Saturday, October 5, 2013

The Affordable Care Act.

I was asked to explain the Affordable Care Act and describe its strengths and weaknesses.  The Affordable Care Act (ACA) is a gigantic piece of legislation meant to expand access to health care and improve its quality by increasing competition among insurers, subsidizing the poor, setting minimum standards for plans, expanding Medicaid, and reforming how payments are made to providers. It does a lot to help a lot of people. But like most of life, tradeoffs are made, and there are some flaws in its design. I currently do not consider them fatal, even if they are sometimes significant. Still, as we discuss these, it will point the way toward future improvements.

 First, it’s useful to think about a couple of background matters. People talk a lot about markets, and markets versus the government, and love to throw around these terms in the healthcare sector. But we should be careful. Markets create wealth with sometimes stunning efficiency. But this can only be expected as you get close to a “perfect” market. While none is perfect, many are close enough to perfect to produce a lot of growth and wealth and make a lot of people better off. But many sectors have what are called “market failures.” That’s not a term for some sort of collapse where the world falls into a recession. It simply means that there is some reason(s) that the sector does not behave according to market forces. When they don’t, the magic of markets goes away or falls short and consumers and investors will, as a whole, end up worse off than they would be if the market did function. Economists have documented the reasons for these market failures for several decades, and there are often well known ways to address these. Usually the best way to address serious market failures is through government regulation. This is actually not a controversial statement in most economics circles. The controversy among conservative and progressive economists is not whether there should be regulation in such cases—it’s about how bad the market failure needs to be before government intervention is appropriate and effective. Progressives want to intervene earlier, whereas conservatives will tend to think the likelihood of it getting botched means we should be more conservative about intervention. But both will support it in some cases.

One of those cases in Healthcare. The American healthcare sector is a classic example of a market failure. It fails to function like a market for many reasons. Conservative and Progressive economists have both provided lots of ideas about how to reform it—those from both sides have come up with ingenious ideas to fix these deep flaws and get it working more like a market. Others have favored a single payer system, treating healthcare as a public good, like education, infrastructure or the police. Despite the horrors told by opponents of all three types (conservative and progressive pro-market solutions, or state sponsored solutions), the truth is that most of the main approaches have good arguments to recommend them. They all include tradeoffs, and a lot of uncertainties.

Now, whatever the case, we can be sure that our healthcare system is neither particularly market based, nor is it effective. It’s the most costly in the world by far. We spend the largest percentage of our economy on it, by far, despite being the richest nation. Despite it being world-class for some, its overall effectiveness lags that of other nations, and we have almost 50 million people without insurance. The ACA attempts to address some of these problems by both expanding social medicine (Medicaid) for the poor, and (somewhat) enhancing market forces through the exchanges and a variety of other means.

Now, returning to the market thing. The reasons healthcare doesn’t make for a market very easily were first documented by Kenneth Arrow (he won a Nobel and basically created the field of Healthcare Economics). He pointed out that with health care you can’t know what your needs will be and you cannot know if service you are thinking of purchasing is what you want or going to be helpful until after you have bought it (and even then, you may not know!). This makes valuing the “goods” of healthcare difficult, which is unfortunately key to a functioning market. The imbalance of information between buyers (you) and sellers (the medical system) is dramatic, which undermines market forces. The barriers to entry are high (hard to become a doctor) and set by essentially a union (doctors!), which allows them to exclude people from work that could easily be done without an MD (this is decreasing, thanks to more Nurse Practicitioners, PAs, etc., but is still a problem). In Medicine, weirdly, supply creates demand. If there are more doctors in a city, people go the doctor more. If the ratio of specialists to primary care doctors shifts in a city, so does the number of visits to those kinds of doctors – and costs move with them. More hospital beds equal more hospital visits, even when the populations have the same level of health—with no better outcomes. This may have something to do with the nature of the relationship between the patient and the physician (one of trust, rather than sales). In any case, this thing I’m describing is called “physician induced demand.” Supply doesn’t just create demand out of thin air in a functioning market, and it is another reason this sector performs poorly. And since we have “fee for service medicine” (where we pay a fee based on whatever the doctors decide to do, rather than, say, on what it should cost an average person like us to get treatment), the bill keeps growing. The fact that third parties (insurers) pay for our regular needs is also extremely weird, and not as normal in markets.

The Affordable Care Act (ACA) stems largely from the work of the MIT Professor Jonathan Gruber, one of the leading medical economists in the world. As an economist, he thought it would be valuable to propose something that extended care to the uninsured, but also largely preserved the private market, and actually enhanced market forces (the first love of any economist). His ideas formed the backbone of the policies for both “Romneycare” in Massachusetts, and “Obamacare.”

A couple items to keep in mind: The ACA is not social healthcare. It does include an expansion of Medicaid (which is social healthcare), and some improvements to Medicaid and Medicare (both government payers as well). But the act is many other things, including changes in the tax code and both pro and anti market regulation. We aren’t taking on the Canadian system, for better or for worse.

Another thing to realize is that the healthcare sector is already full of government intervention. Drugs cannot come to market unless they are deemed safe by the FDA, for instance. And employer based healthcare is one of the biggest subsidies in the tax code—something like $150 billion. The reason your employer healthcare is so (relatively!) cheap, is in part because of this subsidy. Some of the intervention is less straightforward—private insurers often actually follow Medicare’s lead on how they do their billing. It’s not intervention, but it is an example of an odd relationship between the public and private sector.

Last—before diving into the details, think about rationing. A lot of people are worried about rationing. One thing to keep in mind is that healthcare, especially quality health care, is currently rationed—by whether you can afford it, hospital capacity, whether you have a preexisting condition at the wrong time, etc. The ACA won’t increase rationing—if anything it will decrease it, since the minimum level of benefits that an insurer may offer has increased so much. But each insurer will of course be making decisions about how to spend its resources, including government insurers. These are the “death panels” people worry about. Fortunately, the government ones have to use evidence for rationing (so, don’t give people expensive care that won’t help them get better) and the private ones will surely do something similar if they want to survive. And it will decrease rationing based on wealth.

As to the act itself. First, the ACA is expanding and transforming government paid healthcare. Medicare (healthcare for the old) often sets the path that private enterprise follows when adjusting their billing practices. Medicare and the private sector are currently doing amazing things here. They are creating what is called “accountable care.” The current setup involves too much treatment because doctors want their patients to be happy (generally, and to avoid lawsuits), hospitals have a strong financial incentive to over-treat (because of fee for service medicine—they just get paid more), and patients are more satisfied when they see stuff being done. Also, in this system, prevention doesn’t pay all that well. If I have an unnecessary hospital visit, it doesn’t hurt the hospital, after all. Accountable care pushes back on this. First, it involves something called “capitation.” All that means is that Medicare takes a group of people for whom, with the right data, it can predict with great accuracy what the average cost should be to treat each person (the individual is impossible to predict). Then, Medicare says, “ok provider, here is your $100 million to treat these 10,000 people with diabetes,” If the provider runs spends more, it finally hurts the provider’s bottom line.

Medicare is also bonusing (and punishing) providers based on quality. So if a provider meets certain quality standards (say, avoiding preventable hospital infections, getting its people with high blood pressure on blood pressure medicine, etc.), it gets bonuses (or penalties, for doing a bad job). One of the key things they do is look at hospital readmissions. For a lot of sicknesses, one hospitalization is enough, but mistakes in care (particularly in follow-up-care) create more hospitalizations. This is one of the many quality measurements being used to pay hospitals. There’s actually a host of these being introduced and experimented with, many of which going under the affordable care act. The government is actually leading the way in getting the incentive right (unusual!).  My assessment is that this part of the act is undeniably awesome.

There is this thing called the “donut hole” – a gap in Medicare coverage. Basically, once Grandma has used used up some of her prescription drug benefit, she reaches this spot where she starts to have to pay for all of her drugs out of pocket.  This continues until she has spent quite a bit more, and her coverage kicks back in and covers her drugs (this is the part to cover “catastrophic” costs). This means high annual out of pocket costs for seniors, although often not the bankrupting sort associated with hospital bills. Still, it’s a huge problem for lots of poorer seniors. The ACA offers discounts of 50% on drugs purchased while grandma is in the donut hole, eventually covering the whole donut hole for her by 2020.  It does right by our seniors, and I like that, although the added expense is a challenge.

Both Medicare and Medicaid are doing more with prevention, like expanding preventative services they cover and making it so that people are less likely to have to pay co-pays for preventative stuff. This should save money in the medium and long term.  It's very good.

Medicaid is becoming available to a lot more people. Medicaid is free healthcare for the poor. As was noted in the comment string, Medicaid reimbursement rates are low. Now, many providers don't mind treating Medicaid patients, either because they still make a profit on them, or enough on others, or as a hospital they are are not-for profit. So Medicaid patients do get treated (even if not always very well). Keep in mind too, that Medicaid is run by the states (this is a Republicans favoring policy), and so experiences may vary from state to state. In any case, a large minority of small scale providers are moving away from accepting new Medicaid patients, and this will increase wait times for Medicaid patients, especially as it expands. It's not unreasonable for doctors to decide not to take Medicaid patients if they cannot make a profit doing so. But for the poor whose only other alternative is the ER, this is still a dramatic improvement.

Note also that Medicaid will not be expanding in a bunch of the states. The Supreme Court decided that federal government couldn’t make the states do so, even though the federal government is providing 90% of the funds for doing so. This means many poorer people newly covered in some states would not be covered if they lived in other states. So coverage will vary, state to state.  This will leave a gap in those states that refuse the expansion—for those that cannot afford healthcare on the exchanges, but aren’t poor enough to get Medicaid. The ACA has flaws.  This gap is not one of them, though.  It will only be created by the states refusing it (currently all the states refusing are  Republican led, and are protesting the ACA and worried about future spending requirements).

Finally, a bunch of funds will go into public health centers. These take care of the uninsured (there will still be a lot of these people).

In the private sector, the ACA does a lot of things that will both help the health care sector work more like a market. Some things will also hinder market forces, and some will do both. First, it sets up health care exchanges, with gold, silver, and bronze standards. Think of an exchange as a kind of eBay (but nowhere near as user friendly, I’m sure!). Exchanges (like stock exchanges, and eBay) where information is standardized and searchable do amazing things for markets. They help you compare apples to apples. And they make finding and comparing plans way, way easier. This lowers “transaction costs” and “search costs,” both of which make markets work better. Think about it. When you are at the airport, competition is reduced, because it is hard to find a good competitor for a Wendy’s quickly and easily. And guess what? Prices are higher. That’s because the costs associated with switching burger joints (Wendy’s to McDonalds) are higher than normal. When that happens, the burger joint can charge more (to a point). This is a simplified version of why a lack of competition hurts consumers.

Also, by setting up tiered (gold, silver, bronze) plans, and including minimum standards for the plans, the plans are easier to compare and contrast. When you can compare apples to apples, you can make “rational” decisions (which are necessary for markets to work). Before, the plans were so sprawling and complicated and different from one another. This wasn’t just because it made people happy to have a million options. Instead, it reduced competition, since it was so hard to compare the plans, even if you had the time to go out and find them all. Now you can compare, because there are a bunch of things that don’t vary, but coverage amounts do vary. This effect is pro-market.

As I said, there are certain minimums for the plans. By now, a lot of this will be familiar. If you have a dependent who is 26 or younger, (s)he can stay on your family plan. Maternity care must be covered. There are certain minimums for mental health care. No more limits on lifetime payouts, since benefit caps are the opposite of insurance (no more “we cover you if you get really sick, but not really, really sick”). There are others, and there is some flexibility on the part of states when it comes to some of them, but you get the idea. No more crappy coverage plans.

Now, as I said, standardization is pro-market, because it enhances competition. But it has an anti-market effect too. It reduces consumer choice and raises costs. You may see a headline that says “health insurance costs going up due to Obamacare.” While the exchanges make prices lower than they would be otherwise, the truth is, by saying that insurance can only be so bad, the overall average price will have to go up. This is true of any kind of consumer protection. If a company sells toasters but one in a hundred of the toasters blow up because of cheap wiring, the government might say, “you can’t use toasters with that cheap wiring in it.” Now no more blown up toasters! But no more cheap wiring—the average toaster is now more expensive. This is how minimum standards work. They raise the minimum quality, but reduce consumer choice or raise the average cost.

If your plans were identical, the exchanges should lower the cost substantially. But the details of your plan will be different, and so it will be a little hard to say whether the plans are more expensive or not. You’ll just know if you are paying more or less.

Here is where I think some of the biggest flaws of the ACA are. Having minimum standards makes sense, but the fact that my father-in-law must purchase insurance that includes maternity and pediatric child care coverage drastically raises his costs. While this does not mean that minimum standards are wrong, it does suggest that this stuff should be tinkered with substantially, lest people be forced to buy a bunch of stuff they will obviously never need. Still, that leaves us with other complex questions (like should young, fertile women have higher costs simply because they are young women?). I think few people realize is, but this is where a lot of the tradeoffs associated with the ACA are happening, and more of the debate should focus on this part. This is where it is pro-market and anti-market. This is where it sometimes helps the little guy and sometimes hurts the little guy, just like the toaster example.

The ACA also is doing a lot when it comes to measurement. Not just hospital effectiveness, as I said before, for Medicare bonuses, but physician reporting too. By putting this data into the hands of consumers, consumers will have a much better ability to makes choices among providers (again, fostering competition, pro-market). This is very, very, very good and needed.

The private sector health insurer sector famously suffers from administrative bloat. The ACA requires some simplification and standardization of billing practices that should simplify things for these payers (and the providers) and save everyone some money. It also limits how much can be spent on administrative costs at an insurance company (85% of the premiums people pay in must go to healthcare). That means more of the money will go to healthcare, and less to supporting corporate bureaucracies. (As as side note, Medicare is actually (surprisingly!) far more efficient—they spend about 3% of their money on administrative costs—this is an example of how the private sector doesn’t always present a clearly more efficient alternative, even though it usually does). Requiring simplification should help with efficiency, though, and it doesn’t look like it will hurt experimentation by the insurers. Mandating that most of the money go to actual healthcare seems reasonable too, since so much fails to do so, normally.

The ACA also mandates that people get insurance, or pay a fee. This is the one part that the majority of Americans don’t like (most of the other stuff polls pretty well). Part of what is so tricky about this is that insurance in a traditional sense is different than health insurance. When we get, say, fire insurance, we are pooling risk with others. We know there is a 1 in a 1000 chance we’ll need to use it. Insurance is like if we were to get together with 1000 other people and each pay 1/1000 of the cost to replace whoever’s house burns down. But with health insurance, we pool risk in the same way, but instead the insurance pays for our regular, yearly expenses. It’s weird. But we want it to do that—since people fail to get preventative care if it isn’t paid for, and their later illnesses cost a lot socially, and economically, and not to the sick people and their families. So, we have health insurance. It’s this funny thing that behaves in funny ways.

What’s difficult about this is that at different stages of life, you are more or less likely to get sick or have a baby, and you know it. Theoretically, if your insurance company was like God and could look at every aspect of your health perfectly, it could predict everything and would charge you accordingly (this year, you will cost $10,000. Go ahead and pay $10,000 now). Of course, that’s not real life. We rate people by risk. But if we let insurance companies do too much risk rating, it creates situations we don’t like. Old people have to pay an obscene amount of money. Kids with cancer or congenital illnesses are extremely costly. The better our risk-rating, the more it costs these people to get coverage.

The idea of insurance is instead to insure against such things (like getting financially ruined because you are old or have a disease). So we “group rate”. If you get a group of people together with differing levels of risk, the price is a bit higher than it would be for the many healthy people, and much cheaper for the unhealthy. This is what employer-based insurance has done for years. It accounts for a few things (maybe your age), but largely allows the whole pool to have a rating, rather than just you. It’s actually a form of redistribution (which is what insurance is).

The individual market has not worked this way. With no group to buy with, there was no way to do this. Now, the exchanges are making this more possible. But the only way to make it financially viable, is if healthy people join. After all, if everyone that joins is sick and old, the costs themselves will be as high as they would have been in the first place. And the healthiest of these sickly people will quit, since they are much healthier than the average person in the sick little group (and so they figure they can get by without insurance, when they see the super high price of the insurance). But if the healthier sickly people leave, the average group member is even sicker, and the cycle repeats itself. This process is part of something called adverse selection and if it gets out of hand, it is called a death spiral. It dooms an insurance pool. The mandate is to prevent that. It’s to create group-rating for people who cannot access it because they don’t work for a company that provides insurance. And just like group ratings inside a company involve redistribution (yep, private sector does it too!) this too involves redistribution from the healthy to the sick. In some sense, that’s the essence of insurance. In any case, it’s why there is a mandate.  There are pressure groups actually trying to get young people not to sign up, so the overall premiums will shoot up and it will tank the whole system.  So it seems that at least some on both sides of the debate think the mandate is necessary for the whole thing to work.  Whether it is, I cannot say.

Medicare works similarly. The young subsidize the old, with the promise that when they are older, the new young will subsidize them.

There are a few subsidies and tax breaks that expand access to insurance. If you buy insurance on the exchange, and you have certain income levels (up to 4X the poverty level, I think), you can get subsidies that lower the price of your insurance. That means that society as a whole will pay a part of your insurance (this is a classic subsidy to help the poor get what has been deemed an essential item). There is also a tax break for small businesses, making it cheaper for them to provide insurance. This is a form of subsidy, this time to employees of small businesses. This was probably because the tax code has mostly helped employees of large businesses get insurance in the past, and it make it so the employees of small businesses have a chance at it too.

There are a couple of other items. There is research like data gathering for understanding health disparities (which communities, income levels and racial groups get worse care, or outcomes, and why, and what we can do about it). Long term care plans will be offered (I think on the exchanges), which will be helpful to many families.

The ACA obviously needs a revenue source, given all the subsidies and tax breaks. Those will come from a small increase on the Medicare Tax on high income, some fees to insurers and taxes on pharmaceutical companies and device makers. There will eventually be a tax on “Cadillac” plans. These plans are super fancy and encourage too much health care consumption. The intention of this is to raise the cost of buying into such plans, because they make the system more expensive. Lastly, the subsidy (tax break) for health spending accounts will not cover over-the-counter drugs (like Advil) that were not prescribed by a doctor anymore.

The effects of taxes are more complicated than most people let on. The taxes on pharma, for instance, will likely roll down to consumers (or the stockholders of those companies) to some degree through increased costs. So health consumers in general, or maybe healthcare investors, will subsidize the needier people in particular. The Medicaid taxes on high income are small enough that they are unlikely to affect incentives to work, I think. They aren’t perfect, but aren’t too badly designed, from what I can tell.

The act sadly does create what are called “perverse incentives” too. These are incentives that undermine the goal itself or other related goals. So, the fact that employers with 50 or more full time workers have to provide insurance will get a lot of people insured. It also means a lot of employers will turn to using contractors or keeping people from reaching full time. Some large employers are dropping coverage, now that the exchanges are in place and going to be subsidized. Some of those workers will be less well off, although it’s not clear how much. By dropping insurance, the employer will save a lot of money, and this may ultimately free up resources for competitive wage increases (since they were already willing to put the money into benefits). You’d have to consider whatever wage inflation occurs when you think about the costs and benefits. The money may instead flow to shareholders, depending on the dynamics of the particular industry that the employee is in. It may also just preserve the firm, or a number of jobs in the firm, instead. That’s hard for you to measure, since you don’t know if you would have been cut, but you have to figure it in.

Since many employer sponsored plans are nicer plans, that means that the new minimums (in terms of benefits) for plans in the exchanges, probably won’t add many features (nor costs) to the people who get dropped by their employer. But it will depend on the person, and depend on how heavily the employer was subsidizing the plan to begin with.

One more danger is poor subsidy design. The Washington State online tool for estimating your costs seems to reveal something very stupid to me. It looks like at a certain income level you go from a lot of subsidy to zero subsidy. This is a classic frustration of Republicans with many pro-social justice policies from the left. The way the website looks, for some people, if they make an extra thousand dollars in a year, they will pay an extra six thousand dollars for their health insurance! The subsidy should taper gradually, as a percentage of income, not in big steps like it seems to. That creates an incentive to make less money and actually punishes you for making more. I don’t yet know if that is a state specific thing, if the website is estimating inaccurately, or what. In any case, if it is that way, it should be changed to a smoother transition.

Like any policy, there are winners and losers. Everything is redistributive compared to some other alternative way the world could be (and redistribution doesn’t always go to the poor). Life before the affordable care act was redistributive compared to the nineteen eightys, and the ACA has shuffled the deck again. The young and the healthy, just like inside companies, will now subsidize the older and the sicker. The people are satisfied with a spartan plan (usually the healthy, but not always) will now subsidize the rest by having to buy a better plan. Men will subsidize women, particularly of childbearing age, and those past childbearing age will subsidize women and other people’s children. The rich will subsidize the poor and everyone will subsidize the poor. Providers, less able to charge for duplicate or unnecessary testing and procedures, will have some of their resources redistributed to consumers.

Again, every economic policy, free market or otherwise, redistributes wealth in all kinds of directions. There are big questions about who it should go to, when, why, and how much. I have lots of opinions about this stuff, but am trying not to let them infect this analysis. My goal here has just been to help you see what is actually happening under the Affordable Care Act.

 In my opinion, it’s overall a good idea, one that will make the world a more just place, expand the effect of the market and make consumers, as a whole, better off. But I think the minimum standards for the plans is too high, and I don’t think older people should have to support younger people’s fertility, especially when they already pay more somewhat simply because they are older. The subsidies better be gradual, instead of what they appear to be, and some of the perverse incentives could use some tinkering. And where the purposeful or accidentally redistribution happens in a way that hurts those in need, or even regular folks very much, it needs some reworking. A radical market based plan might work better in the future as we get better data for evaluating providers and procedures and drugs.  A single payer plan works far better in lots of countries. Still, overall, I think the ACA is worth it, and I think it’s a substantial improvement. But I don’t want to minimize the costs and challenges and the stuff that should be adjusted. These are real.

Wednesday, November 5, 2008

Obama Wins

I'd be lying if I didn't say I was elated.

What a night. An electoral landslide, and a decisive popular vote.

The man faces a nearly impossible task; I'm hopeful he can have a powerful impact. John McCain was right: for most any political persuasion, several hundred years of pain, suffering and advocacy really culminated in a powerful sense of unshackling last night. (McCain's concession speech was really, really classy, by the way).

I cannot imagine what it feels like to be in the minority, to be disenfranchised, to live on the outside, but I believe that Obama's win will warm the hearts of those who do and perhaps inspire us all.

For now, this blog will be on hiatus. If I choose to write more in the future, I'll be sure to promote it on facebook and myspace.

Thank you my friends for the spirited discussion.

Ron

Monday, November 3, 2008

Closing Remark

The case is clear. Obama is a better, more inspiring leader, with better ideas about how to fix our economy, help the poor, bring healthcare access to the American people, save us money, conduct foreign and energy policy, and who will reduce abortion (and the desperation it tends to represent).

As a citizen, I believe Obama's policies and persona will provide us with a better future than John McCain can provide. He isn't the messiah, perfect, or the answer to all our problems. But as presidents go, he is pretty great. He will more reliable provide a path to a more prosperous future, and a prosperity that isn't just for the few, but the many.

As a Christian, I believe this election has profound moral implications. It's time to repudiate the patronization by the national Republican party, who has never tackled abortion or faith based initiatives. It is time to recognize the warrior nation label for what it is--the antithesis of the Jesus of the gospels. It is time to realize that the social and economic fate of widows, orphans and immigrants and how we treat them as a society is given far, far, far more time in scripture than gay marriage, abortion, abstinence or public profanity. Jesus, in continuing the prophetic tradition, argued for the "least of these" and we have continually left them behind.

It's time for our policy to reach out to the least of these, rather than rewarding those who are in the front of the line. It's time to recognize that some of us have benefited in far greater measure from the social situation, and that we thus owe a greater debt to our society. A debt of money, time, energy, civic engagement and social action.

I believe that Barack Obama represents this vision in far greater measure than his opponent, and I hope you will join me in voting for him tomorrow.

Blessings to you all.

Ron Davis

One Evangelical's Question

One of my most mission minded evangelical friends asked me an interesting question a month or two ago. He asked me to respond on the blog--this is my belated response.

He was curious about foreign policy from a missions vantage point. His concern is that Christians are called to serve the people of the world and share the good news that Jesus can set them free from captivity--from the powers of the world through resurrection and living the kingdom of God--and from the power of our own sick selfishness to separate us from God.

There may be some disagreement about who would be most effective in terms of Foreign Policy. But for the question of the goodwill of our neighbors, of cooperation with our allies, and for a firm, but not illegally ceding moral high ground, response to our enemies--I think the answer is pretty obvious.

Obama would engender the goodwill of far more people internationally. The credibility of the US and its citizens would increase. This would make international travelers, such as myself, possibly more safe, and I believe it would provide the more amenable situation to sensitive missionaries.

Now, some people's reactions are already set for the matter ahead of time. But for the "swing" citizens of the world, who undoubtedly number in the hundreds of millions or more, our choices will effect their perceptions of us. Barack Obama's reputation would be a boon to missionaries' safety and opportunities.

If you are an evangelical Christian, this is something you should be considering.

10 Reasons to Vote for Obama

I've explored a few matters on this blog of why you should vote for Barack Obama. If I had more time, I'd hit quite a few more. So, please forgive me for claims I make in this post that are undefended elsewhere. You all know I'm capable of defending them. I'm going to summarize why I'm voting for Barack.

1. Barack is the better leader: look at the brilliant organization he's built, his ability to inspire people from such varied ideological and socioeconomic backgrounds, his measured responses, his intellectual and tactical prowess, and his visionary skills.

2. Barack's economic policies are better: no candidate is perfect, but Barack has demonstrated more willingness to pay for what he proposes (and he's tied to the party who has done far better in this category for decades), and his proposals are better for the disenfranchised and oppressed of this world. Markets create wealth efficiently, but they don't self manage all that well (see the current crisis) and they distribute rather poorly. The system itself exploits some people, but the system gets a lot done. It needs to be preserved, but it also needs correctives along the way. This isn't socialism; it's social justice.

I've argued that democrats are more fiscally conservative, that stocks, GDP, inflation and unemployment all fare better under Democratic presidents, and that there is far more to a succesful society than these measures.

There are lots of ways to be pro-growth. You can certainly do what you can to unfetter markets. You can also use regulation to create new markets and raise revenues (Carbon Credits) or invest in the infastructure of a future economy (roads, ports, education, fiber optics, research, etc). When you invest in individuals, and keep those on the lower economic rungs from the risk of financial ruin, you grow the economy and save everybody a lot of money.

His economic policies will be as good or better for our economy in general, and they are more socially just. As a Christian I cannot ignore the latter.


3. Heath Care: In one of the defining matters of our time, Barack has a far better vision. His plan has been shown by bipartisan organizations to cover FAR more people (30 some million) at a comprable cost (1.3 trillion to 1.6 trillion) to John McCain. They both include some measures to curb costs, but Barack's plan addresses the problem of the uninsured and their role in increasing costs.

There is a lot of fear mongering around these issues--and certainly government provided medicine can and does have its faults. But in comparable market economies that are democracies and share cultural history with us, it is working. These countries pay half and way less than half of what we do, and have better health outcomes across the board. The data is very clear on this matter.


4. Iraq. We are in a terrible, unnecesarry, illegal war that was built on unfounded arguments. There are not clear answers at this point about what we should do, and both candidates can claim victories surrounding their judgment (Obama opposed, McCain and the surge). In reality, I'd prefer the man that wouldn't have gotten us in to this mess in the first place, the man who stood up and said no when almost the entire country (Democrats included) was rolling over. I believe that Obama will be faced with a lot of complicated reality in removing our forces incrementally, but the Iraqi government has 80 billion dollars saved up, and it is their responsibility to govern their own affairs. Because we have put them on this path, it is our responsibility to work to stave off a humanitarian crisis, but it is not our responsibility to govern.

Our treasury is being drained by this war, and the insurgency is because of our presence. The surge has helped but it is entirely unsustainable.

Barack has demonstrated better judgment on the matter.

4. Foreign policy in general: a steadier hand, a more strategic mind, McCain's history of overreacting (how many "greatest threats of our time" can we have, anyway?), Barack's popularity with the world and his willingness to work within the structures of multilateralism to leverage our allies resources on our own strategic behalf. Need I say more?

5. John McCain: A man whose greatest claim to personal character (Maverick) has caved to his party leaders by tacking significantly to the right. A man whose temperament isn't pretty, and whose policies are, on the whole, wrong. A man who has led a haphazard campaign.

6. Sarah Palin: I know a lot of moms, moms I love and respect. I wouldn't put them in charge of the country. Just because we identify with a candidate, would rather have a beer or hunt with a candidate, doesn't mean we should elect that candidate. Case in point, George Bush. She views our wars as holy wars, a dangerous, unbilical and historically naive assertion. She is divisive. She is incredibly lacking in foreign policy knowledge and judgement. She has demonstrated very little independent thought. She's agressive in a very unselfconscious way.

7. The big wedge issues. I addressed abortion rather thoroughly in my first posts. I argued that, whatever his intentions, Barack Obama's policies would bring about fewer abortions. I argued that if you really believe abortion is murder, then practicality matters more than ideology (it has been shown that outlawing abortion doesn't lower the rate of abortions). If you believe that abortion is murder, then you should consider that an Obama adminstration will likely pursue policies that result in fewer abortions. By preventing teenage pregnancy, and by providing an adequate social net for young, unwed mothers, desperation is reduced and more people chose to have their babies. It's the basic premise of the Pregnancy Resource Centers and it should effect the way you vote.

8. Judicial Appointments. The court has moved substantially to the right, and at the very least it needs balance. I am not going to attempt to argue for a paradigm here, except to say that the founding fathers saw the constitution as a live document. The world has changed, and although we ought to be constrained by the constitution, it needs interpreting because it has to both be relevant and it has to be acceptable to the population for our whole project in democracy to work. I prefer a candidate who sees this. Also, the founding fathers were not perfect, but we have had to understand the spirit of what they meant to move our democracy forward (their notions of equality, for instance, did not extend to women or black people--we have had to come to greater understanding while still being bound to the call for equality).

9. Democrats are more fiscally conservative. I alluded to this in issue #2. For decades, the Democrats have run smaller deficits than the Republicans. They have been outgunned in their marketing departments--the Republicans have pretended to be fiscally conservative. In fact, they have put our future on credit, running up the vast majority of our ten trillion dollar federal debt. Their resource allocation is indeed different than the Democrats, but they are still doling out trillions of dollars and also refusing to actually pay for it (through taxation).

I don't think I have to explain why that is bad. Let's repudiate that and vote against them.

10. Energy Policy: The "Drill Baby Drill" chant should be enough to see the matter for what it is. Fossil fuels not only are big carbon sources, but they are a limited resource and the need for energy is virtually unlimited. They represent a massive strategic problem, and we only seemed to finally get a sense of this as gas prices ran amok.

Obama will do more to create a whole new category of green jobs, and through carbon credits would create a new market for raising revenue and pushing the business world toward a more responsibile existence.

Foreign Policy

Having been back in the US for Trina's interviews, my discretionary time has been swamped with other obligations and fun distractions

So I've done a bad job at hitting the leftover areas--Foreign Policy, Social Justice, some of the more nuanced elements of economic policy, environmental matters. I haven't analyzed Sarah Palin, who I find to be the scariest candidate in recent history. I haven't hit heavily on matters of character--moral, intellectual and leadership--and these issues matters as well. Unfortunately, even a loquacious guy like me takes breaks. I haven't really gotten in to the illegal torture issue of the Bushies, or the rapid deterioration of civil liberties (read: freedoms) at the hand of the homeland security department.

I'm going to do a quick summary on foreign policy, and then I'm going to summarize the main thrust of my blog's argument. I haven't decided if the blog has a real future after tomorrow.

On Foreign Policy:

First and foremost, the experience argument has got to be examined. The McCain claim that Obama isn't qualified is eviscerated by his choice of Sarah Palin. I'm not talking about Presidential Experience, Executive Experience or any of the other vacuous claims made surrounding election experience--I'm talking about Foreign Policy. You cannot have your cake and eat it too, saying Barack is naive because he wasn't a POW and hasn't been doing foreign affairs in the Senate for decades.

But, for a moment, let's ignore this hypocrisy. My pointing that out could be a bit of a straw man--is Obama going to be a capable international leader, compared with John McCain, Sarah Palin aside?

Yes.

There aren't guarantees with anyone, (McCain included) of course. But the signs point to yes.

Barack has demonstrated substantial awareness of the issues, and the intellectual acuity to see good strategy. Everything from his answers in debates, to his policy proposals and the way he has run his campaign points to the fact that he is able to organize a hierarchy of values and goes, subjugating some and elevating others, and is able to be fluid in response to the challenges that come up.

His answers on Foreign Policy--despite McCain's words--"you just don't understand"--were not silly neophyte answers. Pick up an issue of Foreign Affairs sometime, one of the most respected journals (that normal humans can understand, anyway) in the country on the matter. You will find both conservative and liberal voices in Foriegn Affairs, many of the leading thinkers in the country. You can easily find a lot of grounding for foriegn policy as Obama would have it.

And also please pay attention to the fact that Colin Powell endorsed him. George Bush's Secretary of State, who (before his case before the UN for Iraq) is one of the most respect statesmen and diplomats in the country, and who is a republican.

Also, think about leverage. There is this fear of ceding our interest to the world. It seems that when we act alone in our own interests, we risk losing partners with the net effect being a negative for our own interests (read: Iraq).

That said, there are many threats we face. Radical Islam, a resurgent and assertive Russia, instability in Pakistan, rogue regimes in Iran and North Korea and Burma, civil wars and genocidal conflict in Africa, an autocratic and rapidly rising China, the emergence of non state threats, a shrinking global economy, a limited amount of fossil fuel, rising population, and a huge proliferation of weapons and weapons technology. And global poverty and starvation in hundreds of places around the world.

We need our allies. We are powerful, but we do not have the power to take it all on. We barely have the resources to handle our own affairs right now. We need someone who can bring coherence to US policy, one not founded on illegal and failed principles (Bush Doctrine). We need someone who can keep a steady hand on the war hawks in the Pentagon (didn't JFK, in his "inexperience", save us from Nuclear winter when he said no to the Joint Chiefs of Staff during the Cuban Missile Crisis?"), who will offer measured but clear responses, and who will consider the implications of our behavior.

We need someone who will pull our allies together, so that we can leverage their resources toward our policy goals. China's GDP will likely pass ours in just a couple decades, their purchasing power even sooner. Our best option for handling this is building robust institutions that China needs, and balancing relative power by linking arms with our allies. China's GDP won't surpass that of the US and Europe together in the foreseeable future, and India represents another massive power-partner in the effort to check potential future agression.

These linkages are matters of leverage. I understand that we do not want to cede our national interest to international organizations, but we have to be willing to look at what we get out of those international organizations. They are an opportunity to project our values, much like domestic law is here in the US, but they need to be robust and the laws need to be enforceable. That will depend on our cooperation.

Fortunately, the world (however naive) is enamored with Obama. He will face all the challenges a normal president does, but he will start with an enormous amount of goodwill from the worldwide electorate. I cannot imagine this will hurt his standing with international leaders.

There is the question of John McCain's war experience. No doubt it qualifies him to be a compassionate veteran's advocate, it has shaped his thinking on torture, and it makes him a bona fide hero. How many people do you know who have been to war, fought on the front lines, and really been through traumatic experiences? It's horrible. But it doesn't qualify you to lead a country, decide about when to go to war, or anything like it. If anything, the trauma may have the opposite effect. In either case, comptenece has to be demostrated.

McCain has the habit of chronically overreacting to foreign policy challenges, and overreaction is what got us into this Iraq mess to begin with (and McCain voted for that). He's not an idiot--despite being (fairly) linked with Bush, I don't believe he would be the bufoon that Bush II has been (Palin would), but I think when compared with Obama, he is not what we want as Commander in Chief.

We want someone who understands the issues, who has the goodwill of our allies, who is consistent, and who can run a tight and highly strategic organization in a shifting environment.

Given the choices, the clear one is Barack Obama.

A Libertarian Vote for Obama

Christie posted a link to this in a comment, and I wanted you to see the whole article.

For those of you who are historically somewhat conservative, have been thinking about Barack, but are having cold feet, please read.


David Post
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Why I’ll Be Voting for Obama:

As those of you who followed the dust-ups here on the VC after some of my earlier postings critical of Sarah Palin will not be surprised to hear, I’ll be pulling the Obama lever on Tuesday – and quite enthusiastically, too. I consider myself a “pragmatic libertarian” – I’m not a big fan of the state, I believe that power inevitably corrupts, that individuals, when left to their own devices, are capable of remarkable feats of self-organization and problem-solving, and that the freedoms of speech, conscience, and association are, by far, our most precious ones and need to be zealously protected from the folks with the monopoly on coercive force. I haven’t voted for a Democratic candidate for President since 1980 (and I came to regret that one pretty soon thereafter). My personal list of great Presidents is a short one: Jefferson, Lincoln, FDR, and Reagan.

So that’s where I’m coming from, and in my eyes the choice couldn’t be easier. My reasons:

Reason 1 is John McCain. During the two months since he was nominated – the two months during which he (and Obama) got to act “shadow presidents,” and in which we all got to ask ourselves, more seriously than we had been able to before: “If this guy were the president right now, would we like what he’s doing?” – McCain has, time and time again, shown himself to be a panicky, impulsive, shoot-from-the-hip decision-maker, and we don’t need panicky, impulsive, shoot-from-the-hip decision-makers at the moment. I really used to like John McCain a lot. In his role as “maverick Senator,” McCain was a real asset – I think he showed enormous political courage in taking on the culture of earmarks, and in standing up to the more xenophobic elements of the Republican party on immigration, and even on political financing, and I trusted his instincts on the important questions about national security, war, and peace. I also think he’s an immensely likable guy. But with each decision he’s made – his choice of Gov. Palin as his running mate, his almost pathetic reaction(s) to the financial crisis (from his initial “Fire Chris Cox!” to his belated discovery that there’s actually greed on Wall Street – who knew! – to his suspension, and un-suspension, of his campaign), to the choices he made about the overall tone and tenor of his campaign – each one made him less and less credible, in my eyes, as president.

Reason 2 is Barack Obama. The country, and the world, are in a precarious state at the moment, and the prospects for a very dark and gloomy future are very real; it took three years for the effects of the 1929 stock market crash to be felt throughout the global economy, and I can’t help but worry that something similar is on the horizon today. We have, as a nation, become demoralized and pessimistic and cynical about our ability to solve our problems. It’s not just that our “infrastructure” is crumbling, it’s that nobody seems to give a shit. Our belief that we are, in fact, the greatest nation on earth has always been one of our most precious assets – something of a self-fulfilling prophecy that has made us the engine for economic growth, and for freedom, for two centuries. It is becoming increasingly difficult for people to believe that, these days, and when people stop believing it, it will no longer be true. Countries can descend into the ranks of the second-rate in the blink of an eye (historically speaking): it happened to Spain, and to Portugal, and to Argentina, it is now happening to Italy, and it can happen to us.

We need a truly great president right now – and for me, a great president isn’t one who magically solves all our problems, but one who inspires us to solve our problems. No president can get us out of the mess we have made unless he or she can inspire us to do great things, and there is at least some real chance that Obama has it in him; that’s no guarantee that he’ll be a great president, but given the alternative (see Reason 1) that’s plenty good enough for me. I think he grasps the significance of the moment, and I think he understands that ideology is not policy and policy is not ideology. His gift for oratory, far from being the sideshow that some of his detractors claim, is in fact central to the prospects and the possibilities of an Obama presidency. The Great Ones – Jefferson, Lincoln, FDR, Reagan – have had one thing (and maybe only one thing) in common: the ability to stir us to great deeds with their words. It is, I think, a necessary (though not sufficient) condition for greatness, and Obama’s got it; McCain does not. Obama’s astonishing capacity to connect with young voters is also part of why he might be a great president; like it or not, the young have a bigger stake in the future than the old because they’ll see more of it, and if they are energized to take the reins of power they deserve the chance to do so.

Nor is Obama’s obvious, and profound, appeal to the people of the world irrelevant to my choice. Whatever you, personally, think of Obama or his policies, it is simply an indisputable fact that hundreds of millions, or possibly billions, of people across the globe are damn near infatuated with him, and that the world will, almost instantaneously, become much better-disposed to the United States when he is elected. It’s quite astonishing, when you think about it; he’s the first global candidate for office. There are many good reasons, to be sure, why a (rational) voter in the United States should ignore the views of the French, the Indians, and the Kenyans etc. when deciding for whom to vote in this (or any) election; presidential elections are and should be about our “self-interest,” and there are plenty of good reasons why we don’t give French, Indian, or Kenyan citizens a vote in our elections. But a world in which hundreds of millions of people are far, far better-disposed to the US is a world in which we are more likely to get a handle of serious global problems, from terrorism to the banking collapse to global warming and the energy crisis. It’s just easier for me to imagine, say, the people of Pakistan actually helping us out in our efforts to protect ourselves from the madmen who are taking refuge in their country if they think we stand for something important and that we deserve protection, rather than because Pervez Musharraf orders them to do so. I know that it’s not all about “hearts and minds” and all that, but it won’t hurt.

Reason 3 is Bush. George W. Bush has, almost single-handedly, destroyed (a) the Republican party, (b) our standing among the nations of the world, and (c) our pride in being Americans. His “compassionate conservatism” turned out to be mean-spirited and exclusionary, his attitude towards the people he was elected to serve contemptuous, and his capacity to lead virtually non-existent. His approval ratings are an accurate indicator of how miserably he has performed. I’m not enough of a historian to know whether he’s the worst president we’ve ever had, but he’s on the short list, and he is certainly the worst I have encountered in the 40-some years I’ve been paying attention to this stuff. The Republicans needs to be punished for allowing it to happen.

Reason 4 is energy policy. For my money, this is the big domestic issue for the next several decades, because pretty much all other important domestic issues will turn on whether or not we can solve it. The sight of 10,000 oil-addicted junkies shouting “Drill, Baby, Drill!!” at the Republican convention (repeated over and over again at campaign rallies this Fall) was chilling. The idea that we can drill ourselves out of the economic and ecological hole in which we find ourselves is as wrong as an idea can be (as McCain, before he began pandering, understood quite well).

So I hope he wins. Ultimately, in a democracy, you take what your fellow-citizens give you, and you accept that whatever answer the democratic process has produced is the “right” one. If a majority of the people in this country think McCain is the man to lead them, then so be it; they must view things very differently than I do. But I’m pretty confident that we’re going to be taking the other course, and that we’ll be better off for having done so.

Friday, October 31, 2008

Gridlock is better?

I am pretty close to some people who think it is...and in some cases it is.

But, in the (albeit narrow) question of the stock market, a democratic president with a democratic majority in both houses is better than a democratic majority in both houses with a republican president.

So, since there will, in fact, be a democratic majority in both houses, this is just another (small) point for Barack Obama over John McCain.

Focus on the Family Action

Focus on the Family action, which is basically an arm of Focus on the Family, has published yet another embarrassing letter. It is a made-up letter from a Christian in America in 2012. In it they make outrageous claims, absurd conjectures, and they preach a message of fear.

Beside being incredibly far-fetched, Focus on the Family has committed itself to irrelevance as an organization offering a prophetic view of our society because it has been so transformed by one political party's platform. That's not to say they are not entitled to their political opinions, but they have become such a caricature of themselves that it is hard to imagine that anyone behind these letters has any measure of humility, history, or self-conscious thought.

Whether in making the claim that "at no time has America been in greater danger" because of "judicial tyranny" during the Terry Shiavo case (when the country was run from top to bottom by Republicans), to spreading their gospel of fear (nuclear attacks, churches being forced to close because they won't allow gay staff members, hardcore pornography on television, terrorist attacks because Obama is president--be serious), Focus on the Family has sacrificed credibility for power, and a sacrifice for power is anything but Christian.

Obama's Tax Cuts

For those of you who are concerned that Obama will be raising your taxes, and independent review of the two candidates tax plans has been conducted by Deloitte and the Brookings institution.

Turns out John McCain is being deceitful in trying to convince you that Obama wants to rob your pocketbook.

See the details here.