Outcomes

If you are at all interested in the health care debate, read the New Yorker article by Atul Gawande on health care costs. He examines McAllen, Texas, a community that has Medicare costs per person that average $15,000. This is twice the national average and three times some of the lowest cost areas. His core finding is that these costs don’t relate to the relative health of the community or quality of care, or even bad administration, fraud, or waste. It is all about how doctors are reimbursed and the culture of medical practice in that area.

In our system doctors generally are reimbursed by procedure. Do an MRI and the cash register rings. Blood test, ka-ching. Colonoscopy, ka-ching. Sit down with a patient for extra time and discuss their medical history in depth, no ka-ching. Get advice from a colleague without referring the patient for a procedure, no ka-ching.

Gawande found that the hospitals with the lowest cost per patient were ones that set up cooperative structures for the payment of their doctors, encouraging communication and mutual assistance and discouraging excessive procedures. Patient health outcomes were just as good or better than high spending institutions.

Well, here’s a thought: reimburse doctors according to patient outcomes. That’s what we actually want, right? Not a number of tests, but an actual improvement in the functionality of our bodies.

Modern medicine is a numbers game, after all. When we enter the medical system we get interviewed, tested, and our condition quantified. Depending on the affliction, medical personnel might establish dissolved oxygen in our blood, range of motion in a limb, our heart rate response to exercise, or the concentration of any number of chemicals in any number of tissues. This is then compared to what is considered normal for someone of the patient’s age, gender, and general condition. There are also more subjective tests of comfort and range of abilities.

When reimbursing a doctor we should consider the condition of the patient at intake and compare that to the condition of the patient over a time period relevant to the common recovery period for the particular injury or disease. Add a difficulty factor, as in Olympic diving. During a transitional period we should slowly reduce reimbursements for procedures and increase an outcome bonus. We should distribute that bonus among a group of doctors that work with the same hospital or in a limited geographic area. That would encourage doctors to collaborate and also to police their underperforming colleagues.

The exact formula for this kind of reimbursement is beyond the scope of this essay and, frankly, beyond the knowledge base of your Minor Heretic. But doesn’t it make sense to reward our health providers for making us healthy, rather than making us endure yet another procedure?

The Economics of Quality

I just read in a news report that if our economy keeps going the way it is now, the U.S. will post a 5.7% drop in GDP by the end of the year. This is, of course, considered dire. In contrast, the GDP of China is on course to grow by 6% this year, down from their usual 8-10%, but still firmly positive. The lucky bastards. Or are they?

GDP, or Gross Domestic Product, is the grand sum of all the goods and services bought and sold in the U.S. in a year. The measurement was formulated during the great depression of the 1930’s as a rough indicator of how well the economy was recovering.

It is not an original thought to point out that GDP is a speedometer, not a compass. When someone has a fender bender in a parking lot, that increases GDP, as do tornadoes, cancer, and a host of other undesirable events that cost people money. It doesn’t indicate anything about income distribution or the ability of ordinary people to pay their bills. Various other indicators of the well being of society have been proposed, but the mainstream media, politicians, and the general public remain fixated on GDP, often referred to simply as “the economy.” The economy speeds up and we cheer. It slows down, and everyone is worried.

It is also not an original act to point out that we live in a limited environment, with diminishing amounts of fossil fuels, minerals, forests, arable land, and fresh water. One would think that more people would make the connection that an eternally growing economy is a planetary impossibility. One would be wrong.

I’d like to point out a different direction for our economy, what might be called the Quality Economy. It involves focusing on the quality of production rather than mere quantity.

Our present system is focused on quantity. Great quantities of raw materials are shipped across oceans to Asia where they are transformed into mountains of mostly cheap, disposable goods. It is profitable for manufacturers to maximize the flow of goods. This is achieved through favorable trade laws and currency exchange rates, sweat labor, and planned obsolescence. But what does this really get us?

Some seriously underpaid, unskilled schmuck in Shanghai spends seven 12-hour days a week pulling injection molded plastic chairs out of a machine, while slowly dying of chemical poisoning, malnutrition, and overwork. The chairs get shipped in bunker-fueled cargo vessels to the U.S., where they end up getting stacked in a Wal-Mart by some other underpaid, unskilled schmuck. A third underpaid, unskilled schmuck whose father used to build furniture buys these ugly, flimsy chairs. They break within a year and he has to go buy more. Shanghai Plastic Chair Co. makes money, Shipping Inc. makes money, and Wal-Mart makes money, but everybody else loses.

Consider instead an economy where a skilled worker in Shanghai makes wooden chairs for people in Shanghai and a skilled worker in, let’s say, Des Moines Iowa, makes wooden chairs for people in Des Moines. Both workers can get paid a living wage for what they do. Being skilled, they have more unique economic value and therefore more economic power and control over their work environments. They will probably feel better about what they do. They will be able to afford the products of other local manufacturers. The chairs will last longer, reducing resource flow from the environment and pollutant flow to the environment. Shanghai Plastic Chair Co., Shipping Inc. and Wal-Mart lose out, but my heart does not bleed for them.

The end result is that GDP could stagnate while the lives of people here and abroad could improve. Granted, the chair example is simplistic, but the overall strategy is to go in the opposite direction of the standard economic wisdom. The trend in industry for the past two centuries has been to reduce the number and skill level of workers. The more recent trend has been to send manufacturing jobs to countries with the lowest wages, least worker rights, and lowest environmental standards. This has maximized the flow rates of materials and capital at great expense to humanity.

One objection to this concept is that it will lower productivity. We worship productivity, but what does it really mean? It is dollars of output divided by hours worked. Note that the variable we are supposed to increase is “dollars,” without any indication of the quality of what was done or its value to society. Today, greater productivity means that you work harder so that a shareholder somewhere else can make more money. Increases in productivity haven’t been matched by increased wages for workers in the U.S. for the past 30 years.

Another objection is that most people can’t afford quality. I would counter that none of us can afford quantity. In a recent essay I discussed how globalization and outsourcing is sinking this country in debt. Our vast consumption of cheap sweatshop goods is unsustainable in terms of economics, the diminishing supply of resources, and the environment. A generation or two ago, American factory workers manufactured goods that were sold to other American factory workers. We could do that again.

And don’t tell me, a la Thomas Friedman, that the world is “flat,” in terms of global trade. Last time I checked we were a sovereign nation, capable of deciding what can and cannot pass over our borders, and under what conditions. We don’t have to be part of NAFTA or GATT. The world can be as flat or as bumpy as we want it to be. It will take some significant political change to get Congress out of the pockets of Wal-Mart and Shipping Inc., but that has to be done anyway.

I’ll leave you with a photo of something I made a while back.

Your Minor Heretic started out as a blacksmith. I apprenticed to a master smith right out of high school, working for room and board. He taught me how to take fifty cents worth of steel and a few hours and make what he called “house jewelry.” The item above is a Suffolk style door latch, hammered out of a few inches of half-inch square stock. It isn’t the best thing I’ve ever done, but you could put that on a door and it would be there for your great grandchildren. It isn’t a massive amount of material, but it contains a great deal of labor and skill. It epitomizes what we need to do with our economy – apply a great deal of knowledge, skill, and labor to limited resources to produce things of lasting quality.

Judge Sotomayor, meet Dick Deadeye

(With apologies to legal scholars for my simplifications and thanks to my father for a tutorial on appellate procedure)

I have been following the news of the nomination and confirmation process of Judge Sonia Sotomayor. The howling from the right wing politicos and punditry brings to mind a character from Gilbert and Sullivan’s musical H.M.S. Pinafore, namely Dick Deadeye. Here’s the explanatory passage from the libretto:

BOATSWAIN. Well, Dick, we wouldn't go for to hurt any fellow-creature's feelings, but you can't expect a chap with such a name as Dick Deadeye to be a popular character — now can you?
DICK DEADEYE No.
BOAT. It's asking too much, ain't it?
DICK. It is. From such a face and form as mine the noblest sentiments sound like the black utterances of a depraved imagination. It is human nature — I am resigned.

The running gag is that Deadeye utters commonplace statements that reflect reality, whereupon the rest of the cast recoils from him in horror. My comparison is no comment on Judge Sotomayor’s actual face and form; her appointment by President Obama and her political position somewhere to the left of Newt Gingrich serve as her appearance to the conservatives. For some right wing-nuts her gender and ethnicity are strikes against her. She could express a fondness for the American flag and they would find an excuse to stick in their knives.

One of their key attack points was a conveniently edited tape of her saying that the courts are where policy is made. She was joking, of course, and the full tape (See below) exonerates her from the charge of advocating legislation from the bench. Nevertheless, she spoke a kind of truth, a truth that legal professionals would recognize.

The courts of appeal are the arbiters of the meaning of laws. Some laws are definitive, like speed limits, but others are complicated or vague enough to require interpretation. One of the basic tasks of an appellate court is to determine whether the law applied in a lower court case was actually appropriate to the evidence presented. The judges in these courts, as Sotomayor stated in her now-famous quote, have to think about the general application of the law as well as the case at hand. The higher courts also accept or reject laws based on constitutional precedent. An appeals court or Supreme Court judge cannot escape this interpretive duty. Some like to claim that they are originalists, sticking to the intent of the framers of the constitution. Aside from the historical mind reading problem, our forefathers used words such as “unreasonable,” “excessive,” and “cruel.” Somebody has to decide what those words mean today, and that alters the effect of a law in practice.

The right wing will continue to heap abuse upon Sotomayor for saying and doing what other judges have said and done. Her opponents don’t seem to have comprehended the near-instantaneous fact checking available online, along with the ability of her supporters to post full length quotations and video clips, both of her and of conservative judges caught in the act of saying the same sorts of things. Barring a black swan event, her nomination will go through, after some obligatory heel-digging by the Republicans. I predict that her credibility will increase as her opponents continue to make themselves look foolish.

DICK DEADEYE. Ah, it's a queer world!
RALPH RACKSTRAW. Dick Deadeye, I have no desire to press hardly on you, but such a revolutionary sentiment is enough to make an honest sailor shudder.

H.446 – The Vermont Energy Act of 2009

 I’d like to put in a plug for H.446 and a request to my Vermont readers to act. H.446 is a groundbreaking piece of legislation that will promote the development of renewable energy in Vermont.

The core of the bill is what is called a feed-in tariff or standard offer for renewable electricity. What this means is that utilities will be required to pay a fixed contract price for wind, solar, biomass, and hydroelectric power. The Public Service Board will set that price as follows:

“(II) The board shall include a rate of return not less than the highest rate of return received by a Vermont investor-owned retail electric service provider under its board-approved rates as of the date a standard offer goes into effect.

(III) The board shall include such adjustment as the board determines to be necessary to ensure that the price provides sufficient incentive for the rapid development and commissioning of plants and does not exceed the amount needed to provide such an incentive.”

In other words, whatever the cost of solar electricity from the panels on your roof, the price you get must ensure that you will make as good a return as the big boys with their coal and nuclear plants. The prices will start out fairly juicy and go down over time as the technology gets cheaper. This will motivate people to put in renewables sooner and lock in good prices. It puts renewable energy, especially solar and small wind, in the “stupid not to do it” category of investments.

Germany was the leader in this, enacting a feed-in tariff back in 1991, but only for wind and hydro. That was expanded to all renewable sources in 2000. The German government wanted to get 12% of the country’s electricity from renewables by 2010. They already have hit 15%. Germany has become the number one country in the world for green energy investment and has created hundreds of thousands of jobs in the industry.

And the cost to ratepayers? In Vermont it will add about 20 cents to a $100 electric bill. Not a bad price for weaning us off polluting and unsustainable energy sources and jump-starting a job creating industry. In addition to the feed-in tariff, the bill has a number of other useful measures. Quoting from Renewable Energy Vermont’s legislative page:

“Key items in the bill include:

• a standard offer for renewable energy
• clarification that thermal energy fits within the purview of the CEDF
• regulatory incentives ensuring utilities can recover permitting costs for renewable energy
• requirement that ANR reconsider its policy prohibiting wind on State lands
• improvements to residential- and commercial-building standards
• pilot downtown-community renewable-energy projects in Montpelier and Randolph
• clean energy assessment districts that would allow towns, cities, and incorporated villages to use municipal bonds to finance residential renewable-energy or energy-efficiency projects
• limitations on the power of municipalities and deeds to prohibit residential installation of renewable-energy and energy-efficiency devices, such as solar panels, residential wind turbines, and clothes lines”

Of course, Governor Doorstop, er, Douglas, is expected to veto the bill. It passed the Vermont House and Senate by reasonable, but not veto-proof majorities. It is time to make calls and send letters and emails. Send a brief, polite note to the Governor, asking him to sign H.446, although it will be a mere formality with Entergy’s man in Montpelier.

Here’s a link to Renewable Energy Vermont with links to your Rep and Senator’s vote on H.446 and how to contact them. Please do.

Update on Monday, June 1, 2009 at 10:03PM by Minor Heretic

Apparently Governor Douglas was expecting a veto override vote - he just let the veto deadline slip by. H.446 is law in Vermont. This is a big deal for the solar business in Vermont in the short term and the state's energy future in the mid to long term. Someday we are going to thank the legislators of 2009 for enabling the timely installation of the only affordable power sources we will have.

Inalienable rights, unacceptable wrongs

First, it bothers me that I feel the need to write this at all. I suppose the work of humanism is never done. You’d think that the issue of torture, what it is and why it is wrong in all cases, would have been laid to rest a few years ago, if not a century ago, but some people still seem to need reminding.

Torture, as defined by Merriam Webster: the infliction of intense pain (as from burning, crushing, or wounding) to punish, coerce, or afford sadistic pleasure. (from Latin tortus, past participle of torquēre to twist)

The United Nations Torture Convention of 1984 defines it as: "Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity." Why the definition is restricted to public officials is beyond me.

The Inter-American Convention to Prevent and Punish Torture, a treaty among nations of the Organization of American States, is broader in its definition: For the purposes of this Convention, torture shall be understood to be any act intentionally performed whereby physical or mental pain or suffering is inflicted on a person for purposes of criminal investigation, as a means of intimidation, as personal punishment, as a preventive measure, as a penalty, or for any other purpose. Torture shall also be understood to be the use of methods upon a person intended to obliterate the personality of the victim or to diminish his physical or mental capacities, even if they do not cause physical pain or mental anguish.

The treaty also notes that, “The fact of having acted under orders of a superior shall not provide exemption from the corresponding criminal liability.”

Also: “The existence of circumstances such as a state of war, threat of war, state of siege or of emergency, domestic disturbance or strife, suspension of constitutional guarantees, domestic political instability, or other public emergencies or disasters shall not be invoked or admitted as justification for the crime of torture. Neither the dangerous character of the detainee or prisoner, nor the lack of security of the prison establishment or penitentiary shall justify torture.” I should note that the U.S. is not a signatory to this treaty.

This definition makes sense. Torture can be gory and immediate, or subtle, long term, and mostly psychological. The definition is inherent in the act, not the victim, not the perpetrator, and not the situation. Pared down to its clinical extreme, torture could be defined as the deliberate application of aversive stimuli to degrade a person’s physical and/or mental state.

The two latter definitions I mentioned above also have clauses exempting incidental suffering resulting from lawful penalties such as imprisonment. Doing time for armed robbery is unpleasant, but it isn’t torture.

It is the understandably broad sweep of these definitions that makes former Attorney General Michael Mukasey’s evasiveness about waterboarding so vile. It also renders the present debate offensive. It is all torture, from the sleep deprivation and stress positions to waterboarding and worse. There are varying degrees of severity, but one standard of immorality.

Having laid out internationally accepted definitions of torture, I’d like to discuss why it is wrong in terms of its purpose and our constitution.

History has demonstrated the ineffectiveness of torture as a means to obtain accurate information. People under torture, or just the threat of torture, have confessed to a variety of things they never did, and have accused others similarly. The era of persecution of people for witchcraft, roughly 1480 to 1710, saw endless confessions of supernatural deeds, sexual intercourse with the devil, and the naming of innocent persons as accomplices. Military and intelligence service experts who have been studying and practicing interrogation for decades have declared repeatedly that coercive methods are not only ineffective but counterproductive in obtaining accurate information.

So if it doesn’t produce accurate information, then what is the purpose of torture? As I have written previously, it is a form of terrorism. Terrorism is the use of violence (or threat of violence) to induce fear in order to achieve a political goal. Torture is intended to become public, despite the pseudo-secrecy surrounding it. If the innocent suffer along with the guilty, it is all the more effective at suppressing opposition. And that is its primary function: making people afraid to oppose a government or political movement. It has a secondary function as well; eliciting false confessions to justify government actions. Frank Rich wrote recently in the New York Times about the Bush administration effort to connect Iraq with Al Qaeda, using torture when legitimate methods didn’t produce the desired results.

The use of torture strikes at the heart of our Bill of Rights. The fifth amendment to the constitution states, in part, “…nor shall be compelled in any criminal case to be a witness against himself, nor be deprived of life, liberty, or property, without due process of law…” The framers of the constitution put in the clause against self incrimination particularly because of their abhorrence of torture. They were not far removed from the widespread use of torture in Europe, especially during religious conflicts. If defendants could be required to confess, then there would be an open invitation to coercion. Torture also circumvents our right to due process. The eighth amendment prohibition against cruel and unusual punishment would bar torture by itself, but torture is punishment before proof of guilt. Presumption of innocence and due process are principles vital to our judicial system, and torture annihilates them.

We have heard much quibbling about the status of detainees. Are they prisoners of war, or “unlawful combatants,” or just prisoners? This debate is irrelevant. The principles enumerated in the fifth and eighth amendments are not right because they are in the constitution. They are in the constitution because they are right. They were right yesterday, last year, a century ago, and before the Egyptians built pyramids. They are right in Guantanamo Bay, in Kabul, and down at your local police station. They are right for all 6.2 billion people on the planet, including those Guantanamo detainees and you.

That is why we need to prosecute torturers and all the people in the hierarchy who gave orders to the torturers. Torture is not new to this country, but in the past it had to be done off the books, with deniability for upper level personnel. The Bush administration was the first to try to justify the practice. The Yoo and Bybee memos were attempts to legitimize the unacceptable, to institutionalize the unconstitutional. It is not enough that they are out of power. Senator Leahy’s concept of a truth commission is inadequate. The Department of Justice under the Obama administration must drive the concept of legitimized torture into the ground and firmly reestablish the rule of law.

If we allow the constitution to be trampled and the torturers to go free, then who are we as a nation, really? A nation of laws, or of men? If we are a nation governed by the whims of those in power, and whose laws are enforced according to political expediency, then our conflict with despots and terrorists is one of tribalism, not principle. At this moment we are merely the Taliban with better plumbing. .