Topic: Cato Publications

Overkill

balko_whitepaper_300x394.jpgToday, my paper on SWAT teams and paramilitary tactics is finally released. It’s been the thrust of my research for nearly a year, now. It offers a history of SWAT teams, legal background, analysis and criticism of their increasingly frequent use and abuse, and an appendix of case studies that documents more than 150 botched raids.

You can download it for free [pdf]. If you want a slick, bound copy, you can order one for $10, and you’ll also get a copy of Gene Healy and Tim Lynch’s paper on the constitutional record of George W. Bush.

We’re also launching an interactive map to accompany the paper. The map plots every botched raid I’ve found in my research, with a description of what happened and a list of sources. You can sort the map by type of incident. So, for example, if you want to see only those raids where an innocent person was killed, it would look like this. If you want to see raids where a nonviolent offender was killed (a recreational gambler or potsmoker, for example), it would look like this. If you want to see all of the “wrong door” raids where no one was killed, it would look like this.

The map is also searchable by year, state, and type of incident.

Cato’s news release on the paper is here.

Premium Medicine vs. Watchful Waiting

In a response to my defense of health savings accounts, Dr. Hébert makes a thoughtful case for the value added by primary care physicians. One way that PCPs add value is through “watchful waiting”:

It used to be that observation was one of the mainstays of medicine. Now everything is scanned, biopsied, and aggressively worked up because specialists find it easier to bill for expensive procedures than for recurring office visits. This shift away from observation towards aggression runs the risk of hurting patients, and is one of the casualties of the microspecialist system.

The (over-) use of such “premium medicine” is one of the main themes of Crisis of Abundance, a new book by Cato adjunct scholar Arnold Kling. As an illustration, Kling writes about a blogger named Quixote who received intensive treatment for her swollen eye:

My guess is that 30 years ago, a patient with similar symptoms would have been treated “empirically,” a term doctors use to describe a situation for which they do not have a precise diagnosis and treatment, so that instead they must use guesswork. A layman’s synonym for treated empirically would be “trial and error.” In this case, the patient might have been sent home with an antibiotic and perhaps a prescription for Prednisone, a steroid used to reduce inflammation. There would have been nothing else to do. In 1975, computerized medical imaging technology was new and exotic, with limited applications.

In contrast, in 2005, over the course of a few days Quixote was given a computed tomography (CT) scan, referred to a specialist, sent to a different hospital, referred to a specialty clinic, seen by a battery of specialists there, and given yet another CT scan. Ultimately, however, she was sent home, as she might have been 30 years ago, with an antibiotic, Prednisone, and no firm diagnosis.

Compared with 30 years ago, Quixote received more services, in the form of specialist consultations and high-tech diagnostics. However, the ultimate treatment and outcome were no different. This does not mean that medicine is no better today than it was a generation ago. The CT scans and specialist consultations could have turned out differently. They might have been critically important, depending on her actual condition. Under some circumstances, treating Quixote empirically with an antibiotic and Prednisone could have been a mistake, perhaps costing some or all of her sight in one eye.

Such is modern medicine in the United States. Doctors are able to take extra precautions. They can use more specialized knowledge and better technology to try to pin down the diagnosis. They can perform tests to rule out improbable but dangerous conditions. But only in a minority of cases does the outcome deviate from what would have been the case 30 years ago.

That’s from chapter one. The remaining chapters wrestle with the question of when we should make use of premium medicine.

(The Cato Institute will host a book forum for Crisis of Abundance from 12-2pm at Cato on Tuesday, August 29. Kling will present, and the Washington Post’s Sebastian Mallaby and NYU’s Jason Furman will comment on the book. Keep watching www.cato.org for more details.)

More on McCloskey’s Bourgeois Virtues

Following up on Radley’s mention of Deirdre McCloskey’s article on bourgeois virtues, here’s what I just posted at the Guardian’s “Comment is free” site: 

At Cato Policy Report the brilliant economist Deirdre McCloskey of the University of Illinois-Chicago and Erasmus University of Amsterdam (formerly the brilliant economist Donald McCloskey) writes about “bourgeois virtues,” the subject of her new book. McCloskey says that in Western civilization we have traditionally recognized two kinds of virtues — the aristocratic virtues such as courage, and the peasant or Christian virtues such as faith, hope, and charity.

But, she argues, these virtues were developed for a pre-capitalist world of defined social classes. In the United States and an increasing part of the world, very few people are aristocrats and no one is condemned to peasant life. Rather, we are all bourgeois now. We live in commercial society, mostly in towns (the root of the word bourgeois). We’re mostly middle class and engaged in business, as entrepreneurs, investors, managers, or employees, and also as customers.

And since the beginning of bourgeois society, the vocabulary of virtues has been used to berate and denounce capitalism. We’re told that business is based on greed, not on virtue. It may be necessary to modern life, but businessmen are still expected to accept their dubious moral standing. Wouldn’t sharing be more virtuous than selling? Isn’t it better to serve society than to produce wealth?

McCloskey points out that the assaults on the alleged vices of capitalism “led, in the 20th century, to some visions of Hell.” Surely capitalism has proven better than the alternative. But she wants to make a stronger case than that: “bourgeois life improves us ethically.” It has led not just to vast increases in material wellbeing but to civility, religious tolerance, cosmopolitanism, and honesty. She examines how the classical virtues apply in a commercial world. “The leading bourgeois virtue is the prudence to buy low and sell high…but it is also the prudence to trade rather than to invade, to calculate the consequences, to pursue the good with competence.”

She goes on to add temperance — to save and accumulate, but also to look for compromise. Justice is private property, along with respecting merit, not privilege, and viewing success without envy. And so on through courage, love, faith, and hope, the old virtues for the modern world.

McCloskey says that her goal is to take the word “bourgeois” back from its enemies, to make it a term of honor, by showing how the virtues inform capitalism and how capitalism encourages the virtues.

Medicare Reform: Just Give Seniors the Cash

Matthew Holt at TheHealthCareBlog.com raises a good question about Medicare’s renewed effort to offer medical savings accounts to beneficiaries:

Those taxpayers who can do basic math might wonder why you’d want to to give healthy Medicare beneficiaries cash for health services that they’re not going to use, while taking that cash away from the pot that pays for the sick beneficiaries that do use said services. But we’ve asked that question so many times before and no one on the free market side dare answer it. And I guess you might say, why not give the taxpayers money straight to the “healthys” instead of laundering it through Medicare Advantage plans as we’re doing it now so that they can hand out free gym memberships to seniors and boost their executives’ stock holdings.

But given that risk adjustment is coming to Medicare Advantage, it may be that that gravy train is ending.

The Medicare MSA concept raises some interesting problems. Fortunately, Holt solves them — though I’m not sure he knows it.

A bit of background: The Medicare Advantage program currently pays private health insurers a flat amount for each senior those plans cover. As Holt notes, that encourages the plans to seek out the seniors whose medical bills will be less than that flat amount. Thus some plans “hand out free gym memberships to seniors” as a way to attract the healthy, profitable ones and avoid the unprofitable sick ones. That can end up costing taxpayers more than if those healthy seniors just stayed in traditional Medicare. 

But as Holt says, Medicare is working on adjusting those payments according to each beneficiary’s health risk. Instead of some flat amount per beneficiary, insurers would receive a payment from Medicare that better reflects each individual enrollee’s expected medical expenses. That way, health plans would have less reason to cater to the healthy or to avoid the sick. 

But once Medicare risk-adjusts those payments, why should the insurance companies get that money? As Holt postulates and Mike Tanner and I discuss in Healthy Competition, why not give it to the beneficiary? Confine it to health care uses, if you like. Healthy people would get smaller payments; sicker seniors would get larger ones. That would enable each to purchase health coverage (high-deductible or whatever) and still have some money left over for their out-of-pocket expenses. Seniors would get more control over their health care and coverage; they would make much smarter cost-benefit decisions than they do now; and Congress could limit the burden that Medicare imposes on taxpayers.

Is the point of the program to help insurers? Or providers? Or seniors? To whom do we want insurers and providers to be responsive?

“We Don’t Have a Colonial Office in the United States”

Go to any event on nation building in Washington these days, and you’ll hear endless bickering about whose fault it is Iraq hasn’t gone better. Maybe it’s DOD’s fault for commandeering the planning process. Maybe it’s the State Department’s fault for not letting Ahmed Chalabi be more involved. Maybe (this is the current favorite) we need a new Goldwater-Nichols Act to unify the bureaucracies behind the sorts of nation-building missions we find ourselves in in Iraq.

During a recent event at the US Institute of Peace, both Marine Corps Major Ben Connable and Matt Sherman, a former CPA official, blasted the State Department for not providing sufficient personnel for the mission in Iraq. As it happened, Bob Deutsch, the deputy senior adviser to Secretary Rice for Iraq policy was in the audience, and, well, let’s just say the sparks flew. A rough transcription of part of Deutsch’s comment is below:

We don’t have a colonial office in the United States. And the kind of—when I hear the criticisms of the civilian side of the government, that the State Department doesn’t have a whole bunch of police trainers that we can send out, that we don’t have a whole bunch of people who know how to run electricity companies, who know how to run oil companies. The Department of Energy doesn’t have people to send out to run oil companies. We don’t have a colonial office. And if we are going to do nation building, in Iraq or elsewhere, we’re going to need one. And I agree that that is a decision—that Secretary of State has made some decisions that we’re going to move the foreign service in directions with our transformational diplomacy in that direction. But it would have to be a larger U.S. government decision that we’re going to do that—which has all sorts of bureaucracy and fiscal implications that I’m not sure we’re prepared to buy off on.

I’m not sure whether to be reassured by the senior adviser’s tepid invocation of “bureaucracy and fiscal implications” that he’s “not sure we’re prepared to buy off on” as the primary obstacle to setting up a colonial office, or alarmed by the fact that he suggests that Secretary Rice has “made some decisions” that the foreign service is going to be “moved in that direction.”

At any rate, it’s sure a great time to pick up Chris Preble’s and my Policy Analysis on the topic of building a nation-building office into the State Department.

Fraudulent Identity Fraud Statistics

Slate has a great piece up on the use and misuse of statistics by reporters.

The magic number for journalists covering the identity theft beat has been $48 billion—the estimated annual losses suffered by identity theft victims—which carries the Federal Trade Commission’s imprimatur. … Fred H. Cate, a law professor and director of Indiana University’s Center for Applied Cybersecurity Research, notes that if the estimate were accurate, it would wipe out up to half of the banking industry’s $103 billion profits in 2005. “If those numbers were true, we’d have a banking crisis on our hands,” he says.

When I worked on the Hill, I came to recognize a similar dynamic at play: There were things everyone believed and no one questioned. I called them “political facts” because the source of the fact was consensus rather than any measurement or observation. Repetition of political facts in Members’ speeches and floor statements just made them all the more true.

A political fact relating to identity fraud is that it is a stranger crime, often a product of data breaches, that is conducted mainly over the Internet. It sometimes is, but in my book, Identity Crisis, I point out the results of an actual study showing that:

[M]ore than a third of individuals who had been impersonated in a true identity fraud knew … who the perpetrator was. And in more than half of those cases, the perpetrator was a family member or other relative. Other prominent perpetrators of identity frauds are people in companies or financial institutions with access to personal information, as well as friends, neighbors, or in-home employees of impersonation victims. So much for the Internet being the cause of identity fraud, though it certainly plays a role in some cases.

Alas, … my source was a Federal Trade Commission study.

New at Cato Unbound: Ted Galen Carpenter Replies to Gerecht

Today at Cato Unbound Cato’s own Ted Galen Carpenter argues that Reuel Marc Gerecht’s strategy of bombing Iranian nuclear facilities may be harder than advertised and that “thousands of innocent Iranians would perish in U.S. air strikes.” Such an attack might trigger a “massive regional crisis,” Carpenter says. “America’s troubles with the Islamic world do not yet constitute a war of civilizations,” he writes, “but Gerecht’s strategy could well produce that result.” Carpenter argues that the U.S. should try to persuade Iran to give up its nuke program by offering a “grand bargain,” and if that doesn’t work, should pursue a policy of containment and deterrence, that, while “nerve-wracking,” has proved effective against deadlier and more fanatical regimes.

Don’t miss replies to Gerecht on Friday from Edward N. Luttwak and on Monday from Anthony H. Cordesman.