will not accept having the largest incarcerated population in the world. I will not accept using our ineffective, expensive war on drugs to tear apart families and impose lifetime bans on citizens voting as a result of their conviction. I will not accept congressional districts that are precisely gerrymandered to rob people of meaningful choices. I will not accept burying or obfuscating scientific evidence to win an argument. And I will never, ever accept the premise that Americans with different skin colors and different languages and different religions than myself are entitled to anything less than the same protection under the law I receive.

I want to be clear that it will be extremely difficult to transform a party. Many of the administration's policies remain wildly popular among self-identified Republicans. Defeating the lawmakers that prop him will require massive support from politically exhausted Americans that often don’t vote and independents who have wandered away from the party. It will require luring in moderate Democrats who are disaffected with their current leadership. And most importantly, it will involve contesting primaries from the bottom up. Success will require hundreds of candidates in primaries for state legislatures throughout the country with motivated supporters that can get out the vote.

In the coming months, I will be posting more thoughts, including but not limited to policy suggestions, thoughts on election strategies and election targets, and hopefully making connections with like-minded people. 

For now, though, I leave you with the words of Aziz Ansari: “If you look at our history, change doesn't come from presidents. Change comes from large groups of angry people.” It is time to be angry that common sense, decency, and integrity are being thrown in the dumpster. It is time to stop believing that being a moderate means being docile. It is time to fight, and it is time to stop making excuses and looking away when the best values of America are being assaulted.