Tag: New York

Medicaid’s Cash Cab

As Congress hashes out an agreement behind closed doors to expand the government’s role in health care, a Medicaid story out of New York serves as another reminder that government is part of the health care problem, not the solution. Audits released by the state’s comptroller found $169 million in misspent funds, including a $196,000 cab bill for a woman who took a daily $300 taxi ride to visit her son in Albany for three years.

The following are some of the findings:

  • $53 million in overpayments for Medicaid recipients who had multiple identification numbers.
  • $20 million that was nearly spent because the state’s computer system failed to catch a clerical error. Auditors caught it before it was paid out.
  • $5.4 million in overpayments to 10 hospitals that billed for discharging a patient when, in fact, the patient had been transferred to another facility. Hospitals receive higher payments for discharges rather than transfers.
  • $1.2 million paid for services that were not medically necessary or not provided.

According to the state’s comptroller, “[T]he state Medicaid system is leaking millions of dollars… Safeguards designed to protect the taxpayers by detecting waste, fraud and abuse keep failing.” However, this is business as usual when it comes to New York’s notoriously fraud-ridden Medicaid program, as a Cato essay on fraud and abuse in federal programs notes:

The former chief investigator of the state’s Medicaid fraud office believes that about 10 percent of the state’s Medicaid budget is consumed by pure fraud, while another 20 to 30 percent is consumed by dubious spending that might not cross the line of being outright criminal.

A 2005 investigation by the New York Times found remarkably brazen examples of fraud and abuse in New York’s Medicaid. The article noted that the program has “become so huge, so complex, and so lightly policed that it is easily exploited… [T]he program has been misspending billions of dollars annually because of fraud, waste, and profiteering.”

With the massive and complex expansion of Medicaid and other health programs in the pending legislation, we can expect a gargantuan expansion in fraud and abuse. The good news, I suppose, is that the government will need a massive hiring of new health care auditors, which should reduce the nation’s unemployment rate.

For more on fraud and abuse in government healthcare, see here.

Talking about Terrorism

Terrorists are named after an emotion for a reason. They use violence to produce widespread fear for a political purpose. The number of those they kill or injure will always be a small fraction of those they frighten. This creates problems for leaders, and even analysts, when they talk publicly about terrorism. On one hand, leaders need to convince the public that they are on the case in protecting them, or else they won’t be leaders for long. On the other hand, good leaders try to minimize unwarranted fear.

One reason is that we shouldn’t give terrorists what they want. Another is that fear is a real social harm, particularly when it is exaggerated. Stress from fear harms health. It causes bad decisions. For example, if people avoid flying and drive instead the number of added fatalities on the road will quickly surpass the dead from a typical terrorist attack. Most important, excessive fear causes policy responses that often damage the economy without much added safety. Measured in lives on dollars, reactions to terrorism often cost more than the attack themselves.

If leaders talk only about the danger of terrorism and everything they are doing to fight it, without putting danger in context, they may be on safe political ground, but they risk causing or prolonging groundless fear and encouraging all sorts of harmful overreactions. That is the Bush Administration’s counterterrorism record, in a nutshell. If leaders just say “calm down and worry about something more likely to harm you,” they will be butchered politically.

So a reasonable approach is to sound concerned but reassuring. You want to convince people that they are mostly safe without appearing complacent. I don’t like many of this administration’s counterterrorism policies, starting with Afghanistan, but thus far its communication about terrorism is far more sensible than the last administration’s. That includes the aftermath of this attempted Christmas Day attack.

The administration made it clear that it is unacceptable that a guy we just got warned about got onto a plane wearing explosives. But the President also said Americans should be generally confident in their safety from terrorism. He didn’t act as if this incident was the most important thing on his schedule this year or compare the Al Qaeda affiliate in Yemen to the Third Reich or what have you, exaggerating their capability and power. I wish he had gone further and said that detonating explosives smuggled on to a plane is tricky and that flying remains incredibly safe. (Jim Harper will soon have more to say here on the security failures and how to talk about them.)

In a different political universe, the President could describe the terrorist threat honestly. He would say that recent attempted terrorist attacks in the United States show more amateurism and failure than skill and success. He could add that we are fortunate that our greatest enemy, al Qaeda and its fellow-travelers, are scattered and weak compared the sorts of enemies we historically faced. He would sound more like Michael Bloomberg, who told New Yorkers that they had a better chance of being struck by lightening than killed by terrorists, after a particularly inept terrorist plot on JFK airport was uncovered. He could even quote Nate Silver, who calculates that in the last decade of US flights, there was one terrorist incident per 11,569,297,667 miles flown. It’s true, as Kip Viscusi demonstrates, that people don’t think like actuaries. They rightly value different sorts of deaths in different ways, and want more protection against terrorism than other dangers. But knowing the odds is still important in weighing the appropriate amount of concern and forming policy preferences. The president could also have treated voters like grown-ups and pointed out that whatever flaws in airline security that this attempted attack reveals, there is no such thing as perfect safety, and sooner or later even the finest security systems fail.

I also disagree with the argument that the trouble with our airline security or national security policy-making in general is insufficient presidential attention. Overall, we could do with a little more masterly inactivity in security policy, to use an old British phrase. Aviation security is another matter, but I struggle to see how presidential involvement would have fixed this problem. The 9-11 Commission did claim that September 11 occurred because leaders failed to pay sufficient attention to al Qaeda, but there, as in other matters, the Commission is wrong. At least in the executive branch, the attention paid to the threat in the 1990s was quite substantial, as you can see in this essay by Josh Rovner or in my contribution to this book. The historical record shows that the threat was well understood by security officials and the reading public. Time, for example, called Osama bin Laden the most wanted man in the world when they interviewed him in 1998. The trouble, in my opinion, was not misperception but our policies and the difficult and unprecedented nature of problem–a terrorist group ensconced in hostile country that refused to do anything about it.

Getting the line between confidence and vigilance right is not easy, but it starts with acknowledgment that there is such a thing as overreaction. That subject will be the on the agenda for our January 13 counterterrorism forum with James Fallows, State Department Counterterrorism Coordinator Daniel Benjamin, Paul Pillar and others.

*My attempts to explain this stuff to Politico yesterday resulted in some confused and inaccurate uses of my quotes in this story by Carol E. Lee, which unconvincingly compares the Obama’s response to this terrorist attempt to his silly involvement in the Henry Louis Gates arrest fiasco. First, Lee absurdly uses me as example of “predictable” attacks from the right on Obama, when I said I was glad that the President said Americans should feel confident but that I’d have preferred if he’d done it more forcefully by saying flying remains safe and al Qaeda weak. That is more or less the opposite of the predictable take on the right. Then, she says that my views on the President’s response to the attacks referred to his post-press conference golf outing. I was talking about his overall response, or lack thereof, over the last several days. I can’t decipher the meaning of presidential golf.

The John Yoo Theory of Gun Control

A modest proposal: Suppose that we decide to streamline our inefficient criminal justice system by treating people under suspicion of involvement with violent crime—whether or not they’ve been arrested, charged, or even informed of this suspicion—as equivalent to convicted felons.  Suppose, then, that we permit them to be stripped of certain constitutionally protected rights at the discretion of the executive branch.

Outrageous?  Some depraved brainchild of the Bush administration’s Office of Legal Counsel?  Actually, it’s the editorial position of The New York Times:

Under federal law, people who pose a heightened risk of violence cannot buy or own firearms, including convicted felons, domestic abusers, the seriously mentally ill and several other categories. Suspected terrorist is not one them.

Individuals on the government’s terrorist watch list can be barred from boarding airplanes, but not from purchasing high-powered guns or explosives. Bipartisan legislation in both houses of Congress would end this ridiculous loophole, commonly known as the “terror gap.

The Times does note, before dismissing the fact with the wave of a hand, that “thousands” of people have been found to be on the list improperly.  But let’s linger a bit longer over this.  The terrorist watch list, at last count, boasted about a million entries.  When you eliminate variant spellings and duplicate entries—and rest assured that this would be another enormous source of problems—there are about 400,000 unique individuals on the list, of whom some 20,000 are Americans. Thousands more are nominated for inclusion on the list each week.

Employ, for a moment, some common sense and arithmetic. The 9/11 attacks were carried out by 19 people. (I should add: 19 people armed with box cutters.) If even one percent of those 20,000 were truly intent on staging violent domestic attacks, doesn’t it seem likely we would have noticed? To be sure, some small subset of them really are serious threats. They are probably the very people the government is actively investigating, and would prefer not to tip off by, say, having their attempted gun purchases denied.

There’s also, of course, an almost heartwarming faith in formal process here.  I can imagine circumstances where blocking someone at a point of sale might prevent bloodshed—some guy in the heat of passion or the haze of liquor acting on impulse to settle a score. But trained and fanatically committed terrorists, backed by the resources of an international network, who typically spend months or even years plotting significant operations? Are they serious? How does that conversation go? “No, no, I’m sorry Osama.  Yes, the Wal-Mart clerk, she would not sell us a pistol! I know, and after Ayman went to all that trouble making our fake passports by hand. I was disappointed too.  But I guess we’d better scrap the plan and head back to Yemen.”

What the other categories of “risky” people the Times lists have in common is  that they’ve been determined to be dangerous by a court, which is normally the process by which we go about depriving people of their rights. It seems perverse to depart from that principle precisely for the category of suspects least likely to be hampered by these sorts of limitations.

A Victory for Property Rights

Ilya Shapiro warns us that the U.S. Supreme Court probably will not uphold property rights in a case involving Florida beachfront property.  But property rights did receive an unexpected boost in New York yesterday, where an appeals court overturned a taking for the benefit of Columbia University.

Reports the New York Times:

A New York appeals court ruled Thursday that the state could not use eminent domain on behalf of Columbia University to obtain parts of a 17-acre site in Upper Manhattan, setting back plans for a satellite campus at a time of discord over government power to acquire property.

In a 3-to-2 decision, a panel of the Appellate Division of State Supreme Court in Manhattan annulled the state’s 2008 decision to take property for the expansion project, saying that its condemnation procedure was unconstitutional.

The majority opinion was scathing in its appraisal of how the “scheme was hatched,” using terms like “sophistry” and “idiocy” in describing how the state went about declaring the neighborhood blighted, the main prerequisite for eminent domain.

The $6.3 billion expansion plan is not dead; an appeal has been promised, and Columbia still controls most of the land. But at a time when the government’s use of eminent domain on behalf of private interests has become increasingly controversial, the ruling was a boon for opponents.

“I feel unbelievable,” said Nicholas Sprayregen, the owner of several self-storage warehouses in the Manhattanville expansion area and one of two property owners who have refused to sell to the university. “I was always cautiously optimistic. But I was aware we were going against 50 years of unfair cases against property owners.”

New York state is not a particularly friendly venue to property rights, but the judges rightly saw through the claims made by state official to justify seizing property from a private person for the benefit of a private organization.  The ruling could be reversed, but nevertheless is an important affirmation that property rights warrant constitutional and legal protection even in New York.

Schumer Fouls Out

Chuck Schumer is perhaps my favorite U.S. Senator because of his endless capacity to make me laugh.  He often reminds me of Inspector Clouseau, the earnest but bumbling detective from the Pink Panther movies.

Through an excellent post by Scott Lincome today, I learned not only that official NBA jerseys (those worn by the players) are made for Adidas in upstate New York, but that Senator Schumer is attempting to thwart the company’s decision to move production to Thailand. 

I share Scott’s assessment of the absurdity of Schumer’s efforts, but more importantly, I wanted to share this humorous footage of Schumer’s awkward nativist appeal that basketball is an American-centric game….conducted in front of German-born NBA Star Dirk Nowitski’s jersey. 

Classic!

The Third Strategic Actor

I agree with Chris Preble’s assessment of Steve Simon’s opinion piece in the New York Times Tuesday. Why We Should Put Jihad on Trial” is animated by a sound understanding of the strategic logic of terrorism. Simon knows that the proper response is outclassing terrorists in terms of ideology and legitimacy. Trying KSM transparently in New York is just, and doing justice is powerful counterterrorism. The procedural and security fears about it are poorly founded.

It’s useful to compare another opinion piece, written with welcome thought and care, but missing a key point about counterterrorism. In “Holder’s al Qaeda Incentive Plan,” Wall Street Journal “Main Street” columnist William McGurn assesses the incentive structure terrorists face if they are accorded the niceties of a trial should they attack civilians in the United States, compared to the rough treatment they would and should expect were they caught attacking U.S. troops on a foreign battlefield.

It’s a troublesome irony, and it’s very smart on McGurn’s part to game out the thinking of terrorists rather than indulging impulses to react as they would have us do. But terrorists are not the actors a trial in New York is most meant to influence.

In her book, How Terrorism Ends: Understanding the Decline and Demise of Terrorist Campaigns, U.S. National War College professor of strategy Audrey Kurth Cronin writes:

Most people think of terrorism as a dichotomous struggle between a group and a government. However, given their highly leveraged nature, terrorist campaigns involve three strategic actors—the group, the government, and the audience—arrayed in a kind of terrorist “triad.” More specifically, the three dimensions are the group that uses terrorism to achieve an objective, the government representing the direct target of their attacks, and the audiences who are influenced by the violence.

Similarly, at Cato’s counterterrorism conference, I argued that terrorism seeks to induce overreaction on the part of victim states, driving support to terrorists from their geographical and ideological neighbors. Declining to overreact, and having the discipline to meticulously accord terror suspects fair treatment, dissipates the gains terrorists want and expect: increased support from their neighbors.

This is why a public trial—for all its costs and complexities—is worth doing. It’s to gain advantage with the third strategic actor.

Tuesday Links

  • Dear members of Congress: If you’re not going to read the bills you pass,  at least read the Constitution. Don’t fret; it’s short and written in plain English.
  • NYC: “The city that never smokes.” A proposal to ban lighting up in New York’s parks has exposed the puritanical agenda behind the crusade against smoking.
  • Tyler Cowen: With health care costs high and rising, government mandates to buy insurance would make many people worse off.