Wednesday, April 29, 2009

Political Opportunists

We like to think that a politician’s job is to represent her constituents. Most politicians parrot those words, but most also understand — either consciously or subconsciously — that their primary job is to further their own career. Sometimes representing constituents can be a means to that end; other times, not so much.

I’m not saying that politicians are not also driven by certain ideologies and philosophies. Those are part of the whole package. If you carefully observe what politicians really do, you will discover that they are opportunists that exploit every possible avenue to further their career. Politicians with staying power not only enjoy what they do; they are among the best political opportunists around.

As a political novice, Senator Orrin Hatch (R-UT) took advantage of shifting party loyalties in the 70s to unseat three-term Democratic Senator Frank Moss in 1976. On the campaign trail, he would ask, “What do you call a senator that has spent three terms in Washington, DC?” He would then answer his own question, “You call him home!”

The point was to insinuate that someone that had been in the U.S. Senate for 18 years was out of touch with his constituents back home. This line was such a crowd pleaser that it was incorporated into radio and TV ads. Today as Hatch prepares to run for term number seven in 2012, he emphasizes the value of his “experience” and “tenure,” seemingly oblivious to any concerns about being out of touch with constituents.

Even the most casual political observer can see how Hatch has changed his stripes over 3½ decades. Democrats have said that among GOP senators, Hatch is “one of the most bipartisan and easy to work with.” When any politician says something of that nature about a politician from the opposing party, it means that the politician being praised pretty much shares the ideology of the opposing party or is a push over.

This ideological shift has not harmed Hatch. The last time he faced even somewhat serious competition was 1982. He continues to successfully take advantage of the conditions in which he finds himself. Although many of Hatch’s loyal voters would be shocked to find how much they differ with him on legislation he has supported, he knows that he has the resources to nip in the bud any would-be challengers from the right and can count on reliable Republican votes, as long as he doesn’t do anything like have an affair or kiss a male gay-rights activist on the lips in public.

Another example of effective opportunism is Senator Arlen Specter of Pennsylvania, who has just switched from the GOP to the Democratic Party as he prepares to run for a sixth term next year. Specter has always been a moderate in a state that has both Democratic and Republican strongholds. But he is not wrong when he says that the Pennsylvania GOP has shifted right in recent years.

Straddling the middle worked well for Specter until 2004 when he faced a strong challenge in the GOP primary. To beat conservative Congressman Pat Toomey, Specter had to appear to lean right, only to have to rapidly track back left to beat his Democratic opponent in the general election.

Specter has long enjoyed a higher approval rating from his state’s Democrats than from registered Republicans. It has now become apparent that Specter would lose a primary rematch against Toomey. Rather than face certain primary defeat, Specter has decided to switch parties. These kinds of occurrences are the results of backroom deals. I suspect that Specter extracted promises from his new party of certain committee assignments and no serious primary contest.

This is political opportunism at its finest. By switching parties now, Specter will likely cruise to re-election. While Toomey might trounce Specter in a GOP primary, Specter is likely to soundly beat Toomey in a general election. He will be better funded and have more name recognition, and his centrist views will appeal to more of the state’s voters. After holding powerful roles in the GOP during the years they were in the majority, Specter will now get to be part of the Democratic powerhouse. It’s the best of both worlds for him.

Diminishing GOP
Since it is looking more likely that the Democrats will pick up the Minnesota seat currently contested by Republican Sen. Norm Coleman and Democrat Al Franken, it seems that Specter’s shift will provide Democrats with the critical 60th vote in the Senate that will allow them to override Republican objections to passing any legislation they want. That is, at least until January 2011. Then perhaps Democrats will pick up even more senate seats, as happened in the 1934 mid-term election, giving them an even clearer mandate.

This is quite probable because Senate (and House) Republicans currently appear feckless, rudderless, and disingenuous all at the same time, and because more GOP than Democratic Senate seats will be vulnerable next year. Another problem for the GOP is that far fewer voters self identify as Republican than as Democrat. (Even more self identify as independent.) From today’s limited vantage point, the most likely outcome of the 2010 elections will be that Democrats will pick up enough seats in the Senate to be safely filibuster proof, even if a few Democrats occasionally defect.

Some conservatives are happy to see Specter go. They’d also like to see moderate (RINO) Republican Senators Snowe and Collins take a hike. The argument is that by achieving more ideological purity the party will eventually attract more voters. At the very least, a more purely conservative party would offer a starkly contrasting alternative once voters sour on Democratic excesses.

There may be some validity to this viewpoint, but it is a very long-term plan. With the GOP now achieving irrelevancy in national politics (albeit not as irrelevant as it was in 1936), it begs the question of whether there will be anything useful left by the time this supposed future point arrives. I also find it instructive that Republicans have not had as advantageous of a position as that in which Democrats now find themselves since Harding was elected in 1920, while Democrats have enjoyed such an advantage several times since then.

WSJ Editor James Taranto writes, “In the real world of politics, a small but principled minority can get things done only by forming coalitions with other factions on the basis of common interests or partial agreements of principle.” A party that is too small to leverage power has little chance of participating in that give and take. In that case, a party can gripe and moan. Or it can figure out how to actually appeal to more voters.

Regardless of party, politics involves politicians. Our Founders understood what drives politicians. They designed a system that they hoped would harness competing ambition in a way that works for the public good. That worked to a degree until men discovered that they could successfully twist the words of the Constitution to mean anything they could get the people to swallow without rebelling.

Americans would do well to drop the pretense of altruism that is tied to political office and to recognize the unbridled opportunism that is the currency of the political class. In a way, our system’s political ambition is a thing of terrible beauty, akin to that of a violent summer storm. Without proper controls, it can likewise be destructive.

Tuesday, April 28, 2009

Driving Rules They Don't Teach You

I am in the wrapping up phase of teaching my second child how to drive. As encouraged by Utah law, he now has many hours of driving under his belt. He has driven under many different conditions on many different types of roads.

I have purposefully had my son drive in very nasty weather, at night and under low visibility conditions, in heavy traffic, through construction zones, and in busy parking lots. I figure that if he can safely drive in the worst conditions with me in the passenger seat, he will be much more likely to drive safely in most conditions when he is on his own.

Last night he drove on the high school’s driving range along with five other drivers. After an hour and a half of driving under 15 mph, he was bored stiff. He’s used to driving in real traffic and actually driving to purposeful destinations.

As I have taught my two oldest to drive, I have told them that regardless of what they learn in driver education courses, there are three additional rules to which they must strictly adhere at all times:
  • Idiots always have the right of way.
  • Your job is to drive safely; not to enforce the law.
  • Be kind, but not to the point that it endangers someone’s safety.
In my decades of driving, I have learned that there are a lot of bad drivers on the roads. (Don’t bother with superfluous griping about how drivers in some specific geographic location are the worst. Objective studies usually find that such anecdotes are ill founded.)

The simple fact is that some people drive bad often and that most drivers — even the best ones — occasionally do something stupid. If another driver insists on doing something idiotic, by all means, get out of the way and let him do it. It is never worth sacrificing your safety simply because the traffic law recognizes that you are in the right.

If your safety is endangered by another driver’s activity, go ahead and honk and then mutter under your breath. But don’t get aggressive either with driving, language, or hand gestures. Wish the person well in your heart, and move on with life. You will be happier and safer.

This ties in closely with the second rule. You are not a traffic enforcer. Police officers can’t be everywhere and can’t see every traffic infraction, but it’s not your job to regulate traffic. If another driver is being dangerous, go ahead and get the license plate number and call the 911. But don’t try to play the cop yourself. If someone is dangerously tailgating you, it’s better to move over and let them go by than to try to slow them down.

We also have a lot of kind people on the road. You should be one of them. But it is not smart to allow your kindness to create a hazardous situation. A good illustration of this principle is the traffic patterns surrounding the 7-11 that is less than a mile from my home. It’s not hard to get into the parking lot, but at certain times of day it can be nearly impossible to get out of the south exit. You can almost always get out of the west exit.

During the predictable heavy traffic periods, a savvy driver in the 7-11 parking lot that wants to go either east or west will avoid the south exit. She will instead turn north out of the west exit and make a quick trip around the block to get to a safer intersection where she can turn west or east.

Unfortunately, many drivers aren’t that wise. You will see them attempting to turn out of the south exit during the busiest times of day. It’s one thing when a kind driver stops to allow someone exiting 7-11 to make a right turn into traffic. But when a driver stops to allow a driver to turn left, he endangers a lot of other people, including those in the adjacent westbound lane and those in the eastbound lane that have poor visibility of such activity.

I’d almost prefer that traffic engineers prohibit left turns out of the 7-11 south exit (as well as left turns into that entrance), but there are other times of day when there is little traffic in the area and such a turn can be made quite safely. It’s good to be kind, but you simply do not have the right to endanger others so that you can feel magnanimous.

All drivers should do their best to drive safely. (If you feel you must rant about cell phone usage, please write your own blog instead of threadjacking this one.) In addition to the basic rules outlined in driver education courses, I believe that following the three rules I have listed above will go a long way toward making you and other users of the road safer and happier.

Thursday, April 23, 2009

Reining In Leviathan by Amendment

“We no longer have sovereign states,” I told my friend when he mentioned that term in conversation. “We fought a war over that,” I told him. “When the dust settled, we had redefined our system of government so that we now have a central authority with vassal states rather than sovereign states with a central power that manages limited common concerns.” And it has only become more centrally focused and sprawling since then.

Constitutional law professor Randy Barnett thinks it’s time to take the Constitution back to its original meaning (plus most amendments). The way to do that, argues Barnett in this WSJ op-ed, is through a new constitutional amendment that “would restore a healthy balance between federal and state power while protecting the liberties of the people.”

Barnett’s article is a reduction of arguments made in part of his 2003 book Restoring the Lost Constitution. (You can read part of the book online at this Google Books link.) In his 2000 book The Structure of Liberty, Barnett promotes the idea of legal libertarianism. He explains individual rights and our duties to each other as defined by natural law and lays out the reasoning behind a properly limited government.

Trying to pass a constitutional amendment that would limit federal power would be a nearly insurmountable task. After all, two-thirds of both houses of Congress would have to vote to limit their own power. Rarely has there been an instance of a politician actively working to reduce his own power, let alone a large group of politicians doing so. In general, politicians will always seek to limit their own accountability but will fight tooth and nail to avoid giving up the least scintilla of power.

But the reality is that the collective number of state politicians vastly outnumbers that of federal politicians. Barnett suggests that states could do much as they did when promoting the 17th Amendment. Back then enough states petitioned for a constitutional convention over the issue of direct election of senators (as allowed by Constitution Article V) that Congress acquiesced, rather than risk a “runaway convention that states can exploit to bring Congress to heel.”

Would states actually petition for a constitutional convention in this day and age? Quite a number have passed toothless resolutions reaffirming their sovereignty under the 9th and 10th Amendments. But many states are so beholden to the federal gravy train that it is difficult to imagine them threatening that revenue stream.

Still, these are unusual times. “States,” claims Barnett, “have nothing to lose and everything to gain by making this Federalism Amendment the focus of their resistance to the shrinking of their reserved powers and infringements upon the rights retained by the people.” Well, nothing but a load of cash with strings tied to it. Those strings, ladies and gentlemen, translate into jobs that employ real people like your neighbors and mine.

You can argue until you’re blue in the face that cutting the federal apron strings would ultimately lead to better, more productive jobs, but libertarians knows that it’s very difficult to get people to buy that line. People losing jobs makes the news big time. Job creation by entrepreneurial businesses makes small time news if it makes the news at all. Job losses are very real while promises of future jobs are ethereal. Little will turn a feisty politician into a lap dog quicker than threatening to pin job losses on him.

Barnett’s suggested language for a Federalism Amendment is somewhat bold. On first reading, I figured that it would cause a significant sea change in the way things currently work in the U.S. On second reading, I think that it would result in sweeping changes, but not quite as broad as I first imagined.

Perhaps the greatest change Barnett is proposing is one he discusses rather lightly: the repeal of the 16th Amendment. Federal income tax would go away five years after the Federalism Amendment was ratified. “Congress,” explains Barnett, “could then replace the income tax with a "uniform" national sales or "excise" tax (as stated in Article I, section 8) that would be paid by everyone residing in the country as they consumed, and would automatically render savings and capital appreciation free of tax.”

Without using the actual words, Barnett is proposing replacing the federal income tax with the FairTax, a national sales tax system (but perhaps without the revenue neutrality element). Doing so, claims Barnett, “would strike at the heart of unlimited federal power and end the costly and intrusive tax code.” Yes, but would it only be replaced by another costly tax code? There are legitimate concerns about the FairTax from various perspectives (see here and here for example). Much debate would be needed on this issue.

Another of Barnett’s provisions would reign in a judiciary that has become quite comfortable with legislating from the bench and applying supposedly modern nuance to the language of the Constitution. This provision states (in part), “The words of this article, and any other provision of this Constitution, shall be interpreted according to their public meaning at the time of their enactment.”

I have often argued that we follow this same precedent with respect to every other legal document in the nation. How is it that we fail to do so with respect to our most important legal contract? Members of the judiciary would go nuts over this provision. They would say that it is unworkable. But it would re-enthrone the amendment process outlined in Article V as the only way to bring the Constitution up to date. Changes would require a general national consensus rather than a ruling by the majority of an elite few.

While Barnett’s proposal is intriguing, he seems to assume that most Americans would welcome something like the Federalism Amendment. I’m not at all sure that is the case. For one thing, there is a nearly dogmatic pursuit of uniformity that runs through many facets of society. In our increasingly interconnected world, there is a decreasing level of tolerance for diversity in state and local policy. It’s just too darn inconvenient for some people.

Another significant issue is that all Americans are either currently financially beholden to the federal government or will be so in the future. Barnett suggests that his amendment would get rid of most federal wealth transfers, including Social Security. Although the amendment would grandfather everyone living into Social Security, few want to consider relegating future generations of Americans to the poverty situation in which many elderly found themselves in the days before Social Security.

Trying to sell such a plan at a time when people have seen their 401k balances evaporate simply isn’t going to fly. Besides, most Americans can’t believe that Social Security will eventually become insolvent. How can it be that we can’t afford to bolster Social Security, they wonder, when we can afford to throw around trillions of dollars of ‘stimulus’ money? You can lecture people about Social Security being a pension plan with a limited balance, but too many shenanigans have occurred for people to believe that anymore.

At any rate, a Federalism Amendment would have to be carefully worded, since experience shows that the potential for mischief in constitutional language is substantial. Could a Federalism Amendment be something that conservatives could get behind, as Barnett suggests? That’s quite possible. But unless it appeals to a much broader segment of the population it will be relegated to permanent fringe status.

Monday, April 20, 2009

A Visit to a Socialized Dentist

The streets were quiet as we made our way through the business district late one night in the dead of the Norwegian winter. Sticking to the shadows, we found the professional building at the address scrawled on a piece of notebook paper.

As promised, we found the unlit rear entrance unlocked. We looked around to make sure nobody was observing the alley we were in, and then we quickly slipped inside, locking the door behind us. We quietly walked down the darkened corridor and found the office we were looking for. We knocked using the sequence we had been given. A voice quietly said to come in quickly.

On the other side of the door we found ourselves in the darkened waiting room of a dental office. A tense faced dentist quietly led us through the dark to a small treatment room that had no exterior windows. Once inside, he switched on the lights. “I have to be careful,” he said. “I could lose my job for this.”

Even though I had seen most of the office only in half light, it was apparent that it was neat, orderly, and well cared for. But everything about the office, from the appointments and furnishings to the equipment and supplies was like stepping into a U.S. dental office twenty years earlier. I marveled about this, because Norway has one of the highest living standards in the world. When I made some comment about the office’s retro appearance, the dentist looked at me strangely. “This office is among the most modern in the country,” he proclaimed.

The dentist wasted no time seating my companion in the treatment chair. He then found that he needed to return to the cabinet for some supplies. “I’m sorry,” he said, “my assistant usually handles this part, but I can’t have her here because she can’t know that you have ever been here.”

When the dentist opened the cabinet, he opened a panel to a seemingly hidden compartment, from which he drew out several items. “I can’t use the regular supplies,” he said, “because the ministry tightly controls those. I have these supplies because we secretly store anything that is left over after a procedure, just in case we need it later.”

When the dentist prepared to inject an anesthetic, my companion asked why he didn’t use gas instead. Was the cavity too deep for that? No, the dentist replied. It was just that the gas was metered so that it couldn’t be misused. Regulators could easily discover any gas usage that had not been approved.

The dentist had a pleasant treatment manner and seemed quite proficient. He drilled and filled the cavity and then prepared to send us on our way. He instructed us to let ourselves out, making sure that no cleaning people were in the outer corridor and making sure that no one saw us leaving the building.

“I don’t quite understand all the stealth,” my companion said. “Can’t you treat anyone you want to treat?” “In Norway,” replied the dentist, “all of the means to do dental and medical treatment are either owned or controlled by the state. There are strict rules about how anything can be used. The rules are all well intended, but sometimes they have unfortunate consequences.”

When my companion asked what he meant, the dentist said, “Sometimes I can’t do what I know is best for the patient. The ministry, for example, will let me do only a certain number of certain procedures each month. Once I’ve hit that limit, if a patient needs that treatment I have to tell them no, even if they’re in great pain. That’s why I hoard as many supplies as I can, so that I can treat people in the last week of the month if they need it. Everyone knows that all dentists do this, but no one can talk about it. If you get caught, you’ll lose your license. Treating foreigners like you out of charity is strictly forbidden. If anyone finds out about this visit, I will lose my license.”

“This all seems so wrong,” said my companion. “Well,” replied the dentist, “it’s one of the prices you pay for having socialized medicine. You can visit a doctor anytime you want, but you can’t necessarily get adequate treatment, even if the doctor wishes he could provide it.”

When my companion asked how much he owed the dentist, he replied, “Nothing. I can’t take any money for performing charity. In fact, I wouldn’t even know how much to charge you for it. We don’t get paid by procedure like dentists in America do; we get paid a salary. I have no idea how much it costs to do a procedure. Only the ministry knows that kind of thing.”

“Are you leaving with us?” asked my companion. “Are you crazy?!” replied the dentist. “I will wait here for at least 20 minutes after you are gone before I dare to leave. If anyone were to see us leave together, I’d be finished.”

As we made our covert escape into the dark cold night, I couldn’t help but be struck by how strange the whole experience had been. I remarked to my companion, “At least it will never be like this back home in America.” Given the current push for socialized medicine, I may have spoken too soon.

Wednesday, April 15, 2009

Choosing Healthcare

“70 percent of healthcare costs are driven by behaviors.” —Steven A. Burd, CEO of Safeway, Inc.

While other companies have seen their chunk of healthcare costs increase at a brisk rate in recent years, Safeway has kept its healthcare costs steady since 2005. The main reason for this, says Safeway CEO Steven Burd in this Reuters article, has been the company’s focus on healthy lifestyle choices.

I have no idea where Burd gets the statistic quoted at the top of this post or how accurate that number is. But he is saying is that the vast majority of health costs are directly tied to lifestyle choices. Safeway has capitalized on this by offering an insurance discount to employees that make healthy choices that the company promotes. Those choices include maintaining a healthy weight and not smoking.

Each year employees that participate in Safeway’s health plan receive a score based on their health choices. “[T]hose who score the lowest pay 51 percent more for health insurance premiums than those who score perfectly,” says Burd. He also says that the company has incurred no additional expenses to implement this plan.

The Health Care Blog’s interview with Safeway Sr. VP Ken Shachmut goes into much greater detail about the company’s health initiative. Shachmut calls the company’s health insurance system “market-based health care.” He says, “Our basic premise was that if people were given responsibility for their decisions, and there was transparency to the financial consequences to those decision (both good and bad, mind you!), that they would choose to maximize both their health and their financial benefit.”

Shachmut says that implementing this plan not only slowed the growth of health care costs, it “reduced all-in per capita healthcare spending 13%.” This allowed the company to cut the insurance cost for employees “by 25% or more. … These new plans introduce mutual benefits - by controlling costs, improving outcomes, and helping to leave more money into our employees’ pockets through encouraging healthy choices.”

This sounds interesting, but doesn’t it seem a bit coercive? Shachmut says:
“I want to be clear - we were adamant about designing this program to cover only those things for which our employees had control and which were clearly behavioral in nature. We do not differentiate for genetics, and we did everything prospectively and transparently so that everyone had equal opportunity to improve their behaviors. And, where there are special circumstances documented by a physician, we authorize exceptions.”
Among the accountability included in the plan are annual tests for “weight, tobacco, blood pressure, and cholesterol.” Nagging people about health choices doesn’t work, says Shachmut. But people are driven by their wallets. By demonstrating healthy choices, an employee using the family option can save “almost $1,600” per year in insurance costs. The company also offers a number of benefits designed to enhance health, including “discounted gym memberships” and full coverage for preventative care.

On top of this, Safeway is working to identify good providers, based on “price, outcome, satisfaction, etc,” and get this information out to employees. Shachmut says, “Healthcare is a complex topic and there is no one “silver bullet” – but full transparency on cost and quality comes close.”

It seems from the Shachmut interview that Safeway would prefer to move away from the “employer based insurance system that we have inherited is an accident of history from the WWII era.” But executives realize that this would require a revolutionary change that is beyond their control. So they have decided to make the best of the situation they have. “There is no need to wait for government action,” says Shachmut. Still, the company advocates the following reforms:
  • Market-based healthcare system.
  • Universal coverage with individual responsibility.
  • Financial assistance for the low-income.
  • Healthier behavior and incentives.
  • Equal tax treatment.
Shachmut says that the math shows that when “the entire nation addresses healthcare in a way similar to our approach at Safeway, there will be enormous savings – in both the public and private sectors.” I doubt that simply applying the Safeway plan to all Americans through the federal government will produce these kinds of outcomes.

Shachmut’s math appears to have discounted one of the main features that makes Safeway’s plan work: individual choice. Safeway employees apparently have some choice in whether to participate in this plan. About 30% of non-union employees and 70% of union employees don’t participate in the accountability plan. Aside from this, does anyone know how many employees have chosen to leave the company and work elsewhere rather than submit to the requirements of the plan?

How much different would the health and cost outcomes be if all Safeway employees were forced to participate in the plan, they had no choice but to work for Safeway, and Safeway couldn’t fire anyone? What if the company were required to cover a proportionate number of the currently uninsured population to boot? That is effectively what Shachmut is suggesting when he pushes for universal coverage.

Under universal coverage, no one could opt out of the plan, as a significant number of Safeway employees currently do. No one could choose to leave the plan without emigrating outside of the country. Plan providers would have to cover everyone, regardless of how bad their health choices were.

Many of those making the worst choices are also the ones that could least afford to pay for coverage. So even if you raised their rates through the roof, those high rates would necessarily be subsidized by others that actually pay. The poor that make bad choices wouldn’t actually pay more, so they wouldn’t actually be incentivized to make healthy choices. On the contrary, their poor choices would be subsidized, providing additional incentive to make bad choices. Moreover, this means that rates for the responsible would be much higher than for current responsible Safeway employees.

Beyond this, it must be recognized that Safeway commands only a smidgen of the healthcare market, even in the area of its corporate office. What would costs and outcomes be like if Safeway commanded the entire healthcare market in the region and if Safeway were instead a political entity? It would effectively dictate uniform pricing and even treatment details. As the company controlled more healthcare details, healthcare professionals would lobby the regime for more beneficial conditions. A different breed of ‘paint-by-the numbers’ provider would become the norm.

Removing choice in the name of compassion cannot and will not produce the kinds of health benefits and cost savings that Safeway is currently experiencing with its healthcare plan, even if all of the elements Mr. Shachmut touts were to somehow miraculously pass political muster to become part of a national universal healthcare plan.

Safeway has apparently achieved some wonderful and noteworthy results with its healthcare initiatives. We’re not just talking cost; we’re talking about longer life and a better quality of life for many of its employees. But it is foolish to assume that these same benefits will be realized on a broad scale with universal healthcare coverage. Safeway has actual personal choice on its side. Regardless of the kinds of ‘market based’ elements employed, no universal coverage plan can obtain the benefits of personal choice.

Monday, April 13, 2009

A Troubled Youth

He was just a kid, but he was a big kid; much taller and broader than any of the other boys in our Scouting group. At age 13, he was already as large as most of the adult volunteers involved in the program. Occasionally he inadvertently caused damage because he didn’t know his own strength.

I could tell right away that there was something odd about this boy. He seemed much less stable than other boys his age. He alternated between being a bully and a wimp, almost within the blink of an eye. Even the boys that were closest to him had difficulty carrying on normal conversations with him. Based on the interactions I have had with hundreds of boys this age, I must say that this boy’s behavior was sometimes bizarrely abnormally antisocial. While he was intelligent and was often quiet and respectful, he seemed to have difficulty separating reality from fantasy.

This boy had been adopted by a kindly couple when he was very young after the courts had taken him from his natural parents. His adoptive parents had provided a good home for him, but they occasionally sought professional counseling in dealing with him.

Two of the most popular boys in our Scouting group lived near this boy. They worked hard to befriend him. He came to our meetings because they brought him. He basked in the attention these popular boys gave him, but he would occasionally treat them harshly for no apparent reason whatsoever. Other times he would follow them around like a lost puppy dog, although, they sincerely just wanted him to be their equal.

Eventually, the boy stopped coming to our meetings because he temporarily relocated. By the time he returned, I had relocated and was involved with a different Scouting group. A few years later, I moved back to my previous area. The boys I had worked with in Scouting had moved on. Occasionally I would run into one of these young men. On one such occasion I asked what had become of the troubled boy. The report of self destructive behavior was not good.

Then one day the news reported that this large young man had been arrested for murder. He had apparently killed a friend so that he could steal the friend’s dilapidated worthless automobile. I felt deeply sad, but I was unsurprised by this turn of events. It seemed to be part of a pattern.

The young man’s parents soon moved away. Many years have passed since then. I have no idea what has become of this man. He may still be in prison. If that is the case, I have no idea where he might be incarcerated. Whether in prison or not, I wonder what condition he is in. I’d like to hope that he is being successfully treated for mental illness so that he is not a danger to others, but that may be too much to ask for. At any rate, I hope that he senses something positive about the time he spent with our Scouting group.

When you work with young people, you don’t get to determine the course they will take in life. The best you can hope for is to have some kind of constructive effect on their future choices, given the circumstances they face in life. Among my former Boy Scouts I count doctors, soldiers, teachers, engineers, architects, musicians, craftsmen, builders, salesmen, entrepreneurs, correction officers, social workers, and many other productive people. But I also count at least one murderer.

Thursday, April 09, 2009

The Doctor Regulator Will See You Now

As my wife and I waited at her OB-GYN’s office, we could hear the doctor on the phone across the hall speaking rather gruffly with someone that he obviously felt was trying to push him around. After slamming the phone down, he stormed into the room grousing that the insurance company’s hired doctor had no right to tell him how to practice medicine or determine what was best for his patient. After all, my wife’s doctor steamed, the man had had his license suspended as a result of his alcoholism. He hadn’t seen a real patient in over nine years and had no idea how to effectively treat patients in real life.

Third party bean counters have been able to improve medical outcomes up to a point. Doctors Jerome Groopman and Pamela Hartzband explain in this WSJ op-ed that “standardized protocols” developed as the result of research have remedied a number of sloppy medical practices that harmed people. These protocols include hand washing and catheter insertion routines, for example.

These successes have prompted many to assume that similar protocols could be successfully developed that would improve outcomes in cases of complex diseases by standardizing treatment and practices. Both government and private insurers have implemented “pay-for-performance” programs in recent years. You might think that this means that they pay more for better outcomes, but you would be wrong. Rather, they are paying for how well doctors follow guidelines developed by committees.

In some areas, extremely coercive means are used to force doctors to rigidly follow these guidelines. Actual outcomes don’t matter. Only compliance matters.

We all want our doctors to follow best practices, but when it comes to complex diseases, explain Doctors Groopman and Hartzband, flexibility is called for; not rigidity. After listing a number of situations where metric driven treatment has proven to be useless or harmful, they write:
“These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.

“Yet too often quality metrics coerce doctors into rigid and ill-advised procedures. Orwell could have written about how the word "quality" became zealously defined by regulators, and then redefined with each change in consensus guidelines.”
Do you want your doctor to treat you according to what she thinks will truly be in your best interest, or do you want her treatment of you to revolve primarily around unseen regulators that demand exact compliance with general guidelines? Studies have already found that doctors are shying away from even lifesaving treatments in some cases “out of fear of receiving a low grade if the outcome is poor.”

I recently commented to a doctor that the pharmaceutical industry thinks that a controlled study where 56 percent of the patients have a somewhat positive outcome is stupendous. I complained to him that doctors often give the impression that a medication with such a success rate will be effective for everyone. He admitted that I was correct. He added that doctors are usually “just following guidelines.”

We want our medical practitioners to have the latest technology and medical information. But it is folly to create unyielding rules based on these this. Hopefully we are training medical personnel to employ good judgment. Turning them into automatons that unstintingly follow committee recommendations makes ill use of those skills and arguably leads to worse outcomes for non-average patients.

Wednesday, April 08, 2009

Consequences Shmonsequences

A friend of mine that is a primary care physician was on his soapbox a couple of days ago. Actually, he was quite entertaining as well as informative.

“I have patients,” he said, “that eat Twinkies and watch TV for a hobby. Not surprisingly, they have high blood pressure. They don’t want high blood pressure, but they also don’t want to take blood pressure medicine. And, by golly, they’re not about to give up their hobby. They whine to me, ‘But, Doc, that’s my hobby!’”

I have a lot of respect for my friend. A few years ago he was overweight and out of shape. He finally decided to take some of the same advice he had been giving his patients. He went on a healthy diet and exercise program and dropped a lot of weight. Now he does triathlons.

“I had a couple in my office today,” my doctor friend ranted, “that do dope as their primary form of recreation. They want me to give them some kind of magic pill that will take away all of the negative physical effects of their drug abuse. In today’s world,” he groused, “you’re not supposed to take away anyone’s personal recreational activity. Oh, no, that would be wrong.”

We live in a world that increasingly promotes a disconnect between choices and their consequences. In many cases, we teach that it is wrong to hold people accountable for their choices. We tell people that they can have their cake and eat it too. When groups have sufficient political clout, we protect them from their choices via public policy (and public money).

When we as a society continually send the message that you are not accountable for your choices and that you can have whatever you think you ‘deserve,’ regardless of whether you have paid the price for that outcome, is it any wonder that we have Twinkie popping, dope smoking dolts looking for a doctor that will mystically make their consequences vanish (all for a $25 co-pay)?

We’re creating a moral hazard. Too many people expect to be bailed out of their bad choices.

Monday, April 06, 2009

Willingness Is the Key

A few years ago I was chatting with a relative that had retired after working for nearly two decades as a secretary at a major university. She explained that her career at the university had been split almost equally between two departments.

During the first half of her tenure, she worked in the school of education for the department of counseling and special education. During the second half, she worked in the college of fine arts for the theater and media arts department.

My relative had enjoyed both jobs, but said that the contrast between the two departments could not have been starker. The differences she described ran throughout the entire culture of each department. They were embodied in everyone — from the professors to the students to the support staff — and in everything — from the architecture to the furniture.

Most of the people in the special education program seemed to focus their entire lives on others. Even people that had no apparent reason to gain from doing so treated a lowly secretary like my relative with genuine personal concern. Such sentiments were ubiquitous throughout departmental interactions.

The majority of people involved in the performing arts, on the other hand, made it abundantly clear in everything they did that they were the central focus. They exemplified the term, “It’s all about ME.” It wasn’t that people weren’t nice when necessary. It’s just that their self centered focus was emphatically and continuously on display throughout the department’s culture.

A few years ago I saw a report on TV about a famous media star that had spent the day doing the kind of ordinary service project in which many of my neighbors and I often participate. This fellow had dressed a bit nicer than we dress for these kinds of projects, but he had actually gotten in and worked with his hands. At the end of the day, he had a look of exultant joy on his face as he said, “This has been a catharsis for me.”

I almost felt sad for this man, because he had apparently waited until his sixth decade of life to discover the happiness that lies in unselfish service to others. It made me wonder how many others live out their lives so wrapped up in satisfying their own desires that they miss out on much greater personal fulfillment than they will ever derive from selfish pursuits.

Giving selfless service is good for us. It makes us happier. Studies show that it makes us healthier. But I have noticed throughout the years that forcing someone to serve rarely brings such benefits. In many cases it creates resentment rather than joy. Occasionally youth that come to a service project begrudgingly will start to get the spirit of it from those around them and will discover an ennobling sensation overcoming their antipathy. But more often they end up being more of a hindrance than a help.

I think that if more people understood the good things that come to them from serving others, they would go out and serve just to gain those benefits. For that reason, I invite others to serve. But I am not in favor of forcing people to “serve.” The ends do not justify the means, nor will compulsory “service” develop the kind of character traits we hope will accrue through giving willing assistance.

School and university programs are increasingly requiring public service. There has been a lot of talk about the government requiring public service from our young people, or of at least offering other benefits to entice them into rendering such service.

I believe that this is a misguided effort. In some cases it amounts to taxation in disguise. In other cases, it is just quid-pro-quo — a job by another name. At any rate, it is unlikely that it can generate either the kind of joy that comes from unselfish service or the kind of culture of selflessness its promoters hope for.

No amount of compulsory public service would turn the self centered students in the performing arts department into the selfless students in the special education department. Well intentioned attempts to force such a result would produce detrimental unintended consequences.

Friday, April 03, 2009

Going for Gold

A friend of mine is absolutely confident that the nation’s monetary model will completely crash within five years. Most people that say this are simply engaging in idle philosophy. Not him. He has taken a large amount from his 401k and has used it to buy gold.

When my friend explained this to me, I couldn’t help but think of another acquaintance that had said the same thing, almost verbatim, during another economic downturn. This man strongly affirmed that the U.S. monetary system would collapse within five years, rendering all dollar denominated assets completely worthless. Gold, he assured me, was the only logical answer.

That was more than 20 years ago.

This time is different, asserts my friend. He wonders why I can’t see all of the crazy and unprecedented things the government and the Fed are doing with our fiat currency. Yes, I can see it. He wonders if I haven’t studied history and found that gold has replaced every fiat currency in the past 3,000 years. That’s a handy statistic tossed about in certain circles, but what they imply by it is a gross distortion of fact.

To be sure, fiat currencies have their problems, not the least of which is centralized government control. But before jumping into other kinds of currencies, it would be wise to understand their pitfalls. Gold is not the panacea that its promoters make it out to be.

By buying actual gold, my friend has exchanged some of his fiat currency assets for a commodity currency. This is different than having currency based on a gold (or any other commodity) standard, which is a representative currency.

(Those that favor a gold standard representative currency seem conveniently ignorant of the widespread dissatisfaction with it throughout many areas of the U.S. during the last half of the 19th Century and first part of the 20th Century — even being a major issue in presidential campaigns. All types of currencies have their advantages and disadvantages.)

When I opined to my friend that selling mutual fund shares at a low point in favor of buying gold at near historic high prices was probably an unwise strategy, he would have none of it. “I’m not doing this for investment value. I’m doing this for survival.” At that point I suggested that making financial decisions based on fear is rarely a successful model. He replied that he is quite certain that he will end up far more secure.

SmartMoney’s Jack Hough explains in this article why gold has been used as money and why he thinks it is a bad way to go, even if you do believe that Armageddon is only months away. Gold has been used as money because it doesn’t decay, isn’t consumable or useful in very many applications, and is “exceedingly rare,” “divisible,” “easily shapeable,” and “easy to test for purity.”

Those are fine qualities. But gold, says Hough, “doesn’t work to make itself more valuable. It just sits.” The price of gold rises and falls with demand, of course. But over time, gold’s value is relatively stagnant. One “dollar invested in gold in 1802” would be worth about $2.80 today. That same dollar invested in stocks would be worth about $420,000. Even investing it in U.S. Dollars would have returned over $250.

Fair enough, my friend would say, but he’s not in gold for its investment value; only for its barter value. He also isn’t going to be around for 207 years. Besides, he is confident that the $420,000 in stocks and $250 USD mentioned above will be worth $0 within five years, so gold is where it’s at, even if its value doesn’t change.

My friend could be right. Despite the government’s shenanigans, however, it is much more probable that gold will plummet within five years, much as it did after its 1980 high point. Not everyone buying gold today is a survivalist. When stock prices rise and gold prices drop, many gold owners will sell their gold and buy stocks.

Most people are emotional investors that buy high and sell low, doing the exact opposite of what generates wealth. Non-emotional investors know that volatility can be their friend, not their foe. When it comes to creating and maintaining wealth, volatility does not necessarily mean insecurity.

If you’re a millenarian, you believe that there will eventually come a doomsday and that many awful things will happen in the run up to that event. But will that happen within the next five years? That’s a much harder question. Such has been the forecast from certain folks every time there has been an economic downturn or a disaster. We always seem to bounce back. (Yeah, I know. That’s like what people said to Noah before the flood.)

It would be hubris to say that it is impossible for our monetary system to collapse. The most likely course of events, however, will be that human ingenuity will kick in and we will work our way through the current economic downturn. Policies will be tweaked and tempered. There will be ups and downs. As normalcy sets in, some that prepared for doomsday will feel that their preparations were in vain.

Even if you do think doomsday is just around the corner, Hough suggests being “cautious about stashing too much wealth in something so fickle [as gold], especially when it’s popular.” He advises that a better instrument would be “ordinary commodities,” or better yet, “the means of producing them.” People will always need such things and will find ways to pay for them, even in a collapsed economy.

One survivalist friend of mine has a huge stash of toilet paper. As long as it’s kept dry it doesn’t deteriorate very fast. He is positive that people will be willing to pay top price for TP in the dystopian future’s barter system.

One final word on buying gold. It has been my experience that buying anything that everyone else in a given group is buying eventually yields undesirable results. Engaging in the time honored tradition of chasing fads will produce the same kind of outcome that always results from such faddish pursuits. Somehow that makes me think of a large dusty stash of vinyl LP disco albums a friend still had lying around in 1993.