Will and process

Back in August, I got involved in a rather heated discussion over at Reclusive Leftist. Among other things, I asked why those on the Left were so eager to turn health care over to the government (RL favors single-payer) when they were forever complaining about government when it came to war, domestic surveillance, and so on down the whole litany of things the Left hates about the government. What if, I wanted to know, all health care is controlled by government and the Republicans return to power? Don’t you worry that certain procedures - including abortions - will be eliminated from government-paid health care?

Reclusive Leftist’s response was (emphasis mine):

It’s not a question of trusting goverment. It’s a question of using government for what it’s best at, which is managing shared resources and doing things which require society’s collective action. Government is just society imposing its will as a group. [snip]

A drawback in this country is that government-funded programs are susceptible to political attrition, particularly when Republicans get in office; but at least we have recourse in terms of voting.

As the health care bills moved through Congress and the attendant battles over covering abortion made the headlines, I wondered if those on the Left who are also feminists would begin to see that perhaps government-paid health care was not necessarily a totally good idea. Certainly the refusal to allow Federal money to pay for abortions is about as clear an example of society imposing its will as we can find: 61% of those polled by CNN in mid-November “[oppose] using public money for abortions for women who can not afford the procedure”; only 37% favor such use. Clearly the position that Congress has taken on funding (or rather not funding) abortion under the new Exchange reflects the will of society.*

Now it looks like society imposing its will as a group is not such a good thing after all. In a post entitled “Abortion restrictions violate women’s Freedom of Religion”, Reclusive Leftist quotes approvingly RiverDaughter’s argument that:

With anti-abortion measures, women are not just subject to the state, they are forced to recognize a religious presence in their lives whether they have faith or not. Men do not need to recognize any faith. They are allowed complete freedom of conscience.

RL then says:

... it’s absurd for the government to honor the anti-abortion scruples of conservative Christians while simultaneously forcing the rest of us to pay taxes for war or torture or capital punishment or any number of policies we abhor. [snip]

Anti-abortion laws essentially force every woman in this country to be a conservative Christian whether she likes it or not. No matter what she personally believes — whether she’s an atheist or a Unitarian or a Jew or a Muslim — she must obey fundamentalist Christian law.

It’s no different than forcing every woman into a sharia court if she wants a divorce, or forcing her to wear a veil.

Oh, dear. Where to start? Let’s get the Christianity thing out of the way first. It’s not just conservative Christianity and Catholicism that oppose abortion. Some very minimal research - a look at the Wikipedia article on “Religion and abortion” - uncovers the fact that all five major religions have objections to abortion. So while Leftist feminists are certainly free to pursue the religious freedom argument they’ll have to move away from using it to bash fundamentalist and evangelical Christians and Catholics.

Even with that, however, a lot of activities we forbid by law are also forbidden by some or all of the major religions; murder, theft, and perjury spring to mind. One simply cannot argue with a straight face that if a religion prohibits an activity, then prohibiting it by law violates religious freedom.

That leaves us with the argument that only those who are deeply or conservatively religious have reservations about using government money to finance abortions. This doesn’t hold water either. Abortion pits a woman’s right to bodily integrity against the fetus’ personhood. You don’t have to be deeply religious to accept the fetus’ personhood any more than you have to be not at all religious to accept a woman’s right to bodily integrity. Abortion is simply not a strictly religious issue. And, of course, funding abortion has even less to do with religion than abortion itself.

The argument the Leftist feminists should be making, of course, is the slippery slope argument: the government refusing to pay for abortions is the first step to the government refusing to pay for other procedures people can now purchase on their own. They cannot, of course, make this argument since it validates the central argument against single-payer or any type of government-paid health care: the fear of rationing. I hope I will be forgiven for finding their dilemma somewhat amusing.

More seriously, what the Leftist feminist’s line of reasoning is really about, of course, is two things. First, the desire on the part of Leftist feminists to avoid recognizing that a policy they believed would be an unalloyed good - government health care - is not as totally wonderful as they thought it would be. This is human and understandable: no one wants to think they’ve fought hard for something that didn’t work out and no one wants to give up the dream of something that will fix everything that’s wrong. That doesn’t exactly make them reality-based but we all have our blind spots.

The second underlying issue is more serious and far more dangerous. It’s about ends and means and whose will should be considered society’s will. If the legislative process produces the end result desired by Leftist feminists - government health care - then the legislative process is the means by which society’s will should be expressed. However, when that process produces a result not desired by Leftist feminists - exclusion of abortion from government health care - then the legislative process is invalid and it is the courts through which society’s will should be expressed. Clearly it is not really society’s will that is to be expressed by government but the will of those who know best what society’s will should be.

I don’t imagine this is a new phenomenon. I’m sure that throughout our nation’s history every political group has sought to insure that its will is considered society’s will and is therefore the will government expresses. But as the health reform effort makes clear, the more government does the higher the stakes become. And, therefore, the more dangerous is the idea that any one group’s will is the correct will for the government to express.

I have a very good friend who has always said his preferred form of government is a benevolent dictatorship - with himself as dictator of course. The fact that that is everyone’s preferred form of government seems to me to be the basis of democracy. That formulation acknowledges both our own conviction that we always know best and some healthy laughter at that conviction. Out of that acknowledgment and that laughter comes the understanding that we must let everyone’s policy aims play out in an open, democratic manner or risk ending up with just the benevolent dictatorship we desire - but with someone else as the dictator. To be so convinced that one’s own policies are the correct ones that one is willing to insure those who prefer other policies are not permitted an equal shot at achieving their goals is to undermine the very bedrock of democracy.

I have a fair number of half-finished posts laying around and at some point I realized that a common thread running through many of them was a concern with process. Democracy is not about outcomes; it is about process. In some sense democracy begins with the idea that in many policy areas there is no “better” outcome; there is simply what the majority of the citizens want. In our particular form of democracy, the founders attempted to insure both a good process and protection for those policy areas where there was a “better” outcome. Then they gave us a process to change the protections if we so desired. But process is all-important.

In writing about the passage of the Senate’s health care bill, Megan McArdle said:

But to a libertarian, process matters. Having a good process is better than getting a good outcome, because a good process is one that maximizes your chances of getting good outcomes over time.

This is not an argument in favor these days with either side of the political aisle. We have become a nation focused solely on outcomes and seem to scarcely even remember we have a process - except of course when we accuse the other guys of making an end run around it. Somehow we have managed to forget that when we distort the process to get the outcome we want today, we open the door for those who oppose us to distort the process to get the outcome they want tomorrow. We forget that our “good process” is our only protection against that benevolent dictatorship where - I can absolutely guarantee you - all but one of us is not going to be the dictator.

*****

* I simply have to comment on another result of that CNN poll: 26% of those polled thought that “abortion should be legal under any circumstances”. I find this impossible to believe. Surely a quarter of the country does not support a perfectly healthy woman expected to give birth without difficulty to a perfectly healthy baby having an abortion when she is 8-1/2 months pregnant. And I sincerely hope that a quarter of the country does not support having an abortion simply because the mother - or father - is unhappy with the baby’s sex. I’d really like to see some more in-depth answers from the “any circumstances” people.

*****

Reading:

FindLaw: An interesting FindLaw article by Marcia A. Hamilton that argues the Stupak Amendment is unconstitutional on three grounds. I’m unimpressed but expect to hear much more of these arguments. She credits the United States Conference of Catholic Bishops with achieving the Stupak amendment and seems to think that proves this is a strictly religious issue. I doubt that anyone on either side of the health care reform issue would similarly interpret the USCCB’s support for universal health care as clear evidence such reform is a religious issue prohibited under the Establishment Clause of the Constitution.

Interestingly, Hamilton makes a slippery slope argument but only in a limited sense: that not funding abortions will lead to not funding contraception. I took a brief look at her other writings for FindLaw and recommend this one: “The Case for Instituting Healthcare Reform at the State, Not Federal, Level”.

Grim writes approvingly of RiverDaughter’s concerns about taxes being used in ways an individual taxpayer does not want and proposes a system to make sure that doesn’t happen.

I hate HaloScan

I’m just about to put up a post and all I need to finish it is a link to something at Grim’s. I go to his blog to get the URL. What do I see? A blank screen and in my status bar at the bottom the ominous message: Connecting to www.haloscan.com.

Time passes. Oceans rise and fall. Kingdoms prosper and crumble. Look! Transferring data from www.haloscan.com. Now I have the red screen and I can see the words.

I simply do not understand HaloScan. Sometimes it loads right up and all is well. Other times I could read War and Peace before it deigns to respond. If I disable it via AdBlock the blogs that use it load super-fast but I can’t comment.

I hate HaloScan. But not as much as I hate those vertical banner ads that display on top of the text in my iMac/Firefox configuration. Luckily I can disable those without losing functionality.

When I started this blog, I decided I’d never have videos, ads, continuously refreshing links, bottleneck access points, or slow-loading graphics. Every time I'm tempted to reverse that decision, I go into a Website that has one or more of those “enhancements” and remember I’m fighting the good fight for all of us who access the Internet from our home computers rather than our employers’ - and don’t have blazing fast access and more memory than NASA and NORAD combined.

The best things

Cassandra has written an amazing post, rich with themes to be explored. She writes of the political and the cultural and she is concerned but hopeful. Not so two of those she links: Vanderleun talks of national diminishment; InstaPunk talks of despair, of an existential crisis. The distress of both those writers is driven by politics in general, by Obama in particular.

Yet, at this moment in my life, I read Cassandra’s words not as a call for political solutions but as a reminder of the need for private virtue independent of what our government or our neighbors are doing. Cassandra writes:

What if the malaise that seems to have taken hold of America is not the disease itself but the cure for what ails us?

If we are able to turn this malaise into a cure, to grow larger than Vanderleun’s smallness, to replace Instapunk’s crisis with opportunity, it will not be because we elect a different President or Congressman or Governor; because we successfully pass a particular piece of legislation or successfully thwart it; because we write the perfect editorial or post; because we make the most cogent argument. If we as a nation are able to regain our energy, our surefootedness, our faith in our ability - and our desire - to “continue improving our lot”, to “leave the world a better place than we found it” we will do so based not on what we do in the political realm but on what we do as individuals, how we each live our lives.

Twenty-one years ago, I read an essay in Time magazine. I tore it out and it has traveled with me ever since. The entire essay is worth reading; written by Alan Paton, the author of Cry, the Beloved Country, it pays homage to the power and beauty of words. But despite my own love of words that’s not why I treasured it.

I’m not particularly religious; I’m not even sure I’m particularly spiritual - whatever that means. And yet one of the quotations from Paton’s essay resonated so strongly that it has lived on my bulletin board for all these years, transcribed by me in fading purple ink on fading purple paper. Its impact has never diminished and it remains for me a remarkable description of courage and faith:

In the year 1652 when throughout England all things sacred were either profaned or neglected, this church was built by Sir Robert Shirley, Bart., Whose special praise it is to have done the best things in the worst times and to have hoped them in the most calamitous.

Merry Christmas.

Hadassah

[A note about names. In this post I often refer rather familiarly to Senator Joe Lieberman as “Joe” and to Hadassah Lieberman as “Hadassah”. I simply couldn’t think of a better way to alleviate any confusion about which Lieberman I’m discussing when. Using “Senator Lieberman” would do for Joe but “Mrs. Lieberman” doesn’t provide enough of a visual clue for Hadassah - at least if you desperately need new glasses as I do. So my apologies for the familiarity.]

When I read this morning that FireDogLake was calling on Susan G. Komen for the Cure (the breast cancer foundation) to disavow any knowledge of Hadassah Lieberman, wife of Joe Lieberman, I spent some time trying to track down the ins and outs of this story. Here’s how it seems to go.

In the Spring of 2006 (probably) Hadassah Lieberman quits working for Hill & Knowlton after less than a year of employment. She seems to have made $77,000 during her time there.

Hadassah Lieberman joins Komen. I cannot find the exact date but this post was written in November of 2007 and Hadassah was already at Komen.

On November 5 (yes, November) of this year, Joe Conason wrote a Salon article in which he discussed the contradictions he saw in Hadassah Lieberman’s work with Komen and her husband’s opposition to Democratic forms of health reform (which I am hereinafter going to refer to as Demcare simply for lack of a better term). Depending on how you read it, it’s either a plea for Hadassah to convince Joe to support Demcare or a sarcastic slap at the idea that Mrs. Lieberman could possibly be sincere in her support women’s health issues given her husband’s political position on Demcare and her ties to “the insurance-pharmaceutical-lobbying complex that employed her for decades.” (Given Conason’s earlier - 2008 - article about Hadassah Lieberman, I’m betting on the latter.)

On the night of Tuesday, December 8 (yes, December now) of this year, the New York Times reported “Reid Says Deal Resolved the Impasse on the Public Option”. The deal “would sideline but not kill the public option”; proposed the buy-in to Medicare for those aged 55-64; and did that weird thing where the Office of Personnel Management would re-create the Federal Employee Health Benefits Plan. According to the NYT:

In announcing the agreement, Mr. Reid was apparently trying to create a sense of momentum for the health care legislation, which has been on the Senate floor for nine days, with no immediate end in sight.

On the morning of Wednesday, December 9, Joe Lieberman released the following statement:

“I am encouraged by the progress toward a consensus on proposals to send to the Congressional Budget Office to review. I believe that it is important to pass legislation that expands access to the millions who do not have coverage, improves quality and lowers costs while not impeding our economic recovery or increasing the debt.

“My opposition to a government-run insurance option, including any option with a trigger, has been clear for months and remains my position today.

“Regarding the ‘Medicare buy-in’ proposal that is being discussed, we must remain vigilant about protecting and extending the solvency of the program, which is now in a perilous financial condition.

“It is my understanding that at this point there is no legislative language so I look forward to analyzing the details of the plan and reviewing analysis from the Congressional Budget Office and the Office of the Actuary in the Centers for Medicare and Medicaid services.”

The Corner said this statement:

pours some cold water on the talk of a huge Senate health-care breakthrough. He signals that the public-option trigger won’t work for him, he raises a red flag about the Medicare “buy-in” expansion ... , and he says the proposals will have to be fully scored by CBO and analyzed by the CMS actuary before they can be taken up — all of which are problems for the Dems.

Further:

Reid’s strategy depends on building a sense of inevitability with this proposal. That doesn’t seem to be happening this morning, if Lieberman’s reaction is any guide.

On the morning of Friday, December 11, Jane Hamsher of FireDogLake put up a post (hereinafter “the letter post”) reproducing a letter she sent to Komen explaining why it was inappropriate for Komen to associate with Hadassah Lieberman. She explains that her concerns were caused by that Salon article from November.

Late Friday afternoon, The Plum Line reported that Komen did not intend to sever its ties to Hadassah Lieberman.

On Sunday, December 13, Joe Lieberman:

[makes] the rounds [of the Sunday political shows] to say that no, he will not vote for any plan that has a medicare buy in, a public option, or basically any of the other proposals to throw liberals a bone.

The progressives are, of course . . . well, livid is probably too weak a word.

On Monday, December 14, Hamsher puts up a post calling for the celebrities who support Komen to “join me in asking the Foundation to end its ties with [Hadassah] Lieberman, whose professional agenda is antithetical to the cause they purport to advance.” Let’s call this “the celebrity post”.

Also on December 14, Joe Lieberman told The Washington Times that “the campaign to push his wife out of Komen” is "over the line and offensive.”

On December 15, Hamsher responds to Lieberman’s statement with another post. Let’s call this one “the outrage post”.

Somewhere along the line - I don’t know exactly when because it’s not dated - Komen put up a statement on Hadassah Lieberman in which they state, in part:

Hadassah Lieberman has long been associated with Susan G. Komen for the Cure®, working with us on breast cancer education and awareness in other countries as a Susan G. Komen Global Ambassador. Her efforts have been invaluable and we intend to keep tapping her expertise to fulfill our goal to bring breast cancer programs to women in countries who have few resources to battle this disease.

Mrs. Lieberman’s efforts on our behalf are separate and unrelated to our advocacy on health reform.

To me this looks mostly like a simple case of Hamsher going after Hadassah Lieberman because Joe Lieberman is obstructing - or is seen as obstructing - Democratic attempts to pass a health reform bill that includes something approximating a public option, although I suspect Hamsher’s previous very ugly history with Lieberman figures in as well. I don’t like this for a number of reasons. First, I don’t in general think we should attack or punish politicians we don’t agree with by trying to take their spouses’ jobs away from them. I think this principle holds whether we’re talking about a very rich politician whose spouse has a very nice job or a not so rich politician whose spouse has a crummy job. Family should be off limits and family member’s jobs should especially be off limits.

Second, this is very sexist. Hamsher’s letter post is somewhere between hysterically funny and deeply disturbing to anyone who has managed to pass Feminism 101. Basically Hamsher urges Komen to dump Hadassah partly because:

It is widely known, however, that not only has Senator Lieberman been an instrument of obstruction to the kind of health care reform advocated by Susan G. Komen for the Cure... [snip]

... as Hadassah travels the globe under the banner of Susan G. Komen for the cure, decrying the inadequacies of our health care system and the desperate need to reform it, her husband is at home to kill the reform efforts we so desperately need.

In other words, Hadassah should lose her job because her husband (at least according to Hamsher) doesn’t support the kind of work her employer is doing. This is ludicrous. Women get to have lives separate from their husband’s. They even get to have opinions that disagree with those of their husbands. Why, I hear that Mary Matalin often does work her husband doesn’t support.

Third, this is the same old “lobbyist” bugaboo which pretty much ignores reality. Besides her husband’s politics, Hamsher also attacks Hadassah Lieberman for having worked for a major player in the health industry. Well, yes she did. In fact, she’s worked for several major players in the health industry. To put it another way, Hadassah Lieberman has lots (see also the linked pdf for more detail) of professional experience in the health care industry. She also has lots of community service credentials and she has political connections through her husband’s job. In other words, her background makes her perfect for an organization like Komen. The hard truth is that people who truly understand a problem or an organization or an industry must - almost by definition - be insiders. This is even more true if those people have some influence and some political connections. Someone like me, on the other hand, would have no possible conflicts of interest, no ties to other players - and no hope of even getting anyone’s attention much less getting anything done. As comment 47 (well worth reading in its entirety) on Hamsher’s post asks:

So, what do we fear? That Mrs. Lieberman will suddenly be advocating for what? Increased cancer rates to profit current clients of her former employer? The thing we seem to be saying here is, you once worked for a company that represented clients we don’t like. Now you’re disqualified from meaningful work in a cause you may care about. Let’s applaud her for working for a good cause, for which she is probably being paid much less than she was as a lobbyist. And if its volunteer, let’s thank her for working hard on a cause we care about.

Fourth, it’s not like Hadassah Lieberman just joined Komen. She’s been there for at least two years. If Hamsher is so terribly, terribly concerned about Hadassah’s pernicious influence on Komen she should have said something earlier. Yet I can find no indication that she did so. Neither Hamsher herself nor any of the other blogs I’ve read about Hamsher’s crusade mention any previous objections by Hamsher to Hadassah’s tenure at Komen.

So, no, I don’t like Hamsher attacking Hadassah Lieberman in order to further her little war with Lieberman. But what I like even less is Hamsher attacking Komen itself to further that war. Yet, unable to persuade Komen to dump Hadassah, that’s exactly what she does. Hamsher’s celebrity post is presented as an attempt to get those celebrities who support Komen to pressure Komen to drop Hadassah. Rather, the post is actually an attack on the Komen Foundation itself.

Hamsher begins by writing that she asked the Foundation to “stop using money that was raised for cancer research to pay Hadassah Lieberman”. (Not exactly but we’ll let that slide.) The Foundation, reports Hamsher, “issued a statement saying that they refuse to do so.” Hamsher then calls upon celebrities “to join me in asking the Foundation to end its ties with Lieberman, whose professional agenda is antithetical to the cause they purport to advance” (emphasis mine).

Hamsher continues:

The death of health care reform will no doubt please the clients of Hadassah Lieberman’s lobbying firms, but it would appear to be out of step with the goals of the Susan B. Komen Foundation. ... They are by far the biggest breast cancer organization, with close ties to the Republican Party. Executive Director Nancy Brinker was appointed by George Bush as Ambassador to Hungary in 2001, shortly after the Komen Foundation helped defeat a meaningful Patients Bill of Rights and promoted the watered down version Bush advocated. [snip]

Despite the obvious questions this raises about the impact of environmental factors on breast cancer occurrence, the Komen Foundation focuses its resources on developing treatments that increase the profitability of pharmaceutical companies like the ones that employ Mrs. Lieberman rather than prevention. Unlike other breast cancer organizations, they refused to sign on to the 2006 Consensus Statement on Breast Cancer and the Environment.

The drugs that are developed by the Komen money are being put out of the financial reach of average middle class women by Hadassah Lieberman’s lobbying firms. ... When the underlying causes of breast cancer are never addressed in a way that benefits women who will never be able to pay those high prices to stay alive, the name might as well be the “Race for the Cure You Can’t Afford.”

Translation? Komen isn’t really helping women with breast cancer or women who may get breast cancer or their families or the search for a cure. No, Komen is just an arm of the Republican Party funneling money not just to Hadassah Lieberman but also to pharmaceutical companies. Real translation? If Komen won’t support Hamsher’s quest to punish Lieberman, then Hamsher is going to do her damnedest to make sure people stop supporting Komen.

But wait. Perhaps I’m being too harsh. Surely if Komen is so awful then Hamsher has always had these concerns about Komen and this is the umpty-umpth time she’s taken the Foundation to task. If so, I can’t find any evidence of it. Rather Hamsher’s concerns about the Komen Foundation seem to have sprung full-grown like Athena from the head of Zeus. Using Google as a search engine and looking within the FireDogLake domain for entries that contain the word “Komen” and do not contain the word “Hadassah” I found 10 entries. In most of these, Komen appears only in the comments. For example, in this post comment #179 provides a link to a Komen Foundation press release on a study of the role of environmental factors in breast cancer. There is one FireDogLake post that actually mentions the Komen Foundation in the body of the post. Written by Lisa Derrick, the post applauds Obama’s choices for the Presidential Medal of Freedom. In describing former recipients of the Medal, Derrick says:

The recipients all share a commitment to bettering the human condition, and include: ... Nancy Goodman Brinker, founder of Susan G. Komen for the Cure, the world’s leading breast cancer grass roots organization;

So while there’s no evidence Hamsher previously supported the Komen Foundation there’s also no evidence she ever previously felt compelled to detail its manifold transgressions. Until, of course, it got between her and Joe Lieberman.

Threatening the vocational or avocational status of a private citizen to punish her husband is cruel, sexist, stupid, and tiresome. Threatening the financial well-being of an entire charitable organization because you hate the husband of one of its employees is monstrous.

*****

Notes:

About money. In cruising around the blogosphere, I’ve found a number of commenters who insist that Komen paid Hadassah Lieberman lots of money or hundreds of thousands of dollars. As far as I can tell, there are no reliable figures on what Komen paid Lieberman. In her celebrity post, Hamsher says:

How much is she being paid? It’s hard to tell — the Senate Finance report only indicates that it’s “more than $1000.” But money paid to spouses is one of the primary ways that members of Congress manage to wander into serious money while in office, and Hadassah made $328,000 in speaking fees in one year.

In this formulation, Hamsher is pretty clear that the $328,000 is from all speaking fees not just from Komen. By her outrage post, Hamsher is not being quite so clear:

If Senator Lieberman would like to talk about the “merits,” he should explain what his wife has done to merit $328,000 in speaking fees in one year rather than trying to obscure the issue with his theatrical brand of “outrage.”

Although Hamsher refers to “speaking fees” without claiming the entire amount came from Komen, the context - Hamsher is responding to Lieberman’s comments on his wife’s association with Komen - leaves the impression the entire amount came from Komen. (The reviews of Hadassah Lieberman on the Harry Walker Speaker Bureau site come entirely from Jewish groups which leads me to believe those groups are where Hadassah does most of her speaking.)

The simple fact is that we don’t know how much Komen paid Hadassah Lieberman or what they paid her for. (You can view Komen’s most recent annual report here. Download the “2007-2008 Annual Report - low resolution” pdf and see page 13 for a general breakdown of revenue and expense.)

About faux manufacturing. In her outrage post, Hamsher refers to Joe Lieberman’s “manufactured outrage”. In an August 2006 post about Lieberman, Hamsher refers to his “faux indignation”. Apparently nothing Hamsher ever says about Joe or Hadassah Lieberman is ever truly outrageous and therefore any reaction to it must be faux manufacturing.

About slippery writing. It seems to be thick on the ground at FireDogLake. Hamsher’s easily misinterpreted reference to how much money Hadassah Lieberman makes is one example. Similarly when I read her celebrity post statement that:

The drugs that are developed by the Komen money are being put out of the financial reach of average middle class women by Hadassah Lieberman’s lobbying firms ...

I assumed Komen was contributing money to drug companies. But in Komen’s statement in support of Hadassah they say:

It’s been reported that Susan G. Komen for the Cure provides funding to pharmaceutical companies. That is simply not true. We have never funded pharmaceutical company research – our grants, totaling $450 million, have gone to research institutions in the U.S. and abroad. Another $900 million in Susan G. Komen for the Cure funding has gone to programs in communities world-wide. We will commit another $50 million to research in the coming year.

After I read that, I reread Hamsher’s post and realized that she never actually said Komen was giving money to drug companies; she merely let it be understood.

In her outrage post Hamsher slides into shape-shifting territory. Responding to Lieberman’s statement that:

My wife is a private citizen in a movement that is looking for a cure for breast cancer and educating women about what they should do to protect themselves from breast cancer.

Hamsher replies:

If Hadassah Lieberman wants to volunteer to educate women about breast cancer, I think that’s great. But she has no special qualifications for this - nothing that Komen should be paying her for ...

Yet Lieberman never claimed his wife was educating women and as I’ve discussed above Hadassah Lieberman’s “special qualifications” lie in the fund-raising and interest-garnering fields. Surely Hamsher understands that charities must raise money and attract interest so she is being rather disingenuous here.

On Susan G. Komen for the Cure. I don’t know much about them except that when you say “breast cancer charity” almost everyone thinks of them. In the course of researching this post, I did a little reading and I discovered that Jane Hamsher’s is not the first attempt to drag them into a political fight. This article on one pro-life group’s clash with Komen will sound very familiar to anyone who reads Hamsher’s posts.

On one point of agreement with Jane Hamsher. In May of 2007 Hamsher wrote:

[Battling breast cancer] is scary enough when you have insurance and the resources to be able to get the treatment you need — I can't even imagine how frightening it must be to know you can't.

On that point, Ms. Hamsher and I are in perfect agreement.

Catastrophic comparison, Part 2.1

Now, where as I? Ah, yes. Before getting side tracked into my Five Health Insurance Issues series I was discussing three proposals for government-paid or government-provided catastrophic health care. As I said in my previous post:

So all three proposals are designed to make individuals see clearly what they are paying for their own health care because, the authors believe, that will result in careful decision making about what treatments are really worthwhile and which doctors and hospitals provide the best value which will in turn result in less spending on health care. At the same time all three writers want to make sure everyone has access to care and no one is financially destroyed by medical costs. Their goals are the same; the methods differ.

The question for today is: Are these plans paid for? Please note that this is a different question from whether we can afford them, either nationally or as individual taxpayers. Here I’m just examining whether the income streams they depend on are sufficient to cover the costs of the health care they must pay for.

Let’s start with Martin Feldstein's proposal since there’s no math involved. Feldstein proposes that the government give everyone a voucher to buy catastrophic health insurance from a private insurance company. The catastrophic amount would be 15% of the individual’s or family’s income. He would pay for this by taxing employer health insurance payments. He does not address the issue of low income individuals; that is, those with employer-paid health insurance and low incomes.

I simply don’t see how Feldstein’s plan can possibly be paid for. I said in my earlier post that I discuss his plan with trepidation because it makes no sense to me and that’s even more true when it comes to the question of paying for it.

Feldstein relies on taxing employer health insurance payments to pay for the vouchers everyone is going to get:

My calculations, based on the government's Medical Expenditure Panel Survey, indicate that the budget cost of providing these insurance vouchers could be more than fully financed by ending the exclusion of employer health insurance payments from income and payroll taxes.

But surely the value of employer health insurance payments will drop like a rock under his plan. Employer health insurance payments are based on the value of the coverage: the better the coverage, the higher the payments. Yet Feldstein himself anticipates - indeed, hopes - that the value of coverage will be squeezed from the bottom:

Because employer payments for health insurance are tax-deductible for employers but not taxed to the employee, current tax rules encourage most employees to want their compensation to include the very comprehensive "first dollar" insurance that pushes up health-care spending.

Clearly Feldstein anticipates that once employer payments for health care are being taxed, the plans will become less generous. In fact, he counts on this effect to reduce overall national health care spending. But less generous coverage - the higher deductibles he hopes for - means lower employer premium payments which means less revenue from taxing those payments. So based just on Feldstein’s own anticipated consequences for his plan, the revenue stream he’s counting on is already reduced.

Even worse for his revenue stream, the value of coverage has - by definition - been squeezed from the top. Right now an employer-paid health plan must cover the possibility of extremely large health care costs; the higher the possible health care costs, the higher the premiums; the higher the premiums, the more money you collect when you tax them. Under Feldstein’s plan, employer-paid health insurance plans will never have to cover more than the catastrophic deductible: no more than 15% of payroll. The possible health care costs go down, the premiums go down, the money you collect when you tax them goes down. Now not just Feldstein’s hopes for less generous coverage but the economic reality of such coverage will erode his proposal’s own funding base.

Furthermore, I can see employer-paid health insurance disappearing completely under Feldstein’s proposal. Once employer-paid health insurance is taxable (both income and payroll - ouch) it’s rational for employees to decide they’d rather have the money as salary. They can spend it on health care if they need it but if they don’t it’s available to them for other purchases. This would completely eliminate the money Feldstein is counting on to fund his catastrophic insurance plan.

As I’ve now said twice, I fear I’m missing something since the problems in Feldstein’s plan seem so obvious. Unless someone can explain what that something is, however, I consider Feldstein’s plan unworkable and will not consider it further.

In the next installment, I’ll look at whether DeLong’s plan is paid for.

That's funny

The most exciting phrase to hear in science, the one that heralds new discoveries, is not 'Eureka!' but 'That's funny...' - Isaac Asimov

Deafening Silence has up an excellent post on ClimateGate, examining the parallels - and divergences - between climate science now and the study of physics at the turn of the last century. And, like me, she’s wondering about ghosts.

Go, read.

Medicare nation

In discussing the possibility of allowing people between the ages of 55 and 65 to buy into Medicare, The Nation is horribly confused. Most of their article makes it sound like Americans will be able to start collecting Medicare benefits at age 55 rather than having to wait until age 65. They quote John Kenneth Galbraith:

I would also argue for lowering the age of eligibility for Medicare to (say) fifty-five, to permit workers to retire earlier and to free firms from the burden of managing health plans for older workers.

They claim that in the Senate health reform struggles “the idea of dropping the Medicare eligibility age from 65 to 55 has resurfaced as a prospect.” They refer to the need for determining exact “funding mechanisms”. They report:

Several progressive members of the House and Senate have confirmed to this reporter that lowering the Medicare eligibility age would have serious appeal in their caucuses. But there is some disagreement about how serious the prospect may be, especially considering the determination of some conservative and moderate members of the Democratic caucus in the Senate to control entitlement costs.

In other words, about 99% of their article talks about this proposal as if it’s a straight expansion of the Medicare entitlement: start collecting your Medicare benefits early. Only in one small sentence do they mention the true nature of the proposal (emphasis mine):

Under the proposal, which is being weighed by Senator Jay Rockefeller, D-West Virginia, and several other senators who are in the thick of the latest negotiations, Americans as young as 55 who lack affordable coverage could buy plans under Medicare.

Got that? Buy. This is not lowering the age of eligibility for Medicare; this is not enlarging an entitlement. This is letting people under 65 purchase insurance “policies” from Medicare just like they now purchase them from Aetna or Blue Cross Blue Shield.

Will there be government subsidies? Maybe. I think that depends on whether the final bill raises the ceiling for Medicaid coverage; it may be that anyone who would have been subsidized to buy into Medicare will simply be eligible for Medicaid instead. Which is, of course, just another kind of subsidy. But since apparently Medicaid reimbursement rates are lower even than Medicare reimbursement rates, it should cost less to subsidize people in Medicaid than in Medicare.

Which brings me to another point. If we’re going down this road it seems to me it makes more sense to let people buy into Medicaid rather than Medicare. Given Medicaid’s lower reimbursement rate, people should be able to buy into Medicaid more cheaply than into Medicare. Medicaid also appears to allow some variation from State to State so issues like abortion coverage could be taken care of at the State level.

Allowing some people to buy into Medicare is just one of the options on the table. Another?

Senate Democrats in search of a health reform compromise Sunday zeroed in on a new alternative to a government-run insurance plan — signaling that the chances a final bill will include a pure public option are diminishing.

The new idea — for the government to create a national health insurance plan similar to the Federal Employee Health Benefits Plan — seemed to gather momentum as the weekend went on, and the differences between liberals and moderates on the public option became even clearer.

That sounds familiar in a half-witted sort of way. Guys, there is no reason to re-invent the wheel. The Federal Employees Health Benefits Plan already exists. Just piggyback on it. Yes, you’ll need a separate risk pool so Federal employees don’t see their premiums rise to subsidize “outsiders” but all the legwork is done. We know which treatments are covered and which aren’t; we don’t need a bill or a separate government agency to figure all that out. Whatever Federal employees get - and that includes Congress - outsiders who buy in get. That should take care of fears that Congress will end up rationing care. Reimbursement rates are set; the insurance companies are already in. Just use what’s already there. Figure out some formula for subsidies based on the cheapest rate available in each State and let ‘er rip. Really poor people get subsidized decent coverage. People with more money can buy higher end policies.

This approach would also obviate the need for “the Exchange” so beloved by the various Democratic health reform bills. The Exchange, like this new “national health insurance plan”, simply replicates FEHBP. This is not necessary. We’re all supposed to be green now, remember? So refill, reuse, recycle. FEHBP already exists. Don’t waste all that energy building it anew.

The specter of ClimateGate

I miss Michael Crichton. A lot.

And in my more whimsical moments I wonder if perhaps the East Anglia Climate Research Unit had a ghost in its computer.

Social Security Solutions, Part 1: The social contract

Back in the mid-1980s I visited an elderly cousin of mine. She would have been in her mid to late 70s at the time and she had a number of health problems. Nothing major but her vision was very poor and she was generally weak. They - whoever “they” were at the time - were talking about reducing Social Security, possibly across the board, possibly through means testing. My cousin had a pension from her husband and money in the bank - she and her husband had worked hard to make sure she had both - but her Social Security money was something she had counted on when planning for retirement. When we discussed the possibility of her Social Security being reduced she was almost in tears. “They can’t take that money away from me,” she said. “I have no way to make more.”

I went home and wrote a letter to Bill Bradley, one of my Senators at the time, saying that I realized Social Security was unsustainable but that I thought it would be criminal to suddenly cut Social Security for people already over 65 or for those close to 65. Instead, I said, we should start telling younger people that their Social Security would be means-tested. Perhaps, I suggested, we could say that for everyone over 55, Social Security would not be means-tested. For everyone under 55 Social Security would be means-tested when they were old enough to qualify but the reductions would be phased in. For example, let’s say you were between 50 and 55 when the new rules went into effect. When you started receiving Social Security, means-testing would be done to see if your Social Security should be reduced. However, if the means-testing said your Social Security should be cut by $100, it would only actually be cut by $25. For someone 45-50 when the new rules went into effect, the cut would be $50; 40-45, the cut would be $75; and for those under 40 the cut would be in full effect. Knowing head of time that Social Security would be means-tested would give those younger people a chance to save more of their own money for their retirement while not unfairly taking money away from those who were counting on Social Security and no longer had the time or the ability to earn and save more.

Needless to say, nothing like this happened (I got a very nice form letter from one of Senator Bradley’s aides) and here we are twenty years later. Unfortunately the great bulge of baby boomers who would have been subject to means-testing if we’d done this twenty years ago are now so old that we can’t give them advance warning of means-testing. That means we can’t cut their Social Security without great unfairness. How would suddenly beginning to means-test Social Security be unfair to the well-off elderly who would lose money as a result of it? Well, here’s how Megan McArdle puts it when talking about a different entitlement, higher education in California (emphasis mine):

... shutting down prior entitlements suddenly is a very bad thing, even if you're the kind of heartless conservative who hates entitlements ...

People plan their lives around public programs. Allowing an unsustainable program to run until it comes to a screeching halt is often worse than having no program. The UC system is very good, and I am in no way suggesting that we would be better off if it didn't exist. But many, many California students, and their parents, planned their lives around a reasonable expectation of what in-state tuition would be. The protests are childish, but the rage underneath them is understandable: if you suddenly have to leave school because legislators have broken your implied social contract, you're probably going to be pretty mad.

And that, of course, is the problem with a change to Social Security that involves cutting benefits for those already receiving them or for those on the verge of being eligible for them. It’s all very well and good to say that well-off old people shouldn’t be getting money from less well-off younger people but those well-off old people made plans based on those Social Security payments. When they decided what job to take, how much money to save for retirement, what to buy and what to forego so they could have the kind of retirement they wanted, the money from Social Security was always in their calculations. To see how this works, let’s take a look at two hypothetical couples.

Ann and Bob have worked hard their whole lives. They married right out of college and bought a three-bedroom ranch house in a nice enough subdivision; both sets of parents helped them out with the down payment. They lived close to the bone - no dinners out, modest Christmas presents, no getting away on vacation - until they paid back those loans. Once they were making a little more money they had a couple of children but they still watched their pennies. Vacations were driving trips, often to visit relatives; they shopped at discount stores for clothes and food; Christmas and birthday presents were still modest and always included a little extra cash tucked away in their kids’ college accounts. And they always, always put away as much as they could for their retirement. They figured they’d have the house paid off and the kids through college by the time they retired and they calculated that with the $2000 per month - $1000 for each - that they’d get from Social Security plus the $2000 per month they planned to have from their own retirement investments, they’d have enough money to do all the traveling and wining and dining they weren’t doing now.

Carol and Dave have also worked hard their whole lives. They, too, married right out of college and bought a three-bedroom ranch in a nice enough subdivision with the help of their parents. They, too, scrimped and saved to pay back their parents. After that, though, they saw no need to continue to be frugal. They never ran up a lot of debt but except for saving for their kids’ college they spent every penny of their income on trips and clothes and restaurants and just plain stuff. As soon as they got halfway decent equity in their ranch house they traded up to a McMansion. There was no way they could save for retirement after that but they figured that the $2000 - $1000 for each of them - that they would get from Social Security would be plenty: they’d be so old when they retired that they wouldn’t want to do much of anything anyhow.

Now both couples are retiring. Ann and Bob will get $24,000 a year from Social Security plus $24,000 a year from their own retirement investments; their house is long since paid off. Carol and Dave will get $24,000 a year from Social Security but they have no retirement savings and not only is their house not paid off, the lousy real estate market means the value of the house is just barely enough to cover the outstanding mortgage.

The government decides to means-test Social Security. What’s going to happen? Why, Ann and Bob are going to lose their Social Security because they’re financially secure without it. Carol and Dave are going to keep theirs because that’s all they’ve got. And that’s not fair.

So are there ways to keep Social Security solvent without unfairly penalizing those who counted on their Social Security benefit when they planned for retirement? Yes and I’m going to discuss three of them: the three-month solution; the 10% solution; and the Lifetime Endowment. As always, I’ve created a new category to group together the posts in this discussion.

Redargue

A friend gave me one of those page-a-day calendars for Christmas last year, this one called “Forgotten English”. For some reason the September 18 entry on “redargue” amused me. The word itself means “to refute” but what I liked was the quote from James Boswell about Samuel Johnson . (Johnson celebrated his birthday on September 18 hence the reference to him in the calendar.)

About Johnson, Boswell writes:

The truth, however, is, that he loved to display his ingenuity in argument; and therefore would sometimes in conversation maintain opinions which he was sensible were wrong, but in supporting which, his reasoning and wit would be most conspicuous. He would begin thus: "Why, Sir, as to the good or evil of card-playing—"; "Now, (said Garrick,) he is thinking which side he shall take." He appeared to have a pleasure in contradiction, especially when any opinion whatever was delivered with an air of confidence; so that there was hardly any topick, if not one of the great truths of Religion and Morality, that he might not have been incited to argue, either for or against.

I must admit to being in sympathy with Johnson’s view. There is nothing that makes me feel more contrary than an opinion “delivered with an air of confidence”.

ClimateGate

[Updated November 25, 2009, at about 4:30pm to add extra Reading.]

Deafening Silence is doing her usual excellent work on ClimateGate, providing a brief narrative, some key points, info on major players, what each side says about the data dump, and links to other sites where more information - including the emails and data themselves - can be found.

I’ve been wandering around reading about this for the last few days and I think the most telling exchange occurred at RealClimate, the Website run by some of the “working climate scientists” who are in the forefront of the research and advocacy that supports the idea of Apocalyptic Anthropogenic Global Warming. Here you will find AAGW luminaries like Gavin Schmidt and Michael Mann and here you will also find Schmidt’s response to ClimateGate. Called “The CRU hack”, this post is a RealClimate masterpiece and well worth reading. As is usually the case at RealClimate, the comments are worth your time also - - although I freely admit I have not made it through all 1,092 comments on the post much less the 502 comments on Schmidt’s follow-up post.

If I may digress briefly, I have often thought there must be a word for writing that is an example of what it is discussing. An easy on the beauty of the English language that uses English beautifully. A piece bemoaning poor grammar that is itself filled with grammatical errors. A paean to courage that required great courage to write. A childish refutation of accusations that the writer is childish. A rant about rants. Onomatopoeia writ large, so to speak. Schmidt’s original post, written in response to charges that science comes far down on the priority list of the AAGW establishment; that said establishment is knowingly making dubious claims; and that said establishment slurs and marginalizes those who disagree with it, would deserve pride of place in any list of such writings.

Back to the post. Schmidt writes:

Clearly no-one would have gone to this trouble if the academic object of study was the mating habits of European butterflies.

Commenter lgarvin replies in part:

That depends on whether or not people were trying to re-order the global economy on the basis of those butterfly studies.

And that, of course, is the crux of the matter. I am willing to accept that most scientific disciplines seethe with personalities, politics, pettiness, and personal attacks. (Hey, I went to grad school.) I am certainly aware that older software often suffers from ugly code, indecipherable routines, an excessive need for manual intervention, and - shall we way - hinky data sets. But most scientific disciplines are not insisting that we need to immediately radically alter the entire basis of our way of life or face cataclysm.

If you’re prophesying the end of the world then - unless you're speaking directly with God - you should be sure both your data and your programs are clean; you should be not merely willing but eager to provide your data and your programs to the whole world for verification; and you should be delighted that people with expertise in related fields like statistics are interested enough in what you’re doing to dissect it. Most important, you should make clear to those who lives you want to at best upend and at worst pretty much destroy that you are, in fact, sure, eager, and delighted. Making it clear that you uncertain, recalcitrant, and scornful is not a good way for you to convince me that you know what you’re talking about, much less that my world is safe in your hands.

*****

Reading:

Deafening Silence points out that the Climate Audit site is difficult to get into due to increased volume. This problem now seems to be resolved but posting is occurring at a Climate Audit mirror site here.

Watts Up With That is posting on Climategate. The oldest post is here.

A stand-alone Website has a searchable data base of the CRU emails, organized somewhat differently from the one Deafening Silence links to.

The emails sound bad but much of what is in them can be explained or spun or is understandable to anyone who has ever written an exasperated email. Not all, but much. I think the state of the computer software code and databases is much more interesting:

L'Ombre de l'Olivier looks at some of the code. He has a link to his copy of HARRY_READ_ME.txt. This is apparently a log kept by the poor programmer who inherited the software at the East Anglia CRU when the original developers left. The programmer (Harry) documents the problems he encounters while trying to figure out what’s going on. You don’t need to read code to follow what’s going on - Harry’s comments tell the story.

HARRY_READ_ME is both agonizing and hysterical. (Be sure to visit Item 17 for a look at squared numbers going negative.) I haven’t read through the whole thing yet but so far my favorite line is in Item 27:

Oh GOD if I
could start this project again and actually argue the case for
junking the inherited program suite!!

Amen, brother. Amen.

*****

Updated November 25, 2009, at about 4:30pm:

This post from the CBS News blog is a must-read. It provides more background thus complementing what Deafening Silence has up. The post concludes with:

The irony of this situation is that most of us expect science to be conducted in the open, without unpublished secret data, hidden agendas, and computer programs of dubious reliability. East Anglia's Climatic Research Unit might have avoided this snafu by publicly disclosing as much as possible at every step of the way.

I found this via Megan McArdle although I’d seen references to it elsewhere. Please do also read McArdle’s post in which she draws an interesting conclusion about the value of any cost-benefit analysis based on the East Anglia CRU software and points out that if - as appears to be the case - the East Anglia CRU itself “cannot now replicate its own past findings” then:

Obviously, this also casts their reluctance to conform with FOI requests in a slightly different light.

Buyer Be Happy

That’s the current Best Buy slogan. It’s cute with that whole play on “Buyer beware” thing going on. The problem is it sounds an awful lot like, “Buy or be happy”. Which, given the problem of consumer debt, is probably closer to the truth.

Five health insurance issues: Back to the grocery store

After I finished my Grand Finale post on five health insurance issues I began to worry I had not distinguished clearly enough between health care and health insurance and the role of the free market in each of these. Grim’s comments to that post confirmed my concerns on that score. So let’s return once more to the grocery store and see if I can make myself clearer.

I do most of my grocery shopping at Kings Supermarket, the one on Route 23. It’s bigger than the one in Upper Montclair so there’s a larger variety and it’s less claustrophobic. At the same time it’s smaller than the ShopRite and PathMark stores near me and usually less crowded so it’s a more pleasant place to shop. I think Kings’ prices are in line with those of the larger stores perhaps a few cents cheaper but it’s been worth it to me to have a nicer shopping experience. Now Kings is revamping its product line, however, and attempting to bring prices down. I still do most of my shopping there but I’m beginning to feel like they have too many products on the shelves with too-short expiration dates and I’m not always totally happy with their meats. I just found a butcher shop in Upper Montclair so I may try buying meat there next time. I think they’re a little more expensive but I’ll have to do some comparison shopping to be sure - and then decide if the extra money is buying me better quality.

I don’t do all my shopping at Kings. I like the 365 Day brand olive oil from Whole Foods so I’ll run in there every so often and stock up on that. When I’m in there I also like to pick up a bag of their 365 Day Salt and Pepper Potato Chips - yum! I used to buy more groceries from Whole Foods but once Kings realized how popular some of their stuff was they started carrying it. So now I can buy my soy sour cream from Kings. And, of course, almost every store now carries soy milk. That’s still cheaper at Whole Foods than anywhere else but it’s not enough cheaper to make a separate trip worth the gas and time. I made a wonderful Five Cheese Penne for my husband’s birthday last year and Whole Foods had the best selection of the cheeses I needed for that.

If I need a lot of canned goods - tomatoes, beans - or a lot of non-food items - aluminum foil, laundry detergent - I’ll run to ShopRite. I really don’t like their meat at all but I think they have slightly better prices on non-perishables so it’s worth it to me to make a trip there if I’m going to stock up. They also have a much better selection of Duncan Hines cake mixes than Kings so I’ll pick up a bunch of those while I’m there. ShopRite’s produce is usually quite good so if I’m in there anyhow I’ll buy what I need in the way of lettuce, apples, and so on. And if I want a wide selection of frozen foods - pizza, yum - ShopRite is much better than Kings. It used to not be worth it to run in there just to pick up a California Kitchens Margherita but now that they’ve installed self-checkout - and gotten the bugs out - it’s a breeze especially if I’m already in the area.

I used to hit the FoodTown further up Route 23 because I love Spice Islands spices and it was the only place around here that carried them. They don’t anymore so I never go there. I’ve pretty much adjusted to life with other spice brands - most of the Morton & Bassett brand spice are really good, their bay leaves are great, and the name of the spice is on top of the lid which is very handy is you’re looking down at rows of spices trying to find the one you want. Still I’ve never found a garlic powder that comes anywhere near Spice Islands; luckily I can order that over the Internet.

There is a PathMark near us but I really don’t like shopping there. Their shelves always seem to be understocked and they’re often out of the one thing on my list that I just have to have. However there’s a very nice little Italian deli close by that has wonderful bread and is often a stop to pick up rolls and turkey for lunch.

I love Trader Joe’s but there isn’t really one all that close - and the closest one is near a super-busy mall. I have vegan friends who shop there a lot and also hit a lot of Indian and Asian markets for more exotic ingredients. We do have a farmers’ market in town where I can find wonderful corn and those fabulous Jersey tomatoes during the summer. They also have a brief but incredibly delicious few weeks of peaches.

I buy flour tortillas at Kings but for corn tortillas I like the little corner store up the street. They sell them in packs of 25 or more and they’re always super fresh. There’s also a small liquor store very close to us but their selection is limited so for wine I go to the Wine Merchant. It’s handily in the same shopping center with the ShopRite so sometimes I run in there, too.

I’m sure that by this time you’re fascinated by my grocery shopping adventures - or at least ravenous. But you may be asking what this all has to do with health care and health insurance.

Health care is - or should be - like groceries: a great variety that can satisfy all needs at the best possible price. Health insurance companies are like grocery stores: they don’t produce health care but they are to all intents and purposes where we purchase it. Unfortunately health insurance companies function nothing like grocery stores. We can’t flit from company to company looking for the best deal on a treatment we want or need; we can’t comparison shop; we can’t decide we’ll pay a little more for this treatment because we want this particular doctor.

When I buy health insurance as it is currently structured, it’s as if I can now shop at one and only one grocery store. I get only the products that store chooses to carry. If I need something it doesn’t have, I’m out of luck - no Five Cheese Penne for a birthday dinner. If the store decides to start cutting corners on products, I’m out of luck - dinner may have to be whatever is going to expire tomorrow. If Spice Islands decides to stop doing business with the store I’m committed to, I’m out of luck - I spend my life eating inferior garlic bread.

If I get my health insurance through my employer, the situation is even worse. Now it’s as if I’m forced to buy all my groceries from a store I didn’t even get to pick myself - if my employer picks PathMark, too bad for me.

A free market in health care - like a free market in groceries - is a Very Good Thing. Consumers (patients) must decide whether a treatment is worth them spending their own money on. If they decide it is then they will pay careful attention to exactly what they are getting and exactly how much they are paying for it. They will comparison shop; they will seek out innovative products that provide better quality or lower costs or both. On the other side, many producers (health care providers) will compete to make their product better and lower priced. Others will strive to make their product outstanding so they can charge more for it. Some will find innovative ways to deliver services. Both consumers and producers benefit.

A free market in health insurance may or may not be a good thing but to me that’s irrelevant. Health insurance as currently structured deforms the free market in health care. It doesn’t matter if we’re talking about private health insurance or public; traditional or HMO; catastrophic or first dollar. All our existing forms of health insurance are incompatible with a truly free market in health care.

In contrast, I believe the catastrophic health insurance plans of DeLong and Goldhill - if correctly structured - offer the possibility of providing the advantages of a free market in health care while avoiding the great danger of such a market: that in catastrophic situations, people will be unable to purchase the health care they need. That’s why I’ve already spent so much time analyzing their plans and why I’ll be spending even more time doing so.

*****

Reading:

Health 'Reform' Gets a Failing Grade: Read the whole thing but this is what jumped out at me:

Our health-care system suffers from problems of cost, access and quality, and needs major reform.

[snip]

The system we have now promotes fragmented care and makes it more difficult than it should be to assess outcomes and patient satisfaction. The true costs of health care are disguised, competition based on price and quality are almost impossible, and patients lose their ability to be the ultimate judges of value.

The headline says it all (via TigerHawk): This post quotes Milton Friedman’s observations on the four ways to spend money. I contend that health insurance functions like a combination of the second and third ways. The insurance companies think like this:

Then you can spend your own money on somebody else. For example, I buy a birthday present for someone. Well, then I'm not so careful about the content of the present, but I'm very careful about the cost.

The policyholders think like this:

Then, I can spend somebody else's money on myself. And if I spend somebody else's money on myself, then I'm sure going to have a good lunch!

Fear, hate, and Palinoia

I like Sarah Palin in that visceral sort of way that one likes or dislikes public figures. I think she would have made a perfectly adequate Vice-President and I don’t think electing her as such would have been a disaster under any circumstances. Best case scenario? John McCain would have served out his term and Palin would have buckled down, taken the opportunity to learn what she didn’t know, and emerged as a clearly qualified Presidential candidate in four (or, less likely, eight) years. Worst case scenario? McCain would have died before his term was over and Palin would have proven to be a bad President. The country would have survived - the goddess knows we’ve survived lots of bad Presidents in our history.

Middling scenarios? McCain would have served out his term and Palin would haven’t learned anything more than how to attend lots of state funerals and weddings. Or McCain would not have served out his term and Palin - with help from everyone in government who would have rallied around in time of crisis - would have proved her mettle and done a decent job as President.

At the same time, I understand there are lots of people who don’t like Sarah Palin in that visceral sort of way one likes or dislikes public figures. I also understand that there are people who thinks she’s not smart enough, too naive, too far right, not experienced enough, not intellectually curious enough to ever be seriously considered as Vice-Presidential material, much less Presidential material. That’s their prerogative and they may be at least partially right. I have some very similar thoughts about Barack Obama.

What I don’t understand is why so many people hate Sarah Palin. I mean really, really hate her. They can’t just ignore her and they can’t mention her without saying something ugly. They think every form of misogynistic insult is perfectly justified as long as it’s directed at Palin. They’re happy - really, really happy - to attack her children. They sound exactly like some bitter drunk who can’t stop talking about his or her ex, who left for a younger, more attractive lover and got the kids, the cars, the house, and the bank accounts. It is quite possibly the most bizarre phenomenon I’ve ever witnessed in politics.

As it happens, three of the bloggers I read regularly are writing about this very phenomenon - from three very different points of view. Reclusive Leftist writes about Fear of women:

... our nation is also in the grip of some kind of atavistic looming fear of women as evil monsters. Sarah Palin is no weirder than most Republican politicians; [snip] Yet based on the media coverage of the woman, you’d think she was the greatest threat to western civilization since the Battle of Tours.

All of her writing about the attack-Palin phenomenon is must reading and this post is no exception.

Megan McArdle presents the best brief summary I’ve seen of the Newsweek problem and coins the term Palinoia (perfect word, perfect concept):

It's when you think people are out to get you, and then they do their best to justify your erroneous belief.

She concludes:

There seems to be an unhealthy obsession with tearing her down. And really, guys, if you'll just back off a little, she'll do the job for you. Have you seen that resignation speech? How about we all act like she's a former governor and vice presidential candidate, rather than Public Enemy #1?

This, of course, is one of the most bizarre aspects of Palin Derangement Syndrome. People were also deranged when it came to George W. Bush but at least he was, like, you know, the President so he couldn't just be ignored. Palin holds no office, has no political position. If she’s as bad as her detractors think, she’s going to disappear without a trace when her fifteen minutes of fame are up. Why the compulsion to keep bashing her?

Meanwhile, Eric at Grim’s Hall quotes and links to InstaPunk, a blogger I don’t read. InstaPunk’s piece, Hating Sarah Palin, contains some language that I, as a feminist, can’t countenance but he asks the right question (emphasis his):

But here's what I don't get. Hating Sarah Palin. That's my whole point here. Think about it. Who do you have to be to hate Sarah Palin?

I can’t pick just one part of his answer to quote - you have to read the whole thing.

I’ve said it before and I’ll say it again. I really hope I’m alive 20 or 30 years from now when sociologists and political scientists look back at the Presidential campaign of 2008 and its aftermath and explain what the heck was going on with all the people who hated - truly hated - Sarah Palin.

Five health insurance issues: Grand finale (updated)

[Updated, November 21, 2009: Grand, perhaps, but not the finale. I have up one more in the sequence here.]

In response to my post on catastrophic health insurance, Grim commented:

I like the idea of market-based reforms. However, I'm not sure why a government plan would be better at simulating the market than, you know, the market.

For example, the DeLong plan that I surrender 20% of my income for health care expenses? The market as it currently exists offers much better deals than that.

In general my preference is for a free market with only as much government regulation as is necessary to keep the more predatory impulses of capitalism in check. However, I have a lot of reservations about whether a totally free-market approach is appropriate for health insurance. I prefer regulation that says, “Thou shalt not” rather than regulation that says “Thou shalt”. Once you wander into government telling private companies what they should do, you’re in trouble and that’s increasingly the case with government regulation of insurance companies. They’re being told what they must do - who to cover, what conditions to cover, how much treatment to provide. That’s a bad situation; bad for the companies, bad for the government, bad for the company’s customers.

Yet I understand why we’ve gone down that road. We want certain things from health insurance and we are trying to get them via government intervention while still maintaining - or appearing to maintain - the companies as private entities. I’m not at all sure that’s working well. We may simply be unable to get what we want from health insurance within the framework of our current system.

This is a big part of why I was so intrigued by the catastrophic insurance plans I discuss in my earlier post. These plans may be the best way to address five issues I think any health care or health insurance plan must handle, the issues we’re trying to handle through our increasingly intrusive regulation of the insurance industry. In sorting out why I think these plans are promising, I’ve written at considerable length about those five issues. As usual, I’ve created a new category - “Five Health Insurance Issues” - to link the posts.

To review my five issues before I sum up:

Issue 1 : While most of us could pay for normal health care expenses ourselves, most of us need health insurance to cover serious situations.

Issue 2: Health insurance is not universally available or universally affordable through the market as it currently exists. Lack of health insurance does in fact often mean less effective medical care when someone is seriously ill. This is not right.

Issue 3: A health care system run entirely by the government is a bad idea.

Issue 4: As currently structured, all insurance - private or government, cheap or expensive, HMO or traditional, catastrophic or first-dollar - masks the true costs of treatment from those who purchase that treatment. This is bad for patients and bad for health care providers and bad for any hope of reining in health care spending through individual decision making.

Issue 5: Either we have to toughen up and let people - including children - die when they - or their parents - are too dumb to buy health insurance they could get and could afford or we have to find a way to force them to chip in for the health care we’re willing to give them if they get sick.

My conclusion - and I assure you it’s a reluctant one - is that a totally free market in health care and health insurance cannot address these issues. A free market will not make insurance affordable or obtainable for everyone; it will continue to mask the true costs of treatment; and it will do nothing to address the problem of free riders - which in a totally free-market system means we’d have to let them and their children die. If someone can describe to me a free-market plan that doesn’t have those effects, I’m all ears. Bonus points is you can describe a system that will guarantee that someone like me, who has cost her insurance company vast sums of money and more pre-existing conditions than you can shake a stick at, will be able to retain my health insurance in a free-market system at a cost I can reasonably expect to afford. Extra bonus points if you can figure out how I could change health insurance companies if I wanted to.

As my third point above makes clear, a single-payer system is not the way to go either. Yes, it will make health insurance/care universally available and it will take care of the free-rider problem. It may make it universally affordable but only if you ignore the taxes necessary to pay for it. However, it most definitely does not unmask the true cost of treatment. This means there is no hope of getting health care spending to come down via individual decision-making; we will be left with no options except to squeeze providers, refuse to cover treatments, and decide what is and isn’t covered based on some political hell’s brew of money and lobbying. If someone can describe to me a single-payer plan that doesn’t have those effects, I’m all ears. Bonus points if you can make me love the fact that birth control is not part of the Basic package on the exchange. Extra bonus points if you are pro-choice and can embrace the Stupak amendment.

What we have now is a hybrid. The free market for health insurance copes well with people who are healthy and employed. The free market copes well with people who are unemployed, healthy, and reasonably well off financially. The free market copes poorly with people who are unemployed and either not healthy or not financially well-off; to some extent the government picks up the slack. If you’re poor enough, there’s Medicaid; if you’re old enough, there’s Medicare; if you’re sick enough, emergency rooms have to treat you. Some people fall through the cracks. The more people who lose their jobs the more people there are who may fall through the cracks. (Surely the idea that health insurance should be tied to jobs is the handiwork of some imp of Satan.)

We can continue with this system, using regulation, government subsidies, and government programs to patch those cracks. If this is what we want to do, then I still think the best solution is to let anyone who wants to buy into the Federal Employees Health Benefits Plan (under a separate risk pool) with government subsidies for those who need them. We’d get rid of Medicaid but keep Medicare. We’d forget the health reform bills currently floating around Congress. We’d keep people from falling through the cracks but we wouldn’t even be attempting to rein in health care via individual decision-making; we’d just be postponing the day when the costs would eventually have to be faced up to.

Alternatively we can follow the route of the Democratic health reform bills. Frankly, I think they’re worse than single-payer. Under those bills we keep Medicare; we expand Medicaid; we set up the Exchange; we get a public option; we force so many conditions on private insurance companies that they’re basically public utilities. We get twice the bureaucracy and twice the overhead. We get less individual choice rather than more. We don’t get any incentive for people to make decisions about how much health care is worth to them. Instead of incentives for providers to innovate we get government pilot projects, government bundling initiatives, government this, that and the other. They won’t work; just look at Medicare. We get a monster.

If we truly want to do something major to overhaul the system then I prefer the Goldhill and DeLong models. They help those who need help but do not put the government totally in charge and do not mask the cost of treatment. Their plans are mandatory which means everyone is forced to buy catastrophic insurance and to set aside money in a Health Savings Account - no free riders here and everyone can (must) participate. Yes, the government runs the catastrophic insurance part of the plan. But the HSA part of the plan is for individuals to do with as they please which means they are fully exposed to health care costs up to the point of their deductible or trigger. Because any unspent money goes back to the individual each of us can decide what health care is important enough for us to spend money on - and each of us has to be willing to spend his or her own money before we can start spending other people’s.

I’m fully aware of the coercive nature of the requirements to buy government-run catastrophic care and to put money in Health Savings Accounts. I know these are an absolute bar to this plan for Libertarians and most Conservatives. I am sympathetic to that point of view. However, I have neither the courage nor the hard-heartedness to live in a world where health care and health insurance are strictly free market. I don’t want to fall through the cracks and I’d rather my fellow citizens didn’t either - especially the young ones. It seems to me that the best combination of free-market and government involvement comes from the Goldhill/DeLong approach. Yes, it takes my money but if structured correctly it gives me back control over my health care decisions while providing a safety net if disaster strikes.

Five health insurance issues (5)

In response to my post on catastrophic health insurance, Grim commented:

I like the idea of market-based reforms. However, I'm not sure why a government plan would be better at simulating the market than, you know, the market.

For example, the DeLong plan that I surrender 20% of my income for health care expenses? The market as it currently exists offers much better deals than that.

In general my preference is for a free market with only as much government regulation as is necessary to keep the more predatory impulses of capitalism in check. However, I have a lot of reservations about whether a totally free-market approach is appropriate for health insurance. I prefer regulation that says, “Thou shalt not” rather than regulation that says “Thou shalt”. Once you wander into government telling private companies what they should do, you’re in trouble and that’s increasingly the case with government regulation of insurance companies. They’re being told what they must do - who to cover, what conditions to cover, how much treatment to provide. That’s a bad situation; bad for the companies, bad for the government, bad for the company’s customers.

Yet I understand why we’ve gone down that road. We want certain things from health insurance and we are trying to get them via government intervention while still maintaining - or appearing to maintain - the companies as private entities. I’m not at all sure that’s working well. We may simply be unable to get what we want from health insurance within the framework of our current system.

This is a big part of why I was so intrigued by the catastrophic insurance plans I discuss in my earlier post. These plans may be the best way to address five issues I think any health care or health insurance plan must handle, the issues we’re trying to handle through our increasingly intrusive regulation of the insurance industry. In sorting out why I think these plans are promising, I’ve written at considerable length about those five issues.

My post about the first issue is here; about the second issue is here; about the third issue is here; about the fourth issue is here. This post is about the fifth issue; my next post is the grand finale. As usual, I’ve created a new category - “Five Health Insurance Issues” - to link the posts.

Issue 5: Not only are we not willing to let people die because they’re too poor to afford or too sick to get health care and/or health insurance, we’re not willing to let people die because they’re too stupid to buy health insurance even when they could get it and could afford it. And even if we’re willing to let an adult die from such stupidity, we’re not willing to let his children die.

Take a look at Tom. He’s 45 years old, married, two children. He’s made a good salary all his life and been in good health all his life. He’s always free-lanced and has never been willing to ante up for health insurance for himself or his family. Suddenly he’s diagnosed with, say, Hodgkin's lymphoma. This is an eminently treatable disease but Tom can’t afford to pay for the treatment himself - and he’s got no health insurance. It’s possible Tom will be unable to obtain treatment and will die - it depends on whose horror stories you listen to - but if we as a society knew about that outcome we’d be unwilling to tolerate it. And even if we were willing to tolerate Tom’s death, what if his eight-year-old was diagnosed with leukemia? Again, very treatable; again, very expensive. There’s no way we’d be willing to knowingly let her die just because her father was an idiot.

So point the fifth: Either we have to toughen up and let people - including children - die when they - or their parents - are too dumb to buy health insurance they could get and could afford or we have to find a way to force them to chip in for the health care we’re willing to give them if they get sick.

Five health insurance issues (4)

In response to my post on catastrophic health insurance, Grim commented:

I like the idea of market-based reforms. However, I'm not sure why a government plan would be better at simulating the market than, you know, the market.

For example, the DeLong plan that I surrender 20% of my income for health care expenses? The market as it currently exists offers much better deals than that.

In general my preference is for a free market with only as much government regulation as is necessary to keep the more predatory impulses of capitalism in check. However, I have a lot of reservations about whether a totally free-market approach is appropriate for health insurance. I prefer regulation that says, “Thou shalt not” rather than regulation that says “Thou shalt”. Once you wander into government telling private companies what they should do, you’re in trouble and that’s increasingly the case with government regulation of insurance companies. They’re being told what they must do - who to cover, what conditions to cover, how much treatment to provide. That’s a bad situation; bad for the companies, bad for the government, bad for the company’s customers.

Yet I understand why we’ve gone down that road. We want certain things from health insurance and we are trying to get them via government intervention while still maintaining - or appearing to maintain - the companies as private entities. I’m not at all sure that’s working well. We may simply be unable to get what we want from health insurance within the framework of our current system.

This is a big part of why I was so intrigued by the catastrophic insurance plans I discuss in my earlier post. These plans may be the best way to address five issues I think any health care or health insurance plan must handle, the issues we’re trying to handle through our increasingly intrusive regulation of the insurance industry. In sorting out why I think these plans are promising, I’ve written at considerable length about those five issues.

My post about the first issue is here; about the second issue is here; about the third issue is here. This post is about the fourth issue; my next post will deal with the fifth issue and then I’ll have a grand finale. As usual, I’ve created a new category - “Five Health Insurance Issues” - to link the posts.

Issue 4: The New York Times, in an article about how Democrats are concerned the health reform proposals on the table won’t control costs, writes (emphasis mine):

There are a variety of ideas for attacking cost increases more aggressively, including setting Medicare reimbursement rates for doctors and hospitals more rigorously and discouraging workers and employers from buying expensive health insurance policies that mask the true costs of treatment.

Guess what? All health insurance policies - private and government - mask the true costs of treatment. I go to the doctor. I have a copay. I pay the copay, let’s say $30. Is that all the doctor gets? I have no idea. Or I go to the doctor. I have a traditional plan so I pay nothing during my visit. The doctor bills my insurance company for $150. My insurance company allows only $70 for the visit. I haven’t met my deductible so I pay the $70. Or I go to the doctor. I don’t have any insurance. I pay $150 on the spot. What is the true cost of the treatment? $50? $70? $150? Who knows?

Why is this bad? For a number of reasons. First, it means patients - health care consumers - with insurance have less incentive to think twice about seeking health care. This reason usually gets expressed as “people go to doctors when they don’t need to”. I’ve never been sold on that idea - I personally would be willing to pay money not to have to go to doctors. I will somewhat grudgingly concede that having insurance means I don’t blink when my doctors tell me I need another blood test or another X-ray or another MRI . And the doctors don’t blink either - we all know I’m not paying for it. But this is not the real problem with that lack of incentive to think twice.

The real problem is that when the true costs of treatment are masked an individual neither has to decide nor gets the opportunity to decide whether a particular treatment is worth what it costs him. This is an easy formulation to attack: why, I’m suggesting some poor person should have to choose between getting a flu shot and putting food on the table. No, I’m not. I am suggesting that all of us should have to choose between getting flu shots and getting FIOS - or buying a latte every morning or buying a new winter coat every year. If you would rather have cable TV than a flu shot why should my tax dollars buy your flu shot?

This is why I’m so intrigued by the catastrophic coverage proposals I wrote about in my earlier post. The existence of Health Savings Accounts (subsidized for those who need it) gives everyone - rich and poor - a chance to decide how to spend their money: health care or something else. If you never, ever get the flu then skip the flu shot and use the money for something else. If you really, really need to avoid the flu then get the flu shot and give up something else. Under these types of plans if my doctor tells me I need another X-ray, I do a lot more than sit glassy-eyed. I ask how much that X-ray will cost me and when I realize getting the X-ray will cost me, say, as much as buying gas for a visit to my relatives, I’m likely to ask a lot more questions about exactly why I need that X-ray and how bad would it be if I waited and can we just see how things go. The flu shot and the X-ray are there for those who need them enough to pay for them - but they’re not forced on those who would rather spend their money on something else.

There is a second reason why masking the true cost of treatment via insurance is a bad idea: it doesn’t give patients any incentive to patronize providers who come up with ways to improve treatment and/or lower costs - which means it doesn’t give providers any incentive to do those things. For example, let’s say I need shoulder surgery. I can get it done at a hospital-based outpatient center for $3000. I’ll need follow-up pain blocks from an anesthesiologist for a few days and for that I’ll have to go to the Emergency Room - there’s no other way for the anesthesiologists associated with the hospital-based center to handle that administratively. On the other hand, my surgeon participates in a free-standing surgical center. I can get my surgery and my follow-up pain blocks there. The surgery will cost me $2500.

Obviously, I’d much rather go to the surgical center - it’s more pleasant, more convenient, and cheaper - and if I’m paying for my surgery myself, I will. The orthopedic group is rewarded for providing a better product at a lower cost. But what if the surgical center doesn’t participate with my insurance company while the hospital does? Then I get the surgery for nothing from the hospital so that’s where I go. The orthopedic group is not rewarded for providing a better product at a lower cost. And why doesn’t the surgical center participate? Because the insurance company won’t actually pay $3000 for the surgery; it won’t even pay $2500. No, the insurance company pays the hospital $1000 for my surgery. The hospital makes this up by charging uninsured patients a higher price; the surgical center can’t do that - their prices are fixed.

And not only is the surgical center not rewarded for its efforts to provide better health care at a lower price, we also have no idea what the market price for my shoulder surgery really is. It might be $1000, $2500, or $3000. Or it might be $500 or $5000. We simply don’t know and we have no mechanism for figuring that out.

Or take this recent editorial from AARP. According to them, manufacturers are selling power wheelchairs to suppliers for about $1000. Then the suppliers are selling those same wheelchairs to Medicare recipients for about $4000. To AARP this is a clear case of waste made possible by the “medical equipment lobby, which spent $6.3 million in presidential and congressional campaign contributions last year” resulting in “Congress [blocking] attempts to impose competitive bidding.” To me this is a result of insurance masking the true costs of treatment. If I was spending my own money to buy a power wheelchair, I’d look for the best possible price. A supplier who was willing to sell the chairs for $3000 would own the market - until another supplier stared selling them for $2500. When producers and consumers deal directly with each other you don’t need competitive bidding.

Ah, you say, but if I bought catastrophic insurance from my insurance company I’d be well aware of the cost of treatment. Um, no. Somewhat more aware, yes; totally aware, no. Even with catastrophic insurance - at least around here - the insurance company differentiates between in-network and out-of-network providers. The company also decides how much it’s going to allow for a procedure. So my shoulder surgery would still cost $1000 for the hospital-based surgery versus $2500 for the surgical center surgery. The difference is that now I’d be paying the $1000 instead of having my insurance company pay it. On the other hand, I’d probably be less likely to think $4000 was a good price for my power wheelchair if I had the high deductible of catastrophic insurance. So catastrophic insurance can help keep government health insurance from paying unreasonably high prices (that’s not usually a problem with private insurance) but even catastrophic insurance as it’s currently structured doesn’t do enough to expose patients to the true cost of their health care. The true costs of treatment will always be masked to some degree as long as insurance companies stand between the consumer (the patient) and the producer (the health care provider).

These two reasons together - lack of incentive to consider the opportunity cost of purchasing health care on the part of patients and lack of incentive to produce a better product at a lower price on the part of health care providers - are also bad for society. It means we have no hope of reining in health care costs via individual decision-making and will be forced to do so by more draconian means such as paying providers less and refusing to pay for certain treatments. This will result in a “one size fits all” approach that will provide some people with services they would have foregone in order to get other, unavailable services they need or want.

So point the fourth: As currently structured, all insurance - private or government, cheap or expensive, HMO or traditional, catastrophic or first-dollar - masks the true costs of treatment from those who purchase that treatment. This is bad for patients and bad for health care providers and bad for any hope of reining in health care spending through individual decision making.