Author: Megan McArdle

Prediction is Hard, Especially About the Future

Ezra Klein says that he has made testable predictions about the future of health care: to wit, that in twenty years we will have peer reviewed research showing that health care reform has saved tens of thousands of lives. I didn’t mean to single out Ezra in particular; he is but one of many enthusiastic pundit advocates for this bill from whom I would like to see some criteria for judging success or failure. But I’m glad he’s stepping up with some numbers.

That said, while this is certainly a prediction, it’s not a very strong one. I too, believe that by 2030 we will have at least one peer reviewed research paper showing that health care reform has saved many lives. There will probably also be at least one peer reviewed research paper showing no effect.

Given the magnitude of the claims about the uninsured, however, I don’t think we need to wait for 2030, or peer review. If you believe that 45,000 people in this country die from lack of insurance every year–a figure that Ezra, among many, many other commentators, has treated seriously–then conservatively, by 2030, we should have something like 30,000 fewer lives lost every year in the 18-64 age group.

Yes, I know–you want to tell me that being long-term uninsured may take a toll years later! But of the panel surveys from which the relative risk estimates are usually taken, the longest follow-up was 16 years. By 2030, we should be seeing the full effect. We should be seeing noticeable impacts much faster, particularly if–as many people have argued–insurance status has a huge and measurable impact on trauma outcomes.

That’s a 5% drop in mortality–a huge drop against the background rates. Even if you only think that the correct number of the uninsured is 20,000 a year, you should believe that there will be a drop that is, so to speak, visible to the naked eye.

If you think that the number will be much, much smaller than that–so small that only tens of thousands of lives will be saved in fifteen years–then it seems to me that you’re saying that those estimates were radically off, by a factor of five or more. Given just how prominent those numbers were in the debate, that’s kind of a problem. It’s an even bigger problem because a few thousand deaths a year will not really be distinguishable from statistical noise.

But the biggest problem is how much we’d then be spending per year to get this added benefit. I think it’s entirely plausible that we’ll be saving 3,000 people a year. But 3,000 people a year, at a cost of $200 billion, is almost $70 million per life saved.

Of course, there are supposed to be other benefits, like preventing bankruptcy. But let’s say that Himmelstein et. al. are right, and there are about 500,000 “medical bankruptcies” in the United States. Let us further assume, very implausibly, that these bankruptcies are 100% caused by medical bills.

Well, the average unsecured debt discharged by debtors in bankruptcy is something along the lines of $50,000. (Yes, this number is deliberately vague, because the only studies I know of were done in the late 1990s–but these numbers do not usually take dramatic fourfold leaps over the course of a decade).

For $25 billion a year, we could solve the entire problem by just paying off their debts. Yes, in reality, there would be a moral hazard problem. I’m just pointing out the relative size of the problem–and in reality, the medical bill problem is almost certainly far smaller than that; more medical bankruptcies appear to be driven by lost incomes than by bill problems. You do not spend $200 billion to save $12 billion or so for our nation’s debtors–and that’s really a pretty generous estimate of how big a problem this is.

Thus we quickly end up in immeasurables like morbidity. In fact, we should be able to measure at least some of this, because a lot of conditions with high morbidity also have high mortality–diabetes springs most readily to mind. But a lot of morbidity is hard to measure, so if you’re a program’s advocate, your belief in its efficacy is basically non-falsifiable.

The bottom line is that what I think the public is expecting from the bill is something much more dramatic than a decrease in mortality that won’t be large enough to make any noticeable impact on things like US life expectancy or death rates. And frankly, I think that they are expecting this because a whole lot of commentators–and this is not about Ezra in particular–made it seem as if this was something reasonable to expect.

Does that mean I think the bill will be repealed? No. I think entitlements are very hard to repeal or reform. Ezra regards this as a vindication of the entitlements. I regard this as a public choice problem that may well push us into a nasty fiscal crisis. Both may be true, which won’t make us any less hosed when the crisis comes.

Ezra’s other predictions are not about benefits; they’re mostly political. We are radically in disagreement about the fiscal future, possibly because I regard any future moves to repeal significant revenue and cost control measures as a fairly predictable risk of the bill, while Ezra probably thinks of them as separate events that do more to signal Republican malfeasance than the political sustainability of reforms.

But interestingly, I think we’re actually in agreement on the core predictions: there will be few measurable benefits of this bill, and certainly not any large enough to justify the gross cost of the coverage provisions. Unless the cost-control provisions are sustained in the face of considerable political pressure, and also do not result in any adverse impact on the elderly, belief in this bill’s success or failure rests on outcomes that we won’t be able to measure in any reliable way on a national scale. So it’s probably not really falsifiable, especially since some of the benefits that progressives see–like civic togetherness–aren’t things that people like me put a high value on, unless that togetherness results in some more tangible improvement in peoples’ lives.

But Ezra may vehemently disagree with my interpretation of our areas of agreement–in which case, I fearlessly predict (99.5% certainty) that he will correct me.

March 25, 2010
In Funds We Trust

Every time I write anything about Social Security, I get at least one person arguing that everything is fine because after all, the trust fund is not going to run out until 2036 or so.

I want to assume good faith, but I have a hard time believing that anyone takes this argument seriously. Today, because social security payments exceeded revenue, we’re going to either have to raise taxes, or borrow more money, in order to cover the benefits.

How would this be different if we didn’t have the trust fund?

Entitlements are a problem because they represent a growing demand on tax revenue. You can’t fix this problem by changing the way you account for the transactions, any more than a corporation could fix runaway inventory expenses by charging them off to the IT department instead.

March 25, 2010
Social Security Goes into Deficit

Every since the early eighties, when the Greenspan commission kicked the can down the road with a combination of tax increases and later retirement ages, analysts have been awaiting the day when the system would finally go into deficit. That date has been sliding around between 2016 and 2020 for some years now, but the suspense is finally over: the system is going into deficit this year.

” . . . payments have risen more than expected during the downturn, because jobs disappeared and people applied for benefits sooner than they had planned. At the same time, the program’s revenue has fallen sharply, because there are fewer paychecks to tax.”

According to the CBO report from which that article is drawn, the deficit will persist until around 2014, at which point it will go temporarily back into surplus before returning permanently to the red in 2018. This is a small but permanent deterioration of the program’s finances–the people who have retired early will pay no more FICA taxes, and they’ll have less in the way of taxable Social Security benefits.

Meanwhile, at a time when tax revenues are already hurting bad, this will force the general fund to subsidize Social Security, rather than the other way around.

This is the canary in the coal mine; if Social Security’s finances are in trouble, Medicare’s will also be looking worse. While I was at the Kauffman Foundation’s economics blogger forum last Friday, a show of hands indicated that about 80% of the people there thought America would have a serious fiscal crisis in the next two decades. This is how it starts–not with a bang, but with a moderate decline in revenues.

(Nav Image Credit: pedrosimoes7/flickr)

March 25, 2010
Building a Wall Around Inflation

There’s a current spat between various left-members of the blog world, like Paul Krugman and Ryan Avent, and the Atlantic’s own Mike Kinsley. Kinsley is worried that the government will start inflating away its debt, to which Krugman and Avent say, essentially, “Pshaw, it won’t be so bad!”

I don’t believe that the US government will try to inflate the value of our debt away. Having the world’s reserve currency is a valuable asset for a nation’s government, and besides, the government has a lot of financing needs. Inflating away the value of your prior debt only works if you don’t need to keep borrowing more money–if you do, the higher interest rates quickly wipe out the value of the inflation.

But I am not convinced that higher inflation is a good idea, even though it has lately become fashionable. I understand the logic–in a liquidity trap, the government has more room to quickly pump up the money supply. But liquidity traps are pretty rare events, and there are other mechanisms for doing this. I mean, apparently, because we’re not having GD II: Trap This!

Meanwhile, a 4% rate of inflation has real costs, even if they are not as high as the costs of hyperinflation. First of all, there’s the simple cost of surrendering the credibility on inflation that our central bank has spent thirty years building up. Yes, in a theoretical world, we could just all switch the inflation target, and everyone would know that this was just a technical change. In the real world, people are apt to wonder if the central bank might not switch the target again.

Inflation is a delicate thing. Once people expect inflation, you get more of it–and the cost of disrupting those expectations last time around was short term interest rates as high as 20%, and a nasty recession. Right now, people believe a sort of story about inflation: we were stupid about it in the 1960s and 1970s, but we learned from that experience, and now we won’t go back there–not least, because markets would punish any central banker who tried.

That narrative may not be really true. Certainly, the events of the last year should make us skeptical of stories about how much smarter regulators have gotten. Nonetheless, that story is important, because it holds the market’s expectations for inflation in check. So we should be careful about disrupting it, because we don’t know what the new equilibrium would look like.

Moreover, a sudden change to a 4% inflation target would harm many people. Those with annuities or non-indexed pensions, current holders of bonds, and so forth. In the past, those problems have been smoothed, at least for the neediest, by increasing government spending in other areas. But we don’t have so much room to do that this time around. Every government in the world is coming up against fiscal constraints, and we just accelerated the pace at which we’re running towards them.

Besides, if we had a 4% inflation target, it might actually undo some of the benefits of the inflation. Economists like modest inflation because it eases the problem of “sticky wages”. People are extremely reluctant to accept nominal wage cuts, so employers often deal with declining demand by laying off workers, rather than cutting their wages. Inflation eases this problem by eroding the real value of their nominal wages.

But If we had higher inflation targeting, we’d probably have a lot more people with wage contracts indexed to the CPI. That means that inflation would be less effective at dealing with the “sticky wage” problem, because wages would increase at the same rate as inflation.

When I took my world religion survey in college, I was fascinated by the concept of “building a wall around the torah”. That’s why commandments like “thou shalt not boil the kid in the milk of its mother” have turned into a prohibition against eating meat and dairy together. It means that there’s no chance you can even accidentally cook milk and meat together.

The “wall” has its ridiculous aspects–you can’t have a chicken cheesesteak either, even though chickens don’t give milk. But it means you don’t accidentally violate the commandment–and that you aren’t tempted to “accidentally” violate it, either.

I think of inflation targeting as sort of like this. It isn’t that 2% is a magic number. It’s that now that we know it’s there, we’re all agreed that we’re not in danger of excess inflation. If we change that, we will disrupt a now-stable market in unpredictable ways. Not all of them would be bad, but some would, and I’m not convinced that the putative benefits are worth it.

Update: A reader thinks that I am creating a “straw man” and that I just made up this crazy 4% number in an attempt to smear Paul Krugman. Sorry, y’all–I sometimes forget that you’re not all following every debate I am. This has been a really big thing in the deep wonkosphere, but it hasn’t attracted much attention outside of it.

Paul Krugman is indeed a fan of Olivier Blanchard’s propose to double the target inflation rate. Contra what some right-wing commenters are probably thinking, this is not a totally crazy idea–it would certainly help in the situation we’re now in. But to me, the history of economic policy is littered with proposals that help whatever situation you’re now in, only to create bigger problems later. I’m not sure that I see the benefits in one specific and fairly rare situation outweighing the costs.

On the other hand, Paul Krugman and Olivier Blanchard are about a hundred times smarter than I am, so take that for what it’s worth.

(Nav Image Credit: dan taylor/flickr)

March 24, 2010
Is High Fructose Corn Syrup Making Us Fat?

Its an old debate, but Derek Lowe links to some suggestive new evidence. It’s far from conclusive, but confirms my decision to start trying to limit my exposure to the stuff. Hopefully, it will also inspire Americans to limit their exposure to noxious sugar subsidies, which keep the price of sugar artificially high, and thus encourage food processors to use more HFCS. If anything can overcome the evil twins of ADM and the sugar lobby, it might just be America’s neurotic fear of fat.

March 23, 2010
Commenter: The New System Will Enhance Entrepreneurship

Meanwhile, commenter jreffell says:

As a counter: I’m in the tech industry, and I’ve been postponing my “strike out on my own” phase until reform was enacted. And some of the folks I’d like to strike out with are in the same boat. For us, the biggies are the end to rescission, end to annual and lifetime caps, and especially the pre-existing condition rules.

(Megan, your distinction between consulting and startups is messy here — there are a lot of examples where startups have used a consulting phase to bootstrap, or consultancies have generated startups.)

I think the emphasis on “young” in the above comment is revealing — maybe now we’ll see more folks with families willing to take the jump. I’ve definitely seen a career pattern where startups center around the before-family and after-the-kids-are-grown phases, with a big-company stage while raising kids. Much of this is probably due to non-healthcare factors, but in my case, healthcare has been the biggie.

Whether we’ll actually strike out, and whether we’ll be successful and transformative — well, check back in a few years, eh?

March 23, 2010
Commenter: the New System Actually Impedes Entrepreneurship

Commenter DFooter writes:

As an entrepreneur that has started three tech businesses in the last 15 years, I have yet to hear of anyone who chose not to go out on their own due to health insurance concerns. I think this is due to two factors: most entrepreneurs are young and don’t need insurance, or they are married and their spouse has insurance (my case). Because of the individual mandate that will force everyone to have insurance, I think that, at least in the tech industry, Obamacare will decrease entrepreneurship, as the young people who start most tech companies will now have a large, unproductive and unaffordable expense in paying for generally unneeded health insurance. That cash would otherwise go towards productive business building activities.

I hadn’t thought of that, but it’s at least plausible that having to buy insurance if you do strike out on your own might encourage younger people to stay in the corporate nest.

March 23, 2010
Will Health Insurance Reform Spur Entrepreneurship?

I’ve heard a lot of arguments that health care reform will increase the rate of entrepreneurship. Most of them go along the lines of this piece from Jonathan Gruber: lack of an alternative source of health insurance creates “job lock”, where employees are afraid to switch jobs. The better your recourse to alternate insurance, the more likely you are to be self-employed.

It’s certainly a plausible story. And certainly, the number of people who wish to start businesses, but are held back by the health insurance problem, cannot be zero. The question is, is that number actually large? The age group that worries most about health insurance is also the age group that has other commitments, like mortgages. How many people are financially stable enough to strike out on their own, but have no recourse to COBRA, and cannot afford to buy private insurance?

It is not enough to point to self employment statistics. Self employment is not the same thing as entrepreneurship–a lone consultant, professional, or contractor is a fine thing, but it’s not quite what we are talking about when we worry about rates of entrepreneurship. For some people, self-employment is essentially tax arbitrage, so it’s not surprising that you see more of it when people are able to take advantage of, say, a spouse’s generously tax-subsidized health care. But moving those people between self-employment and wage slavery would not much change the dynamism of the American economy. Similarly, a physician who starts his own practice is probably not affecting GDP much one way or another.

Which is not to say that it isn’t a large problem. Here are the questions you need to ask about the net effect of this bill:

1) How many “job locked” people would really create new businesses? About 2/3 of Americans say they’d like to start a company, but far fewer than that actually do. How many marginal entrepreneurs are being held back by health care, rather than the other risk aversions of middle age?

2) Has the marginal impact changed over time? It is now easier to port insurance than it used to be, so how much extra boost can we get from health care reform, over things like COBRA and HIPAA?

3) Is this the kind of entrepreneurship where you start a new firm, or where you take a professional practice solo, or go to contract work? The best data we have is on Medicare, which seems to show a noticeable discontinuity around age 65–but the size of the effect is small, and as I understand it, entrepreneurship among the elderly is usually a matter of retiring into a part-time consulting practice, not founding a new company with the potential for major economic impact. Arguably, Medicare is actually slowing the economy, by letting people retire before they otherwise would.

4) How many would-be entrepreneurs have no recourse to spousal insurance, and also are so resource-constrained that they can’t afford to buy insurance?

5) New taxes on capital income are a major source of funding for this health care plan. Does this ultimately make a difference in rates of entrepreneurship? I can see two ways that it would: by reducing the return on the entrepreneur’s savings, so that they need to dip into the principal; and by reducing the prospective return of investing in said entrepreneur. On the other hand, how significant is a 4% tax?

6) Does the health care reform slow cost growth? That would be beneficial for small businesses, especially–either because they’re in a bigger pool, or because we’ve slowed the rate of inflation. But that does not seem to have been the experience in Massachusetts.

7) Does the health care bill create a threshold effect that impedes firm growth? Firms smaller than 50 employees don’t have to offer insurance; firms with 50 or more workers do. Other regulations of this sort tend to encourage firms to keep their companies artificially small, because hiring that fiftieth worker is so costly: his salary, plus health benefits or a $2.000 fine for him and the other 49 workers. But is this really a large problem? I’m not sure we know.

8) If social safety nets are so great for entrepreneurship, why are European rates of entrepreneurship so much lower than ours? I can imagine a countervailing force: people left without a good, insured job who become so desperate to make it that they build an exciting new business. But that is merely a just-so story; there are a lot of differences between us and Europe, and perhaps universal health coverage simply isn’t adequate to overcome the other barriers.

9) What about the regulatory compliance costs? Will these increase for firms under the new regulation, and what does that imply for their growth rates?

These suggest some empirical tests. For starters, around 2020, do we see higher rates of entrepreneurship? Entrepreneurship seems to have been fairly stable in this country, so an uptick would be meaningful (though not right around 2014–you might see bunching, as people wait a few months to start their companies, without any real increase in the overall rate of entrepreneurship). And, do we see firms bunching right under that 50 employee mark? That’s complicated by the fact that 50 is one of those nice, intuitive cut-offs, and so probably there’s already some bunching due to state-level regulations. But if this is a meaningful problem, it should get worse in the latter part of this decade.

On net, I’d suspect that this will be positive for entrepreneurship–but I don’t know that this will translate into a lot more growth. Enabling people to become self-employed is a fine thing, but it is not the same as enabling them to start transformative new businesses.

Update: economist Scott Shane quantifies it better:

The latest Small Business Economy an annual publication of The Office of Advocacy of the Small Business Administration explains that 60.7 million people have employer-sponsored health insurance from their employment (people covered by their spouses don’t matter here because they don’t face job lock). Therefore, 607,000 additional people per year would begin the entrepreneurial process if we eliminated health insurance job lock.

But not everyone who begins the process of starting a business manages to get one up and running. In fact, analysis of the Panel Study of Entrepreneurial Dynamics data by Paul Reynolds shows that a new business results from about one-third of startup efforts. So we will get about 200,000 new businesses if we can eliminate the job lock that comes from employer-sponsored health insurance.

This same research shows that only about 19% of new businesses employ someone other than the founder. Because people who leave jobs to start nonemployer businesses don’t generate any net new jobs, it’s the 38,000 additional new employer businesses that would be created if we eliminated the health insurance job lock that would be the source of any additional jobs.

JOB LOSSES FROM HEALTH-CARE REFORM?

Data from the Small Business Administration’s Web site reveals that the average number of employees in a new employer firm is 5.6. Therefore, we will create an estimated 213,000 annually if universal health care eliminates the problem of job lock.
While this may sound like a lot of jobs, it is not. In general, estimates of the number of jobs that will be lost because of health reform are larger. For instance, the Lewin Group, a health-care consulting firm owned by UnitedHealth Group (UNH), calculated that the original House bill would have destroyed 260,000 to 600,000 jobs and that “the estimate would increase a bit under the House bill as passed, because employer costs are a little higher.” Researchers at RAND Corporation make similar estimates to those of the Lewin Group.

Note–that’s the previous House bill, not the current version, for which I don’t have any estimates on job loss or creation.

(Nav Image Credit: AndyRob/flickr)

March 23, 2010
More on Health Care Predictions

Apropos of my earlier post, Ezra Klein writes to complain that I have erroneously grouped him in with Nick Kristof. I should be clear that Kristof’s estimates on their own suggest that the death rate should drop by 20% or so over the next ten years; Ezra’s estimates are just gravy.

But this triggered a back and forth about what it means to claim that “hundreds of thousands” of people will be saved by this bill, and similar. A lot of my correspondents on the left seem to think that I am trying to set up some sort of a gotcha–to make this into a “contest”. Or that making predictions is just “sour grapes”.

That seems like a more apt description of people who just induced us to pass a bill that will ultimately cost more than $200 billion a year–the fifth or sixth largest line item in the US budget. During that debate I heard a lot about the 20-45,000 people who were dying from lack of insurance every year. I heard about how US mortality indicators lagged behind the rest of the developed world. I heard about infant mortality. I heard, over and over again, about medical bankruptcies, and how medical bills were bankrupting America. I heard about the CBO score that said this bill would be deficit neutral. Let me know if I’ve missed anything, but it seems to me that mortality, financial protection, and deficit-improvement were the three major planks upon which this bill was sold. They are certainly the bulk of the anecdotes that fill heart-rending articles and presidential speeches.

Forgive me, but to my admittedly naive ears, this sounds like what you are saying is that you think that if we cover the uninsured, we will have lower mortality rates, fewer medical bankruptcies, and a lower deficit.

So what I want is not some sort of contest between me and some other blogger, but accountability for the bill. The bill has passed. The CBO estimates that when it is fully implemented, virtually all native-born Americans will be insured. That’s the best that any health care bill in America was ever going to do, because America is just not going to pay people to come here. (Maybe you think we should cover illegal immigrants, but hey, I think we should privatize Social Security, and I’m sure we’d both like to fly to the land of Oz on a magic unicorn. All three are irrelevant preferences.)

However “imperfect” this bill is, you got what you wanted: virtually all the uninsured are covered, and those who aren’t covered probably aren’t particularly unhealthy. So now you should be willing to state that all the marvelous things you claimed would come to pass, will actually come to pass. Over a reasonable time frame. You cannot tell me that we will save hundreds of thousands of lives over a fifty or sixty year time frame. I mean, you can, but then I don’t take you seriously. That’s a few of thousand lives a year, far lower than the number of American lives claimed annually by “non-steroidal anti-inflammatory drugs such as aspirin”–at a cost of $200 billion a year, or $70-100 million per life saved. I know, every life is priceless, but US policy cannot actually be operated as if this were true. Moreover, when you stretch out the time frame this way, your theory is non-falsifiable: a few thousand lives a year is too small to be distinguished from statistical noise.

To me, that just won’t do. Americans were not told that American households would be 1% less worried about bankruptcy, or that we’d save a hundred thousand lives over thirty years. They were regaled with eye-popping statistics on deaths from lack of health insurance–I certainly was, by many of the very same commenters who are now suddenly wary of prediction making. If you quoted those statistics, you were committing to a pretty strong position on the benefits of this bill. By my count, since we’re now supposed to be covering at least 2/3 of those who are currently uninsured, and the remainder are often immigrants who trend younger than the general population, you believe that we should see a reduction of at least 15,000 deaths a year. You might argue me down to 12,000, but you couldn’t get me as low as ten. That is what is implied by citing a figure of 20,000 deaths a year.

If you quoted Himmelstein et al’s 45,000, obviously you should be expecting deaths to fall by at least 25,000 a year, very conservatively. If we don’t see such improvements, then those studies were wrong. And if you won’t commit to saying that you expect such a sizable reduction in our mortality rate, then you were wrong to cite them.

I mean, maybe we say that there are a bunch of combo benefits: we reduce bankruptcies by a third, save five thousand lives a year, get some harder-to-measure morbidity benefits, and so on. But there have to be some measurable benefits. If this helps families stave off financial ruin, we should see a meaningful and sustained reduction in the number of bankruptcies. If it improves health, that should show up in life expectancy. If it doesn’t, then the bill doesn’t do what you said you expected it to do. That’s valuable information! Not so much about you, as about health care bills.

If you don’t think that any of the effects of this bill will be large enough to measure and hopefully, large enough to justify the price tag of this bill, then I have to ask two questions:

1) Why the hell are we spending $200 billion a year, plus the mandated spending by individuals and employers on premiums, plus the new money the states will have to spend on Medicaid?

2) Why on earth did you bring up all these apparently irrelevant statistics?

I’m all for accountability for beliefs. That’s how you make your beliefs better. That’s why I want to see all the people who threw around all sorts of theatrical arguments commit to what they are actually reasonably willing to predict will happen. Then explain why the outcomes that they are actually confident enough to predict justify spending about $2000 for every household in the country.

I don’t think that’s unreasonable. I sure wish people had done it before the bill passed–it would keep us more honest in our debates. But post-facto accountability is still a lot better than nothing. Otherwise the bill’s supporters, and opponents, will be too tempted to move the goalposts.

Which is why I made my predictions. I’m sure at least some of them will be wrong, human fallibility being what it is. But the point is not to prove who the best pundit is. It’s to see how confident people really are in their mental model of the world. We’ve got a lot staked on those models, now. We deserve to know.

March 22, 2010
8 Predictions About Healthcare That Will Depress You (The First One: The Death Rate Won’t Fall)

Obviously, yes, I was upset yesterday. I’m glad that this could bring so much joy to peoples’ hearts, and of course to know that for many people, the happiest part of passing health care reform seems to have been knowing that it made people like me unhappy. The people wondering why I was so upset should contemplate that first, I think you people just screwed up both our health care system, and our fiscal system (even further), and that if I’m right, that’s not really funny.

If you think there is actually no chance that I’m right, you need to go read a book like Jonah Leher’s How We Decide.

So now, onto predictions!

Judging by the statistics that have been used to sell this thing, over and over, liberals are expecting big things.

1) Ezra Klein is confidently predicting that it will save hundreds of thousands of live.

2) Nick Kristoff expects miraculous improvement in our national life expectancy.

3) Michael Moore thinks this will stop people from getting thrown out of their homes in a Medical bankruptcy.

4) At least one of you must be willing to claim massive improvements in infant mortality, after you’ve cited those statistics to me over and over.

I think we ought to be able to work this into a little prediction test. My predictions:

1) Conservatively, Ezra’s arithmetic implies a reduction in the death rate of people between 18-64 of at 20,000-45,000 a year. Let’s take the low bound–20,000 deaths a year–and assume that we should see that, or something close to it, by 2020. That’s about 3% of deaths in the relevant age group, which would show up as a very noticeably kink in the death rate. For comparison purposes, the entire fall in mortality between 1980 and 2000 was about 2.7%.

Contra Ezra, I am predicting that this will not happen. I’m about 75% confident that you will not be able to discern any effect from the health care reform among the statistical noise. But I am 95+% confident that the effect will not be as large as 3%.

2) I’m pretty sure that Kristof read the table he was drawing from wrong–he was looking at life-expectancy at birth, but he interpreted the data as if it was about adults in the 1940s. Still, age-adjusted mortality fell about 15% in just 10 years, an achievement that hasn’t been matched since. If Kristof is right, and this had more to do with health care access than antibiotics, we should be able to get a similar improvement this time around–especially since we’re already seeing terrific reductions, with a 10% decline in age-related mortality just between 2001-6. Hell, both Ezra’s numbers and Kristoff’s imply that we should be able to knock down the death rate by at least 20% between 2014 and 2024, when we add their improvements to the existing trend.

I do not think that there will be a noticeable kink in the trend line around 2014. The death rate jumps around quite a lot, so there may be a big drop (or increase) in 2014, neither of which would be meaningful. By 2025, however, I’m skeptical that we’ll see a major inflection in the trend.

3) David Himmelstein claims to believe that the majority of all bankruptcies are related to medical issues, and that this is a strong argument for national health care . . . i.e., he claims to believe that medical bills rather than income loss are the main causal driver here. That’s the data Michael Moore is citing. I will make a bold counterclaim: the bankruptcy rate after 2014 will not fall by half. It won’t even fall by a quarter. This is among the easiest effects to measure, as if the people citing these statistics are right, we should see a sharp and immediate reduction in bankruptcy rates in the first year, with the full effects evident by 2018.

4) Infant mortality should be no greater than that of the Netherlands by 2018. Again, I predict that this will not happen, and indeed, that infant mortality rates may not fall at all.

5) I predict at least one of the major funding sources, and possibly all of them, will be substantively repealed: the Medicare cuts (except Medicare Advantage), the excise tax, and so forth.

6) This program will not reduce the rate of growth in medical costs by anything like 1.5% a year.

7) A fiscal crisis of some sort is quite likely by 2030, though not just because of this program. But this program will make it worse, either by increasing the deficit directly, or by using up the low-hanging fruit that should have funded Medicare reform.

8) By 2030, there’s an 80% chance that the government will have imposed substantial price controls on pharma and other medical technology–and this will noticeably slow the rate of innovation.

I feel like any reasonable proponent of health care reform should be willing to take the other side of most of these bets, without weaseling that this isn’t the health care reform that you wanted. If you aren’t confident that we can get at least some of these results, than we shouldn’t have committed to spend $200 billion a year . . . and you shouldn’t have deployed these arguments in the run-up to health care.

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March 22, 2010
8 Predictions for Health Care

Obviously, yes, I was upset yesterday. I’m glad that this could bring so much joy to peoples’ hearts, and of course to know that for many people, the happiest part of passing health care reform seems to have been knowing that it made people like me unhappy. The people wondering why I was so upset should contemplate that first, I think you people just screwed up both our health care system, and our fiscal system (even further), and that if I’m right, that’s not really funny.

If you think there is actually no chance that I’m right, you need to go read a book like Jonah Leher’s How We Decide.

So now, onto predictions!

Judging by the statistics that have been used to sell this thing, over and over, liberals are expecting big things.

1) Ezra Klein is confidently predicting that it will save hundreds of thousands of lives.

2) Nick Kristoff expects miraculous improvement in our national life expectancy.

3) Michael Moore thinks this will stop people from getting thrown out of their homes in a Medical bankruptcy.

4) At least one of you must be willing to claim massive improvements in infant mortality, after you’ve cited those statistics to me over and over.

I think we ought to be able to work this into a little prediction test. My predictions:

1) Conservatively, Ezra’s arithmetic implies a reduction in the death rate of people between 18-64 of at 20,000-45,000 a year. Let’s take the low bound–20,000 deaths a year–and assume that we should see that, or something close to it, by 2020. That’s about 3% of deaths in the relevant age group, which would show up as a very noticeably kink in the death rate. For comparison purposes, the entire fall in mortality between 1980 and 2000 was about 2.7%.

Contra Ezra, I am predicting that this will not happen. I’m about 75% confident that you will not be able to discern any effect from the health care reform among the statistical noise. But I am 95+% confident that the effect will not be as large as 3%.

2) I’m pretty sure that Kristof read the table he was drawing from wrong–he was looking at life-expectancy at birth, but he interpreted the data as if it was about adults in the 1940s. Still, age-adjusted mortality fell about 15% in just 10 years, an achievement that hasn’t been matched since. If Kristof is right, and this had more to do with health care access than antibiotics, we should be able to get a similar improvement this time around–especially since we’re already seeing terrific reductions, with a 10% decline in age-related mortality just between 2001-6. Hell, both Ezra’s numbers and Kristoff’s imply that we should be able to knock down the death rate by at least 20% between 2014 and 2024, when we add their improvements to the existing trend.

I do not think that there will be a noticeable kink in the trend line around 2014. The death rate jumps around quite a lot, so there may be a big drop (or increase) in 2014, neither of which would be meaningful. By 2025, however, I’m skeptical that we’ll see a major inflection in the trend.

3) David Himmelstein claims to believe that the majority of all bankruptcies are related to medical issues, and that this is a strong argument for national health care . . . i.e., he claims to believe that medical bills rather than income loss are the main causal driver here. That’s the data Michael Moore is citing. I will make a bold counterclaim: the bankruptcy rate after 2014 will not fall by half. It won’t even fall by a quarter. This is among the easiest effects to measure, as if the people citing these statistics are right, we should see a sharp and immediate reduction in bankruptcy rates in the first year, with the full effects evident by 2018.

4) Infant mortality should be no greater than that of the Netherlands by 2018. Again, I predict that this will not happen, and indeed, that infant mortality rates may not fall at all.

5) I predict at least one of the major funding sources, and possibly all of them, will be substantively repealed: the Medicare cuts (except Medicare Advantage), the excise tax, and so forth.

6) This program will not reduce the rate of growth in medical costs by anything like 1.5% a year.

7) A fiscal crisis of some sort is quite likely by 2030, though not just because of this program. But this program will make it worse, either by increasing the deficit directly, or by using up the low-hanging fruit that should have funded Medicare reform.

8) By 2030, there’s an 80% chance that the government will have imposed substantial price controls on pharma and other medical technology–and this will noticeably slow the rate of innovation.

I feel like any reasonable proponent of health care reform should be willing to take the other side of most of these bets, without weaseling that this isn’t the health care reform that you wanted. If you aren’t confident that we can get at least some of these results, than we shouldn’t have committed to spend $200 billion a year . . . and you shouldn’t have deployed these arguments in the run-up to health care.

(Nav Image Credit: Wikimedia Commons)

March 22, 2010
The Future After Health Care

Regardless of what you think about health care, tomorrow we wake up in a different political world.

Parties have passed legislation before that wasn’t broadly publicly supported. But the only substantial instances I can think of in America are budget bills and TARP–bills that the congressmen were basically forced to by emergencies in the markets.

One cannot help but admire Nancy Pelosi’s skill as a legislator. But it’s also pretty worrying. Are we now in a world where there is absolutely no recourse to the tyranny of the majority? Republicans and other opponents of the bill did their job on this; they persuaded the country that they didn’t want this bill. And that mattered basically not at all. If you don’t find that terrifying, let me suggest that you are a Democrat who has not yet contemplated what Republicans might do under similar circumstances. Farewell, Social Security! Au revoir, Medicare! The reason entitlements are hard to repeal is that the Republicans care about getting re-elected. If they didn’t–if they were willing to undertake this sort of suicide mission–then the legislative lock-in you’re counting on wouldn’t exist.

Oh, wait–suddenly it doesn’t seem quite fair that Republicans could just ignore the will of their constituents that way, does it? Yet I guarantee you that there are a lot of GOP members out there tonight who think that they should get at least one free “Screw You” vote to balance out what the Democrats just did.

If the GOP takes the legislative innovations of the Democrats and decides to use them, please don’t complain that it’s not fair. Someone could get seriously hurt, laughing that hard.

But I hope they don’t. What I hope is that the Democrats take a beating at the ballot boxand rethink their contempt for those mouth-breathing illiterates in the electorate. I hope Obama gets his wish to be a one-term president who passed health care. Not because I think I will like his opponent–I very much doubt that I will support much of anything Obama’s opponent says. But because politicians shouldn’t feel that the best route to electoral success is to lie to the voters, and then ignore them.

We’re not a parliamentary democracy, and we don’t have the mechanisms, like votes of no confidence, that parliamentary democracies use to provide a check on their politicians. The check that we have is that politicians care what the voters think. If that slips away, America’s already quite toxic politics will become poisonous.

March 21, 2010
Chat-Tastic: Blogger Megan McArdle Explains It All To You

The Washington Post has me doing a live web chat at 2:00 on the now apparently inevitable health care reform. If you wan to ask me some questions, please head over there . . . you can actually submit questions now, but the answers won’t go live until 2:00.

March 21, 2010
Politico’s ‘Doc Fix’ Memo: Fake, But Accurate?

Update: Please READ THE POST before launching into your attacks. Hint: the headline is name checking a famous quote, not suggesting that this was a valid idea. Had you read the post before beginning your cringe-inducing denunciations of my “hypocrisy”, you would have, um, known that.

It’s widely believed that the Democrats have been holding the “doc fix” above the head of the AMA in order to keep them out of the health care fight. This is not just believed on the right; I don’t know any left wing pundits who believe that there is any chance that Congress will allow the “automatic” cuts to Medicare doctor reimbursements to take effect, because that would result in a 21% fall in payments–and a mass defection of doctors from the program, as Medicare patients suddenly became literally money-losers. A mob of angry seniors would descend on Congress with pitchforks shortly thereafter.

The fact that Democrats keep doing very short-term temporary fixes to the program–the current one is just for a month or so–while saying they want to do a permanent fix, seems to make it clear that this is the price of AMA support.

So naturally, when a memo was posted on Politico, allegedly from some Democratic communications person, that seemed to be evidence for exactly such back-room dealing, the right half of the blogosphere leaped on it.

Democrats, however, are saying it’s a fake, and Politico has taken it down.

I’ve seen the memo, and If it’s a fake, it’s a very good fake; just as people who write political dramas and novels can almost never bear to give the opposition any convincing arguments, the kind of people who write the fakes I’ve seen generally make the alleged authors sound like unreasonable buffoons. This memo actually makes some compelling arguments for the Democratic side, which is one reason to believe that it might be real. (The other major reason, as far as I’m concerned, is that Politico posted it; one assumes that they vetted it somehow).

On the other hand, there are also reasons to be suspicious:

1) The memo nowhere identifies where it’s from

2) There are several very juicy, very damning bits, and I am always suspicious that people would actually put such things into writing

3) In some subtle way that I can’t put my finger on in any particular quote, the memo writer tends to make the GOP sound too convincing, too powerful

4) Its appearance is at an awfully convenient time for the GOP–although of course, this is the actual time when communications memos are circulating.

5) The Democrats are denying it’s theirs; of course, if Politico can confirm the provenance, this will only elevate a minor kerfuffle into a big story.

If it’s a fake, “fake but accurate” is not a defense. I mean, it may be of Politico, provided they act swiftly to rectify the mistake. But rightwing bloggers should not do what the left did in the Dan Rather case, and insist on its accuracy well past the point of reason. There are decent reasons to worry that it’s a fake, and no one should circulate the talking points from the memo until the provenance has been confirmed.

March 19, 2010
Arizona Kills SCHIP, Puts Medicaid on a Diet

On the eve of the possible passage of a health care bill, Arizona has provided a glimpse of our possible future by shutting down its SCHIP program and booting a bunch of people out of Medicaid:

The Arizona budget is a vivid reflection of how the fiscal crisis afflicting state governments is cutting deeply into health care. The state also will roll back Medicaid coverage for childless adults in a move that is expected to eventually drop 310,000 people from the rolls.

The reason this is so troubling, of course, is that the new proposed health care plan gets about half of its coverage expansion through adding people to Medicaid. The state side of this expense doesn’t show up on the books as a government expenditure (neatly enabling the bill to get a lower CBO score), but someone in America has to be taxed to pay for it, and there is a big problem when tax revenues fall short of the required expenditure.

There are two frightening possibilities, for people who support this bill (and the rest of us, as well . . . but we’ve been frightened for a while)

1) States pull out, and coverage drops

2) States don’t pull out, and they go bankrupt.

The third, and to me the most likely scenario, is that the Federal government basically bails out the states, perhaps taking over Medicaid. But that’s its own problem, because taking over the Medicaid obligations is not going to come attached to any revenue stream to pay for it. Where are we going to get the money?

Of course, that’s what I want to know about the whole thing. But this makes the problem much more vivid.

March 19, 2010
Democrats Want to Buy Now, Pay Later With Health Care?

I don’t want to be overconfident in my predictions, as obviously I’m rather invested in the health care issue. I don’t know what’s going to happen in November, and to the extent that I do know, it’s because I think the broad macro forces simply aren’t going to improve much in the next six months. Maybe Obama will even get a bump out of the polls–and maybe Republicans will unleash their publicity push, and the tea party will go nuts, and he’ll fall (a possibility progressives seem curiously unwilling to entertain, even to dismiss it). I think the latter is more likely than the former, but I just don’t know; we’re in uncharted territory.

But this I am confident of: they’re not going to “pass this bill and then fix it,” and the people saying that this should be the priority of people who are against the bill–including people like Rep. Lynch–seems borderline delusional. You think the Democrats are going to take up health care again this term? Given that they look more likely than not to lose the House, you think Democrats are going to take it up again before these laws go into effect?

Those like my colleague Andrew, who want Republicans to turn to the task of improving this monstrous bill–how is that going to happen? The “fixes” are all the unpopular stuff: the taxes, the spending cuts. You think that now that Democrats got to hand out the goodies, Republicans are going to be the nasty folks who volunteer to hand around the bill for a law they didn’t even want to pass?

Every time I hear comments on this sort of thing, I want to say, “And what other things have you been wondering during your visit to our planet?” I am not perfectly confident about much in regards to this bill. Maybe I’m wrong and politicians won’t step in to stop the unpopular stuff already in the bill from happening. Maybe they’ll actually bend the curve. Maybe this won’t impact innovation (I don’t see how that could possibly be, but whatevs, maybe my imagination is limited).

But there is one thing of which I am nearly perfectly certain: If we pass this thing, no American politician, left or right, is going to cut any of these programs, or raise the broad-based taxes necessary to pay for them, without any compensating goodies to offer the public . . . until the crisis is almost upon us. I can think of no situation, other than impending crisis, in which such a thing has been done–and usually, as with Social Security, they have done just little enough to kick the problem down the road. The idea that you pass a program of dubious sustainability because you can always make it sustainable later, seems borderline insane. I can’t think of a single major entitlement that has become more sustainable over time. Why is this one supposed to be different?

March 19, 2010
What Do Markets Say About the Popularity of Health Care?

There’s a limit to how much weight you can put on InTrade numbers; the markets are pretty thinly traded, and in cases like health care reform, the people trading on it simply don’t have access to the relevant information. (You’ll be pleased to know that in regular stock markets, insider information starts showing up very quickly in prices.)

Nonetheless, they tell you what the crowds think–and on matters like elections, where the crowd’s opinion is what matters, they have decent predictive value. You can throw them off with erroneous information, like the infamous 2004 election when the markets were accurately predicting a Kerry loss until early (and wrong) leaked exit polls started showing a victory.

So I found this pretty interesting:

If President Obama’s story is correct, and passage of the bill will be good for all House Democrats — and for the Obama Presidency — then the bill’s improving prospects over the past month should have been reflected in at least two key ways.
First, there should have been an increasing likelihood that the Democrats will be able to hold on to their majority in the House after this fall’s elections.
Oops! The Intrade contract on that subject shows exactly the opposite (see below).

While the chances of health care reform becoming law increased, the chance of the Democrats holding on to the House dropped from 58 percent to 52 percent.

Second, for the President’s argument to hold water, the chance of the Democrats retaining the Presidency through the next election also should have increased over the course of the last month.
Oops again! The Intrade contract for this topic once again shows trends going in exactly the opposite direction (see below).

A month ago, the chances of a Democrat — presumably President Obama — winning the next Presidential election were about 58.5 percent. At the end of the day yesterday, the chances were down to about 55.5 percent.
There are, of course, all kinds of caveats one should make about these numbers. I’ve argued in my previous article, for example, that the health care reform Intrade contract probably overstates the chances of the Democratic billl becoming law.
But, even with all those caveats, the story is pretty transparent. If health care reform passes, it will be bad for House Democrats overall, and it will be bad for the Democrat’s chances of holding on to the Presidency come 2012.

The post goes on to note that polls seem to be saying the same thing–as it looks like Obama is succeeding in getting this thing through, his popularity has dropped sharply.

That could be a fluke, of course. And maybe Democrats are right and a flood of positive coverage will give everyone a bump. Although since no one’s ever passed this kind of legislation on such negative polling, maybe it will cause the ratings to fall further, particularly if congress ends up using something like Deem and Pass. I don’t recall Clinton getting a huge bump out of the 1993 budget. I seem to remember that it helped cost him the House.

(Nav Image Credit: Wikimedia Commons)

March 19, 2010
Here’s The Truth About That CBO Report (Hint: We’re Still Headed For Fiscal Catastrophe)
As fate would have it, on the day that the CBO report is released, I am in standby hell, and running low on laptop juice. So my thoughts on the CBO score, and the revised reconciliation bill, are necessarily somewhat preliminary. But here is what I’ve noticed so far:

1) Thanks to reconciliation instructions, they needed to improve the budget impact by at least $1 billion in the sidecar. They improved it by exactly $1 billion. Which goes back to what I’ve now said several times: the CBO process has now been so thoroughly gamed that it’s useless.

2) The proposed changes increase spending dramatically, most heavily concentrated in the out-years. The gross cost of the bill has risen from $875 billion to $940 billion over ten years–but almost $40 billion of that comes in 2019. The net cost has increased even more dramatically, from $624 billion to $794 billion. That’s because the excise tax has been so badly weakened. This is of dual concern: it’s a financing risk, but it also means that the one provision which had a genuine shot at “bending the cost curve” in the broader health care market has at this point, basically been gutted. Moreover, it’s hard not to believe that the reason it has been moved to 2018 is that no one really thinks it’s ever going to take effect. It’s one thing to have a period of adjustment. But a tax that takes effect in eight years is a tax so unpopular that it has little realistic chance of being allowed to stand.

3) As I expected, the size of the magic asterisk–the modern equivalent of David Stockman’s infamous “savings to be named later” in the Reagan budgets–has had to be beefed up to offset the new spending.

4) Medicare Advantage is being effectively outlawed–in some areas, the reimbursements will actually be below those of the fee-for-service programs.

5) A disturbingly high percentage of the revenues still come from insurance premiums for other programs. About $53 billion of the net deficit reduction is from Social Security taxes collected on the wages people will now be getting in lieu of health care benefits. But since those contributions raise the amount Social Security will eventually have to pay out, the Republicans convincingly argue that this is not true “deficit reduction”; it’s just deficit shifting. Ditto the premiums for the new long-term care insurance.

6) Ultimately, this rests on the question: are we really going to cut Medicare? If we’re not, this gargantuan new entitlement is going to end up costing us about $200 billion a year next decade, which even in government terms is an awful lot of money. There are offsetting taxes, but they’re either trivial or likely to be unpopular–look forward to a 4% rent increase when your landlord has to stump over the same amount for the new tax on rents. Then look forward to repeal of same.

I think this is a fiscal disaster waiting to happen. But no one on the other side cares, so I’m not sure how much point there is in saying that any more.

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March 18, 2010
First Thoughts on the CBO Score

As fate would have it, on the day that the CBO report is released, I am in standby hell, and running low on laptop juice. So my thoughts on the CBO score, and the revised reconciliation bill, are necessarily somewhat preliminary. But here is what I’ve noticed so far:

1) Thanks to reconciliation instructions, they needed to improve the budget impact by at least $1 billion in the sidecar. They improved it by exactly $1 billion. Which goes back to what I’ve now said several times: the CBO process has now been so thoroughly gamed that it’s useless.

2) The proposed changes increase spending dramatically, most heavily concentrated in the out-years. The gross cost of the bill has risen from $875 billion to $940 billion over ten years–but almost $40 billion of that comes in 2019. The net cost has increased even more dramatically, from $624 billion to $794 billion. That’s because the excise tax has been so badly weakened. This is of dual concern: it’s a financing risk, but it also means that the one provision which had a genuine shot at “bending the cost curve” in the broader health care market has at this point, basically been gutted. Moreover, it’s hard not to believe that the reason it has been moved to 2018 is that no one really thinks it’s ever going to take effect. It’s one thing to have a period of adjustment. But a tax that takes effect in eight years is a tax so unpopular that it has little realistic chance of being allowed to stand.

3) As I expected, the size of the magic asterisk–the modern equivalent of David Stockman’s infamous “savings to be named later” in the Reagan budgets–has had to be beefed up to offset the new spending.

4) Medicare Advantage is being effectively outlawed–in some areas, the reimbursements will actually be below those of the fee-for-service programs.

5) A disturbingly high percentage of the revenues still come from insurance premiums for other programs. About $53 billion of the net deficit reduction is from Social Security taxes collected on the wages people will now be getting in lieu of health care benefits. But since those contributions raise the amount Social Security will eventually have to pay out, the Republicans convincingly argue that this is not true “deficit reduction”; it’s just deficit shifting. Ditto the premiums for the new long-term care insurance.

6) Ultimately, this rests on the question: are we really going to cut Medicare? If we’re not, this gargantuan new entitlement is going to end up costing us about $200 billion a year next decade, which even in government terms is an awful lot of money. There are offsetting taxes, but they’re either trivial or likely to be unpopular–look forward to a 4% rent increase when your landlord has to stump over the same amount for the new tax on rents. Then look forward to repeal of same.

I think this is a fiscal disaster waiting to happen. But no one on the other side cares, so I’m not sure how much point there is in saying that any more.

March 18, 2010
Poor Health Care History

Nick Kristof argues that once we pass health care, we’re going to see a big spike in life expectancy. Why? Because, well, it worked in the 1940s!

Was it the late 1800s, when anesthesia made surgery easier and far
more common? Was it the 1930s, when antibacterial medicines became
available? Or recent decades, when CAT scans and heart bypasses
proliferated?

The correct answer is: none of the above. While
data differ and the statistics aren’t fully reliable, a good bet is
that the best answer is the 1940s. In that period, life expectancy
increased about seven years.

Indeed, American life expectancy appears to have been longer
in 1942, 1943, 1944 and 1945 — even as hundreds of thousands of young
Americans were being killed in World War II — than it had been when
America was at peace in 1940.

A prime reason is that with the war
mobilization, Americans got much better access to medical care. Farmers
and workers who had rarely seen doctors now found themselves with
medical coverage through the military, jobs in industry or New Deal
programs.

This is just not right. While it’s true that the first antibiotics, the sulfa drugs, were discovered in the 1930s, they didn’t come into widespread use until the late thirties–the paper announcing Prontosil’s miraculous effects wasn’t even published until 1935. Penicillin, the forerunner of the new class of miracle antibiotics, was first produced in 1942.

There is no medical improvement in modern history that can compare with the improvements in water supplies and other public sanitation measures of the 19th and 20th centuries, the synthesis of insulin for Type I diabetes, or the invention of antibiotics. But we’re not talking about expanding access to antibiotics, which are among the most widely available medicines in the country–some supermarkets in the south literally give them away as loss leaders. We’re talking about expanding access to more expensive treatments with less dramatic results, and more side effects.

On a side note, there weren’t a lot of people suddenly taking New Deal jobs in 1940.

But it’s a nice testable prediction. I assume health care reform will pass. And if Kristof is right, and I am wrong about the limited mortality benefits of expanded health insurance access, then we should see a dramatic increase in life expectancy. Maybe seven years is too much, so let’s make it easy–say three or four years by 2020. That would make American among the the longest-lived people in the world. And if this happens, then absent some miracle invention like a broad-spectrum cure for cancer, I will happily admit that I was wrong.

Of course, if this doesn’t happen–if American life expectancy improvements continue to grind along at roughly the same slow pace–then it seems to me that Nick Kristof et. al. should unhappily admit that they were wrong, and that they seem to have convinced us to spend a whole bunch of money without saving many lives. Will this happen? Or will we be told that the problem is that we just didn’t spend quite enough money, and must spend even more to actually realize the full glory of reform?

March 18, 2010