What to make of this

So, yesterday as I read the Washington Post website, I noticed this AP Story praising Hawaii, which under the Pre-Paid Health Care act has an exemption from the Employee Retirement Income Security Act (ERISA) of 1974, Pub. L. 93-406. Overall, I have always been happy that Hawaii has sought to expand access.

However, I would like to point out some other issues. First, the employer mandate has strict as Hawaii's likely would not work nationally. Businesses often complain about the various situations regarding this expense, but in some other way there is a cultural desire to hold the center. Furthermore, there are other more problematic issues with ESI, which I and others have pointed out.

Secondly, Hawaii has some interesting risk pools. Their BCBS does have a huge amount of the market share, however, it does differ from other BCBS systems, because of how it operates. HMSA is a weird duck in the normal insurance market. The other large group is Kaiser Permanente, which many have cited for high quality care.

So Hawaii has some other factors that make it unique. I wish we could just export these ideas wholesale, but it's far more complicated and nuanced.

One other weird Hawaii fact is that even if you did start including ESI in income, Hawaii residents actually will see smaller tax increases than comparable individuals in other states. Again, this points to lower costs in the system.

How much Change in Health Care?

Obama came to Washington promising change. The notion of change however is always abstract. Now the question arises, how much change do you want in health care?

The Washington Post today has two opinions from two worthwhile writers. The first is Dan Balz, the dean of the press corps. In his article, Balz balances a notion that Obama overstepped his bounds, but also makes note that even if he chose a more modest route, that would not mean success. Delay can kill proposals, and even delaying health reform until after 2010 or until a second term could mean nothing would happen there too. Balz points to the delicate balance of having an ambitious agenda, but also understanding the limits.

Those limits are what come into focus in Ezra Klein's piece in the Outlook section. Here he argues that what Obama is seeking to do is far more limited than a remake of the system. It lies in the tension in the polls. People want health reform, but they want to keep their coverage. In some sense, there is a weird status quo bias that we seem to have. However, as a result, the change that people want, which is more choice, actually does not come. Most people still keep their employer sponsored insurance (ESI), and they cannot change it if they are in a large employer. They are stuck. Such is the schizophrenia of trying to walk the line that Balz points to, which is utterly necessary.

Finally, there is the New York Times "Week in Review" piece by David Leonhardt. Here the crux of his point is that the very people we tend to trust, doctors, are also split on this matter. Here again, radical change would lead toward a panel that would look at comparative effectiveness data and look also at costs when making reimbursement decisions. The so-called IMAC proposal would lead to a better sense of cost control. However, many people are wary of the government entering into the doctor-patient relationship, even if doctors may order procedures, because they may be good for the patient, but these procedures also happen to pay very well. Here too we see something odd going on, doctors are fighting doctors, with the procedure heavy specialties like surgeons or radiology going against the more primary care type doctors like family practitioners or OB-GYNs.

So, where does this leave us. I think what each of these articles reveals is the total schizophrenia in our public opinion when it comes to health reform. We want things to stay the same in some sense but have expansions of coverage. We want to lower the costs, but we also want the way our doctors work to remain in place. It is as if we the public do not have a clear crystalized view of what we want.

It is scary. Indeed, change unlike what Mr. Obama said is something we feel ambivalent about or even dislike. We are creatures of habit. Our minds have evolved to handle certain circumstances and radical change of complex systems that involve many moving parts and long-term probabilistic thinking, which is what is health care (and for that matter a lot of our problems are about). On some hand, I think people logically know that we cannot continue in our system as it is. Yet, never underestimate fear of the unknown.

So, thus lies our schizophrenia. It is in some sense situational. We do not act like rational dispositional actors. Instead the situation around us, and our own internal situations, dictate what is going on.

This is not to say that I am pessimistic about reform. I still think it will come, and I think we will have important but modest change. Unfortunately, if we do not do this, we will have disaster down the road.

Religion and Women

This past week, Jimmy Carter lost his religion. In an Op-Ed placed in an Australian paper, Carter states that he is leaving the Southern Baptist Convention because of how it treats women. NPR also had a story on the fallout that examines the issue within the convention.

Let me just respond. I am Jewish, and while I have discussed in the past about my weird take on mitzvot, I often tend to hang around people who are practice-wise more religious than me. However, many of the people in my communities are either committed egalitarians or if they inhabit a more traditional halachick (spelling?) space, are involved in some level of feminism through groups like the Jewish Orthodox Feminist Alliance (JOFA).

In each of these groups they try to make women count. Traditionally, in the halacha women are mentioned in the same legal category as slaves and minors. A few of my teachers at Pardes have said that they personally feel that the legal category of women in that sense no longer exists. Civilly women can own property and provide for themselves. Women are not lorded over by husband. Yet, even if they think this, they understand that development comes slowly in practice, and careful calibrations are often necessary.

However, Carter does have a point. Too often we have used our scriptures, regardless of our faiths, to oppress women. Why does this sexism persist and exist? Again, I do not know. In many ways, I think such sexism sometimes grows stronger because of modernity. The chipping away of male power that the modern age has created leads to greater fears of women taking control and entering the sphere of men.

Yet, as Carter mentions, it is not good. Women have a lot to offer. They add their perspectives as human beings to these conversations. They are about half the population. Educated women lead to children who are better off. In so many ways they just enrich our lives if they are actually able to pursue things (this is not to say that they could not choose to stay at home, and perhaps a man like me may also consider the same).

This post is rambling, but I think what is necessary for us to see is the interpretation of texts leading to sexism, and how reinterpreting them could also lead to freedom.

Larry Summers and the Crisis at Harvard

I am stealing liberally from Felix Salmon's recent post on his blog. Here we hear greater details of what Larry did, and what happens next.

While the President of Harvard is traditionally a very weak position. The only great power is that she can turn down people up for tenure, even if Departments and Faculties approve of such an individual. However, Larry Summers sought to indirectly increase the power of the President. Such was his involvement in the Allston campaign, as well as other matters. What appears here is Summers intervening in the financial matters.

Drew Faust in some sense has returned to a more modest role of President and central administration. She is a rather colorless figure who writes great books on the Civil War, and supports the arts, something Summers failed to do. However, the University is in crisis and needs strong leadership.

The largest problem arises in the Faculty of Arts and Sciences (FAS). Already the infighting has started. Science Faculty are annoyed that they do not have their labs in Allston. Humanities faculty members, sort of the largest group against Summers who in many ways showed disdain for them, want to have greater say over the direction of the University. The students have lost hot breakfast and will likely see more cutbacks in the fabled House system that creates smaller communities.

What really needs to happen is that the faculty itself must change with the changing situation. Their life of relative comfort will not stay the same. They may have to see freezes in their incomes as well. Faust and FAS Dean Smith should help facilitate and solve a collective action problem. And perhaps, the University might need to undergo a more radical corporate change.

Personally I am not in the administration. I am just a person who has had ties to the venerable institution (too many) and would not want to see it fail. For all the hatred that the University inspired, it has done good as well. This institution is probably one of the few in the U.S. that is admired around the world. Its collapse would likely weaken soft power.

CBO and IMAC

So, I just got the news, and clearly this kind of news does not break through the normal media channels, because it is kind of wonk-tastic. The tip goes to Ezra Klein, who has a great analysis.

The CBO has released a report discussing IMAC. OMB responded and there seems to be a fight brewing.

I love CBO, and I almost always defend them. However, in this instance, it has gotten weird, because CBO admits that it cannot plug in numbers, and yet seeks to do that. In some sense too it may be driven by a Congress trying to balance numbers.

Oddly too, the Administration's heartburn over the proposal, which I still think is good even if one must better examine the details of how you implement it, may also arise from the fact that now it might have to do the unthinkable, tax ESI. CBO itself has stated that they can more concretely calculate these numbers and has hinted that it would be favorable.

However, the Obama attacked this idea on the trail, although one should realize that McCain's plan did not have all the other safety features that the current bills or any other proposals have in place, which makes a great deal of difference. Unions would blow up at the idea (wrongly so, in my opinion). The administration would have to raise taxes on a group that it promised not to raise taxes on. So the politics gets more dicey.

I think in the end Orszag comes out right in this matter, but Congress must take the CBO's estimates. But, in a perverse way, this could lead to some inclusion of ESI in income.

Update: Jon Cohn has an excellent viewpoint too on this matter.

Where do we go?

Again, I want to remain positive. The fallout on Friday of the Energy and Commerce Committee creates some concern as to where we will go in health reform.

There are problems. It does create a prisoner's dilemma between the House and Senate. The problem is collective action. Even if they can talk, no one wants to take the first step and put herself out their for attack.

Perhaps it is time for the Blue Dogs to show their cards too (according to Steven Pearlstein) and outline specific proposals in greater detail and in public. Chairman Waxman should also avoid getting angry at them, which is something he rarely does but may feel more likely to do because of the great pressure.

Yes, it seems depressing, but again, I still remain guardedly optimistic that something will result. It is likely not to reach anything near what the liberals want, but it is also will start us down the path, incrementally, of restructuring our system.

The MedPAC/IMAC Proposal

Many have written about the IMAC proposal. Overall, I support the idea. One of the key reasons is that Congress itself has never shown itself willing to make hard choices. Ezra Klein's piece highlights this matter, as did the Ruth Marcus column posted a while back.

The reason why Congress has pushed back stems from the fact that they do get the ability to micromanage these things in a political manner. In some ways it is like defense earmarks on steroids, because instead of targeting a project, you have to fundamentally affect the payment structure of the entire Medicare (and thus all other health insurance) programs. That leads to a system that creates problematic incentives.

However, like so much of what I talk about, the devil is in the details. The question is how do you design the institution. Right now, the Medicare Payment Advisory Comm ) ission (MedPAC, which is the body that the Independent Medicare Advisory Commission (IMAC) is based on, falls under the auspices of Congress. It does not create binding policy but just makes recommendations that are rarely followed, as the example in Klein's post shows you.

Senator Jay Rockefeller wants to create an IMAC that is closest to the Federal Reserve. Essentially the Congress would completely delegate to an entity that is completely independent of any branch, much like the Federal Reserve is. This of course though may overly insulate it from the political process, and could lead to future gutting by Congress itself.

The President and Peter Orszag have a more refined proposal. This idea follows from the highly successful Base Realignment and Closure Commission (BRAC). BRAC worked by having a panel create a base closure recommendation. The President approved of it. Congress could pass a joint resolution of disapproval, but it could not fundamentally change the recommendation.

The big concern, and one that I personally have with my administrative law hat is the idea of executive power. Under INS v. Chadah, after all, a joint resolution passed by both chambers is like a regular bill. It has presentment requirements, meaning, the President must sign it. However, note the problem here. Even if the Congress by a majority rejects the recommendations, the President, who remember supported the recommendation, would likely veto it. That requires an override vote, and that takes 2/3.

Now perhaps it is likely good to further limit the politics of Congress in this manner, but one should always beware about a new institution, as some liberal Democrats are. The structure does matter. The view of the White House actually represents a major increase in executive power. Furthermore, IMAC would be much smaller than MedPAC, consist only of physicians, and have Commissioners likely appointed by the President (with Senate confirmation). This gives the President greater control over the policy than anyone else.

As someone who deeply loves the legislature itself, while bemoaning some of its inability to do certain activities, I support IMAC, but I think it is important to change the structure. IMAC should remain as an independent agency with delegated authority. Congress should have greater say in appointing commissioners, and five is probably too small. IMAC should draw on other health care sectors too. And something should arise to create a level of procedural consensus at the IMAC level before anything reaches the President or the Congress.

I have also thought of an interesting matter of how to structure the procedure beyond IMAC itself. Instead of having the President make the first say, give the proposals to Congress to vote on as a bill. Require that it have fast track procedures, and limit its amendments to completely budget neutral matters as determined by IMAC and CBO jointly. This would likely limit amendments. If Congress does fail to act, then and only then do you trigger the BRAC type process where the President either approves or disapproves. That way, you give Congress a first crack.

I understand Congress's concern, but David Broder does state that we are actually used to a lot of institutions that limit political power and are highly anti-democratic beyond even the structure of the Senate that progressives love to attack. Agencies themselves are not so democratic, and neither are the Federal Courts.

Of course, I am not really an Administrative Law expert. But, ideas like this are important, and these details are probably sadly lost in the discussion of this issue.

Financial Products Safety and choice

We have safety for our homes. We know our toaster will not burn down our house. Yes, likely we may have to pay more, but we at least know these things within a reasonable range. If we want, we can access some information about these things.

But, what about financial instruments?

Many people have raised the specter that if we regulate, if we try to ensure that your mortgage does not "burn down your house" or your credit cards do not utterly destroy you, we will stifle financial innovation.

However, Elizabeth Warren, who started this idea, tends to disagree.

If we do what she says though, credit card companies could not longer create great deals. If we do what she says, people would not be able to own a home with subprime mortgages.

To that she offers something about how innovative products can still occur. Essentially with the FDA regulating drugs, more actual companies wanted to invest. The idea too of creating an agency with the focus on consumer safety solely and granting power there also makes a great deal of sense and prevents the weird stovepiping (separating things out) we see now.

But, one thing I want to get to is the matter of choice. Right now you get a credit card. Warren wants information that you can read and understand. The industry says it is bad for innovation and bad for your choice. However, how does one choose when information is in very small font and very complex. I consider myself of somewhat average intelligence, and I struggle too.

Secondly, even if you do make it clear, without some other regulatory standards, things can fail. We often have a problem cognitively with discount rates. Again, I have the same problems myself. Things in the future that are probabilistic we do not have a great grasp on. After all, I hunt mammoths.

Finally, choice is always discussed of as an unbridled good. However, many of us would not choose a super risk product (well unless you are Larry Summers investing the Harvard endowment). Also, as many who know the Jam Study can respond, more choice actually paralyzes people. It is now considered a well-documented psychological phenomena.

What this boils down to is that a regulatory agency like this, as weird and for all the problems agencies can have, is likely necessary. Indeed too, limiting choice, may have a paradoxical effect of allowing us to actually choose.

Last Night's Press Conference

Matt Yglesias hates the Washington Post, sort of. I love it. I find it far more interesting to read than the NY Times, because often I feel the political coverage is better, and indeed some of the editorials are ridiculous. It's nice to know what the other side is thinking.

But, when it comes to covering the health care debate, they are doing a great job. With wonderful opinion columnists and a great team of reporters, they are doing things fairly right.

With that in mind, let me tell you about a Press Conference that I only read about.

First, Dan Balz has an excellent take on the optics, from someone whom I consider less in my quasi-liberal echo chamber. He writes

The president will need a sustained public campaign of rhetoric and persuasion to prevent public opinion from sliding farther in the coming weeks and perhaps months of this battle. He will continue to make the public case for health care reform Thursday when he travels to the Cleveland Clinic. As he's done on most days the past two weeks, he will be looking for ways to use the bully pulpit to counteract the growing assertiveness of his Republican critics that no reform is better than what Congress may be brewing.

But he will need to do more as well to push the process forward in Congress. Right now, it's not clear where he is placing his real bets. Is it with the Senate Finance Committee bill that is not yet fully formed but that holds out the possibility of some semblance of bipartisanship? Or will it be with a Democrats-only strategy that forces a bill through with a bare majority, using in the Senate the reconciliation process that would amount to a declaration of war with the Republicans?

Obama wants success above everything else. But he has now begun to put down some more explicit markers about what constitutes success. The question is whether, through public advocacy and legislative diplomacy, he can now pull off a victory that has eluded so many other presidents.

Balz does a good job laying out how difficult this process is. The President can only do so much, but now he has started and must continue to lay down markers, while balancing carefully some tricky political waters in Congress.

That said, it was not the press conference that was exciting, but rather an interview with Fred Hiatt of the Washington Post earlier in the day. First, you should read the whole interview. Anyone who wants to understand where Obama is coming from would actually find this more illuminating than the presser last night.

That said, as Jon Cohn states, some things are still on the table, and not dead. First, the President thinks some sort of independent body with some ability to enact Medicare change is still on the table. Second, the President is open to the inclusion of employer sponsored insurance (ESI) under I.R.C. § 61 (and eliminating parts of I.R.C. § 105) also known as the exclusion from income. I have talked about this matter before, and will bring it up again in a separate post.

Another good analysis comes from Merideth Hughes at New America. She shows how much is already in the House bill that could help improve our value, and how the last two major CBO changes could help.

The post also has two excellent stories from yesterday and this morning. The first is about the individual mandate. More and more people support it. Such mandates are necessary for creating a broad risk pool that make health insurance exchanges work. These mandates also have a lovely tinge of personal responsibility attached to it.

The second is how business is divided. While the Chamber of Commerce rails against the employer mandates, large companies have started to support them, and even local chambers are split on the matter.

With a sense of caution, with the AMA behind such legislation, with businesses divided what remains to be done on health care? Well, now comes selling it to the people. Last night's press conference, as Joanne Kenan points out, was one of those moments. But, Obama did not get those ideas from himself. He got them from David Leonhardt of the New York Times, and Steven Perlstein at The Washington Post. I have linked to these columns too and they are worth a read.

Yes, there may be some softening of opinion as a Kaiser Health Tracking poll shows, but overall it is still seen as popular. Overall the public is behind it, and Obama must just reassure the people and help Congress feel safer on the matter (such large reform is NEVER safe). Indeed, the safer route may be to just vote for it if you are a threatened Democrat. As Nate Silver shows, you are screwed if the President's platform fails, because you have now shown yourself and your party to be ineffective. If it works out though, and you passed it, you have something at least to hang your hat on.

Finally too there is always the concern about the timeout announced by Harry Reid. I agree with Nate Silver's other posting too, that there really are too many positive factors going forward. I may be overly confident and positive, but I really think that this is the case with all these other signs I cited/linked to in my own piece here.

The question is that if the public cannot support something like this now, I wonder if we can ever achieve something worthwhile on the issue.

A new Siddur

I gave in and recently got the new Koren-Sacks siddur. I will willingly admit that this was an impulse buy.

Many have written about the siddur. However, really davening with it is incredible. The font is great. It is clear. The translation is nice (I am not a Hebrew scholar, but have some functional ability with the language). The commentary is great by a scholar that I find thoughtful, Rabbi Jonathan Sacks, Chief Rabbi of the United Hebrew Congregations of Great Britain and the Commonwealth.

So, what does this mean for the hated Artscroll? Well, Artscroll will still continue. It is established and a well-known, if offensive product. It has a wide range of products too, beyond that, some of which are useful (if you know their bent and can dig a bit deeper).

However, what this does is add competition into the market of Orthodox/Traditional Siddurim. It offers the buyer choices. While I often state that choice is something that we do not often have, here we have a market of fairly well defined goods, a set liturgical book with instructions, translation, and commentary in English. The advent of choice, actually could only help this market.

While I do not want the traditional siddurim market to turn into a veritable cola aisle (with so many choices that it becomes paralyzing), I do think a limited set of wortwhile options is good. And so, I welcome this siddur not only because it is aesthetically appealing, less offensive to me, and wonderfully put together, but because it really does offer a choice.

And note, I am not even that traditional.