The Best Care Anywhere

When it comes to health care, it’s a government bureaucracy that’s setting the standard for maintaining best practices while reducing costs, and it’s the private sector that’s lagging in quality.

In my last post, I mentioned Paul Krugman’s mention of Phillip Longman’s Washington Monthly article on the remarkable turnaround of the Veterans’ Health Administration system.

But when it comes to health care, it’s a government bureaucracy that’s setting the standard for maintaining best practices while reducing costs, and it’s the private sector that’s lagging in quality. That unexpected reality needs examining if we’re to have any hope of understanding what’s wrong with America’s health-care system and how to fix it. It turns out that precisely because the VHA is a big, government-run system that has nearly a lifetime relationship with its patients, it has incentives for investing in quality and keeping its patients well—incentives that are lacking in for-profit medicine.

One reason is that the market incentives in our privatized health care system are dysfunctional. For example,

Or suppose an HMO decides to invest in improving the quality of its diabetic care anyway. Then not only will it risk seeing the return on that investment go to a competitor, but it will also face another danger as well. What happens if word gets out that this HMO is the best place to go if you have diabetes? Then more and more costly diabetic patients will enroll there, requiring more premium increases, while its competitors enjoy a comparatively large supply of low-cost, healthier patients. That’s why, Casalino says, you never see a billboard with an HMO advertising how good it is at treating one disease or another. Instead, HMO advertisements generally show only healthy families.

And cost?

The [VHA] system runs circles around Medicare in both cost and quality. Unlike Medicare, it’s allowed by law to negotiate for deep drug discounts, and does. Unlike Medicare, it provides long-term nursing home care. And it demonstrably delivers some of the best, if not the best, quality health care in the United States with amazing efficiency. Between 1999 and 2003, the number of patients enrolled in the VHA system increased by 70 percent, yet funding (not adjusted for inflation) increased by only 41 percent. So the VHA has not only become the health care industry’s best quality performer, it has done so while spending less and less on each patient.

Longman concludes,

As the health-care crisis worsens, and as more become aware of how dangerous and unscientific most of the U.S. health-care system is, maybe we will find a way to get our minds around these strange truths. Many Americans still believe that the U.S. health-care system is the best in the world, and that its only major problems are that it costs too much and leaves too many people uninsured. But the fact remains that Americans live shorter lives, with more disabilities, than people in countries that spend barely half as much per person on health care. Pouring more money into the current system won’t change that. Nor will making the current system even more fragmented and driven by short-term profit motives. But learning from the lesson offered by the veterans health system could point the way to an all-American solution.

Longman is skeptical of our ability to move directly to universal health care, where a VHA-style system would work well. Instead, he argues for an expansion of the VHA to cover more people.

I hope he’s wrong about universal health care.

America’s Senior Moment

Paul Krugman on demographics, Social Security, and health care.

In the March 10 NYRB, economist Paul Krugman uses a review of The Coming Generational Storm: What You Need to Know About America’s Economic Future, by Laurence J. Kotlikoff and Scott Burns, to address demographics, Social Security, and health care.

Krugman’s a dandy writer, but he’s never been at his best in the cramped confines of his NY Times columns. The NRYB format–nearly 6,000 words here–lets Krugman stretch out, and the results are well worth the longer read.

Let’s sneak a peek at Krugman’s wrap-up.

Unless something very unexpected happens, Kotlikoff and Burns’s vision of an America that in 2030 has an older population than Florida today will come to pass. It’s also quite possible that the state of the nation will be as bad as they suggest in their opening account. But one won’t be the result of the other, and in a perverse way exaggerating the demographic challenge makes that grim future more likely.

Here’s how the debate is really playing out, in four easy steps:

1. Talking heads and other opinion leaders perceive the issue of an aging population not as it is—a middle-sized problem that can be dealt with through ordinary changes in taxing and spending—but as an immense problem that requires changing everything. This perception is, alas, fueled by books like The Coming Generational Storm, which blur the distinction between the costs imposed by an aging population and the expense of paying for medical advances.

2. Because the demographic problem is perceived as being much bigger than it really is, the spotlight is off the gross irresponsibility of current fiscal policy. As you may have noticed, right now everyone is talking about Social Security, and nobody is talking about the stunning shift from budget surplus to budget deficit since Bush took office.

3. The focus on Social Security— the one part of the federal budget that is actually being run responsibly—is, in practice, offering the architects of our budget deficit an opportunity to do even more damage.

4. Finally, we’re not having a serious national discussion about the bigger problem of paying for health care, and we probably can’t in today’s ideological climate.

Krugman has long since come over to the universal health care side.

Systems that provide universal coverage, like those of France or Canada, are much cheaper to run than our market-based system, yet they yield better results with respect to life expectancy and infant mortality. Or if you don’t trust foreign examples, consider the remarkable renaissance of the Veterans’ Administration hospital system, described in an important article by Phillip Longman in the February Washington Monthly: he shows that the VA system’s centralization of information and control over resources allow it to provide better care at lower costs than any private system.

Longman’s article is online as well. Read ’em both.

Raising the retirement age

Why not? Because we don’t want to.

One of the solutions tossed about for the Social Security “crisis” is to raise the retirement age–or to raise it more quickly; it’s already headed up to 67.

Kevin Drum says no:

So why not work longer and retire later?

Answer: because we don’t want to. Sure, we could continue inexorably raising the retirement age, ensuring that no matter how much richer we get and no matter how many medical advances we make, we’re still working til we drop. We could do that, but we don’t want to. Most of us like the idea that we’ll have more years of “active retirement” (i.e., “free of chronic functional impairment”) than we did 60 years ago.

And guess what? We can.

I’m convinced.

If I had to pick from the other solutions on the table, I’d eliminate the cap on FICA wages, with a caveat: to the extent that Social Security is overfunded (as it would be if the economy grows more quickly than the Social Security Administration projects in its intermediate model), raise the floor on FICA wages. That is, exempt the first $10,000 (replace with the appropriate amount) of wages from the FICA tax.

That way we don’t create a permanent Social Security Trust Fund surplus to be siphoned off in income tax cuts.

Update: Nathan Newman (among others) points to a new SSA actuarial memo that shows that removing the cap would indeed fix the shortfall under the Administration’s 2004 intermediate assumptions.

Update 3/2: Nathan Newman responds to Mark Schmitt’s objection to raising the cap.

Schwarzenegger vs. Gerrymander

In a NY Times op-ed, Steven Hill suggests that, based on reent experience in Arizona and on California demographics, Scharzenegger’s plan to reform California’s political districting is not likely to produce the beneficial results we’re being promised.

So Governor Schwarzenegger’s plan, while well intentioned, is bound to fail. The old ways of thinking about redistricting and its impact no longer apply in California – nor in many other states. Shifting demographics have outstripped the abilities of the mapmakers to encourage competitiveness.

A nonpartisan redistricting commission may make a few more legislative seats more competitive. And it certainly would have the salutary effect of changing the public perception that incumbents have a hand in rigging their own district lines. But such tinkering is not likely to change much else. It will not “blow up the boxes” of state government, as Mr. Schwarzenegger has said he wishes to do.

Hill, a senior analyst with the Center for Voting and Democracy, advocates the use of proportional representation to elect representatives from multi-member districts, thereby giving representation to smaller voting blocs.

We can’t change where people choose to live, but we can begin using some type of proportional representation system. For example, California could use a system like that in Peoria, Ill., for municipal elections. Instead of electing 40 state senators from 40 districts, voters in 10 districts could elect four senators each. Any candidate who won at least a quarter of the vote would earn a seat. These districts would be far more likely to be bipartisan, even electing some urban Republicans and rural Democrats.

This makes sense, and gives a voice to many more voters than our current system does, gerrymandered or no.

But while we’re at it, let’s have one more reform: expand California’s legislature. A drawback to multi-member districts is that the resulting districts are geographically larger than they are now, and California’s Senate and Assembly districts are already far too large for effective local representation.

So yes, let’s move to multi-member districts, but at the same time let’s double or triple the number of seats in the state legislature.

The seven deadly absurdities of No Child Left Behind

The more one digs behind NCLB’s noble goal of universal proficiency (for some definition of proficiency), the more one is forced to question the good faith–or good sense–of its authors. Bracey’s litany of absurdities is worth a look.

Gerald W. Bracey is an associate professor at George Mason University, Fairfax, Virginia and an Associate of the High/Scope Educational Research Foundation, Ypsilanti, Michigan. His most recent book is Setting the Record Straight: Responses to Misconceptions About Public Education in the U. S.: Second Edition (Heinemann, September 2004).

In her confirmation hearings, Secretary of Education, Margaret Spellings expressed her desire to fix the No Child Left Behind law, but also stated, ‘We must stay true to the sound principles of leaving no child behind.’ This will be difficult because the ‘sound principles’ are nowhere to be found. Consider the following seven deadly absurdities of the law….

Read the article.

Jerry Brown and charter schools

In an LA Times article, Oakland mayor and ex-gov Jerry Brown preaches to the charter school choir.

There’s certainly something to be said for charter schools, especially to the extent that they’re able to provide a greater diversity of educating style, but I’m not sure what to make of this:

Brown said he successfully lobbied Gov. Arnold Schwarzenegger last year to veto legislation that would have prohibited charter schools from dropping students who did not meet their academic standards.

“How can we hold schools accountable if we don’t allow schools to hold their students accountable?” Brown said, alluding to the federal No Child Left Behind Act, which calls for sanctioning schools whose students do not meet expected achievement levels.

If and as charter school proliferate, what happens the the students they drop? Do we abandon universal public education, or do our public schools become a dumping ground for all the students that don’t meet “expected achievement levels” at the charters?

All kinds of minds: Mel Levine

Last night, I was struggling to remember the name of an educator I had come across a couple of years ago. He was stressing the need for a pluralistic approach in teaching children, something that our one-size-fits-all approach to academic proficiency seems to entirely ignore–except in the special education arena.

In one of those small miracles of coincidence, NPR ran a story on Dr Mel Levine this morning.

Throughout the country this Institute is working to provide parents with the best assessment techniques and to train classroom teachers to help kids with learning differences. We strive to ensure that children receive the individualized education that will help them enhance their innate strengths and overcome difficulties they may have encountered in school.

Dr Levine’s work raises a serious question for those of us interested in the definition of “proficiency” for the purposes of standardized testing in our public schools. More to come….

Advice for high school students

“Rebellion is almost as stupid as obedience. Nearly all textbooks are bad.”

In What You’ll Wish You’d Known Paul Graham offers sound advice to high school students. Here’s a sample. (via /.)

It’s dangerous to design your life around getting into college, because the people you have to impress to get into college are not a very discerning audience. At most colleges, it’s not the professors who decide whether you get in, but admissions officers, and they are nowhere near as smart. They’re the NCOs of the intellectual world. They can’t tell how smart you are. The mere existence of prep schools is proof of that.

Rebellion is almost as stupid as obedience. In either case you let yourself be defined by what they tell you to do. The best plan, I think, is to step onto an orthogonal vector. Don’t just do what they tell you, and don’t just refuse to. Instead treat school as a day job. As day jobs go, it’s pretty sweet. You’re done at 3 o’clock, and you can even work on your own stuff while you’re there.

One of the most dangerous illusions you get from school is the idea that doing great things requires a lot of discipline. Most subjects are taught in such a boring way that it’s only by discipline that you can flog yourself through them. So I was surprised when, early in college, I read a quote by Wittgenstein saying that he had no self-discipline and had never been able to deny himself anything, not even a cup of coffee.

A key ingredient in many projects, almost a project on its own, is to find good books. Most books are bad. Nearly all textbooks are bad. [9] So don’t assume a subject is to be learned from whatever book on it happens to be closest. You have to search actively for the tiny number of good books.

[9] Even college textbooks are bad. When you get to college, you’ll find that (with a few stellar exceptions) the textbooks are not written by the leading scholars in the field they describe. Writing college textbooks is unpleasant work, done mostly by people who need the money. It’s unpleasant because the publishers exert so much control, and there are few things worse than close supervision by someone who doesn’t understand what you’re doing. This phenomenon is apparently even worse in the production of high school textbooks.

Budget follies: round one

From the Governor’s new budget proposal:

Total 2005-06 Proposition 98 support for K-12 education will increase 6 percent over the revised 2004 Budget Act level, as adjusted for changes in local revenues, average daily attendance growth (ADA), and forecasted economic factors.

You’d almost think we were looking at an increase in funding for next year, but as Nanette Asimov, writing in the Chron, tells us,

Because the proposed increases cover only cost-of- living adjustments and new enrollment, school districts with declining enrollment — which encompass half the state’s students — won’t see much of the new money.

CUSD, as we all know by now, is one of those districts with declining enrollment.

The January budget proposal is only the first shot in the budget wars; we’re not likely to know the final outcome for another six months or more. But it’s not a promising start.

Merit Pay: Gerstner, Kevin Drum

Kevin Drum links to an article by Lou Gerstner on the merits of merit pay for teachers.

I don’t entirely buy Drum’s contention that principals don’t know enough about teachers to adequately evaluate them. Or rather, I’m convinced that, under the right circumstances (in particular a manageable number of teachers), a good principal has a very good idea of what her teachers are doing.

Of course this assumes good principals and small schools, but there are reasons enough, merit pay aside, to insist on both of these.


Even an imperfect system would be far better than the current single-salary schedule. And while we reward the best, we need to empower principals to lead, making sure they have the proper authority to hire and fire teachers. And as far as competition goes, since when is a little healthy effort to be the best at improving reading or math scores such a bad thing?

I frankly doubt that we’ll see a useful proposal from Arnold, given California’s budget constraints and his apparent intention to hold down education spending. But it could lead to a useful discussion.

BBC: Small-class pupils ‘do no better’

New British research suggests that there “is no evidence that children in smaller primary classes do better in maths or English”.

Via Sam Smith, who points out that small schools, on the other hand, are another matter entirely.

Yet California continues to fund class-size reduction to the tune of over a billion dollars per year while ignoring the benefits of smaller schools. California’s modest goals–classes of 20 students in grades K-3–may help account for its very limited success with CSR, but greater reductions (research suggests that 12-15 is a better target) would be correspondingly more expensive, as would expanding the program to higher grades.

Experimenting with WordPress

I’ve been playing with assorted weblog software, including iBlog and assorted flavors of Blosxom. I’m not really thrilled with any of them, but so far WordPress looks promising.

WordPress is implemented in PHP, and uses MySQL as its back end. Initial configuration was simple, assuming that one has straightforward access to the required PHP and MySQL facilities.