Our Foreign Policy Minsky Moment

If there can be any kind of silver lining to our ongoing “Great Recession” it might be that it has elevated the level of economic discussion, at least slightly. For instance, when’s the last time you heard anyone talking about the “magic of the marketplace?”  On the contrary, a fair number of writers and economists seem to have experienced recovered memories of things the country once used to know – like that a capitalist economy is cyclical and inherently prone to crises such as the current one.  In this, the ninth year of our Afghanistan War, the discussion of our foreign policy cries out for similar flashes of enlightenment.

The most interesting economic concept to emerge from recent obscurity is the “Minsky Moment,” Hyman Minsky having been an economist who described a type of social amnesia that occurs as people will themselves into believing that business cycles are things of the past as they engage in riskier and riskier financial activity.  Admirers of Minsky, who died in 1997, named the point when the dream comes crashing down into the nightmare of the next financial crisis after him.  Minsky saw several stages to the process, as gradual societal memory loss of past depressions and recessions leads to something of a state of euphoria when we may hear arguments, such as heard only a few years ago, that transformative innovations like computerization and the Internet have created a “new economy” of permanent prosperity.

Looking at the course of American foreign policy from the Vietnam War to the current day, it is hard to miss a similar dream cycle playing out there.  After Vietnam, a new sense of modesty came over American foreign policy.  Yes, our military could unleash destruction upon southeast Asia that was in some respects unmatched in world history.  And, yes, we might be able to keep it up indefinitely – we would not be “defeated” in the conventional sense.  But the ultimate message of that war was No: No matter what our military might, we could not impose our will on a country that did not wish to have its system dictated by foreign armies from halfway around the world.

Not every one approved of this national dose of humility, of course.  The “Vietnam Syndrome” was roundly denounced in interventionist circles, as the new reticence toward foreign military intervention steered policymakers toward subversion rather than invasion.  Nicaragua can probably thank the Vietnam Syndrome for the fact that Ronald Reagan merely funded its government’s  political and military opposition rather than engaging in full scale invasion.

But slowly the memories faded and were replaced with new ones.  The first George Bush’s Gulf War did not turn into a quagmire. And Bill Clinton’s bombings of Somalia, Bosnia, Sudan, Afghanistan, and Yugoslavia sort of returned the country to its old habits. The euphoria stage surely arrived with the second George Bush when a senior adviser to the President could inform a reporter that he was merely ”in what we call the reality-based community” who ”believe that solutions emerge from your judicious study of discernible reality,” while the White House recognized that ”We’re an empire now, and when we act, we create our own reality.”

We have left that stage, clearly. A statement like the above now seems as unimaginable as it did in the first decades after the Vietnam War.  Yet the turnaround is obviously far from completed; the country has not really shed the omnipotence illusion.  For, while the rationale for the Iraq War may now be widely understood as farcical, the Afghanistan War remains on the upswing.

Every war is different, to be sure, and at one point the Afghanistan and Vietnam Wars appeared to have little more in common than the fact that they were on the same continent.  After all, who could be further apart than the communist Viet Cong and the fundamentalist Taliban?  But as time has passed an overwhelming resemblance has come to the fore: Both wars are attempts to “create our own reality” in countries that have many times demonstrated that they will not allow this to happen.

Our foreign policy Minsky Moment, if there is to be one, will certainly not originate in the White House or the Pentagon, though. The White House would be too afraid of the political consequences of facing the facts and the Pentagon would be too embarrassed to do so. We will have to figure out how some other way to wake the country from its dreams.

Nuclear Posture Review: Oops! We Missed One!

In one of the more remarkable public course changes Washington has yet seen, U.S. Defense Secretary Robert Gates has added Israel’s name to the previously released short list of exceptions to the general policies articulated in the Pentagon’s new Nuclear Posture Review. Originally released on April 6, the Review, which stands as the highest expression of the nation’s nuclear strategy, stated that nonnuclear nations abiding by the Nuclear Nonproliferation Treaty would generally not be threatened with nuclear retaliation for non-nuclear attacks.

The policy did note the exception of “outliers” which were identical to the “rogue states” referred to by the Bush administration. At the time of the document’s release, Gates told a press conference, “There is a message for Iran and North Korea here…if you’re not going to play by the rules, if you’re going to be a proliferator, then all options are on the table in terms of how we deal with you.” North Korea is known to have nuclear weapons and Iran is widely thought to be in active pursuit of a nuclear capability.

Now Gates has amended that list, noting that “upon careful consideration we have decided that a realistic appraisal of the situation requires that we acknowledge the existence of another nation widely believed not to be in compliance with the Nonproliferation Treaty – Israel.” President Obama himself immediately asserted that what he called a “simple policy clarification” implied no change in United States policy toward its closest Middle East ally, saying this “in no way alters America’s commitment to the existence and security of Israel.” The addition, he said, “should not lead anyone to believe that hostilities with our great friend are even remotely anticipated.” He described it rather as a “signal” that his Administration considered it “important to convey to all parties in the region that we see the situation as it really is, not as we might wish to see it.”

Although the President steered clear of further detail, this first American acknowledgment that Israel, a non-signer of the Nonproliferation Treaty, has amassed a nuclear weapons arsenal is seen by many Middle East analysts as representing a potentially tectonic shift in world politics. Israel’s nuclear arsenal has been an open secret for decades. Former Israeli nuclear technician Mordechai Vanunu served 18 years in prison for telling the British press details of the nuclear weapons program in 1986. At the time, London’s Sunday Times estimated its production to be in excess of 100 weapons.

Israel’s first warhead is thought to have been produced in the late 1960’s. The country is also believed by many to have collaborated with South Africa in that country’s development of nuclear arms, before its force was dismantled in 1989 on the eve of the nation’s transition to majority rule. Current estimates put Israel’s warhead numbers at anywhere from 75 to 400; the high figure would likely make the country the world’s third largest nuclear power – after the United States and Russia. Israel’s official policy is to offer no comment on the matter.

Observers attributed this astounding “policy clarification” to delayed effects of the Nobel Peace Prize Committee’s surprising decision to name the President as the award’s recipient during his first year in office. One White House insider, speaking on condition of anonymity, said, “As you know, the President in no way sought the Prize. In fact, a lot of people around him urged him to decline, thinking that it would place too high a burden of expectation around his future policies. But you see, the thing is the award seems to have gotten under his skin – to the point where he appears to have decided that if he’s ever going to play any kind of role in bringing peace to the Middle East, both sides have got to see him as being reality-based.”

Other sources noted that Gates was considered the right choice to be the messenger of such a bold policy alteration since he has altered it in the past – it is less than two years since the Defense Secretary declared that the U.S. would not forswear first use of nuclear weapons in retaliation for chemical or biological attacks upon the US or its allies, a policy that the new Review repudiates. At the time of his earlier statement, Gates was serving in his current position in George W. Bush’s Cabinet. One CIA source thought it would take several days for world opinion “to sort itself out over this shocking outbreak of candor.”

Okay, so Gates and Obama didn’t actually say anything about Israel’s nuclear arsenal and the way it might make the highly touted new Nuclear Posture Review seem hypocritical. But since the new policy was unveiled in early April, we could hardly wait until next April Fool’s Day to satirize it, now could we? The point of this little thought experiment in candor is not to suggest that any of the actual nuclear policy changes Obama is currently making or proposing are in any way wrong or useless. It is rather to illustrate just how much further the U.S. would need to go in order to actually be seen as “reality-based” in many parts of the world.
Domestically, the current administration is widely viewed as relatively “dovish” on matters relating to nuclear weaponry – at least in comparison to its predecessor. Likewise, the idea of dissuading Iran from joining the world’s nuclear powers is hardly a controversial one here at home. But the presumption that our government therefore enjoys worldwide credibility in these matters runs up against some harsh perceptions: For much of the world, the global campaign to prevent Iran from getting what Israel already has seems to indicate only that the one nation to have ever used nuclear weapons has no immediate plans to change its policies in any serious way.

GOP Demands to see Nobel Committee’s Birth Certificate

When the news broke earlier that sitting American (or is it Kenyan or Indonesian?) President Barack Obama was bequeathed with the Nobel Peace Prize, I naturally assumed that the Rush Limbaugh’s head would explode and the Republican Party would be stuck with a gargantuan body instead of a party head. Moreover, I instinctively knew that the blogosphere would be buzzing with more Republican and Conservative invective than Democrat or Liberal encomium.

Am I really that prescient or do Republicans really hate Barack Obama that much that many would put breathing oxygen in abeyance in order to vituperatively criticize President Obama?

“This fully exposes the illusion that is Barack Obama,” said conservative talk show host Rush Limbaugh. Rush continued: “And with this ‘award’ the elites of the world are urging Obama, THE MAN OF PEACE, to not do the surge in Afghanistan, not (sic) take action against Iran and its nuclear program and to basically continue his intentions to emasculate the United States…. They love a weakened, neutered U.S and this is their way of promoting that concept. I think God has a great sense of humor, too.”

Oh Rush, did you run out of Oxycontin refills again? While we rational Americans have grown accustomed to the bile invective spewed daily from Mr. Limbaugh more effortlessly than potato chip crumbs, some Republicans decided that Rush Limbaugh is just too understanding and flirted with invective of their own.

Eric Erickson of the ever-so enlightening Red State.com had these encouraging words to say:

I did not realize the Nobel Peace Prize had an affirmative action quota.

Knee-jerk vitriol and racist commentary notwithstanding, the award is baffling some on the left as well.

Michael Moore, for example, offered his congratulations but boldly declared action as well.

Congratulations President Obama on the Nobel Peace Prize–Now earn it! Freedom can not be delivered from the front seat of someone else’s Humvee. You have to end our involvement in Afghanistan now. If you don’t, you’ll have no choice but to return the prize to Oslo.

Indeed, Obama may have made such lofty pronouncements such as closing Guantanamo, bringing the troops home from Iraq, wanting a nuclear weapon-free world, admitting to the Iranians that we overthrew their democratically-elected president in 1953, etc. But he has yet to follow through any of his pronouncements with concrete action and, worse yet, is risking escalating a lost cause in Afghanistan by extending our outstretched and vitiated troops in a purposeless battle.

Don’t believe me, just click here to read about the growing numbers of troops suffering from PTSD.

I realize that President Obama is looking to make up for the fact that Afghanistan and the “just war” was abandoned by the ruthless Bush Administration to pursue a petty vendetta in Iraq and make billions of dollars in no-bid contracts for their cronies. However, 6 years have passed since troops were shifted away from the Afghanistan conflict, and the situation has grown increasingly dire for our supposed mission. After all, the primary objective for going into Afghanistan was to kill and capture Osama bin Laden and his key associates, disrupt the vast Afghan terror network, and prevent Afghanistan from becoming another hotbed for terrorism.

Has blowback and the situation in Iraq taught us anything? The U.S. is  not in Afghanistan to police a nation beset by tribalism and internal conflicts. We cannot naively expect to train a miserably incompetent army at the aegis of a corrupt government,  an army that may ultimately joins the Taliban anyway.

Barack Obama winning the Noble peace prize–something that not even he expected–is certainly momentous and naturally is being lauded by the sane world. But it is imperative that we do not allow ourselves to get stuck in the warm and fuzzy clouds of this achievement as many did immediately following the election of Barack Obama. Intelligent critics must ensure that President Obama does in fact earn this prestigious prize.

Obama is from America, Birthers are from Kookistan

If there’s ever been a phenomenal, breathtakingly ludicrous political fringe, excluding the organization that actively pursues legislation that legalizes man-boy love, it would have to be the “birthers”. Boy, I really yearn for the days of Karl Rove.

I’m referring of course to a noisome movement of obstreperous ultra-right wing nut jobs that is currently hell-bent on co-opting the entire GOP’s “Just say No” agenda by relentlessly questioning the veracity of President Obama’s birth certificate. Moreover, the birthers have managed to convince themselves that Barack Obama was not born in a manger in the United States, and therefore is ineligible for the presidency. And to think all us loony liberals were contumaciously clinging to absurdist, unsubstantiated claims of voter fraud, voter disenfranchisement and intimidation, ballot alteration, ballot substitution, ballot box stuffing, and ballot destruction so as to deny the Presidency of George W. Bush.

At any rate, one woman claims to have an authentic copy of President Obama’s Kenyan birth certificate.

Orley, I have a better question. Have you asked your doctor if Thorzine is right for you?

Indeed, it has been abundantly shown that there is not a modicum of authenticity, or even the vaguest ambiguity, to validate the birther claim. Hawaiian public officials have stated ad nauseam that Barack Obama was, indeed, born in Honolulu on August 4, 1961, and they have happily supplied copies of his certificate of birth to the birthers upon demand. If you’re a die-hard birther, however, you must believe that these sinister Hawaiian officials are involved in some diabolical scheme to infiltrate your minds with hope and change. How else do you explain how Hawaiian pineapples could wind up on a pizza?

Alarming enough, a recent political survey discovered that 83 percent of Democrats and Independents absolutely, positively believe–no shit–that Barack Obama was born in the United States, whereas only a mere 42 percent of Republicans believe he was. That a fairly sizable chunk of Republicans are unconvinced is irrefutable proof that the party is drifting further and further away from reality, ensnared in the brazen lies and rumors propagated by far-right wing radio and television.

But it isn’t just relegated to Fox News or Rush Limbaugh...

Seemingly beyond the healthy bounds of sanity is CNN anchor Lou Dobbs, who has been devoting countless shows to the birther lunacy, despite the fact the he claims to not believe in it. It is almost equivalent to not believing in leprechauns and coming into work every day in a green cap, orange beard, and green-striped shoes.  Of course, controversy is nothing new to Mr. Dobbs who has often substituted objectivity and the truth in his unrelenting crusade against illegal immigration by regularly citing erroneous facts and figures.

Mr.  Dobbs’ undying love affair with the “birther” story is increasingly becoming a quite an issue for CNN, which prides itself on presenting news without the fervent left/right biases commonly found on MSNBC and Fox News.  But hey, at least he’s not screaming at illegal aliens anymore.

One must ask what the motivations are for the birther movement for orchestrating such a patently absurd campaign? Is it the fact that some people are uncomfortable with the first African American president? Is it that some people had the bongo drums played on their soft spots like Ricky Ricardo?

Nonetheless, any attempt at explaining the birther movement is akin to debating whether it’s hot or cold in Atlantis. In sum, nothing remotely substantive can be extracted from this committed (non pun intended) mass of sad, pathetic, and miserably uninformed people. I just hope that they find a better scanner.

On Electricity, Or, Can A Public Option Work?

Over the next few weeks there will continue to be great hub and bub about the “public option.” If there is a public option in the health care reforms that are being considered, it will be the end of all medicine in America, we are told. Some are positing that nobody will be able to get care because doctors will not accept the payment levels of the public option, and some believe that it will no longer be possible for private insurers to stay in business because they will be unable to compete with an enterprise operated by the government.

In today’s story that theory is tested—and it’s done by looking back in history, to a time when another government-owned business paradigm was introduced to the market. And if you guessed that comparing the health care market to the market for electricity in the Pacific Northwest would be the test…well, slap yourself on the back, ‘cause you’re the winner.

To make the story work, let’s pretend that you are a consumer of electricity living in Seattle. So you purchase electricity from Seattle City Light, which is owned by the citizens of Seattle, and they purchase their power from both publicly-owned and private sources. Other consumers in the State, including yours truly, purchase power from private sources. (I’m a customer of Puget Sound Energy, which is a stockholder-owned operation.) Still others purchase from a variety of Public Utility Districts (PUDs).

(Fun Fact: Snohomish County PUD is famous for discovering those astonishing “Grandma Millie” phone calls while reviewing the Enron Tapes; in which it was proven that Enron’s energy traders habitually manipulated markets for their own gain.)

The generation side of the equation is also based on a mix of private and public sources. Seattle City Light owns two hydroelectric projects which provide roughly half of the City’s power. They also purchase from the spot market on occasion, and on occasion they sell surplus power to the market.

Puget Sound Energy also owns generation resources, and sells surplus power of its own into the market. Virtually everyone who sells power to retail customers in this region also purchases power from the Bonneville Power Administration (BPA). The US Army Corps of Engineers own and operate a series of 31 dams in the Columbia River basin; the BPA sells the hydroelectric power generated at those dams to both public and private utilities. (They also operate most of the region’s transmission and distribution resources.)

One of the stated goals of the organization is to provide power at cost, and consumers in Washington, Oregon, Idaho and Montana are today paying about 1/3 less than the national average and roughly 1/2 the cost of electricity in New England.

So how is all this conversation about electricity relevant to health care? Some, like Georgia’s Congressman Phil Gingrey, believe that a public health insurance option means “turning the whole system over to the government to run like they do the DMV.”

But in this corner of the country, there are public options available for electricity consumers with private industry successfully operating alongside the public option. Further, the biggest recent shock to the system came from a private company that was caught manipulating the market for its own gain.

The presence of the public option has led to lower consumer costs compared to other regions of the country, suggesting that removing the profit motive from the business is indeed bringing benefit to consumers. And if you add customer satisfaction surveys to the overall picture, the “public option,” at least in the Pacific Northwest electricity market, equals happy customers who are saving significant amounts of money.

So the next time someone tells you a public option automatically equals The End Of The World…tell ‘em they should have a look at my power bill some time.

Review of Embedded With Organized Labor

Embedded With Organized Labor: Journalistic Reflections on the Class War at Home, by Steve Early
Monthly Review Press, 288 pages, $16.95

Ed Sadlowski; Jay, Maine; Pittstown Coal, Tony Mazzochi, the Charlestown Five; Ron Carey – as the names float by on the pages of “Embedded With Organized Labor: Journalistic Reflections on the Class War at Home,” it sometimes seems that Steve Early’s new collection of articles must encompass every person, place, or corporation of significance to the labor movement over the past four decades.  Not quite, but actually the volume’s thirty nine essays – most of them book reviews – cover even more ground than that.  For instance, there’s stories of labor journalists from the deep past of whom you’ve likely never heard.  But the topic most of interest to Early, recently retired from the Communications Workers of America but preferring to think of himself as “redeployed,” is the future of the American labor movement.

There was a time when leftists of a certain age asked themselves how they could love a labor movement that didn’t seem to want to love them back. Certainly the welcome mat wasn’t out on that day Early recalls “In May of 1970, [when] hundreds of flag-waving New York City construction workers … attacked a crowd of antiwar demonstrators on Wall Street.”  The breach between labor and the left would actually broaden two years later when the AFL-CIO refused to back George McGovern against Richard Nixon.  The South Dakota Senator would come closer to espousing the politics of the leftists of the day than any other Democratic nominee in their life time, but for AFL-CIO President George Meany he was too antiwar, too radical. Some see payback in McGovern’s current opposition to the Employee Free Choice Act.  But ironically, the individual he cites for past opposition to the concept of binding arbitration that constitutes one of the bill’s components is none other than Meany.

Still some, like Early, persisted.  A few unions like the United Electrical Workers (UE), which to this day maintains the egalitarian tradition of paying no official a salary higher than the highest you can earn under a UE union contract, actually worked with and encouraged student radicals – such as this writer.  (Early drops the sobering fact that this honorable organization – which had half a million members before leaving the CIO in 1949 rather than submit to the government-driven purge of Communist Party members going on in other unions – has now shrunken to 17,000 members.)

Acceptance came much harder in most other unions, though, but ultimately those who didn’t see the labor movement as a collection of “real-life Archie Bunkers who railed against a whole generation of spoiled ‘meathead’ college kids,” would even prevail, to a degree, and by “the fall of 1999,” Early notes, “steelworkers and radical students were seen marching side by side (or at least on the same side) in street protests against the World Trade Organization.”

The signal change of those intervening years was John Sweeney’s 1995 election as AFL-CIO president.  Although a book that Early reviews on that subject bears the tile, “Not Your Father’s Union Movement,” his election did represent a return to the past in the sense that afterward the labor movement would again more or less openly welcome the left as it generally had before the Cold War.  Of course, with Joseph Stalin now more than forty years dead and the Soviet Union itself gone for a decade, this thaw came none too quickly.

Sweeney comes in for his share of criticism in Early’s book, yet it seems fair to say that he did pretty much try to do what he said he would  –  reverse the long term decline of labor that Early notes in the book’s first paragraph: “When I first got involved the labor movement in the early 1970s, unions still represented almost a quarter of the country’s workforce.  Now, unionization is down to 12.4 percent overall and only 7.6 percent in private industry.”  Sweeney had assumed the Federation’s leadership largely on the strength of the fact that his own Service Employees International Union (SEIU) had been an exception to the general downward trend, largely due to the fact that much of its constituency was public employees, more than a third of whom are now unionized.

But Sweeney has not been particularly successful in reversing the overall trend, although SEIU has continued growing to the point where it is has become the nation’s largest union.  And in 2005, Andy Stern, Sweeney’s successor at SEIU, led unions comprising about a third of the AFL-CIO’s membership into a rival Change to Win federation dedicated to doing what Sweeney could not.  About the best thing that can be said about the split to this point is that it has not damaged the labor movement nearly as badly as some had feared.  The overall national percentage of union membership has even risen for the past two years, although it remains lower than before the split.

Not one to see easy fixes for labor’s decline, Early is skeptical that even the Employee Free Choice Act (EFCA) currently pending in Congress will represent the cure-all some hope for.  He cites a Canadian labor relations scholar’s findings that “union density and bargaining coverage are falling even in provinces such as Saskatchewan and Quebec that have card check and first-arbitration clauses” – precisely the EFCA items that its advocates hope will save union representation drives from the often debilitating process of National Labor Relations Board elections and management refusal to bargain.  The measures he thinks are really needed – repeal of “Taft-Hartley Act restrictions on real union solidarity and the Supreme Court’s seventy-year old sanctioning of the use of striker replacement” are not part of political discourse today – “except in the speeches of Ralph Nader.”

And as SEIU has dominated the labor movement of recent years, so it dominates Early’s book, with Stern coming in for fairly severe criticism.  “Since 1996,” he writes, “when Stern replaced Sweeney, 40 SEIU locals – or 14 percent of its 275 affiliates – have been put under trusteeship to implant new officers.”  While he grants that “[S]ome of those ousted ran old-guard fiefdoms,” others just didn’t want to go along with what he views as questionable programs coming from the top, and perhaps the “air of arrogance and exclusivity” emanating from some SEIU staffers or an “attitudinal style … closer … to Silicon Valley entrepreneurs than to veteran staffers of the trade union movement” that one reviewed author describes.

(The largest of these trusteeship battles is currently playing out with the leadership of the newly formed National Union of Healthcare Workers claiming to have filed decertification petitions aimed at taking back close to 2/3 of the 150,000 members it formerly led in SEIU’s now trusteed California-based United Healthcare Workers West.)

The fact that book reviews constitute the core of Early’s book naturally constrains him largely to topics that other writers have chosen and many of the more interesting matters are raised only peripherally.  There is the fairly central question of just what a labor radical is to do.  At the one end are the “colonizers” like Wellesley graduate Elly Leary, interviewed in Staughton and Alice Lynd’s “The New Rank and File,” who spent twelve years building cars at the Framingham, Massachusetts General Motors plant.  Jobs like this were hard enough, Early notes, “without the additional task of proselytizing.” The group of radicals that Leary eventually became part of was just about learning its ass from its elbow on how to proceed sensibly when the plant closed in 1989 and they were deindustrialized out of the working class.

At the other end there is “SEIU’s ‘best and brightest’” who come in for Early’s criticism because “most have never been a janitor, security guard, nursing home worker, home health care aide or public employee.”  Of course, Early himself came in for that very criticism back in the mid-1970s as he recounts in the book’s first piece: when he was interviewing coal miners for the United Mine Workers Journal, one obviously wary miner politely shook hands with him, then “looked me in the eye and said knowingly, ‘Ah, pencil hands.’”

And then there’s the question of why the labor radicals do what they do.  I don’t think I’m going too far out on a limb in saying that most of the people we encounter in these pages saw themselves as socialists, if not by that name precisely then by some synonym they thought more appropriate to the time and place.  They weren’t motivated just by the hope of a better labor movement, but of a better country, a better world – and they saw the labor movement as the best means to that end.  For that sort of thing we will have to wait for Early’s next book, though – he is currently writing his history of the sixties radicals and the labor movement.  But the current book will give you plenty to chew on for the moment.  And, oh yes, it comes with an excellent index, unusual in an essay collection, but extremely useful because this book is dense – and I mean that as a complement.

Gallup, Abortion, and Shades of Gray

With the economy, health care reform, environmental regulation, and other important issues being widely discussed in policy circles, it would be easy for one to forget about wedge issues, such as abortion. However, with the news of the shooting of  Dr. George Tiller, among other recent acts of extremist right-wing violence, and the debate over a new Supreme Court nominee, abortion is back on the front pages.

In this light, I decided that I would take a deeper look into a recent poll that was conducted by Gallup that found changing attitudes toward abortion in the US. Gallup’s results showed that for the first time since they began polling the issue 14 years ago,  more Americans identify themselves as “pro-life” than “pro-choice”.  According to this new poll, virtually all movement in public attitudes toward the pro-life position has occurred within the past year.  After reading about these results, I had several questions, including:

1. The dramatic shift in the past year looked a bit odd to me.  Could Gallup expand upon the bottom-line reasoning from their reporting?
2. What was the party breakdown of the poll? It doesn’t mention weighting, but perhaps they did weight. (If I remembered correctly from the Presidential tracking polls in 2008, one of the big differences between Gallup and Rasmussen was that Rasmussen weighted and Gallup did not, leading to more swings in the Gallup tracker.) My concerns here were that a smaller, more extremist Republican tent, could indicate a misleading swing if they were still weighted at their 2008 levels.
3. Relating to #2, I recently read that Gallup had nearly a 50/50 split in Party ID in this poll. Was this correct?
   

Thanks to my former graduate school classmate, Cynthia English, a Gallup writer and researcher, I had the honor of having my questions answered by Lydia Saad, a Senior Editor at Gallup who worked on this poll. Ms. Saad gave very thoughtful answers to my questions and went above and beyond what I expected. Here are some of Ms. Saad’s responses:

• Kevin’s memory is correct; we do not weight our surveys by Party ID. Although some pollsters do it, weighting by Party ID is not the standard in national RDD surveys. Party ID is essentially a political attitude like every other that we measure; and while it is generally stable from one survey to the next, it does change over time and is susceptible to survey-to-survey variation due to the content of a given survey. Weighting by party ID on election polls, for example, can be problematic since it’s asked after the candidate preference ballot, and therefore largely mirrors the ballot. To weight by party ID on these surveys is to essentially weight by the ballot.

• We did obtain a near 50-50 split in leaned party ID on the 2009 May Values survey. Because this was unusual, we did two things to check the validity of the data. We re-ran the abortion questions on the G1K track two days later, and obtained nearly the same results. That survey had a 10-point advantage for the Democrats on leaned party ID. We also did a post hoc reweighting of the data by party ID, using targets giving Democrats/Dem leaners a 14-point advantage (typical of what we’ve been getting on recent stand-alone polls) and re-ran the survey results . (This was for internal analysis only; we are not publishing the reweighted figures.) The figures changed by only 1-2 points in most cases – indicating that the party distribution of the sample did not account for all or even much of the change seen in the abortion trends. However, as noted in point A, we don’t consider the party ID distribution we obtained in the survey “wrong” just because it was different from what we obtain on other surveys. Thus, we stand behind the published figures based on our standard Census-based demographic targets.

• As highlighted in the story, and expanded on in the “bottom line” analysis, the major change in abortion attitudes over the past year was seen among Republicans and independents who lean Republican. Thus, even if we were to hold party ID constant across the two surveys, attitudes would have become less friendly to abortion rights because Republicans moved to the right, while Democrats stayed the same. The question is, why did Republicans become more conservative in their views on abortion? The “pro-life” side has been eager to attribute it to the “success of their efforts” on the issue. I’m dubious about that. Without a high profile “pro-life” campaign over the past year to attribute this to (which I can’t),  I would expect to see that sort of attitudinal change happen more gradually. This was abrupt. The major change that’s happened is that Obama was elected, and since he is “pro-choice” and those views have been forefront in the news over the Notre Dame flap, I think it’s reasonable to hypothesize that this has compelled some.

• The external validation component is very important. We are not alone in showing a shift toward the “pro-life” position (or anti-abortion position, in the case of legality questions). Aside from Gallup, four other organizations have come out with abortion data in recent weeks, and all of them show a more “pro-life” stance than they did in their last measurement in 2008 (all pre-election).

• “PRO-LIFE” V “PRO-CHOICE”
  Gallup Values survey shows a 7 point increase in “pro-life” and an 8 point decline in “pro-choice” (May 08 vs. May 09) SWING=15 POINTS.    Gallup G1K survey shows a 6 point increase in “pro-life” and a 7 point decline in “pro-choice” (May 08 vs. May 09) SWING=13 POINTS.    Fox News shows an 8 point increase in “pro-life” and 6 point decline in “pro-choice” (September 08 vs. May 09) SWING = 14 POINTS.    CNN shows a 1 point increase in “pro-life” and a 4 point decline in “pro-choice” (Aug 08 vs. April 09) SWING=5 POINTS.

• LEGAL/ILLEGAL
  Gallup Values survey shows a 3 point increase in “legal in only a few/illegal in all” and a 4 point decrease in “legal in all/most” SWING=7 POINTS.    Gallup G1K survey shows a 5 point increase in “legal in only a few/illegal in all” and a 6 point decrease in “legal in all/most” SWING=11 POINTS.    Quinnipiac shows a 3 point increase in “always/usually illegal” and a 5 point decline in “always/usually legal.” (July 08 vs. April 09) SWING=8 POINTS.    Pew shows a 3 point increase in “always/usually illegal” and an 8 point decline in “always/usually legal” (Aug 09 vs. Apr 09) SWING=11 POINTS.

Given these responses, I think it is fair to say that Gallup and others are on to something. There does seem to be a change, albeit possibly temporary, in attitudes toward abortion. Given this change, several questions come to mind:

1. Is reporting about abortion with only two binary options the most appropriate way of showing public opinion? What are some other options to polling about abortion?
2. Will this change be permanent or just a temporary blip in public opinion due to reasons that Gallup points out?

As far as reporting such polling results as binary options (”pro-choice” v. “pro-life” or always/sometimes legal vs. always/sometimes illegal), Gallup also thankfully breaks down its legal/illegal question into four categories. Granted, opinion on abortion is probably more nuanced than four categories, but it is encouraging that Gallup offers these details:

• Legal under any circumstance (change from 2008 to 2009):  -6 points
• Legal under most circumstances: +2 points
• Illegal under most circumstances: – 3 points
• Illegal under all circumstances: +6 points

While it is possible and in fact likely that many Republicans who once had a nuanced position on abortion now identify themselves in the extreme given the polarization of the GOP tent and the fear of an “abortion-loving president” from the talk radio set, the movement away from the “legal under any circumstances” category is still a bit  perplexing by the “Republican Party being more extreme” movement theory.  Are there really many Republicans who just one year ago thought abortion should be legal under any circumstance who now are 1.) Still Republicans AND 2.) No longer hold this position?  It’s possible, but definitely not as likely or as easily explainable as the movement toward the “illegal under any circumstances” camp.  Perhaps this cross-tabulation is just random noise, which wouldn’t be surprising since the margin of error is going to be much higher among these subgroups.

What are some other approaches for asking about abortion?

While I commend Gallup for asking about this question in more than a strictly binary fashion, it’s important to point out that there are other possible ways of asking about abortion that could possibly lead to very different baseline conclusions.  Paul Rosenberg does a nice job of summarizing the findings of the General Population Survey (GPS), which gives survey respondents three different abortion scenarios and asks them to indicate whether they think abortion should be illegal in:

1. None of these cases
2. One of these cases
3. Two of these cases
4. All of these cases

Since many people may have a hard time defining exactly what “pro-choice” and “pro-life” are (Gallup admits that it doesn’t necessarily endorse these terms, and hence uses them in quotes), this approach is nice because it conceptualizes the issue in three nuanced situations, ranging in acceptability.  By using this approach, the GPS finds that only 9% of respondents believe that abortion should be illegal in all three given cases.  This is not to say that this bottom-line result is more accurate than other polls, as it is  asking about slightly different things. (It’s also important to note that these numbers are not meant to in any way dispute Gallup’s trend, but rather to show that a different interpretation of baseline values could be made by using a slightly different methodology.)

What does this mean?

The book Myth of a Polarized America further explores some these issues and argues that most of the “pro-choice” versus “pro-life” debate is in fact media driven and that most Americans actually lie somewhere in the middle, holding a nuanced opinion about abortion and other social issues.  In this light, is it possible that media reports that only repeat binary results of such wedge-issue polls encourage the narrative of a divided, polarized America?

Although recent right-wing extremism may be afoot, it is important to remember that most of those that are pro-life are anything but extremists.  Despite what they may tell pollsters, one can legitimately argue that most Americans hold nuanced views that deserve nuanced reporting that respects the complexities that are inherent in such social issues. Given the apparent sudden change in attitudes, it will be interesting to look at this issue again in five or six months or in a year to see whether this is a short-term blip in response to the first brand-new Democratic President in 16 years or a sudden, sustainable change in public opinion.  The best period to which to compare this recent movement would be 1993, when President Clinton first took office. Unfortunately, 1993 was two years before Gallup began polling this issue.

Bottom Line

I applaud Gallup and others for looking in-depth at these issues and hope that the mainstream media can begin to report such public attitudes and beliefs with the nuance and respectful tone that they deserve.  Like most things in life, abortion does not involve mutually exclusive sets of ideas and values for most individuals.

Review of West of the West: Dreamers, Believers, Builders, and Killers in the Golden State

West of the West: Dreamers, Believers, Builders, and Killers in the Golden State
by Mark Arax
Public Affairs: 350 pp., $26.95

It’s coming to America first, the cradle of the best and of the worst.

“Democracy,” Leonard Cohen

As America is to the world, so is California to America. If you’re looking for the greatest opportunities and the biggest dreams – along with the biggest absurdities and the greatest atrocities – well, you go to the U.S. of A. And if you’re already there, in one of the other forty-nine states, why then, you go west. Or, more precisely, as author Mark Arax notes, you go west of the West which is where Teddy Roosevelt said he felt he was when he was in California. You might say that California is America to the next degree – America squared.

Much of the rest of the country’s knowledge of the Golden State is limited to the Pacific Coast from San Francisco down to Los Angeles or maybe San Diego. Not that this doesn’t encompass a lot – this 550 mile stretch includes the country’s largest county, Los Angeles (whose nearly ten million population almost doubles that of runner-up Cook County, Illinois) along with four of America’s thirteen most populous cities. Arax wrote for the Los Angeles Times for twenty-seven years, so his new collection of essays, “West of the West” does cover this well known California, but ultimately he is not of it and his writing on it is not his best work.

“Eyre of the Storm,” for instance, is a bit of stereotyped mockery of the “far out” Bay Area that covers “Naked Day” in Berkeley, a convention of conspiracy theorists, and an old family friend in Berkeley who is “a believer in UFOs and past lives,” including her own past life as Mary Magdalene. Arax ends the piece lamenting the decline of meaningful political activism and “[t]he social transformation of San Francisco and Berkeley, its iconic foot bath and organic tampon self-absorption, [and] the inexhaustible consumption made possible by the ascent of the silicon chip.”

Unfortunately he appears not to have examined much past his preconceptions, otherwise he would have found a left wing majority on the San Francisco Board of Supervisors actively involved in creating programs like a municipal minimum wage, maintaining rent control, and generally grappling with the problem of ensuring that the city’s working class and poor population is not swept away by the waves of wealth washing up from Silicon Valley. And quality aromatherapy is not high on their agenda.

Arax himself originally hails from Fresno, whose population of nearly half a million makes it California’s largest city not bordering on the Pacific Ocean — in other words, California’s largest unknown city. “If you want to see concentrated poverty,” he writes, “unlike any other city – Fresno number one, New Orleans number two – or witness the nation’s highest per capita IV drug use, come to our inner city.”
And it is in his reporting on the unknown California that Arax shines. As the state’s banks repossessed $100 billion worth of houses over a two-year period – 1,300 houses emptying each business day – he tells us that no area was hit harder than the Central Valley where Kern County had become so pro-growth that it abolished its planning commission, helping to make “Bakersfield, the most sprawled city in the West.”

Leading up to the crash, “[f]or every dollar the boom was generating,” he writes, “cities were spending roughly two dollars to provide streets and sewers and cops to serve the new suburbs. … When the city’s [Fresno’s] own economic impact studies began showing that each housing tract was putting Fresno deeper in the red, Mayor Jim Patterson stepped in. The city, he said, could no longer afford to do economic analysis.”

But the best parts of “West of the West” concern California agriculture – and its amazing extremes. “The Summer of the Death of Hilario Guzman” is a story of migrant farmworkers. Now, most of America thinks it already knows that one; after all, United Farm Workers founder Cesar Chavez has even had his own postage stamp. But these are not Cesar Chavez’s farmworkers. Today one out of every five farmworkers in the Valley – 75,000 – are Mixtec Indians who have left behind villages in Oaxaca, Guerrero, and Puebla now largely depleted of working-age men. Their children often struggle in California schools not just because they don’t speak English, but because they don’t speak Spanish either, but rather Mixtec languages such as Triqui.

Arax rides a farmworker bus headed to the raisin fields filled with speakers of six indigenous languages. “They had left villages of slash-and-burn farming for the most technologically advanced agriculture in the world,” he writes, and yet “the work could not have been more primitive.” He found the fastest pickers earning between $10 and $12 an hour; they might make $10,000-12,000 in a summer. The slowest “were not even making $30 a day – somewhere between $2 and $3 an hour.” He concludes that “[w]e are more than happy to buy a bag of plums for the same $5 we paid in the 1990s but give no thought as to how that trickles down to the farmer and his field hand.”

“Highlands of Humboldt” covers the other end of California agriculture – geographically and economically. Arax visits a plot where no one earns “less than $40 an hour, likely the highest piece rate in all of American agriculture.” These farmworkers harvest marijuana, “the biggest single cash crop in all of California, dwarfing the $10 billion a year agricultural bounty of Fresno and Kern – the number one and two farm counties in the country.” In the geographic top of California – 7,081 square miles, 215,000 people, 85 percent of them white – “nearly every standing thing in a two-hundred-mile stretch from Ukiah to McKinleyville … was almost wholly reliant on the unfettered cultivation of marijuana.”

Although the marijuana-growing “Emerald Triangle” pre-existed it, the 1996 passage of Proposition 215, the state’s medical marijuana law, took the industry to a whole other level as it made it quasi-legal. That is to say, legal – with certain restrictions – under state law, but still illegal under federal law. And about once a decade the feds will attempt to assert themselves as they did on June 24, 2008 “when residents awoke to a convoy of 450 federal, state, and local police – cars, trucks, all-terrain vehicles, three-wheelers, a mobile communications center, portable toilets – roaring up the hillside” to raid the fields and grow houses.

Meanwhile, the Emerald Triangle has become home to a cultural divide that few outsiders would conceive of. Arax attends a community meeting, complete with a professional facilitator, called to discuss the problems of “diesel dope” in the Humboldt County town of Garberville. As a grower from Mendocino County to the south had told him, “Weed is a spiritual experience here. We grow it in a sustainable way. We grow it in the backyards using the sun. [In Humboldt t]hey build these huge indoor grow houses and use diesel generators to keep the lights burning.” With the estimated seventy-five gallons of fuel needed to produce one pound of indoor pot being about what an average car burns in a trip from California to Texas, bumper stickers have begun to appear that read: “Diesel Dope: Pollution Pot.”

The Humboldt “rasta rednecks,” as Arax dubs them, are “hill people, the sons and daughters of the old lumbermen and fishermen” whose industries have died out. And he notes that some chapters of the county’s history are of the sort that the nation prefers to speed read through; In 1854, four years after California’s admission to the Union, the Sinkyone, Yurok, and Karok Indians of Humboldt had not seen a white man; ten years later their societies had been destroyed by them. An early edition of the Humboldt Times describes “the red-skin scourge that has long been preying upon their [the colonists’] lives and property.” Arax describes a massacre of three hundred natives, driven by “the calculus that for every white man killed by an Indian, 150 Indians needed to die in return.” (A cynic might note a similarity to the nation’s post-9/11 policy in regard to Muslim nations.)

Where California goes from here is an ever-fascinating question. Just the other day a University of Southern California study reported that for the first time in its history, a majority of the state’s residents were born and raised there. Meanwhile, renewed efforts to cover farmworkers under federal labor law and to legalize and tax marijuana for general use have surfaced. For now, if you want to catch up on a few developments in the state that so often seems home to what is best and what is worst in America, Arax’s book is a good place to start.

Health Care Reform: A Lesson From the Big 3

US health care reform is the biggest domestic issue facing America today, and action is needed to fix it. But as I was reading about Chrysler’s bankruptcy the other day, it got me thinking about the similarities and differences between the auto industry and the health care industry. As the rhetoric and furor over health care reform gets more and more heated, it might help the debate if we step back and take a look at the failed auto industry and try to learn some lessons about what to do and what not do when reform is needed.

To use an oxymoron, American health care is sick. As many reports have stated, Americans spend twice as much on health care as similar western countries. Half of this cost is paid thanks to the American taxpayer (or the American taxpayer’s children and grandchildren, thanks to budget deficits). But even with all that spending, objective impartial statistics rank America’s health care near the bottom when compared with those same western countries. (See Demockracy article from February 16, 2009, “Health Care in America – A Time for Change” for a full discussion of this issue.) However, even with the groundswell of support from many different corners, this is not a problem which will be fixed at the flip of political switch. This is a problem which has been forty years in the making and will probably be forty years in the fixing.

So, as we watch the plight of the Big 3 automakers, I can’t help but compare their plight to the current situation of the health care industry and compare the position of the auto companies of 1960s to the health care providers of today. For many, many years, the Big 3 automakers were the most celebrated and profitable companies in the world. CEOs, executives, shareholders, unions, and car salesmen all got rich and fat on the profits from the US auto industry. They were the “Masters of the Universe” in the mid 20th century. A national infrastructure was built to support the industry. “What’s good for General Motors is good for America” was the oft-quoted refrain.

GM, Ford, and Chrysler made cars that were the shiniest, biggest, boldest, and the envy of the world. Even if you didn’t need or want rear fins or white side wall tires or big V-8 engines,  you got them because it was the American way to do things. Cars got bigger, more expensive, and more inefficient, and the industry run by the three big oligarchs with almost no other meaningful competition slowly lost touch with the consumer.

And then in the 1970s the car industry had a hiccup. The Japanese (and others) devised a cheaper, more sensible way to make cars which fit the needs of the consumer. These cars were cheaper and on objective criteria, better (sound familiar to an industry we know?). Detroit of course tried to react in the 1970s and 1980s. The industry went through thirty years of pain – a government bailout here, a merger there, a few concessions from the unions. They pared down their product lines to sell mostly SUVs and big cars (cars which people really didn’t need, but old habits die hard). Salesman and marketing programs claimed that the quality statistics comparing the Japanese cars were flawed, and anyway, who wants to drive a small little Japanese car (“I don’t care what the statistics say, the American made car is better”).  And now thirty years later, the Big 3 are on the critical list. Their infrastructures were just too cumbersome to change in the radical ways that were necessary to survive. Chrysler has now died, and GM and Ford are gasping their last breath. It is sort of ironic that one of the biggest problems of the auto industry is the escalating health care costs of the labor force that simply cannot be reduced under the current system.

Saying all that, and even with the Big 3 in their current sad state, I don’t think I know one American who is not a lot happier with the car they drive now compared to what they drove thirty years ago (OK, maybe we need to exclude owners of ’57 Chevys or ’64 Mustangs). All of the trauma and gut-wrenching decisions and layoffs and closures, although obviously difficult for those directly involved, were part of the process required to allow the American consumer to buy the product that was best for him.

So the similarities to the health care industries today and the auto industry of thirty years ago are obvious. The health care infrastructure is bloated and inefficient – it is providing products and services which are too big, expensive, and inefficient to many US citizens. It is more expensive and has less quality than other countries’ health care systems. A huge and complex national infrastructure has been built to support the entire industry. CEOs, executives, and shareholders, along with many powerful physician specialties, are all getting rich on the profits of the health care industry. These constituents do not want to stop the gravy train – but stop it will and stop it must – someday. In the long run, the American consumer will force the change – and it will most likely lead to trauma in the industry. It might take thirty years or longer – but the health care industry will change. In fact, I will make a bold and a rather pessimistic prediction: We will know that health care is “fixed” when one or more of the health care giants of today go bankrupt. The trauma that is necessary to change the system will almost certainly lead to the bankruptcy of a major player in the industry. Just like the Big 3, one or several major health care players will not be able to adapt to changes in the industry, and the result will be predictable. The somewhat tricky issue here is that the bankruptcy that occurs could well be the US Government, which foots nearly 50% of the health care bill in the U.S. – the bankruptcy in the health care industry which occurs might be US.

CHANGING HEALTH CARE IS DIFFERENT – IT’S HARDER

Although there are similarities in the predicaments of the auto and health care industries, there are three major differences worth noting, none of which are going to make reform any easier.

First, there is limited foreign competition to replace and offer alternatives to an inefficient industry. Health care, especially in- patient and primary health care is almost inherently a domestic industry. Japan, India, or China cannot easily begin a strategy of exporting health care to America and provide a competitive hammer to the industry. But this trend can be hard to predict.  If a consultant would have advised the CEOs of the Big 3 in 1960 that they would be brought to their knees by Japanese companies exporting two ton cars from Japan across the Pacific Ocean, he would have been laughed out of the board room. In the high technology world of internet, ipods, blackberrys, and instant data transmission, it is not inconceivable that a cheaper, more efficient health care model could be imported into the US and provide consumers with an alternative. If this does happen, you can be sure the first persons to cry foul will be the doctors, US health care companies, and their lobbyists who, predictably, will complain about low quality, “non-approved” health care, cheaper replacements, job losses, un-American competition, etc. – the mantra that car companies have moaned about for years.

Second, the US government does not just regulate or support the health care industry – it is the health care industry – as mentioned before, approximately 50% of health care spending is through Medicare, Medicaid, and other government programs. Moreover, the rules, regulations, and reimbursement programs developed and administered by the government are incredibly complicated when compared to other private industries. So when we speak of infrastructures that need to change, we are not speaking of a board room in Detroit; we are speaking of the mother of all infrastructures – the US Government. Needless to say, changing the direction of this US battleship will not be an easy task.

Third, the health care industry by its very nature involves life and death situations. The auto industry had to deal with issues like increasing miles per gallon, faster times for 0-60 mph, and how many grocery bags could fit in the trunk. Health care involves more serious issues – which cancer drug is likely to cure a sick child, kidney transplants, strokes, and heart attacks. Health care is emotional and stressful. To affect change within this emotional environment will be much more difficult given the potential side effects if a particular policy is in error.

If anything, then, these three major differences of the health care industry, as compared to the auto industry, will make change harder not easier. The lack of  foreign competition to drive changes and to lower costs, the gargantuan bureaucracy of the US government, and the emotional issues involved all are roadblocks to change. Change will not be easy.

LESSONS TO BE LEARNED

It has been said that he who fails to learn from history will be destined to repeat it. So what can the health care industry learn from the plight of the auto industry?  In my opinion,  there are several important things.

First, what is required to fix the health care system is major surgery. The cost structure and system is fatally flawed. The auto companies cost structure was fatally flawed thirty years ago. Tweaks here and there allowed thirty years of survival for the Big 3, but they did not fix the problem. The health care companies, the insurance companies, and the US government cannot keep forcing their “SUV” solutions when what the consumer needs is a reliable, efficient, quality health care system. If rich people want to pay for big SUVs, then let them, but the average person needs good and efficient, not excessive and gaudy.

We will need to accept that this major surgery to the health care system will be painful and it will take a long time. There will be winners and losers. Jobs will be lost, salaries may be lowered, and mistakes will be made. And given the emotion and seriousness of health care, the mistakes may lead to serious consequences. Let us be prepared for these mistakes and issues. These issues that change brings about cannot reduce our desire and drive to change the system for the better. And as we are going through these painful changes, let’s not let lawyers and tort laws allow even more money to be sucked out of the system by legal confrontation. Tort reform is needed to limit damages and to let providers make the decisions necessary to cut the waste out of the system without worrying about multimillion dollar lawsuits that ultimately just add more costs to an already inefficient system.

Second, good old fashioned competition will ultimately serve the needs of the health care consumer best. Whatever the system looks like in twenty years, it must be a competitive system where individual consumers choose what is best for them. This does not mean that government cannot be involved, but government needs to develop and nurture a system which promotes competition. However, it must be noted that just introducing competition into a system which is broken is not just a cure all. The private and public health care system does have competition now, but it takes place at the wrong levels and on the wrong things. This dysfunctional competition does not focus on delivering value for money to customers, but instead motivates providers to capture more revenue, shift costs to the deep pocket, and restrict services to those who cannot pay. The competition is more about profit and revenues and less about providing value to the patient. Flawed model – flawed competition. The industry needs to develop new business models that reward quality and efficiency, not simply a fee-for-service mentality. Reform should focus on creating a system whereby providers compete directly on the six overarching “Aims for Improvement” (as identified by the Institute of Medicine) for health care. These aims are:

• Safe: Avoid injuries to patients from the care that is intended to help them.
• Effective: Match care to science; avoid overuse of ineffective care and under-use of effective care.
• Patient-Centered: Honor the individual and respect choice.
• Timely: Reduce waiting for both patients and those who give care.
• Efficient: Reduce waste.
• Equitable: Close racial and ethnic gaps in health status.

If competition is refocused along these parameters rather than just on profit and revenue, then the competition will bring value to the customer. The book Redefining Health Care: Creating Value Based Competition on Results by Michael Porter and Elizabeth Teisburg is an excellent treatise on how competition can be implemented into health care systems to drive the most efficient solutions to the consumer.

Regarding competition, it would be interesting, indeed, if a foreign competitor could begin importing health care services into the US.  I have traveled and lived extensively overseas and experienced health care in many foreign countries.  I can testify that many, many overseas providers would be more than willing to provide health care to US citizens at a fraction of the cost that is paid in the US (and this is from persons living in Western Europe – the opportunities from a low cost country like India or China must be staggering). And remember, before you get protectionist, these other countries’ health care statistics are better than ours – don’t be fooled like the automakers who claimed that your 1972 Ford Galaxy is really better than the Toyota Corolla.

Finally, the leaders of the health care industry, public and private, must focus on what Detroit did not – the needs of the consumer – what does the average citizen want and how much will he pay for it.  In too many cases, the health care industry has lost touch with its customer – the patient.  Instead, the dysfunctional system we have now has redefined the customer as the payer, which usually is Medicare, Medicaid, or a large insurance company. As a simple illustration of this, let’s assume there are two viable, equally effective procedures available to cure a patient: Medicare pays $100 for Procedure A and $1000 for Procedure B. Guess which procedure will be recommended by the Provider – the Provider will choose the one giving him more revenue (assuming more revenue generally leads to more profit). The patient won’t argue, he just wants the best treatment, and there will be an implied view that the more expensive treatment is the “better” treatment. No one is worse off except the government, and they have lots of money – right? This is a simple example, but this is how it works. There are scores of accountants, lawyers, and clinicians who are employed not to provide better care to patients, but to maximize revenue from the “customer” (Medicare, Medicaid, et al.).

The current system and structures are designed to maximize revenue and profit from the intermediaries – they are not focusing on the needs of the customer. The average person does not need the “Cadillac” of health care; the average person does not need the Mayo Clinic. The average person does not need a multimillion dollar tort settlement. The average person needs and wants good, reliable, quality health care at a reasonable cost. The average consumer knows in his heart that health care bills are too large, but that there are currently no viable alternatives for the average citizen. (There are no inexpensive imports he can turn to!) The industry leaders cannot let their existing infrastructures, inefficient practices of the past, or bloated costs and salaries be the drivers of the decision-making process. The industry cannot survive with a “if we build it, they will come” attitude. The health care industry must give the consumers what they want.

Other countries have health care systems (public and/or private) that give the same or better health care results to its citizens for about half the cost of the US. The Big 3 automakers did not survive such inefficiencies, and neither will the health care industry. Change must come or the health care industry will ultimately face the same crisis as the Big 3. Change is imperative; failure is not an option.

Same-Sex Marriage: Obama’s Lincoln Moment

On Wednesday night, Governor John Baldacci of Maine signed legislation that he struggled to support. While governors are often pressed by their legislatures and constituents to support laws that they do not necessarily agree with, this bill—one that legalizes same-sex marriages—was a personal dilemma for the first-term governor. After weeks of agonizing over the decision, the Governor released a statement to the press that outlined the reasoning behind his eventual approval:

In the past, I opposed gay marriage while supporting the idea of civil unions. I have come to believe that this is a question of fairness and of equal protection under the law, and that a civil union is not equal to civil marriage.

The first governor to sign a same-sex marriage bill, Baldacci touches on the heart of the same-sex marriage debate: The arguments for or against same-sex unions based on morality, religion, tradition, or any other logic is irrelevant. What matters is the law. And the equal protection clause of the Fourteenth Amendment of the Constitution that he refers to clearly states “[no] State [shall] deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.” Which means that, like it or not, from Baldacci’s perspective, gays and lesbians should be entitled to the right to marry if straight people are allowed to marry.

Over the course of the past several months, four states have legalized same-sex marriage in their states: Connecticut, Vermont, Iowa, and New Hampshire (Massachusetts legalized gay marriage back in 2004). Recently, both New York and Washington D.C. have decided to recognize same-sex marriages performed in other states. And now there is talk that New Jersey may become the sixth state to legalize same-sex marriage in the coming months.

Throughout this civil rights upheaval,  President Obama and his administration have remained conspicuously mum. According to the New York Times, Obama has said that as a Christian he opposes gay marriage but remains a “fierce advocate of equality” for gay men and lesbians. And so far, he has remained true to that statement by pledging to sign a U.N. declaration, which Bush refused to sign before he left office, that calls for a worldwide decriminalization of homosexuality (the United States was the only western nation not to support the measure). Moreover, Obama has continually recognized qualified persons with same-sex sexual orientations for top level jobs: In his short time in office, he has appointed numerous openly gay officials for executive administrative positions and may be considering two prominent lesbian lawyers to replace Justice Souter on the Supreme Court.

Although the saying goes that “actions speak louder than words,” his silence is an action that may indicate his political discomfort with gay rights advocacy. During the election, he reiterated that same-sex marriage is an issue that should be decided by the states. And, to a certain extent, he’s constitutionally correct: There is currently no federal marriage license that any straight couple can apply for but, then again, opposite-sex couples who marry in their home state trust that their marriage will be honored no matter which state they travel to or live in. And while there is no federal law regulating straight marriages, the 1996 Federal Defense of Marriage Act passed by Congress regulates same-sex unions. The Act explicitly outlines that states do not have to recognize same-sex marriages or civil unions performed in other states. That is a gross discrepancy.

While Obama has said that he supports a repeal of that legislation and of the military’s “Don’t ask, Don’t tell” policy, he has remained virtually silent on the gay marriage issue since he took office and has chosen to not comment on the landslide of same-sex marriage laws in recent months. Although this issue may not seem like a priority for the administration when they have an economic crisis and two wars to contend with, it should be a priority for the president since Obama has repeatedly stated that he wants America to rebuild and renew its reputation in the world. In a 2007 article he wrote for Foreign Affairs, he stated:

At moments of great peril in the last century, American leaders such as Franklin Roosevelt, Harry Truman, and John F. Kennedy managed both to protect the American people and to expand opportunity for the next generation. What is more, they ensured that America, by deed and example, led and lifted the world — that we stood for and fought for the freedoms sought by billions of people beyond our borders. […] They used our strengths to show people everywhere America at its best.

Yet, how can those freedoms be realized if America does not follow its own laws and ensure that all of its own citizens receive the same “protection” under the law? If President Obama is going to continue to reiterate that marriage laws should be left to the states, then he should actively pursue a repeal of the Defense of Marriage Act since it is a federal measure. So too, if he wants America to “lead by deed and example” then he must show support for states that have passed inclusive marriage legislation and encourage others to do the same. It sets a very bad “example” to have some areas of the country have more “freedoms” for its citizens than others.

Or, Obama could take a cue from his favorite president, Abraham Lincoln. When Lincoln took office in 1861, he viewed slavery as a states’ issue and expressly stated that he had “no purpose, directly or indirectly, to interfere with slavery in the States where it exists.” However, two years later, he delivered his Emancipation Proclamation that freed the slaves because it was “an act of justice, warranted by the Constitution.” Certainly, it is thorny comparison between slavery and gay rights and America is not in a civil war where gay marriage is, like slavery was, the catalyst for domestic combat; nevertheless the United States is at a civil rights crossroads that needs to be addressed by the President. Had Lincoln chosen to never take that stand on slavery, decided to put it off until later, or thought he could leave the responsibility on to the next administration, Obama may have never even had a chance to be our president. Obama should take a page from the book of his presidential idol and realize that, regardless of the political risk, he is obligated as America’s national leader to stand up for the rights of all Americans.

Obama has continually said that he wants his presidency to speak to and for all Americans. In his famous Democratic nomination acceptance speech, Obama evoked Martin Luther King and reiterated that “now is the time” for the United States to rebuild and renew:

[I]n America, our destiny is inextricably linked, that together our dreams can be one. “We cannot walk alone,” the preacher cried. “And as we walk, we must make the pledge that we shall always march ahead. We cannot turn back.”

Indeed, we cannot turn back and now is certainly the time.

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