Wednesday, August 31, 2005
My Irish and German great grandfathers emigrated to the U.S. at 17, by themselves we think, which is much the same age as many current immigrants. It seems to me that modern progress, by shrinking the size of families, increasing the premium on competition and learning, and giving us more to learn, is in a race with the healthcare industry, itself a vital part of progress.
What's the race: whether the life span is going to grow faster than the span of adolescence. I fear, over the next millennia, we're doomed to see adolescence grow faster until there's just a month or so between the time the last child becomes independent and the parent goes into the nursing home.
Tuesday, August 30, 2005
"Bill Clinton was a bona fide liberal and George W. Bush is a legitimate conservative, but neither they nor the vast majority of their supporters are as liberal or as conservative as their predecessors of a generation ago. No Democrats talk about nationalizing industries, and no Republicans talk about abolishing Social Security or Medicare. Whether the maximum marginal tax rate at the federal level should be 40%, as it was at the end of the Clinton administration, or 35%, as it is now, is a serious public policy issue; but it is frankly ridiculous to denounce proponents of either view as extemists.
Even in foreign policy, I don't think Republicans and Democrats are as far apart as they might seem. Democrats are violently opposed to the Iraq war, I think, because it is being conducted by a Republican. If the President were a Democrat, the Democrats would support the war just as they did every one of Clinton's military adventures. "
Monday, August 29, 2005
My wife and I almost every Saturday visit a nearby strip mall in Herndon to patronize the Tortilla Factory. I guess it's Tex-Mex. It's been around since 1975 serving good food cheap. There's a supermarket in the mall. When we first went in the late 70's, it was a national chain, maybe A&P. But it's rather small so A&P left. Then a local chain came in. This outfit was specializing in taking over the smaller stores as Giant and Safeway, the two big chains in the DC area, built super supermarkets. If I recall correctly, it survived by being non-union.
But patronage wasn't enough and the local chain left. The supermarket building was closed. The strip mall had a number of empty buildings, although a laundramat was able to survive. Meanwhile, down the road, someone established a Hispanic store in the house next to the bank branch. My wife tried it once, but it was small and didn't attract. Then we stopped using that branch as bank mergers created a branch and ATM closer to home.
Finally someone put a Hispanic supermarket in the vacant building. My wife finds it has good vegetables for good prices, perhaps because it's also nonunion. The parking lot in front is crowded on Saturdays now. As I wait for my wife, I see all sorts patronizing the store, though heavily Hispanic. The patrons are driving cars, and some SUV's, all newer than mine (because I'm cheap). Sometimes you can see people loading up, presumably either doing a week's shopping for a family or for a group home, but it's not that different than my local Safeway, except significantly busier.
What's the moral?
"The biggest culprit behind declining ticket sales is the car; even the poorest rural family likely has one. But, from a business point of view, Greyhound's leaving is an affirmation of many towns' decline as destinations and points of departure.
'The real reason that service has gone down is that people are leaving those communities,' says Elvis Latiolais, general manager for Carolina Trailways, a Greyhound subsidiary."
Saturday, August 27, 2005
The Washington Monthly: "Malcolm Gladwell asks the key question about American healthcare in the New Yorker:
"One of the great mysteries of political life in the United States is why Americans are so devoted to their health-care system. Six times in the past century — during the First World War, during the Depression, during the Truman and Johnson Administrations, in the Senate in the nineteen-seventies, and during the Clinton years — efforts have been made to introduce some kind of universal health insurance, and each time the efforts have been rejected. Instead, the United States has opted for a makeshift system of increasing complexity and dysfunction. Americans spend $5,267 per capita on health care every year, almost two and half times the industrialized world’s median of $2,193; the extra spending comes to hundreds of billions of dollars a year."Gladwell mentions the historical fact that unions in the U.S. worked individually in collective bargaining to get health care for their members; in Europe they worked together through social democratic parties to get health care for all. The theme of the article is tracing the impact of ideas: Americans focus on individual responsibility and moral hazard, therefore on actuarially sound insurance; Europeans focus on the community and sharing the burden of accidents and random illnesses.
I don't quarrel with this, but I do note with bemusement the blinders that liberals wear. Americans spend much more on health care than others--that's the message that Kevin Drum and other liberals repeat incessantly. What I don't see is analysis of what it means, as thus: If we spend more on healthcare, that means organizations and individuals who are getting the money. All of the paperpushers in each of the separate laboratories, medical practices, hospitals, research organizations, rehab units, nursing homes, hospices. All of the professionals in these places. All of the individual practitioners. Now they aren't all overpaid by comparison to a French style system. But they all can and will fear that they are. It's eminently rational for the participants in the current system to fear any proposed changes, particularly when we say that the system is wasteful. (Just as government bureaucrats rationally fear the politicians who attack government waste.) Under a new system, most of today's fat cats would lose and they'd hate that. But even the alley cat who works hard for a meager diet of leftovers from the fat cat meals has fears. Better the known present than the unknown future.
With this as the background, is it any wonder that Harry and Louise saturated the airwaves?
Friday, August 26, 2005
The Last Waltz - Los Angeles Times: "Leinart, who announced in January that he would forgo a chance to turn pro and would return for his final season of eligibility, is taking only one course: ballroom dancing. The elective fulfills the final units Leinart needs to graduate with a sociology degree.As a contrast, Joe Namath is trying to beat his daughter to be the first in his family with a college degree and has only an education paper to complete.
Wednesday, August 24, 2005
As a bureaucrat I've been in many meetings, some of which were committees, some just work groups. A minority of meetings had some sort of product representing the consensus of the members. Typically the mere fact there was a meeting meant that some people had strong feelings and we needed to be inclusive. So there's a parallel to the Constitution making process. Some of the meetings were of peers, some were with a decision-making authority.
What happened when issues arose after the meeting? The way I remember it, we seem to have wavered between two rules of interpretation. At one extreme we adhered to strict originalism, particularly so when it was a meeting with a decision maker who wasn't in the room when we debated interpretation. The issue was what we thought the decider had meant and intended. Ordinarily if that made sense, we went with original intent. But if new factors had arisen we'd often try for a new meeting (i.e., a process of amending the original result). Sometimes, though, we'd decide we could read the mind of the decider, that today he or she would decide X, even though the original intent might say Y.
Toward the other extreme, particularly in the wake of a meeting of peers, the question was whether the issue was such we, as a subset of the meeting, felt comfortable deciding it or whether the uncertainty was so great and the importance so crucial that it was worth the hassle of reconvening a meeting.
Seems to me the same applies to the Constitution. Take one example raised in the comments on Kevin's blog--the Lousiana Purchase. While Jefferson wasn't in the Constitutional Convention, and had many doubts about the Constitution and how to interpret it, he does count as a "Founding Father". In 1803 the LAP(urchase) fell into his lap. He recognized that buying it would stretch the Constitution beyond what he was comfortable with. But the practicalities were that he couldn't afford the time required by the amendment process and enough of the elite agreed with the need for LAP to get the treaty through the Senate. Presumably, the same elite would and could have pushed through an enabling amendment, if time had permitted.
So I view "originalism", "legal realism" (the idea that the Court follows the election returns and the power elite), "critical realism" and all the other theories as make-work for lawyers. The reality is that SCOTUS can and will make decisions they can get away with, based on the reasons that make sense to them. There's no magic rule, except what works.
One of the problems an originalist runs into is that illustrated above in the reference to the split between Scalia and Thomas. It seems that Thomas might well say that we should give back the Louisiana Purchase, because he applies originalism to the original document. Scalia seems a bit more apt to say while originalism might lead me to position A, 202 years of history makes me disregard the original intent in favor of pragmatism.
I'm always reminded of committees I've participated in. We don't reach an agreement on how our work product will be interpreted. In my experience the question of interpretation is answered by wavering between "originalism" and "avoiding stinks"--the latter saying: if no one with a concern in the issue will raise a real big stink, we'll all quietly change the committee's work. Seems to me that's the way the Constitution has operated. The Federalists didn't make a big enough stink about the LA Purchase to void the treaty, so we changed the Constitution.
Tuesday, August 23, 2005
I think he's right. We've globalized opinion, so everyone now is competing in the global marketplace of ideas. The Sopranos may still believe in death as the punishment for treason, but the rest of us don't.
"'It seemed very, very similar to the experience of people who are compulsive gamblers,' Platt points out. 'While it's always dangerous to anthropomorphize, it seemed as if these monkeys got a high out of getting a big reward that obliterated any memory of all the losses that they would experience following that big reward.'"I've always thought people were dimorphic--there are the gamblers and the nongamblers--and this has evolutionary advantages. If we were all sticks-in-the-mud, we'd have no progress; if we were all gamblers, we'd destroy ourselves. So I'm looking for future studies that show the study is wrong. Maybe the scientists just created a monkey fad, similar to hula hoops or chlorophyll. Maybe it's true what Lincoln almost said: you can fool all of the monkeys some of the time, you can fool some of the monkeys all of the time, but you can't fool all of the monkeys all the time.
Monday, August 22, 2005
"As best I can tell, the only real factual claim in the piece is that 'strange questions' were being asked during the investigation. The piece doesn't say who was asking the alleged strange questions, however, or two whom they were addressed. In addition, the two specific questions mentioned don't sound to me like something an FBI agent would ask (especially the second question). David suggests that the asking of such questions wouldn't surprise him because some anti-Semitic views are popular in 'many 'intellectual' circles,' but I don't think such circles are generally thought to include the Federal Bureau of Investigation.My feelings on the case--from the papers it sounds like Washington's iron triangle of lobbyists and bureaucrats operating as usual, that there seems to have been a violation of law, that the case is overblown, except as a warning shot to people in similar situations to remember classification rules, and that the AIPAC side is doing what everyone does who's caught with their hand in the cookie jar--yell "police brutality" (i.e., misconduct). The last reflects my normal tendency to go with the authorities in most cases.
However, today's Post shows the limits of Kerr's logic. Would a police detective, who's investigating a murder with a suspect would continue blithely on after the suspect asked for an attorney. I would have said "probably not"--thinking Miranda had impacted police behavior. Tell me that the interview is being videotaped and I'd say: "surely not."
I'd be wrong. See this piece in the Post. So, Orin Kerr and I should remember it is possible to overestimate the common sense of people, even PG detectives and FBI age. And maybe we should consider requiring all interviews to be recorded--the technology is there, why shouldn't we use it?
Sunday, August 21, 2005
The patient gains from the visit--a break from the boredom, knowledge that someone cares enough to take the trouble, a chance to learn news from the broader world, reaffirmation of family and friendship ties. Note that most of these benefits don't decline in value over a succession of visits. The patient seldom has costs, assuming he is fit enough to receive visitors. (I may be jumping to conclusions--a proud patient can suffer from being seen as incapacitated. That cost may decrease as the patient becomes adjusted to the new role.)
What does the visitor gain from the visit?
The visitor learns the status of the patient, something difficult to assess over the phone. The visitor probably can't learn much news from the patient, except to the extent you can assess what you might face when and if you become a patient. My sense is that the visitor experiences a greater rate of diminishing returns than does the patient. The visitor benefits from showing he's a good person who conforms to social norms. But the sense of self-approbation can decline rapidly.
The visitor has significant costs--a visit is a distraction from the daily routine, which economists seem to assume is a stable balance between costs and benefits.
All of this would suggest that visits should decrease over time.
The salesperson said that we couldn't move the phone number from the pay-as-you-go plan over to a family plan because the plans were on separate servers and separate towers. That's not a reason; it's a description. (It might reflect a corporate takeover in the past--mergers and takeovers are a good way to accumulate lots of silos. A test of the management of the company is whether they are able to merge silos or decide to do away with one set altogether.) Cingular may have decided it wasn't worthwhile to enable such changes, or they may not have had the time to do so.
He also said that he couldn't sell me a Virginia area code from upstate New York; he was limited to his territory. Sales management may have decided it's simplest to run their organization this way. Certainly my request was probably rare. (But how about parents who buy their kids phones for college--don't they have to deal with different area codes? Or does the question reveal how far out of it I am--do most kids get a cell phone when they graduate from elementary school?) But good organizations are flexible.
These two silos won't keep me from going Cingular, but they're worth remembering when we and Congress criticize the FBI bureaucrats for their own silos.
Thursday, August 18, 2005
"Call it situational libertarianism: Liberties should be as unlimited as possible -- unless and until there arises a real threat to the open society. Neo-Nazis are pathetic losers. Why curtail civil liberties to stop them? But when a real threat -- such as jihadism -- arises, a liberal democratic society must deploy every resource, including the repressive powers of the state, to deter and defeat those who would abolish liberal democracy.I hope to start a dialog between the two conservative/libertarian types, particularly given Volokh's post today on First Amendment rights on which I commented. J.S.Mills observed somewhere that it's easy to be tolerant of those obviously in error and too weak to pose a threat. The test, he thought, was when your opponent was formidable.
Civil libertarians go crazy when you make this argument. Beware the slippery slope, they warn. You start with a snoop in a library, and you end up with Big Brother in your living room.
The problem with this argument is that it is refuted by American history. There is no slippery slope, only a shifting line between liberty and security that responds to existential threats."
I suspect Krauthammer is right as a matter of history--we do waver back and forth on the bounds of tolerance. Volokh may be right that as a matter of intellectual rigor and honesty, there should be a slippery slope. But people are neither rigorous nor honest.
Based on my recent experience, the article is true enough. I'd focus on the data problem: each specialist needs his or her own data. Actually, "specialist" is misleading--it raises the specter (ouch!) of a white coated expert "...ist". What I, as a layman with no recent experience of modern medicine, didn't realize was that each test involves a different organization. For example, the patient is referred by the personal physician to a medical lab for X-rays and blood work preparatory to a hip replacement operation. But in this case, the "lab" is a building, housing multiple testing organizations, X-ray being one and blood work being another. So the patient ends up going from one to the other, filling out forms for each with partially redundant information. Because the lab is separate from the personal physician, there's potential delay and loss of data. In fact, in the case of my sister, the blood work didn't get back to the physician for several days. This failure to communicate delayed diagnosis and treatment of an infection, which means a considerable cost in money, use of scarce hospital beds and staff, and suffering.
Comparing this experience under private health insurance to my own limited experience with HMO's, it's likely the communication among units would be better and the costs reduced. Costs for the patient and the system. But what's a cost for the payer is income for the payee. And the physician and labs have more freedom under the current system. It's all tradeoffs. (More to follow).
Wednesday, August 17, 2005
* the rest stops along I-81 were very busy, usually 2 or 3 men in the restroom at a time. Very seldom did someone urinate and leave; the pattern I observed was that everyone washed.
* in the upstate NY hospital I was visiting, the vistor's lounge had its own bathroom, which seemed to be used both by hospital staff and visitors. Sitting in the lounge you could hear the toilet flush and the sink run. But much of the time, I'd say at least half, you only heard the flush and no running water.
Why the difference? I'd guess it's the visibility. While you don't look at each other in the restroom, you're very conscious of others so you live up to the norms they display. In the bathroom, you're by yourself and easily forget that your activities can be heard. So you don't wash your hands, which is the cause of much death in hospitals.
If I understand correctly, Islam doesn't have this problem because it's taken specialization to the point of dedicating the left hand for sanitation. Failure to comply may be a sin.
As a true American, I'd suggest that we put a sign outside bathrooms. Most new public bathrooms have motion recognition triggering the flow of water, that that to the sign and to the door. The sign goes dark when the door closes, lights up when it opens if the water has run and says: "last user washed hands". I offer the idea free in the interests of improving life expectancy.
"In Dr. Goffman's account of life in a mental institution in the 1950's, he describes the admission process as a stripping away of possessions, 'perhaps the most significant of which is not physical at all, one's full name.'Based on recent (vicarious) experience, all true, but somewhat overdone. In the hospital I was visiting (I plan more blogs on this, and will limit identification to "upstate hospital") they were trying. Staff were supposed to identify themselves to the patient. There was a white board for each patient that was to show the nurse and aide assigned on each shift.
In modern medicine, patients more commonly become exasperated because they do not know the names of the doctors or other medical staff. At many clinics and hospitals, staff members come and go without introductions, patients say. Name tags are in lettering too small to read easily; the names embroidered in script on doctors' coats can get lost in folds."
But as with any bureaucracy, changing procedures and instilling habits is difficult. The white board was someone's bright idea, but it was too small for an older patient without her glasses to read. The markers for use with the board got mislaid. And, I strongly suspect, the "someone" was an administrator who never really got buyin at the working level. A big part of the problem is that change takes time and money. If an organization is strapped for both, the "bright ideas" don't get fully implemented, which increases cynicism and makes future change harder (see Dilbert).
What was good in this hospital was the acceptance that names should be known, so there was little awkwardness about asking. The social norm had been established, even though the practice was somewhat ineffective.
Thursday, August 11, 2005
My title takes off from thoughts on the health care system--it's pervaded by the influence of American individualism. (More to follow.) But the "nini's" are also a symptom of individualism--nini as in:
- "Not invented here"--NIH
- "Not in my backyard"--NIMBY.
Are there more ninis?
Saturday, August 06, 2005
At any rate, I'll be blogging a bit, perhaps talking about the amazing prevalence of silos, both in the Northeast and in hospitals, at least until I take off again to see my sister.
Threat to Divest Is Church Tool in Israeli Fight - New York Times: "The Presbyterian Church U.S.A. announced Friday that it would press four American corporations to stop providing military equipment and technology to Israel for use in the occupation of the Palestinian territories, and that if the companies did not comply, the church would take a vote to divest its stock in them."