A Citizen's Guide to Indiana

Today is the Great American Smokeout 2009, the American Cancer Society’s annual effort to get smokers to quit for a day in the hopes that it will convince and enable them to quit permanently.

Hoosiers need this program more than most. Per capita, Indiana has the second greatest number of smokers, behind only West Virginia. It’s bad for you. Really bad for you. Everybody knows that now despite years of obstruction by the tobacco industry and claims that the science is inconclusive. It’s also addictive. That’s a rough combination.

So, congratulations to all those who have kicked the habit. I have a number of friends and family members who fit into this category, and I couldn’t be happier for them. Congratulations to all those who never started. You chose . . . wisely. And, to those who still smoke but want to stop, good luck. Maybe today is the day you stop.

This is just going to be a drive-by post, since I haven’t thought it through and probably don’t have the expertise to think it through if I tried. But, it seems to me that health care financing has both a risk management component and an entitlement component. Maybe we need to break those things apart to have a rational method of financing health care.

The idea of insurance is to manage risk. You know that, in a given population, Bad Thing X will happen a given number of times and you know that the total cost to the given population of Bad Thing X will be $Y. You just don’t know which individuals will suffer from Bad Thing X. So, for that population, it makes sense for everybody to pay into a pool of money that will be used to pay the $Y in costs when Bad Thing X inevitably happens to someone. Where everyone’s risk is more or less equal, it makes sense to buy into the pool. (Interestingly, Congress has passed the Genetic Information Nondiscrimination Act which, as I understand it, prohibits decision making about risk management based on genetic information. In a sense, this requires the risk manager to maintain a fictitious level of uncertainty. I’m not saying it’s wrong, but as a policy choice, it’s very interesting.)

However, where it’s certain that Bad Thing X will happen to a particular individual, it does not make sense for other people to buy into a pool with that person. At this point, you’re not managing risk, you’re just subsidizing that person’s costs. However, as a society, we have made policy choices that we won’t allow unmitigated suffering from certain Bad Things even if a person doesn’t have the funds to pay for treatment of the Bad Thing. If someone hits a certain poverty level, we pay for certain things. If someone is having a heart attack at the emergency room, we require treatment. There are humanitarian concerns here as well as some direct benefits. (For example, if you subsidize proper medical delivery, that might reduce the number and long-term societal costs of birth defects. Or, if you subsidize vaccination, that might reduce the overall costs of disease.)

I wonder if it would be possible to bifurcate the risk management aspects of health care financing from the entitlement aspects. Pay for the former through typical principles of insurance and pay for the latter through a general system of taxation.

Today is Organization Day at the State House. Legislators meet for a day to perform mostly ceremonial functions and then don’t typically return until January when they get to work. Organization Day always struck me as being a little like the first day of school – any divisions between legislators are mostly forgotten and lawmakers are just happy to see each other again after summer break.

Organization Day is used in election years to choose House and Senate leaders and adopt legislative rules for the next two years. But in non-election years like this one, the day is primarily symbolic.

“Organization Day helps to get re-engaged, to begin to focus on the issues coming up,” said Rep. Jeff Espich of Uniondale, the House Republican fiscal leader.

It also marks the first day that members of the House can begin filing bills — senators started a couple of weeks ago — and chamber leaders can start assigning bills to committees.

For me, it means I can start looking at the LSA website for legislation to talk about. I feel like I’ve been spinning my wheels here on the blog for awhile.

Good has defeated evil, Frodo has dropped the Ring in the Cracks of Doom, Aragorn has claimed his crown, and none of it would have been possible if Sauron hadn’t stupidly decided to go for it on 4th & 2 at his own 28 instead of punting.

And Collinsworth is still a tool. The last Sunday night game, Collinsworth was talking about how Manning couldn’t be in the same conversation with Marino in terms of great quarterbacks until Manning had won at least another Super Bowl. This time he was running his mouth about how the Colts had trouble playing high caliber teams.

For those who didn’t watch the game, the Colts came back from a big hole against the Patriots. They were down 17 points in the 4th quarter (31 – 14). They pulled within 6 and kicked the ball to the Patriots and then stopped them, leaving them with a 4th & 2 on their own 28 yard line with about 2 minutes to go. Clearly you punt this one. But Bill Belichick is an arrogant jackass and decided to go for it and failed, turning it over on downs at the 29. Manning had to kill clock on his way to a Reggie Wayne touchdown pass with 13 seconds left. Colts win 35 to 34 in their second or third greatest comeback ever. (First is clearly the AFC Championship game following the 2006 season. Vying for second is the Tampa Bay game in 2003).

So, the Colts go to 9-0, but still have some tough work to do in terms of teams they play. But, with seven games left, they have a four game lead over the rest of their division and a two game lead over Cincinnati. The complexion of the rest of the season looks a lot different with a win tonight than it would have with a loss.

I tell friends from elsewhere that, despite what they may have heard, Hoosiers aren’t a bunch of rubes. Then, I see things like the report that Indiana is passed only by West Virginia in percentage of adult smokers. At 26.1%, we have more smokers than Kentucky. In this day and age, what in the world would possess you to start or continue smoking? Of course, the fact is, while starting smoking is a free choice, once the habit is established, the decision to stop smoking is not a simple matter of choice. Your body is addicted, and your mind is no longer the free agent we contemplate in simplistic economic scenarios. An Indy Star editorial notes the General Assembly’s failure to adopt a smoking ban and the correlation between smoking cessation efforts in states and lower smoking rates in those states.

It occurs to me that some of the arguments made by social conservatives against normalizing homosexuality in our society actually make some sense when applied to smoking. Smoking is a choice, not how you are born. Smoking is harmful behavior. There is a Tobacco Industry agenda to convert young people to make a lifestyle choice. Smoking in mainstream culture may make my kids think it’s o.k., and cause them to choose a harmful lifestyle. So, while I don’t necessarily support criminalizing smoking, I might be open to the idea of getting the behavior into the closet.

I freely admit to not being perfectly dispassionate on this topic. I grew up with smoking and didn’t like it. I’ve seen family members suffer from health problems attributable to smoking. I’ve seen family and friends wanting to quit but being unable.

Smoking is not a self-contained behavior which causes efforts to paint smoking regulation as solely a property rights issue to miss the mark. Property owners aren’t entirely free to discharge toxins even on their own property, particularly if they hold themselves open to the public.

The Indy Star editorial has this to say about reducing the number of smokers:

Numbers likewise don’t lie when it comes to fighting back against this scourge. The CDC report confirms that states with the lowest incidence of smoking are those that spend the most on tobacco cessation and charge the highest cigarette taxes.

They also are more likely to have state and/or city laws forbidding smoking in all indoor public spaces.

Fewer smokers means a healthier population, lower health costs, and maybe a little extra money at the end of the month to pay bills. This is anecdotal, but in my collection practice, I can’t tell you how many people unable to pay their bills seem to smell of fresh cigarettes, suggesting that they are foregoing paying their obligations in favor of buying another pack of smokes.

Today one of my friends, with whom I do not see eye-to-eye politically, posted a complaint about trying Khaleed Sheikh Mohammed in the United States District Court for the Southern District of New York. His complaint was that our criminal justice system was not meant for war criminals. Also in the news are the charges against Nidal Malik Hasan for the Fort Hood murders. There will doubtless be rumblings against the legal process he receives under the United States Code of Military Justice along the lines of “the people he killed didn’t get a lawyer.”

Whenever I hear complaints about bad people receiving due process of law, I’m reminded of the exchange between Roper and More in A Man for All Seasons about how we should give even the Devil the benefit of law, not for his sake, but for our own:

Alice: Arrest him!
More: Why, what has he done?
Margaret: He’s bad!
More: There is no law against that.
Roper: There is! God’s law!
More: Then God can arrest him.
Roper: Sophistication upon sophistication.
More: No, sheer simplicity. The law, Roper, the law. I know what’s legal, not what’s right. And I’ll stick to what’s legal.
Roper: Then you set man’s law above God’s!
More: No, far below; but let me draw your attention to a fact — I’m not God. The currents and eddies of right and wrong, which you find such plain sailing, I can’t navigate. I’m no voyager. But in the thickets of the law, oh, there I’m a forester.I doubt if there’s a man alive who could follow me there, thank God.
Alice: While you talk, he’s gone!
More: And go he should, if he was the Devil himself, until he broke the law!
Roper: So now you’d give the Devil benefit of law!
More: Yes. What would you do? Cut a great road through the law to get after the Devil?
Roper: I’d cut down every law in England to do that!
More: Oh? And when the last law was down, and the Devil turned round on you, where would you hide, Roper, the laws all being flat? This country’s planted thick with laws from coast to coast — man’s laws, not God’s — and if you cut them down — and you’re just the man to do it — do you really think you could stand upright in the winds that would blow then? Yes, I’d give the Devil benefit of law, for my own safety’s sake.