One way to move forward on health care

One way or the other, a single-payer health care financing system looks like a non-starter in the current political climate.  Personally, I think it is the best way of doing things, but it seems like we might as well shelve the idea for a while.

I do hope something comes out of the current discussion of reform, but I am growing pessimistic.  The problem is that many of the reforms, like mandating coverage, forbidding insurance companies from excluding based on preexisting conditions, and so forth, only work if they all come in together.  Mandating coverage is useless if insurance companies can turn people away for having preexisting conditions, and forcing insurance companies to cover preexisting conditions is silly without mandates.  Without a mandate for coverage, but with a ban on excluding preexisting conditions, there is a strong incentive for people who think they're healthy not to buy insurance until they're sick.  Conversely, with a mandate but no requirement that insurance companies cover people with preexisting conditions, people with preexisting conditions who are trying to obey the mandate may not be able to obtain coverage.  For any reform to be effective, it has to be all or nothing.  So who knows what will come of all this...  Also one of the criticisms of the current reform ideas does seem to hold some water: there is very little in the current discussions that would help control costs.

Here's an idea for something that could be done right away, would help contain costs, and shouldn't be too controversial...  Why doesn't the federal government take over paying for screening and routine management of chronic conditions that are relatively inexpensive and straightforward to screen for and manage, asymptomatic in the early stages and therefore rarely diagnosed in the absence of screening, and that when not managed properly, lead to enormous costs that are borne disproportionately by Medicare because even though the conditions may begin in adulthood, the expensive complications tend to arise in old age.  I am thinking of diabetes types I and II, hypertension, high cholesterol, and maybe a few other things that I am not aware of.

Diabetes type II, hypertension, and high cholesterol are especially important here.  These can all be screened for at relatively low cost, can be managed with existing medications, and if not properly managed lead to enormous expensive complications.  Moreover, people are often asymptomatic for years, so unless people are specifically screened for them, they may not be diagnosed and treated properly until they do begin exhibiting symptoms, typically at later ages and often after damage has been done.  Undiagnosed or poorly managed diabetes type II can lead to amputations, dialysis, blindness, and a variety of other conditions.  Hypertension and high cholesterol, of course, lead to heart disease, stroke, and other conditions.  Again, because these complications tend to emerge later in life, Medicare picks up a big portion of the tab.

My specific reason for the federal government to become involved with the diagnosis and management of these conditions for the whole population is in fact that it is already picking up the tab for the complications, and might be able to reduce expenditure on complications if these conditions were picked up earlier and managed better.  We have a situation where people may develop these conditions in adulthood but may not be screened or treated for them because they don't have insurance, or they have insurance but aren't screened properly, but when they are old enough to qualify for Medicare, begin experiencing very expensive complications that Medicare pays for.  In these situations, a small amount of money spent on screening and management in adulthood would reduce or at least delay substantial expenditures by Medicare in old age.

So my idea is that the federal government pay for universal screening and management of chronic conditions like diabetes, hypertension, and high cholesterol that can be identified and treated relatively cheaply in adulthood, but which lead to expensive complications in old age that are covered by Medicare.  Set up a system where the federal government pays for diabetes, hypertension, and cholesterol screening for everyone, insured or not, and also pays for medications for anyone who is diagnosed.  In this system, health care providers would send all bills for screening and management of these conditions to the government, to be paid for at some specified rate, and not send them to the patients' insurance companies, or bill the patients.  I suspect that in the long term this would pay for itself by reduced Medicare and other expenditures, but in the short term it could be financed by a levy on insurance companies to reflect the money they would be saving by not having to cover screening and management of hypertension, high cholesterol, and diabetes type II.  Even if it was politically impractical to ban insurance companies from covering all preexisting conditions, in this scenario, they could be forbidden from denying coverage based on existing hypertension, high cholesterol, or diabetes type II.

This would be a win-win situation.  Medicare expenditures would be reduced because people old enough to be eligible for Medicare would be much less likely to have expensive complications that Medicare would have to cover.  People would be better off by having access to screening and management for potentially debilitating chronic conditions.  If the financing arrangements were done properly, this would be revenue neutral for insurance companies and health care providers.

In terms of selling an arrangement like this, the key is the likely reductions in Medicare and probably Medicaid expenditures, which in a few years would probably more than offset the costs of covering screening and management for working age adults.  Think about the savings if there were a substantial reduction in the number of people requiring dialysis because type II diabetes had already led to kidney failure.  And the savings, and increased tax revenue, if people who were debilitated by blindness or loss of their foot or other limbs by complications of diabetes could remain healthy, and continue to work.  And so on...

The main reason for doing something like this would be a hard-headed cost-benefit analysis.  This isn't about social justice, or any other existential, philosophical issues about equality or access or fairness, but rather about reducing Medicare and Medicaid expenditures in the long term by spending on screening and management of chronic conditions that we already know are 1) cheap and easy to screen for, 2) manageable with relatively inexpensive medications, and 3) if unmanaged lead to very expensive complications that the federal government, and therefore the taxpayers, already pay for.  An $1000 investment in screening, statins, beta-blockers, and other drugs by the federal government might avert or at least delay $10000 in spending by Medicare, Medicaid, or private insurers to cover dialysis, amputation, disability, intensive care and so forth.

As a conclusion, I guess I would say that I am disappointed that so much of the discussion of health care reform is being framed in terms of abstract philosophical concepts like social justice and equity (from progressives) or individual choice and freedom (from conservatives).  The concern should be about public health, and the implications of whatever we system for other features of the economy.

The real problem with the status quo in health care in the United States is that it is screwing up the economy, and affecting our competitiveness, by introducing complications and inefficiencies.  Individuals are afraid to change jobs out of fear of losing benefits.  Companies waste time and money in ongoing negotiations with insurance providers.  Individuals and doctors waste time dealing with insurance companies, sorting out billing problems and so forth.  All of these are sand in the gears of the economy.

Imagine an economy where individuals could change jobs without even thinking about their health insurance coverage, and where companies could focus on their products and their customers without needing to devote personnel to negotiating with insurance companies.  The main reason to fix the health care system isn't some abstract concern about equality and social justice, or individual choice and freedom, it should be about making American companies more competitive by letting them focus on their customers, their employees, and their products, without wasting time negotiating with insurance companies to cover their employees.

I should clarify that when I propose federal government coverage for screening and management of chronic conditions like diabetes II, hypertension, and high cholesterol, it isn't because I think of this as some sort of clever thin end of the wedge that will eventually lead to a single-payer system, but because I think it would result in substantial net savings to Medicare and Medicaid and private insurers.  We shouldn't be so blinded by an obsession with 'individual choice'  or 'freedom' on the one hand or 'social justice' on the other hand that we let it dictate our preferences for policy, we should be doing a hard-headed calculation about what is best for the economy, in terms of reducing government spending, or improving competitiveness.
As I said at the outset, I would prefer a single-payer system, but I am realistic enough to conclude that it just isn't in the cards right now.  My preference for a single-payer system isn't based on some sort of hazy concern with social justice, whatever that is, but rather based on a belief that anything else is inefficient, and ends up being a tax, direct or indirect, on the economy.

We should think about the time that Americans spend on health care, whether it is time spent trying to find coverage, find a provider that their insurance will pay for, sort out billing questions, as an indirect tax associated with the current system, and think about the improvements if people didn't have to spend minutes or hours on hold with their health care provider or insurance provider on questions related to billing or coverage, if companies didn't have to devote time to negotiating with insurance providers, if doctors didn't have to spend time filling out paperwork for insurance companies, and so forth.  The real virtue of a properly implemented single-payer system is the time it saves for companies and for individuals.  I would like to see the conservatives who advocate for market based solutions that include private companies as insurance providers at least acknowledge that patients and doctors waste with billing, negotiations, and so forth is in fact a tax, paid not with money, but with time.  But I am realistic enough to think that a single-payer system is not in the cards, and we should be thinking about other, incremental changes.


One thing I would add is that when we discuss single-payer systems, we should look at examples beyond Canada and England.  I think the Canadian and English systems work very well for serious conditions, but acknowledge that they probably don't do quite so well for chronic conditions that affect quality of life but are not by themselves life threatening.  Knee surgeries and hip replacements shouldn't be thought of as a luxury that people have to queue months or years for, since these are debilitating conditions that impair productivity.  We should be looking at other systems as well, like in Taiwan, and the Scandinavian and Northern European countries, that are also single-payer, but at least to my knowledge don't seem to generate the same numbers of complaints as the Canadian and English systems.  I'm not an expert on those systems but the point is that the Canadian and English systems are not the only game in town.

I was particularly impressed with the Taiwanese health care system during my visit there in December.  I needed to have something checked out.  I ended up going to Taiwan Adventist in Taipei.  I was absolutely amazed that all of my appointments started right on time, no paperwork was lost or misplaced, the staff were uniformly efficient and courteous, and everyone seemed to be on the ball.  Since as a visitor, I wasn't covered by the national insurance system, I paid cash for everything, but the final bill was ridiculously low.  Several consultations plus a number of tests that in the states would have cost somebody thousands of dollars cost only a few hundred dollars.  My in-laws who live in Taiwan and use the national health insurance all seem pretty pleased with the care they are receiving.  So maybe we should be looking into what the Taiwanese have done.

Google and Sogou Pinyin IME on the Nexus One

A friend of mine lent me a Nexus One that I will try out for a few weeks.  I would like to buy one, but  before I do, I want to confirm it works in China with my China Mobile M-Zone service.  I will be going to Beijing later this month so will have an opportunity to swap in my SIM when I get there and see what happens.

One of the first things I did was install the Google Pinyin IME and Sogou Pinyin IME.  I activated both of them in Language and Keyboard but nothing seemed to be happening when I entered text.  I kept getting the usual Android keyboard.  Finally I saw somewhere on the net that pressing on the text entry field for a few seconds would bring up a selection menu for choosing the input method.  I don't think this was the case on the G1, the G1 used whatever keyboard was selected in Locate and Text.  Anyway once I found this out, I pressed on the text entry field on the screen for a little bit and sure enough a menu came up, giving me a choice between the Android keyboard, Google Pinyin IME, and Sogou Pinyin IME.  Being able to select input methods from the text entry field rather than the Settings is certainly a nice touch.  I have not previously tried the Google Pinyin IME so I will see how it compares with the Sogou Pinyin IME and report back in a few weeks.

Caribou, and the new track "Odessa"

Today I'll talk about music.  Specifically, I'll talk about one of my favorite artists, Caribou.  That is the name under which Dan Snaith records.  As with many of my recent posts, this has nothing to do with photography, but I feel like writing and I don't have any new photos to talk about.  I suppose I could write about how much I would like to buy a new camera, the Canon 5d MkII, but that isn't going to get anywhere.  So I'll talk about Dan Snaith aka Caribou and his music.

I bought my first CD by Caribou a few years back in Madison, Wisconsin.  I was visiting the university to give a talk and was killing time before a dinner with a visit to a CD store.  They had some CDs by Manitoba, which was the name Snaith was recording under at the time.  I had never heard of Snaith, or the band Manitoba, but since I went to elementary school in Winnipeg, and have family there, I was surprised and pleased that anyone would name a band after the province.  I was even more tickled to see that some of the track titles on one CD, Up in Flames, related to Canada.  For example, there was one track titled "Dundas, Ontario" and another titled "Brandon".  I assumed, perhaps incorrectly, that it referred to Brandon, Manitoba, which I believe is the 2nd largest city in Manitoba.  I bought Up in Flames and Start Breaking My Heart.

I returned to my hotel room after dinner and listened to the CDs on my laptop and was blown away.  I had bought them mainly as a novelty, and wasn't sure what to expect.  I had some hopes since Canada produces a lot of talented musicians, some of whom hail from Winnipeg, or at least spend time there, but was prepared to be disappointed.  Well, I wasn't.  This was a completely unique, intricately layered sound that I couldn't compare to anything I had ever heard before.

Later, I bought Milk of Human Kindness and was even more pleased.  By this time, Snaith was recording as Caribou because of bizarre complications with the name Manitoba that you can read about on the web with a little searching.  This was just as creative and novel as Up in Flames and Start Breaking My Heart, but to my ears at least, tighter and more disciplined, the working of a maturing artist.  This was also something I could play for my wife.  Then came Andorra and I was even more hooked.  My favorite tracks on Andorra is probably "After Hours" for its intensive, relentless beat.

Around that time, I saw that Caribou was touring, and would play at the Troubadour in West Hollywood.  I talked my wife into going with me.  I had played Andorra for her so she was prepared, but this was still pretty new for her, since she is from Taiwan and tends toward honey-voiced romantic balladeers like Fei Yuqing (费玉清) and so forth. 

It was spectacular.   I had never been to a rock concert in such a small, intimate venue before.  I used to attend concerts in high school and college, but usually in stadiums, never in small clubs.  We were in the front row of balcony.  What made the strongest impression on me was the percussion.  It was loud.  Our ears rang for two days afterward, but it was incredibly tight.  Snaith and another percussionist were going at it and I just couldn't believe that two people could drum that loud and that fast, but remain completely tight.  It was amazing to me that such a small number of people could produce such an intricate sound.  Somehow I take it for granted listening to a CD, which I always assume reflects lots of studio work, but it was inspiring to see a live show like this where this small group was recreating the incredibly intricate sounds of the CD, live.  I loved it, and more importantly, my wife loved it, and added Caribou to her rotation along with her Taiwanese and HK pop ballads.

I was really pleased when I saw on Caribou's twitter feed that he had a new record called Swim coming out, and a track from it called "Odessa" was available.  I just listened to it at an entry at the Hero Hill site and once again, it's great.  It is a real departure from the sound on Andorra, which was an evolution of the sound on Milk of Human Kindness, which in turn was a real departure from the sound on "Up in Flames" and "Start Breaking My Heart".  For the first few seconds I thought about Beck's "Cellphone's Dead" and then afterward it opened up into an incredible and impossible to characterize mixture.  There are layers and layers of different sounds, that seem to always be on the verge of collapsing into chaos, but somehow it all works beautifully, and everything makes sense.  I'm really looking forward to the album, and hope Caribou comes through LA so we can see him again.

If you want to download and listen to Caribou's new track, check out his website.  Overall, it seems like these few months are good for album releases from some of the musicians that I like.  Monolake and Four Tet and The Field all came out with albums recently that are pretty good, Caribou has one on the way.  And I have this idea, perhaps incorrect, that Brad Mehldau and Thievery Corporation are at work on new albums.

One other neat thing about Caribou: he has a PhD in mathematics from Imperial College.  Indeed, he seems to come from a family of mathematicians.  If you search on Google Scholar, you can find what I assume is his dissertation.  I really admire anyone who starts out as an academic, but ends up doing something even more interesting. 

Reminiscing about my first time in Beijing, back in 1987 (追忆我第一次访问北京)

Now that China is in the news every day, I can't help but think about my first time in China, more than 20 years ago, and how much it has changed since then, mostly for the better.  I had just finished by sophomore year in college in 1987 and went to China with one of my professors to help out with some research.

I still remember vividly our arrival in Beijing.  We arrived late in the evening.  We deplaned the old-fashioned way, down a stairway that had been rolled up to the side of the plane, and we boarded rickety old buses that took us to the terminal.  I remember there were soldiers with rifles standing around on the tarmac looking bored.  Their uniforms were clean but they still seemed disheveled.  The bus, which I am pretty sure was diesel, shuddered to the terminal.  This was the old, awful, original terminal.  We approached the customs inspection and before we reached it, our host showed up waving a piece of paper that exempted us from inspection.  We finally boarded a car that took us to Peking University, which is where we were staying.  We dropped off our bags, then went to an apartment of our host.  It was already late and I was tired after a long flight but I was excited at being in China for the first time.  At the apartment, we had a fabulous home-cooked meal.  Unfortunately given my exhaustion I probably wasn't up for it, especially the glutinous rice (zhongzi) and I ended up throwing up everything that I ate, right there in the apartment.  I was fine afterward though.

Even though we were staying at Peking University, we were working downtown, so every day we either took a car or more often a series of buses from Peking University to downtown.  The buses were really an experience.  These were the crowded, old, diesel, yellow, articulated buses that rumbled down the streets.  We had to fight to get on, and usually to get off.  After each stop the conductors would mutter "卖票儿" in Beijing accent.  We usually had lunch at hole in the wall places in the general vicinity of the Imperial Palace, though on a few occasions we went for hamburgers or other Western food at the Jianguo Hotel, at the time the height of luxury.  There wasn't much air condition where we were, but it was OK.

At that time in China, foreigners were not supposed to use renminbi, and were supposed to only use FEC (外汇卷) to buy items at specific shops designated for foreigners.  In practice, this meant that whenever we needed anything, it required an expedition to the Friendship Store on Jianguomenwai.  Last time I looked at the Friendship Store, it was pretty sad, but back in the day, it was a real oasis in the desert for foreigners, with all the necessities, like shaving cream and razors, and shampoo, and instant coffee, and peanut butter, and all sorts of other goodies.

That summer we also spent some time in northeast China, especially Shenyang.  My most memorable meal in Shenyang was one where we brought two bottles of Johnnie Walker we had bought at the Friendship Store in Shenyang at a shopping expedition.   Our hosts, of course, provided beer and distilled spirits (baijiu or 白酒).  We gorged on northeastern dishes and toasted each other.  Outside the restaurant, there was some kind of road repair underway, and the workers were taking turns pressing their faces against the windows of the restaurant to get a view of us.  At some point during the dinner, my stomach under assault by all the northeastern dishes, the beer, the baijiu, and the whiskey, I began to feel unwell, so I excused myself and went outside to where the road repair was underway.  The workers had dug a ditch alongside the road, presumably to lay some drainage pipe, and I bent over and threw up in it while the workers looked on in amusement.  Once I was done, I stood up, smiled, gave them all a thumbs-up, and returned to the meal, where with my stomach voided, I was free to continue eating and imbibing.

Another vivid memory I have is a visit to the apartment of a famous doctor who was a family friend of the professor I was working with.  He had an IBM PC, which was quite rare in China at the time.  But he was one of the most prominent doctors in China, so it wasn't entirely a surprise.  He and his family lived in a modest apartment with perhaps two bedrooms.  That was luxurious by the standards of Beijing at time, but remarkably small considering his prominence as a doctor.  He had been having problems with his PC and the professor I was travelling with had volunteered me to come take a look at it to see if I could figure out what was going on.  I played with it a bit and as far as I could tell, the hard drive (I think a whopping 10mb or something) was failing and that was about all I could say.

Another odd memory was that when we took the train from Beijing to Shenyang, after we settled into our compartment in 'soft sleeper' (软卧), another American suddenly materialized and settled in.  I can't remember his name, but it was all very odd.  At the time it was very hard to get train tickets of any sort, and ours were purchased quite some time in advance.  He had some strange story about how something had come up in Shenyang and he had just decided to take the train up at the last minute, which is why he had no luggage.  He spent most of the evening asking us about our business in China, but was vague about what exactly he was doing in China, or how he was able to procure train tickets at short notice.  After we arrived in Shenyang, we never saw him again.   I seem to remember that he was skinny, red-haired, and very intense.  All very strange.  I wonder who he was, and what he was doing.  We had our theories but they all seemed sort of implausible.

Looking back, it really is remarkable how much China has changed, again mostly for the better, since that summer.  While some things have deteriorated, like the air pollution, and perhaps social inequalities, all in all it is now a much better and I would say freer place than it was back then.  At that time, there was a palpable barrier between foreigners and Chinese as a result of the political atmosphere.  Chinese, for example, were not allowed into international hotels.  If they had foreigners as visitors, they had to write reports afterward explaining to the neighborhood committee (街道办事处) explaining themselves.  There was considerable self-censorship in all interactions.  What we would think of as basic necessities were rationed, and difficult to obtain.  People who were unhappy with their jobs had difficulty changing them.  Everything was politicized.

All that is gone now.  When I visit Beijing now, it is completely different.  People speak their minds to each other and to foreigners.  While there are all sorts of things going on now with regard to the internet and the media that are of concern, people now enjoy remarkable freedom in their daily life.  They can speak their mind freely without worrying that their neighbor or coworker will inform on them.  So whatever is going on right now in China, I keep thinking that the general trend is a positive one.  It will always be 'two steps forward, one step back', but when I compare China now with what I remember from my visit in 1987, the changes are almost unimaginable.

My dad was in Beijing even earlier, in 1983.  He visited as part of an academic delegation.  They stayed in a guesthouse at one of the universities in Zhongguancun, Beijing Aeronautics University (北航). They didn't have Western-style toilets.  Every morning, a cook who knew how to fry eggs came out from one of the international hotels or state guest houses to help prepare breakfast for the delegation.

I just wish I had taken more pictures when I was in China in 1987.  But it never occurred to me that everything might change so completely, and that everything I saw then would be gone in a few years.  I still see people I met then, and they are all doing well, at least as well as can be expected given aging.  It is partly because of my regrets at not having much in the way of pictures from that early that I now take pictures everywhere I go, motivated by fear that whatever I see will be gone in a few years.

Fixing California. Part 2: State Finances

The first thing we have to get straight if we want to fix the state's finances is that there is no moral dimension to spending or taxation. The state budget, in particular revenue sources and expenditures, shouldn't be an instrument of ideology any more than the budget of a homeowner's association should be. I don't mean that the state shouldn't choose some ways of spending money over others based on political preferences. Rather, I mean that the total amount of spending should somehow reflect an ideology, whether that ideology is that government spending is somehow inherently bad and should be minimized, or that government spending is good and that it should be maximized. Similarly, taxes aren't inherently good or bad, and manipulating taxation to reflect some ideology is ridiculous. There isn't anything inherently good about lowering or raising taxes.

What should matter is that revenue is adequate to fund a reasonable level of expenditures of the state, so that over the long run, or even the short run, the state's balance is balanced. Taxes shouldn't be cut for the sake of lowering taxes, nor should they be raised solely to punish the rich, or grab money from people who have it just because 'they can afford it'. When expenses increase and cuts are impossible or at least impractical, taxes should rise. When revenues from existing taxes decline and corresponding cuts are imprudent, other revenues need to be found. Conversely, when expenses decline, taxes should be lowered, or surpluses put into a rainy fund to be used next time there is a short term shock in tax revenues.

To achieve these goals, the state government, especially the unicameral legislature that I suggested in my previous post, needs the flexibility to adjust spending and taxation as it sees fit on a year by year basis, just like parliamentary democracies. That means wiping the slate clean and eliminating all of the mandates, caps, dedicated funding and so forth that have turned the state budgeting process into such a disaster. Let the elected representatives decided on a year by year basis what to do about taxes and spending. If the voters don't like what they do, throw out the party in the next election, and give the other party a try. The current mass of restrictions, caps, mandates, limits, dedicated funding streams and so forth, imposed by initiatives, reflects a complete abdication of responsibility by voters. If we don't like what our representatives are doing right now, we shouldn't be passing laws that bind future representatives who may be operating under very different circumstances, rather we should be voting our representatives out of office and replacing them with a new batch.

When I say wipe the slate clean, I really mean wipe it clean. Everything has to go. Proposition 13 has to go, so property taxes can be set by elected officials based on current circumstances. Again, if we think elected officials are raising taxes too high, replace them, don't pass some sort of cap that has consequences years or decades down the road. All of the other formulas and caps and mandates and dedicated revenue streams have to go as well. The state should be free to allocate whatever it raises each year in whatever way it sees fit. Don't like what they do? Vote against your representative at the next election. Don't pass some silly initiative that tells the representatives how to do their jobs.

The most important goal of tax policy should be to provide a stable revenue stream to the state that doesn't jump around wildly from one year to the next. Revenue volatility is bad for all sorts of reasons. When times are good, there is too much temptation to assume they will last, and initiate new programs that will need to be funded in future years. And when times are bad, of course, the state runs a deficit, like we have right now. Predictability should be a key goal for tax policy.

Taxes should not distort the economy, intentionally or otherwise. Individual and corporate taxes should be simplified to sweep away the tangled mass of deductions, credits, exemptions, and other distortions that have accumulated over the years as the state, or the voters, have sought to encourage or discourage certain types of expenditures. Let's get back to a simplified income tax with no deductions, credits, exemptions or anything else that are intended to reward or punish specific types of expenditures by individuals or businesses. Maybe a flat tax would make sense, or a mildly progressive income tax.

Similarly, if we want a sales tax, let's clean it up and tax everything equally. No exemptions for particular kinds of goods or services. If we think sales taxes hurt the poor, lower sales taxes overall, rather than singling out particular types of goods or services for special treatment.

'Sin taxes' or fees can stay, or perhaps even be increased, for goods or services that generate negative externalities for which the state or society at large picks up the tab. Thus alcohol, tobacco, and other taxes should remain in place to the extent that we think that the purchase price of the goods doesn't reflect the full cost to society of the good. The state, the federal government, and society at large, ends up picking up the tab for the health consequences of smoking through higher Medicaid and Medicare expenditures, and higher insurance premiums, so tobacco taxes should remain in place. Similar reasoning could be applied to justify taxes on alcohol. When someone drinks enough to harm their health, we pick up the tab. And sometimes people who drink harm others, or otherwise require expenditures on the part of the state, if only because they waste the time of our police.

Along these lines, I would also like to see a calorie tax, not as a punitive measure, or a measure to alter behavior, but to recover costs that are currently born by the state, the federal government, and society at large. I don't like the idea of a sugar tax, or a junk food tax, if only because such micromanagement is hopeless. Taxes on specific sources of calories also miss the point that the health problems associated with overweight and obesity like diabetes, heart disease and so forth are not necessarily due to single, specific sources of calories, but really reflect an overall problem with overconsumption of calories in general, whether through the grotesquely larger portions served by most restaurants, junk food, soda, or even fruit juice. The state should figure out what the social cost of a calorie is in terms of increased health care expenditure, increased premiums, reduced productivity, and impose a calorie tax as a means of cost recovery. Again, though, this should not be a dedicated funding stream for healthcare, but one more stream for the state budget, to be allocated as the legislature sees fit.

While we're at it, why not legalize marijuana and tax it like anything else. I'm not saying that because I am a fan of marijuana. I don't smoke it, and don't like it. But the current effort to restrict its use is a complete farce. It isn't working, and probably never will. Everyone who wants to smoke it seems to be able to get it whenever they want, so by not legalizing it and taxing it, the state is essentially leaving potential revenue on the table. If people are concerned about the high THC content of modern marijuana, regulate its content. We should also treat the recent proliferation of marijuana dispensaries in LA as an experiment in what happens if marijuana is legalized. Civilization didn't collapse, so let's end this farce and treat marijuana like anything else. We should also look carefully at other drugs and assess whether they should also be legalized, on the grounds that some of them may not be much worse than alcohol and are already in widespread use. Again, I am not advocating for use of any of these, but rather suggesting that our approach be based on evidence and practical considerations, not ideology.

Obviously, many illegal drugs really are dangerous, and should never be legalized, and hopefully law enforcement would have more time to focus on heroin, meth, and all the other really nasty stuff. Legalizing marijuana and some other drugs would probably aid law enforcement's fight these other drugs by depriving traffickers of a relatively easy source of revenue based on smuggling pot and other products. At the same time, I would like the state to take seriously the abuse of prescription drugs, whether it is painkillers, stimulants or worse. These appear to be misused wildly and many of them may have even more pernicious consequences than drugs that are now illegal, but somehow they aren't being taken seriously.

While we're at it, why not get the state out of the business of building and operating controlled-access highways, i.e. freeways? Create a non-profit, tightly regulated tollway authority, and turn all the freeways in the state over to it to run as tollways, with the requirement that it be self-sustaining. Of course it would have the ability to borrow from banks and issue bonds, like other such authorities. This would mean that every freeway in the state would become a tollway, but the state would be out of the business of building and maintaining freeways, and the costs of using a freeway would be borne entirely by users, and not imposed on people who rarely use a freeway because they use rapid transit or commute on surface streets. Of course the tollway authority would be free to experiment with various pricing schemes to maximize revenue, like congestion pricing, with higher tolls at peak hours.

That's enough for right now, I had better get back to work... I'll sort out the state's remaining problems in the next few weeks.

Fixing California. Part 1: The Constitution and the Legislature

California is broken, and I have figured out how to fix it.  See below for the first installment in my presription.  This has nothing to do with photography, or software, or any of the things I usually write about here, but I have been thinking about this a lot in the last few months, and finally decided that I couldn't hold my tongue any longer... 

Before I get going, though, a word about why I care so much about California.  You might reasonably, ask, if I think California is broken, why not pack up and leave?  Go somewhere else?  Well, there are some practical problems with that.  Most other places in the United States, and indeed in the world, are unappealing to me for other reasons, most importantly related to weather.  Leaving the weather aside, however, California is still one of the greatest places in the world, not just because of its fantastic physical endowments, including mountains, deserts, coastlines, agricultural land, forests and so forth, but also because of its people, who have come from all over the United States, and indeed all over the world, to make a better life for themselves, and in the process, have made California, at least Los Angeles, the most exciting, diverse, and cosmopolitan place in the world. 

Here goes...

Reboot the state government with a new constitution 

The state government needs to be fixed.  The problem is not the individuals who make up the government, either by serving in the legislature or leading our state agencies.  Many of them, probably most of them, are serious and talented people who want to do right by the people of California.  I suspect that many of them could make more money and suffer less public abuse by doing something other than what they are doing, and I am grateful that they are there trying.  Unfortunately, though, the system in which everyone operates now seems to have evolved into something where nobody can do anything.  Thus even though we have lots of capable and well-meaning people in Sacramento, we have reverse synergy, and the whole is substantially less than the sum of the parts.

Let's tear up the state constitution and write a new one, hopefully one that is much shorter, simpler, and more difficult to amend.  There is talk of a constitutional convention and I hope that happens.  Based on the experience of the recent decades, I think an important guiding principle for writing the constitution is that it should set out the basic principles by which the state should be governed over the long term, and not try to address specific current and probably short-term concerns that may be irrelevant in a few decades.  I am really concerned that a constitutional convention will turn into a free for all where dozens or hundreds of special interests will try to have their pet concerns written in as clauses.  In that case, we will end up with a constitution hundreds of pages long that is an incoherent pastiche of mandates, restrictions, caps, and limits that reflect various parochial interests.  The new constitution should be a minimalist one that establishes a small number of basic principles by which laws are made, officials are elected, and so forth.  It should leave the handling of specific issues and situations to the legislature and the courts.  And it should be very, very difficult to amend.

I favor minimalism in the new state constitution because I think that the notion we can solve our problems by having some sort of exhaustive, all-encompassing constitution that addresses dozens or hundreds of specific pet issues by binding the hands of elected officials is delusional.  Indeed, it is the idea that we can solve our problems with more and more limits, mandates, caps and restrictions on the activities of the legislature and state government that led us into our current mess.  It also represents an abdication of responsibility on the part of voters.

Legislature and state government


Basically, I would like to see a clean and simple unicameral system for the state.   As I envision it, the state government would be organized like a provincial government in Canada.  The legislature would essentially be a parliament, with a governor selected from whichever party or coalition of parties holds a majority.

The current system of a separately elected governor and bicameral legislature was intended as part of a system of checks and balances, but increasingly I think it is archaic and somewhat mindless imitation of the federal system.  Most disturbingly, the current system has morphed into one in which no party, and no single individual, seems to be responsible or accountable for the successful or failure of anything.   In other words, it has become a device for evading Now whenever something falls apart, each party can tell its supporters that it was the other party's fault, and nothing happens.  Indeed the current system seems to reward obstructionism.

A state parliament with a governor selected from the majority party would clarify responsibility and improve accountability.  If one party was in office and botched everything, they wouldn't be able to pin the blame on another party.  And if they succeeded, they would get the credit, and the voters might give them another chance.  The voters could throw them out in the next election and give the other party a try.  Basically a party that is put into office has to put its money where its mouth is, so to speak, and deliver the goods while they are in control, because they can't fall back on claiming that they were obstructed by the other party.  The current system in which in effective legislators or governor can be reelected again and again by claiming that their party was trying to do good but was obstructed by the other parties would be eliminated.

Along these lines, I would abolish most if not all statewide elected offices.  The governor would have the equivalent of a cabinet that would include agency heads and equivalents of the current elected officials.  This makes whichever party holds office solely responsible for success or failure in governing.  If the voters don't like what is happening, there is no ambiguity about who deserves to be blamed, and who should be thrown out of office at the next election.  And if things are going well, the governing party can get the credit.

We should also eliminate all term limits, except perhaps some sort of cap on length of service for the governor.  Term limits in the state government are silly.  If voters don't like the job that an elected official is doing, they have a responsibility to vote them out, or live with the consequences.  Frankly, I think term limits are an abdication of responsibility, and have contributed a great deal to the mess we are in now.   A parliamentary system along the lines I outlined above would ensure turnover because voters would be choosing their legislator and governor at the same time.  An unpopular governor would drag down legislators with him because voters upset with his or her performance would have to vote against their local legislator.

As in most parliamentary systems, of course, the option would exist to bring down a government by a vote of no-confidence.  If the legislators from a majority party decided that the governor was leading them over a cliff, they have a vote of no confidence, and government would fall, and there would be new elections.


A key principle in the drawing of boundaries for legislative districts should be that internal heterogeneity should be maximized, not minimized.  Basically the goal should be to make every district as representative as possible of the state, or at least its region, so that every election is competitive, and a successful candidate has to assemble a coalition of voters from a variety of groups.  This would push candidates toward the center, and favor candidates who could appeal to a broad spectrum of voters.  I haven't thought this through, but one approach might be to randomize the drawing of boundaries. Rather than try to find some deterministic algorithm that draw boundaries that maximize conformity to some present criteria, and thereby reify some notion of what the key groups to be balanced are, maybe there is a way of redrawing boundaries through some kind of random process every ten years.  Of course districts would need to be compact, i.e. you would have to be able to reach any point in the district from any other point in the district without leaving the district.  While by luck of the draw individual districts might be skewed toward one demographic or another, overall there would be fewer safe seats for either party, and elected officials would need to be more attuned to the concerns of the center.

Right now it seems that district boundaries are drawn to maximize internal heterogeneity, and thereby create safe seats for specific parties.  This ends up making party primaries more important than the actual elections.  For both parties, this results in the election of extremists who seek to satisfy their base and thereby survive the primary. 

Stay tuned.  Now that I have sorted out the constitution and legislature, I will move on to state finances, education, and infrastructure.

Night scenes in Taiwan, December 2009 (台湾的夜景)

I spent the last two weeks of December in Taiwan. I didn't have as many opportunities to shoot as I might have liked because the main purpose of the trip was to visit relatives. But on three occasions I did get a chance to get out and wander around with a camera.  Check out my blog entries about my photos from the former gold mining town of Chiufen (九份), the waterfront town of Danshui (淡水), and the Shilin Night Market (士林夜市).  Or go straight to my Chiufen, Danshui or Shilin Night Market galleries.  Below is a slideshow combined all my favorite shots from this trip.



As usual, I really enjoyed my time in Taiwan.  I have a soft spot for Taiwan, having spent six months there in 1989, a year in 1992 and 1993, and made a number of visits since.  The people are about as friendly and reasonable as you can get, and there is a lot to see and do.  In some ways, it is even nicer now than when I lived there in 1989, 1992 and 1993.  The pollution isn't nearly as bad now as it used to be, the traffic is much better and the mass transit system has made everything more convenient, and there generally seems to be much more civic-mindedness, so drivers obey traffic rules, there isn't much litter anymore, and so forth.  I would swear that the food is much better now too, but maybe that is because when I was there before I was a student and couldn't afford anything but noodles and beer, and now I have the money for better restaurants.

While in Taipei, I had something checked out at the Taiwan Adventist Hospital, and was really impressed with how efficient it all was.  All of my appointments started right on time, the clinic seemed to manage its records well so that nothing was lost, and best of all, it was incredibly cheap.  I ended up having four appointments, and a variety of tests that I think in the United States would have cost several thousand dollars, but in Taiwan the total came to only a few hundred dollars, which I put on my credit card.  I kept all the receipts and paperwork, we'll see if my insurer will reimburse me.  I wish hospitals and clinics in the United States were as efficient, competent, and easy to deal with.  For its residents, Taiwan also has a national health insurance system that seems to work reasonably well.  It is nice to be someplace where the health care system isn't a complete train wreck the way it is in the United States.  I am sure the system in Taiwan has its shortcomings, but overall, what I saw of it was pretty impressive.

In Taiwan I also visited Hualien which was lovely, but I was too busy to get out and take pictures.  Hualien is on the east coast, perched between the mountains and the sea like Santa Barbara, and has a much nicer climate than Taipei.  When we were there, it was sunny and mild, just like being back in LA.  It is close to the spectacular Taroko Gorge.  Oh wait come to think of it I did take some pictures at the Gorge, I will get those uploaded soon.