Is Romney a Wazzock?

It is, for me, always a delight to learn a new word.

The news media on both sides of the pond have been full of stories about impolitic things said by U.S. presidential candidate Mitt Romney concerning the 2012 Olympics being held in London.  Romney has been traveling overseas in an effort to demonstrate that he is comfortable with international relations.

Although Americans have consistently shown that they are far more concerned about the domestic economy than anything else (recall the 1992 Clinton tag line, "It's the economy, stupid!"), especially when the economy isn't doing so well, we do expect a president to have some foreign policy "credentials," and without them we worry that our head of state might be viewed as a bumbling twit by our allies or as having exploitable weaknesses by our enemies.

Recently Mitt Romney has been on a trip labeled with one of my favorite oxymoronic terms in electoral politics: a "charm offensive." The objective is to get foreign leaders to take a liking to him and say nice things about him.  This is important, because one of the major advantages President Obama has over Romney (or anyone else) is that he is well-liked in the international community, and has been since his candidacy in 2008.  One may question how useful those sentiments have been to American foreign policy endeavors, but intuition suggests it can't hurt.

So why on earth would Romney question anything about the London Olympics, except perhaps how many medals Michael Phelps might add to his collection? To suggest that there might be something imperfect about security measures that have been implemented, or worse - much worse - that Londoners may not enthusiastically embrace their role as hosts of the Games cannot do anything but alienate the people he is trying to impress.

Referring to Romney's "charm offensive," a British newspaper called him "offensive" and said he was "devoid of charm."  And then the word that caught my eye: the writer for the Daily Mail who thus criticized Romney also said he is a "wazzock."

From 1966 to 1999 William F. Buckley had a television program called "Firing Line," full of spirited intellectual discussion of what would now be called "hot topics" in public affairs.  Beginning in 1971 this program was an hour long and ran on PBS, and nary an episode was missed in my household.  One of the things I really liked about the show was that Buckley was very attentive to the careful selection of words and had an impressive vocabulary.  He would never choose a word familiar to his viewers if there was an unfamiliar one that meant exactly what he wanted to say.  And so he sent me scurrying to the dictionary quite often.

I suspected "wazzock" was the sort of word I might find in my copy of Samuel Johnson's dictionary of insults, but for the sake of convenience I first consulted the New Oxford American Dictionary that resides in my Mac.  The meaning: a stupid, annoying person.  Origin 1980s, informal, British.  Not very satisfying, but likely correct.  When I consulted my mini-OED (the New Shorter Oxford English Dictionary, a wonderful compromise for those who cannot or will not commit to the many-volumed full-fledged OED), which has a publication date of 1993, there it was, with the same definition, and the notation "origin unknown." My older dictionaries had no "wazzock."  Oddly enough, neither did the latest edition of the American Heritage Dictionary of the English Language, published in 2000.  (Even their online version came up empty.)  So "wazzock" is apparently not part of British slang that has caught the attention of American lexicographers.

Surely this means that an American wazzock would not grasp the insult, at least not without consulting the right dictionary.  No doubt the writer for the Daily Mail knew this and liked the sense of irony.

But does the insult fit?  Romney headed up the operations of the Olympics when the games were held in Salt Lake City.  Surely he thinks he, and everyone who worked with him, did a great job.  He may even think they did a better job than anyone else ever had or ever will.  He clearly is a believer in "American exceptionalism."  His 2010 book is titled No Apology: The Case for American Greatness.  A good friend of mine recently posted a quotation from the book online:

England is just a small island. Its roads and houses are small.  With few exceptions, it doesn’t make things that people in the rest of the world want to buy. And if it hadn’t been separated from the continent by water, it almost certainly would have been lost to Hitler’s ambitions.

Romney believes the United States of America is the greatest country in the world.  Fine.  So do most of the people who live here.  (If you want a citation, too bad.  I just made that up, and I think it's an accurate appraisal of public opinion, but I have no survey data to support it.)

But this is truly a gaffe.  Why would he say such things about the Brits when he is supposed to be on a "charm offensive?"  I'm afraid the answer is self-evident: he is a wazzock.   

The ACA Survives the Challenge; Now What?

Unless you've been hiding under a rock - a really big rock - you now know that the Patient Protection and Affordable Care Act (the ACA) has (mostly) survived judicial review.  The "mostly" part of that statement is important, as we shall see.

The centerpiece of the challenge to the ACA's constitutionality was the contention that the individual mandate to purchase health insurance is an exercise of congressional power that exceeds congressional authority.

Absent any claim to being a constitutional scholar  - I do not even play one on TV - last August I briefly outlined the arguments that Congress was exceeding its authority under its enumerated or implied powers to regulate interstate commerce or provide for the general welfare (8/19/11):

http://bobsolomon.blogspot.com/2011/08/thou-art-commanded-buy-health-insurance.html

At the risk of substantially oversimplifying matters, I might say the Court reached much the same conclusion.  Then, however, notwithstanding the plain language of the statute, the Court upheld the ACA based on the notion that the requirement that everyone purchase health insurance is not a regulatory mandate with a penalty for noncompliance (which would exceed the constitutional authority of Congress) but rather a tax.  And the power of Congress to tax and spend (to "provide for the ... general Welfare") is essentially unlimited.

(In between the Court's pronouncement that Congress had no authority to do this one way and its further pronouncement that Congress could - and did - do it another way, major news outlets jumped the gun - in the middle of the explication by Chief Justice John Roberts - and announced that the ACA had been struck down, thereby making complete fools of themselves.)

I will not recount here what I view as the tortured logic of the majority opinion declaring it a tax or the incisive and compelling logic of the dissent on that point. (I do, however, commend both to you for your reading pleasure, or at least your enlightenment - although Scalia's opinions are, more often than not, reading pleasure for me, even when I disagree with them).  I will merely point out what I consider to be a common-sense view.  When you tell people who are not doing something that they must do it or pay a fine, that is a regulatory mandate with a penalty.  When people are engaging in an activity - typically involving goods, services, or money changing hands - and you estimate the value and exact a payment in relation to that value, then that is a tax.  In other words, inactivity can be forcibly replaced by activity through a mandate, while activity can be taxed. So, contrary to the language of the ACA itself, which many times describes a mandate of activity (purchasing health insurance) and a penalty for inactivity (failure to purchase), the Court has decided the penalty is a tax, as if the government were taxing inactivity.

Perhaps you have no interest in reading the majority opinion or the dissent. Perhaps all you want is to know that the Court has upheld the individual mandate, and you think it really matters not a whit whether the decision passes your personal logic test (or mine, for that matter).  The Supreme Court has the final word on that point, unless you want to disagree with Chief Justice John Marshall's Doctrine of Judicial Review, and then you're really going off on your own.  Fair enough.  That brings us to the "Now What?" part of the title.

It is possible that the Congress will repeal the ACA.  As you surely know, that would require the same thing the Act's original passage required: majority votes in both houses - and, as practical matter, because of the filibuster/cloture stuff that goes on in the Senate, a sixty-vote majority (instead of 51) there.  Given that not a single pundit I've come across thinks the Republicans are going to have 60 senators next January, repeal seems exceedingly unlikely.  Oh, and by the way, if President Obama is reelected, it would take a veto-proof majority of two thirds in each chamber, and you know what they say about flying pigs.

So the ACA is here to stay.  (No rhyme intended, and if you like the sound of that, please don't start chanting it.)  What, then, are the other implications of the Court's decision for the effect of the Act?

As you know if you are a regular reader, I think we need universal health insurance coverage in the United States, and I have been critical of the ACA because it really doesn't get us there.  We have some 50 million uninsured people in this country.  The ACA as enacted held out the promise of reducing that by about two thirds.  Thirty-some million folks would be added to the rolls of the insured.  Short of the goal of universal coverage, yes, but nevertheless welcome progress if it panned out.  However, the Court has tossed a bit of a monkey wrench into the works.  You see, about half of the newly insured were going to be covered not by health insurance they bought in response to the mandate but by expansion of Medicaid, the joint federal-state health insurance program for the poor.

That is enough of a problem in and of itself, because Medicaid is not "real insurance," as I've explained before and will come back to in a bit.  But now the Court has said Congress does not have the leverage included in the ACA to get the states, which administer Medicaid, to add all those people to its rolls.  Under the provisions of the ACA, states that didn't expand Medicaid as required by the Act would lose all of their federal Medicaid funding.  But the Court said no, Congress cannot do that.

And now some states have already said they will not expand Medicaid coverage as envisioned by the ACA, with more announcements to that effect predicted. Depending on how many states decide they just cannot afford to expand Medicaid coverage, even with a substantial initial infusion of federal tax dollars, this could put a serious damper on the ACA's effect in reducing the number of uninsured.  Today on NPR commentators noted the claim by some state officials that this is dauntingly expensive, and voluntarily expanding Medicaid coverage would be like booking passage on the Titanic.

And so it appears there may be millions who would have been newly covered by Medicaid under the ACA who will remain uninsured, unless Congress comes up with a different solution for them.

What about those who do become new Medicaid recipients?  That brings us back to the problem mentioned earlier, that Medicaid is not "real insurance."  You see, what Medicaid pays to the providers of health care services (doctors and hospitals, among others) is far less than what is paid by private health insurance. Therefore, many doctors will not accept Medicaid patients into their practices.  In some states Medicaid pays so poorly that Medicaid recipients have tremendous difficulty finding doctors to treat them anywhere but the one place where the answer is always yes: the emergency department.

When the disparity between access to care for Medicaid recipients and those with private insurance is large, because Medicaid pays poorly, that violates the "equal access" provision of the federal statute underlying the program, and states where that is the case are supposed to be forced to pay better and narrow the gap.  Who has the responsibility for enforcing the "equal access" provision?  The Department of Health & Human Services (HHS).  And who is failing to enforce this provision, so that equal access continues to be a distant dream for those on Medicaid?  That's right: HHS.

In many states Medicaid programs have been moving in the opposite direction, narrowing coverage and cutting payments to providers.  And so the improvement in access to care envisioned by the ACA is in serious jeopardy, notwithstanding the Supreme Court's decision to uphold the individual mandate.

Surely the ACA may have the effect of reducing the numbers of uninsured by a substantial proportion.  I fear, however, that far from the dramatic improvement promised by the Act's proponents, it may ultimately prove to be more incrementalism that falls well short of the goal.  And then Congress will be where it really doesn't want to be: back at the drawing board.  

Should We Spank Our Children?

If you're a regular reader of this blog, you probably realize this essay may not tell you the answer to that question. You know that I often examine questions to which we do not really know the answer, and I am often more interested in how we try to answer the question than in the answer itself.

The pediatricians say no. They've been saying that for years. The August issue of Pediatrics, the official journal of the American Academy of Pediatrics, includes an article (just published online) telling us of an association between physical punishment (such as spanking) and subsequent diagnosis of mental illness. The story has already hit the popular press.

The authors used a database called the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to discern an association between physical punishment during childhood and later being diagnosed with any of various mental illnesses, including depression and bipolar disorder, anxiety and panic disorder, post-traumatic stress disorder, substance (alcohol and other drug) abuse and dependence, and an array of personality disorders. They separated "harsh" physical punishment from more severe maltreatment. The former included being "pushed, grabbed, shoved, slapped, or hit" by parents (or any adult living in the household), but not being hit so hard it left a bruise or caused an injury.

Pediatricians have long believed (and assert that there is abundant scientific evidence) that more severe physical abuse is associated with subsequent development of mental illness. In this study they find an association between milder (yet still "harsh") physical punishment and mental illness.

So the first question is, do we care? And the answer depends on whether the association reflects a cause-and-effect relationship. Let us examine that question. We could start by looking at the journal article itself, which says the study's "design precludes determining any causal ... relationship between harsh physical punishment and mental disorders." And we could stop right there.

But the authors didn't stop right there. They are clearly inclined to believe there is some causality. So let us consider that question more carefully. Why might there be an association without cause-and-effect relationship?

The most common situation in which A is associated with B, but A does not cause B, is that A and B have contributing factors in common. Examples from everyday life are abundant. "People who get speeding tickets face higher costs to operate their cars." When we look at this, we find that they are not getting into more crashes, so that's not the source of the expense. Maybe if we stopped giving them speeding tickets, and they saved the money on fines and higher insurance premiums, they wouldn't face higher costs, and they'd be better off. But when we look more closely, we find that people who get speeding tickets are people who tend to drive faster. (In other words, they aren't just failing to keep an eye out for the highway patrol.) And people who tend to drive faster get worse fuel economy and burn through tires faster. And that's what causes the higher operating expense. So the speeding tickets don't cause the higher expenses (when you separate out fines and insurance premium hikes). The speeding tickets and the higher operating expenses are both caused by faster driving.

Now back to beatings and mental illness. Maybe the beatings don't cause the mental illness. Maybe they are associated because they have common contributing factors. The authors tried to adjust for some possibilities by looking at whether parents were dysfunctional (meaning parents were alcoholics, or drug addicts, or had mental illnesses, or had been in prison, or had attempted suicide). They also tried to take into account marital status, race/ethnicity, level of education, and household income. From the paper it appears that they looked at these variables for the children rather than the parents, which seems odd (why not both?), but perhaps they didn't have adequate data for the parents. The questions about parents being dysfunctional, like the questions about being beaten, were based on the recollections of the (now grown) children.

There could be any number of things (other than being "dysfunctional" as defined in this study) about the parents that made them inclined to beat their children and made them "bad" parents in other ways that put their kids at risk of later being diagnosed as mentally ill. Maybe it was those other things (and not the beatings themselves) that were the important contributing factors to later diagnosis of mental illness.

We could also look at factors inherent in the children. Maybe there were innate traits in the children that caused them to behave so badly that their parents found it appropriate to beat them, and those same traits resulted in their later being diagnosed with mental illnesses.

Why should we try to figure out whether there is a cause-and-effect relationship?

It is only if there is a cause-and-effect relationship that the finding of an association has any implications for medical practice or social policy. The pediatricians believe parents should be counseled not to beat their children but to use other disciplinary measures instead. And the authors of this paper point out that 32 nations (the U.S. and Canada not among them) prohibit such punishment, the clear implication being that the U.S. and Canada should climb onto this bandwagon.

This study has found an association, and the authors themselves admit the design of the study "precludes" a determination of causality. So if we want to know the answer to the question of causality, how might we find it?

We must first recognize the existence of a potentially large number of what scientists call "confounders" - additional variables that could be influencing the relationship between the two we are trying to study. We must also recognize that we may not be able to identify all possible confounders. And so we must design a study in such a way as to eliminate (or at least minimize to the greatest extent possible) the influence of confounders, both known and unknown. The way medical scientists do this is by conducting a large, randomized study. Randomization and sample size are the keys to minimizing the potential influence of confounders.

So here is the design. We take a very large number of children (say ten thousand) whom we are going to follow from birth. We assign them at random to either of two groups. The first group has their parents counseled (early and often) by pediatricians (or family practitioners) that beating children is not a good idea (and why) and is given advice about alternative methods of discipline. The second group receives no specific counseling of parents about disciplinary measures. We then follow the children into adulthood and see whether they develop mental illness (or anything else we think might be influenced by whether they are beaten as children).


(We could examine lots of other questions and assumptions.  For example, we think we know that boys who are beaten as children are more likely to beat their wives, and girls who are beaten as children are more likely to accept such mistreatment as adults.  I am as sure as I can be that this is true - it makes so much sense that it has to be true - without compelling scientific evidence.  Are they also more likely to beat their own children?  Many of us think so.  The kind of study I'm describing could answer these and many other questions.)

Of course we realize that in each group there will be children who are beaten and children who are not, so we will also be sorting the subjects into those two groupings. We will compare subjects who were beaten with those who were not, and we will compare those whose parents were counseled with those whose parents were not.

We want to answer two fundamental questions. First, does counseling seem to reduce the likelihood of beating children - in other words, do parents follow the advice they are given? Second, does not being beaten seem to produce emotionally healthier adolescents and adults? If the answers - from a study like this one - to both questions are "yes," then we know this is the advice doctors should be giving parents. And then we can talk about whether this should go beyond advice from doctors to parents and become a matter of social policy (and law).

This study will not be done. Pediatricians will not randomize children to having their parents counseled not to beat them or not counseled about that. And that is because they believe they already know the answer.

We design studies to answer questions to which we believe we do not know the answers. This is called "equipoise" - the answer could be A or B, and we really don't know.

The premature dismissal of equipoise is one of the major challenges in science. You cannot answer a question if you do not study it correctly, and you will not study it correctly if you believe you already know the answer.