Saturday, September 13, 2014

Consumer choices vs. Community choices

I came across this quote in Ravitch's book.  It's part of a discussion of school choice, but I think it applies to Oregon measure 90 as well.  Emphasis mine:
The market undermines traditional values and traditional ties;  it undermines morals, which rest on community consensus.  If there is no community consensus, then one person's sense of morals is as good as the next, and neither takes precedence.  This may be great for the entertainment industry, but it is not healthy for children, who need to grow up surrounded by the mores and values of their community.  As consumers, we should be free to choose.  As citizens, we should have connections to the place we live and be prepared to work together with our neighbors on common problems.  When neighbors have no common meeting ground, it is difficult for them to organize on behalf of their own self-interest and their community.
What is the top-two concept but an attack on political parties?  And what are political parties but the vehicle by which residents organize and collaborate for political activity?  I think parties are exactly the common ground Ravitch references above.  Without that common ground, we're just a bunch of individuals screaming in the wind.

Sunday, September 7, 2014

Elected Officials are not Cheeseburgers

I think there are multiple reasons to dislike this Oregon's ballot Measure 90, which would create a top two primary.  It essentially discards our current system by doing away with primaries as we know them, moving the real election to May, and relegating November to a mandatory runoff.  It tosses out a century of work at opening party primaries, replacing them with an amorphous endorsement process whose value is unclear.  If current party primaries are bad because of limited participation, how much worse will an endorsement process be which has no rules or customs?  If most people don't vote in the pre-election now how many will vote in the pre-pre-election?  And for what?  To tread water on overall voter participation?

But I want to focus on one particular aspect of arguments for Measure 90, the idea that it increases competition and that this is unambiguously good. A recent Oregonian editorial was dedicated to the concept, and it's a common element in arguments for the measure.  But is it right?  Is an uncompetitive election necessarily bad?

We have good reason to take the idea for granted.  For most consumer decisions it holds true, having more choices allows a more specific decision that better aligns with our preferences.  The more restaurants that serve cheeseburger, the more likely it is that one of them serves the exact combination of product and price that you want.  But are elected officials like cheeseburgers?  Not really.
  • The decision to buy a cheeseburger is individual, one person makes the choice and immediately gets what they asked for.  Elections are a community decision.  Votes are cast by individuals, but they are cast for one office and only one individual wins.  In the end everyone will be served the same thing.
  • The timing of the decision to buy a cheeseburger is entirely at individual discretion.  One can buy cheeseburgers as often as one wants, it can be centennial or hourly or anywhere in between.  Elections are on fixed schedules and the decision generally lasts for a fixed term.
  • Cheeseburgers have a price constraint.  That constraint overrides any other preference, one cannot buy what one cannot afford.  The price constraint doesn't apply to voting, there is no cost to choosing one candidate over another.
Put those elements together and think about what a cheeseburger decision would look like if it had the same properties as an election.  Communities would decide by majority rule what cheeseburger everyone would have to eat, over a term of years.  They would have to make this decision without a cost constraint, so any topping, ingredient, style, or quality level would be allowed.

That would be a miserable decision even for just a married couple.  It would be miserable because in effect the only reason one couldn't get their "dream burger", one that matched exactly to what they wanted, would be the constraint of getting their spouse's agreement.  And the spouse would have the exact same problem.  Now expand the voting pool to an entire community and you can see why elections are contentious, even violent, things.  Unlike the individual's decision to buy a cheeseburger, I think communities need some structure to effectively reach a decision.  That's where parties and primaries come in.  They facilitate coalitions and compromises, they provide organization to what would otherwise be a war of all against all.

As an example of how this plays out consider approval ratings.  Who would you guess has higher ratings, an incumbent running unchallenged or a newly minted freshman who won a narrow victory?  Which election did the public feel better about, George W Bush's ultra-narrow victory in 2000 or the dominant wins by Reagan in 1980 or Obama in 2008?  The closer an election, the more competitive it is, the more people necessarily are unhappy with the outcome.

When measure 90 supporters uncritically support competition they are using the wrong model.  Elections aren't consumption decisions, elected officials aren't cheeseburgers.  An election is much more like a hiring decision, the community is hiring someone to do a job.  Competition isn't totally irrelevant to making a good hire, but it's significance depends on the circumstances:  is it an open position or already filled?  If the latter is the person competent?  Are they so incompetent that it warrants firing them in favor of an unknown?

Looking at it that way it's easy to see why many elected offices aren't always competitive, it's because voters are reasonably good at filling them.  What's wrong with that?

Thursday, March 27, 2014

Do you know your doctor's expiration date?

CMS is considering new rules to protect seniors if their Medicare Advantage Plan drops their physician.  I think that's a great idea, and wish everyone had such protection from network changes.  I was pretty sure I'd written something about that, but couldn't find it posted.  After digging through old files, here it is.

January, 2012

Imagine going to buy milk at the store, only to find that none of the cartons are marked with an expiration date.  You ask a clerk about it, only to be told that the dates exist, the store knows what they are, but that they are a trade secret and they can't disclose them to you.  All they will tell you is that the milk is not expired as of today.  "How," you ask, "will I know if it is safe to drink tomorrow?" 

"Check back tomorrow", is the answer.  "All we can ever tell you is whether your milk is expired as of the day you ask."

Such an arrangement would be absurd on its face, and if a store attempted to impose such conditions a regulatory or legislative remedy would surely not be far behind.  But in one industry such absurdity is the norm.  Do you know your doctor's expiration date?

Most private health insurance plans are circumscribed by networks.  Go outside the network and you face a steep increase in out of pocket expense through  copays or deductibles. In some plans the out of network coverage is so restricted that patients are functionally uninsured.  Most people know this and quickly learn to identify in-network providers.  But those networks change over time, depending on whether or not doctors and insurers continue agreeing to terms.  And included in those agreements are expiration dates.  If no renewal agreement is reached the contract expires and the provider drops out of network.

What notice do patients get when that happens?  Whatever their doctor feels like giving them.  Maybe they'll tell you when you make your next appointment, or maybe not.  As the paperwork repeats ad infinitum, patients are solely responsible for managing their insurance, and patients are solely responsible for payment.  Even if you've seen a doctor a hundred times and checked your insurer's web site to verify their network status yesterday, nothing guarantees that they are in network on the day of your appointment save checking with your insurer on that day.  Realistically, you probably won't find out until you get an Explanation of Benefits statement from your insurer stamped "Out of Network" followed by a hefty out of pocket medical bill.

What makes such circumstances frustrating is how unnecessary they are.  By simply disclosing the expiration date of the provider-insurer agreement, people would know when they needed to check to see if it renewed.  Not only could they avoid hundreds or even thousands of dollars in out of pocket expenses by being better able to avoid out-of-network physicians, they could improve the continuity of care.  Knowing at once if a provider had dropped out of network would allow more time for selecting and transferring records to a new provider, it could be done ahead of time rather than starting the process on the day you realize you need treatment and go to make an appointment.  All that, just from disclosing a date.

The only argument I've seen against such disclosure is that contracts between insurers and providers are trade secrets.  According to that logic, the contracts must remain secret to prevent collusion on prices.  I won't argue for or against that point, but I'd observe that the contract expiration date has no bearing on it.  What is the harm in disclosing an expiration date?  Is the market for milk screwed up because people know ahead of time when a particular carton will go bad? 

It's worth thinking about, because paying medical bills out of pocket because a physician's office didn't disclose they dropped your insurance  stinks worse than rotten milk.

Thursday, February 6, 2014

Why are we still talking about the CRC?

Generally speaking, you don't loan out money you're banking on getting paid back without collateral.  That's because people who don't put up collateral, who don't have any disincentive against walking away from their debt tend to walk away from their debt.

Applied to the CRC, if we think we need Washington support to build the CRC than we must have collateral to ensure their support.  That can come in the form of direct funding up front or it can be irrevocable collection rights against Washington citizens to the same effect, whatever.  What matters is that it's skin in the game, a reason for Washington to not walk away when the bridge is built but the bonds are only half paid off leaving Oregon holding the bag.

With that in mind it's hard to understand what Governor Kitzhaber is thinking.  How likely is Washington to put up collateral if they think Oregon can be suckered into going it alone?  Every step Oregon takes toward building the bridge without Washington support validates their inaction and makes their support on the next step less likely.  The path Kitzhaber is following  doesn't lead to a bridge supported on both ends.

If we really want Washington support we ought to give them a reason to give it.  The screamingly obvious one is to walk away from the CRC.  If the Feds are as loose with money as Kitzhaber's plan requires, a year isn't going to matter.  The only risk is that Washington might judge the benefit of a new bridge not worth its cost.  If that's the case aren't we better off finding that out now rather than 10 years and hundreds of millions of dollars in unsecured debt later?

Saturday, December 28, 2013

How We Do Harm

It's one thing to read a statistical assessment of overtreatment, and how some "cures" are either ineffective or worse.  It's quite another to read the personal stories of people who underwent such treatment. 

A woman suffered brutal side effects getting HDC-ABMT, only to discover that studies show the treatment doesn't prolong survival.  A few years later she finds the cancer has come back, and at almost the same time she loses her insurance for having blown the life time benefit max.

A 70 year old man gets free prostate cancer screening at the mall, finds an abnormality and gets "treated."  He spends his remaining years incontinent and with a colostomy bag before dying of a UTI.

Even as we spend vast sums on overtreatment we have people suffering from undertreatment, such as an uninsured woman who walked into an ER with a body part in a bag after suffering auto-mastectomy from advanced, untreated breast cancer.

Health care reform is going to have its ups and downs.  But if you ever need a reminder about why the pre-ACA system was unacceptable, why it was a gross moral failure, check out How We Do Harm by Otis Webb Brawley and Paul Goldberg.  In their words, incidents of failure weren't aberrations from the system, failure was the system. 

Saturday, December 7, 2013

Hollywood Micro Apartments- what exactly is the problem?

Micro-apartments continue to draw opposition, particularly the Hollywood location. Why?

Street-parking near the Hollywood location is already at capacity, it's extremely rare to see open spots.  And because of the configuration of the highway and Sandy Blvd there are no nearby neighborhoods that would absorb parking by new residents.  Given that, what difference could new residents make?  There's no such thing as negative parking spaces, street parking can't be more full than it is now.  I get the distinct impression neighborhood concerns are not about parking, but about other things.

A recent letter from the Hollywood Neighborhood Association Board printed in the Hollywood Star reinforces that impression, emphasis mine:

Imagine the effects on your neighborhood if small, single-family homes on standard 50-by-100-foot lots were replaced by 64-foot tall apartment buildings that housed 70 or more people stuffed into 56 dormitory-like units with no parking.  Imagine further that the buildings' tenants were temporary with no connection to each other despite its so-called "group living" designation.  Imagine no dorm proctor to keep things from getting out of hand.  It is easy to anticipate noise problems, even worse parking problems than we've already experienced from no-parking apartments…

Never mind the false insinuation that the block in question is for single family homes when in reality it is surrounded by commercial property and highway, and zoned CX intended for intense development.  And never mind the hand-wringing over the plight of people "stuffed" into dormitory like units since no one will be there except by choice, meaning without that choice they'll be somewhere worse. 

 Look instead at the concerns:  The residents will be noisy and temporary, they won't have a proctor.  Those concerns have nothing to do with parking, and everything to do with fears and preconceptions about potential new residents.

If residents of the new buildings create noise problems or "get out of hand," whatever that means, then it should be addressed via law enforcement just as it would be if they lived in a single family home.  And yeah, people in single family homes do get out of hand and we find a way to cope and the world goes on.  But do we prohibit construction of new single family homes because their residents might be criminals?  How is that any more rational with apartments?

People should be judged on what they do, not on where they live.  It is shameful when we do otherwise.

Saturday, November 30, 2013

Portland's problem with density

Portland has a problem with dense development.  The problem is that we are too willing to reject it, whether because we're enamored with what we have or afraid of what is new.  That mix of complacency and xenophobia will in my view doom efforts to build and sustain a livable city if it goes unchecked.

One problem is suburbs.  When we don't accommodate people living in the city, we force them into suburbs.  By their nature such areas are vastly more car-centric, and its citizens car-dependent.  Disproportionate population growth there will, through democracy, lead to a more car-centric public policy.  Highways instead of streetcars, more space devoted to parking instead of retail or other human use.  We can't force most of the metro population into an environment antithetical to livability without inviting blowback.

Another problem is economics.  What happens when you increase the desirability of something, but not its supply?  Prices go up.  And in Portland, housing prices go up a lot.  Despite the bubble, housing prices have increased more than 60% since 2000 as measured by the Case-Shiller index.  How many households have seen their income grow by 60% over this time?

Inflationary housing prices mean the city will be accessible only to an ever smaller, wealthier class.  That compounds the public policy problem (why should poorer suburbanites accept policy dictates that cater to urban elites?), and it reduces Portland's diversity.  Cities thrive on diversity and the interplay of different ideas that come from different backgrounds and experiences.  That dynamism creates jobs.  Restricting housing in the city will push out not only people, but creativity and job creation.  How livable is a city without those?

Here is a litmus test for Portlanders.  Take the number of years you've been living in your house and imagine someone born that many years after you.  Suppose this hypothetical person grew up in a similar environment as you and made similar choices about education, family, and career.  Would they now have the same ability to move into a city neighborhood, not necessarily the same neighborhood but one with comparable amenities, as you did years ago?  Extending the idea, I'd say a community which by design bars our children from doing and living as we do cannot be called sustainable. 

It isn't enough for livability to be a good idea, an affectation that we put on like a fancy hat.  To mean something in the real world it has to be able to grow.