Who says cousin marriage is wrong? Who says it's not a legitimate political issue?

I am supposedly on blogging hiatus right now, but I just had to announce the arrival of this awesome new article from the New York Times by writer Sarah Kershaw.

WHEN Kimberly Spring-Winters told her mother she was in love, she didn't expect a positive response -- and she didn't get one.

"It's wrong, it's taboo, nobody does that," she recalled her mother saying.

But shortly after the conversation, Ms. Spring-Winters, 29, decided to marry the man she loved: her first cousin.

Shane Winters, 37, whom she now playfully refers to as her "cusband," proposed to her at a surprise birthday party in front of family and friends, and the two are now trying to have a baby. They are not concerned about genetic defects, Ms. Spring-Winters said, and their fertility doctor told them he saw no problem with having children.

This article contains a lot of new and previously unearthed material, including quotes from cousin couples and also Representative Harvey Hilderbran, who authored the recent Texas statute in 2005 banning cousin marriage.

Those interested should also check out the new cousin marriage Wikipedia page that I have updated in the past few days.

How can we get repealing bans on first cousin marriage on the US legislative agenda?

I think it would clearly help in getting started to consider why it has not already been raised as an issue, given facts like that no other Western country prohibits it and that the genetic arguments have been shown to be hollow.

I can see at least two big reasons why it's been neglected:

1) The affected percentages are lower in the US than in many other countries. The most recent studies were done around a half century ago and found 0.2% of Roman Catholics married to a first or second cousin. We don't have any data at all on non-marital relationships or for non-Catholics, a demographic that is now over 75% of the public.

2) Cohabiting cousins can blend in amongst strangers, acquaintances and at least some friends.

However, we should definitely balance these factors against this:

1) Cousin marriage is largely still seen as a perversion and is not recognized even as a legitimate political issue in the United States.

In addition to understanding this as oppressive, it is itself another reason why bans on cousin marriage haven't been disputed. For example, today there is a great deal of media coverage about the issues of race and gay marriage in the United States. Gays and ethnic minorities may receive their share of cruelty and bigotry, but at least there is an expanding community recognizing that these phenomena are unjust. On the other hand, when cousin couples are made out to be stupid, disgusting, incestuous, "polluting the gene pool," etc., there is no comparable consciousness and especially anger at the injustice. Discrimination against cousin couples is not being fought through any kind of coordinated effort, and so those afflicted are inevitably left atomized, alone, and at the mercy of potential accusers.

I think an apt analogy here, and probably a much better one than comparisons to gay marriage, is actually to miscegenation. Compare the uproar over the fact that a justice of the peace refused an interracial couple a marriage license in Louisiana last month to the fact that in over half of US states it is official policy to deny the same license to cousin couples. If we restrict ourselves to black-white marriages, the numbers involved are on the same order of magnitude: there were 422,000 black-white marriages in 2005, according to the Census Bureau, or 844,000 individuals. If we use the 0.2% figure, then multiplying by 124 million married individuals gives 248,000 people. However, we need to take into account that cousin marriage is illegal in most states, so this understates the number somewhat. Also, the number of black-white marriages has exploded since the landmark Loving vs. Virginia ruling, with the percentage more than tripling since 1970.

On Justice Bardwell's behavior in Louisiana, the ACLU says that it represents "bigotry and prejudice" and "would be both embarrassing and disturbing in any year." It therefore recommends "the most severe sanctions available, because such blatant bigotry poses a substantial threat of serious harm to the administration of justice." But in the case of denying cousin couples the right to marry, their organization presumably does not believe this constitutes bigotry or prejudice, since none of its state chapters have ever raised the issue.

That brings me to the question of how to get this issue on the agenda. In order to start, it will be necessary to contact progressive organizations and convince them to take up the cause. To identify some possible candidates I decided to consider Wikipedia's list of organizations advocating gay marriage, since I couldn't find a comparable list for miscegenation or civil rights. Removing organizations exclusively devoted to gay rights, we find:

National Organization for Women,[82] the AFL-CIO,[84] the ACLU,[85] the American Psychiatric Association,[86] the National Association of Social Workers,[87] the Service Employees International Union (SEIU),[88], the National Education Association[89], the Leadership Conference on Civil Rights[90], People for the American Way, Secular Coalition for America, Center for American Progress, Moveon.org, Drum Major Institute[91], Institute for Policy Studies[92], Americans for Democratic Action[93], Progressive Democrats of America, Campus Progress, Democracy for America, Progressive Majority, NARAL Pro-Choice America[94]

There's also the Green Party and various state Democratic parties. I would hope that eventually all of these organizations can be persuaded to advocate cousin marriage, but since resources in getting this started are scarce and I may be acting alone, prioritization is needed. I tend to rule out the unions as good starting points because unlike discrimination against gays, discrimination against married cousins is probably not much of a workplace issue (in the same way as discrimination against interracially married couples is not, per se, much of a workplace issue). Somewhat analogous reasoning about their foci leads me to axe the American Psychiatric Association and the National Association of Social Workers, though these might be worth coming back to. The feminist organizations I rule out for a different and unfortunate reason: many of the Islamic societies with the highest rates of cousin marriage are also extremely patriarchal, and I fear that some feminists may have an impression of cousin marriage as a kind of back door for Middle East-style sexism. This superficial association is one that I think can certainly be overcome, but not without a good deal of dialogue. The Leadership Conference on Civil Rights has to go because it's an umbrella group, not a real organization, but I ended up considering one of its members, the Citizens' Commission on Civil Rights. A couple of think tanks got removed because their issue focus isn't relevant. Finally, I ruled out Moveon.org and Democracy for America because my personal impression is that they're incapable of taking issue stances that aren't explicitly Democrat-approved beforehand.

That leaves us with:

Green Party
ACLU
Citizens' Commission on Civil Rights
People for the American Way
Progressive Democrats of America
Secular Coalition for America
NJ Democratic Party (my state)
Center for American Progress

This list is ranked: it represents a very rough gauging of how easy I think it would be to get these organizations to support cousin marriage. The Green Party is simply awesome and if the issue was properly explained, I think there is a very good chance of actually getting it into their national platform for the 2012 elections. The ACLU is a natural ally here, though as a judicially focused organization they would doubtless be more motivated if an actual case was presented of first cousins being denied a marriage license. A major task in soliciting the ACLU is hence finding a couple willing to come forward and file a speculative legal case. As a preliminary effort one would surely also want to consult with ACLU staff about their willingness to actually accept the case.

The next few organizations are small academic think tanks. The modus operandi there is pretty straightforward: just contact their staff and discuss any willingness to take a position. Progressive Democrats of America is fantastic but their issue focus is mostly concentrated on non-social issues. Their state chapters, however, do engage in some gay rights work. Meanwhile Secular Coalition for America is an explicitly anti-religious organization, so it would be probably be necessary to find a religious organization banning or restricting cousin marriage that it could be properly "anti" to. The Catholic Church and its requirement for a dispensation for first cousins comes to mind as a possibility, but it's not one I'll take up since I personally have Catholic roots.

Then we have the NJ Democratic Party. Unlike states like Massachusetts, I'm not even sure that we even have a party platform in New Jersey. Anyway, this is a huge task, far beyond my individual capabilities. Dead last we have the Center for American Progress, which I almost discounted for reasons similar to Moveon.org and Democracy for America, but in the end retained because it's an academic organization and might perhaps have a member or two who can be individually persuaded.

That about rounds out the list! I will try to influence some of these organizations to endorse cousin marriage in the future, in addition to promoting causes that benefit everyone like Medicare for All. Actually, I won't be blogging for a while-I have some personal concerns that desperately need taking care of, like say finding employment. I will be back at around 5 or 6 p.m. to address comments on this post, though. Cheers!

This is a copy of the long reply that Maggie Mahar made to my post "Why Is Maggie Mahar Lying About Health Reform?" at TPMCafe. I've now gone through in turn and posted responses to her statements. I will not have time to do another round of replies, but hopefully this will be enough. I suggest that people show up to the Firedoglake book salon on November 9 and ask her to stop saying that the public "option" is anything at all like "Medicare E (for everyone)."

I am, of course, not lying about Health Care reform.

If you read CBO director Elmendorf's letter to Charles Rangel where he suggests that only 30 million Americans will be in the h Exchange in 2019 (six years after reform begis) and that just 20% of the people eligible for the Insurance Exchange will choose the public plan, you would find that he has No basis for saying this. No numbers. No real analysis.

When Elmendorf explains why, in his opinion only 1/5 of the folks in the Exchange will choose the government plan, the paragraph is filled with "probably's." (I will be publishing a post quoting that pargraph very soon.)

CMS estimated 40% compared to CBO's 1/3 when the public option paid at Medicare rates. Both CBO and CMS do say that there is a lot of uncertainty involved, so upon consideration I agree that no one is sure. However, they're not saying that the uncertainity is in a particular direction: it could be either up or down. (Kip Sullivan has argued that it is down.)

The truth is that No One can guess what percentage of millions of Americans will choose a public plan three years from now. We don't know anything about the details of the public plan. Or the price. We know little about the private plans that will be competing.

Elmendorf is indulging in an exercise in mind-reading-guessing what millions of Americans will decide three years from now.

And when I heard that Elmendorf said only 30 million would be in the Exchange in 2019, and that the public plan would be tiny and more expensive than private plans, I wondered: how did he come up with those numbers?

So I went to the source where he laid out these figures, a letter he wrote to Rangel in late October. There I found all of the "probably's"-
and no facts to justify his conclusion.

He just assumes that because the public plan is a governement plan, it "probably" will make no real effort to control costs or utilization-which makes no sense whatsoever. Medicare makes a real effort to control costs (see below) and going forward, Medicare plans to slash some fees beginning next year (see blow). The public plan will too.

CMS reached a very similar conclusion to CBO about the public plan having higher utilization. It's not just Elmendorf.

Moreover, what we know with certainty is that a public family plan will be at least $2000 less expensive because it won't have the private sector's administratie costs. (This number is from Commonwealth.) The public plan will not have to lobby. It will not spend much (if anything) on marketing and advertising. EVeryone will know that it exists, and it will get much free advertising in the many,many stories that will be written about it in the press, on blogs, plus stories on television.

Commonwealth Fund talks about a completely different situation with an enormous exchange that takes up around half of the nation's health insurance market. One crucial assumption that differs is that their public plan uses Medicare's provider networks and claims processing. This public plan, by contrast, must set up its own networks. In my original post I pointed out Karen Davis's statement on how their study's assumptions differ from the bills now in Congress. You ignored it.

(Mahar did an article on the Commonwealth Fund report here. Somewhat shockingly because it directly contradicts her arguments below, at one point she says: "...in many cases, the doctors who treat them would be paid less. As a result, patients who choose the public sector plan might well have a hard time finding physicians willing to take their insurance...The private plans would have the funds needed to pay providers more and create "integrated networks," overcoming some of the fragmentation that leads to errors in our health care system.Quite simply, they would be able to offer better care." The emphasis is mine.)

The full and much longer version of this post is available on ZBlogs. You may need to click this link twice if they redirect you to the Emergency Funding Appeal.

On November 9, Maggie Mahar is doing a book salon at Firedoglake on her book Money-Driven Medicine. I think it probably contains many useful facts, and even decided to order it last week from Amazon. For example, it correctly points out that the largest problems in the American health care system today are unnecessary procedures and overpayment for services. However, I now know that I will need to closely scrutinize its every word before accepting it as true. Why will it be hard to take this book at face value? Because Mahar has lately engaged in a complete flight of fancy about the proposed "public option."

She now exhuberantly and routinely describes the public option as "Medicare E (for everyone)" (1,2,3,4,5). This was before the rates tied to Medicare were removed, but even when they still existed, this was not an accurate characterization of the public "option." In the first place, she herself says: "At most, I'd estimate that 25% of the population will be able to choose the public plan in 2013." In my view this is not totally unreasonable, but it certainly contradicts her description. Her estimate is higher than the CBO's (10%) because she is considering who can legally join the public plan, not how many are expected to join the exchanges. She even makes what by itself is a valuable point: the CBO is not telling us that 10% of the public can legally join the public plan.

But the more important question is: how many actually will? Let's say that we had a public plan operating at near Medicare rates. CMS says its premiums would be about 11 percent lower than private premiums. Does that mean everyone would flock to the public plan? No. For one, there's another big factor that has to be taken into account in discussing consumer preferences: the provider network. For example, I can start an insurance plan in my backyard that pays at Medicare rates. No one will join it because no providers are willing to do business at those rates, unless I happen to have a pre-populated pool of customers at least somewhat comparable in size to Medicare's (43 million) to negotiate with. In fact, this is a big unsolved problem (1,2) that public option advocates have yet to address. But even assuming it can be dealt with, paying lower rates would certainly have an adverse effect on which providers accept the public option. (Today some providers even refuse Medicare itself.) That will impact consumer choices.

Indeed, if Mahar had paid more attention to the Commonwealth Fund whose work she cites in her articles, she would have noted Karen Davis's admonition that:

Unfortunately, as legislation has worked its way through congressional committees, the potential power of a public plan has been substantially eroded in three ways: by dropping the requirement that providers that receive Medicare payment also participate in the public plan; by requiring the U.S. Health and Human Services Secretary to negotiate provider payments rather than base prices on Medicare rates; and by restricting access to a public plan option to individuals and small firms. As a result, a strong public option is no longer a component of several bills now being debated in Congress.

And because the public "option" will not be a single payer system like Medicare, its administrative costs will not be as low, though they are expected to be lower than those of private insurance.

There is also no reason to believe that most who are legally eligible to enter the exchanges will do so. For individuals with employer sponsored health insurance, it would in general make no sense to purchase individual insurance on the exchanges any more than it would make sense to purchase individual insurance elsewhere. Administrative costs for individual plans are higher than for group negotatiated employer sponsored plans. It would certainly make sense for many individuals eligible for subsidies to join the exchanges, because in many cases the subsidies would outweigh the high cost of purchasing individual insurance. That is why Congress has limited the subsidies to those without access to employer provided coverage, and mandated that all except the tiniest employers provide such coverage. Arguments such as this are hence generally moot:

...anyone who becomes uninsured during the course of the year can join the Exchange. And even if their circumstances change (for instance they find a job that offers insurance), they can stick with the plan they chose in the Exchange.

Those purchasing individual insurance who are eligible for subsidies would have a clear incentive to join the exchanges. Most who currently purchase insurance individually are fairly well off, so this is a minority, but others would make the shift and the CBO did try to account for that. I wouldn't be suprised if the CBO figure is not exactly right, but there's no clear reason why it should be wildly inaccurate. Healthier people would seemingly have an incentive not to join the exchanges because of all the relatively unhealthy categories of people who would get subsidized in, thus raising premiums.

The full version and end of this blog post is available on ZBlogs. You will need to click the link twice since new visitors are redirected to the Emergency Funding Appeal.

This is a transcript of the chat I had with Matthew Kerbel about his new book celebrating the "netroots," including groups like Daily Kos and Open Left which he considers to be part of "the Left." In this chat I tried to pin him down more specifically about what he meant by "the Left" and "progressives." First I'll post the Firedoglake summary so you can get more of an idea of what his book is about, and then the chat.

For members of the Firedoglake community, I expect Matthew Kerbel's Netroots:Online Progressives and the Transformation of American Politics will prove to be equal parts familiar and insightful. The familiarity comes from the rich descriptive account he provides of the netroots community itself. Unlike many of his contemporary academics, Kerbel has clearly done the legwork of getting to know progressive blogging communities like FDL, DailyKos, OpenLeft, and others. In offering a detailed account of the goals, values, and achievements of this community, Kerbel portrays the netroots as it is; rather than perpetuating the easy stereotypes so often provided by defensive political pundits and the like.

The insights come from the broader academic framework he provides. In chapters that compare the netroots to previous technologically-mediated social movements in American history, compare the progressive netroots to the conservative "rightroots," and discuss the netroots community as a venue for social capital-building, Kerbel provides a scaffolding of sorts for viewing the very activities that Firedoglake participants are engaged in, yielding valuable insights in return. I highly recommend the book.

One particularly refreshing element of Kerbel's work is his decision to focus on the netroots as a social movement rather than focusing on blogging more generally. For several years now, academic researchers have gotten stuck in an intellectual cul-de-sac of sorts, asking what impact blogging in the abstract has on politics or equating all blogging with the rarely-defined term, "citizen journalism." Firedoglake provides a fine illustration of the flaws in this framework: FDL features both high-quality journalism from Marcy Wheeler and company, and cutting-edge political advocacy through FDL-action's Whip count tool. FDL is a hub for a political "community-of-interest," and that makes it different from a random wordpress blog. Some blogging (but not all) offers an alternative venue for journalism. Some blogging (but not all) has a real impact on elite decision-makers and public narratives. By focusing on the political Netroots rather than the abstract architecture of blogging software, Kerbel is able to add considerably to our knowledge of the substantive achievements of Netroots progressives over the past several years. I expect it's going to be an important book for years to come, specifically because of the serious attention he pays to the actual achievements of this community.

His focus on netroots achievements yields an immediate result in the opening chapter, which offers a series of pithy insights that receive elaboration over the course of the book (and probably provide good starting points for our discussion with the author):

* "Technology facilitates political change - eventually"
* "The power of the internet rests with the ability to understand and use its decentralized structure"
* "The Left is better situated than the right to take advantage of open source Internet politics"
* "The progressive blogosphere is neither particularly ideological nor extremist"
* "The netroots are an elite movement"
* "The Internet does not need to penetrate society in order to be a politically influential vehicle"
* "Netroots activists oppose the Democratic establishment as strongly as they opposed the Bush administration"
* "Netroots activists oppose mainstream journalists as strongly as they opposed the Bush administration and oppose the Democratic establishment"
* "Netroots activists gauge their effectiveness on how well they influence political outcomes, media narratives, and political engagement"
* "There is evidence that the netroots are making progress toward their political objectives"
* "There is only limited evidence that the netroots are making progress toward influencing mainstream media narratives"
* "The evidence of netroots community building is strong"
* "Netroots bloggers practice and seek a politics of community facilitated by Internet interactions"

The book is engaging, readable, and not-too-long (158 pages). Chapter 2 offers a look at the deep historical roots of the moment we now find ourselves in. Kerbel demonstrates that, throughout American history, moments of technological change have been accompanied by dramatic changes to the practice of American politics. Chapter 3 discusses how the "vertically-integrated" conservative blogosphere, relying as it does on earlier institutions of movement conservatism, is less well-suited to the decentralized structure of the web than the their "horizontally-integrated" progressive counterparts. Chapters 4, 5, and 6 then provide a detailed look at netroots achievements based on the community's own stated goals of affecting political outcomes, media narratives, and developing a strong progressive voice within the democratic coalition. It is in these chapters, and in the concluding seventh chapter, that FDL community members are most likely finding themselves shaking their heads in familiarity at events that they themselves helped make happen.

Some FDL members may have already heard Matt talk about his book at a Netroots Nation panel this past summer titled "academic studies of the netroots." Chris Bowers, the chair and coordinator of that panel, memorably described it as "the meta-panel to end all meta-panels." I think that's a good lens for us to view the book, and to think about this book salon. Matt Kerbel has decades of experience observing how technology affects political communication, and his newest book tells us how the netroots are moving America into an era of "post-television politics." For the next couple of hours, let's put our meta-blogging hats on and see what we can learn about the netroots social movement that we are ourselves engaged in.

Welcome, Matthew Kerbel!

 

Now for the chat.

The full version of this post is available at ZBlogs. (You will need to click the link twice. First time visitors are directed to the Emergency Funding Appeal.)

A new poll on the Massachusetts Senate race has state Attorney General Martha Coakley dominating the field with 37 percent support from registered Democrats and unenrolled voters, who are eligible to vote in the primary. That is more than double her nearest challenger, with 14 percent backing Boston Celtics co-owner Steve Pagliuca and 13 percent supporting Congressman Mike Capuano.

What are the stances of these candidates on issues? Amazingly, in a state where seven out of ten representatives have endorsed HR 676, the United States National Health Care Act, only one candidate out of four Democrats and one Republican supports Medicare for All, and that's Mike Capuano. Even his support is not the most avid, since he doesn't talk about it very often and has sometimes qualified it with "if I were emperor." But support is still support, and he's an HR 676 cosponsor.

In contrast, Martha Coakley supports a plan that is quite different: the so-called "strong public option," no doubt meaning the version that the CBO estimated in July would cover only about 10 million people after it was implemented. In the recent white paper released by her campaign, she says:

The full version of this blog post is available at ZBlogs. (You'll need to click the link twice. New visitors are redirected to the Emergency Funding Appeal.)

I was just reading this article from WaPo by Lori Montgomery. It's ostentatiously titled "CBO: House bill's health-care spending would dwarf Senate proposal's." It claims that: 
 

The health package released Thursday by House leaders would increase federal spending on health care by nearly $600 billion over the next decade, according to the nonpartisan Congressional Budget Office, a dramatic increase that dwarfs the expansion envisioned by the latest Senate bill.

And in general:

less than half of the cost of the House coverage expansion would be offset by other changes, leaving the government spending $598 billion more on health care by 2019 than it otherwise would have -- seven times more than under the Senate package.

Only problem is, this seems to me to be a complete misinterpretation of CBO's numbers.

The CBO actually says:

Net Change in the Federal Budgetary Commitment to Health Care 85 598

This is not a change in spending. Rather, it's a change in the amount of federal revenues raised from outside the health care system that are being spent inside the health care system. The Senate has a much smaller figure, unsurprisingly, because it taxes employer sponsored health coverage and doesn't rely on a tax on the rich that is unrelated to health care. The spending for each bill is:

Gross Cost of Expanded Insurance Coverage 829 1,055

What's particularly unnerving is what a big deal the writer apparently thinks this "revelation" is:

The first measure, impact on the federal budget deficit, has been widely reported: The House bill would reduce deficits over the next decade by $104 billion while the Senate Finance Committtee bill would reduce deficits by $81 billion. 

Yes, the first (accurate, real) measure has been widely reported. But look--I've got this. 

I didn't write this post. I stole it from ralphbon, a poster on Firedoglake. This is the original. I'm posting it because it's a very important action request.

(I did write this about the new House bill's CBO numbers, but the below is more important.)

As reported earlier, House leaders have stripped the Kucinich amendment from the House health care reform bill. This amendment would help nullify legal challenges against efforts by individual states to enact their own single-payer systems.

To my surprise and disgust, Politico reports that Nancy Pelosi has also signaled her intention to renege on her promise to allow a symbolic floor vote (aka the Weiner amendment) for HR 676, Expanded and Improved Medicare for All.

According to Tim Carpenter of Progressive Democrats of America, one avenue of appeal remains regarding these efforts:

Democratic House leaders can insert what is called a "Manager's Amendment" into legislation, even when it is closed to any other amendments. The managers are the majority and minority members who "manage" debate for the bill on each side.

Today, tomorrow, and beyond, we need to call these "managers" and insist that the Kucinich Amendment is restored into the healthcare bill....

The "gang" that holds our future in their hands includes:

* Speaker Nancy Pelosi: Washington, DC, office (202) 225-4965; San Francisco office (415) 556-4862

* Majority Leader Steny Hoyer: Washington, DC, office (202) 225-4131; Greenbelt office (301) 474-0119; Waldorf office (301) 843-1577

* Rep. Henry Waxman: Washington, DC, office (202) 225-3976; Los Angeles office (323) 651-1040

*Rep. Charles Rangel: Washington, DC, office (202) 225-4365; New York office (212) 663-3900

* Rep. George Miller: Washington, DC, office (202) 225-2095; Concord office (925) 602-1880; Richmond office (510) 262-6500; Vallejo office (707) 645-1888

It's crucial for everyone in PDA to make these calls, to make them more than once, and to tell others to make these calls. Act NOW!

The ellipsis in the above quote covers the following line, with which I part company with PDA:

We also need to urge these leaders to exert pressure on Speaker Pelosi --- and exert it on her ourselves --- to follow through on her promise to put the Weiner Amendment to a vote.

People I respect greatly disagree with me on this point, but I think it's tactically foolish to waste a final Hail Mary effort on a double request. The likelihood that leadership will bend on either of these requests is minuscule, but if they do bend at all, it will be to allow the purely symbolic HR 676 floor vote as a sop to single-payer supporters and take no action to restore the Kucinich amendment, telling progressives that one for two isn't bad.

I will call leadership, but only to demand restoration of the Kucinich amendment. California, Pennsylvania, and other states with active movements to establish their own single-payer systems deserve that measure of help.

According to Progressive Democrats of America and this OpEdNews piece, the Kucinich Amendment to waive federal ERISA regulations that might hold up state single payer movements has been stripped out of the final House health care bill. This will be a blow for state single payer movements because insurance companies may now be able to file disingenuous court cases holding up the implementation of any legislative victories. (This is reminiscent of what happened in California after that referendum on car and other types of insurance back in the 1980s.) It's important to note that it's not a fatal blow, however, because speaking objectively federal ERISA regulations may not actually impact single payer systems. But it's still not a chance we wanted to take.

Also, the public plan for the uninsured is not tied to Medicare rates, which probably means that even the skimpy 9-10 million people estimated to sign up by the CBO for the original plan is a big overestimate. It is even possible, if the plan resembles the one in the Senate HELP bill, that no one would sign up for this plan; in other words the plan would be moribund.

As Pelosi said would happen some time ago, the surtax on the rich has been significantly reduced as a funding source. This raises the obvious question of where they are getting the rest of the money. I guess we'll know tomorrow.

The full version of this blog post is available at ZBlogs. (You will need to click the link twice as the first time you'll see the Emergency Funding Appeal.)

By blogging on a certain website, we help to legitimize its viewpoint. We generate advertising revenue for the site through our own hits and through hits that are a result of responses to our posts from others. We contribute to any reputation the site may have for being especially renowned and important. We contribute to the personal reputation of its editors and founders and help their voice extend further and sound louder than it might if we stayed away. In exchange, we get a place to share our views and learn about others.

I've reluctantly come to the conclusion that the views being presented right now on health care at Daily Kos are, at least at this time, doing more harm than good in the fight for reform. First among my concerns is the total failure by the editors to promote any kind of national health care system, which could but does not necessarily have to be Medicare for All. Given public opinion polling showing that a majority of the public probably would favor Medicare for All given the choice, the current monotone focus on the public option is simply a red herring that does more to hurt the fight for real reform than to help it. Secondly, even this focus is not what it claims to be. As Kip Sullivan has said, it's a "bait and switch."

The fundamental question is: why is a blog that claims to be "from a liberal perspective" not strongly promoting a national health care system given public opinion statistics like those currently in America? Isn't liberalism supposed to be defined with respect to public opinion? If not, then who should define it? The word statistics I wrote about a few months ago are unchanged at best, with stories by the editors mentioning "public option" outnumbering those mentioning "single payer" or "Medicare for All" by over ten to one.

There are all sorts of arguments that can be made to defend this. For example, take editor DemFromCT, who in the comments to my above post said:

But what of it? Health reform is a rich, complex tapestry and you want to reduce it to a single thread of "liberal vs right".

It is true that health reform is complex. I for one have become increasingly aware that health insurance reform by itself is not all of health care reform, because there's also reform on the provider side. And Medicare for All is not the only way to implement national health care. But none of this is relevant here, because the Daily Kos editors are not focusing on any other way to do it. They're just focusing on the public option, and that is not anything even remotely close to a viable alternative.

My assessment of Daily Kos is that, while it is certainly a Democratic blog, it has no claim to being a liberal or progressive blog on health care. In fact, don't take my word for it. Take its founder's:

This is a Democratic blog, a partisan blog. One that recognizes that Democrats run from left to right on the ideological spectrum, and yet we're all still in this fight together. We happily embrace centrists like NDN's Simon Rosenberg and Howard Dean, conservatives like Martin Frost and Brad Carson, and liberals like John Kerry and Barack Obama. Liberal? Yeah, we're around here and we're proud. But it's not a liberal blog.

Most Congressional Democrats do not favor a national health care system, including everyone from the "conservatives" to the "liberals" that Markos Moulitsas names above. But most of the public probably does, so when push comes to shove, one has to choose between being more Democratic and being more progressive. You can't be both on this issue. Daily Kos is firmly Democratic.

And I can see the utility of that. Thinking independently doesn't win you many friends. If Daily Kos did embrace national health care and strongly criticized Congressional Democrats on health care policy, as would then become logical, then its status as being the biggest political blog on the net would likely be over. Does anyone think that Countdown would really have Markos Moulitsas on as much, or maybe even at all, if he started focusing on national health insurance? Would the corporate media, and also Democratic establishment groups like Campaign for America's Future and the rest of the HCAN/Herndon Alliance crowd cite the blog as much? Perhaps even more pressing, would national Democratic politicians like John Kerry, Howard Dean, Barack Obama, or Chuck Schumer ever post there? Of course not! They would run for the hills. That would be it! Daily Kos has every reason to align with elected Democrats on issues. It would make absolutely zero sense, from a narrow self-interested perspective, to make a serious break with them on the huge issue that health care is right now.  

Also worth noting is editor BarbinMD's reply to a sharply critical post of mine about their coverage:

First, this is a Democratic blog and we're dealing with the reality of what's currently happening in Washington.

You seem to be missing what this place is about - the editors aren't the leaders, everyone who participates here is. If you have an issue that you care about, you write about it, you don't tell other people what they should be writing about.

She's right in her first judgment. It's a Democratic blog and will therefore not stray too far from whatever the Democratic consensus in Washington is. Ever expecting wholesale criticism of that consensus was indeed naive of me.

But where she's wrong is to say that everyone who participates in the blog are leaders. The FAQ should disabuse us of that:

No. Daily Kos is owned by Kos. The servers are his. He pays the bandwidth charges. He makes the rules; we are here as his guests. If he decides tomorrow that anyone not posting in iambic pentameter will be banned, your options are either to brush up on your poetry skills or find/start another forum.

More specifically, Kos is the leader. He has set up Daily Kos with a certain purpose, and given the editors a prominent voice through the front page. So I was imprecise in saying that the editors are the leaders; in reality Kos is the leader. And it was indeed foolish and naive of me to ever think that talking to the editors would make any difference in the blog's agenda, because they don't make the rules. I apologize for that naivete.

To see how unflinching Daily Kos is at sticking to the elected Democratic consensus, also consider that the whole public option idea is not even remotely close to what its defenders and most elected Democrats make it out to be. To understand why, check out Kip Sullivan's bait and switch piece from a few months ago. Because this is so important, I'll quote a few paragraphs:

The people who brought us the "public option" began their campaign promising one thing but now promote something entirely different. To make matters worse, they have not told the public they have backpedalled. The campaign for the "public option" resembles the classic bait-and-switch scam: tell your customers you've got one thing for sale when in fact you're selling something very different.

When the "public option" campaign began, its leaders promoted a huge "Medicare-like" program that would enroll about 130 million people. Such a program would dwarf even Medicare, which, with its 45 million enrollees, is the nation's largest health insurer, public or private. But today "public option" advocates sing the praises of tiny "public options" contained in congressional legislation sponsored by leading Democrats that bear no resemblance to the original model.

Of interest as background is that virtually the entire battery of polling data on this, in a truly stunning display of mass media conformity, has been about a real public option as opposed to the tiny option actually being proposed in Congress. The whole US corporate media has ignored the fact that the "option" in HR 3200 would not be an option to anyone outside of the Exchange, which is limited to around 10% of the public. And the version in HR 3200 is the strongest in any of the bills.

So the "robust public option" trumpeted by mcjoan (1,2,3), slinkerwink (1,2,3), Jed Lewison (1,2,3) and others is anything but robust. The whole notion has essentially been a huge lie, and these people have proved remarkably adept at believing in it, to the point where it seems to me that they could care less about the truth as long as most elected Democrats agree and their own popularity with readers remains high. All three of them are full time political writers, and ought to have enough exposure to the facts to understand that what the Democrats are selling isn't what the public thinks it's buying.

To cite an example, when I wrote a blog post about the tiny size of this public "option" a few months ago, slinkerwink was very adamant about telling me the opposite. She has also done the same to her readers, for one by quoting mcjoan's comments on the Commonwealth study about a huge public option, and even moreso just through omitting the essential facts. Events since then (like Obama's speech) have made it more clear that the public option is tiny, but I'm not aware of any big statements by slinkerwink or mcjoan apologizing to their readers for grossly misleading them about its size. I'm also disturbed that slinkerwink is being paid to write diaries (which are normally written by unpaid writers) on a daily basis, because this makes it impossible for other views to compete. I would have less of a problem if the diaries were more reasonable, but given that they systematically ignore the most important parts of the situation, the whole arrangement seems to me a kind of dangerous propaganda mill.

On Daily Kos, though, doublethink is a matter of routine. So when mcjoan did her online interview of T.R. Reid about his important new book, The Healing of America, his final and most concrete point about the American health care debate was that all the proposals so far were just "tinkering at the margins" of our health care system. mcjoan even acknowledged that a true "unified system" like the one he favored wasn't on the table. But despite this acknowledgment, she then turned right around and, of course, pushed the usual public option proposals the very next day. The message is that while it's fine to call T.R. Reid's book "required reading" for all US leaders, it's quite beyond the pale to actually advocate what it says yourself.

The result of all this is a whole mythology of how vital it is to stop the public option from being "triggered," from being subject to a state opt-out, or from being replaced by co-ops. In reality, all of these results will be completely invisible to about 90% of the population, whether they come out favorably or unfavorably. The bottom line of this health care bill, as people like Ezra Klein have noted, is that it doesn't alter the structure of the system much for anyone except the uninsured or sick. Yes, it does institute community rating and bans on rescission and discrimination on pre-existing conditions. But for those who already have insurance and are not seriously ill, the system remains the same, even though it's that very system that is making health insurance unaffordable. And for reasons that I pointed out above, any establishment Democratic organization like Daily Kos fundamentally cannot deal with that, because most Congressional Democrats are currently against changing it.

Daily Kos's situation is hardly unique, though it is probably the biggest and worst example of public option fixation in the blogosphere. Firedoglake apparently has a similar stance, though it's also decidedly less controlled and rigid. Still, the recent move by founder Jane Hampsher and nyceve to create a permanent nonprofit organization called Public Option Please, to exist even after the current legislative battles are over, is really depressing to me. This is the very same nyceve that wrote this awesome piece as recently as last year calling out MoveOn.org and HCAN for rejecting single payer as a position. Apparently she herself has now fallen into the very same trap. I hope that she'll return to her previous well thought out stance.

I will still post on Firedoglake and TPMCafe, because though I may have my differences with the editors on these blogs, there is a large and vibrant single payer community on Firedoglake. These blogs also lack one feature of the Daily Kos setup that pretty much eliminates the possibility of free debate, namely the hide rate system, in which users can remove the posts of other users if they find them to be too upsetting. Whatever the official justification for this system on Daily Kos, in effect it's little more than a subtle tool for promoting conformity. (For example, when I wrote several angry posts about John Kerry's and Howard Dean's failure to support Medicare for All, the posts were consistently hide rated.) If a person really is a troll, they should just be banned, and that should be the end of it.

In the longer run, I hope that more people will move to blogs such as ZBlogs where the official editorial stance of the blog is, instead of being pro-Democratic, pro-progressive and pro-leftist. (The link must be clicked twice.) I for one don't feel able to post only on ZBlogs right now because, well, there aren't many people there, and also the software is still pretty rickety. Nevertheless, I will be doing a lot of "exclusive content" posts where I crosspost one version of a post on other blogs and a more extensive version on blogs like ZBlogs. That way every post is in effect a marketing effort for a more progressive media.

My central message to those in the blogosphere and media right now who seem to think, as I once did, that Daily Kos is somehow a liberal blog on health care is: it's not. It has zero legitimacy as speaking for the left on this issue, and like most elected Democrats right now, is actually more on the reactionary, elitist, neoliberal, and pro-industry side of public opinion. (About four out of almost sixty Democrats have endorsed Medicare for All in the Senate.) So when you see Kos on Countdown talking to Keith Olbermann, don't have any illusions about who he represents. He represents Democrats, and right now, I'm sorry to say, on this issue Democrats mostly represent the health care lobbies.

For those media figures interested in having a balanced health care debate, pick an actual leftist to represent the left. And for those bloggers who want to support conscientious blogs, don't make Daily Kos your forum of choice.

Crossposted on ZBlogs, Daily Kos and Firedoglake

It seems to me that many people who consider themselves left wing are unaware of the polling data on Medicare for All. On the one the hand we have the Democratic establishment crowd, who typically assume that, because Democratic leaders largely oppose Medicare for All, public opinion must be against it as well. (About four of one hundred favor it in the Senate.) On the other hand we have the Medicare for All activist crowd, who sometimes believe support is higher than it really is. (For example, a two thirds majority hasn't been recorded in any poll this year.)

To explain the true situation, I did the following exercise. I took all the polls I could find from this year on Medicare for All, along with a roughly equal number of polls on the "public option," and plotted them on this graph:

 

 

There are four bands in this picture. The first two bands, one black and one red, represent Medicare for All support and opposition. In any poll, we will have a certain number in support, a certain number opposed, and some undecideds. The next two bands represent support and opposition to the public option. The blue dots represent the mean of the closest band. The mean for the first band indicates that a very narrow majority (50.4%) is in support of Medicare for All and a slightly larger majority supports the public option.

 

The Medicare for All polls I used are listed here. Most are available through this link.  I also made sure to use the one commented on by Matthew Yglesias here.

Kaiser Tracking Poll (Phrasing #1, yearly average) 46.8-49%

Kaiser Tracking Poll (Phrasing #2) 58-38%

CBS/NYT Poll (covering only emergency problems) 59-32%

CBS/NYT Poll (covering all medical problems) 49-42%

Grove Opinion Research Corp. Poll 59-?%

Time Magazine Poll 49-46%

Rasmussen Poll 32-57%

 

The public option polls I used were:

Rasmussen Poll 41-41%

Kaiser Tracking Poll 65-29%

Economist/YouGov Poll 41-33%

CBS/NYT Poll 72-20%

Quinnipiac Poll 62-32%

Time/SRBI 56-36%

 

Choosing public option polls required some thought because there are so many. I adhered to the following guideline: either use Nate Silver's recommended polls or choose one from the same source as a Medicare for All poll. (All the polls above are also linked to by Silver's page.)

At this point I thought it would be helpful to try to get rid of polls that might not be valid and look at the results. Therefore, I removed both polls by Rasmussen because the way they're phrased seems biased. I also removed the NYT/CBS figure asking about coverage of emergency problems only, since Medicare for All would cover more than that. (Of course, one could argue that the other figure for all medical problems is bad too, since Medicare doesn't cover all medical problems. Ideally, we might perhaps then use a weighted average, but I did not bother.) Finally, I threw out the CBS/NYT public option poll because it calls the public option a plan like Medicare, which it is not.

Here are the results. 

The full version of this blog post is available at ZBlogs. (You will need to click the link twice due to the Emergency Funding Appeal.)

In his classic book Taking the Risk Out of Democracy, Alex Carey argued that corporate propaganda shapes public political opinion on two different levels: grassroots propaganda aimed at the masses, and "treetops" propaganda aimed at elites and intellectuals. In contrast to grassroots propaganda like, for example, the recent Chamber of Commerce national advocacy campaign,1 "'Treetops' propaganda is not directed at the person on the street," Carey wrote. "It is directed at influencing a select group of influential people: policymakers in parliament and the civil service, newspaper editors and reporters, economics commentators on TV and radio." In the words of one former director of a British neoliberal think tank, it helps to use "intellectual artillery to soften up the enemy's entrenched strong points," so that eventually the "ground troops can advance."2

The purpose of this post is to refute three falsehoods perpetuated by two neoliberal think tanks, the Heritage Foundation and the American Enterprise Institute, in their steady campaign of "treetops" propaganda. These falsehoods have in my experience either been a source of confusion for progressives or have been cited by moneyed organizations like insurance companies to help discredit policies that might threaten their profits. A longer version of this post is available on ZBlogs.

The American Enterprise Institute (AEI) was founded in 1938, partly by executives from corporations such as Eli Lilly, General Mills, Bristol-Myers, Chemical Bank, and Chrysler who were disgruntled with the effects that the New Deal was having on society. Its board is today made up almost entirely of executives from major corporations, and it's staffed mainly by intellectuals and former government officials. Growing rapidly between 1970 and 1980, when its revenue expanded from less than $1 million with a staff of ten to about $8 million with a staff of 125, it played an important role in ushering in the current era of Reaganist, supply side, neoliberal economics.3 It is currently ranked sixth on a list of America's most influential think tanks, the second highest of "partisan" think tanks, just behind the Heritage Foundation.4

The Heritage Foundation was founded in 1973 with help from beer magnate John Coors. It was instrumental in creating the Contract with America that helped Republicans win a 1994 majority in Congress. In partnership with the Wall Street Journal, it publishes the annual Index of Economic Freedom. The Index notes that this year, "Regrettably, populist attacks on the free market, fueled by the economic slowdown and the political temptation of quick interventionist remedies, have gained momentum." It is currently ranked fifth on a list of America's most influential think tanks,  the highest ranked of those that are considered "partisan."5,6

Falsehood #1. The US does not spend an excessive proportion of its GDP per capita on health care.7

This statement is so clearly untrue that it doesn't seem to be quoted much even by other right wing sources, but it's still important because it demonstrates a total lack of intellectual integrity by the AEI authors who made the claim.

To understand how they rationalize this, let's start with another analysis of US health spending by Princeton economist Uwe Reinhardt published on the New York Times Economix blog.8 Here's the graph from that website.

Reinhardt explains:

You'll notice that there is enormous variation in health spending per capita in different countries within the O.E.C.D. But the graph also indicates that there exists a very strong relationship between the G.D.P. per capita of these countries (roughly a measure of ability to pay) and per-capita health spending. The dark line in the graph is a so-called regression equation (whose precise mathematical form is shown in the upper left corner).

That line tells us something important about the relationship between a country's wealth and its health care spending.

An additional insight from the graph, however, is that even after adjustment for differences in G.D.P. per capita, the United States in 2006 spent $1,895 more on health care than would have been predicted after such an adjustment. If G.D.P. per capita were the only factor driving the difference between United States health spending and that of other nations, the United States would be expected to have spent an average of only $4,819 per capita on health care rather than the $6,714 it actually spent.

Now let's compare the American Enterprise Institute source. After listing a similar graph to Reinhardt's, they then explain that it is irrelevant because the U.S. "residual" is sensitive to "model specification." In other words, you can just do this:

But as other bloggers have noted,9 they give no justification for why you would do that. They do state the US is an extreme value, because it's richer than almost all other countries, but that difference pales in comparison between differences between many of the other countries in the model (in other words, US GDP isn't an "outlier" in a technical statistical sense). And as Reinhardt states, the more intuitive model is a very good fit:

Just knowing the G.D.P. per capita of nations helps us explain about 86 percent of the variation in how much different countries pay for health care for the average person.

Finally, there's also the small matter that if we extend the above AEI model out another twenty-five years and assume a reasonable rate of economic growth, it eats up literally the entire US economy. But doing the slightest sanity checking is evidently uninteresting to these authors.

Falsehood #2. If you adjust US life expectancy for violent deaths, it becomes #1 in the world.

This is simply a lie. Unlike the falsehood above, though, it's not completely obvious that it's wrong, and so it's been used extremely successfully to muddy the debate.

What AEI did was create a model that predicted life expectancy from two factors: GDP per capita and violent deaths. But despite that the US ranks #1 in this model if you remove sources of violent death, that doesn't mean anything because the other factor, GDP per capita, totally fails to correctly predict US life expectancy. Putting it simply: the model's wrong, so any conclusions drawn from it are also.10

The OECD explains it thus:

It has been claimed (Ohsfeldt and Scheider, 2006) that adjusting for the higher death rate from accident or injury in the United States over 1980-99 than the OECD average would increase US life expectancy at birth from 18th out of 28 OECD countries to the highest. In fact, what the panel regression estimated by these authors shows is that predicted life expectancy at birth based on US GDP per capita and OECD average death rates from these causees is the highest in the OECD. The adjustment for the gap in injury death rates between the United States and the OECD average alone only increases life expectancy at birth marginally, from 19th among 28 countries on average over 1980-99 to 17th. Hence, the high ranking of adjusted life expectancy at birth mainly reflects high US GDP per capita, not the effects of unusually high death rates from accident or injury.

It took about a year for this study to be refuted after it was published, finally prompting the authors to divulge to the Wall Street Journal that they were "not trying to say that these are the precisely correct life-expectancy estimates. We're just trying to show that there are other factors that affect life-expectancy-at-birth estimates that people quote all the time."11

What is really more interesting, though, than the study itself is the vast extent to which this keeps being repeated in the (supposedly more democratic) blogosphere because people are just unaware of the falsity. For example, when Betsy McCaughey cited these statistics on the Daily Show, most people even on Democratic blogs like Daily Kos and Firedoglake did not realize that this study had already been definitively refuted, though of course they were very skeptical of McCaughey in general. On Daily Kos not one post mentioned it at the time, though of course it's possible that people were distracted by McCaughey's claims of "death panels." But on Firedoglake we still have people wondering about this in blog posts--and no one pointing out it's already been refuted--as of a few weeks ago.12 Meanwhile a July post on the "slightly left of center" blog Angry Bear cited this study as "casting serious doubt" on the significance of the life expectancy difference, with no refutations in the first few pages of comments.13

Senators like John Ensign have also cited these statistics in Congress. Meanwhile Amanda Terkel, a Deputy Research Director of the Center for American Progress, doesn't realize in her Think Progress blog response to Ensign that it's all a complete lie despite being skeptical in general.14 And don't even mention the right wing blogs!

What seems to be happening here is that the traditional media has mostly ignored the fact that these figures are false, leaving amateur bloggers to wander about hopelessly in a swamp of misinformation. If the media was more decent, they would call these people out vigorously as liars, not write, say, one Wall Street Journal blog post and then forget about it. (The post cited above concludes ambiguously, "What do you think? Should certain deaths be excluded from life expectancy? Is it a solid basis for comparing health systems? Please let me know in the comments.")  

In an effort to promote Z Magazine, ZNet, and ZBlogs, I have made a longer version of this post (including falsehood #3) available exclusively on ZBlogs. Z Magazine is currently in dire financial straits and desperately needs support. It had to reduce the size of the October issue due to lack of funds and reportedly may fold up as soon as January 2010 if donors don't help. Given its extremely valuable perspective and twenty year history, this would be a tragedy. Also, for those bloggers of explicitly leftist persuasions, ZBlogs is one of a very few blogs that is too--so you may want to consider becoming a Sustainer and posting there.

After reading some comments here lately I wanted to address a few myths on health care that have been circulating. Medicare for All advocates and critics alike, please read this so we do not have to keep rehashing the same old flawed arguments.

Myth #1. (Two distinct versions, both wrong.)

A. For-profit insurance system administrative overhead is the biggest source of waste in our health care system

B. For-profit insurance system administrative overhead is a very small or even trivial source of waste in our health care system

The truth is somewhere in the middle. In the first place, we should consider the size of the problem. The US health care system costs about 17% of GDP, compared to perhaps 11% in more reasonable systems. So in order to reduce spending to that level we need to cut costs about 36%. 

There are two main sources of administrative waste caused by the US for-profit insurance system, namely insurer overhead and the provider overhead needed to keep up with insurance billing. Both Medicare for All advocates and their critics seem to concentrate only on the first one, but the second one is probably the bigger of the two. To understand the size of the first one, check out this Ezra Klein article. The overhead of private insurers is about 12% on average. By comparison, Medicare's real overhead is probably about 5%, which is somewhat larger than the official rate of 3% cited by most Medicare for All supporters, but certainly lower than for private insurers.

The other part of administrative waste from this system, and the larger one, comes from all the costs providers must incur to deal with an extremely fragmented for-profit insurance ("free") market. Because fees are negotiated directly by individual insurers, provider billing becomes much more complicated. No other country compares to the US system in this regard. In single payer systems it is obviously not an issue. In systems with non-profit private insurers, fees are either negotiated directly by the government (Japan) or at a regional level by associations of providers and insurers (Germany, Switzerland). Incidentally, the way that Japan does this, combined with the fact that its insurers do not compete with each other, actually makes it a de facto single payer system (see T.R. Reid, The Healing of America).

Putting these together accounts for the difference in overhead between the US system, at roughly 31%, and the Canadian system, at 17%. Hence if we could get to Canadian levels we could save roughly 14% of health care expenditures. Some people think you could quickly get all those savings by switching to single payer. Others don't--but even if you could get 10%, that is not a trivial fraction of the 36% that I said earlier is needed.

The truth is therefore somewhere in the middle: these savings are not a majority of the waste in the US health care system, but they are still a big chunk.  

Of course, the question now is where we get the rest of the savings. This leads to the second myth.

Myth #2. (Again two versions, both wrong.)

A. Provider waste is not the biggest issue in health care reform; insurance waste is.

B. Proper reforms of the insurance system would not curtail much of this waste.
 

We just refuted the first part. The second seems intuitively obvious when one realizes that much provider waste takes the form of unnecessary procedures and excessive payment fees, which can respectively be denied and reduced by a properly functioning insurance system. In short, what is needed is bargaining power. Obviously a single payer system where the government just negotiates rates by fiat has a huge amount of bargaining power, although there are other ways to get it too.

This is why provider lobbies like the AMA and the ACP only favor a public option that can compete "fairly" with private insurers, meaning one that does not crowd out the marketplace and accrue substantial bargaining power. They are amenable to a public option only that negotiates rates directly with providers, not with rates based on Medicare, and basically want it to look exactly like a non-profit insurance company that happens to be owned by the government. They're absolutely terrified of the idea of a really strong public option, much less Medicare for All, because it would mean painful cost cutting. 

Part of that also relates to actual personal income of doctors, which is not most of the problem, but is still a non-trivial part and is too high.

Finally it's worth noting that under a single payer system we would most likely be able to save a respectable amount of money on pharmaceutical bulk purchases. Now there's an industry with a high profit margin!

To conclude, my central points here for both Medicare for All advocates and critics are:

1. Most administrative waste due to US for-profit insurance is actually laid at the feet of providers, not the insurers themselves. 

2. Administrative waste is a big problem but not the majority of waste.

3. Single payer would still help us cut down on much of the other part, the provider waste.

    



 

Lately I have been thinking about the concept of "technological singularity" as advanced by Ray Kurzweil in his two books The Age of Spiritual Machines and The Singularity Is Near, as well as by Vernor Vinge, who invented the term. The singularity strikes me as a very real possibility that many people have written off via hand waving because it just seems too crazy, radical, and at odds with current trends. For example, The Economist featured an article mocking the concept with a comparison to trends in the number of blades on a razor, saying that the number of razor blades was projected to rise exponentially. The implication is that a steady Moore's law for the number of transistors that can be etched on a silicon chip, and more generally, for computer processing and all its spin-offs, is just as silly and outlandish as a hundred blade Gillette. Other observers such as Francis Fukuyama and John Searle assert that computers equaling human intelligence is impossible or at least far more difficult than science alone suggests. (I cannot answer these arguments here because it would take too long, but Kurzweil's latest book has a chapter called "Response to Critics" that presents compelling replies.)

My impression so far has been that dismissal of the singularity is especially common among progressives and leftists, although this may just be a result of it being more common among anyone who is not a radical neoliberal in the tradition of Kurzweil and Vinge. In the progressive community, the main comparable focus right now is on stopping global warming and the destruction of biodiversity on land and in the sea. This is myopic, though, in that it counts a threat attributable to present day technologies and one that could be halted at any time by accepting a lower standard of living as being more important than those that might arise in the future. The truth is that it's not enough to just look at threats that are possible with current technology because technology is a moving target. If you want to understand the threats of the 21st century, you have to view them through the lens of technology in the 21st century, which is likely to be extremely different from technology today. It is likely that we would find ideas about the threats humanity faced from authors publishing in 1909 to be quite comical, and completely ignorant of the nuclear bomb that was to inspire such fear just a generation or two later. And however right they would have been, someone who warned in 1909 about the likelihood of a bomb that could blow up a city probably would have been dismissed as a quack and an eccentric. Of course, just as it would have been literally impossible for anyone in 1909 to predict the creation of nuclear weapons, it may also be impossible for us to predict exactly which technologies will be feasible in 2045--but that there will be some that are true game changers seems a sure bet.

It seems to me that we should take the singularity seriously, not as a certainty, but at least as a real possibility that could actually happen even by the 2045 date that Kurzweil projects. If we do that, then the question is: what should our response be?

My view increasingly is that we should actively try to forestall it from happening any time soon because it's an inherently bad outcome. As Bill Gates said in his book The Road Ahead, any development of real artificial intelligence is concerning because it would raise profound questions about "the purpose of our species." Authors such as Kurzweil talk about posthuman intelligences, whether they be derived from non-biological computing technology or from somehow modifying humanity, as also being in some sense human. They apparently appropriate the word "human" to mean anything that is conscious. But I think this redefinition is at a gut level repugnant, not to mention fanciful and specious: humans are homo sapiens, no more and no less, and no amount of technological growth can change that. I reject the view that the purpose of technological growth is simply to expand the abilities of conscious beings. In my view, the purpose of technology should be to create a more fulfilling, edifying and sustainable existence for humanity for many generations to come, not to replace mankind with some Godlike entity or entities that can far exceed our capability in every way.

I also worry that in a capitalist society, any real transhumanist trend is likely to constitute a race to the bottom wherein people feel compelled to embrace new intelligence enhacing technologies that cut away at their own humanity or threaten the dominance of humanity as a whole. Even at the current time, surveys show that 20% of all college students have used Ritalin or other ostensibly cognition-enhancing drugs to try to improve their academic performance. What if at some point in the next twenty years, pharmaceutical companies invent a drug that, like drugs we have today that can boost memory retention in mice by incredible amounts, can improve human scores on standardized tests by entire standard deviations? Beyond the obvious ramifications at virtually all levels of human life, can anyone maintain that employers would not instantly discriminate against workers who refused to embrace the drug? It seems to me that, if we are to forfeit the position of unaltered humanity as the leading force on Earth, we should at least wait to do so until we have a system that doesn't compel individuals to help.

If these seem like bizarre speculations, I can only agree that they do seem bizarre, with the caveat that they may turn out to be well founded. I wish that others would take the idea of rapid technological growth in the next century more seriously, because if they did, they might well find the consequences to be as distasteful and unappealing as I do. And if they did, then we might be able to work together to try to combat the now well developed transhumanist movement that quite explicitly glorifies the idea of ending the human era and replacing mankind with more capable intelligences in this century. Instead of just laughing at this strain of thought as the product of nerds who read too much science fiction, we might actually try to formulate a comprehensive set of policies that would deter future technological growth in areas that could threaten humanity. Instead of cavalierly waiting until scientists come up with an advance that will drive people competing in a capitalist system to modify themselves, we could try to match the ratiocinations of the transhumanists with some equally compelling points of our own. We can start by banning the development of drugs for the explicit purpose of enhancing cognition in healthy individuals--this is without a doubt a far more threatening possibility than the human cloning red herring that uninformed leaders have attacked in recent years to much fanfare.  

It's a popular leftist talking point that the US doesn't have the best health care system in the world. However, deciding which health care system is best really depends upon how we measure success. The WHO rankings are often cited as proof that the US system is not the best, but this ranking has several problems, the most obvious being that it's nine years out of date. But even aside from that, this study is open to question because it does not just measure health care quality but also, in part, health care equity and even potential health care quality given GDP.

Another oft-cited fact used to lampoon the US health care system is life expectancy. Though the US does rank a poor 35th in that statistic, this is not really evidence of very much because life expectancy depends on all sorts of factors besides the health care system, and that system probably isn't even one of the biggest.

Both the left and neoliberals have disputed the importance of life expectancy in various ways: researchers affiliated with the American Enterprise Institute published some bogus statistics at one point claiming that if violent deaths were removed as causes, the US would rank first in the world. (These statistics were later cited by Betsy McCaughey on the Daily Show, not to mention an alarming number of right wing blogs.) As it turns out this was completely false, and the OECD, which published the original statistics, actually took the trouble to point out the error in print. Meanwhile a study funded recently by the Commonwealth Fund claims that the US ranks dead last among 19 industrialized nations in "mortality amenable to health care." However, as pointed out in a review by University of Pennsylvania researchers, this is dubious methodology because even confining ourselves to factors like the roughly half of ischemic heart disease deaths judged most easily preventable, there are still many factors in play besides the health care system. (For example, the US ranks first in the industrialized world in obesity. If that did not have a large effect on heart attacks I would eat my hat.)

The most direct evidence we have for the success of the health care system in preventing deaths after diagnosis has to be survival rates. Here the US appears to do rather well. Its cancer survival rates are probably the highest in the world overall, while its survival rates from heart attacks are on the high side though probably not the best. Cancer and heart attacks together make up around half of all medical deaths and are by far their two largest sources.

Of course, it is possible to criticize using preventing deaths after diagnosis in the first place as the measure of success of the health care system. The United States is on the whole simply a sicker society than most other rich nations, partly due to cigarette smoking and obesity, and one could argue that a properly functioning health care system would prevent disease from ever occurring by helping people avoid these risk factors in the first place. That seems plausible, because after all, differences in prevention are generally more important than differences in treatment in lowering mortality from cancer and heart attacks. A properly functioning health care system would therefore put more money into nurturing this crucial contributor to health.

And while the US system does fare well on treatment of diseases that are often terminal, it appears mediocre in treating chronic conditions. For example, hospital readmission rates for asthma, an indicator of poor treatment, were 2nd highest among 19 OECD countries reporting. Life expectancy for patients suffering from end stage renal disease has also been found to be higher in Canada than the United States. A study of diabetics found that more than half had received four recommended services, comparable to the UK and Germany, though above Canada, Australia and New Zealand.

My conclusion from the evidence is that our system does do better than most industrialized nations at treating life threatening diseases once diagnosed, though some of this is no doubt attributable simply to our higher GDP per capita. Aside from that, however, there is one reality that we would be very foolish to overlook and is in fact routinely and quite comically overlooked by neoliberals touting the US health care system. This reality is Medicare: it's a single payer system that provides coverage for those aged 65 and over, precisely the group that accounts for most heart attacks and 60% of all cases of cancer. Not only does Medicare pay for treatment of most cases of these deadly ailments in the United States, but there is evidence that differences in cancer treatment effectiveness between the United States and other nations actually rise when considering senior citizens and sometimes fall to zero for younger folks.

When discussing the American health care system, then, we need to realize that it's a split system. Almost half of all expenditures in the US system are paid for by government, including roughly a third that fund Medicare and Medicaid. The least disputable successes of the US health care system apply mostly to the Medicare eligible age group, and may actually be lessened or even in some cases nonexistent outside it. While this is not an attempt to state that US single payer health care is completely responsible for seniors' high cancer survival rates, the facts do make it impossible to argue that for-profit health insurance is the driving force. Given the split system of the US, we need to be very careful when arguing that health data either supports or detracts from single payer health care, because we might just find it supporting the exact opposite conclusion.