Monday, December 12

My First Comment and Response

Dear Anonymous,

First, let me thank you for bothering to leave your mark on the site--though, frankly, I'm puzzled how anyone could stumble back to this site so soon after its resurrection. I hope that you don't mind my making your welcome comment an excuse for a rambling, multipart post, but it isn't often that we have visitors around here (I feel like a lonely spinster inviting the encyclopedia salesman in for tea).

Because your comment raised so many questions, I will organize my post loosely around them, in order.

It sure is good to have you back. The years 2002-2005 have seemed much darker in your absence.

Thank you kindly. I would be flattered if I wasn't suspicious that such an over the top compliment wasn't mostly in jest!

Although I must say that after three years away I expected more from a first posting than a fairly superficial analysis of why Tookie must die.

I am sorry that you were disappointed by the superficiality of the Tookie post. I am not going to quibble with your objection, however, because it is really such a straightforward case that it doesn't take much digging to solve. Some questions have easy answers and this was one of them. Had Mr. Williams apologized for the four murders, this would have been a very difficult issue indeed.

[UPDATE: I'm glad to see that Governor Schwarzenegger agreed with my superficial analysis. According to this account, the governor explained his decision to deny Mr. Williams clemency by asking "Without an apology and atonement for these senseless and brutal killings, there can be no redemption." Just right.]

Any complications that have been raised in this case are ancillary to the facts. Whether the death penalty is ever an appropriate punishment, for example, is an endlessly debatable, though ultimately fruitless, inquiry. I have written about what essentially boils down to a debate over aesthetics elsewhere, see Capital Punishment, The Salisbury Review, Autumn 2004) (unfortunately, not available online), and didn't feel like revisting the issue here.

And whether, for political reasons, Governor Schwarzeneger should bow to pressure from prominent Hollywood actors and Mr. William's other defenders (some more respectable than others--Mr. Sharpton, Jesse Jackson, Tony Robbins, I'm looking at you), is an interesting question for the governor and his political advisors, but not, I'm afraid, for me.

The one point I did want to make was in defense of the institution of executive clemency. I am particularly afraid that, if Governor Schwarzenegger commutes Mr. Williams's sentence, it will inspire a popular movement to limit this privilege of office. Something of the sort happened with respect to the presidential pardon power after President Clinton's midnight pardon of, among others, Frank Rich. For an interesting discussion of that debate, please look here. That I could combine this limited point with a discussion of my favorite cannibalism cases from first year Criminal Law was just a lagniappe!

I was hoping for some sort of intelligent view from the right about the current state of American foreign policy (perhaps the sort of thing Christopher Hitchens might write if he ever sobered up

It is little wonder your expectations have not been met! Though his prolificacy is understandably a constraint on the quality of some of his shorter articles, when Hitchens's quill is sharp, he is a dazzling wordsmith, whether one agrees with him or not. Some of his latest writings on Iraq (which is, admittedly, only a subset of American foreign policy), are available here (the Slate articles from November 22 and 29 in particular), and he will be appearing in a live debate somewhere in upstate New York (i.e., somewhere north of Union Square) on December 20th. The same website has travel details. I cannot vouch for his sobriety.

As for my views on these issues, they may well be forthcoming. Give me a chance to ease back into the habit. Baby steps. Baby steps.

or the state of things in Israel, where even your pal Sharon seems to have abandoned the dead-end Likudnik dream.

My pal Sharon! You must think I travel in much more exalted circles than my nights at home, alone, posting to a single reader would indicate. Since I don't recall much of what I posted on this site three years ago, I did a quick search and didn't turn up a single reference to any Sharon (either as a first or last name). I did, however, find this post, in which I said some positive things about a plan to withdraw from more than 97% of the West Bank and Gaza, to secure the border, and even to offer the Palestinians a capital in East Jerusalem--and that was three years before "my pal" came on board (at least for most of the first two of these proposals). I don't broadly disagree with much from that old post, but I am willing to be convinced otherwise.

As to this posting, as an initial matter I note that the New Yorker had an interesting article analyzing the question of moral hazard in the context of national health insurance. It might be tough to pull yourself away from high-brow reading like the New York Sun (if that rag even still exists), but I'd recommend the New Yorker piece on this question.

Gliding past the cheap jibe about the New York Sun (which continues to provide the best original, local New York news coverage of any paper in that city and whose Op-Ed page is every bit as high-brow as that of the New York Times (are they stil indulging Maureen Dowd's sophomoric Lewinsky/Clinton pee-pee routine?)), I somehow managed to miss the New Yorker piece. During my transition from Portland to Washington, via a month in London, access to my subscription was temporarily interrupted. The piece appeared in the August 29th edition, which explains the oversight. I have now read it, and thank you for bringing it to my attention. My response, such as it is, is below.

You are obviously right that the position espoused by NICE in the Times article is laughable and morally indefensible.

Glad we've settled that.

But with respect to the greater question of moral hazard, I find it hard to believe that you're seriously raising the question of whether a national health system encourages people to engage in risky behaviour that they'd otherwise avoid if forced to deal with their own medical expenses. For the love of God, man, you live in the United States - how can you even ask whether being faced with his or her own medical expenses will affect one's actions in terms of, for example, diet and regularity of exercise. Yes, clearly the lack of national health insurance has made Americans, and in particular the poor and uninsured, paragons of a healthy lifestyle, eschewing fast food at all costs and exercising regularly. The question you raise fails the laugh test. The simple fact is that the specious linking of hazardous lifestyles to effective national health insurance is a typical conservative red herring, unsupported by facts (and by any reasonable view of the world around us), but sufficiently compelling as a sound-bite to gain some currency in the world of Fox News (and, probably, the New York Sun).

Where to begin?

First, you may have noticed that my post did not dwell on this point at length and certainly did not stake out a position on the issue. I merely raised the question and asked for comments (ably provided by you). My real interest was with the second question, which is why the NICE proposal prompted me to post in the first place. But returning to moral hazards, the original question was posed to a British politician and doctor for precisely one of the reasons mentioned in Malcolm Gladwell's New Yorker piece: you don't hear much about the issue outside of the United States. I was curious to learn why. I have an open mind about the issue (which is more than appears to be the case from the tone of your comment) and am interested in learning more (but not so interested that I am prepared to delve into what I have no doubt is a contentious and complicated online debate). Hence the question.

Second, what you dismiss as "a typical conservative red herring, unsupported by facts (and by any reasonable view of the world around us), but sufficiently compelling as a sound-bite to gain some currency in the world of Fox News (and, probably, the New York Sun)" is, according to Gladwell's article, the subject of the "single most influential article in the health economics literature." For a red herring, this one has impressive durability (the article was published in 1968) and persuasive power. Still, for all its influence, the idea of moral hazards in the context of national health insurance may be a crock. I certainly have no empirical evidence either way, but the idea itself most emphatically does pass the laugh test. I would like to learn more (which is why I posed the question), but I would also like to retire to the Scottish highlands one day, so as long as work must take priority over dilletantish pursuits, I will have to rely on the well-presented arguments of others on the issue.

Third, many of those you describe as "paragons of a healthy lifestyle, eschewing fast food at all costs and exercising regularly" are not "poor and uninsured," but are eligible for Medicaid, whether they avail themselves of it or not. Between 1999 and 2004, the number of people eligible for Medicaid coverage increased from 34 million people in 1999 to 47 million in 2004. (See this report for information about the source of the data.) According to this story, "[t]he expansion has cemented government's role as the nation's primary health insurer. About 100 million people — 1 in 3 — now have government coverage through Medicaid, Medicare, the military and federal employee health plans." And "[t]oday, a family of four can earn as much as $40,000 a year in most states and get government health insurance for children. The nation's median household income was $43,318 in 2003, the Census Bureau says." Granted, these last numbers apply only to children, but the basic point--that many of these people neglecting their health, including many of the worst cases, are not the uninsured--stands.

Fourth, I am no economist (which will hardly come as a surprise to anyone who has visited this site before), but then again neither is Malcolm Gladwell (B.A. (History) from Trinity College, University of Toronto, I believe). This latter fact is amply demonstrated by his confusion of some basic concepts. For example, he offers the following as an illustration of a moral hazard:

If your office gives you and your co-workers all the free Pepsi you want—if your employer, in effect, offers universal Pepsi insurance—you’ll drink more Pepsi than you would have otherwise.

Actually, this is not an example of a moral hazard. This is a fairly elementary example of increased demand. But I am not interested solely in pointing out Gladwell's economic ignorance; the same and worse could no doubt be done to me. The question is, does the essence of his article make sense?

I could answer this question better if I understood exactly what it is he is arguing. He seems much more interested in recounting--with distressingly voyeuristic relish--gruesome stories of people extracting their own rotted teeth than marshalling his rhetoric into coherent points. In response to what he does say, I offer the following three observations:

1. Gladwell says that "the fear of moral hazard lies behind the thicket of co-payments and deductibles . . . which characterizes the American health-insurance systems." I don't think that this is accurate, and believe that Gladwell's mistake again lies in his confusion of moral hazards with the basic laws of supply and demand. Most health insurance plans provide for complete coverage of expenses beyond a certain annual amount (I believe that this is about $6,000 in the case of my plan). This is catastrophic insurance, which I think virtually all economists and policymakers, of all stripes, agree is a good thing. Co-payments primarily make the cost of non-catastrophic expenses bearable (i.e., they increase supply), and are not primarily intended as a reaction to a perceived moral hazard problem. My health care plan, as it happens, does provide a good response to the purported moral hazard problem in the form of an incentive to seek basic, preventative care: I receive one free check up each year under my medical plan and (Gladwell will no doubt be disappointed to hear) one free teeth cleaning under my dental plan.

2. Gladwell's article takes a sudden detour away from the issues of moral hazards and tooth decay towards the end of his article. This rhetorical swerve is responsible for much of the article's internal incoherence. What begins as a (slightly confused) discussion of the influence of the idea of moral hazard on American health insurance policy ends as a comparison of what Gladwell calls the actuarial and redistributive models of health insurance. This latter point, which he fails to link satisfactorily to the first point, is what Gladwell chooses to leave his readers with. To wit, his conclusion:

In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.

Gladwell never explains how a country in the thrall of policymakers who recoil at the thought of redistributive health insurance has overseen a rapid increase in the number of people insured by government, to a point where fully a third of the population, including the poorest and the elderly, receive virtually free health care. Neither does he offer any quotes from or even references to contemporary economists who oppose Medicaid, or some such system of government health insurance for the poor. His pitchfork is aimed squarely at a straw man. I certainly haven't heard so much as a peep from a Republican Congress, a Republican Senate, or a Republican Presidential administration, about restructuring government health insurance. Wait, I can think of one example, but that one added a hugely expensive prescription health benefit and received bipartisan support.

3. I obviously haven't thought about this issue as much as many, many people (which puts me firmly in the Gladwell camp). My uninformed preference, however, is for something similar to the health plan proposed by Governor Mitt Romney in Massachusetts. You can find Romney's own defense of his plan here. Briefly, it requires all people to purchase basic catastrophic health insurance (which I have some minor qualms about, but clearly some compromises must be made by all sides in this debate) and provides for a sliding scale of assistance based on income. (Interesting numbers from Romney's opinion piece: in Massachusetts, there are 460,000 uninsured, 106,000 of which are actually eligible for Medicaid and 168,000 of which are members of families earning more than $56,000/year). For a positive review of the plan by a (from as far as I can gather) libertarian economist no less, please see here.

Finally, for what it is worth (and I don't hold isolated, anecdotal evidence in high regard myself), the moral hazard argument fairly accurately reflects my experience of health care, which is why it first intrigued me (long before I read any of this economic mumbo jumbo). The number of trips I make to the doctor after my $300 deductible has been met increases substantially. Persistent clicking in the ear? "Funny ache" in my leg? Odd swallowing sensation? Off to the doctor! Heck, it's not much more than the price of a movie and brings peace of mind--something few movies can boast. Now, you might retort that I am an atypical and self-indulgent hypochondriac (to which I, of course, plead guilty) but facts is facts.

I apologize for the haphazard response, but I can only devote so much time to nonbillable vanity projects. I may revise this post over the next day or so (or at least reread it for grammatical and spelling mistakes.)


Anonymous Anonymous said...

Interesting response. Thanks. I'm impressed that you located, read, assimilated, and commented at length upon the New Yorker piece in one evening. It usually takes me a week of streetcar rides just to get through the Talk of the Town.

Defend the NY Sun to your heart's content, but I will continue to mock a newspaper that would begin an editorial with the following line: "If we were President Bush - a stretch, to be sure, but all the greater the honor ..."

Sure, I cherry-picked that line, but trust me when I say I didn't have to look very far to find it, and it had plenty of competition in the contest for "most ludicrous line from a NY Sun editorial, December 2005 category".

11:34 AM  
Blogger H. said...

RP: Thank you for the reply. I won't try to defend the Sun's fawning encomium to the president, though it doesn't enlighten me one way or the other regarding the quality of the editorial's content. I have revised my post slightly (mostly stylistic clean up) since I first posted it.

1:14 PM  

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