Avik Roy, Uber, and Stupid Idea Healthcare Ideas

Avik RoyInvestor’s Business Daily (IBD) has an editorial asking one of the stupidest questions you are likely to hear this year, Why Is There No Uber For Health Care? It is based on a paper by pretend wonk Avik Roy, Health Care 2.0: Ushering in Medicine’s Digital Revolution (pdf). Before I get to the specifics of the stupid question, let’s go over a few issues that the editorial raises.

First, IBD thinks healthcare costs are all about technology. This isn’t even close to being true. For one thing, in Japan, they have a lot more healthcare technology than we do, yet their healthcare spending is much lower. People who make these kinds of arguments are all free marketeers who are just looking for some reason to claim that the free market will save us if we just let it.

Well, a free market in healthcare might be just fine. But the people at IBD aren’t interested in that. And Avik Roy certainly isn’t interested in that. They aren’t calling for an end to licensing of doctors. In fact, they aren’t even calling for an end to restrictions in doctors immigrating to the US. Because that’s the reason healthcare costs so much: doctors get paid two to three times as much in the United States as they do in other advanced countries. Do we have better doctors than they do in Canada and Japan and Germany? I don’t think so.

Then IBD asks a question about all this technology, not understanding its wider ramifications, “Why would any consumer demand a more expensive product if they had no idea whether it would work?” Well, the truth is that most people do not demand a more expensive product. But generally speaking, healthcare customers are not knowledgeable enough to make good healthcare buying decisions. This is why the neoliberal approach (Not to mention the free market approach!) is not a good way to provide healthcare.

The great Avik Roy trick in all this is that technology will save us. This is the answer that conservatives have for every problem.

But the editors — based upon Avik Roy — go in the opposite direction. The real solution is to get rid of insurance! It’s the conservatives’ great solution to everything: health savings accounts so that people can count every penny and not go in for expensive procedures! Of course, they started with the understanding that people don’t know what they are doing when it comes to healthcare.

But there’s another issue here. Ultimately, conservatives all think we should save money on healthcare by getting less of it. They don’t want to deal with the issue that the healthcare itself is too expensive. And let’s face it: it’s a false saving. Because if you get people to count their pennies, many of them will decide they can save a buck by not getting preventative care or taking drugs that will lead to much more expensive care later on.

Big on Avik Roy’s radar is that the insurance that people get, they don’t pay for directly. Thus the “direct consumer is largely indifferent to the price.” But surely the businesses and government agencies that are paying for the insurance care about price and are in a much better position to negotiate it. Again we are back to the idea that the more the individual has to pay for care, the better. But the truth is that increasing co-pays and similar devices have not been shown to cut down on unnecessary care.

The great Avik Roy trick in all this is that technology will save us. This is the answer that conservatives have for every problem. And there is no doubt that technology can help. But the kind of technology that Roy and Carly Fiorina and the editors at IBD want is market innovation. They want a way to make it easier for customers to compare prices. They want a little app that will allow people to get the best price on a colonoscopy. Okay. I’m not saying that might not save a few pennies.

But it wouldn’t be like Uber. Uber saves money because it is a low-skill service. It has thrived because there are a bunch of out of work, desperate people. And it effectively placed all the burden on these powerless people. In as much as it has changed the market, it has taken a pretty bad job and made it worse. Yet in the entire IBD editorial, the word “doctor” is used only once — and then in a quote that they attack. Do they really think that doctors are going to allow themselves to be Uberred?

No. What it all comes down to is that the people at IBD and Avik Roy (who I’ve been following for years), don’t give a damn about providing healthcare. They just want to keep taxes down and salaries high for the already rich. So they will nibble around the edges. Medical technology! Skin the game! Malpractice insurance! In fact, the article even talks about the high price of drug entrepreneurship, without discussing all the billions of dollars that the government does in drug research that makes the drug companies rich.

A couple years ago, Avik Roy went through a cycle. He kept writing articles about this or that country that had a supposed free market healthcare system that worked. And then, an actual healthcare wonk would point out why he was wrong. So Roy would move onto another country. Because there just isn’t a country that provides reasonably priced high quality healthcare without having the government very much involved.

The problem is as it always is with conservatives on any issue. They are constrained by conclusions. Yes, they would like everyone to have good paying jobs, but only if the solution is that we lower taxes on the rich and get rid of regulation. And they would like everyone to have good affordable healthcare — but only if it involves the government only helping the rich stakeholders in the process. If it involves subsidizing individuals, forget it.

For more on this, see my article from three years ago: Avik Roy: Healthcare Apologist.

Krugman: Republicans Are Bigots So Vote Clinton

Paul KrugmanI devised The Paul Krugman Bernie Sanders Giving Game just three days ago. If I were actually playing it, I would now be broke. Three days! Krugman doesn’t seem to be interested in much of anything but how wrong it would be to vote for Bernie Sanders and how Hillary Clinton is the only sane choice.

He also has taken to complaining about Sanders’ supporters not being nice to his friends and him. In fact, last week, he wrote, Health Wonks and Bernie Bros. Now I don’t know the etymology of the term “Bernie Bros”; it probably started with Sanders supporters, but among the liberal punditocracy, it has become a pejorative. The implication has long been that Sanders appeals to young men and that being a Sanders supporter is somehow sexist (despite the fact that the people supporting Sanders first wanted Elizabeth Warren). And note: young women now support Sanders far more than Clinton.

But Krugman’s column yesterday was truly over the top, Plutocrats and Prejudice. It’s a straw man, as so many arguments against Sanders are: Sanders is an idealist who can’t get his big ideas accomplished and Clinton is a pragmatist who will make incremental improvements. The implication is always and forever that Sanders is some ossified old sixties socialist who can’t adjust to political reality. Listening to Krugman, you would think that when the public option was off the table, Sanders had voted against Obamacare. What actually happened was that he got the Senate to roughly double funding for community clinics in exchange for his support. Sounds like a guy who is capable of making incremental change.

So we have a Republican Party that is bigoted. One of their great bigotries is against powerful women. And one of their greatest bigotries is Hillary Clinton herself. And she’s the one who is going to be able to make incremental progress?

So Krugman argues that since Sanders talks insistently about economics, he must think that is the only (or almost the only) issue. It’s funny. Just a few days before, Jonathan Chait wrote pretty much the same thing, What Bernie Sanders Doesn’t Understand About American Politics. I’m not suggesting that these guys are on the Clinton payroll, but they both have the same ax to grind, and they grind it the same way.

But it is worse than that. Because Krugman starts off by going over territory that I’ve gone over before: the plutocrats were able to get their lower taxes and decreased regulation by supporting politicians who got votes by demagoguing against minorities. But that isn’t entirely true. We got the Taft–Hartley Act in 1947 — long before the Silent Majority, Welfare Queens, and Willy Horton. But does Krugman really believe that Sanders doesn’t understand the role that bigotry has played in helping the plutocrats since the 1960s? I don’t think so.

If you look at the other things that Krugman has been writing, you’ll see a certain level of hysteria. He’s been looking for anything he can hammer away at Sanders on. There’s never a kind word. And there is never a negative word for Clinton. No, in Krugman’s world, Clinton is right and perfect and Sanders is wrong about everything that matters. As one commenter (PN) put it, “Prof Krugman seems to dream of ways to disagree with Sanders and to support Hillary.” It’s true.

So we have a Republican Party that is bigoted. One of their great bigotries is against powerful women. And one of their greatest bigotries is Hillary Clinton herself. And she’s the one who is going to be able to make incremental progress? Krugman ended the article with a question, “Isn’t there something noble, even inspiring, about fighting the good fight, year after year, and gradually making things better?” Yes! Yes! Again, I say, yes! But isn’t there also something incredibly suspicious about a candidate who campaigns in that way?

Everyone (and certainly Krugman) knows the Mario Cuomo quote, “You campaign in poetry. You govern in prose.” And Bernie Sanders’ entire career has demonstrated that. The only place that isn’t true is in the fever dreams of people like Krugman. It could be that Krugman either doesn’t really like Sanders’ positions, but this seems unlikely given that they really aren’t that different from Clinton’s. I think it is that Krugman doesn’t think Sanders can win the general election. That’s a fair argument. Make it! Don’t give us this garbage about how Sanders is too high minded and naive to be president.

Morning Music: Doug Yule’s Velvet Underground

SqueezeTo most Velvet Underground fans, Doug Yule was an interloper. After replacing John Cale as of the third album, he grew in importance to the point where he forced out Lou Reed and tried to take over the band. That is absolutely not true. For the last couple of years, it is better to think of Yule as Reed’s right hand man. Yule ended up singing four of the songs on Loaded because Reed simply couldn’t.

After Reed left, the band carried on. But soon Morrison left to pursue his PhD, and finally Tucker left to raise a family — Yule was all alone. And in 1972, Doug Yule found himself alone in London — abandoned by the group’s manager and expected to make an album. And he made that album, Squeeze. Most people don’t even know that it exists. Those that do write it off as another reason to hate Doug Yule. It was just another sign of him trying to leverage the fame of the Velvet Underground for his own personal aggrandizement. There’s just one problem with that: it’s completely wrong.

Reappraising Squeeze

Almost five years ago, Steven Shehori wrote an amazing article, Criminally Overlooked Albums: Squeeze by Doug Yule’s Velvet Underground. Other than the overestimation of Loaded, I completely agree with this:

The haze of nostalgia leads many to believe the Velvet Underground made an indelible mark on the music scene in its brief lifetime. In reality, VU’s iconic status was posthumous, not cemented until years after Loaded hit stores in 1970. Which means in the summer of 1972, Yule wasn’t recording Squeeze to ride the slipstream of one of the most cherished rock n’ roll records in history. He was crafting a faithful follow-up to a genius yet poor-selling album from a cult band most people had never heard of. And outside of the brilliant Lou Reed, I’m convinced the only person earning the right to venture into such waters would be Mr Doug Yule. The fact he pulled it all off so seamlessly makes Squeeze a doozy of a criminally overlooked album.

It’s a short album: just a half hour long. And the thing is: it sounds just like a followup to Loaded. The best things on the album are not as good as the best of Loaded. But the worst things on it are not as bad as the worst of Loaded. The fact that the album is so easily pushed aside says everything about the cult of stardom. Doug Yule was 26 years old when he made this album — interestingly, the same age that Reed was when he made The Velvet Underground & Nico.

Listen to Squeeze

Squeeze is a really good album. If people had dismissed Loaded as the Velvet Underground going commercial, that would be one thing. But they didn’t, and they haven’t. Squeeze is of comparable quality. It deserves your attention. And Doug Yule deserves an apology from the music press.

Anniversary Post: the 47 Ronin

47 Ronin GravesOn this day in 1701, two feudal lords met. Asano was the weaker of the two and he was visiting Kira. Kira treated Asano very poorly for uncertain reasons. This led to Asano attacking Kira, wounding him slightly. However, to attack a feudal lord in his own home was consider the gravest of offenses, and Asano was forced to kill himself. This made all of his hundreds of retainers lose the title of samurai and become ronin. Forty-seven of these ronin plotted revenge against Kira, killing him exactly two years later. Then the 47 were allowed honorable deaths. That is the story of the 47 ronin. It is perhaps the most famous story in all of Japanese art, having been rendered in painting, literature, and theater. It’s been made in movie form countless times.

Given this, I had always assumed that it was just a myth, but it really happened. It is generally now seen as an act of honor, but certainly at the time, opinion was mixed. Ultimately, it is just a tale of revenge. “They raped our queen, so we raped their city, and we were right!” Even the story we have leaves it open to interpretation. It matters quite a lot if Kira had a good reason to be rude to Asano.

But it does show an amazing amount of loyalty. And for those who believe in hierarchy, the act is laudable at least on those grounds. And the attack was successful in the sense that it allowed Asano’s heir (his younger brother) to re-establish his feudal reign. And the other ronin were allowed their titles back (basically, allowed to make a decent living). Still, a lot of people died.

In the film Ronin, there is a wonderful scene in which the great French actor Michael Lonsdale tells the story of the 47 ronin. It is in the context of honor among thieves. Lonsdale’s character seems to know that Sam (Robert De Niro) works for the CIA. He is making the case that the ultimate master is not the employer but that sense of honor. Sam at least pretends not to understand, but then Sam is not a very interesting character. Ultimately, Lonsdale has nothing to worry about because Sam is an American Good Guy™. The story of the 47 ronin is much more complex, even if American screenwriters have begun playing with it.