Category: Health

A Big Deal on Climate

The details are barely in, but it seems, at long, long last, that the number 1 and number 2 world economies – also the number 2 and number 1 world polluters – have finally come to an agreement on carbon emissions. This is such a big deal, and such good news, that conservatives are tripping over themselves to take a giant dump on it – as a preemptive first strike, since this deal is poised to take a giant dump on them.

That’s because conservatives for years have used China as a shield to avoid serious discussion of the issues related to climate change. Cap and trade, the subsidization of renewable energy sources, new EPA standards on greenhouse gases: name a climate-change initiative, and you can line up conservatives around the block to oppose it, with China the first and last word they utter. They’ve been telling us for years that the US would be a sucker to work toward any reduction in emissions, because the US would merely be encouraging Chinese polluters – with the logic that whatever the US doesnt pump into the atmosphere, the Chinese will pump extra to compensate, taking American jobs and profits along the way.

China, for their part, have long opposed adhering to a common set of standards with the developed West, reasonably asserting that (1) present atmospheric CO2 levels are chiefly attributable to the past activity of Western economies, not China; and (2) unfettered Chinese development has lifted hundreds of millions of people from poverty, and promises to lift hundreds of millions more – just as it did in the West over the past two centuries.

The rest of the world has thus been held hostage to the intransigence of the world’s two largest economies and polluters. After all, any deal on climate change that doesnt include the US and China leaves out nearly half the world’s emissions and half the world’s economy.

But everything changed when US President Barack Obama and Chinese President Xi Jinping announced that they reached agreement on greenhouse gas emissions. China has finally agreed to capping emissions, while the US has agreed to steeper reductions. And now there is every reason to be optimistic that the US, China, and the rest of the world can hash out the deal that has long eluded them, when the climate summit meets in Paris in late 2015.

Obama seems ready to do an end-run around the US Senate, which is now controlled by conservatives, and headed by Mr. Coal himself, Kentucky’s Mitch McConnell. Any further international deals on climate are likely to be styled as “Agreements” – as opposed to “Treaties” – further to a 1992 treaty, the United Nations Framework Convention on Climate Change. Treaties require 67 votes in the Senate, where even 50 are now impossible. In past decades, what was once the world’s preeminent deliberative body could have been relied upon to see past partisan posturing on the most critical issues of the day, to at least have an intelligent debate. No more: the cancer that is conservatism has made the US Senate so dysfunctional that it cannot even meaningfully address matters concerning the planet’s long-term ability to support life.








ACA – No Retreat

The average rust-, corn- or biblebelter never had a passport, and might regard as exotic travel a trip to another county’s fair. To them, Copenhagen is chewing tobacco, Dutch Masters are fancier tobacky, and Monte Carlo was the best durn Chevy ever built. The notion that America is just one among a growing number of rich, developed countries is at best an abstraction. And so when they’re told that, relative to the residents of other rich countries, Americans live shorter lives, American babies are less likely to survive infancy, and American children are less likely to see 1st grade, they become angry, confused and incredulous.

And then come the usual lame excuses. Americans are richer, have cheaper happy meals, and watch hours of TV on their ginormous flatscreens. And over in fascist Western Europe you cant buy a gun at a show, plug a pesky co-worker, and be home in time for dinner, y’all.

But as a matter of empirical fact, Americans are not particularly sedentary. And while they are fatter (and better armed!) than other westerners, neither diet nor guns adequately explain why Americans are so much more likely to die from the day they’re born till age 75, compared to people in other rich countries. The most comprehensive review to date significantly blames the US healthcare system itself for poor US health outcomes – while costing Americans double the OECD average in per capita healthcare expenditures.

Enter the Affordable Care Act, also known as the ACA, or Obamacare. The ACA has several policy objectives – chief among them are reducing the number of uninsured, and controlling the growth of healthcare costs. And contrary to misinformation passed on by conservatives at every opportunity, the ACA is proving to be a great success.

Rates of uninsured are dropping nationwide – fastest in states that have participated in expanded Medicaid, but rates are even dropping in those who opted out. Enrollment through the exchanges has exceeded its target, despite a sloppy rollout that cost HHS Secretary Sebelius her job. And, amazingly, the growth in healthcare costs has slowed to its lowest level since measurements were first taken in the 1960s, which is all the more remarkable given that the economy is still recovering from a sharp recession – a period during which health care costs have traditionally spiked.

The notion that a country can pay less for healthcare and get better health outcomes is not theoretical – it is demonstrable. Nearly every western country pulls off this feat vis-a-vis the US, year-in and year-out. The notion that public health insurers (like Medicare) can outperform private insurers is likewise not theoretical, but demonstrable, both between and within countries. Medicare beats Medicare Advantage. Other countries’ primarily public systems beat the US’ primarily private system.

The GOP has a good chance of taking control of the Senate in the coming midterm elections, and should that happen, we should expect to see yet more congressional attempts to repeal the ACA. But Americans should be steadfast in their support of the law – there can be no going back to the failed system of old.

Democrat In, Deficit Gone – Again

The latest projections have the US budget deficit falling to 3% of GDP in fiscal year 2015, which started this past Wednesday, October 1st. 3% is the magic threshold for deficits. Under that level, they are theoretically sustainable forever, because the US economy, on average, grows by that amount every year.

On inauguration day, January 20th, 2009, the Obama administration inherited a projected budget deficit of $1.2 trillion for fiscal year 2009. (“FY 2009” began October 1, 2008, while Obama was still a senator.) Fiscal stimulus packages and other legislation passed soon thereafter added an additional $200 billion, to create what would become FY 2009’s largest-ever deficit in US history ($1.4 trillion). As a fraction of US GDP (9.8%), it was and is the largest deficit since WWII.

It’s remarkable how much the US fiscal outlook has since improved. Following FY 2009, the US experienced three more years of trillion-dollar deficits – albeit each year’s deficit was smaller than that of the year before. The deficit for FY 2014, which ended on Tuesday, September 30th, is expected to be less than $650 billion. It’s projected to shrink to about $450 billion in FY 2017, when Obama leaves office – about 2% of GDP. (For the past several years, actual deficits have proved smaller than Congressional Budget Office projections.)

To put this in historical perspective, consider that between FYs 1982 and 1993, Reagan and Bush ran precisely one deficit of less than 3% of GDP – and six that were 4.4% or greater. But under Carter and Clinton, every deficit was less than 3% of GDP. Half of Bush Duh’s eight years saw deficits surpass 3%, culminating in FY 2009’s record-setting $1.4 trillion in his last year in office. The pattern could not be more apparent. During the 32 year period 1977-2009, the annual US budget deficit was less than 3% for all 12 years that Democrats held the White House – but over 3% for 14 out of 20 years that conservative Republicans held it. And under Obama the deficit has only ever shrunk.

Obama’s fiscal stewardship is impressive. CBO now projects Obama will become the first two-term president in US history under whom budget deficits will shrink year-over-year, every year. (Bill Clinton and Andrew Jackson came close, each with declining deficits in their first seven years in office.)

The icing on the cake is what finally pushed US deficits under the 3% threshold: Medicare. Under the ACA, growth in healthcare costs have fallen to their lowest rate ever recorded, and Medicare is leading the way, with the public insurer returning slower cost-growth than private insurers.

The Obama administration has returned the US from typical conservative Republican fiscal irresponsibility to moderate Democratic sensibility – enduring conservative recriminations all along the way. It’s the same thing Clinton experienced while he was turning red ink into surpluses. Just as Al Gore cast the tie-breaking vote to enact the tax increase that put the US on track for the Clinton boom and balanced budgets, so Nancy Pelosi and Harry Reid used a side-door reconciliation scheme to enact the ACA, which was the last step the US needed to get under the 3% threshold – without a scintilla of GOP support.






Taxing Smokes and Drinks

Smoking is bad for you. Sugar-sweetened sodas are probably bad for you too. But taxes on cigarettes and sugary drinks are dumb and mean-spirited, and liberals should oppose them.

Smoking causes cancer, heart disease and emphysema. Despite this knowledge, some adults still want to smoke – and their decision should be respected, even if most other adults dont understand it. Levying punitive taxes on tobacco – as high as 400% on a pack of cigarettes – as if to help others make the “right” decision, is paternalistic and obnoxious. It’s well known that smoking causes disease – helping it cause poverty too is gratuitous.

Many are familiar with the argument: since society ultimately picks up the tab for the health consequences of smoking, society can rightfully tax it to reduce smoking rates. Milton Friedman rightly critiqued this as a slippery-slope to tyranny – that the sum of such policies will greatly erode liberty. But few realize that the math doesnt work either: smoking probably reduces government spending because smokers live shorter lives, and so collect less social security than they would otherwise. We should be glad to pay a premium for liberty – but it’s nice to know that we can let smokers smoke in peace without fretting over the bill.

Conservatives look stupid when rejecting gay love or marriage – seemingly unable to make the rather simple inference that gays can naturally and normally have romantic feelings for members of the same sex, even though such feelings can seem strange or repugnant to some heterosexuals. The inability to tolerate – much less acknowledge the validity of – preferences different from their own, reveals a fundamental lack of insight and imagination.

But liberals look just as stupid when they beat up on the working-class over their Marlboros and Coke Classic. Driving without a seatbelt is idiotic – but if informed adults want to go that way, they should have at it, free of state intrusion. It is in fact NOT at all obvious how one goes about weighing the trade-offs between unhealthy behaviors and shortened lives. You dont have to understand why someone else is willing to give up 10 or 20 years to smoke, eat badly, ride a motorcycle or skydive – but as a liberal, you must accept their informed decision, else you fall into the same species of error that conservatives make on gay rights.

There’s also a more modern, fancier slippery slope: that since smoking is addictive, we can dismiss the choice of adults to smoke because their decision is not consensual. We might treat smokers as people who have been duped into an addiction, and so disregard their apparent preference, and look for ways to help set them straight. Despite the efficacy of medical models for the treatment of drug abuse and addiction, invalidating the considered, informed decisions of adults is dangerous business. A liberal society demands that adults be given the benefit of the doubt.

Liberals are sometimes rightly critiqued as elites who are so sure they know better than other people, that they’re willing to substitute their judgement for those they deem to be in need of guidance. Smoking and obesity patterns follow class lines, with poor, uneducated working people far more likely to smoke and be overweight. Cigarette taxes thus seem as paternalistic as they are regressive, and feed the perception that liberals are out of touch with the working class.

Respecting other people means, above all, recognizing that their choices on activities that impact their own lives are valid per se. It is the government’s role to disseminate information so people can make the best possible decisions. But manipulating prices through tax policy to impact preferences is simply not a proper role for a liberal government. The decisions of informed adults should be respected, even if they are not understood.



GMO Labeling

People have been modifying the genes of food plants and animals for thousands of years. The process traditionally relies on selective breeding – what Darwin called “artificial selection.” More recently, science has facilitated a faster approach: altering genes directly, adding completely new, foreign sequences to an organism’s genome; knocking out or deactivating others. Plants can now be changed in ways never before imagined, and change is effected far more rapidly.

While in theory one can produce toxic plants via artificial selection, in practice the reverse has frequently occurred: plants that were toxic have been made edible through domestication. Almonds are one example: undomesticated trees commonly produce fruit containing lethal amounts of cyanide. Some today are concerned that so-called “genetically modified organisms” (GMOs) might adversely impact human health. While their concerns have a theoretical basis, they remain empirically baseless. Despite the widespread use of genetically modified corn, soybeans, and numerous other fruits, there is absolutely no evidence that human health has been harmed. Meanwhile enormous benefits have been conferred, with food production costs dramatically reduced, productivity increased, and several crops saved from destruction.

The debate often centers around labeling requirements. Numerous western countries require that foods containing GMOs say so on their label. The US is not among them – but some states are independently entertaining such laws, including New York, where a bill is now pending. Advocates for labeling often couch their arguments in terms of consumer choice – but in the absence of any evidence that GMOs differentially impact human health, consumers’ desire to avoid them is a “pure preference”, without a basis in health, nutrition or otherwise. As such, it is proper to defer to the market to meet this particular consumer demand, and not legislate that market into existence.

The reason why these laws do not exist in the US is because of aggressive corporate lobbying against them – outspending proponents several times over. Counter-intuitive though it may be, not everything that agribusiness wants is bad. (!) Proponents include purveyors of so-called “organic” produce, who have also grown into big businesses, and have their own profit-motives.

One major advantage of liberalism is that one does NOT need to hide from the facts to maintain one’s positions. Those who pursue truth before any agenda can, in any case, make no exceptions. Liberals who take the scientific high road against conservatives on topics as varied as sexual education, evolution and climate science, should be true to their principles, and take the same approach on this issue. If GMOs were indeed harmful, we should expect to see some evidence of harm. In the utter absence of any, we can reasonably defer consideration of labeling requirements until circumstances warrant. As the facts now stand, required labeling for GMOs is capricious and unreasonable.

One must also consider the challenge of feeding a world of 7 billion people – expected to reach 8 billion in 10 years, and 9 billion in 25 years. GMOs are among our most valuable tools toward that end.








and for what it’s worth, the plants and animals we keep around us have in turn modified our genes.

Medicare For All

The notion that a country can pay LESS for healthcare and get BETTER outcomes is not theoretical – it is demonstrable. Nearly every western country pulls off this feat vis-a-vis the US every year. The notion that government-run health insurance can outperform private insurers is likewise NOT theoretical, but demonstrable, both between and within countries. Other countries’ publicly financed healthcare systems beat the US privately financed system, as measured both in lower costs and longer lives. So there’s no need for ex ante theorizing – we’re left to the task of explaining post hoc why US private insurers get outdone year-in and year-out.

Medicare (public) beats Medicare Advantage (private), no matter how you measure it. Medicare has lower costs, slower cost growth, lower overhead, and even has better outcomes. Medicare Advantage’s net cost to taxpayers has been estimated at about $10 billion per year – that’s the extra amount that Americans end up paying simply because 30% of seniors are enrolled in Medicare Advantage instead of conventional Medicare. And CBO projects that the situation will only worsen over time, as Medicare continues to do a far superior job at containing cost growth.

But Medicare Advantage has become big business for insurers, who use a fraction of insurance premiums to lobby Congress to keep the party going. Lobbying and advertising costs, incidentally, are not counted in the overhead estimate for private insurers, which run about eight times higher than overhead for traditional public Medicare.

The solvency of Medicare’s trust fund is not about health or economics, but politics. That insurers are quicker to jack your premiums than politicians are to fund Medicare is a matter of cultural idiosyncrasy, not the reality of paying to heal the sick. Americans lay out about $8000 per person per year on health care – double the OECD average. Conservatives would have you think that people prefer paying $8000 in fees and premiums to insurers and providers, instead of $4000 in taxes to the government for the same services. Given all that we know about public versus private health insurers, an all-public system – Medicare-for-all – would almost certainly have lower costs and better outcomes than the current mostly-private system.

Surely there other factors that partially explain inferior health outcomes in the US. Relative to other westerners, Americans are more likely to be obese, poor, drive without seatbelts, own guns and abuse drugs. But they are also less likely to smoke, and more likely to exercise. Observing, for instance, that even Americans who are not obese live shorter lives than their non-obese counterparts abroad, the most comprehensive study on point concludes that the US health care apparatus is itself one likely partial explanation for lower US life expectancy.

The ACA is a step in the right direction, in that it will bring insurance to many who previously lacked it. But the ultimate goal should be Medicare for all.



big report (300pp+):

report brief (4pp):–Extra-Payments-to-Medicare-Advantage.aspx

Coal (literally) Blows

Each year, from its smokestacks, a typical coal plant blows off 200 lbs of arsenic, 170 lbs of mercury, 100 lbs of lead, 4 lbs of cadmium, smaller amounts of thorium and uranium, plus an extraordinary 1 MILLION lbs of assorted particulate junk, perfectly sized to fit into your lungs’ alveoli. Remarkably,¬†coal contains 76 of the 92 naturally-occurring elements on planet Earth – so when it’s burned, clouds of toxins are released into the environment, to settle on lakes, farms and cities, to find their way into our bodies through the food we eat and the air we breath. We havent even mentioned the coal ash that gets left behind – which is so radioactive that, kW for kW, coal delivers 100 times more radioactivity into the environment than nuclear power.

And so even if coal released no CO2 at all – as in the case of so-called “clean coal” (which doesnt exist) – it would still spectacularly suck. But coal billows CO2 into the atmosphere like nothing else. Few are aware that even though natural gas and coal create electricity via similar processes, coal is so inefficient that it releases DOUBLE the CO2 per unit of energy generated.

Obama this week released a plan to reduce American CO2 emissions. Given that 40% of all such emissions come from electric power plants, and 40% of all American electricity is generated by burning coal, any such plan will involve transitioning out of coal. But what makes the transition so economically attractive in the short term isnt about CO2 – it’s about the 25,000 premature deaths and MILLIONS of days of work lost each year in the US because of all the other stuff released when we burn coal.

Quite reasonably, rich and poor countries have different attitudes toward environmentalism. In rich countries, people have huge individual stockpiles of human capital, and so it’s extremely costly when workers get sick and are unable to work – and even more costly if they die prematurely, taking their human capital with them. In poor countries, coal may make economic sense, because workers are less productive, and so you can come out ahead trading off health for cheaper fuel. Even poor areas within rich countries may likewise be tempted by cheap energy. The logic driving the demand for coal in China also drives demand in Kentucky.

In rich countries, coal is only cost-effective because health and environmental costs incidental to its use are not internalized by users. Coal would not be cheap if the electric companies who burn it, and their customers, bore the cost of the harm that their activities impose on others. Again, it isnt just about the CO2 they pump into the atmosphere, adversely affecting climate for everyone on the planet – it is no less about the people downwind from coal-fired plants who are sickened and killed. One major problem with the US federal system – and Obama’s state-by-state plan – is that the costs and benefits of coal use sprawl across state lines. Coal might be mined in West Virginia, burned in Ohio, to generate cheap electricity in Pennsylvania and lung disease in New Jersey.

Environmentalism disproportionately benefits middle class people in wealthy countries. The poor would often prefer to have a bit more income, at the cost of their health – ask any coal-miner. The rich frequently have the means to buy their way out of environmental degradation, e.g., by moving to someplace cleaner, or by filtering their air and water. It’s the middle class who gain the most by sacrificing a fraction of their income for a cleaner environment.

And thus conservative opposition to environmentalism usually takes the form of the wealthy and powerful drumming up support from low-wage workers – which, for the GOP, is simply business as usual. Environmentalism for Americans of ordinary means is common sense. Many of the tradeoffs conservatives cite in opposition to environmentalism generally – and the move to cleaner fuels specifically – are false in rich countries. American lives are too valuable to be compromised by a 19th century fuel source, which made sense in its time and place, but is today an anachronism. Coal indeed helped America become rich – but to continue to improve our lives, we as a nation must move on to cleaner energy.