Tuesday, January 11, 2022

Health care and central planning

This is Joseph

This tweet thread is worth reading in detail. As a recently repatriated Canadian myself, I think that it is spot on. In fact, this statistic is so obviously true to me and explains my amazement at modern Canadian healthcare:
When I got here, I wondered, has it always been this bad? The answer is no. 

Specialist physicians in 2020 reported a median wait time of 22.6 weeks between referral from a general practitioner and receipt of treatment— compared with 9.3 weeks in 1993.

I think that this does highlight one concern about "Medicare for all" -- that if the entire health care sector is planned by the government then you become vulnerable to all of the failings of central planning. I known it is hotly disputed these days, but the central planning of the USSR was not an advantage in its great power competition with the United States. It just wasn't. 

The consequences of it in Canada on the ability of health care to weather an external shock (like covid-19) are clear. Look at this, which leaves people unable to do basic tasks like driving if wait times get too long:

 Manitoba has seen the largest decrease in Canada in cataract and lens surgeries during the pandemic.

We estimate the backlog is 4,945 and growing for cataract surgery.

Or this:

The Winnipeg Regional Health Authority (WRHA) is advising residents of Winnipeg that community health services – home care services, in particular, could be delayed, rescheduled or cancelled due to staff shortages. 

Or this:

Prairie Mountain Health, which services a wide swath of western and southwestern Manitoba, currently has eight rural emergency departments closed, leaving some communities with no open hospital and long drives to access urgent care.

Or this:

Let's say you do a job that requires 14 highly skilled people. Suddenly, you only have 7 people and 3 of them are untrained. Your working conditions remain like that for months. And you keep getting told you’re fine and that you can, in fact, actually increase what you’re doing. 

Or this (from a working MD):

I understand drive to reassure - but IMO hospitals need to stop promising "we've got you." Our politicians have pushed our systems to the edge of the cliff and we don't know what is going to happen as a result. That's the truth. A lot is about to go into freefall. 

The common theme is that a centrally planned system lacks resilience if the politicians in charge (because administrators ultimately report to politicians) decide to let the system crumble. Now think carefully if you want the typical politician making tough decisions about long term health care needs and about how to staff/run the system. Now, it is true that hospitals are currently mostly not run by the government but the group in charge of finance easily evaded that obstacle:

Planning in the hospital sector is subject to many of the same challenges as the medical sector, as most hospitals are privately owned nonprofit organizations. Allocation of resources within each institution tends to be at its own discretion. This is tempered at the provincial level, however, by splitting the planning process into operational and capital planning. Thus, while day-to-day operations are largely institutionally based with some input from the ministry, the decision to build and update facilities or purchase new equipment is subject to more extensive central control. Therefore, even though the institutional sector accounts for the preponderance of provincial health care budgets, provinces have had more planning and financial control than in any other sector

 This is a European report on Canada. Not that they also report on Canada's restrictions on training medical personnel in order to constrain costs. 

I am not saying that socialized medicine is a mistake, it isn't. But I think that there is a very important piece that we need to make sure that the institutions are well planned and robust to political administration types. Good government is key and planning this out in advance may evade some of the surprising challenges Canadian healthcare is suddenly facing. 

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Monday, January 10, 2022

Some thoughts on the career of Betty White

 The older I get, the more interesting I find second acts. 

White was a pioneering broadcaster -- Ken Levine argues she was literally the first woman on television -- but before the age of fifty (barring some very obscure shows), no one had any idea the woman could act. Putting aside her work as a producer which was entirely out of the public eye, Betty White's job was to be a guest and occasionally a host on game shows and talk shows and to be a pleasant foil for other celebrities like Lorne Green during the Macy's or Rose Bowl Parades. 




This job is waaay harder than it sounds, and Betty White was very good at it for decades, but it's not the kind of work that makes you one of the most beloved stars in the country. 

The career that everyone has been celebrating over the past week was one of the most impressive second acts in American entertainment, and she did it at an age when most women in the industry saw their opportunities dry up.

The breakthrough role was Sue Ann Niven, the Happy Homemaker and initially a big part of the joke was having a famous perennially cheerful TV personality play the always smiling but privately vicious Niven, but White's performance (combined with brilliant writing) almost immediately moved past stunt casting and established her as a major comic actor, winning two Emmys for the role.  (About this time, in a much smaller but still telling accomplishment, she was the only guest star given a permanent spot in the Carol Burnett Show's Eunice sketches, playing the least likeable member of that very unlikeable family).

MTM made people take White seriously as an actor; Golden Girls established her as a star. It was a critically acclaimed hit show and White was playing a character 180 degrees from Sue Ann Niven (the result of a last-minute casting switch). She turned seventy the year the Golden Girls went off the air. 

As Pauline Kael observed, some actors have everything it takes to be a major star, but they never get that one role that pushes them to the next level. Others just have to wait a little longer. 











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Friday, January 7, 2022

Damn, this has been sitting in the queue for a while.

Fortunately (or unfortunately) they seem to have remained relevant.



SPACs + Trump... What could go wrong?













































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Thursday, January 6, 2022

Policy that ignores the real poor

This is Joseph.

I was reading Slow Boring and was struck by this passage about student loan forgiveness:
So while there are certainly lots of individual cases where debt relief sounds like an appealing idea, under the current circumstances the case for broad debt relief has become extremely weak. There’s basically no other situation in which progressives would talk themselves into this kind of idea, which is currently being propped up with some very odd math about the racial wealth gap.

It reminded me about the argument you always hear about gasoline taxes, even from most progressives, that they hurt the poor the most. Of course, the really poor do not own cars. For some reason the really, really poor are often neglected in the discourse. 

For example, a homeless person who does not own a car is not especially directly hurt by gas taxes. Now you might argue that there are indirect impacts on prices that a gasoline tax creates but, at some margin, there is always somebody hurt by tax relative to the benefits they receive. Goods would be clearly more expensive if we allowed the roads to collapse. 

In the same sense, bike lanes and good bus systems tend to help out the disadvantaged. Sure, there is a culture of entitled bicycle enthusiasts who are a bit annoying. But low cost transportation helps the very poor the most.

Similarly, the real contest with student loan forgiveness is whether other forms of support might be more effective. Food stamps, for example, probably have a larger and positive effect on the really poor as opposed to student loan debts.

Now, there is actually some evidence that higher education is harder to access for black students, leaving more debt and lower completion rates. This has real social justice issues. But I would argue that the best way to address this is some combination of broader reform (to prevent the most extreme student debt issues) and targeted support to encourage minority success. Now it is true such policies might come under legal fire, but that is hardly an excuse to them do a blanket policy. 

Now, full disclosure, I did have student loans, I paid them off, and I would much rather not have done so. I think high loans are a bad thing. But I am not sure that just forgiving loans whenever they get too high is a good policy. But, more importantly, it is not a policy that is aimed at the most disadvantaged. Look at the level of income challenges for people without a high school diploma, in Canada with a richer social safety net. These are likely the real poor (just look at unemployment and the jobs that they have). 

Similarly, one cannot go far wrong by improving transit services that the poorest and sickest among us need to use. 

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Wednesday, January 5, 2022

Just to keep this top of mind...

The NIMBY/YIMBY politics used to be simpler and tended to break fairly cleanly along progressive/reactionary lines. As the debate has shifted to density and gentrification, the lines have gotten much blurrier. Though you wouldn't know it from the press coverage, some of the strongest voices on the NIMBY side are coming from people of color in places like Boyle Heights.

 This doesn't make the NIMBYs more right or the YIMBYs less, but it does suggest that the good guys/bad guys narrative pushed by the NYT et al. should be reconsidered.

[corrected from the original.]

TUESDAY, MARCH 13, 2018

When the NIMBYs were primarily motivated by racism and class bigotry, there was no YIMBY backlash.

We've commented before that much of the discussion of urban density, particularly on the advocates' side, tends to be overly simplistic and inappropriately moralistic. This last point is greatly complicated by the fact that historically the motivations for NIMBYism were more often than not pretty repugnant. Opposition to public transportation, low-cost housing, and integration of neighborhoods was based almost entirely on the desire to keep people of color and the poor as far away as possible.

These issues haven't gone away, of course – – try to add another subway stop in Beverly Hills and check out the response you get – – but the NIMBY/YIMBY conflict that makes the news and dominates the public discourse here in Los Angeles (and, I suspect, in the Bay Area as well) has very little racial and class component.

At best, the battle over Santa Monica is a struggle between the top decile and the top quartile. Sometimes, there's not even that much of a class distinction. To be hammer blunt, you have a bunch of well-off people who enjoy the fantastic weather and bland conspicuous consumption of the town and who don't want other well-off people coming in and clogging the place up.

Advocates generally argue that development will drive down prices both in the city of Santa Monica and in the county of Los Angeles. I'm skeptical. While I'm not saying this is a bad approach in general, the arguments I've seen so far seem simplistic and overly linear, and the proposed impacts wildly overoptimistic. I could easily be wrong on these questions but either way, this is not a moral argument and framing it in moralistic terms simply serves to cloud the issues.
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Tuesday, January 4, 2022

Simpsons > Good Will Hunting (mathematically speaking)

Mathematician Jordan Ellenberg breaks down Math films & TV shows





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Monday, January 3, 2022

Why I see SCOTUS packing as inevitable

This is Joseph.

I have, for a while, held the opinion that the US supreme court is almost certain to be packed. One thing that needs to be clear is that the US supreme court is, at least partially, a legislative arm of the government. After all, no law can stand in the United States unless it can pass judicial review. Like a lot of things, judicial review sounds simple until you put it into practice. 

Just look at how complicated the history and interpretation of the second amendment is.  Now imagine trying to apply this to individual cases. This is ok if there is a lot of judicial restraint but activist judges can quickly make things very complicated. 

Now look at recent cases like SB8 which seem to be tilted towards allowing certain, less favored, constitutional rights to be suppressed. Or the affordable care  act and Medicaid expansion, which is nearly a decade old and still seems questionable. Even Bush versus Gore pushed important boundaries. 

Now some of this is older law. What has changed? I argue the following

  1. Merrick Garland showed that the senate majority would keep a seat open for a year for a more favorable president (and if they will do it for a year then why not three? If your answer is shame look at point two)
  2. We also saw the senate speed a candidate through in the last two months of a congressional term a candidate on a 100% party line vote. 
  3. We also saw a strategic retirement to bolster the youth of the Republican justices, meaning a one-term president appointed one third of the court, people like to serve for decades. 
  4. With a narrow senate majority and a democratic president, the 83 year old senior liberal has ruled out senior status. 
  5. With the 6-3 court, we now have a part of the court (5 members) who appear to be abandoning a slow and cautious implementation of the conservative agenda and instead are becoming firebrands. 

Point 5 is probably the most controversial but see what the Republican appointed Chief Justice has to say about Whole Women's Health versus Jackson:

The clear purpose and actual effect of S. B. 8 has been to nullify this Court’s rulings. It is, however, a basic principle that the Constitution is the “fundamental and paramount law of the nation,” and “[i]t is emphatically the province and duty of the judicial department to say what the law is.” Marbury v. Madison, 1 Cranch 137, 177 (1803). Indeed, “[i]f the legislatures of the several states may, at will, annul the judgments of the courts of the United States, and destroy the rights acquired under those judgments, the constitution itself becomes a solemn mockery.” United States v. Peters, 5 Cranch 115, 136 (1809). The nature of the federal right infringed does not matter; it is the role of the Supreme Court in our constitutional system that is at stake.

To be clear, this is a George W Bush appointed conservative justice who is fine with the destruction of many cherished rights or programs of Americans on matters like healthcare and voting.  

Furthermore, the arguments against packing are so weak that they are embarrassing. Consider this one:

Term limits, by providing each president with two Supreme Court appointments in every four-year presidential term, would risk enmeshing the appointments in the presidential election cycle, further politicizing the appointment process.

It seems possible, even likely, that presidential candidates would announce their Supreme Court choices as part of the campaign, turning potential nominations into political fodder. 

Like does nobody remember these news stories?  

It is the way that these all tangle together that make me think that packing is now inevitable (just like ending the filibuster on SCOTUS nominations became inevitable when the stakes got too high). Holding seats open means that you'll get campaigning on court nominations. Loud decisions that make a big push, SCOTUS already defending themselves because they look political, and extremely long appointments mean that this will become a crisis, sooner or later. Packing is a sacred tradition in the US -- just ask why there is a North and South Dakota. 

Now could it all work out? Well, what stopped the last few crisis points. Well, Andrew Jackson decided to just ignore the supreme court, which seems like an unlikely strategy in the modern legal environment. Going into the civil war, SCOTUS was adamantly opposed to Lincoln but he ended up defusing the crisis by appointing FIVE justices (including an expansion of the court from none to ten justices -- later revised by Andrew Johnson to 7 and US Grant to 9). The court survived these court size changing schemes quite handily. The last major crisis point was FDR, where a single switched vote could matter. But that was a 5-4 court and we might already be seeing that switch with Chief Justice Roberts. 

This history is also why I am so annoyed about Breyer's retirement. If the court drifts 7-2, then it gets harder to imagine moderation on some of the more forceful decisions. CJ Roberts is hardly a friend of the left (bitter enemy is more correct) but he at least is willing to be incrementalistic and defuse confrontation with the other branches. But passing over a clean chance for a successor is mad. He is 83 and the oldest member of the court by a decade (Trump's 3 nominees are 49, 53, and 48 -- likely to be with us for 3 decades with these retirement ages). There are currently 3 retired SC judges (retired at 69, 75, and 82) -- all 3 appointed by republicans and all three strategic. The last three judges to die in office were: Ruth Bader Ginsberg (87), Antonin Scalia (79), and William Rehnquist (80). This is not an early retirement that is being suggested. 

Now consider this comment from him:

Justice Breyer made the point more broadly in his new book. “My experience from more than 30 years as a judge has shown me that anyone taking the judicial oath takes it very much to heart,” he wrote. “A judge’s loyalty is to the rule of law, not the political party that helped to secure his or her appointment.”

And now I return to where this all began. Interpreting the law is hard and words are inherently ambiguous.  It is quite compatible for a person to both believe they serve the law first and to have a view of the law that is favorable to a particular political movement. Sooner or later this will be an issue and I suspect we'll follow the footsteps of Lincoln and Grant. 

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Saturday, January 1, 2022

Happy New Year's -- Little Nemo grows up

Season's greetings from Windsor McCay.



Apologies for the formatting. Copy and paste for the full effect. (I hate blogger.)




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Friday, December 31, 2021

So would this be Happy Halloween een^297? *


* You do realize I just made up the number of days to Halloween, right?

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Thursday, December 30, 2021

Why the right to a lawyer is so important

This is Joseph.

I was talking to Mark and this video came up. One of the reasons why having a lawyer is so important is that mere civilians cannot be expected to know the subtle nuances of the law. 


One of the eye-opening moments of this video, at least for me, was discussing the consequences of the police making a mistake. The example of a mistaken identification contradicting your alibi is exactly the sort of complication that one really, really wants a trained professional to navigate. 

Here is a more complicated example via Ken White:

Imagine this scenario, based on an actual situation:
A business associate calls you and says, "my dear business associate, the shit has hit the fan; Federal Agency X is investigating Project Y we did together. Two Agency X agents are interviewing people."

"Oh coitus," says you, or words to that effect, and terminate the conversation.

Later that day, two well-dressed and polite agents of Agency X visit you. Because you despise me and want me to weep and gnash my teeth, you consent to be interviewed. At some point, they ask you "have you talked about this investigation with anyone?"

"No," you say.

They smile.

At the end of the interview, it occurs to you to ask, "Hey, am I in trouble? Do I need a lawyer?"

The agents smirk. "No," they say. "I mean, unless you lied about talking to anyone about this investigation."

See, you've fallen into a false statement trap, which I've talked about before. The feds know that you've talked to somebody about their investigation. They were probably standing next to your friend when he made that call this morning. And now you've talked your way into a felony.
This is the sort of fact that will come up in discovery and a skilled lawyer will know about. You don't need to worry about a failure of recollection or the proper interpretation of a discussion. Innocent error could easily be an explanation for the scenario above, but it becomes a felony. 

Lawyers are an important part of criminal justice and right to competent counsel is extremely important. Here are some more examples of how this can go wrong. I am not a big fan of the sociopath one, but the rest are all great examples of how unprepared discussion can go quite wrong. 
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Wednesday, December 29, 2021

Extrapolating out of range: education edition

This is Joseph.

Matt Yglesias had a post on the effects of closing schools on learning:
I think that if at any time pre-Covid someone had suggested that regular, in-person school attendance was not that important and kids would be okay just watching video lessons and doing online work, that would have been understood as a kind of right-wing techno-libertarian crank viewpoint. Thanks to the pandemic, though, we got to find out if the techno-libertarian cranks are right about school.

It turns out that they are not. In Virginia, for example, student test scores plummeted and the racial gap in scores exploded 

And we’ve seen this basically everywhere. McKinsey and NWEA found huge learning losses concentrated in poorer kids nationwide. Texas and Indiana reported big early test score declines. A study from the Netherlands indicated that during an eight-week period of virtual schooling, students learned basically nothing on average. 

and

For years, study after study has shown that the effect sizes of education interventions tend to be really small. And when they don’t look small, they tend to be very difficult to scale up. That led some people to infer that schooling is largely pointless. But we learned during the pandemic that if you try something out-of-sample like not having school at all, the effects are actually very large. 

I think that this example illustrates two major themes.

One, which we've been discussing for ages, is that it is very difficult to extrapolate data out of the range of observation. When there is effective teaching going on then small tweaks with how it is done seem can be challenging to show as having an impact. But let us be frank -- the human species has been educating children in numeracy and literacy for (literally) thousands of years. The Lyceum and the Academy were founded before the dawn of the Roman empire. China has been using exams to evaluate qualified graduates for centuries. Now there can be possibilities to use improved technology and such, but the basic idea is old and small tweaks have been tried for (literally) millennia. 

Two, is that disruption is often not focused on the basic delivery of services. Far more common is regulatory evasion. Uber evaded taxi regulations far more than it had a new idea -- taxi companies quickly mimicked the app, the innovation that they had trouble with was the ability of Uber to classify employees as independent contractors. Financial companies often do better by finding ways to evade regulation that protect investors than just finding better investments. [EDIT: In conversations with Mark, he pointed out the precise mechanism by which education disrupters can save money: fewer students with disabilities given the ADA. While this gap is closing, it is still the case that charter schools end up serving fewer students with disabilities than traditional public schools. Insofar as there is any strategy here, this could create a perceived efficiency gap]. 

It is this second point that always worries me with education reform. There is a lot of money in education, finding a way to skim 1% off of the top would be worth billions per year. When real progress is hard because a system has already been extensively optimized then one should be suspicious of claims of important advances, especially if there is a lot of opportunity for the investment to pay off for the "innovators" involved. Taking away 1% of educational spending and inflating a few numbers might well be a easy pathway to success.

But the first point is well worth remembering -- the system, as is, is already delivering a lot of value and taking it away shows immediate and large effects that reduce outcomes. These are despite the efforts of teachers and parents to continue online. 

Or, in other words, one can innovate but always be worried about the arguments that a system centuries in the making is fundamentally flawed. It might be for some areas (e.g., computer programming is relatively new and perhaps autoshop is less related to other crafting skills than I suspect) but this is not a place where the current equilibrium is obviously easy to beat. 

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Tuesday, December 28, 2021

The biggest problem in California right now is that we don't have enough fires

It's raining as I type this, snowing not that far from here. We've gotten lucky in the past couple of weeks and we are supposed to have another major storm before New Year's Day. All of this means that we desperately need to start planning as soon as possible for teams to go out into the forest and start some fires.

As Elizabeth Weil explains in her Pulitzer-worthy Propublica piece (which we discussed earlier here). [emphasis added]

Yes, there’s been talk across the U.S. Forest Service and California state agencies about doing more prescribed burns [a.k.a. controlled burns -- MP] and managed burns. The point of that “good fire” would be to create a black-and-green checkerboard across the state. The black burned parcels would then provide a series of dampers and dead ends to keep the fire intensity lower when flames spark in hot, dry conditions, as they did this past week. But we’ve had far too little “good fire,” as the Cassandras call it. Too little purposeful, healthy fire. Too few acres intentionally burned or corralled by certified “burn bosses” (yes, that’s the official term in the California Resources Code) to keep communities safe in weeks like this.

Academics believe that between 4.4 million and 11.8 million acres burned each year in prehistoric California. Between 1982 and 1998, California’s agency land managers burned, on average, about 30,000 acres a year. Between 1999 and 2017, that number dropped to an annual 13,000 acres. The state passed a few new laws in 2018 designed to facilitate more intentional burning. But few are optimistic this, alone, will lead to significant change. We live with a deathly backlog. In February 2020, Nature Sustainability published this terrifying conclusion: California would need to burn 20 million acres — an area about the size of Maine — to restabilize in terms of fire.

...

[Deputy fire chief of Yosemite National Park Mike] Beasley earned what he called his “red card,” or wildland firefighter qualification, in 1984. To him, California, today, resembles a rookie pyro Armageddon, its scorched battlefields studded with soldiers wielding fancy tools, executing foolhardy strategy. “Put the wet stuff on the red stuff,” Beasley summed up his assessment of the plan of attack by Cal Fire, the state’s behemoth “emergency response and resource protection” agency. Instead, Beasley believes, fire professionals should be considering ecology and picking their fights: letting fires that pose little risk burn through the stockpiles of fuels. Yet that’s not the mission. “They put fires out, full stop, end of story,” Beasley said of Cal Fire. “They like to keep it clean that way.”


Why is it so difficult to do the smart thing? People get in the way. From Marketplace.

Molly Wood: You spoke with all these experts who have been advocating for good fire for prescribed burns for decades. And nobody disagrees, right? You found that there is no scientific disagreement that this is the way to prevent megafires. So how come it never happens?

Elizabeth Weil: You know, that’s a really good question. I talked to a lot of scientists who have been talking about this, as you said, literally, for decades, and it’s been really painful to watch the West burn. It hasn’t been happening because people don’t like smoke. It hasn’t been happening, because of very well-intended environmental regulations like the Clean Air Act that make it harder to put particulate matter in the air from man-made causes. It hasn’t happened because of where we live. You don’t want to burn down people’s houses, obviously.

The term "controlled burn" is always at least slightly aspirational, and as the Western fire season gets longer and longer, our window for safe prescribed burns gets shorter and shorter. As a result, this may be the most urgent environmental action places like California need to take. If the weather takes a bad turn, a delay of two or three weeks can mean missing an opportunity to mitigate disaster in the Summer and Fall. 

We've missed too many already.

 

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Monday, December 27, 2021

Against feral disinformation, the very liars themselves contend in vain.

Feral Disinformation


Without feral disinformation and the cultivation of the lunatic fringe, we never would have had a Trump nomination. The Republican establishment was forced to accept a candidate whom they felt was extremely dangerous to the future of the party because the conservative movement had lost control of the narrative they created; it took on a life of its own.

Initially, Trump spread more more disinformation -- downplaying the severity and promoting worthless cures -- because that approach appeared to help him politically. Now, it is in his advantage to take credit for the vaccines and their impact, but the narrative kept evolving until even he isn't allowed to correct the lies he told.




FRIDAY, JULY 23, 2021

Feral Disinformation

Another one for the lexicon.


Disinformation has gone feral when:

1. It is no longer in the control of the group that created it.

2. It has continued to grow in popularity and influence.

3. It has started to evolve in such a way that the nuisance/threat it presents is as as great to the people who created it as it does to the original targets. 

The most prominent example of the moment is the right wing movement opposing covid vaccines and increasingly vaccination in general. 

The Conservative Movement spent decades depicting the scientific establishment as alarmist and corrupt because undermining it served a clear political purpose at the time. Recently this narrative took on an added usefulness as the Republicans tried to contain the fallout from the pandemic. It was an unspeakably evil position to take, greatly adding to a horrific death toll, but it had a certain ends-justify-the-means logic, "had" being the operative word.

In 2021, being the anti-vax party is not in the Republicans' best interest. It devastates  areas that voted for Trump and it makes the most comically crazy people imaginable the face of the GOP. On top of that, it's bad for business. 

The best messaging for the Republicans at this point would be to start referring to the "Trump vaccines" and to work the phrase "Operation Warp Speed" into every statement and interview response, regardless of topic, then take credit for the end of the pandemic. That is, however, not an option. Control of the narrative has been lost, Things have gone feral.

Over the past the past week, the GOP establishment made a coordinated effort to move away from this disastrous message. 


The pivot is not going well.
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Saturday, December 25, 2021

Merry Christmas from Little Nemo

  



















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Friday, December 24, 2021

"Albert and Pogo's Christmas" by Walt Kelly

 


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