interviews
Water and the American West
by Richard Frank
October 25, 2021
This interview with Richard Frank, professor of environmental practice at the UC Davis School of Law and Director of the California Environmental Law and Policy Center, was conducted and condensed by franknews.
frank | Can you tell me a little bit about the story of water and how it's tied to the West, and to California in particular?
Richard | A friend of mine who's a Court of Appeals Justice here in California wrote an opinion on a water law dispute and started it with the quote, "the history of California is written on its waters." And I think that the point is true of the entire American West.
Water policy and legal issues are inextricably tied to the development of the Western United States; water is the limiting factor in so many ways to settlement, to economic development, to prosperity, and to the environment and environmental preservation.
Can you talk about the difference between groundwater and surface water– and the policies that regulate each?
There are really two types of water when it comes to human consumption. There's surface water: that is the water that is transmitted by lakes, rivers, and streams. Then there is groundwater, and a substantial amount of water that Americans and the American West rely on is groundwater. That is water that is stored in groundwater aquifers, which are naturally occurring groundwater basins. Both groundwater and surface water are critical to the American West and its economy and its culture.
Traditionally a couple of things are important to note, first of all, water is finite. Second, water gets allocated in the Western United States generally at the state level. There's a limited federal role. Primarily, policy decisions about who gets how much water for what purpose are made state by state.
I think allocation is really interesting in that it's more state-level than federal. How was water and the allocation of water in California designed? Is it a public-private combination? What goes on in terms of the infrastructure of water?
Another very good question. The answer is it depends. Most of our water infrastructure is public in nature.
Again, in the American West, the regulation of water rights is generally done at the state level, but the federal government, historically, has a major water footprint in the American West because it has been federal dollars and federal design and management that really controlled much of the major water infrastructure in the American West — you know, Hoover Dam, and the complex system of dams and reservoirs on the Colorado River in California, with the Central Valley Project that was built and managed by the federal government with Shasta Dam on the upper Sacramento River as the centerpiece of that project. But we also have a California State Water Project, the key facility being the Oroville Dam and reservoir on the Southern River that is managed by state water managers. If we were starting over, that kind of parallel system would make no particular engineering or operational sense.
But, we are captive to our history.
And then you have these massive systems of aqueducts and canals that move water from one place to another throughout the American West. They are particularly responsible for moving water from surface water storage facilities to population centers. In the last 50 to 75 years, these population centers have really expanded dramatically, so you need massive infrastructure to deliver water from those storage facilities, the dams, and reservoirs, which generally are located in remote areas to the population centers. So it takes a lot of time and energy to transport the water, from where it is captured and stored to where it is needed for human use.
California has faced continuous drought – what measures is the state taking now to manage water?
Just to frame the issue a little bit — we have, as I mentioned, a growing population in the American Southwest at a time when the amount of available water is shrinking due to drought and due to the impacts of climate change. We have growing human demand for residential and commercial purposes and at the same time, we have a shrinking water supply. That is a huge looming crisis.
And it is beginning to play out in real-time. You see that playing out in real-time. For example, several different states and Mexico rely on Colorado River flows based on an allocation system that was created in the 1920s, which is overly optimistic about the amount of available water. From the 1920s until now, that water supply has decreased, and decreased, and decreased. Now you have interstate agreements, and in the case of Mexico, international agreements that allocate the finite Colorado river water supplies based on faulty, now obsolete, information. It is a real problem.
What measures do you take now, knowing this information?
If you look at the US Drought Monitor, it is obvious the problem is not limited to the Colorado River. We are in a mega-drought, so cutbacks are being imposed by federal and state water agencies to encourage agricultural, urban, and commercial water users to cut their water use and, and stretch finite supplies as much as possible through conservation efforts.
In California, we have the State Water Resources Control Board, the state water regulator in California, and they have issued curtailment orders. Meaning, they have told water rights holders, many of whom have had those water rights for over a hundred years, that, for the first time, the water that they feel they are entitled to, is not available. Local water districts are also issuing water conservation mandates; the San Francisco water department is doing that, in Los Angeles, the metropolitan water district, is urging urban users to curtail their efforts.
And then agriculture. Agricultural users — farmers and ranchers — have had to get water rights in many cases through the federal government, as the federal government is the operator of these water projects. They have contracts with water users, individual farmers, ranchers, or districts, and they are now issuing curtailment orders. They're saying, we know you contracted for X amount of water for this calendar year, but we are telling you because of the drought shortages we don't have that water to supply. Our reservoirs are low at Lake Shasta or at the Oroville Dam.
When you drive from San Francisco to LA on the five, you see a lot of signage from the agricultural farming community about water. There's apparently some frustration about this. What are the other options for them?
About 80% of all human consumed water goes to agriculture. That is by far the biggest component of water use, as opposed to 20% used for urban and commercial, and industrial purposes.
Over the years, ranchers and farmers, and agricultural water districts assumed that the water would always be there — as we all do.
And the farmers and ranchers have, in hindsight, exacerbated the problem by bringing more and more land into production. You see on those drives between San Francisco and Los Angeles, particularly in the San Joaquin Valley, all these orchards are being planted. Orchards are more lucrative crops than row crops — cotton, alfalfa, and rice. But, if you are growing a row crop, you can leave the land fallow in times of drought.
We don't have to plant. If the water stopped there, or if it's too expensive to get, it may make economic sense, but if you have an orchard or a vineyard it's a high value, those are high value crops, you don't have that operational flexibility and they need to be irrigated in wet years and in dry years. Now, you see these orchards, which were only planted a few years ago, are now being uprooted because the farmers realized that they don't have the water necessary to keep those vineyards and orchards alive. For ranchers, the same thing is true with their herds. They don’t have enough water for their livestock.
The water shortage has never been drier than it is right now. Farmers and ranchers are being deprived of water that they traditionally believed was theirs and they're very understandably, very unhappy about it. They see it as a threat to their livelihood and to the livelihood of the folks who work for them. Their anger and frustration are to be expected, but it's nobody's fault.
To say, as some farmers do, that it is mismanagement by state and federal government officials, I think is overly simplistic and misplaced in the face of a mega-drought. Everybody's going to have to sacrifice. Everybody's going to have to be more efficient in how they use water. All sectors are going to need to be more efficient with the water that does exist.
Looking at this percentage breakdown of water use – is it actually important for individual users to change their water habits?
Well, every little bit helps. When you're talking about homeowners, about 70% of urban water use is for outdoor irrigation. So we're talking parks and cemeteries and golf courses and folks' yards. You know, that used to be considered part of that American dream and the California dream — you would have a big lawn in front of your house and behind your house. Truth be told, that has never made much sense in an arid environment. That's where the water savings in urban areas is critical in the way it really involves aesthetics rather than critical human needs, like water for drinking and bathing and sanitation purposes. There is a growing movement away from big lawns, and away from the type of landscaping that you see in the Eastern US — there is no drought in the Eastern United States. As Hurricane Ida and other recent storms have shown, the problem is too much water, or rather than too little in most of the Eastern United States. So it really is a tale of two countries.
We just need to recognize that the American West is an arid region. It has always been an arid region, we can't make the desert bloom with water that doesn't exist. We need to be more efficient in how we allocate those water supplies. And it seems to me in an urban area, the best way to conserve and most effective way is to reduce urban landscaping, which is the major component of urban water use.
You also write about water markets and making them better – for those who don’t know, what is the water market?
Water markets, that is, the voluntary transfer of water between water users, is more robust in some other Western states. Again Arizona and New Mexico come to mind. California somewhat surprisingly is behind the curve. We are in the dark ages compared to other states. Water markets are kind of anecdotal. There is not much of a statewide system. It is done at the local level, through individual transactions without much oversight and without much transparency. And I have concerns about all of those things.
I believe conceptually watermarks are a way to stretch scarce, finite water resources to make water use more efficient. I can, for example, allow farmers or ranchers to sell water to urban uses or commercial usage or factories in times of drought.
Farmers sometimes can make more money by farming water, than they can by farming crops.
There are efficiencies to be gained here.
The problem in my view is really one of transparency. The water markets are not publicly regulated, and some of the people who are engaging in water transactions like it that way, frankly, they want to operate under the radar.
In my opinion, water markets need to be overseen by a public entity rather than private or nonprofit entities. We need oversight and transparency, so that folks like you and myself can follow the markets to see who's selling water to whom, for what purpose, and make sure that those water transfers serve the public interests and not just the private interests.
There have been a number of stories in the New York Times and the Wall Street Journal and the Salt Lake City Tribune about efforts in some parts to privatize water transfer. Hedge fund managers are buying and selling water, as a means of profiting. And it strikes me that when you're talking about an essential public resource — and in California, it is embedded in the law that public water is an inherently public resource, that water is owned by the public and it can be used for private purposes, but it is an inherently public resource — the idea of commoditizing water through the private, opaque markets is very troublesome to me. I think it represents a very dangerous trend and one that needs to be corrected and avoided.
Why is California so behind?
There's no good reason for it. It's largely inexplicable that since the state was created on September 9th, 1860, we've been fighting over water. In the 19th century, it was miners versus farmers ranchers. In the 20th century, with the growth of urban communities, the evolution of California into one of the most populous states with 40 million Californians, it has been a struggle between urban and agricultural uses of water.
In the second half of the 20th century, there was a recognition that some component of water had to be left in streams to protect ecosystems, landscape, and wildlife, including the threatened and endangered wildlife. That suggestion has made agricultural users in California angry. You will see those signs that allude to the idea that food and farming are more important than environmental values. I don't happen to believe that's true. I believe both are critically important to our society. But the advocates for the environment have a proverbial seat at the water table. So that's another demand for water allocation that exists.
Do you maintain optimism?
Yes. I think it's human nature to look on the bright side. I try to do that through research scholarships and teaching. There are models for how we can do this better in the United States. Israel and Saudi Arabia and Singapore are far more efficient with their water policies and efforts. Australia went through a severe megadrought. They came out of it a few years ago, but they used that opportunity to dramatically reform their water allocation systems. That's an additional model. I think most people would agree in hindsight that their previous system was antiquated, and not able to meet the challenges of climate change and the growing water shortage in some parts of the world.
Here in the United States, we can learn from those efforts. There are also some ways to expand the water supply. Desalination for one. Again, Singapore and Saudi Arabia have led the world in terms of removing the salt content from ocean water and increasing water supply that way. In Carlsbad, California, north of San Diego, we have the biggest desalination plant in the United States right now, and that is currently satisfying a significant component of the San Diego metropolitan areas’ water needs. It's more expensive than other water supplies, but the technology is getting more refined, so the cost of desalinated water is coming down at a time when other water supplies, due to shortages and the workings of the free market are going up.
At some point, they're going to meet or get closer. Unlike some of my environmental colleagues, I think desalination is an important part of the equation.
In a proposal that came up in the recall election, one of the candidates was talking about how we just need to build a canal from the Mississippi River to California to take care of all our problems. That ignores political problems associated with that effort, as well as the massive infrastructure costs that would be required to build and maintain a major aqueduct for 2000 miles from the Mississippi to California. That's just not going to happen. Some of those pie in the sky thoughts of how we expand the water supply, I think, are unrealistic.
interviews
The Questions We Punt
by Alan Sager
April 16, 2020
This interview with Alan Sager, a professor at the Boston University School of Public Health, where he has taught since 1983, was conducted and condensed by frank news.
There is a misconception that closing hospitals saves money – why do some insist that's true?
It seems logical and feasible in the abstract; fewer beds and fewer hospitals sounds like it should equate to lower costs. Closings have been pushed for eight main reasons.
If the only tool you have is a hammer – every closing looks like a nail. You can turn Stephen Berger loose on hospitals in the 1970s, and you could have a Berger commission decades later, and it looks like you're doing something when you are really just repeating the same stale and failed policies.
Health care cost control is something that Americans in healthcare claim to care about, but don’t actually care. If we did, we would enact policies that were actually effective and not continue to insist on hospital closures. Support for cost control is probably a mile wide and an inch deep.
Also, the hospitals that expect to survive, may sometimes support the closure of other hospitals. There's a belief that competitive forces will be sufficient to do the job of weeding out ineffective services, but competition requires competitors, the more the better, and any closing or any merger reduces competition. Which allows the survivors to raise their prices. The pace of mergers in New York City and the consolidation has been very rapid in the last decade. Unfortunately, the hospitals that close tend to be the less costly ones. If the patients displaced by closings obtain substitute care, that's often available only at the very expensive major teaching hospitals that are rarely forced to close.
Right. And the hospitals that did end up closing affect black and brown communities disproportionately.
Well that's right, hospitals nationally are more likely to close in black and brown neighborhoods.
That is partly because a significant share of Latino citizens are located in Southwest cities where the physical shape of the city makes it easier for patients to move by car from one neighborhood to another. But in a place like New York, both ethnicity and race are certainly strong factors.
Black and brown people in New York City have been disproportionately hurt by hospital closings because they lose both inpatient care and emergency room care. And there are harmful ripple effects: when a hospital closes, the doctors that have remained in private practice in the surrounding neighborhoods are more likely to retire or relocate. We see this in city after city.
You also found black patients much more likely to go to the ER.
Yes, in national data, black patients are twice as likely as white patients to rely on the hospital for the doctor visit, whether that is for primary care, an ER visit, or for outpatient clinics. One third of visits by African Americans to see a doctor are visits to a doctor housed in a hospital. When you lose a hospital, you lose all of that care.
In many cities you have enormous expanses of medical deserts. Detroit has four hospitals for an area three times as big as San Francisco or Boston. In East Brooklyn there are very few hospitals or emergency rooms. There are a total of two in the entirety of Southern Queens – Jamaica Hospital and St. John's Episcopal in Rockaway. Queens has two and a half million people just by itself, it’s huge. One of the reasons we allow this to happen is that American healthcare is prejudiced toward raising the ceiling, not raising the floor.
Why do you think that is?
Well, in the abstract, we're committed to equity and we really care about it. That shows up clearly in public opinion surveys. But when decisions are made at an institutional level, the major teaching hospitals take priority. Major medical centers / teaching hospitals are disproportionately likely to survive. Smaller and mid-size community hospitals are much likelier to close. Decision makers are thinking about the Nobel Prize, about how they can push back the frontiers of medical knowledge. That's not evil. They are committed to saving lives, but they're not thinking about the question of what care is affordable for all Americans. That is a political and financial and ethical question that our country consistently punts.
We sometimes imagine that a functioning, competitive free market will give us the hospitals and doctors – the right numbers and the right types in the right places. I'm okay with free markets where they work, but they simply do not work in healthcare. Not a single one of the six requirements for a functioning free market is remotely satisfied in healthcare. We can't trust the free market here. But our nation’s long held faith in the private market combined with a legacy of public sector incompetence, leaves us with no functioning market and no ability for governments to act competently. Without either a market or a government that works, you have anarchy.
How does the closing of hospitals affect outcomes today? How are we seeing the choices already made play out in this pandemic?
We have large expanses in New York City where there are no hospitals and very few doctors – neighborhoods where there is a high share of citizens who don't have a doctor they know and trust. That basic trust in healthcare is a personal and critical one. When the doctors are gone, people in crisis don't have that relationship that carries them into healthcare. When a person lacks a doctor they can consult with, someone they can reach by phone to ask – “what should I do when a fever or shortness of breath hits?”
These large urban areas without hospitals and with few doctors has put healthcare out of touch for a large proportion of Americans. I don't mean to make it sound mystical. Healthcare is personal and human. It's not a machine whose hospitals and doctors are interchangeable parts. Place and people and race and income all matter, and we have ignored that.
Do you think it's possible to move back to a mode of community health care? To create a better relationship between patients and their healthcare providers?
If we made a commitment, as a nation, to have a family doctor for every patient that wanted one, we could certainly do that. Let me go through a few numbers with you.
Suppose we decided to pay $300,000 a year income for a family doctor for every American. And suppose we got really crazy and said we're going to drop panel size for family doctors from 2000 or 2,500 to only 1,000 – so those doctors have time to connect with patients, to follow up and ensure continuity of care, to network with other doctors. That is old fashioned primary care. If we wanted a family doctor at that rate, we would need about 300,000 primary care doctors. That would cost us $90 billion a year. We're spending about half that now. $90 billion during the year is not even two and a half percent of healthcare spending.
And good primary care really does save money. It means fewer lab tests, less imaging, fewer specialist referrals, fewer ER visits, and a diminished rate of intake of inpatient care. Some people have complained about “excessive use” of the emergency room for decades. The ER is nobody's first choice for basic care. Sitting in a crowded room with people coughing on you is not good care. People go to the ER because they don't have a better choice they can rely on.
We have to find ways of channeling enough of this year’s $4 trillion in health care spending into primary care. Today, high medical school debt, low income, and low prestige of primary care, and many other factors make rebuilding a network of primary care for all Americans challenging. But we're good at challenges, when we decide we want to take them on.
A big barrier to rebuilding neighborhood level of care is the public health world. Public health now talks about social determinants of health, like income, education, job training, transportation, environment, criminal justice, nutrition. Those are all crucial. But let’s look at the key numbers. We have a $22 trillion economy and healthcare is $4 trillion out of that. Most of the remaining $18 trillion already goes to the social determinants like food, housing, transportation, education and job training. The money is not spent well – and not equitably. But vast sums are already there to address social determinants. It needs to be spent better and more fairly.
Medical care is about taking care of sick people, and if many public health folks continue to fall in love with social determinants and imagine that most or all medical care is about prevention, they are going to continue to allow those who shape the spending of the $4 trillion to spend it very badly. The result will be to enable three very bad things to persist—the focus on raising the ceiling, the waste of health care resources, and the inequality inside medical care.
Just as bad, it is futile to talk about “social determinants” without identifying any feasible way— politically and financially—to get the hundreds of billions of new dollars to address them. Especially in a nation where higher health care spending sponges up $200 billion more each year. Without health care cost control, how will it be possible to find serious new money to address those social determinants? And so, probably, are attempts to insure all Americans.
You know, it's an interesting thing you point out, because of those we’ve interviewed in the public health space for this issue, many make the point you just discounted. Which is, if we ignore the social contributions to overall health, we cannot make people healthier. I think it's a really interesting distinction to make in terms of funding.
Yeah. I’m not discounting the social contributions to overall health; I’m just insisting that medical care isn’t very good at making those contributions.
I am really suggesting that what doctors and hospitals know how to do is take care of sick people. That’s essential, since prevention has a 100 percent failure rate. And the quicker doctors diagnose people who have serious problems, the better we can help them avoid deterioration, high blood pressure, diabetes, obesity. Trouble is doctors are not very good at helping us lose weight and it goes so much to factors that most medical care really doesn't help with. Most social determinants are products of economic insecurity and legacies of economic and racial and ethnic discrimination. But healthcare doesn't really know how to effectively address any of that.
4 trillion bucks towards healthcare can go a long way. Do you happen to know that that's five times defense spending?
No I did not.
No one knows that.
Why is that such a secret?
Well, because no one pays attention.
Is it enough for immortality? Probably not, since health care has the same 100 percent failure rate that prevention does. But it's enough for medical security, which is a phrase the late Senator Ted Kennedy often used .
Medical security means when you're sick or injured – getting quick, competent, appropriate and kind care without worrying about the bill. And 4 trillion bucks is enough to do that. If your family doctor’s panel of patients were one thousand, I imagine they could be a good channel to refer you to AA or Weight Watchers or a good social worker. I think that's a good way – a patient-by-patient individual approach to addressing social determinants. But saying that public health or health care can handle income redistribution, education, nutrition, housing, job training, criminal justice and the environment is delusional.
If you take your eye off the ball and you stop insisting on healthcare equity, you allow the well-intentioned but misdirected people who channel healthcare spending to control the only money that can go towards assuring medical security. The power then goes to people who are focused on the ceiling rather than the floor.
You wrote ‘the US appears addicted to more money for business as usual,’ which I thought was a succinct way of describing the politics of all of this.
Well, I think it's true. Nobody's evil in this; there are no villains, I think.
Our country began to cover people when the economy was booming in the 40s, 50s and 60s, and we didn't build in any cost controls. Other rich democracies raise the money for healthcare overwhelmingly through taxes. When you have to raise the money through taxes, two things happen. One, there's more of a built in pressure for equity, because it's public money. And two, there's a built in pressure for cost control because politicians don't like losing elections, and raising taxes is the best way to lose elections. When you have tax financed healthcare, you are going to be way more interested in controlling the costs of hospitals and doctors and drug companies, meaning that those actors will have to make much more careful decisions about what they're doing and who gets it.
$4 trillion translates into the U.S. spending more than double the rich-democracy average per person. And those other nations in the OECD typically provide substantially more doctor visits, more hospital admissions—for half the money. And they live longer. Not bad. By some estimates, you could say that half of the $4 trillion we spend today is wasted. It is wasted on care that is not needed, care that is botched, high prices for drugs and much other care, and administrative, and paperwork waste (which stems from multiple payers and complexity—and great mistrust between caregivers and insurance companies).
The primary was very contentious in terms of each candidate's take on healthcare. How do you look at the national conversation? Do you feel like it's helpful? Do you feel like there’s a right solution? Do you wish it was an entirely different conversation?
I think it's mostly unhelpful. I think it deals mostly with abstractions, like "choice of insurance company" or "single payer." These are probably the least attractive political slogans you could imagine. Let’s substitute "health care for all" for “medical security for America.” You take that and you start to think, how do we make sure we have the right kinds of doctors, the right number of doctors, in the right kinds of places. And the right numbers and types of hospitals in the right places, both urban and rural. I fear that single payer is an abstraction. And it’s a big jump in a country where people don't trust the government.
The French government, for all its various oddities, has a completely different sense of accountability than the U.S. Pres. Macron said a few months ago that the government was going to pay the salaries of 200 family doctors to move into underserved urban areas, and 200 more to move into underserved rural areas. The government of France feels responsible for making sure every citizen of France has a doctor. That is the kind of talk —and action— that I think makes a difference.
For my entire adult life, I've listened to a faux debate about healthcare. Usually the argument stalls at, well, where's the money? This end point is, as you’ve explained, not true – we have the money.
Elizabeth Warren even explained how you shift the money from private insurance premiums into a single trust fund. In effect, she’d finance health care for all in large part by requiring maintenance of private effort—premiums from employers—but diverting that money into the trust fund that finances health care for all.
You don't want to take $1.2 trillion in private insurance premiums and convert that into the income tax or social security tax because people will get sticker shock. Nothing beats a 70 percent rise in the personal income tax as a way to get a politician defeated in the next election. However, if you simply take the aqueducts through which the private insurance money flows and hook them up, not to Blue Cross as the payer, but to the single trust fund, it's just a matter of re-piping the aqueduct for the last 20 yards. The money is there. The claim there was a $32 trillion shortfall in the Medicare-For-All proposal was totally bogus. That was the big insurance companies and their executives wanting to keep their jobs.
We know how to save money. If every hospital had a budget adequate to finance efficient delivery of needed care for all people, the hospital administrators and their assisting MBAs would sit down with the clinicians and say, how do we make this money last 12 months and take care of everyone? And that is how hospitals typically operate in other rich democracies.
Is there anything you want to address about what's happening with this pandemic?
We came into this crisis, as everyone now knows, unprepared, with inadequate reserves of equipment, clothing and masks. With a public health infrastructure that had been gutted over the last 40 years. Where the competent people who could have helped craft quick testing and quick contact tracing — and who would have been an effective force for quicker action generally — were not widely available. Dozens of thousands are dying. I think we have to resolve to do better next time. As President Lincoln said in Gettysburg on November 19th of 1863, those who fought consecrated the ground on which they died.
That means rebuilding a vigilant public health capacity that provides accurate early warnings and quick, effective responses. And it means assuring affordable and high quality medical care and medical security for every American
We have to refrain from forgetting. We quickly forget. If hindsight really is 2020, we need to look back on what has happened, when things settle down, and remember what happened and why.