Different River

”You can never step in the same river twice.” –Heraclitus

Quite often, “media bias” occurs not in the stories the mainstream media reports, but in the stories it doesn’t report. Here is blogger Arthur Chrenkoff writing in OpinionJournal:

Stephen Hayes of The Weekly Standard, who traveled to Afghanistan to witness the inauguration of President Hamid Karzai, quotes from the speech by the country’s first democratically elected leader:

Whatever we have achieved in Afghanistan–the peace, the election, the reconstruction, the life that the Afghans are living today in peace, the children going to school, the businesses, the fact that Afghanistan is again a respected member of the international community–is from the help that the United States of America gave us. Without that help Afghanistan would be in the hands of terrorists–destroyed, poverty-stricken, and without its children going to school or getting an education. We are very, very grateful, to put it in the simple words that we know, to the people of the United States of America for bringing us this day.

Sounds familiar? It shouldn’t. As Hayes writes, “Sadly, most Americans never heard these words. Gratitude, it seems, is not terribly newsworthy. Neither is democracy. The Washington Post played Karzai’s inauguration on page A-13, a placement that suggested it was relatively less important than Eliot Spitzer’s decision to run for governor of New York or the decision of the U.S. government to import flu vaccine from Germany.” As columnist Charles Krauthammer commented on the mainstream media’s reaction to the inauguration, “Miracle begets yawn.”

I’d like to add that the United States of America would likely not have done all that for Afghanistan were it not for the attacks of Sept. 11., 2001.

Remember that next time someone says the U.S. responded to 9/11 by doing bad things to innocent Muslims.

David von Drehle, a staff reporter for the Washginton Post Magazine, took a drive with a photographer and an assistiant though four “red states” to try to figure out who these strange beings were who voted for George W. Bush.

Though most of the article practically drips with condescension — the condescension of a 19th-century anthropoligist describing the religious views of rain-forest cannibals — it’s still worth a read — perhaps more for the writer’s reactions to the content rather than the content itself (read it like it’s written by a literate rain-forest cannibal).

A few notes from this field encounter with the cannibal of the Washington Post:

Though the author lives in Washington, DC, he grew up in a then-rural area of Colorado and took long car trips with his family to visit grandparents in Kansas. I’ve long had this theory that childhood car trips across the American heartland give one a perspective as an adult that practically no one without that experience has. This article shows that that perspective is not completely diluted even when one grows up to become an urban-dwelling liberal reporter who can’t quite remember what people in that heartland were thinking.

A couple of times, the author’s clear liberal bias shows through. For example, on page 2 one Nebraskan extols the virtue of living in a place that’s practically crime-free, where people can leave their doors unlocked without fear — and the reporter “hears” a “fear” of “diversity” and goes on to explain how nearly everyone in that county is white and US-born. Note here that it was the reporter, not the Nebraskan, who assumed that crime was the necessary consequence of the presence of non-white people.

He does, point out — sometimes intentionally, sometime perhaps not — that rural folks are not all idiots, and are not all ignorant, and are not all provincial. Many are well-read and seem well-educated, with or without college degrees. Many have travelled, and know what they are “missing” living where they live. He asks a Nebraskan if he’s ever been to New York City, and hears that the fellow has been “to the airport” — changing planes on business trips to Europe! And, he finds that many are quite reluctant to talk to a reporter from Washington, DC. Not out of distrust as such, but because they are in fact quite acutely aware of how “the media” views them. They watch the same TV as everyone else — and read the same internet as everyone else — and they (we?) are watching when the urban-dwellers on TV talk about them in a derogatory fashion. They know they are looked down upon for their religious views, their political views, their professions (farming, e.g.), and above all their social views.

And, they even speak coherently:

Unemployed, burdened by student-loan debt, raising young kids — and voting for Bush because of “his morals and his ethics.” Mark Pack seemed like a perfect person to ask about Thomas Frank’s theory of deranged hicks who cannot make mental connections about their own best interests.

“Mao said basically the same thing when he talked about religion being the opiate of the masses,” Pack answered. “And wasn’t it Lincoln who said you can’t fool all of the people all of the time? Bush got 54 million votes, and I don’t think they were all from blatant idiots. I think we get really carried away by generalizations in this country.

The most interesting part of the article is (on page 3) where Von Drehle notes that there is a social divide between the states where most adults are married, and the states where most are not:

For all the bluster and hand-wringing over the exit polls and the so-called values voters, the real demographic story of the 2004 election, according to Democratic poll-taker Stan Greenberg, was the pronounced victory by Bush among married people, both men and women. The old “gender gap,” in which men voted for Republicans while women favored Democrats, has turned into a “marriage gap.” Before I started this trip, I did some fiddling on the Internet with census data and election returns, and I found some striking correlations. Consider:

There are 30 states — including all the Red Sea states — in which married couples form a majority of all households. Bush won 22 of the 30, by an average of 21 percentage points. The eight that went for Kerry were very narrow victories, an average of five points. Utah, with the highest percentage of married folks, gave Bush his largest ratio of victory: 71 to 26.

In nine states, there are equal numbers of households headed by married and unmarried people. Sure enough, Bush and Kerry split them evenly, four for Bush and five for Kerry — and by middling margins, too: an average 16 points where Bush won, 11 points where Kerry won.

Of the 11 states, plus the District of Columbia, where married couples form a minority of all households, Kerry won seven, by a jaw-dropping average of 24 percentage points. Bush won five, by the relatively skimpy average margin of nine points. The District, with the lowest percentage of married folks, gave Kerry his biggest win: 90 to 9.

Doc Searls has an aerial photo of La Conchita, California taken from an airplane on approach to Santa Barbara this past Friday, after the recent mudslide. It clearly shows the area of the mudslide, and evidence of several other mudslides in the immediate vicinity, mostly in unpopulated areas. Take a look, it’s really does show the “whole picture” (no pun intended).

For reference, for those of you who are familiar with Southern California, but (like me) had no idea where La Conchita is and discovered Mapquest doesn’t seem to know either: It’s on the Pacific Coast Highway (CA-1 and US-101) in between Ventura and Santa Barbara, about 5 miles from Carpinteria. There’s a map here. There is also topographic map from 1869 and an aerial photo from 1927 (the first ever) here , courtesy of Jeff Hemphill, a graduate student in the Geography Department at UCSB.

TennCare is the program sponsored by the state of Tennessee, with the goal of providing health insurance for just about everyone in the state. Basically, it expands Medicaid both in terms of who’s eligible and what’s covered.

TennCare was introduced 1994, after the failure of the Clinton health care proposal, and it was supposed to serve as a model for the nation of how health care could be provided for the uninsured without a government takeover of the entire health care system. It was also supposed to save the state money. (The link is to a pro-TennCare web site.)

It turns out TennCare has serves as a model for the national of how a program that ignores basic economic facts — like the fact that when you give something away for free, people will take more of it — can nearly bankrupt an entire state government. TennCare is being seriously cut back by a Democratic governor who was elected on a pro-TennCare platform. 45% of adults on TennCare are losing their eligibility, and there are going to be limits on care (for example, no more than 12 doctor visits per year).

Captain Arbyte explains the whole thing, so I don’t have to. His post is really, really good. Read the comments, too.

(Thanks to this week’s Carnival of the Capitalists at Small Business Trends for the pointer.)

Via Jeff Jarvis: The Roman Catholic archbishop of Mosul, Iraq has been kidnapped.

This should put an end to the notion that the terrorists in Iraq are merely against the Americans. (Of course, the fact that they are mostly killing Iraqis should have put an end to that notion long ago, but more people will probably notice this one.)

UPDATE (Jan. 18, 2:08 pm): He’s been released.

Senator Edward Kennedy (D-MA), is proposing that Medicare, the federal government’s health-care program for people over 65 or disabled, be expanded to cover every American. In a speech at the National Press Club, he said:

An essential part of our progressive vision is an America where no citizen of any age fears the cost of health care, and no employer refuses to create new jobs or cuts back on current jobs because of the high cost of providing health insurance.

The answer is Medicare, whose 40th birthday we will celebrate in July. I propose that as a 40th birthday gift to the American people, we expand Medicare over the next decade to cover every citizen – from birth to the end of life.

It’s no secret that America is still dearly in love with Medicare. Administrative costs are low. Patients’ satisfaction is high. Unlike with many private insurers, they can still choose their doctor and their hospital.

Putting on my “health economist” hat, I have to say, sorry, but that is just not going to work.

The dirty little secret behind Medicare is that it works only because it does not cover every American. Part of the reason for this is that Medicare’s payment structure is designed to pay doctors and hospitals in such a way as to limit total spending, rather than to ensure they can break even. Clearly, they have to do better than break even to stay in business, and the people running Medicare know that. Medicare depends on the fact that there are lots of non-Medicare patients out there who (through their private insurance) can pay enough to keep the doctors and hospitals in business. This is called “cost shifting.”

Some background: Medicare determines payments for services by assigning a “relative value” to each service based on the estimated amount of “resources” the service requires. “Resources” includes the doctor’s time, the medical supplies, rent for the office, support staff, and even malpractice insurance. (This is the system for doctor’s services; hospitals are paid under a different system, but the basic idea is the same.) Every service has a set number of “relative value units,” and that number gets multiplied by a “conversion factor” to determine the payment for that service.

Every year, the Center for Medicare and Medicaid Services determines the conversion factor for that year. They do this by estimating the total number of each service that will be required that year — based on population, practice patterns, and so forth — and adding up the total number of relative value units for those services. Then — get this — they take the total budget for each type of service, and divide it by the total number of relative value units. They do this with separate budgets for physician services and for hospitals, and for certain sub-categories within those budgets. In other words, they decide in advance how much to pay doctors that year, and divide that payment by the total amount of physician services (relative value units) to get the price per unit. How much the unit is actually worth to the patient is completely irrelevant. (If this sounds like the Soviet-style approach to economic planning, that’s because it is like that!)

Furthermore, if they foul up one year (in predicting the number of units of service that will actually be billed), they make it up the next year by reducing the next year’s payments. This is something like telling your gas station that they have to reduce their price per gallon for 2005 because you drove more miles than you expected in 2004. Those whole process, in all its gory detail, is explained in this document — which also explains how in 1997 and 1999 they reduced the conversion factor. In government-speak, this is called a “negative update.” To doctors and hospitals, it is called a “pay cut.”

There is another subtle reason why this system cannot work in the absense of private medical insurance. The relative value units for each service have to be determined before Medicare can pay for the service, and they are determined on the basis of “actual” costs based on survey data. This means that somebody has to actually be providing the service before it’s covered by Medicare, and that means there have to be patients outside the Medicare system to provide it to. Currently, this is not a problem — almost everybody in the U.S. under the age of 65 is not covered by Medicare. (The only exceptions are for certain types of disabilities, and end-stage renal disease.) Medicare covers everything a year (or more) after everyone else, but at least when they finally get around to covering something, their payments have at least some basis in reality.

If everyone were in Medicare, there would be no data on “pre-Medicare” costs for new (or changed) services, so they’d have to make blind guesses as to how much to pay for things, and the fee schedule would be even more detached from reality than it is now due to the budget process. This would result in patients getting the wrong services, since doctors would be loathe to perform services on which they consistently lost money, and would have added incentive to perform services for which they made more money. If (say) they set the payment for mammograms too low, it would be tough finding anyone willing to do mammograms. That’s true now too, of course, but without the non-Medicare world providing independent cost information, they’d be much more likely to set the payment too low.

One more thing: As far as Kennedy’s claim that “administrative costs are low”: Is he still under that bridge he drove off of? I’ve talked to certain medicare providers, who make literally one penny per unit on certain items provided under Medicare. That one penny is supposed to be enough to cover all their other costs — personnel, rent, etc. That would be bad enough, except that the “administrative costs” of sending Medicare a bill and dealing with the Medicare bureaucracy to get paid is very costly, so costly they lose money on every patient, and would even if the “profit” (hah!) were substantially more than one penny per unit. When they report their costs to Medicare, it’s tough to convince the bureacrats to include the cost of submitting the bills and chasing down erroneous denials of claims in their “allowable costs.”

Why, you ask, would they continue to provide services to Medicare patients even though they lose money every time? The answer is, they depend for their business on referrals, and to keep the referrals coming, as a practical matter they have to accept every patient referred to them. They people doing the referring don’t want to have to keep track of who’s got what insurance when they make their referrals, so they will not refer anybody to providers that don’t accept a substantial proportion of patients, as the Medicare patients are. So in effect, they have to accept the Medicare patients on whom they lose money in order to get the private-insurance patients on whom they make money. (Remember what I said about cost shifting?) Now, if Kennedy’s proposal were passed into law, there would be no more non-Medicare patients, so these providers would lose money on every patient, and they would go out of business completely. And there would, therefore, be no such services provided at all.

Like I was saying: the dirty little secret behind Medicare is that it works only because it does not cover every patient.