Tuesday, April 17, 2012

Tinderbox: How the West Fueled the AIDS Epidemic and How the World Can Finally Overcome It

One of my favorite places to be are in those areas that are not easily aligned along any ideology. I love the complexities, the exception areas. I enjoy being just a little different.  I think, actually this is where the truth typically lies.  Ideology actually can make you stupid.  In that link, they suggest to deduct 10 IQ points anytime you try to simplify an issue into a simple story.  This is why when I listened to the interview with Craig Timberg about a book he co-wrote with Daniel Halperin about the AIDS epidemic and about how the ideological response from both parties proved ineffective when applied in Africa.  The result was millions of dollars utterly wasted in Africa while countless numbers continued to be infected and die from the virus.  I, of course, was interested, and recently, I finished the book.

This book is an extremely interesting and ambitious book, taking the reader through the history of AIDS beginning at the turn of the twentieth century until today. The AIDS virus has been around for a long time but buried in the depths of African jungles, passed among monkeys.  During the early twentieth century when Africa was experiencing rapid colonization, however, western countries invaded Africa for the purposes of exploiting it for its natural resources, particularly ivory and rubber.  These countries forced many more people into these jungles, building transportation networks from the African jungles into metropolitan cities nearby.  This link from the jungles eventually extended throughout the globe.  All it took was for the virus to jump from primate to human and to establish a deep sexual network along the transportation network to get the virus access to the broader globe.

The AIDS virus moved from monkey to man probably when someone was butchering monkeys for food. A single cut could allow the virus access into humans.   Colonization destroyed African familes and ruined cultural norms established for centuries as African men were exported to distance factories for cheap labor.  Prostitution and multiple sexual partners bloomed providing a tinderbox for the AIDS virus to explode globally.

The modern debate about how to combat AIDS in Africa also show just how clueless American policies can be when applied to cultures we know nothing about. Throughout the Bush administration, who admirably, in the name of compassionate conservatism, devoted millions of dollars toward the African AIDS problem ended up being misapplied. Both sides were wrong. The conservatives wanted to emphasize abstinence programs. The liberals wanted condoms. Neither approach realistically worked.

The Uganda leader, Museveni, said about condom use:
In countries like ours, where a mother often has to walk twenty miles to get an aspirin for her sick child or five miles to get any water at all, the practical questions of getting a constant supply of condoms or using them properly may never be resolved.
From  Halperin, Daniel; Timberg, Craig (2012-03-01). Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It (Kindle Locations 1927-1929). Penguin Group. Kindle Edition.
 Or as someone in South Africa said about condom use:
“Ah, Craig,” he replied in a sheepish, smoke-cured voice. Then he began to tell me the truth about condoms. Some people used them some of the time. Some people never used them. Almost nobody used them all of the time.

Halperin, Daniel; Timberg, Craig (2012-03-01). Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It (Kindle Locations 3462-3464). Penguin Group. Kindle Edition.
The problem with abstinence programs is similar.  You can't spend 50 years destroying a culture and all of it's family safeguards and internally established taboos then expect large percentage of people to just turn to a Western imposed morality.

The solution to the AIDS epidemic were pretty simple actually and were two fold.  Communities where a large percentage of the African men were circumcised had much lower rates of AIDS infections.  The foreskin provides a natural and easy way to pass the virus during heterosexual sex.  Second, leaders within the African community - religious, cultural, and political- had to be actively engaged in changing the internal cultural around sexual behavior.  If the number of sexual partners can be reduced, the sexual networks shrink and the virus has less opportunity to spread.
To Halperin, it seemed that the best hope for preventing HIV could be found in places such as this, on the front lines of the epidemic, where values were defined and often powerfully expressed. He thought, as he often had before, that initiative coming from those most directly affected, working in their own communities, could be the most potent force to finally overcome AIDS.

Halperin, Daniel; Timberg, Craig (2012-03-01). Tinderbox: How the West Sparked the AIDS Epidemic and How the World Can Finally Overcome It (Kindle Locations 4692-4695). Penguin Group. Kindle Edition.
The main lesson from the book is to be careful about idealogical rigidity, these tend to be wrong and at times devastatingly so.  We need to be careful and willing to reassess our biases and to accept the truth even if it lies outside the boundaries of our own political party or ideology.

Friday, April 13, 2012

On Lindsay Lohan

David Thomson has some really interesting things to say about the video above.
The faces in the pictures are nearly always the same size, and the close-ups are frontal and direct. Still, there is a sense of seething cell life as the montage moves: A hairline shifts, a jaw juts, the brow pulses, as if bruised, the eyes change mood and hope, the hair runs through a range of colors, the smile becomes professional after infant naturalness, and then it becomes mortal, fatigued and worse. There’s something like the shudder at the end of Psycho when Norman Bates’ staring face lets his mother’s bare skull peep through for an instant.
Twenty-five is still the prime of life, and it’s not that Lindsay Lohan doesn’t look beautiful today, or pretty, or like a movie star. It’s just that a haunted soul lurks in the last faces of the series, a gaze that seems to know the camera is like an illness from which she has no escape, a look that is hard to face or admit now, but which may become banal and obvious in a few years, as well as too late.
The thing about Lindsay Lohan or any celebrity really is how little they matter to almost everybody.   It's crazily asymmetrical.  I'm sure Lohan and other super-celebrities think we care more than we do.  We act like we do.  If we saw a celebrity walk by we would have a look, we'd want to take a picture.  But these are trivial, fleeting things that really don't matter and we know it.  It's just a minor distraction in our day.  Something to waste time on while we put off the really difficult challenges that really do stand in front of us.  I wonder if Lohan had this perspective, that the cameras and the attention have no meaning.  That her self-destruction is really her business.  That really only her family and close relations really care and the rest of us care far less than she thinks.

The only reason Lohan gets so much attention from the cameras is not that she matters much to us, but that she matters just a little bit to so many people.  The reason that is significant is because  so many of us will take a second look, will click on the link, will watch the video, it allows companies to use that bit of attention to  advertise their products.  That's it.  Without that fact, there would be no cameras, no attention.  She would simply be an actress.

This is the rub really.  We spend so much time building products that matter only a little to a large number of people.  Companies go for tiny profit margins that can scale across billions of global customers which translates into many billions of dollars.  Google works this way.  Facebook.  LinkedIn.  PayPal.  Visa.  But the services they provide really don't benefit us that much.    They distract us, they waste our time, maybe the make our lives a tiny bit more efficient in some small ways, while they keep us from really important activities in more important ways.  These tiny transactions we make over and over again, though, translate into huge profits for these companies.  But the single click, the one swipe of the card doesn't matter so much.

By comparison, I just returned from New York and saw Mary Poppins on Broadway.  This was an extraordinary show with amazingly talented actors, but they were just actors.  That was their job.  I would not recognize any of them on the street afterward.  The experience I had there did not scale.  Only, maybe, 100 people witnessed it on that night.   But the event was much more important to me than most of what I consume digitally.

Even more importantly, our plumber, the person landscaping our yard, the local artist, our nurses and school teachers, our neighbors.  The work they do and the relationships we have with this is vitally important - much more important to me than anything coming from Hollywood.  Without properly working plumbing, our lives would be a lot worse than if I lost access to Google.  Without a properly functioning school system or nurses and doctors, without thoughtful neighbors who wave at us and give us grapefruit our lives would be much worse than if I had to pay with cash instead of with a credit card.  These professions and relationships require time and skill but they do not scale.   These individuals have significant meaning to me but are irrelevant to most everyone else.   It's impossible to get rich as a plumber or school teacher.  I'm assuming it's tough to make a bunch of money even as a theater actor.  These jobs don't scale like Google does, like movies do.

I'm wondering if Lohan had this perspective, this awareness that she matters a lot less than she realizes, that people care a lot less than what it seems, if this would help her deal with the attention with more maturity and perspective.

Friday, April 6, 2012

Koby Granville for Tempe City Council

No final decision made here yet, but Koby Granville found my blog.  Check him out in the comments section.  This led me to re-look at his white papers posted on his website, and prompted a pretty detailed e-mail with some questions.  I definitely expected a reply but I did not expect to get a response as quickly as I did.  I appreciated the time e took to read my e-mail and give a really quick, thoughtful response.

I have not read all of his white papers, but I intend to.  His first talks about the reason why feels the need to get his thoughts down in this way.
As a 20 year resident of Tempe, and a person who has generally followed Tempe elections, I have always been amazed at the amount of information NOT provided by the candidates.
I say no to truncated politics. I believe the people of Tempe want to really learn about policy issues for each candidate. I believe the people of Tempe will understand that, although they may not agree with all of my opinions, I am actually willing to give you my opinion. Beware the candidate who only agrees with you, it means they are telling you what you want to hear.
 So, he made some attempts to get down to details in a series of white papers.  I read his position on taxes first and he makes what should be an obvious point here, but in today's world where we believe we can both cut taxes and raise revenues, this point must be made:
Taxes should support the services the majority of the residents believe add sufficient value for the required cost. When residents want additional services and believe the value of the new service warrants the new cost, taxes should be raised to cover that cost. If the residents want to tax themselves for increased police, increased public transportation, increased library hours, or for that matter increased anything, and they must be willing to pay the price for the service. That said, if the people are willing to pay the tax, they should be allowed to raise the taxes to cover the cost.
He also takes about how city government funds these services - through a combination of sales tax and bonds paid down through property tax.  In my email I asked him to get specific with the general direction he wanted Tempe to take and offered my general suggestions.  My thoughts:

First, I love Tempe and I think the city is doing a lot of things well:
We obviously need to at least maintain the infrastructure and services already in place - our parks, our schools, our other services.   So, we have a baseline of revenue that's required to maintain the status quo.  I'm pretty happy with the status quo and would be disappointed if anything was rolled back.
 But we can get better:
I do believe though we can be more visionary than this.  I obviously would love to see a better downtown.  I would like to do something about the blighted strip malls that have popped up around us.  I want better schools.  I would love to see a greater injection of the arts here.  And more interconnectedness and cooperation with our cities.  And I'm willing to pay more in taxes to support this broad vision.
Our funding mechanism, though is flawed:
The problem, though, is that sales tax is regressive and is highly volatile based on status of the economy.  Property taxes have obviously been volatile as our home values have increased rapidly and have dropped just as rapidly.  Another problem is at the same time we need government services (during downturns) our revenues drop.
He agreed with my general vision and then provided these thoughts on how to deal with tax revenue volatility:
 The real issue is this, when the city gets more money (for example) from rising home prices and the ability to bond, how do you keep it from resisting the temptation to simply spend the money that comes in the door?  Then, when the market falls, you are stuck where we are now, having to cut services.  So, the real answer is, to solve this problem, you need to solve the human issue of government spending whatever money it has in its pocket.  Clearly, you can't rely on the people to have this foresight, you have to create a structure that requires it.

So, you need to set up a structure that prevents a city from spending into new found money during rising times.  The easiest way to do it, but nobody would be willing to discuss it, is viewing the budget as a lagging average revenue stream over a 5 year period.  So, for example, if the revenue were $5 (year 1), $7 (year 2), $7 (year $3), $8 (year #4) and $10 (year #5), that the city average those years to determine the budget for year #6 ($7.40), even though the actual revenue for year #6 might be $10.  The difference then goes into a rainy day fund.  So, the city isn't tempted to spend into the temporary revenue, because their is a structure in place the prevents it from happening.  The other thing to do is to cost items based on the lifecycle cost rather than the purchase cost.  So, if you want to build a park, you don't simply look at the cost of building it, but the cost of building it and maintaining it over a 50 year period.  That raises the price of the park, and better reflects the true cost.  The city has actually started to do this of late, but it required the downturn to learn this lesson.

You might also review my paper on property tax rates, it outlines why I think what the city is doing now as it relates to property tax rates is the entirely right choice.
I'm obviously not an expert on this, but this seems like a reasonable answer to this problem.  The last recession was obviously devastating and any amount of reasonable rainy day fun is likely to get more than obliterated by such which is why it's on the federal government (which in times of deep recession has access to cheap credit when no one else does) has the obligation to try to fill in the gaps.
But the more local government can do to budget thoughtfully and prepare for times of distress the better.

One final thought, we as a voting public need to be smart about issues such as these.  I was pleasantly surprised that I could ask detailed questions and get a long thoughtful rapid response.  I hope to do this more in the future.

Thursday, April 5, 2012

Debt Problems

It's amusing to see just how un-serious either party, or heck almost any of us are about doing something serious about the national debt.  We squirm about how serious a problem our debt is but we refuse to give our politicians the political space to do what is necessary.  And really, it's not that difficult.

First let me get to some of the non-serious proposals being pushed out there by both parties.  First Paul Ryan's proposal to cut the deficit by cutting taxes for the rich, keeping taxes on investment low and cutting mostly unnamed spending on entitlements that will almost inevitably hurt the poor:
Like David Brooks before him, Stewart has fallen into the trap of believing that Paul Ryan is something other than a charlatan and a political hack. There are real tax reform proposals out there, like Domenici-Rivlin, which would cut the top rate to 27% but tax capital gains as ordinary income). I don’t agree with Domenici-Rivlin because I think now, with looming structural deficits ahead, is not the time to cut tax rates. (In White House Burning, we propose to reduce or eliminate preferences for investment income, mortgage interest, sales of homes, employer-provided health care, charitable contributions, state and local taxes, and state and local bonds, among others.)
Seriously, this is why I believe Mitt Romney is in trouble because without stretching the truth one iota it's really easy to come up with an attack ad like this:

or this:

Consider, in contrast Obama's attempts, which are also un-serious.  Bowles-Simpson's debt commision is one good example.  This was a plan that was never seriously supported or adopted by the Obama administration:
That demonstrated a level of political tone deafness that seriously hurt the credibility of what had now become a B-S cult. They were seriously suggesting that the Obama White House unilaterally support the tax increases and spending cuts included in the two co-chairs' plan even though it was virtually guaranteed that the GOP would never agree to do the same and would punish Democrats for doing so.
The primary difference between Obama and Ryan is that Obama has not pretended to proposed a serious plan to attack the deficit.  Ryan has pretended to, but his plan is one designed to appeal to the most extreme base of his party.

Until both parties can agree to cooperate and pay the political price of taking on some combination of  increased taxes, closed tax loopholes and cuts in spending that would invariably incur, then we are stuck with our current debt and deficit trajectories.

And really, the amount of pain to inflict is not that large and the way forward is not that hard.  One simple idea to seriously reduce our long term debt and deficit is to simply let the Bush tax cuts expire.
More importantly, the Bush tax cuts are responsible for the current political pressure to dismantle the federal government. So far, they have added almost $3 trillion to the national debt.** Despite all the damage they have already done, letting the tax cuts expire would still eliminate a big chunk of our long-term debt problem. Without the Bush tax cuts, we will have more than $300 billion per year, beginning in 2014, at least some of which could go toward helping ordinary people.*** With them in place, there is no chance of finding the money to patch our threadbare safety net, and one of these years the Republican assault on Medicare will finally succeed. It is a prerequisite for any kind of progressive policy that involves spending money.
 A much more difficult idea, politically, but a much better idea practically is to tackle all of the loopholes in our tax code like the tax exemptions on mortgage interest rates, or on employer health care plans, or the low taxes on capital gains.   Broaden the tax base, make the tax code simpler, then the tax rates can be lower and less intrusive while still maintaining or increasing our revenue.

The real problem is that anyone who is serious about debt reduction gets bludgeoned politically.  It is up to all of us to give our politicians to do the right thing.  We need to pay for the stuff we really want government to do.

Wednesday, April 4, 2012

Some Final Thoughts on the Affordable Care Act

Yesterday I addressed  the second of two links from a conservative alternative to Obamacare.   In that post I focused on the problems with the suggested alternative basically claiming that the market would provide "health status" insurance to address the risk we would all face if we only had an individual insurance market and premiums became unaffordable when our health status changed for the worse.

The need for this type of insurance comes to play only if we can successfully jettison the employer-based insurance system we are so dependent on today.   Dumping employer based insurance is an idea Cochrane embraces because it's the result of a deeply regulated system.  Employer based insurance only exists because it's heavily subsidized through the tax code.  Get rid of the tax code subsidies, employer insurance gradually goes away.

I do want to focus this post on the points of the link I agree with.  In part, one reason health care is so expensive, and increasingly so is because we don't currently have a functioning health care market:
In a functioning market, like car repair, or vet services for your dog, you can pay cash and receive services. Lack of insurance is only a problem for a small sliver of people who don't have enough money for an unexpectedly large  needed service. But it's essentially impossible to just pay for health care.
Paying for health care out of pocket gives you freedom.  Making health care extremely expensive to the point you need health insurance to make the purchase for you limits your freedom.   We paid for the birth of our last baby completely out of pocket with the help of a flexible spending account allowing us to spread the cost through the year.  We had the baby in our home delivered by a naturopathic doctor.   It was significantly cheaper than a hospital birth and we had complete control over how it went.

Our hospital birth babies were much more difficult, expensive, and we were forced to do whatever the doctors and nurses at the hospital ordered.   Since cost is no object, the hospital always errors on the side of caution and intervention which often went against our less intrusive  Bradley-inspired inclinations.

To get to the ideal in health care, we really need to nurture a system where routine and predictable services (yes including most child births) are covered and paid for by the person consuming the health care.  Let the consumer of the health care make the decisions.   Make health care providers accountable by allowing the consumer to walk with their feet.  Today, this option is not as available.

The problem, however, is that even routine and predictable health care can be out of reach for the very poor and we even routine health care needs, in a compassionate well-run society, to be universally accessible.  Which is why, the idea proposed at the end of this article resonates with me so much:
And a guiding principle of any reform should be to put the consumer, not the insurer or the government, at the center of the system. I believe if the government took on the goal of better supporting consumers—by bringing greater transparency and competition to the health-care industry, and by directly subsidizing those who can’t afford care—we’d find that consumers could buy much more of their care directly than we might initially think, and that over time we’d see better care and better service, at lower cost, as a result.
A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care—with routine care funded largely out of our incomes; major, predictable expenses (including much end-of-life care) funded by savings and credit; and massive, unpredictable expenses funded by insurance.
The gist of this suggestion is to have a single-payer comprehensive catastrophic insurance policy for everyone.  And by catastrophe, the author means catastrophe, like anything over $50,000.   Chronic conditions with expensive annual costs would also qualify.   Beyond that, everything should be picked up by the consumer with Health Savings Accounts that could be subsidized for the needy and borrowed from for the young to pay for large but non-catastropic expenses.

The ironic thing is that it's much easier to get here from Obamacare than from pre-Obamacare.  Robert Robb has a similar idea to above and describes how Obamacare can be fixed.   The Obamacare exchanges can be migrated slowly over to the catastrophic care described above.  The government just adds HSA to the mix and we're almost there.  Medicare and medicaid could also be rolled in.

How do you get there from here without Obamacare?  With the mess of a crazy mix of medicare, medicaid, employer based subsidized insurance, and the young completely opting out we are currently experiencing?  The answer is you can't.  If the courts renders Obamacare unconstitutional, then our hands are tied.

Tuesday, April 3, 2012

Some Thoughts on the Affordable Care Act - ObamaCare Part 2

In my last post I referred to two links that describe possible alternative solutions to Obamacare and I addressed the first.  The second provides a more interesting critique of Obamacare and I'll take that one on here.  In the second link, Cochrane makes the very good point that the reason our current health care system is so dysfunctional is because of the rules and regulations already in place:
But if "multibillion dollar subsidies" for the employer-based group market are what killed the individual market, maybe, just maybe, the answer is to get rid of those subsidies?
 Why is individual health insurance "unaffordable?" Because both Federal and State regulators have salted it up with mandated coverage that people wouldn't buy on their own. Young, healthy, uninsured need simple catastrophic coverage, or even just a contract that allows them to buy insurance later if they need it. They can't buy it because it's regulated out of existence.
And best yet:
 Those same people could pay cash for their non-catastrophic expenses.  In a functioning market, like car repair, or vet services for your dog, you can pay cash and receive services. Lack of insurance is only a problem for a small sliver of people who don't have enough money for an unexpectedly large  needed service. But it's essentially impossible to just pay for health care.
Finally, here's the suggestion offered briefly here:
But there  is a simple economic answer: individual, portable insurance that includes the right to buy insurance in the future.
 But flushed out with much more detail here.  This link basically introduces the idea of health status insurance, something I haven't heard of before.  It describes two sets of health insurances:  traditional insurance where the premium goes up or down based on your health status; and health status insurance that helps pay the cost of higher premiums when your health status changes for the worse.

For health status insurance to work, it seems to me that everyone would have to opt in.  If some people choose not to buy it, but then became chronically ill, something that is more and more likely as we age, then their premiums increase or worse, they are kicked out of the market altogether.  For a free market system to truly work, we have to be willing to kick people like this to the curb.  Will we as a society tolerate this?   

I'm not sure to what extent health status insurance will work anyway.  Some people are considered uninsurable at any price.   Health status insurance may not work at all for these unlucky people.   But something like this could work, if you just coupled health insurance with health status insurance and paid the combined premium to the same company.  It would be a way to guarantee a consistent premium no matter what happened to you.   But again, near universal coverage would make this work more efficiently.  To keep such rates affordable, you would need enough consistently healthy people in the insurance pool to offset those who are unlucky.

Finally, everyone's health status degrades as we age.  This is predictable right up to the point we turn 65 and become eligible for medicare.  Will an insurance market really cover predictable health care cost increases?  It would if enough of the young and healthy opted in.

You can never get truly universal opt-in to anything without some kind of government intervention.   Combining health status insurance with traditional insurance, in some ways, evens out premiums and gets you closer to Obamacare style exchanges - where everyone pays the same amount.  Finding a way for near universal coverage requires mandates.

Again, I'm not sure how you get there without something similar to Obamacare.    Cochrane suggests we should at least try and see.  Deregulate and let the markets work their magic.  If it doesn't work, people will suffer.  It's an expensive experiment to try and I'm not sure we really have the stomach for it.

Monday, April 2, 2012

Some Thoughts on the Affordable Care Act - ObamaCare

Recently, on one of the more conservative blogs I follow, the Tyler Cowen linked two articles that made some pretty smart critiques of Obama's health care act, one from Ross Douthat and another here from John Cochrane.  Douthat makes the point that whether or not the mandate proves to be constitutional, its unpopularity will ultimately sink it.  He offers some predictions on how both conservatives and the liberals might respond:
For conservatives, these reforms might look like the proposals that James Capretta and Robert Moffit outline in the latest issue of National Affairs — a tax credit available to people whose employers don’t offer insurance, better-financed high-risk pools and stronger guarantees of continuous coverage for people with pre-existing conditions. 

Liberals, for their part, would probably focus on gradually expanding Medicaid and Medicare to cover more of the near-elderly and the near-poor, creating a larger public system alongside the private marketplace. Indeed, the White House apparently considered switching to exactly this approach in the aftermath of Scott Brown’s surprise Senate win.
Let's first talk about the high risk pool for those with pre-existing conditions:
Think carefully about this for a second.  The main properties of Obamacare is that it offers one big community exchange for those not in a big company pool.  The way the insurance exchange works is that it spreads risk across a broad population.  One person in the pool who uses a lot of health care is subsidized by another who uses less of it.  The pool makes health care more affordable for everyone.

This only works, though, if you have expensive people offset by healthier people.  One other important property of the pool is that it gives the manager of the pool (the company or government in the case of medicare) more power to negotiate rates with insurance companies and health care providers.  More customers translate to lower rates.

A high-risk pool does not work as well.  Everyone in the pool is expensive which is why you need the "better financed" part of what Douthat suggests. What this means is that those not in the high risk pool - everyone else, has to pay higher taxes in order to finance the health care of everyone in the high risk pool.  If you play a bit with the linguistics, call this tax a premium, then you have just replicated Obamacare's exchanges with the mandate and the regulation or, at least, you've come awfully close to it.

Second, let's talk about Douthat's proposal to offer a tax-credit to those not in a private employer insurance pool.  Just so we're clear, those of us who get health insurance from a private employer also enjoy a major tax-credit wrapped around that health insurance.  That tax-credit goes to the employer but it makes it more affordable for the employer to provide this benefit to the employees.  More importantly, big companies who have more people on the insurance pool have greater negotiating power, have a greater capability to spread risk across more people, and therefore have a greater capability to provide more affordable health care to their employees.

So, say we decide to adopt Douthat's suggestion and offer a tax-credit for someone on the individual market.  This has the effect of dropping the tax rate for everyone who chooses to purchase health insurance (by an unequal amount by the way,  those in a higher tax bracket gets a bigger tax break).  So, those who don't choose or are unable to choose to purchase health insurance has to pay higher taxes than those who do.  Tell me how this is different than Obama's mandate?  Really, there's no practical difference.  In affect, then, combine Douthat's suggestion and you've implemented the mandate in two different ways.

A bit more on this.  Consider a healthy young person who uses very little health care has the choice between being on the individual market or takes the insurance offered by their employer.  If both options are equally subsidized through a tax-credit, it will likely be cheaper to go with the individual market.  In the company pool, the company is trying to negotiation one common rate for everyone in the pool, which presumably combines young and healthy workers with older, sicker ones.  For the insurance company to make a profit, the premium has to be higher than the cost of the average worker.  The individual, then will logically be able to get a cheaper rate going at it alone.  As healthier people opt out of the company insurance pool, it makes insurance still more expensive for those who cling to the employer pool.  Eventually, more and more companies may stop offering it.  Then, you are left with a single, subsidized exchange for those with pre-existing conditions and an individual market for everyone else.

By the way, this result is not so bad.   Leaning, as we do, so heavily on employer provided insurance is a really bad idea.  Getting rid of the employer based tax-credit loophole would go a long way to both simplifying the tax code and making space for alternative ideas that don't rely on employer cooperation.  However, if you end up with a high-risk pool offered to those people who are likely to need it (I can see this ultimately covering those over 50 - or alternatively, medicare could be expanded to get cover these people) and an individual insurance for people who don't need much health care anyway - you actually have backed into a system very similar to Obamacare.  The difference would be how the high risk pool was implemented.  If it was made of of a collection of regulated private insurance companies, it would be almost identical to Obamacare.  If it was single payer government sponsored insurance, you are a whisper away from medicare for everyone.

I'll get to the second article in my next post.