Increasing Affordability Key to Increasing Health Care Access

For anyone with time to spare, I highly recommend an article by eminent surgeon and recent MacArthur “Genius” Atul Gawande over at the New Yorker (it’s more than 6,000 words and eight pages long — enjoy!).

Gawande discusses the sobering data on our national health care spending, investigates the sources of skyrocketing costs, and sketches some general solutions that the public should keep in mind. Primarily, Gawande argues against the overutilization of medicine, and the excessive use of medical services.

When comparing areas of differing average health care costs, he found that areas of high Medicaid per-patient spending utilized, on average, 20 percent more diagnostic tests. Ironically, the data suggests no positive correlation between spending and quality of care, and even implies that average quality of care per several metrics decreases as per-patient spending rises!

Gawande further suggests that the current structure of incentives for doctors, one based on quantity as opposed to quality, is non-conducive to sustainable costs. He writes:

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later?

Gawande looks to successful, low-cost cities and care networks such as the Mayo Clinic for answers, and he advocates increased cooperation among the community of care providers to best provide transparent, accountable care.

Only so much space is afforded me here, so I will leave you to read the article and simply note that, as the nation descends into a pivotal debate over health care plans, HMOs, doctors, legislators, and common citizens should look beyond “public vs. private vs. co-op.” Rather, what matters most at this juncture  is not who pays (although that’s certainly important), but how much they pay. After all, the first step to making health care more accessible is to render it more affordable.

L.A. Times Charter School Debate

For the past few days, the L.A. Times has run a threepart debate about charter schools. It’s written in a point-counterpoint format by Lisa Snell, director of education and child welfare at the Reason Foundation, and Ralph E. Shaffer, professor emeritus of history at Cal Poly Pomona.

Be sure to read each of the three installments:

This is the kind of debate that’s actually worth having — one that relies on data and careful argumentation, rather than bluster and hand-waving.

Upcoming Friedman Legacy of Freedom Event

Please stay tuned to Show-Me Daily for updates regarding our third annual celebration of The Friedman Legacy of Freedom, which will be held at Washington University and will be cosponsored by the Friedman Foundation for Educational Choice. Our featured special guest speaker is Kevin Chavous, a prominent lawyer, politician, and school reform champion who has authored the book Serving Our Children: Charter Schools and the Reform of American Public Education.

Here’s an interview with Chavous that we’ve linked to before, in which he explains how school choice became such an important issue for him while serving on the D.C. City Council.

Building Codes, Your Thoughts Please …

I support the right of local government to enforce building codes if the citizens in those areas want them. Yesterday’s deck collapse in Wildwood has this issue in the news, and since nobody was seriously hurt, thank God, we can discuss building without being macabre. I would be interested if any of our more libertarian writers or readers wanted to argue against building codes in the comments section. I know that some libertarians, at least, are opposed to them.

Unfortunately, Missouri has a rather prominent history in the area of structural collapses. Those painful memories might explain why the Kansas City Star is covering a relatively minor deck collapse in St. Louis. I support the use of building codes because they fairly fit into a strict definition of “health, safety, and welfare,” and I think there is a legitimate government interest in making sure buildings are built safely. Opponents of a smoking ban quite correctly say that smoke, unlike E. coli, is plainly visible when you choose whether or not to enter a restaurant, and as such you are free to make a personal choice. It is not reasonable to expect someone to review the conditions of every structure they enter before they set foot in it.

Now, let’s be clear, here. The hotel tragedy and arena failure linked to above were obviously constructed under codes and approved by inspectors, so no system is perfect. And we have no idea, yet, whether the deck in Wildwood was permitted and inspected, or whether it was built on the sly. A recent tragic deck collapse in Chicago occurred on a deck built without permits, so obviously these terrifying things can happen under any system. But, if a permitting and inspection system makes them less likely, and the citizens of a community choose to have codes, then I don’t think anyone’s rights are violated by building codes and I support their enforcement.

From the article mentioning libertarian attitudes about building codes, in the first paragraph:

* Libertarians will allow creation and enforcement of voluntary building codes. Government-imposed building codes are coercive invasions of human liberties and need to be speedily eliminated. But what, if anything, will take their place?

Trusting the courts and arbitration to settle property disputes in place of zoning is one thing. I don’t necessarily agree with it, but it makes some sense. But trusting that everyone will construct property up to safety standards because they might be sued if someone dies when the roof collapses is a little nuts. I’ll note that the engineers in the Kansas City hotel collapse were successfully sued and lost their licenses, but they were not criminally charged. The arbitration panel doesn’t do you any good if you get impaled on a rod in a collapse.

I would like to criticize the redundancy — certainly intentional — of having both strict building codes and strict licensing of tradesman. One, or perhaps the other, can do the job the government is looking for, but you really don’t need both. Either license people beforehand to make sure the work is done right, or carefully inspect if after it’s done to make sure, but you don’t need to do both. In our largest cities and counties in Missouri, we have both, and the reasons for this have more to do with political power and union control than public safety.

Districts of Choice

The California legislature is considering whether to extend its inter-district public school choice program. I completely agree with this statement from the L.A. Times editorial supporting choice:

The best possible education for students should take precedence over attendance boundaries.

It would be great if Missouri were to follow suit, create districts of choice, and allow families to choose public schools without regard to street addresses.

St. Louis has the Voluntary Inter-District Transfer Program, but it doesn’t go far enough. For one thing, the eligibility requirements restrict choice to certain groups. Why shouldn’t a white, Asian, or Hispanic city student have the same choice as an African-American student to attend a suburban school? The situation is reversed in magnet school admissions, in which African-Americans are reduced to the lowest priority level. These admissions distinctions reflect someone’s idea of the “right” racial mix for certain schools — an idea that I find very distasteful, to say the least. Restricting educational options by racial group is even more repugnant than limitations based on address. It also makes no sense in a diverse city that’s home to many multi-racial families.

In addition to the race issue, the Transfer Program is inadequate because it doesn’t present parents with enough choices. Parents can choose to participate, but once they do they have little say in which suburban school their children will attend.

It would be difficult to institute a broad public school choice program in Missouri, because districts are wary and parents are used to the way things are. One small step would be to streamline the magnet school admissions process, doing away with tiers and racial preferences. Allow any child from the city or county, regardless of race, to enter the magnet school lottery on an equal footing with other students — or to enter a lottery for other SLPS schools. SLPS could then have the distinction of being Missouri’s first true district of choice.

Honey, I Shrunk the Legislature

A very encouraging post on the Freakonomics blog today mentions that the Maine state legislature recently proposed a bill that would unify the state’s Senate and House into one representative body, making Maine the second state in the union to go unicameral. Unfortunately, the Maine Senate voted it down.

I call this event unfortunate not just because of the obvious benefit of reduced government expenses (some predicted that moving to a unicameral measure in Maine would save taxpayers a whopping $11 million per two-year legislative session), but because the current bicameral system is truly redundant.

According to this Wikipedia entry, it used to be the case that:

[T]he basis of representation in most state legislatures was modeled on that of the U.S. Congress: the members of the smaller chamber represented geography and members of the larger chamber represented population. In 1962, the United States Supreme Court announced the one person, one vote standard and invalidated state legislative representation based on geography. (One person, one vote does not apply to the composition of the U.S. Senate because that chamber’s makeup is prescribed by the U.S. Constitution.)

So, we now have a case in which 49 states have two houses serving the same purpose: per-capita representation. Nebraska — the one place where this good idea of house unification has taken place — has also adopted nonpartisan elections. The best explanation I have heard for why nonpartisan elections are a bad idea came from David Stokes: Political parties provide a general identification of a particular candidate’s political stances, and help voters save precious time obtaining information about every person on the ballot. Stokes has also written about the problems with nonpartisan elections, as well as ways to improve the cost-effectiveness of state government — right here in Missouri.

Livestock Registry Plan Misguided

The National Animal Identification System (NAIS), bureaucratic brainchild of the U.S. Department of Agriculture, mandates identity registration for livestock to allow for centralized tracking and oversight in the event of disease outbreak. The policy may be well-intentioned, but its stated goals don’t justify the incursion into private life, erosion of liberty and livelihoods, and the increase in prices that it would undoubtedly foster. The program calls for livestock owners to furnish federal databases with personal information: their name, home address, telephone number, and the GPS coordinates of their home. Further, if these owners wished to transport the animals outside of their birth farm for any reason (even on a trail ride or to a fair), the animals would need to be biochipped and registered to a federal identification number. It’s no wonder this policy has been the target of recent protests in Jefferson City.

Given that compliance costs for this program are relatively high, smaller farms will close down, farmers will lose their livelihoods, and larger farms will pass on their costs to consumers in the form of higher prices. All for what? Farmers and livestock research organizations argue that the spread of disease is not even initiated at the level of the farms, but rather at meat processing plants, so this policy is misguided not only in implementation, but also in its conception.

Charter School Results Getting Federal Notice

I came across this story about charter school advocates being heard by the House Education and Labor Committee in Washington, D.C.

One of the wonderful points of focus in this piece highlights the benefits of charter innovation, which can then be adopted by other schools. This is precisely the sort of progress promised by charter school advocates.

Particularly encouraging is the following quote:

“Outstanding charter schools are proving that low-income and minority kids can achieve at the highest levels, graduate from college and thrive as adults,” said U.S. Rep. George Miller (D-CA), chair of the committee.

With the data on the side of charter advocates, the movement toward more charter schools is happily gaining inertia.

“Everything’s Up for Counting in Kansas City”

Recalls, recounts, references to songs in Oklahoma — things are a mite bit interesting in Kansas City, wouldn’t you agree, Will Parker?

We have so far avoided commenting on the Kansas City mayoral recall; it’s just a bit too political for us. Speaking just for myself, if I lived in Kansas City I don’t think I would have signed the recall petition. I just don’t see how the Mayor’s actions and problems have risen to the point where he should be removed from office before his term is up. But I certainly support the constitutional/charter rights and use of referendum, recall, initiative, etc., so if the people of Kansas City want to engage in their right as citizens to have a recall election, then I admire their active participation in democracy — even though I don’t necessarily agree with the recall leaders on this exact issue. …

Who knows? A recall election could be a lot of fun. Maybe Paul Rudd could announce that he is running for mayor on the “Tonight Show”? Or Jason Whitlock could announce it on “SportsCenter”! There is no end to the potential fun!

Some of Kansas City’s quirks are coming to light as part of the recall. You might be aware that the recall petition has fallen a few signatures short of qualifying, and its organizers are fighting for a recount of the recall signatures. One of the tricks to the whole process is that they have to deal with four different election boards.

Did you know that Jackson County is one of 34 counties in the country, and the only one in Missouri, with multiple county seats? Independence and Kansas City both serve that role, and Kansas City is the only county seat in Missouri, and probably one of the few in the country, to be the county seat of one county while existing within several counties.

Because Kansas City has to deal with four election boards, and different election officials are giving different counts in the Star article, it is not crazy to wonder whether different standards are being applied by different boards to certify the petitions, and whether those different standards are having an effect on the process. It’s like Florida in 2000! Or maybe it’s not, because you would think the rules are pretty clear as to what the election boards are supposed to certify. And, although I keep referencing four election boards, KC’s population in Cass County is so small that it appears the petitioners didn’t collect any signatures there, so really only three counties are involved.

This whole post was really just an excuse to get into the comparative politics of Kansas City and Jackson County, which is interesting to me and hopefully a few other people. I will have a lot more coming out soon in a study of the many differences between how Kansas City and St. Louis operate their respective governments. The two areas are about as different as they can be for cities in the same state.

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