After Trumpcare, Medicare Part M

Here’s a thought: as soon as we defeat Trumpcare, Democrats in both houses introduce Medicare Part M (for Middle-Aged), covering people ages 50-64.

A. It’s good politics:

1. These are the people who were going to be hit the hardest by Trumpcare premium increases. Offer them a better deal and they’ll support us–and people this age vote!

2. It sounds more moderate than Medicare for All, while also making a solid step closer to single-payer, which the Republicans have managed to make sound like pie-in-the-sky socialism with a side order of end-of-the-world.

B. It’s good policy:

1. These are the sickest people in the Obamacare exchanges–move them out of the pools and premiums go down.

2. BUT they’re healthier than most people now on Medicare: put them into that risk pool and the premiums go down there, too.

DON’T believe Trump when he says Obamacare is collapsing.

DON’T believe pundits who say the Democrats have no platform/positions: this plus increased minimum wage plus let’s get out of Afghanistan is platform a-plenty.

In Memoriam: Thomas C. Schelling

Photo credit: Rhoda Baer

On Tuesday I spoke at the University of Maryland memorial service for my teacher and friend Tom Schelling, who died last year at the age of 95. The photo above was on the dais. I didn’t speak from a text, but this is something like what I said:


 

                                              “How small a thought it takes to fill a whole life.”

 

Wittgenstein’s maxim holds true even of a life as long and productive and brilliant as Tom Schelling’s.

The idea that filled Tom’s life was interactive choice: the obvious but subtle observation that, whatever it is you’re deciding about, other people are also making decisions, and that their choices will influence the consequences of any choice you make, just as your choices influence their outcomes.

Tom applied that small but infinitely expandable thought to large problems and to small ones: to the explicitly strategic interaction among nuclear-armed powers that might have ended in “mankind’s final war,” but which, thanks in no small part to Tom Schelling’s thought and work, led instead to mutual restraint; to the apparently disconnected choices of mutually anonymous individuals that lead to traffic jams and riots and segregated neighborhoods and global warming; and even to the tension within the individual personality, between short-term impulse and long-term goals, that produces both bad habits such as drug addiction and efforts to overcome those habits.

That thought did not fill Tom’s life all by itself; it was combined with the intention to make clear thinking improve public and private decisions, in the service of a better and safer world.

That thought and that purpose together have filled lives other than Tom’s. I, for example, was a college student on my way to law school when I read a paper called “On the Ecology of Micromotives,” which explained how residential segregation could emerge as the result of interactive choices among families who would all prefer integration, simply because none of them wanted to be part of a small minority.  More generally, it pointed to the importance of positive-feedback phenomena, and especially of the “tipping points” where a small and temporary intervention can make a large and lasting impact.  I went to my instructor and said, “I have to learn how to do this.” He replied, “Well, Schelling teaches at the Kennedy School.” I said, “The where?” and haven’t looked back since.  Everything I’ve done and written since is the result of that experience, including my attempts to produce what I think of, in optimistic moments, as Tom Schelling’s book on drugs and Tom Schelling’s book on crime.

As superb a writer as he was, Tom was an even more inspired teacher. I can’t put my finger on the technique, but everybody came out of a class with Tom Schelling feeling a little bit smarter than he was on the way in.

Most of all, though, there was the smile, as though he’d just seen the point of a really excellent joke and hoped that, before long, you’d see it, too.

We will miss him. “We shall not look upon his like again.”

But Tom was like the Cheshire Cat. Even though he’s gone, the smile stays with us.

Photo credit: Rhoda Baer.

Wicked waste: How museum culture cheats citizens out of access to art

There are more Monets in American museum basements than there are total Monets on display in 45 states.

Mike O’Hare explains how accounting policies (no, really) make art museums much less useful than they ought to be. The basic problem is that they don’t account for their art as an asset, and therefore don’t feel accountable – and aren’t held accountable – for whether they’re creating a reasonable return on that asset in terms of the experience that actual people have with art. This fits in with the taboo on “de-accessioning” (i.e., selling) art, which keeps paintings that would be important exhibits in second-rung museums isolated instead in the basements of first-rung museums. (There is one Monet on display in the state of Florida, zero in the rest of the south, zero in the Midwest outside Chicago, zero in the Mountain West, zero in the Pacific Northwest. There are twenty Monets not on display in the inventories of American museums.)

By selling 1% (by value; of course, more by item count) of its inventory, any big museum could endow free admission forever. Another 1% would finance 30% more wall space, allowing more art to be displayed. And the stuff sold wouldn’t drop down into a black hole; someone would be seeing it.

That such an obviously good idea is even controversial testifies to how ossified museum practice has become.

O’Hare’s essay is a classic piece of policy analysis; I may assign it for my first-year course. He starts with the fundamental question: What is the public interest to be served here? And then he thinks carefully through the questions of how to serve it better and what organizational and conceptual barriers are in the way.

Let’s face it: the fact that there’s only one Michael O’Hare is a Heavenly judgment on the wickedness of contemporary society. If we’d just been good, there would be at least six of him. But what’s done is done; let’s enjoy the O’Hare we have, and in the meantime let’s get something done about the scandalous waste of resources created by the way our great museums are managed.

Rob MacCoun on growing your own cannabis legalization

Stop right now and read Rob MacCoun’s essay on cannabis legalization. Whether or not you’re actually interested in the issue – more exciting than it is important – Rob’s piece shows how policy analysis is done. In particular, he focuses on what advocates almost always deny: the fact that policy choices involve tradeoffs among competing values.

Let me offer one technical amendment to what Rob says: in my view, high taxes – as long as they allow prices close to current illicit prices – will decrease health risk and also increase revenue.

Cannabis legalization: “Compared to what?”

Prohibition is perhaps the worst option for cannabis policy. Commercialization may be the second-worst.

David Brooks and Ruth Marcus both have anti-cannabis legalization essays up. Brooks doesn’t mention 650,000 arrests a year, 40,000 people behind bars at any one time, or $35 billion in annual illicit income. Brooks does mention the issue of personal liberty, but immediately bats it away: apparently the liberty to do what Brooks disapproves of isn’t really valuable. Marcus mentions that pot-possession arrests are a bad idea but doesn’t say anything about how to reduce them; she just dances gaily on, wishing that the bad consequences of legalization could be avoided. Both Brooks and Marcus seriously overstate the evidence about the damage done by cannabis by flipping back and forth between studies of heavy, chronic use and conclusions simply about “use.” But they’re right to say that cannabis use is bad for some people, and that the number of people harmed by pot is likely to go up when it’s legally sold.

At the same time Bruce Bartlett writes in favor of legalization without ever mentioning drug abuse. He invokes something he calls “economics.” I take it that he uses “economics” to mean the principle of revealed preference, which asserts that whatever a person chooses is what that person wants, and that getting what you want is, by definition, beneficial. He asserts that he is “not aware of a single economic analysis” coming down against legalization, without giving any evidence of having looked.

Well, guess what? If you ignore the benefits of legalization, it looks like a pretty bad idea. If you ignore the costs, it looks like a pretty good idea.

And of course since Brooks, Marcus, and Bartlett all are engaging in the middle- school version of policy analysis that simply ignores countervailing arguments and blows past the compared-to-what question, none of them has to wrestle with the hard questions:

* If cannabis remains illegal, how should those laws be enforced? Whether cannabis use is bad for you is uncertain; that black-market activity, arrest, and incarceration are all bad for you is unquestionable.
* Should cannabis be legal to use, but not to sell? If so, should individuals be allowed to grow for their own use, or should we leave the industry to the criminals?
* If sale is permitted, should it be restricted to not-for-profit cooperatives or to a state agency?
* If commercial sale is permitted, how high should the taxes be? What rules should apply to marketing?
* What information should be provided to consumers by sellers or by public or NGO bodies? If some forms of the drug are more dangerous than others in terms of unintentional overdose or habituation, should the more dangerous versions carry warning labels?
* Should there be a minimum legal age for cannabis purchase and use? If so, how should those laws be enforced? In particular, should underage users be subject to arrest?
* What rules should apply to driving after cannabis use, and what rules of evidence should apply?

I continue to think that continued prohibition may be the worst option under current U.S. circumstances; I’m still waiting for someone who opposes legalization to sketch a reasonable alternative to the status quo. I’m inclined to think that full commercial legalization with minimal marketing restrictions and low taxes – which is where the country is currently headed – might well be the second-worst. But for now the public debate is dominated by those two bad options.

If Brooks and Marcus, and those who share their concerns, want to do some actual good in the world, they need to get down in the trenches and think concretely about policies. Standing athwart history shouting “Stop!” is an undignified posture.

Update Of course Matt Welch is right to criticize Brooks’s equation of a state’s decision not to make some activity a criminal offense with “encouraging” that activity. But equally of course creating a for-profit cannabis industry – which will derive most of its revenue from people who smoke too much – and allowing that industry “commercial free speech” means that the encouraging will go on just the same, even though the state doesn’t do it. In a sane world, it would be possible to allow an activity but forbid its promotion by firms trying to profit from the weaknesses of their consumers; the notion that there’s no middle term between criminalization and allowing aggressive marketing is bizarre on its face.

Welch and his libertarian friends just love “commercial free speech,” a doctrine that exists, as far as I know, only in American law. Lots of places have open political discourse but don’t, for example, let Big Pharma peddle complex medicines directly to sick people. Perversely, this makes it harder to reduce the scope of the criminal law.

Treatment for drug abusing offenders: the view from Europe

Regular readers of the blog will be familiar with much of what’s currently known about how best to treat people with drug problems. Unfortunately, because so much research on that topic originates in North America, European policymakers can sometimes be left in a tricky position: either they assume that research conducted elsewhere applies similarly their side of the ocean (a justifiable assumption in some cases, to be sure), or they throw their hands up in exasperation. This problem is much less acute when we’re dealing with research on specifically medical interventions, where European research is up-to-par (and indeed superior) in many areas. But when we’re dealing with the criminal behaviours of people with drug problems, much less research comes from Europe.

Some colleagues and I recently published a study in the journal Psychology, Crime & Law that hopefully goes some way towards addressing this problem (link here for those with a journal subscription; otherwise, feel free to email me if you’d like a pdf version). We conducted a meta-analysis on the effect that treatment programmes applied to drug abusing offenders had on crime, health, and drug use outcomes. The hope was to collect everything on the topic that would give a sense of the evidence base, as long as it emanated from Europe.

After combing through nearly 40,000 titles, we found only 15 studies that were sufficiently rigorous to exclude common threats to validity (e.g., roughly equivalent comparison groups, etc). Moreover, those studies came from only six countries (eight were from the UK). Even within Europe, there’s a tremendous regional disparity in who’s doing the research on which other countries rely.

The results showed that there was a clear positive effect of treatment on criminal behaviours, illicit drug use, and physical health. Assuming a base rate of reoffending of 50%, the results corresponded to an average reduction of reoffending of 37% in the treatment groups compared to the control groups. Results were somewhat more mixed for psychological health outcomes, and for illicit drug use after we disaggregated the outcomes based on particular types of drugs.

One of the main conclusions of the paper will not be news to those who follow what others on this blog have been saying for years. If we can persuade policymakers to endorse the proposition that the quantity of drugs consumed might not need to change in order to 1) decouple the drug-crime connection, 2) provide a safe, stable position in which to manage other complications arising from someone’s drug addiction, then we might be able to make serious progress.

For those who wondered whether European evidence points in a similar direction to North American research, this paper suggests that it does. In fact, the results of our meta-analysis are even more positive than what was observed in previous reviews. However, this should be taken cautiously, both because of the erratic properties of small sample sizes, and because of the over-representation of evaluations of pharmacological substitution treatments in our sample (which generally show particularly good effects).

If you’d like a copy of the paper, but you don’t have journal access, you’re welcome to email me at [myfirstinitial][koehler][@][berkeley]”dot”[edu]

Volcker on policy studies

Paul Volcker on the mismatch between the academic study of policy and that of public administration.

Paul Volcker to Ezra Klein:

Those schools [of public administration] are not as strong as one would like to see them. Public administration has not been in fashion for decades. Many schools have turned to what they call policy. Everybody likes to talk about big issues of war and peace and how we take care of poor people and what we do about other social problems in the United States or elsewhere.
They do all this talking but they too seldom know how to implement what they’re talking about. I ran into a wonderful quotation from Thomas Edison. He said vision without execution is a hallucination. We have too many hallucinations and not enough execution.

Characteristically, Volcker isn’t just complaining, he’s launched – at the age of 85 – an initiative to do something about it, the Volcker Alliance.

I don’t have an axe to grind here but the RBC has a strong enough connection to schools of government and policy studies for this take to be worth discussing.

An anecdote about the elder von Moltke and the Prussian General Staff of 1870. According to Michael Howard (The Franco-Prussian War, p.62). Moltke ran the victorious campaign against France, controlling an army of 850,000 men, with a staff consisting of fourteen officers, ten draughtsmen, seven clerks, and 59 other ranks. (It wasn’t responsible for supply, run by a larger organisation under the Quartermaster-General). This tiny cadre worked because Moltke had trained all the staff officers attached to the corps in the field in his methods, so everybody was working in the same economical style. Moltke had solved the problem of strategic control of very large forces that had bedevilled Napoleon with the Grande Armée, a very blunt and unwieldy instrument compared to the smaller and more manoeuvrable armies with which he had triumphed at Marengo and Austerlitz.

I worked for 32 years for a high-minded international organisation that when I left had still, after 60 years, failed to establish a filing system.

Sports rules and laws

There’s something arguably wrong with every sport; how could it not be so? Soccer doesn’t have enough scoring for game scores to be a good indicator of relative performance, football and flat racing hurt their players, NASCAR is climate-hostile, and on and on.  The rules of life  – laws – are perpetually flawed too, but we constantly try to fix them.   I think sport authorities should be more willing than they are to fix the games from time to time, recognizing that some fixes will be mistakes (the DH in baseball was silly and remains so).  Taller and better players have reduced basketball to “the teams run down the court and somebody puts the ball through the net.  Then they run back and someone puts the ball in the other net.  Occasionally the ball doesn’t go in the net: the team that has fewest of these mistakes wins.”  The idea is on the table to raise the net, analogous to the idea (not on the table, though I wish it were) to enlarge the soccer goal by a foot or two each way, and to  banning anchored putting in golf.

The last of these is scheduled not to happen until 2016; easing transitions is often a good idea, but does it take three years for golfers to put their long putter in the attic and buy another?  The basketball idea, which makes sense, raises the interesting question, should we pick a number, say one foot, and raise all the hoops that much at once, or raise them an inch every season until we’re happy with the result?  Sometimes we change laws a lot all at once, like allowing same-sex marriage; sometimes we make small adjustments, like the inflation adjustment in Social Security payments.

Some things have to be highly quantized: for the Brits to convert to right-side driving in stages, as the joke goes (“for the first week, the new rules will only apply to buses and trucks”) would be a bad idea.  But others allow for gradual change.  A one-foot change all at once would greatly devalue the muscle memory of all players, but gradual change would keep those skills mostly in service as the transition occurred.  I don’t think the mechanical costs of converting goals to be adjustable in this way are as daunting as, say, making soccer goals adjustable.

 

The two-soprano rule

I’ve been going around the country trying to convince people that knowing the unsatisfactory results of cannabis prohibition doesn’t prove that any specific implementation of legal cannabis will turn out to be an improvement.

This brings me back to a principle I learned from one of my Kennedy School teachers, Francis Bator, who was honored at a dinner there last night. It’s a policy analyst’s haiku, combining the basic principle of “Compared to what?” with a reminder of the dangers of epistemic hubris.

In judging a two-person singing contest,
never award the prize to the second soprano
having heard only the first.

A principle of wide application

Hume on not fighting on the wrong ground.

From Hume’s essay “Of the Coalition of Parties“:

There is not a more effectual method of betraying a cause, than to lay the stress of the argument on a wrong place, and by disputing an untenable post, enure the adversaries to success and victory.

I have a particular application in mind, but let me propose this as an open thread. What’s your favorite example?

Footnote “enure” = “accustom”