by Conor Clarke
Over at the National Review, the flagship magazine of modern conservatism, Andy McCarthy writes:
I too have absolutely no idea why McCarthy would draw such a connection.
by Conor Clarke
The Obama administration has decided to scrap Cash for Clunkers, the program that let you trade in old gas guzzlers for a federal voucher toward the purchase of a new fuel-efficient car, on Monday August 24.
The simple and important thing to remember is that the speed with which the program is shutting down is a testament to its success, not its failure. If the goal of a program is to boost consumer demand quickly — as the goal of this program most certainly was — then its good to have the allocated funds consumed quickly. Good stimulus is timely stimulus: We want the money pumping into the economy when economic activity is still below its potential. Economics stimulus is counterproductive when it comes too late.
This is separate from the question of whether or not we want an industry specific stimulus, or whether the Cash for Clunkers program was poorly targeted. (I think it was at least a little poorly targeted, since the vouchers were allocated largely on the basis of whether your clunker consumes less than 18 mpg and your new purchase consumes more — such that trading in a 17-mpg car for a 19-mpg car would get you a voucher, but trading a 19-mpg for a 30-mpg one would not.) The fact that the money disappeared quickly is a really a reason to celebrate.
by Conor Clarke
As Peter noted earlier today, Chicago Tribune columnist Steve Chapman challenged conservatives who oppose gay marriage on practical grounds to "make simple, concrete predictions about measurable social indicators," now that various states are letting gays wed. According to Chapman, they refused.
But now I see that Maggie Gallagher, President of the Institute for Marriage and Public Policy, has circled back around to Chapman's question over at the National Review. She writes:
2. Public schools will teach about gay marriage.
3. Parents in public schools who object to gay marriage being taught to their children will be told with increasing public firmness that they don't belong in public schools and their views will not be accomodated in any way.
4. Religous institutions will face new legal threats (especially soft litigation threats) that will cause some to close, or modify their missions, to avoid clashing with the government's official views of marriage (which will include the view that opponents are akin to racists for failing to see same-sex couples as married).
5. Support for the idea "the ideal for a child is a married mother and father" will decline.
Oh come on. Is this really the best they can do? First, none of these things are "simple, concrete predictions about measurable social indicators." But there's a bigger problem here: None of them — with the exception of #4 (where I think Gallagher is just plain wrong) and this vague, unconvincing business of being "punished" in #1 — are bad things! If this is Gallagher's "parade of horribles," then the battle over gay marriage has been won. Every other item on Gallagher's list amounts to this: As support for gay marriage grows, the public institutions and sentiments that oppose gay marriage will become increasingly marginalized.
To which one might add, Rightfully so.
by Conor Clarke
Interesting email from a reader (which I've condensed a bit):
It seems to me that the scope of the "unintended consequences" argument gets overstated. You sometimes hear the very existence unintended consequences brought up and plopped down like some devastating and impenetrable roadblock in the path of government. But even the dimmest of utopian social planners should know that all does not go according to plan.
What matters, obviously and entirely, is the likelihood and severity of unintended consequences.
It's easy to imagine an undesirable consequence that is extremely likely (like the effect of a direct money transfer on the incentives of its recipient) but is still worth the tradeoff (as I believe in the case of, say, unemployment insurance). And it's easy to imagine a consequence that is quite severe but rather unlikely. It's always possible that a NASA satellite could deflect a giant radioactive asteroid into the orbital path of the earth. But no one should take this seriously as an argument against the space program.
Anyway, death panels fall into the second category. It seems to me that if you're going to make the unintended consequences argument in the case of health care, you have to do more than merely cite the abstract possibility of a future government euthanasia program. You have to tell a story about how we get from point A to point B. And since death panels are not in the bill and no one wants them, I don't think that story has a very convincing place to start.
An Afghan burqa-clad woman blows on her inked finger prior to casting her vote at a polling station in Herat on August 20, 2009. Afghans voted to elect a president for just the second time in their war-torn history as a massive security clampdown swung into action to prevent threatened Taliban attacks derailing the ballot. By Behrouz Mehri//AFP/Getty.
by Patrick Appel
Sen. Chuck Grassley (R-Iowa) and Sen. Mike Enzi (R-Wyo.) perform bipartisanship inflation.
by Patrick Appel
Ryan Sager looks at a new study on generational differences and support for marriage equality. No surprises here:
Just how big is the gay marriage age gap? Between the under-30 crowd and the over-65 crowd: 35 percentage points. Or, try this on for size, at the state level: If people over 65 in each state made the laws, 0 states would have gay marriage; if people under 30 made the laws, 38 states would have gay marriage.
by Conor Clarke
The Washington Post answers that question, in a long piece about two of the child stars from the Oscar-trouncing Slumdog Millionaire. The two stars were, prior to filming, residents of actual Indian slums. And now:
[…] Unlike Azhar, [co-star Rubina Ali] has not seen her fortunes improve much since the movie in which she plays the young ragpicker Latika. She filmed a soda commercial with Nicole Kidman and collaborated with an Indian journalist to write her autobiography this year. […] But her family's shack was demolished by city municipal workers and later rebuilt in the same spot, next to an open sewer and piles of garbage. She remains in the slums because her father, despite Boyle's offers for a new home, isn't sure he wants to leave. He also was caught in an undercover sting by a British newspaper where he allegedly agreed to sell her for adoption to a wealthy Dubai family for the equivalent of $290,000; he denies the allegation.
The somewhat obvious and grouchy point to make here is that Indian development is not properly viewed through the lens of two child stars who get offered new homes by a famous British director. (The somewhat grouchy response to that is to observe that we don't live in a world where the gift money could somehow be redistributed seamlessly and efficiently to the millions of other children living in Indian slums. That, and the "moral awareness" value of Boyle's film is hard to quantify.) But, setting that stuff aside for a moment, I think this is touching story, and the product of good journalism.
Otisfield, Maine, 6.10 am
by Patrick Appel
Readers are split on how much tort reform would help. A reader who doesn't think tort reform is the answer:
In Texas, the State legislature enacted drastic tort reform which basically made it extraordinarily difficult and expensive to file a medical malpractice case. They did so on the typical theory that it would reduce the cost of lawsuits and, thus, reduce insurance premiums for doctors. Doctors enthusiastically signed on. While it certainly reduced costs for the insurance companies, the premiums for doctors continued to go up and up. The insurance companies pocketed the monies that would have otherwise gone to victims of medical malpractice (because there really was no problem with frivolous med-mal suits being filed in the first place). Doctors Lost. Patients Lost. Insurance Companies Won. Sound familiar?
I know that a number of states have imposed tort reform, but I haven't done much research into the various outcomes. Can anyone point me to a reform that has had better results? Or does anyone want to challenge this characterization of the Texas reform? A reader with an opposing view on tort reform:
“If you were to eliminate medical malpractice liability, even forgetting the negative consequences that would have for safety, accountability, and responsiveness, maybe we’d be talking about 1.5 percent of health care costs."
Kind of ignores the big one – the application of unnecessary procedures in order to avoid lawsuits. Maybe no hard figure has been put on it – but that is just sophistry. Read here, here, and here. Maybe Daphne Eviatar knows something that medical practitioners do not but I doubt it. That phrase "a lot" may lack the precision she thinks is necessary but is she really still saying that "we are not talking about real money?"
Sheltering doctors from lawsuits might save money on defensive medicine, but it also limits what true victims of medical malpractice (full disclosure: I have family who have worked in this area of law) are able to receive in payment. If you are unable to work for the rest of your life because of medical errors, a few hundred thousand dollars, the cap on damages in some states, isn't going to do near enough to compensate you for your loss, especially if you have ongoing medical needs. On the other hand, workers in fields meant to ensure a public good, like police officers, are given extra legal protections because they would be unable to do their jobs if they were always afraid of lawsuits, and the public good they provide outweighs the grievances of minor victims. You can still sue police officers, or similarly protected professionals, but it's a more involved process and the hurdles you have to clear are higher. Many doctors have some of these protections already, but I'm not against smart tort reform if there is evidence that it works and if it doesn't create too many perverse unintended consequences. A doctor's perspective:
Absence of proof is not proof of absence. It is true that the measurable costs of tort reform, such as malpractice insurance, are such a low percentage of overall health care expenditures that there are few savings to be gained from that specifically. However, the difficulty quantifying the cost of defensive medicine does not mean it is trivial. Avoiding litigation is a significant concern for many clinicians and [over]ordering studies, rightly or wrongly, mollifies patients and reassures (falsely, at times) doctors that they have lowered their risk of a lawsuit.
Even if a better system were implemented tomorrow for collaborative, non-punitive performance improvement while maintaining a means for redress in the courts where appropriate, I suspect it would take a generation, maybe two, for doctors to give up defensive medicine. However irrational it might be, it is deeply, deeply ingrained.
This is related, obliquely, to this post. The credit goes not only to the test, but to the child's pediatrician who heard an abnormal heart sound and made the appropriate referral. Had he missed that finding, the test would not have been done in such a timely fashion and the outcome possibly far different. Another less happy, scenario is that the cardiologist thought the heart sounds were fine and the echo not indicated, did the study "just in case," with the additional bonus of being a billable procedure, and there was a complication of, say, the sedation required for some types of echocardiograms. Some tests have value in asymptomatic patients to detect disease early, when it is treatable. Many others, possibly most, have indications based on clinical criteria. Doing those studies "just in case," outside the confines of a research trial, not only increases cost with little gain, but can also pose additional danger to patients. Discussions about bending the curve should consider this, which is not rationing care or sending grandma to the death panel, but practicing smart, cost-effective, ethical medicine.
Another doctor writes:
There may be "no good study that's been able to put a number on" the cost of defensive medicine, but that cost should certainly not be discounted. During my three-year emergency medicine residency, it was easy to see how the practice of attending physicians who'd been sued differed from those who hadn't. In general, the older physicians, who'd been sued or seen their colleagues sued, were far more likely to order expensive studies or short-term "observation" admissions for young, healthy patients. One attending in particular, who was sued during my second year, began agonizing over every potential discharge from the emergency department, and ordering many more expensive nuclear imaging studies, even though his lawsuit defense was successful, and he was exonerated of the charges of malpractice.
In addition to the financial cost of unnecessary studies, there is a rarely discussed emotional cost for physicians. Most physicians do not enjoy practicing "defensive" medicine. They don't like ordering tests for patients that they would not order for their own family members if they were in the patients' place. They don't enjoy prescribing antibiotics for patients who almost certainly have viral infections. It's no fun going to work when, instead of feeling like your mission is to help people, you start to feel like your most important job is to evade the clutches of unseen, lurking malpractice lawyers.
I really think that these emotional costs, which are felt even by physicians, like me, who've never been sued, have a bigger effect on most physicians than the financial costs of malpractice premiums. They've been a major factor in the decision of the physicians I've known who've left the practice of medicine. And if we want physicians to move away from the fee-for-service model, toward less lucrative salaried positions, I think reducing the emotional toll of the malpractice environment could be an important part of a reasonable healthcare reform deal.
The Dish 
