Medicaid Does Make People Healthier

Planet Money, a special program on NPR, had an episode last week exploring the research recently released by Katherine Baicker, a health economist at Harvard.  Her research has begun to lay to rest at least one argument against expanding Medicaid, but it's also called into question an oft cited rationale people use when they are to expand Medicaid.  You can listen to the whole thing here (which also goes into the methodology of the research), but here are some of the key takeaways:

• Across a similar socio-economic level, people on Medicaid reported better health than people not on Medicaid (reliant on faith-based, charitable, emergency room, i.e. non-government based healthcare).
• Respondents on Medicaid were 40% less likely to go into debt collection.  Basically, we see positive spillover benefits from Medicaid coverage.  People don't rack up a lot of medical debt, so they have less debt overall so they are much more likely to be able to service the debt they have and not slip into collection.
• Respondents indicated feeling more healthy within a month of being on Medicaid, even though it took many of them much longer to really engage with the system.  Basically, without the threat of catastrophic health costs hanging over their heads people instantly felt better, less stressed.

All of these are positive things.  But there are a couple caveats to note.  First, this is based on survey results, credit reports, and various other non-biological data (though the study does include some health records).  The researchers have actually taken blood samples from many of the people surveyed and when those results get released you could have definitive medical evidence of improved healthcare outcomes for people on Medicaid.  The second caveat is perhaps a bigger issue:

• The group on Medicaid actually spent 25% more on procedures than the group not on Medicaid during the first year of the program.

One of the biggest economic rationales for expanding Medicaid is that it will pay for itself.  As people have access to preventive care the overall cost would come down and the expansion would pay for itself.  In the first year of research this didn't prove to be true.  

I would speculate (and I acknowledge it's speculation) that you might be see a binge effect.  People have gone from famine to feast and as they see primary care doctors, those doctors find problems that may have been ignored for a long time.  And the research indicates that most of procedures undergone by Medicaid recipients were scheduled, which would support my speculation.  The researchers are still tracking this group and will report out year two results soon.  I wouldn't be surprised to find that in year two the costs of the Medicaid group drop substantially as people level off into a steady, healthy state.

For now, Baicker says rather eloquently, we have two definitive pieces of information.  One, people on Medicaid have better health outcomes.  Two, having people on Medicaid is more expensive (so far).  So policy makers have to make the cost-benefit analysis for themselves.  What's the value of a healthier populace?  Does it exceed the cost?  I think you all know where I come down on this, but I'm sure there are those that would disagree.

Let’s Talk About War (Armed Conflict)

So, last week I briefly responded to Spencer Ackerman’s Danger Room post on Secretary of Defense Panetta’s concession that the United States is engaged in a war (armed conflict) in Pakistan. This week, Ackerman jumps on the idea of a U.S. war in Pakistan and argues, given that there have been more drone strikes in Yemen than in Pakistan this year then: “Surely, if America is at war in Pakistan, it’s at war in Yemen, too.”

That’s a persuasive a fortiori argument in the abstract, in this moment in time, with that antiquated terminology: war.

“War” is antiquated? Indeed it is. Once upon a time, before World War II, “war” as a legal state existed. But war was essentially a legal status invoked by states and, because war had been outlawed—and because it is a choice of law mechanism imposing certain responsibilities on states—it was often not invoked even when states were quite clearly at war (in a colloquial sense). In this era, states would engage in extraordinary amounts of hostilities over a prolonged period using their regular armed force and refuses to concede what was plain: they were at war. In turn, captured soldiers were denied prisoner of war status; laws respecting neutrality were ignored; civilians were denied the protections of war that the legal status of war affords them.

In the wake of World War II, the drafters of the Geneva Conventions of 1949 set about to rebuild the edifice of the laws of war in a way that they could not be avoided in such a pretextual way. Thus, the drafters chose—and the world acceded to—the notion that international humanitarian law would be invoked when an armed conflict occurs. And this idea, the occurrence of an armed conflict, would be determined objectively without reference to whether the states involved declared themselves to be at war. The drafters also differentiated between armed conflicts of an international character (those taking place between states) and armed conflicts not of an international character (those taking place between a state and a non-state actor or among non-state actors). The International Criminal Tribunal for Yugoslavia famously fleshed out these notion in its “Decisionon the Defence Motion for Interlocutory Appeal on Jurisdiction” otherwise knownas Tadic.

International armed conflicts exist whenever states resort to force against each other. But Tadic teaches us that the existence of a non-international armed conflict is determined with reference to the organization of the non-state actor and the intensity of the violence between the parties. Tadic and further ICTY determinations, as well as the authoritative commentary to the 1949 Conventions provide guidance for measuring relative organization and intensity of hostilities to determine an armed conflict’s existence. Relevant factors include geographic scope and duration of hostilities, whether military-type weaponry is used, whether the non-state actors are hierarchically organized, whether they are responsive to some sort of command, whether a governmental force (if involved) uses its regular armed forces as opposed to its police force, and more.

Importantly, Tadic also makes clear that the geographic and temporal scope of an armed conflict are not limited the immediate time and vicinity of armed clashes. Instead, if a non-international armed conflict exists, it exists throughout the state(s) in which it is occurring. And, it exists until “a peaceful settlement is achieved.”

And that brings us back to Ackerman’s quote. Despite Panetta’s statement, a real analysis of whether the United States is engaged in an armed conflict in Pakistan requires a Tadic analysis. Fortunately, such an analysis has been done and it concluded that, at least by 2010, and at least with respect to hostilities between the United States and Tehrik-e-Taliban Pakistan, the United States was indeed engaged in an armed conflict. For the sake of argument, let us assume that hostilities between the TTP and the United States are ongoing. If that’s true then, no “peaceful settlement [has been] achieved.” Thus, an armed conflict is ongoing in Pakistan.

But that does not mean an armed conflict is necessarily ongoing in Yemen. Although more drone strikes may have occurred so far this year in Yemen than in Pakistan, we would still have to conduct an independent analysis of the intensity of the hostilities between the United States and non-state actors in Yemen to determine whether an armed conflict exists. If, for example, 23 drone strikes in Yemen represent insufficiently intense hostilities between the United States and a non-state actor in Yemen, then there is no armed conflict in Yemen. And, although there have been fewer strikes in Pakistan, because there was an armed conflict in Pakistan previously and there has been no peaceful settlement, an armed conflict in Pakistan between the United States and a non-state actor persists!

This raises an ancillary point: What about the violence occurring between the state of Yemen (or Pakistan) and non-state actors in Yemen (or Pakistan) and what about the United States’s role in that violence? If that violence rises to the level of an armed conflict (and if those actors are sufficiently organized), then an armed conflict exists between the state and the non-state actors. U.S. use of force in that armed conflict constitutes an intervention in that armed conflict, and places the United States in an armed conflict. Depending on whether the United States is using force in support of or against the territorial state in question, dictates the nature of the United States’s armed conflict. For example, use of force against AQAP on Yemen’s behalf places the United States in a non-international armed conflict with AQAP so long as Yemen and AQAP are engaged in an armed conflict.

Notice that this implicates another point Ackerman made in his piece:

Katherine Zimmerman, an analyst at the American Enterprise Institute, doesn’t believe all this fighting adds up to the US being at war in Yemen, although she admits it’s “understandable” why others might hold that view. She sees the difference between the Pakistan war and the Yemen conflict as one of partnership, and intent. “It’s slightly different because of the local cooperation. The effort in FATA [Pakistan's Federally Administered Tribal Areas] are more heavily driven by Americans,” Zimmerman tells Danger Room. “In Yemen, we’re essentially acting as a stop gap until Yemenis can take full responsibility. We’ve got a very willing partner in Yemen. We’re working on making it an able partner.”

Sort of. So, Zimmerman is right that whether we are operating in concert with the local government is important. But whether the Pakistani government is actively or passively cooperating with the United States is irrelevant—at least to an analysis whether there exists an armed conflict. Zimmerman’s point might be directed to questions of jus ad bellum as opposed to jus in bello. In that case, she might be suggesting that in Pakistan the United States is relying on self-defense whereas in Yemen the United States is relying on state consent. Regardless, whether those actions—given the consent or not of the territorial state—rise to the level of an armed conflict is a wholly separate question.  

War in Pakistan, You Say?

Over at Danger Room, Spencer Ackerman blogsthat Defense Secretary Panetta today admitted that the United States isfighting a war in Pakistan. As Ackerman notes, this is hardly revelatory—by 2010, I was arguing that U.S. use of force in Northwest Pakistan rose to thelevel of an armed conflict, at least against Tehrik-e-Taliban Pakistan.

Ackerman states this, however:

In case you’re wondering, there aren’t many legal implications or obligations prompted by Panetta’s admission. The 2001 Authorization to Use Military Force, the legal wellspring of the war on terrorism, clearly authorizes attacking the perpetrator organization of 9/11 unbounded by geographic limits. Besides that, the short document is vague enough to fly a Predator through. There is little upside and much risk for any politician arguing it’s time to end the 9/11 Era. To paraphrase Oliver Wendell Holmes, the life of the war has not been law; it has been politics.

His butchering Holmes aside, Ackerman is correct—but not for the reasons he thinks. The fact is, the existence of an armed conflict, irrespective of the AUMF, does have legal implications for the United States. More importantly, whether an armed conflict exists is a question of fact determined by the intensity of hostilities and the degree to which the parties are organized. If the conflagration in question exceeds this so-called Tadic threshold, then an armed conflict exists. And, if an armed conflict exists, then international humanitarian law—otherwise known as the law of armed conflict or the law of war—is triggered, giving rise to very particular legal implications and obligations. Noticeably absent from this analysis is whether a state has declared itself to be at war.

More importantly, Ackerman’s characterization of the AUMF as being territorially boundless is at least controversial. The Bush and Obama administrations have certainly treated the AUMF as such but they’re practice is hardly the final word. IHL clearly recognizes territorial bounds to armed conflict. In inter-state conflict, the geographic limits are defined by the law of neutrality. In intra-state armed conflict, the geographic scope of the armed conflict is limited to the state(s) in which, under Tadic, the armed conflict exists. Thus, an armed conflict in Pakistan is limited to Pakistan, meaning that a member of the TTP—one party to the armed conflict in Pakistan—who happens to be walking around Iran, say, would not be subject to use of force in the same way he would if he were walking around South Waziristan.

Invest Now to Grow Later

The economy isn't in good shape these days really just about anywhere in the world.  This global economic doom and gloom, though, has created a rather Un-Greek opportunity for the United States.  In an op-ed piece former Treasury Secretary, Larry Summers lays out the situation very succinctly:

 In real terms, the world is prepared to pay the U.S. more than 100 basis points to store its money for five years and more than 50 basis points for 10 years. Maturities would have to reach more than 20 years before the interest rates on indexed bonds becomes positive.

Basically, the U.S. can sell bonds, the market will buy, and we'll pay less than the face value to service that bond for over 20 years.  In other words this is free money.  So what could we do with this money?  Well Matt Yglesias brings up the issue of aging water infrastructure in the nation's capitol where the average water main is 77 years old.  This sort of infrastructure investment will be necessary at some point, and that point, after 77 years, is probably sooner rather then later.  Much like healthcare, it's cheaper to maintain the health of our infrastructure then to pay to replace it after a calamity.  Back to Sec. Summer, he notes: 

Any rational chief financial officer in the private sector would see this as a moment to extend debt maturities and lock in low rates – exactly the opposite of what central banks are doing.

In other words, we're missing our moment, because we've become afraid of debt.  But we aren't Greece and while we have some systemic debt issues we must address, I'm comfortable in suggesting we're still going to want roads, bridge, and running water.  Why not lock in a ridiculously low rate to make that investment now?

George Will’s Retelling of Citizens United

It takes a special level of arrogance—a George Will level of arrogance—to describe the Citizens United decision as “unremarkable.” One might argue that the scope and duration necessary for any controversy to be resolved by the Supreme Court definitionally renders it worthy of remark. Regardless of your preferred outcome in that case, a decision like Citizens United, one in which the Court ordered re-argument on issues not presented in the original brief, one in which the Court overturned a federal law and overruled its own caselaw, and one that was decided 5-4, is certainly worthy of remark.

Will’s mischaracterization of Citizens United does not yield there. No, Will wrongly frames Citizens United as a case over whether individuals yield their First Amendment rights when they join a corporation or a labor union. While this frame—divorced from reality though it is—allows Will to wrap himself in self-righteousness, it both obscures the reality of the decision and ignores the fact that at will employees may indeed forfeit their First Amendment rights when employed.

In fact, the Citizens United decision had little to do with individuals. Instead, the Court determined that the government “may regulate corporate political speech through disclaimer and disclosure requirements, but it may not suppress that speech altogether.” In arriving at this conclusion, the Court took a number of interesting turns, including its determination that the only present danger of corruption is that of so-called quid pro quo corruption and that there is no such danger when a corporation (or union) spends vast sums of money to get a candidate elected so long as they do not give the money directly to the candidate. You are correct: that makes no sense.

But these pesky facts do not stop Will from engaging in a polemic defense of a supposed liberal assault on free speech. While Will busily makes himself the defender of “free speech,” “political speech,” and the “First Amendment” (quoted because of the shear repetition with which Will deploys these terms) in the face of some supposed liberal assault on speech, he manages to make a hash of both history and logic.

Will labels an ABA article as false for correctly noting that Citizens United enabled so-called Super PACs (not PACs at all). Indeed, these organizations would not be possible were it not for Citizens United (with a boost from Speech Now). Will then embraces what has apparently become the Right’s favorite logical fallacy to defend Citizens United: because the Republican primary this year was long and occurred after the Citizens United decision, the Citizens United decision must be the cause of the primary’s length (in this, the best of all possible worlds). Moreover, because a long primary requires political speech, there must be more political speech this year than in previous years—and this must be due to Citizens United! Citizens United improved the quality of our democracy, silly Liberals.

The logic here is nonsense, of course. Worse, the premise is false. The Democratic primary in 2008—before the Citizens United decision— lasted several weeks (and, effectively, two months) longer than the Republican primary campaign this year. More than two times the total number of votes cast in the 2012 Republican primary campaign were cast in the 2008 Democratic primary campaign: 35,442,193 to 16,110,412. But you need not rely on 2008 to attack the premise of Will’s argument. The Democratic primary in 2000 lasted only until March 9 but there were more than 13 million ballots cast in that contest. And the Republican contest that year saw more than 19 million ballots cast! I could go on.

Citizens United, whatever Will may say, is a truly remarkable decision. It has also resulted in a tremendous increase in the amount of money spent on elections. Whether it has improved the quality of speech and debate, whether it has increased the number of voices, and whether it has improved our democracy are more difficult questions to answer. Those are questions worthy of debate—real debate, not the specious variety Will is here trafficking in. 

No One Could Predict

That over-reliance on drone strikes might undermine our long-term strategic objectives: 

“These attacks are making people say, ‘We believe now that al-Qaeda is on the right side,’ ” said businessman Salim al-Barakani, adding that his two brothers — one a teacher, the other a cellphone repairman — were killed in a U.S. strike in March.

See also "No End In Sight." 

Constitutional Reform

Sanford Levinson writes in today's New York Times:

What was truly admirable about the framers was their willingness to critique, indeed junk, the Articles of Confederation. One need not believe that the Constitution of 1787 should be discarded in quite the same way to accept that we are long overdue for a serious discussion about its own role in creating the depressed (and depressing) state of American politics

Levinson's Op-Ed, highlighting several political obstacles hindering decisive action by the federal to address pressing national challenges, is interesting but its analysis leaves something to be desired. Most of his handful of suggested reforms would enhance the power of the President. Such Executive aggrandizement--by allowing the President to weight Congress; by allowing the Congress to override the Judiciary's pronouncements on the Constitution; by requiring a super majority for the Supreme Court to exercise judicial review--may lead to an Executive Branch that is more nimble and more effective in dealing with the challenges present in Levinson's mind. But that agility will be limited to those problems. And Executive strength is not something for which we want currently. 

It seems to this observer that the inability of the country to address its most pressing challenges stems not from interbranch intransigence but from a weak and dysfunctional Congress. One might accomplish more--and do so more safely--by doing away with the Senate's cloture requirement--an act whose execution requires merely the Senate and no other organs of government. 

We could also elect better representatives. 

As If To Ensure A Sectarian Character

Al Jazeera describes the massacre in Houla thus:

Houla then came under an intense artillery barrage that killed about 15 villagers. Members of the shabbiha then entered Houla from the nearby Alawite villages and killed scores of men, women and children by hacking them or shooting them at close range.