Tag: health care

Safeguarding medical workers in hostilities

Yesterday the ICRC released a report on the very scary and depressing trend of attacks on medical workers in situations of armed conflict and civil disturbances:

According to Dr Robin Coupland, who led the research carried out in 16 countries across the globe, millions could be spared if the delivery of health care were more widely respected. “The most shocking finding is that people die in large numbers not because they are direct victims of a roadside bomb or a shooting,” he said. “They die because the ambulance does not get there in time, because health-care personnel are prevented from doing their work, because hospitals are themselves targets of attacks or simply because the environment is too dangerous for effective health care to be delivered.”

This makes for some pretty grim and reading.

Yet the evidence is clear – whether it is the targeting of medical workers in Libya, the targeting of a hospital in Afghanistan by the Taliban, or the unwarranted persecution of doctors in Bahrain. (A problem that Dan Nexon highlighted earlier this year here at the Duck.)  Even the allegation that the CIA found Osama bin Laden using a vaccination program puts medical workers and vaccination teams at risk – a potential disaster for global health.

(Aisde: Most, if not all of these issues, are being followed by Christopher Albon at his excellent blog, Conflict Health. Go read it. Read it now!)

The neutrality of medical staff in all circumstances is a core tenant of the laws of war, and some of its oldest codified principles. There is, quite simply, no excuse for harming someone who is engages in these tasks. This was the genius of the 1864 Geneva Convention:

Article 1. Ambulances and military hospitals shall be recognized as neutral, and as such, protected and respected by the belligerents as long as they accommodate wounded and sick.
Neutrality shall end if the said ambulances or hospitals should be held by a military force.
Art. 2. Hospital and ambulance personnel, including the quarter-master’s staff, the medical, administrative and transport services, and the chaplains, shall have the benefit of the same neutrality when on duty, and while there remain any wounded to be brought in or assisted.

These principles continues today as is clear in the First Geneva Convention of 1949. At the risk of being long-winded:

Art 15. At all times, and particularly after an engagement, Parties to the conflict shall, without delay, take all possible measures to search for and collect the wounded and sick, to protect them against pillage and ill-treatment, to ensure their adequate care, and to search for the dead and prevent their being despoiled.
Art. 19. Fixed establishments and mobile medical units of the Medical Service may in no circumstances be attacked, but shall at all times be respected and protected by the Parties to the conflict. Should they fall into the hands of the adverse Party, their personnel shall be free to pursue their duties, as long as the capturing Power has not itself ensured the necessary care of the wounded and sick found in such establishments and units.
The responsible authorities shall ensure that the said medical establishments and units are, as far as possible, situated in such a manner that attacks against military objectives cannot imperil their safety.
Art. 20. Hospital ships entitled to the protection of the Geneva Convention for the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of Armed Forces at Sea of 12 August 1949, shall not be attacked from the land.
Art. 21. The protection to which fixed establishments and mobile medical units of the Medical Service are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after a due warning has been given, naming, in all appropriate cases, a reasonable time limit, and after such warning has remained unheeded.

The idea behind this is that someone who is seriously injured is hors de combat – in other words, out of the fight, and can no pose a military threat. Allowing someone’s wounds to fester or get worse serves no military purpose once they are hors de combat; it only causes what is normally termed unnecessary suffering. (This is the same principle that bans poisoned weapons – there is no need to uselessly aggravate an injury on someone who is seriously wounded.) The individuals who treat these injured combatants (and civilians) of all sides must therefore be protected from attack. This is why they are allowed to wear the Red Cross/Red Crescent/Red Crystal symbols – it identifies them as neutral medical workers and helps to expedite the process of recovery and treatment. (Abusing these symbols, such as using them as a ruse to conduct an armed attack, is a grave breach of the Geneva Conventions.)

Certainly, there is more law I could cite here. But the main point is that the ICRC is absolutely correct to highlight this as a growing problem.


The Constitutionality of the Individual Mandate

Perhaps because I am not a lawyer, I found the section of Judge Hudson’s ruling dealing with taxation powers difficult to make sense of. Hudson argues that Congress did not intend to use its taxation powers, because (1) it removed the word “tax” from many points in the document and (2) it invoked commerce-clause powers in its preface to Section 1501.

I don’t entirely understand how this is relevant to the constitutionality of the “mandate.” If the act requires that individuals pay a penalty on their income-tax returns for failure to purchase health insurance, then isn’t the question simply whether this is within the scope of its power or not?

Even here the reasoning seems strained, insofar as the quoted text itself reads “[T]here is hereby imposed on the taxpayer a penalty….” The question of the political resonance of “tax” versus “penalty” does not, in my mind, justify a “logical inference” that the penalty is not a tax penalty.

What really gives the game away, though, is Hudson’s footnote 13 (see page 36).

There is, of course, no logical or functional difference between giving someone a tax break for purchasing a product and slapping tax penalty on someone else for not purchasing that product.

  • My mortgage-interest deduction is someone else’s renting (or cash-only home purchase) penalty.
  • My graduate-loan interest deduction is someone else’s couldn’t-afford (or could-easily-afford, or got-a-full-scholarship) graduate school penalty.

And let’s not even get started on the not-have-a-kid penalty, or what everyone actually calls the “marriage penalty.” If I recall correctly, conservatives have been the most vocal about this last “penalty,” which involves–among other inadvertent effects of the tax code–a married couple’s inability to take advantage of certain deductions available to singles.

Hudson’s opinion rests on the confusion of a political slogan with a legal argument. The ritualistic invocation of the idea that HCR is unique because it “requires individuals to buy a product” does not render it logically–or, if you’ll allow me the temerity to say so, legally compelling.


Credit and penalty

The Federal Government makes you pay a penalty if, among myriad other things, you: don’t have children, don’t get married, and don’t take out a mortgage. Of course, we don’t call these “penalties.” We call them “not getting a tax credit.” Yet some people think that reducing someone’s tax liability if they engage in a particular behavior is different than increasing someone’s tax liability if they don’t engage in that same behavior.

The same people also believe, for incomprehensible reasons, in the existence of a meaningful legal distinction between forcing U.S. citizens to pay the Federal Government money if they fail to purchase a product called a “mortgage” and forcing U.S. citizens to pay the Federal Government money if they fail to purchase one called “health insurance.”

Unfortunately, it seems that such irrational beliefs may also extend to a U.S. Federal judge:

“The individual mandate applies across the board,” Vinson wrote. “People have no choice and there is no way to avoid it. Those who fall under the individual mandate either comply with it, or they are penalized. It is not based on an activity that they make the choice to undertake. Rather, it is based solely on citizenship and on being alive.”

As a social scientists, I can’t help but wonder what drives such obviously flawed reasoning. Is this an example of the psychology of loss aversion, the cognitive blinders created by partisan bias, or something else?


The IR Analogy

Periodically, scholars of international relations point out that the “domestic analogy” fails to explain IR. As Hidemi Suganami explains:

The term ‘domestic analogy’ refers to the idea that inter-state relations are amenable to the same type of institutional control as the relations of individuals and groups within states.

Because of anarchy, realists like John Mearsheimer explain, state behavior cannot be managed by external institutions attempting to wield executive, legislative or judicial power.

This past week, I’ve been thinking about American domestic politics — particularly in the context of the ongoing debates about health care and climate change legislation — and what might be termed “the IR analogy.” In the U.S. system of government, Senators representating small states have greatly disproportionate power to their states’ population (and wealth). Alec MacGillis explained the problem in the Washington Post on August 9:

The 10 largest states are home to more than half the people in the country, yet have only a fifth of the votes in the Senate. The 21 smallest states together hold fewer people than California’s 36.7 million — which means there are 42 senators who together represent fewer constituents than Barbara Boxer and Dianne Feinstein. And under Senate rules, of course, those 42 senators — representing barely more than a tenth of the country’s population — can mount a filibuster.

In IR, states are said to have sovereign equality, but no international institution with similar voting representation has anywhere near the kind of power wielded by U.S. Senators.

Perhaps even more incredibly, within the U.S., substantial tax resources are collected in Washington and then redistributed from the largest and richest states to the smallest and poorest states. MacGillis explained how this process works in practice:

California, Illinois, New York and New Jersey are among the 10 states that get the least back per tax dollar sent to Washington; Alaska, the Dakotas and West Virginia are among those that get the most.

MacGillis may have relied upon The Tax Foundation for data, since this organization regularly compiles this kind of information. The Tax Foundation has found that most tax revenue comes from so-called “blue states,” home to constituents who elect Democratic representatives who are most likely to support progressive taxes, health care reform, and perhaps climate-saving legislation. A disproportionate share of this revenue is directed at poorer “red states,” home to constituents who tend to elect Republican representatives who are the most likely to be anti-tax, opposed to the kind of health care reform proposed by the Obama administration, and relatively unworried about climate change.

As viewed by IR theory, this is a topsy-turvy system. Realist theory certainly couldn’t be used to explain domestic politics if we tried to employ an “IR analogy.” In IR, the richest and most powerful states control the agenda, operate within a political system that benefits their interests, and mostly get what they want.

In the IR analogy, California, New York, New Jersey, and Illinois are sort of like the US, Japan, Germany and Australia. Texas would be a state like Russia, sharing some interests of other major powers, but not politically like-minded.

Now, imagine that those rich and powerful nation-states not only shared equal voting power with Bangladesh, Nepal, Haiti, and Liberia in a meaningful international institution, but that they also voluntarily transferred enormous resources to those states. Oh, and they designed the institution so that a minority of states (home to fewer people in all than live in the US) could block any action favored by the coalition of big states.

That’s U.S. domestic politics viewed with the IR analogy.


David Nexon on healthcare reform

Turns out my father is (or, more accurately, was) blogging, although I’m not sure if he even knows what a blog is. Which leads me to suspect that someone else might be entering those posts on his behalf.

Some more recent comments appear here, although he’s much more acting in his capacity as an employee of AvaMed.


Health Care Reform

I don’t usually post on domestic policy issues. I’m even less likely to waste bandwidth explicitly seconding sentiments found on a big-time website. But, I’m afraid, that’s what I’m going to do here.

Theda Skocpol, author of, among other things, a bookthat insiders assure me gets a great deal right about why the Clinton health-care plan failed, gets it right.

Key leaps forward for U.S. public social provision — Social Security, Medicare, etc. — have NEVER happened through “bipartisan” compromises and they always happen in close votes. They have always sqweaked through after gargantuan effort, strong presidential pressure, and refusal to allow eviscerating compromises. Think of Social Security if the Clark amendment — allowing corporate opt-out — had passed in 1935. We would not have it. And conservatives and the medical and insurance establishments cried “socialism” in 1965, too. We would not have Medicare if we had listened.

Obama and the Democrats are coming off a historic, landslide election. They have all the popular support for robust reform they will ever have. Good policy design as well public desire for change and considerations of social justice and economic efficiency insist that they enact health care reform with a strong public plan in the mix. That is the only way to move toward cost control and guaranteed access with quality to all — especially for Americans in lower economic strata or in rural states where one or two private insurers call the tune. There is no need for “bipartisanship” and the calls for it from some weak-kneed Democrats are merely excuses for doing the business of the medical-insurance establishment. Senators Baucus, Conrad, Feinstein, Nelson, Landrieu, Bayh — this means you. All of you come from states where people really need robust reform and you should step up.

So far, though, the Democrats have managed to avoid one of the problems that doomed reform the last time around: a proliferation of alternatives offered by a slew of Senators, think tanks, and opinion-editorial writers. But beyond that, she’s totally right. The Senate Democrats can play the bipartisanship game as long as they want, but only so long as their endgame involves passing reform via the reconciliation process.

None of the “compromises” on the table are likely to garner enough Republican support without weakening reform beyond acceptable limits, although some of the ideas aren’t necessarily bad. For example, I can see an acceptable endgame in which the public-option bargaining chip gets traded in for two concessions from private stakeholders: (1) the creation of regional health cooperatives constituted with sufficient bargaining leverage to mitigate that lost from abandoning a public option and (2) the implementation of government mandates and strong regulatory powers concerning a portfolio of plans that private insurers would have to offer. But I just don’t see this kind of alternative as making much headway on the bipartisanship front.

So, when it comes down to it, I understand why Democrats from “Red States” are trying to cover their behinds. But pointing to a moderate Republican or two who voted for the bill isn’t going to make any difference to their re-election prospects. Swing voters are unlikely to turn against them for standing up to health insurance companies, who, I suspect, are locked in a tight competition with Wall Street firms for “least popular sector of corporate America.” And here’s the deal: there will be a backlash–aided by corporate money–against Democrats whether or not they pass a bill. However, if they pass a bill we’ll also see, for lack of a better term, a countervailing “prolash” in favor of the Democratic party. That lack of a “prolash” arguably made a big difference in the 1994 debacle that crippled the party for the next twelve years.


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