Was health-care reform worth the Democrats' losing the 2010 elections?

William Saletan says yes:

Politicians have tried and failed for decades to enact universal health care. This time, they succeeded. In 2008, Democrats won the presidency and both houses of Congress, and by the thinnest of margins, they rammed a bill through. They weren't going to get another opportunity for a very long time. It cost them their majority, and it was worth it.

And that's not counting financial regulation, economic stimulus, college lending reform, and all the other bills that became law under Pelosi. So spare me the tears and gloating about her so-called failure.

I'm not convinced. First of all, to say that X is "worth" Y implies that Y somehow allowed you to obtain X. It's not clear that losing at the polls last week allowed Democrats to support health-care reform. As this NYT article that Saletan himself links to says:

[E]ven the Democrats who bucked the White House and their party’s leadership by voting against the measure gained little protection. Of the 30 Democrats who opposed the final bill and then stood for re-election, 17 lost anyway.

Indeed, among 49 Democratic incumbents who lost on Tuesday, 32 had voted for the health care law and 17 against it. . . .

Surveys of voters leaving the polls found deep division over the health law. Nearly half of voters — 48 percent — said they thought it should be repealed, while 31 percent said Congress should expand it and 16 percent said it should be left as is.

“When pollsters asked, voters listed health reform among the top issues on their mind, which is no surprise after a long, heated debate,” said Drew E. Altman, president of the Henry J. Kaiser Family Foundation, which conducts health policy research. “But there is little evidence that it was decisive in the vote.”

And if health-care reform was such a huge factor in the Democrats' losses, wouldn't you expect the one member of Congress who was most closely associated with it — Nancy Pelosi — to have performed worse in 2010 than in 2008? But just the opposite happened.

Saletan also ignores state legislatures, which, of course, had nothing to do with enacting the federal health-care law. Democrats in state legislatures still massively lost at the polls.

I also don't accept Saletan's substantive point — that the health-care law was such a great accomplishment that Democrats should feel fine about losing control of the House and getting closer to 50 than 60 Senators. Saletan flatly states that the Democrats enacted "universal health care." If I believed that, I'd agree with him: this would be good and important enough to be worth losing an election.

But I'm simply not convinced that the actual law (as opposed to Saletan's glowing description of it) is good enough to be worth enacting at all, let alone suffering a huge political loss for enacting. This New Yorker article is the best thing I've read about the health-care law. In a nutshell, the article says:

1. The cost and revenue projections rely on unrealistic assumptions and accounting tricks. If you make some adjustments for these, the cost of the plan is much higher.

2. The so-called “individual mandate” isn’t really a mandate at all. Under the new system, many young and healthy people will still have a strong incentive to go uninsured.

3. Once the reforms are up and running, some employers will have a big incentive to end their group coverage plans and dump their employees onto the taxpayer-subsidized individual plans, greatly adding to their cost.

I'm tempted to copy and paste the whole article here, but I'll just give his argument on point #2:

Consider the so-called “individual mandate.” As a strict matter of law, all non-elderly Americans who earn more than the poverty line will be obliged to obtain some form of health coverage. If they don’t, in 2016 and beyond, they could face a fine of about $700 or 2.5 per cent of their income—whichever is the most. Two issues immediately arise.

Even if the fines are vigorously enforced, many people may choose to pay them and stay uninsured. Consider a healthy single man of thirty-five who earns $35,000 a year. Under the new system, he would have a choice of enrolling in a subsidized plan at an annual cost of $2,700 or paying a fine of $875. It may well make sense for him to pay the fine, take his chances, and report to the local emergency room if he gets really sick. (E.R.s will still be legally obliged to treat all comers.) If this sort of thing happens often, as well it could, the new insurance exchanges will be deprived of exactly the sort of healthy young people they need in order to bring down prices. (Healthy people improve the risk pool.)

If the rules aren’t properly enforced, the problem will be even worse. And that is precisely what is likely to happen. The I.R.S. will have the administrative responsibility of imposing penalties on people who can’t demonstrate that they have coverage, but it won’t have the legal authority to force people to pay the fines. “What happens if you don’t buy insurance and you don’t pay the penalty?” Ezra Klein, the Washington Post’s industrious and well-informed blogger, asks. “Well, not much. The law specifically says that no criminal action or liens can be imposed on people who don’t pay the fine.”

So, the individual mandate is a bit of a sham. Generous subsidies will be available for sick people and families with children who really need medical care to buy individual coverage, but healthy single people between the ages of twenty-six and forty, say, will still have a financial incentive to remain outside the system until they get ill, at which point they can sign up for coverage. Consequently, the number of uninsured won’t fall as much as expected, and neither will prices. Without a proper individual mandate, the idea of universality goes out the window, and so does much of the economic reasoning behind the bill.

Is the talk of "death panels" so crazy?

A million articles, blog posts, etc., have made the same point: the suggestion that the health-care reform passed in the United States will involve anything that could be described as "death panels" is crazy and unfounded -- so don't even bring it up.

Well, as my mom argued in this diavlog, there are problems with saying that "death panels" should be out of bounds in civilized debate just because they're not in the text of the pending bills. First of all, we're not seeing the law in its final form. And even if we were, you can't assume that the text of a law gives you a complete picture of how it's going to be applied. It could be interpreted in surprising ways, especially since it's so long and unwieldy.

Also, does it matter if the legislation might represent a baby step toward future reform in the same direction? You might say: no, that's just a slippery-slope argument. But supporters of health-care reform often tell each other that moderate reform in the near future would be good in part because it could make a single-payer system more likely in the long term. (I myself find this argument somewhat convincing and encouraging.) If supporters of health-care reform are allowed to argue that reform would put us on a good slippery slope to something more expansive, shouldn't critics be allowed to argue that a component of reform (for instance, voluntary end-of-life counseling) could put us on a bad slippery slope to something more sinister (involuntary end-of-life rationing)?

It also seems fair to look beyond the text of the currently pending bills -- which, let's face it, few people participating in this debate have the time to read -- and look at the underlying goals of the key actors. So let's look at what President Obama said in April (which Just One Minute recently drew attention to -- via Kaus):

THE PRESIDENT: Now, I actually think that the tougher issue around medical care — it’s a related one — is what you do around things like end-of-life care —

[David Leonhardt:] Yes, where it’s $20,000 for an extra week of life.

THE PRESIDENT: Exactly. And I just recently went through this. I mean, ... when my grandmother got very ill during the campaign, she got cancer; it was determined to be terminal. And about two or three weeks after her diagnosis she fell, broke her hip. It was determined that she might have had a mild stroke, which is what had precipitated the fall.

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

And she elected to get the hip replacement and was fine for about two weeks after the hip replacement, and then suddenly just — you know, things fell apart.

I don’t know how much that hip replacement cost. I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

[Leonhardt:] And it’s going to be hard for people who don’t have the option of paying for it.

THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?

I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

[Leonhardt:] So how do you — how do we deal with it?

THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

The blog Just One Minute (in the same post linked above) sums it up:

So as of April 2009 Obama himself expected the final legislation to include some sort of group (but NOT a "death panel"!) that would produce voluntary guidelines for end of life care with an eye towards saving money.

But is the word "death" just too inflammatory to use? I wish it weren't. Death is a fact of life. We're all going to experience it some day. Society should think seriously about how to deal with it. So I don't think it would be a positive development to ban the word "death" from the debate.

Ah, but any end-of-life consultation would be voluntary, right? Well, what did Obama mean when he said, "[T]here is going to have to be a very difficult democratic conversation that takes place"? If the only issue were voluntarily providing people with information about hospice care and the like -- well, that doesn't sound controversial at all! Why would that require a "very difficult democratic conversation"? Why would Obama say it raises "very difficult moral issues"?

But surely any end-of-life panels would have to remain voluntary, because no one would be in favor of cutting off life-sustaining resources for "grandma," right? (Why is the concern always about "grandma"? Is this another example of women's lives being valued more than men's?)

Well, actually, there are smart, left-leaning commentators who have already endorsed rationing even if it means doing just that. For instance, William Saletan has said:

[J]ust as some people have enough money, others have had enough time. If you make it to 100 and can fund your own surgery, that's terrific. But Medicare should focus its resources on people who haven't been as lucky as you. Living to 99 is no tragedy.

Similarly, Peter Singer wrote a long New York Times piece about "Why We Must Ration Health Care," in which he argued that we should allocate medical resources based on a nuanced cost-benefit analysis that takes into account "quality-adjusted life-years." Specifically, Singer thinks we should put a greater value on younger people (since they statistically have more years left to live) and on those with higher-quality lives.

Of course, I'm not saying that Congress is going to enact Saletan's or Singer's views on these issues. But their views aren't so far beyond the pale that they shouldn't be part of the health-care debate.

To be blunt, those writers would presumably be in favor of something you could call "death panels." Many would strongly disagree with them. Isn't that part of the "very difficult" debate Obama recently said we're going to need to have? So, let's have the debate, and let's stop trying to forbid the use of the term "death panel."

Is the new tobacco regulation law a model for drug legalization?

William Saletan think so. The gist of the argument he makes in that Slate article is: the tobacco law Obama just signed aims at "harm reduction" through regulation rather than outright prohibition of tobacco products; therefore, we should do the same thing with currently illegal drugs. Though he doesn't mention any specific illegal drugs in his whole article about them, I presume he'd like to see marijuana, LSD, cocaine, and even heroin legalized and regulated.

Here are a few of my half-formed objections to this analogy:

1. The regulation is dealing with the pre-existing problem of tens of millions of Americans being hooked on cigarettes. Of course Saletan is right that you couldn't just prohibit them and turn all Americans, or even the vast majority, into non-smokers overnight. But why is it that so many people are smokers already? A big part of it is that cigarettes are legal. The fact that something's illegal makes it a lot costlier to engage in; thus, many people will choose not to do it because, even without any sincere moral qualms about using drugs or even breaking the law, they simple aren't willing to bear the costs (which include paying more money, risking legal consequences, etc.).

If you read Saletan's article, you'll see that he's very skilled at creating a sense that anyone thinking rationally about the situation must conclude that legalization/regulation is the solution to America's drug problem. But this is far from obvious, and it's really hard to test the theory without actually putting it into practice. I'm sure that heroin could be regulated to be less harmful, and that this would benefit some people -- but since it could also lead to some people using heroin who wouldn't have done so otherwise, it's not clear that there would be a net benefit. Somewhere along the line, you'd be sacrificing one person's health (the person who gets hooked on legal heroin but would never have touched illegal heroin) for someone else's (the current junkie).

2. It's easy to take this moment in 2009, right when this law is signed, to point out how rational it is. But you can't assume that if drugs were legalized, they'd be well-regulated right off the bat. The federal government first officially recognized the deadly nature of cigarettes in 1964; it took decades to get to this point.

3. Saletan seems to assume that the new regulations will be effective. I hope they are, but it's good to be cautious when predicting the consequences of a radical change in the law that's ultimately aimed at changing human behavior. As one of the commenters on Saletan's article points out, there are already "mild" and "light" cigarettes, and they've been empirically shown to cause as much harm as non-light cigarettes. That's because, while they may have less bad stuff per cigarette, smokers compensate by smoking more of them, or smoking each one more intensely. It's hard enough to predict the effects of regulating cigarettes; why should we assume that drug regulation would be effective? Even if the regulations are intelligently written, swiftly enacted, and vigorously enforced (all of which are open to question), how do we know that purer, safer drugs wouldn't encourage people to use more of them? And any regulation that makes the drugs milder could lead to the same compensating behavior as with light cigarettes -- again, increased use.

This is all wild speculation on my part; I might be wrong on many of these points. Supporters of legalization, on the other hand, often try to create the impression that they know regulation would be effective. I don't think anyone knows that.

Should we keep collecting statistics on the racial gap in kids' academic performance?

William Saletan doesn't see why we should. He's worried the data will add more fuel to those who claim that blacks are genetically less intelligent than whites. He rhetorically asks:

Why categorize and measure students by race? ... Does that category really help? And what message does it send to kids when headlines assert a persistent "racial gap"?

John McWhorter responds:

I find it hard to imagine that Saletan has seen the countless books and articles on the black-white performance gap and scratched his head wondering just what the epistemological or historical groundings were for addressing race as a metric....

Why would a nationally prominent journalist pretend not to understand why National Assessment of Educational Progress data is broken down by race, as if he lives in a different country--or century--than his own?

Here's Saletan's response, in which backs up his concerns with more details, links, and a metaphor about an oncoming train. He ends on a moralistic note:

Each of us should be judged by his own performance, not by a stereotype.

McWhorter has a powerful reply: data that persistently show an academic-performance gap between blacks and whites, even after controlling for income, could actually help us to clarify our views of how poor black kids' learning environments are less nourishing than poor white kids'. He explains:

[S]ure, it may turn out that whites and/or Asians have higher intelligence than black people. It's not news I would love hearing, for all the same reasons few of us would. But it could happen.

However, to me, the evidence suggests that the difference in question, if it exists, would be quite small. Other factors are just as plausibly responsible for most or even all of the gap between poor white and poor black kids on tests like the NAEP....

[M]ost of us will spontaneously notice that the worst schools in the nation - the violent, understaffed, ramshackle inner-city disasters where little learning happens--don't have many white kids in them....

Poor black kids are routinely subject to less qualified teachers, who stick around for less time, than poor white kids. A classic study on the question by John Kain and Kraig Singleton addressed the situation in Texas.

Or, the typical poor white child is surrounded by fewer poor people than the typical poor black child, and only about 1 in 20 poor white kids go to schools where almost all students are also poor (useful facts on this here).

Notice that I am not claiming (despite sources such as the one I linked because of its handy presentation of other data) that the problem is "segregation"--i.e. that poor black kids are done in by going to school with people the same color as them, a tragic distortion of the meaning and significance of the word segregation in our times which I deplore. "Segregated" KIPP academies are teaching poor black and brown kids brilliantly all over the country (which, itself, is further evidence that the problem is how such kids are taught more than how their brains are configured).

The issue is poverty rather than race, and the cultural baggage it often means kids are bringing to school--which the schools poor black kids attend are less adept at compensating for than those attended by the poor white kids. Plus, poor white kids are more likely to have more fortunate students around them to imitate and learn from.

All 4 linked pieces are worth reading in full.

I think this is a complex debate, but in the end, I have to agree with McWhorter.

One problem I have with Saletan's position is: the data showing the performance gap already exist. So even if we stopped categorizing the students by race, those who are determined to make the case that blacks have genetically low intelligence could simply continue to make the same arguments they've been making, based on the old data. Even worse, they could point to the absence of current data as a sign that the truth is so politically incorrect that the powers-that-be "don't want you to know about it."

It's better to let everyone see all the facts, so that non-racists can drown out the racists' arguments by making the most convincing, reality-based arguments available. If you can continue to make relevant arguments on an issue like education funding, you're more likely to convince the public and lawmakers to make it a high priority.

As an aside, Saletan says he "resent[s]" that his daughter's kindergarten school requires him to fill out a form indicating her race. This is comically unsympathetic. Some things just aren't very important, and the effect of occasional paperwork on white parents' feelings about their own whiteness is one of them.

Cured, all right

We just watched the great Stanley Kubrick movie A Clockwork Orange last night, and today I read in Will Saletan's blog Human Nature that a new drug might "cure the urge to steal."

Saletan quotes a report by the University of Minnesota School of Medicine:

An 8-week, double-blind, placebo-controlled trial was conducted to evaluate the safety and efficacy of oral naltrexone for kleptomania. Twenty-five individuals with DSM-IV kleptomania were randomized to naltrexone (dosing ranging from 50 mg/day to 150 mg/day) or placebo. . . .

Subjects assigned to naltrexone had significantly greater reductions in . . . stealing urges (p = .032), and stealing behavior (p < .001) compared with subjects on placebo. Subjects assigned to naltrexone also had greater improvement in overall kleptomania severity. . . . Naltrexone demonstrated statistically significant reductions in stealing urges and behavior in kleptomania.

Saletan adds:

Naltrexone is better known as a drug for alcohol or drug addiction. Many of us, while accepting these addictions as diseases, continue to regard theft as a matter of personal responsibility. Should we rethink that distinction? If the same drug relieves both conditions, should we take kleptomania more seriously as an illness?

Should we eat Frankenmeat?

As someone who's a vegetarian for largely ethical reasons, I'm intrigued by the prospect of scientists in a lab creating meat from real animal cells -- using the same basic mechanism as human stem-cell research -- that would be food from the start, bypassing the being-a-living-animal stage.

There seems to be a buzz around lab-created meat: there was an International In Vitro Meat Symposium in Norway last month.* And predictably, PETA (an organization I have very mixed feelings about) is promoting the idea by offering a million dollars to the first scientist who brings the concept to fruition.

Unfortunately, the plan has some serious (I'm guessing fatal) flaws. For one thing, the progress has been miniscule (literally) and glacial:

Despite considerable hubbub over the technology in recent months, we're still years -- or, more likely, decades -- away from affordable lab-grown meat. The current experiments are taking place in bioreactors that measure only a few hundred milliliters in volume, and the longest complete muscle tissues are just 2 centimeters long. Researchers are nowhere close to scaling up their production to market-ready levels, to say nothing of market-ready prices. A Dutch team's lab-grown pork, for example, would cost around $45,000 per pound—assuming they could make an entire pound of the stuff.

But what really disturbs me about the whole project is that

manufactured meat promises to replicate only the taste and texture of processed meat; as far as we are from enjoying lab-grown hamburger, we're even further from perfecting man-made rib-eyes. So even if meat labs did become viable commercial enterprises, the naturally raised meat industry would hardly vanish.

Given our penchant for gluttony, affordable lab-grown meat could even be harmful to our health: We might simply increase our beef and pork consumption to keep pace with production, as has occurred over the past half-century. (According to this disturbing assessment, we annually consume 50 pounds more meat per-capita than Americans did in the 1950s.)

As that passage implies, it's foolish to assume that either the production or the consumption of meat is static rather than dynamic, although this is often presupposed in arguments against vegetarianism ("They're just gonna die anyway").** This contradicts the plain facts and basic rules of economics.

But there's one thing that specifically does not disturb me. William Saletan (a liberal who often writes about bioethical issues but is not a vegetarian) says that lab-made meat would be

a colossal concession ... for the animal-rights movement. Lab meat "would mimic flesh," says PETA's press release. Mimic? Lab meat is flesh. ... It won't walk or quack like a duck, so technically, it's not a duck. But if it tastes like duck, chews like duck, and comes from duck, it's duck.

Well, I'm suspicious of arguments that hinge on a semantic distinction like "duck" vs. "a duck." It seems to me that if something is one of those, it's both. If we're attributing momentous moral significance to a little thing like the word "a," that should set off alarm bells: is that really what matters? I don't think so.

People have this impulse to turn moral debates into semantic debates. "What counts as torture?" "What counts as human life?" "When is someone dead?" "Is lab meat made of animals?"

I don't care about any of those questions! When it comes to ethical issues, these are the only things I care about: (1) What exactly is going on? (2) Is it a good thing or bad thing for that to be happening?

I don't care if waterboarding or slapping someone in the face is called "torture." It either will or won't be called torture depending on how any given person chooses to use that word. The important question is: Is that behavior something that we should be engaging in? Skip the semantics and go straight to the ethics.

Yes, language can be essential to thought, but language can also box in thought. (I'm inclined to agree with the thought-precedes-language side of the debate outlined at that link.)

If you want to say that lab meat is made of animals just as normal meat is, then fine. That just means there's no semantic distinction. But what makes normal meat morally problematic doesn't exist in lab meat. A piece of lab meat doesn't have a history as a living, breathing, moving, and -- above all -- sentient creature with feelings. Normal meat does.

Lab meat does raise ethical issues, but they're pragmatic ones like whether the environmental consequences would outweigh the potential for adding more fuel to our meat addiction. I see no fundamental (non-pragmatic) moral problem raised by lab meat.

Again, I doubt the whole thing will work at all. But if producing lab meat from animal cells worked perfectly -- which would have to mean it would be satisfying enough to meat-eaters that they'd reduce the rest of their meat consumption -- then wouldn't it be not just OK, but morally obligatory?


(Photo by Emily Chastain)

* I once had a debate with one of my fellow law review editors about whether you can ever have a capitalized proper noun after an indefinite article ("a" or "an"). Voila! [back]

** I'm planning a series of posts responding to common arguments against vegetarianism like this one. Stay tuned. If you happen to have a favorite anti-vegetarian argument, please send it my way, and I might include it in one of the upcoming posts. [back]