Monday, August 31, 2009

Gone fishin'

Metaphorically speaking.

I’m disabling comments for the blog while I’m away.

Have a good September. I’ll see you in early October.

Lady Rose

We’ve been watching “Foyle’s War”, a British series about a police detective - Christopher Foyle - who investigates crime in a coastal area of England during World War II. In the second episode - “The White Feather” - a young man named David has been arrested. He helps crew his father’s unbelievably tiny fishing boat, the Lady Rose, and came to the attention of the police because he was walking out with a hotel maid involved in a crime. The maid is, David explains, the only girl who didn’t mind that he always smelled like fish.

At one point in the show, David’s father meets with Foyle on the beach to ask for his son’s release:

Father: I want him back.

Foyle: Well, I’m afraid you’re going to have to wait.

Father: No, you don’t understand. I need him now. They’re asking for boats. Fishing boats, ferries, clippers, you name it. We’re going across where the army’s stuck with Germans bombing them and tanks moving in and God know what. They’re putting together a whole fleet of boats and we’re going over there and we’re going to bring back our boys. It’s already begun. They say there were nearly 30,000 of them saved yesterday and there’s going to be 30,000 more today. I can pick up twenty men in my boat. Drop in the ocean, you’d say? But there’s hundreds of boats all along the coast doing the same. Hundreds and hundreds of them. Only I can’t do it without David. Lady Rose is too much for me to handle on my own.

This is Dunkirk, of course. I haven’t thought about Dunkirk in years and yet it seems to me the sort of thing that should never be forgotten.

I don’t remember when I first learned about Dunkirk - I think I’ve known about it my whole life - but listening to the dialogue in the show I realized how little I know about it. Sixty-thousand men rescued? I’d always thought it was a few thousand. Yet when I re-read the little snippet about it in one of my favorite books, To Serve Them All My Days, it says:

But then, like a blessed spate of silence after an earsplitting cacophony, came whispers of a fleet of small ships, and the lifting of 360,000 castaways from the littered beaches of Dunkirk.

I must have read that line a half dozen times over the years but somehow the sheer immensity of the numbers never sank in: not 60,000 but 360,000. No, Dunkirk - the sheer courage, determination, and sacrifice of Dunkirk - should never be forgotten.

Sick and fired

Way to go guys. So the government - Democrats and Republicans - passed a bill that is going to phase out incandescent light bulbs and force us all to us to buy fluorescent light bulbs instead.* This, we are assured, will save the planet. Maybe so but it’s not doing much for the people who live on the planet: not only is this dim bulb of an idea destroying jobs in the United States it’s also poisoning workers in China.

The bibliography for State of Fear includes a description of Searching For Safety by Aaron Wildavsky (my hyperlink):

Drawing on data from a wide range of disciplines, Wildavsky argues that resilience is a better strategy than anticipation, and that anticipatory strategies (such as the precautionary principle) favor the social elite over the mass of poorer people.

I’m well aware that those who desperately want to save the planet sneer at Michael Crichton. I suspect, however, that neither Crichton nor Wildavsky would be surprised to discover that the light bulb legislation was supported by the Alliance to Save Energy - which includes such light bulb luminaries as Philips - and by General Electric. - the very company busy closing factories in Kentucky, Virginia, and Ohio while making fluorescents in China.


* I feel compelled to quote Representative Ted Poe who, according to Wikipedia, contended “that the United States Constitution does not give the federal government the power to determine what light bulbs people are allowed to use.”

The perfect storm

I wrote in my earlier post about the excellent work Deafening Silence is doing analyzing Dr. Ezekiel Emanuel’s writing. I had actually planned to do this myself at some point and I cannot tell you how glad I am to find someone else tackling it. When I was contemplating this project I did complete most of an analysis of Dr. Emanuel’s June 18, 2008, article in the Journal of the American Medical Association. The article is entitled “The Perfect Storm of Overutilization” and Deafening Silence has up three posts about this article: an overview; an examination of his International Comparisons chart; and a closer look at OECD health data in general.

After reading Deafening Silence, I decided to go ahead and put up what I had by way of analysis even though much of it duplicates Deafening Silence’s overview. I come to a particular conclusion about Dr. Emanuel and I think my analysis of this article leads to that overview. Please do go read Deafening Silence’s posts. She goes into far more detail, particularly about his statistics, and her overview of his article is in many ways more detailed than mine - and from a somewhat different angle.

The Perfect Storm of Overutilization (JAMA 2008). This article is actually co-authored but since no one is talking about the other author I will write as if Dr. Emanuel was solely responsible. This article is behind the firewall at the Journal of the American Medical Association but you can access a PDF here. I half agree, half disagree with his contentions here. Emanuel claims that overutilization in the United States is not to be found in quantity; according to him we do not consume “more office visits, hospitalizations, tests, procedures, and prescriptions than are appropriate”. Rather US overutilization consists of:

more costly specialists, tests, procedures, and prescriptions than are appropriate.

It is more costly care, rather than high volume, that accounts for higher expenditures in the United States

Emanuel attributes this type of overutilization to seven factors. The first four impact doctors, the last three impact patients:

1) Physician culture which rewards “meticulousness, not effectiveness” and “the most thorough and aggressive physicians” rather than the “prudent physician”. Emanuel objects to:

... a unique understanding of professional obligations, specifically, the Hippocratic Oath’s admonition to “use my power to help the sick to the best of my ability and judgment” as an imperative to do everything for the patient regardless of cost or effect on others.

2) “[F]ee-for-service payment misaligns incentives; it creates a big incentive for overutilization. ... the current system’s bias toward paying significantly more for procedures rather than for evaluation and management reduces physicians’ inclination to watch, wait, and communicate and increases their propensity to order a test.”

3) The flood of marketing directed at physicians with little or no (you guessed it) comparative effectiveness research.

4) Medical malpractice and the resulting defensive medicine.

5) A culture which values”high technology over high touch” resulting in “a patient perception that doing more tests and receiving more treatments and interventions is receiving better care.” (As an editorial aside, I think this is nonsense. The people I know are far more unhappy with five-minute doctor appointments than they are with a lack of MRIs.)

6) Direct to patient marketing of prescription medicines.

7) Third-party payment. Emanuel is worth quoting more fully on this:

In normal markets, demand is modulated by cost. But third-party payment for patients attenuates this control. Although patients experience deductibles, co-payments, and other out-of-pocket expenses, health insurance and government programs significantly shield patients’ decisions from the true costs of health care.

As you can see, little of this is objectionable other than Emanuel’s continuing distress over the Hippocratic Oath. What is most interesting about his seven elements is that the problems with fee for service and the problems with third-party payment militate against the very sort of government-run health system favored by most Democrats. Even the problems of medical marketing to physicians and patients would be best solved by a system in which patients had a reason to care about the price of their medicine not one in which the government paid for everything. And, of course, tort reform to address the costs of medical malpractice and defensive medicine does not even appear to be on the Democrats’ radar screen.

Thus, overall, I’d put Emanuel’s “Overutilization” article in the conservative column. So why does Thomas Sowell, for example, object to it so strongly that he chose to make it the focus of an article entitled “'Death Panels' Just A Rumor? Go Ask Ezekiel”? Well, in Sowell’s case it is partly because he either misunderstands or misstates Emanuel’s argument. Sowell claims that Emanuel’s overutilization includes the existence of “amenties” such as hospital rooms that “offer more privacy, comfort and auxiliary services than do hospital rooms in most other countries.” Sowell goes on to say:

At one time, it would have been none of Dr. Emanuel's business if your physician prescribed the latest medications for you, rather than the cheaper and obsolete medications they replaced. It would have been none of his business if you preferred to have a nice hospital room with "amenities" rather than being in an unsanitary ward with inadequate nursing care, as under the National Health Service in Britain.

The involvement of government gives Dr. Emanuel the leverage to condemn other Americans' choices — and a larger involvement of government will give him the power to force both doctors and patients to change their choices.

Um, no, at least partly. Emanuel does not consider amenities part of the overutilization problem. He lists insurance administrative costs; higher salaries for doctors and higher costs for prescription drugs; and greater amenities in hospital rooms and doctors’ offices (convenient location, more parking, nicer waiting rooms) as three contributors to higher health care costs in the United States. He then goes on to say:

The most important contributor to the high cost of US health care, however, is overutilization. Overutilization can take 2 forms: higher volumes, such as more office visits, hospitalizations, tests, procedures, and prescriptions than are appropriate or more costly specialists, tests, procedures, and prescriptions than are appropriate.

The amenities Sowell is so worked up about are not part of overutilization. Like insurance administrative costs and higher doctor salaries and drug prices, medical amenities are a driver of higher costs apart from overutilization. It is clear Emanuel considers them relatively unimportant and nowhere in his article does he suggest we do away with them. In other words, Emanuel is not suggesting the United States save money by dumping patients into filthy open wards. Deafening Silence’s analysis of this part of Emanuel’s article is more sophisticated - and more accurate - than Sowell’s.

A second problem with Sowell’s analysis of Emanuel is that it is not clear to me that Emanuel favors the amount of government involvement we have now via Medicare and Medicaid much less further government involvement. His policy section concludes in part:

Realistically, the most effective policy change would be to alter how insurance pays for medical services. ... It would help if patients were financially sensitive to the cost of care, but not if out-of-pocket costs inhibit use of needed services, resulting in higher costs later. This is not an all-or-nothing rationing scheme, but rather an ethical way to have patients experience costs but not at the expense of important outcomes.

In other words, if people knew the cost of the medical goods they were purchasing, understood their options, and had to pay for the care themselves they would make the decisions best for themselves. They might want the newest brand name medicine or they might feel the generic was worth a try; it would be their decision. They might - as they are able to do now - elect a private room or prefer to save their money for something else and choose a semi-private, four-person, or even open ward. That sounds awfully, I don’t know, conservative to me.

And the third problem with Sowell’s article is that none of what he quotes about Emanuel has anything to do with death panels. In fact, Sowell totally ignores the hook he could hang this argument on: Emanuel’s discomfort with the Hippocratic Oath. Sowell does attempt to claim that Emanuel is objecting to “quality” care but his mixing nice hospital rooms with the newest prescription drugs undercuts his argument. Again Deafening Silence does a much better take-down of Emanuel in this regard when she explains the dangers of practicing “good enough” medicine rather than “best outcomes” medicine.

In the end what distresses me about Emanuel is not his philosophical musings about how to ration health care but his attempt to redefine the meaning of the Hippocratic Oath. A generation of doctors who learn to look at old patients, disabled patients, and chronically ill patients and decide which ones should not get further resources is far, far more dangerous to our medical care than a panel convened to formally debate which procedures should be afforded to which patients. The latter is explicit and opposable; the former is implicit and almost impossible to fight back against. Furthermore, it is subtle.

Doctors can be fully committed to doing everything humanly possible for their patients and at some point honestly conclude that any further medical intervention is both pointless and cruel. But without that initial full commitment a doctor’s judgement about when to stop fighting becomes suspect. Is there really nothing else than can be done for me, my child, my spouse, my parent? Or is this one of the new breed of doctors who thinks that because I am in a wheelchair, my child suffers from Down syndrome, my spouse is a diabetic, my parent is old that we’re not worth any more of medicine’s resources?

Interestingly - and based on nothing more than a hunch - I do not think this is where Emanuel believes his views lead.* His 1997 article on physician-assisted suicide and euthanasia reveals a doctor who is deeply committed to the traditional view of the Hippocratic Oath. If I’m right about Emanuel’s basic decency and commitment to life it may simply be that since he would never become the sort of doctor who makes quality of life calculations on the fly he is unable to understand that others who accept his logic will do exactly that.

Along the same lines, Emanuel seems unaware of the contradictions in his own work. That same 1997 paper on physician-assisted suicide and euthanasia warns of the dangers of making those practices legal for fear they will lead to an overly-casual acceptance of them in situations where they may not be appropriate. Yet he seems to have no fear that the inclusion of societal factors in living up to the HIppocratic Oath might introduce equally over-casual acceptance of this type of balancing act. This would result in situations where doctors who would never consider easing an elderly or disabled person on his way see nothing wrong with deciding a little too early that this person is a hopeless case because there’s a teenager in the next room who would benefit from more attention.

As far as claims that Emanuel is a true believer when it comes to something like single-payer or Obamacare, his 2009 “Overutilization” article presents arguments that logically lead to a policy of patients purchasing their own health care to the greatest extent possible; he even recognizes the value of such a policy when discussing how to encourage patients to choose older, less expensive, proven procedures rather than newer, more expensive technologies not yet shown to be more effective. Yet he then goes on to say:

... private and public payers for health care must work on developing better financial incentives for physicians and hospitals to provide more cost-effective care. Many more experiments are needed with pay for performance, bundled payments, partial capitation, value-based payment, or other payment methods that promote prudent use of resources. Such experiments with different ways of paying for health care services must be combined with careful monitoring of utilization, cost, and quality.

He doesn’t seem to quite be able to make that final leap and realize that if patients were purchasing their own health care the market could drive much of what he hopes to achieve by imposition. When I first read this, I decided that either I must be missing some subtlety of Emanuel’s thinking or his range of options must be constrained by his world view to an extent unusual in a man who appears to be an interesting and original thinker.

However, reading this (highly recommended) New York Times article led me to a different conclusion (emphasis mine):

Given Dr. Emanuel’s well-publicized repudiations of doctor-assisted suicide and voluntary euthanasia, and his calls for a national health insurance voucher system that would eventually eliminate Medicare, Medicaid and employer-provided insurance - nonstarters at the White House - Dr. Emanuel says he is perplexed by depictions of him as a socialist euthanasia proponent.

I now think that Dr. Emanuel has made that final leap to realize the free market could achieve many of his goals but he also believes such an approach is not politically feasible. That’s reassuring in terms of his ability to reason logically but I’d prefer he stick to his guns in the political arena.


* This is a terrible thing to say about a 50+ year old man who is a leading scholar in his field but there’s a part of me that can’t help thinking his insistence on the need to redefine the Hippocratic Oath is driven to a large extent by what I call college bull-session logic. You know the kind of thing I mean:

It seems so clear that we don’t have enough money to do everything in medicine; it seems so clear that someone who is 95 and dying of cancer should not get a heart transplant; it seems so clear that we could do so much for children with the money we spend prolonging the life of the terminally ill for another week or month or year. Of course there are logical decisions that can be made here. Why shouldn’t we make them?

As I implied in my earlier post, much of what Dr. Emanuel talks about needs to be talked about. His talking about the problems with the Hippocratic Oath just seems juvenile to me.

Nothing is more useful than silence

[Attributed to Menander of Athens]

The Deafening Silence blog is doing yeoman work taking a detailed look at some of Dr. Ezekiel Emanuel’s writings. The blogger there started with a New York Post article by Betsy McCaughey, tracked down three of the five Emanuel writings McCaughey cites, and is taking a detailed look at them. I think her review of Emanuel’s 1996 Hastings Center writing - the article which most damns him in conservative eyes - is particularly good and she is right on the money when she says:

Fortunately, according to Dr. Emanuel, this rigid insistance on moral neutrality in liberal philosophy is now changing, allowing liberal philosophers to declare what is 'good.'

"Fortunately, many, including many liberals, have come to view as mistaken a liberalism with such a strong principle of neutrality and avoidance of public discussion of the good. Some think the change a result of the critique provided by communitarianism; others see it as a clarification of basic liberal philosophy. Regardless, a refined view has emerged that begins to create an overlap between liberalism and communitarianism."

This new "refined view" appears to solve the problem for Dr. Emanuel. And from here, what might have been a very well-intentioned essay becomes increasingly myopic and narrow-minded.

I have read that Emanuel claims he was explaining a viewpoint he himself did not hold; I have also read he claims he has changed his mind about rationing since writing that article. I simply do not see how you can interpret Dr. Emanuel’s “Fortunately” paragraph as anything other than an endorsement of this more “refined” approach. So while I’m willing to accept that he has now changed his mind about the necessity for rationing (he did write this 13 years ago and, hey, when I was 17 I thought The Population Bomb was brilliant) I am not willing to accept that he never thought this view was a good one.*

That said, I also think Dr. Emanuel is getting a bum rap. Not from Deafening Silence: she seems even-handed and her willingness and ability to dig into the numbers behind the numbers are impressive. (I’m particularly glad she took a closer look at Dr. Emanuel’s rather selective chart in his June 18, 2008, JAMA article.) Furthermore, Deafening Silence is doing exactly what those attacking Dr. Emanuel are not doing: providing links and context.

This lack is really making me see red. I’ve gone through the New York Post article Deafening Silence began with and I’ve also gone through McCaughey’s very similar Wall Street Journal article. I was particularly intrigued by McCaughey’s claim that

Now he recommends arm-twisting Chicago style. "Every favor to a constituency should be linked to support for the health-care reform agenda," he wrote last Nov. 16 in the Health Care Watch Blog. "If the automakers want a bailout, then they and their suppliers have to agree to support and lobby for the administration's health-reform effort."

I cannot find this. I ran through about a half-dozen of the 130,000+ hits I got when searching for the string beginning “Every favor”: none of them contain a link, most of them simply quote McCaughey (some without mentioning her), and one of them even attributes the sentiment to Rahm Emanuel rather than Ezekiel.

This is insane. If there’s one thing the Internet is supposed to be about it’s allowing everyone access to all the data possible. I understand that McCaughey may be writing on dead trees but how hard would it be for the papers themselves to provide links? McCaughey has already found copies of these articles. Perhaps some of them are not available on-line or are behind firewalls but Deafening Silence managed to track down three of them. Surely with all her expertise in the medical field McCaughey could have managed the same feat. But then again her claims work far, far better if she can just rip out all that nasty context and cherry-pick which words she repeats and which words she hides.

The other thing that makes me see red is that not one article or blog or comment I have read attacking Ezekiel Emanuel cites what I think is his most important work: his 1997 Atlantic article arguing against the legalization of physician-assisted suicide and euthanasia. Of course, this makes perfectly good sense: it’s a lot easier to claim Ezekiel Emanuel is a soulless technocrat who wants to kill off everyone except perfectly healthy people between the ages of 15 and 45 if you manage to keep your audience from ever reading what Dr. Emanuel had to say in this article. Go, read - and remember this was published just a few months after his Hastings article.

Do I think Ezekiel Emanuel is beyond reproach? No. I believe his view of the Hippocratic Oath is seriously flawed and I’ll have more to say about that in my next post. In terms of what he does in general though I want to leave you with two thought experiments.

First, imagine that a war-geek journal - say the US Army War College Quarterly - devotes an article to discussing a hypothetical terrorist attack. The scenario is that a biological weapon has been unleashed on the Midwest city of Lincoln, Nebraska. Various articles in the journal discuss possible options to keep the disease from spreading outside of Lincoln. One writer suggests we may have to cordon off the city and let it struggle on its own; another suggests we may have to destroy the city ourselves to keep the disease from spreading. (No laughing from my military readers.) I think it’s good that someone is willing to consider the full range of options and ask some hard questions and even better that they’re doing so now before we’re in the midst of a crisis. Do you agree or do you think it’s horrible that anyone would even consider such a thing?

Second, imagine that terrorists have actually attacked the United States biologically. The disease is brutally effective: it takes a week to kill its victims so they require lots of medical care and it spreads by contact so those providing the care are infected when they try to help. Through heroic efforts the CDC has managed to develop a vaccine. It’s been rushed into production but we simply are not going to be able to produce more than about a million doses a day for the foreseeable future. I’d vaccinate health care workers and the military first. What would you do?


* I will give Dr. Emanuel a bit of a break here. What he is claiming was not his view was the part of his article that begins:

We may go even further. Without overstating it (and without fully defending it) not only is there a consensus about the need for a conception of the good, there may even be a consensus about the particular conception of the good that should inform policies on these nonconstitutional political issues.

Most of what people quote as objectionable - “not guaranteeing health services to patients with dementia” - falls after this caveat. What Dr. Emanuel considers “fortunate” is the overturning of the argument that:

we lack sufficiently detailed ethical intuitions and principles to establish priorities among the vast array of health care services.

So what Dr. Emanuel is distancing himself from is the particular form the “conception of the good” would take. He has not - so far as I know - distanced himself from his distaste for the “moral skepticism” that “suggests there can be no principled mechanism to define basic health care services” and that therefore defining which health care services are basic - and how their cost should be balanced against the cost of other goods - should be left to the democratic process. Nor has he distanced himself from his preference for a “just allocation of health care resources” which - as Deafening Silence so cleverly points out - will be arrived at by a rather limited group.

Sunday, August 30, 2009


Since I’m not going to be around I thought this was a good opportunity to do that blogroll I’ve been thinking about. So here’s who I read. This is in no particular order just the way they come up in my bookmarks - which my Web browser makes very difficult to intelligently sort.

Villainous Company: I read Cassandra first. Her blog is what I’ll miss most while I’m not Internetting.

TigerHawk: A hodge-podge with an emphasis on business and politics, some national security, and the occasional NSFW. Almost always a light touch.

Neoneocon: A mental health professional talks politics. I don’t agree with her take on Obama having a grand design but she’s knowledgable and an excellent writer and her occasional excursions into Jell-O, ballet, and popular culture are always refreshing.

Megan McArdle: Libertarian but not doctrinaire. After Villainous Company she’s the blogger I most recommend.

Greg Mankiw: Economics done Right. Interesting, brief, often humorous, and occasionally charmingly vicious. I also like the fact that his blog design is streamlined and therefore it loads quickly. I like words; pictures, videos, cutsie not so much.

Grim’s Hall: Philosophy, war, politics, gallantry - something for everyone. Grim is a milblogger but this is not a milblog.

Camille Paglia: She only writes once a month which is a shame but she’s well worth waiting for.

Anglachel’s Journal: If you want to know how an intelligent liberal (I do not believe she would say “progressive”*) with an integrated view of the world and a deep respect for those who bitterly cling to their guns and religion thinks, this is a must-read. If someone like her was running the Democratic Party the Republicans might actually be dead in the water.

Reclusive Leftist: Very liberal; very, very system feminist; not an Obama supporter, has no use for the political stance of Institutional Feminism. Unlike Anglachel she has clear contempt for “the little people” who are stupid enough to fall for Republican propaganda - which means I’m not very happy with her. However if you want a clear feminist perspective without having to wade through an ocean of Obama adulation or Palin hatred she’s a good resource. She is also a powerful and interesting writer. And although her Website design violates all my earlier comments on the value of streamlining it always makes me smile.

Everyday Glory: This is a new read for me via Megan McArdle citing her post on “Obephobia”. No final judgment yet - she has up very few posts - but I’m eagerly awaiting her further posts on obesity and am riveted by what she’s revealed so far of her experience with Lyme Disease. I suspect that means she's simply a very good writer.

These are not all the blogs I read but they are the ones whose views I most look forward to reading. Enjoy.


* I have to agree with the blogger I read not too long ago but failed to bookmark: I won’t use the term “progressive” because it implies those who do not agree with the Left’s ideas are somehow regressive in the worst possible sense of the world. For the Left to allot the label “progressive” to themselves is a remarkable act of both hubris and contempt - and a brilliant marketing ploy. Not bad for a group that sneers at conservatives’ cheap shots and soundbite arguments.

The quality of mercy

In response to an earlier post, commenter Mara quoted something I said and then talked about pre-existing conditions:

In particular, group insurance policies provided via large employers are good about this.

Yes, that's true, Elise. HIPPA (Health Insurance Portability and Accountability Act, written by Sen. Kennedy) requires that group insurance policies cover employees with pre-existing conditions. However, as you know, not everyone is covered by group insurance including the millions of folks who are self-employed, small business owners, the unemployed and those whose employers do not offer insurance. For them "pre-existing conditions" such as cancer, down syndrome, even pregnancy represent a costly if not insurmountable barrier to health coverage. You may be surprised to learn as I was that in a dozen or so states even women who have been victims of domestic abuse are deemed to have pre-exisiting conditions. It boggles one's sensibilities.

As for the details of the former Governor Palin's insurance coverage, I couldn't care one wit. I trust she'll continued to be covered by the State of Alaska as is the policy for most former state executives. My point is that I would have hoped she would care enough for all the families who have a down syndrome baby who already face discrimination. Ain't the first time nor the last that she'll disappoint.

I began writing a response to her comment and it turned into a post.

Actually HIPAA is not quite so straightforward with regard to pre-existing conditions:

Title I also limits restrictions that a group health plan can place on benefits for preexisting conditions. Group health plans may refuse to provide benefits relating to preexisting conditions for a period of 12 months after enrollment in the plan or 18 months in the case of late enrollment. However, individuals may reduce this exclusion period if they had group health plan coverage or health insurance prior to enrolling in the plan. Title I allows individuals to reduce the exclusion period by the amount of time that they had "creditable coverage" prior to enrolling in the plan and after any "significant breaks" in coverage. "Creditable coverage" is defined quite broadly and includes nearly all group and individual health plans, Medicare, and Medicaid. A "significant break" in coverage is defined as any 63 day period without any creditable coverage.

This 12-month exclusion is clearly intended to handle the problem of someone diagnosed with a high-cost illness who then seeks employment specifically in order to have coverage with a group health plan. And, yes, I did know someone who did this. Provided the illness is chronic rather than catastrophic or has a long latency period, this is a perfectly rational response to our current health care/insurance system. It is the pre-emptive strike version of continuing to work at a job you hate because you or your family need the health insurance.

That said, I certainly agree there are a lot of people who do not have jobs that include large group health insurance policies and can’t get such jobs. My preferred solution if we’re going to do a total overhaul of health care/insurance would be something along the lines of the Goldhill ideas I wrote about recently - which I think are very similar to what Singapore does. Goldhill’s plan is not fully fleshed out - the devil is always in the details - and I do not know all the ins and out of Singapore’s plan* but they both provide government assistance for those who need help paying while also requiring health care consumers to make choices about how they spend their money - whether they contribute it themselves or get government help. This seems to me to be the only way to restrain health care costs while making the government’s role in deciding what care will and will not be provided as small as possible. (As long as you have any government involvement that role cannot be non-existent.)

If we don’t want to do a complete system overhaul then I would like to see anyone who wants to be allowed to buy into the FEHP with the government subsidizing those who cannot afford it. (Actually, in my heart of hearts I’d like to see this - and a whole slew of other government functions - move to the State level - I don't think the less well off people of Alabama should have to subsidize New Jersey’s sky-high medical costs - but I’m talking realm of possibility here.)

Finally, I cannot begin to imagine the anguish of having a child who needs medical attention and not being able to provide it. I gather you don’t think much of Palin but it’s worth remembering that she does in fact have such a child and - unless you accept that she is a monster - must understand how parents who are not able to provide what she can provide would feel. This is why I would like to see her talk about what she thinks should be done for such children and their parents. Perhaps she truly is a monster who figures that since she and her family aren’t suffering, no one else matters. I don’t believe this but I’d be very interested in more information. (I’d also like some sources for your claim that State governors continue to get benefits once they leave office. If that’s true in NJ, my State legislators are going to hear from me.)

Many people seem to believe that once the government - especially the Federal government - provides a good that good can never be taken away. Thus people argue that if the government would just provide health care for all everyone would be set for life. I don’t believe that. I can remember my aunt’s anger over Social Security because, she said, her parents had been told by the government that if they would just pay this little bit of money then the government would provide fully for a comfortable retirement for them. Less personally the proposals to means test Social Security and Medicare; to raise the eligibility age; to change how increases in benefits are calculated are all examples of how a benefit once promised can be taken away. So is the proposal floated a while back that veterans’ own health insurance pay for some part of the care they needed as a result of being injured while on duty. The proposals make sense given the financial situation but that doesn’t change the fact that the government wants to change the rules and if it succeeds in doing so, those who counted on what the government told them will simply be out of luck. And if the rules aren’t changed voluntarily then we will run out of money at some point and the whole game will change. California is an example of what can happen when promise meets cost.

The Federal government is as capricious and ultimately as cost-constrained as any other entity and what is promised one day may be withheld the next either through choice or through necessity. I do not believe that is an argument that government should do nothing to help its citizens; indeed I’ve argued that to the extent a society can afford to do so it has a moral obligation to help those who cannot help themselves. It is, however, an argument to beware of putting ourselves in a position where government is the only source of a good. Sometimes there is no real choice about that: national security, for example. But if we have competing interests - both private and public - we are far less likely to find ourselves at the mercy of either.


* Singapore’s numbers - if accurate - are astonishing. According to the BBC and various Wikipedia references:

- Singapore spends 3.4% of its GDP on health care; Canada spends about 10-11%.
- Singapore spends about $1,228 per capita; Canada spends about $5,100.
- Singapore’s infant mortality rate is 2.1 per thousand live births; the CIA 2009 figures say 2.31 versus 5.04 for Canada; the UN says 3.0 versus 4.8 for Canada
- Life expectancy in Singapore is 79.7 years; the CIA 2009 figures say 81.98 years versus 81.23 years for Canada.


I’m taking a break from the Internet for the month of September. That not only means no blogging but also no email.

So beginning sometime between 5pm Monday and 9am Tuesday, I’ll be off the air. I’ll be back to email October 1 and back to the blog sometime between October 1 and October 15.

I’ll get at least one more post up before I hiate and - being all linear-closure - I’ll do an “I’m gone now” post, too.

Friday, August 28, 2009


Amidst the cries to pass Obamacare as a tribute to Ted Kennedy, I found a post by Anglachel. I was intrigued because she didn’t suggest passing Obamacare to honor him nor did she suggest passing single-payer to honor him; rather she said:

I think the best memorial we can offer to this man, respecting his political service and offering amends for any political follies, is to enact, in its own right and without any other riders, exceptions, additions and/or emendations, his Medicare for All Act.

Now Medicare For All usually seems to be thought of as synonymous with single-payer so I wondered why Anglachel didn’t just advocate passing single-payer. I clicked on Anglachel’s link and discovered that the Kennedy bill is Senate Bill 1218. Introduced in the 110th Congress (the previous Congress) on April 25, 2007, and entitled the “Medicare for All Act”, this bill was sponsored by Ted Kennedy with no co-sponsors. S1218 never made it out of committee and was not re-introduced in the 111th Congress.

Surprise, surprise. This is not the bill single-payers are talking about. As far as I can determine, the bill single-payers are pushing is House Resolution 676. This bill is entitled the “United States National Health Care Act or the Expanded and Improved Medicare for All Act”. (Arrogant, much?) HR 676 was introduced on January 26, 2009, by John Conyers and has 86 co-sponsors including Patrick Kennedy.

The main difference between the two bills is the level of coercion. I haven’t made a detailed study of either but from brief review the Kennedy bill:

1) Allows for enrollment in Medicare for All. It seems that joining is voluntary rather than mandatory. This not totally clear; if enrollment is in fact mandatory then some - though not by any means all - of the differences between the Kennedy bill and single-payer disappear.

2) Requires the HHS Secretary to allow private insurance companies to provide services so long as those companies offer benefits comparable to those in the Federal Employee Health Benefits Program. In other words, this bill allows for setting up a public version of the FEHP. The bill levels the playing field somewhat by requiring the Secretary to pay private insurance companies the average cost of providing benefits under the program. (I’d have to think about the math more but it’s possible an average that uses cost and includes private insurers is a bit of a Trojan horse as far as getting rid of private insurers.)

3) Uses taxes to fund the program: 1.7% on individuals earning over $25,000; 7% of employee wages on employers. However those taxes are only assessed on the enrolled. If enrollment is - as I believe it to be - voluntary that would leave the possibility of a dual public-private system intact.

4) Specifically allows for the continued existence of private insurance both individually and at a corporate level as a supplement to the program.

By contrast HR 676 is, shall we say, harsh. A brief review indicates that under this bill:

1) The government is the insurer just like now happens with much of Medicare.

2) If you’re qualified to participate you’re enrolled. This is a little unclear but it doesn’t much matter because:

It is unlawful for a private health insurer to sell health insurance coverage that duplicates the benefits provided under this act.

So even if you aren’t forced to enroll you can’t get health insurance anywhere else. (Private insurers can insure procedures not government-covered such as cosmetic surgery.)

3) The bill is rather coy about exactly what taxes are going to be required to fund this program. It gets the revenues already coming in for health care (Medicare, I assume); it increases income taxes on the top 5 percent (no amount given); is institutes “a modest and progressive excise tax on payroll and self-employment income” (no amount given); it institutes “a small tax on stock and bond transactions” (no amount given). Any additional funding will come from the savings realized by reducing paperwork; buying meds in bulk; and providing better access to preventive care (no amounts given).

4) No investor-owned health-care entities will be allowed to provide health care and be paid for it under this plan. Private entities are allowed; for-profit public entities must convert to non-profit entities and “shall be compensated for reasonable financial losses” incurred in the process.

The Kennedy bill is designed to provide universal access to health insurance; the Conyers bill is a true single-payer system designed to make our health care work like Canada’s does. The Kennedy bill may well nudge us down the road to single-payer but if enrollment is truly optional that makes such an outcome less likely. Furthermore, if the Secretary contracts with private insurance companies the Kennedy bill may instead move us toward a version of what Bill Bradley suggested: getting everyone who wants to enrolled in the Federal Employees Health Benefit Program. I suggested we would need appropriate firewalls to shelter the employees; the Kennedy bill firewalls FEHP by setting up a separate risk pool.

It’s also worth noting - worth emphasizing - that the people backing Obamacare can slap a KennedyCare label on the monstrosities they’re pushing but if Senate Bill 1218 truly represents what Ted Kennedy wanted then the Obamacare bills are most definitely not KennedyCare. Heck, Kennedy’s bill is only 27 pages long and if I spent as much time on it as I did on just one section of HR3200 I’m pretty sure I could fully understand all the ins and outs of the whole Kennedy bill. I don’t think anyone does - or ever can - understand all the ins and outs of HR3200. If nothing else, I don’t see the Kennedy bill creating the endless loops of new government agencies that are envisioned by HR3200; that right there should make KennedyCare a heck of a lot cheaper than HR3200.

If you dislike the idea of any further Federal government involvement in health care/insurance you’re not going to like KennedyCare. I’d rather go a different route myself. However, if we’re going to have some kind of overarching health care reform shoved down our throats by the Democrats, I’d rather have KennedyCare than single-payer and I’d rather have KennedyCare than HR3200. KennedyCare appears to actually insure the uninsured (unlike HR3200) and it appears to leave us some choices (unlike single-payer). Furthermore, it does have at least some free-market operation in the (presumed) competition among health insurance companies to contract for the right to provide services under the Federal program. If I’m right that enrollment in the Kennedy plan is optional then there is also competition in the fact that employees can elect to spend their 1.7% tax (and theoretically their employers’ 7% tax*) on buying their own private insurance. Or buy no insurance at all.

Rumor is that House Speaker Nancy Pelosi is going to allow a simple up or down vote on single-payer when the Congress reconvenes in September. I assume that vote will be on House Resolution 676. Most people seem convinced it will fail and I hope they’re right.

However, I suspect that if those pushing single-payer and those pushing the gargantuan Obamacare bills had chosen instead to get behind Senate Bill 1218 it might well already have passed. After all, who could resist a piece of legislation the stated purpose of which is to ensure “that all Americans have access to health care as good as their Member of Congress receives”?


* There is a big hole here that makes me suspect the intention is to make enrollment in the Kennedy plan mandatory (although the language of the bill may create a loophole). If an employee is enrolled in KennedyCare his employer has to ante up 7% of his wages. This seems like a situation tailor-made for an unscrupulous - or simply cash-strapped - employer to refuse to buy his employees health insurance and threaten to fire them if they enroll in the government program. Given Democrats’ (not entirely unjustified) suspicion of employers it seems unlikely they would leave such a land mine in a bill.

Thursday, August 27, 2009

What she said

Over at Cassandra’s we were talking about whether there is a moral obligation to provide universal health care. I struggled to explain myself and did a pretty poor job, getting lost in a tangle of morality, obligation, wealth, affordability, and generosity.

Luckily Senator Mary Landrieu from Louisiana is more articulate than I - and far pithier:

“I’d like to cover everyone — that would be the moral thing to do — but it would be immoral to bankrupt the country while doing so,” Landrieu said.

(Via NRO)

What is a "death panel"?

[This is the third post in my series on “death panels”. The first post is here and contains definitions important to understanding the later posts. All posts in this series are categorized under “Death Panels”.]

What is a "death panel"? According to Sarah Palin:

The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care.

Is anything like that likely to happen? No. This is not a literal description of a likely outcome. Rather it is a very clever symbolic representation* of something that is a likely outcome: the government making decisions to limit the amount of health care it will pay for in certain situations. No particular person is ever going to stand in front of a panel somewhere and ask to be allowed to live - or even ask to be allowed to receive treatment. Instead a government agency is going to provide a ruling on which treatments will be provided (or not provided) under what circumstances. If there is an appeals process it’s going to consist of your doctor filling out forms.

Think even the idea of something like that happening is nonsense? Let’s consider some quotes. Here are two conservatives, one liberal, and one (probably) independent talking about this issue:

Here’s conservative TigerHawk sort of agreeing with Obama:

Barack Obama is right. It is profoundly wasteful to perform hip-replacement surgery on somebody who is probably going to die in a matter of weeks or even months, and as a conservative I am against profoundly wasteful things. The question is, what should we do about it? [snip]

The solution, the only real way out of the end-of-life cost trap, is to privatize health insurance for senior citizens, give them vouchers that subsidize their health care to some baseline, and let them negotiate the end-of-life deal they prefer (and can afford) when they would have become eligible for Medicare.

What services will the government subsidize and what services will they not? Will that subsidization vary based on the senior’s age: heart transplants and hip replacements for the young-old; hip replacements only for the middle-old; nothing but palliative care for the old-old? In other words, who defines the baseline? Seems like a job for super-panel.

Here’s conservative Ross Douthat explaining we need to tell Grandma “No”:

For liberals trying to find the money to make health insurance universal, these inefficiencies make Medicare an obvious place to wring out savings. But you can’t blame the elderly if “savings” sound a lot like “cuts.” When the president talks about shearing waste from Medicare, and empowering an independent panel to reduce the program’s long-term costs — well, he isn’t envisioning a world where seniors get worse care, but he’s certainly envisioning a world in which they receive less of it. [snip]

In this future, somebody will need to stand for the principle that Medicare can’t pay every bill and bless every procedure. Somebody will need to defend the younger generation’s promise (and its pocketbooks). Somebody will need to say “no” to retirees.

That’s supposed to be the Republicans’ job. They should stick to doing it.

Less care but not worse care. That would seem to envision a situation in which the government determines what is and is not necessary. How? Via “an independent panel” according to Douthat who is simply citing liberal Barack Obama:

THE PRESIDENT: I would have paid out of pocket for that hip replacement just because she’s my grandmother. Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else’s aging grandparents or parents, a hip replacement when they’re terminally ill is a sustainable model, is a very difficult question. If somebody told me that my grandmother couldn’t have a hip replacement and she had to lie there in misery in the waning days of her life — that would be pretty upsetting.

INTERVIEWER: And it’s going to be hard for people who don’t have the option of paying for it.

THE PRESIDENT: So that’s where I think you just get into some very difficult moral issues. But that’s also a huge driver of cost, right?

I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill out here.

INTERVIEWER: So how do you — how do we deal with it?

THE PRESIDENT: Well, I think that there is going to have to be a conversation that is guided by doctors, scientists, ethicists. And then there is going to have to be a very difficult democratic conversation that takes place. It is very difficult to imagine the country making those decisions just through the normal political channels. And that’s part of why you have to have some independent group that can give you guidance. It’s not determinative, but I think has to be able to give you some guidance. And that’s part of what I suspect you’ll see emerging out of the various health care conversations that are taking place on the Hill right now.

Obama gets points here - big points. Unlike TigerHawk and Douthat, he provides an actual example of the kinds of decisions he is talking about. Even more impressive, he doesn’t hand-wave by making his example one that almost everyone would agree clearly represents waste or unnecessary care - like, say, a heart transplant for a 95-year-old with end-stage pancreatic cancer. Rather Obama’s example accurately represents the type of murky water we wade into when we consider the issue of health care and costs.

That said, the President of the United States who is - at least in theory - the driving force behind Obamacare is explicitly saying that we need a “group” to give guidance on what the government should and should not pay for in just such heart-wrenching situations. Sounds panel-ish to me.

And finally here’s (probably) independent Ed Koch in the midst of talking about falling out of love with Barack Obama:

In order to keep costs from rising, most people acknowledge the need for some kind of limitations on spending. Rationing of public monies makes sense, e.g., should public monies be used to give a kidney or heart transplant to a 90-year-old patient, when it is necessary to reduce the costs of Medicaid and Medicare to keep them solvent? Both programs are totally government funded and operated. I would say no.

Koch also gets big points. He is straightforward enough to use the word “rationing” and he talks about solvency rather than waste and unnecessary care. He is also honest enough to bring up Medicaid which - while it does fund some care for senior citizens - also funds care for junior citizens. On the other hand, Koch takes the hand-wavy route when he legitimizes his argument with the relatively easy example of transplants for 90-year-olds. (Which is not always actually that easy; there are some darn healthy 90-year-olds out there and while I almost certainly wouldn’t think giving them a new heart is a great idea I might be persuaded about that kidney.)

What Koch is avoiding with his example is the fact that someone is going to have to decide on cases that are not quite so easy. This is the same problem TigerHawk and Douthat sidestep with their references to wasteful and unnecessary care. If we turn again to Obama’s grandmother we learn:

So now she’s in the hospital, and the doctor says, Look, you’ve got about — maybe you have three months, maybe you have six months, maybe you have nine months to live. Because of the weakness of your heart, if you have an operation on your hip there are certain risks that — you know, your heart can’t take it. On the other hand, if you just sit there with your hip like this, you’re just going to waste away and your quality of life will be terrible.

So should an 85-year-old who will almost certainly be dead within the year get a hip replacement? If those who believe we must restrain spending say no, are they willing to let her spend that last year in pain and misery or to hasten her death by making her bedridden? What if she was expected to live two years? Three years? Three months? What if instead of talking about Obama’s terminally ill grandmother, we’re talking about an otherwise healthy 85-year-old, both of whose parents lived well into their 90s? Should she get a hip replacement? And that’s just the tip of the iceberg. Does the answer change if the patient is 80 instead of 85? What if she’s 75 - or 95 or 105? What if we’re talking about arthroscopic surgery to free a frozen shoulder rather than a hip replacement? Can TigerHawk, Douthat, Obama, and Koch define that magic meeting point of age, health, cost, and expected outcome that separates necessary treatments from unnecessary, that separates the wasteful from the worthwhile in all those cases where reasonable people can reasonably disagree?

Whether we claim we’re going to eliminate wasteful and unnecessary treatment or we just flat out admit we’re rationing care to keep government programs solvent, someone somewhere is going to have to sort out all the not so clear-cut cases. Enter a government panel. And if that government panel decides that no 90-year-old is going to get a kidney transplant then some people whose lives could have been saved will die. If that panel decides that no 85-year-old is going to get a hip replacement then some people who could have had several more happy, productive years are going to get painful, restricted years instead. Understanding that makes me neither ignorant nor insane, neither paranoid nor wingnut. Understanding that makes me reality-based.

Does this mean I now believe the Right is correct when it says the Left wants to pull the plug on grandma?** No. I believe each side in this fight has grasped part of the truth. I also believe neither side has helped us have the vitally important, extremely difficult discussion we should be having about the issue of health care and cost . Furthermore those on the Right - some honestly, some for political advantage - are late to the party and looking in the wrong direction: the issue of government control over health care is a ship that sailed long ago; Medicare and Medicaid are already restricting what care they pay for; and a panel to make the sorts of decisions I discuss doesn’t need Obamacare to pass in order to become a reality. I’ll look at those topics in future posts in this series.


* If you’re one of the people who think Palin is dumb as a whole yard of dirt you will be horrified at my describing anything she says as “clever” - and probably even more horrified at my believing she could possibly understand symbolism. Please feel free to continue to believe that she is simply too stupid to understand the subtleties of bioethics. It won’t materially impact my line of reasoning.

** My husband is getting quite irate over the whole “pull the plug on grandma” discussion. He demands to know why we as a society aren’t equally concerned about pulling the plug on grandpa and is considering seeking some type of legal redress for this sexist dismissal of the value of male progenitors.

Wednesday, August 26, 2009

Bound in shallows and in miseries

There is a tide in the affairs of men.
Which, taken at the flood, leads on to fortune;
Omitted, all the voyage of their life
Is bound in shallows and in miseries.
(Julius Caesar Act 4, scene 3, 218–221)

Megan McArdle quotes Clive Crook:

I think Obama needs to drop the public option, despite the dismay this will cause among progressive Democrats, and he needs to be honest about the need to raise taxes to pay for universal coverage.

McArdle then says:

I disagree about the tax increases. It is entirely true that taxes will need to go up to pay for this--all of the proposals on the table seem to be "revenue neutral" only if you squint hard and ignore the year after the 10-year deficit horizon. But Obama cannot say so. If he did, it would doom the reform. And it wouldn't do much for his re-election chances, either.

McArdle is almost certainly right: there may never have been a time when Obama could have talked about raising taxes to pay for universal coverage - and if there ever was such a time it’s long gone now. However seven months ago Obama could have made an argument for universal coverage without raising the specter of raising taxes:

I know we are facing tough economic times and I know many people will say the last thing we should be thinking about is spending more money. But all those Americans without access to our great American health care system shouldn’t have to wait any longer. And all those Americans who still have their jobs and health insurance but fear they’ll lose both tomorrow or next week or next month should know that even if they lose their jobs they and their families will still be able to get medical care when they need it.

I’ve made no secret of my belief that our health care system needs a complete overhaul and I plan to get that overhaul done before the end of my first term. But what’s urgently needed now is a safety net for those who don’t have one today - and for those who may not have one tomorrow.

Therefore I am sending to Congress the Insuring The Uninsured Health Care Bill. This bill provides that every American who wants to can buy into the Federal Employees Health Benefits Plan.* If an individual or a family can’t afford to do that then the Federal government will subsidize them.

This plan will cost $165 Billion a year**. Yes, that’s a lot of money especially at this difficult financial time. But we just spent $800 Billion to bail out Wall Street; surely we can spend half that amount to insure our neighbors - and maybe someday ourselves. You know there’s a $780 Billion stimulus package under consideration. I propose to allot half that stimulus money to Insure The Uninsured. That $390 Billion will pay for a little over two years of the program. Those two years will give us time to look at ideas for overhauling the entire system and give us time to make sure we can pay for that overhaul.

I know there are those who will argue about whether this is the best use of our resources at this critical juncture. I believe it is our moral duty to help those who most need our help when they need it most. I’m sure that this great country will demonstrate once again the incredible generosity we’ve so often shown in the past and do the right thing for everyone in America.

I think that would have been utterly saleable seven months ago. I certainly would much rather have spent some of the stimulus on subsidizing health insurance rather than on whatever it is we spent it on. Today, though, I don’t think a speech like that - even if we could use still unspent stimulus money to fund the insurance - would convince a single person. It would sound like - and be - just one more spin cycle.

And we must take the current when it serves,
Or lose our ventures.


* This is the plan I’ve written about so it’s the one I put in the hypothetical speech but there are other ways to accomplish the same thing: let everyone who wants to join Medicaid and charge a premium to those who can afford to pay something; give people money and let them buy whatever insurance they want. However we did it the first priority should have been to insure the uninsured; bending curves and centralizing information and everything else should have waited.

** This is my worst case estimate. The Gorgomons think you can do it for between $24.8 and $33.6 Billion per year. I think their estimate of the uninsured we’d have to cover is low: they figure 12 Million; I figured 20.2 Million. If I use my estimate of the number of people to cover with their policy costs I come up with between $42 and $57 Billion per year. Even using the latter numbers that $780 Billion stimulus would have paid for between 13 and 18 years of coverage.

I am *so* going to burn ...

... in Feminist Hell for thinking this is hysterically funny - but it will be worth it.

Through some logical set of steps that I can no longer retrace I found myself reading Dennis the Peasant in the middle of the night last night. As is my wont, I looked back to his September 2008 archives to see what he was saying about Sarah Palin - I find this an interesting way to separate the sheep from the goats, so to speak - and I stumbled upon this post. It’s one in the morning and I'm laughing hysterically and pounding the desk with my fist. Good thing we don’t have downstairs neighbors.

I started laughing with the very first blow of the fisk:

Sentence #1:

What I keep not understanding is how right wingers don’t get this, besides the obvious willful ignorance problem.

18 words. Stating that you "keep not understanding" something seems to suggest that effort is required to prevent understanding of said something. For whatever reason, I'm finding that hard to believe when Amanda's involved. All too often, her not understanding things seems pretty effortless. And for the record, just who has the "willful ignorance problem"?

By the time I got to the dead Republicans I was falling off my (not so imaginary) chair.

Even better I searched DtP’s site and he has more Amanda Marcotte posts. I can’t decide if I should read them all in one orgy of hystericalness, ration myself to one a day, or save them for times when it’s all just too much for me.

Without further ado, the link. Okay, a little further ado. There is some language in here and, as the movie ratings say, simulated sexual activity:

This Week’s Amanda Sentence

I just wish I could remember how I found DtP so I could express my undying gratitude to the director.


In her wonderful I Hate To Cook Book, Peg Bracken gives a recipe for Beetniks:

Should you happen to fish the final sweet pickle out of the juice in a pickle jar and, at the same instant, notice a can of baby beets on the pantry shelf (admittedly an unlikely chain of events), you can put the beets into the pickle juice, put the lid back on, and the next morning they will be pickled.

This is a pretty fair description of how I write most of my blog posts - and explains why I’m having such a tough time with the next entry in my Death Panels series: too many pickle jars, too many cans of baby beets.

Tuesday, August 25, 2009


In a post (and comments) that stunned me by revealing how much contempt she has for people like, well, me, Reclusive Leftist cited Rick Perlstein’s essay, “In America, Crazy Is a Preexisting Condition” as the best way to understand the town hall protests. This essay, RL says, “recaps the last 50 years of rightwing panic.” Later RL states that “rightwing agitators are awash in propaganda and madness.”

Perlstein’s essay is a round-up of all the crazy things figures on the Right have said and done over the last 50 years (more really) because - he says - understanding American means realizing that “the crazy tree blooms in every moment of liberal ascendancy.” I’m quite willing to concede that people on the Right - both famous and nameless - have exhibited some serious signs of insanity over time. But so have people on the Left. MSNBC is the most glaring example but at least you can argue they’re using lunacy as a selling point. Red meat for their audience and more akin to the WWF than to serious politics. (The same claim is sometimes made for Rush Limbaugh - he’s an entertainer not the voice of conservatism.)

For a far more serious example of total lunacy on the Left try this article posted at Corrente (part of RL’s blogroll) in December of 2007. This is a serious and very interesting examination of Obama’s post-partisan message during the campaign but suddenly we find the lines:

More importantly, we've given some idea, in the short history above, of how powerful, and how entrenched, the Conservative Movement has become in official Washington (the Village).*** If an election is held in 2008, and if an Democrat is elected, and is allowed to take office, and that Democrat is Obama, the Conservative Movement, and its billionaire funders, are not going to change their playbook.

If an election is held? If an elected Democrat is allowed to take office? Really? This bastion of the reality-based seriously doubted we’d elect a new President in 2008 and yet Leftists expect me to believe all the crazies are on the Right? They must be nuts. Worrying that “the Conservative Movement” was going to hijack the election process is a lot more insane - a lot more insane - than senior citizens and the handicapped worrying that cutting costs in Medicare is going to mean they get less care.

Neither side has a monopoly on crazy. The only people who are really crazy are the ones who don’t know that.

Monday, August 24, 2009

Pick your poison

I’ve run across Uwe Reinhardt’s name in the course of reading about health care/insurance reform but I don’t think I’ve ever knowingly read any of his writing. Now that I have I strongly recommend his New York Times blog entry: “A ‘Common Sense’ American Health Reform Plan”. When I first read it, I thought is was an excellent argument for as much free-market in health care as we can stomach. The list he sarcastically refers to as:

a short list of the design parameters that an acceptable health reform proposal would have to incorporate to conform with the American public’s idea of “common sense” in health care

clearly seemed to be a natural result of separating the entity paying for health care (government and insurance companies) from the entities providing and receiving that care (doctors, etc., on one side, patients on the other). However, buried in the article is a link (pdf) to a letter Reinhardt wrote in January of 2008. This was a cover letter transmitting to the Governor of New Jersey the Final Report of the New Jersey Commission on Rationalizing Health Care Resources. Once I read that letter I realized the situation is not quite as simple as I thought. It’s not that we’ve separated the payer from the supplier and recipient; it’s that while we have not whole-heartedly rejected that separation neither have we whole-heartedly embraced it. As Reinhardt so clearly describes, we exist in a half-private, half-government system: we have done our best to construct an edifice that takes the benefits from both approaches while taking the costs from neither.

In his letter, Reinhardt identifies four areas in which Americans suffer from “cognitive dissonance” when it comes to health care. I summarize them here but you really have to read Reinhardt to get the full complexity.

1) Distributive Social Ethics: Is health care a social good or a private consumer good?

2) Market vs Regulation:

These mutually inconsistent positions – an instinctive distrust of government and faith in the superiority of private markets but an unwillingness to accept the harsh verdicts of the market – have led nationwide into a bewildering system of “halfhearted competition and half-hearted regulation” for health care,to use a phrase coined by Brandeis economist Stuart Altman.

3) Rationing Health Care: Americans refuse to deny any care to the insured but don’t see the costs involved in doing so as rationing care to the uninsured.

4) Health Insurance itself:
a) Americans reject the idea of requiring individuals to purchase even catastrophic health insurance but also reject the idea that the uninsured should not get medical treatment, apparently not realizing that this imposes an unfunded mandate on hospitals and caregivers.
b) Requiring community rating from health insurance companies without imposing a mandate for health insurance converts private insurers into “quasi-agencies of government, albeit predictably dysfunctional ones.”
c) By rejecting government insurance in favor of employment-linked insurance Americans have chosen to put themselves at constant risk of losing that insurance:

When will it dawn on the American voter that,in an age of fierce global competition and ever novel disruptive technology,any individual American corporation is a fragile institution and, at best, a highly unreliable source of health insurance, especially during retirement?

In summing up this cognitive dissonance, Reinhardt says:

In short, Governor Corzine, in my professional view, the extraordinarily expensive, often excellent and just as often dysfunctional, confused and confusing American health system is a faithful reflection of the minds and souls making up America’s body politic. ... Alas,no Commission can provide a complete blueprint for a truly rational health system for this State – or for any state in the nation – until the citizens of this country reach a politically dominant consensus on a more logically consistent set of preferences for their health system, starting with a consensus on the distributive social ethic that should govern the system. Until that happens, any attempt at “health reform” will always degenerate into mere tinkering at the margin, which means that for the foreseeable future Americans will have to muddle through with the kind of health system we now have.

I think Reinhardt’s letter is an excellent explanation of why our health care system looks like it does. I believe, based on some of what he says in this letter, that Reinhardt thinks we would do better to fully embrace government funding and control of health care. This belief is somewhat reinforced by a later article of Reinhardt’s, called “Lost in the Shuffle.” In that, for example, he seems (although not unambiguously) to be in favor of “reforming the market for small- or non-group health insurance” via a combination of regulation and subsidy:

If (1) either private or public health insurers must accept all comers and may not base premiums on the applicant’s health status, then (2) individuals must be mandated to purchase at least a basic package of health insurance, lest they freeload on the system. Such a mandate, in turn, requires that (3) families be publicly subsidized to make the cost of that basic package affordable to them. A sound reform of the health insurance market cannot have just two of these features. It must have all three.

However, the summary in Reinhardt’s letter clearly recognizes the possibility that the “politically dominant consensus” reached by the citizens could just as well totally reject any government involvement beyond the most minimal regulation and result in a truly free-market system. Again his openness to this possibility is reflected in his “Lost in the Shuffle” article:

On the means to reach the goals there is, alas, still wide disagreement among politicians and the policy experts who advise them. These disagreements are rooted only partly in ideology. They also reflect different and sincerely held perceptions about how competition in the health care sector works, how individuals choose health insurance and health care and how physicians choose clinical responses to given illnesses.

My guess is that Reinhardt would prefer that the United States accept health care as a social good and take the steps that follow from that but at the same time I imagine he believes either a full acceptance of the government or a full acceptance of the free-market would work better than the hybrid we have now.

If so, he’s probably right. On the other hand, there is something to be said for stumbling along with what just grew. Democracy, after all, is an inherently messy business not susceptible to “rational” decision-making, technocratic solutions, or imposed outcomes. If F. Scott Fitzgerald is right that:

The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.

then the current US health care system is brilliant. When you think about it that way, “tinkering at the margins” - for example, by insuring the uninsured - doesn’t sound like such a bad thing.

Assuming, of course, that we’re willing to pay the bill - and understand clearly that one way or the other we will eventually have to pay it with our own money.



You can access Reinhardt’s letter as well as the Commission’s Final Report here.

I got to Reinhardt’s “Common Sense” article via his later “Lost in the Shuffle” article. I got to that via Mickey Kaus - who seems to think well of it - and to Kaus via JustOneMinute - who has a serious issue with it.

Crossing state lines

I’m not saying the argument for selling insurance across State lines is totally without merit but I am saying this Wall Street Journal piece doesn’t do much to convince me. For example:

Affordability would improve if consumers could escape states where each policy is loaded with mandates. "If consumers do not want expensive 'Cadillac' health plans that pay for acupuncture, fertility treatments or hairpieces, they could buy from insurers in a state that does not mandate such benefits," Mr. Herrick has written.

There are so many problems with this I don’t know where to start. How about with “if consumers could escape states”? Well, they can. If you don’t like the mandates in your State, either elect State representatives who will change them or move to a State that doesn’t mandate anything. This is what Federalism is supposed to be about: citizens of a State deciding for themselves how they want to be governed. If the citizens of my State of New Jersey have decided they want to force insurance companies to pay for everything from soup to nuts, that’s their decision. How any conservative can advocate negating their decision by riding roughshod over State law is beyond me.

In fact, let’s all sort ourselves out this way. I wonder how many bloggers who are vociferously in favor of more Federal government involvement in health care are liberals living in States where health insurance companies are lightly regulated. Living in New Jersey, I view many of their arguments with amazement. The situations they describe simply don’t exist in New Jersey where insurance is regulated and mandated within an inch of its life. I’ve never had a treatment so much as questioned much less not paid for and I’ve had some whopping big treatments. So maybe people who hate State insurance mandates should move to States without them and people who love government intervention in health care should all move to New Jersey.

Returning to the WSG article. The argument lumps together one extremely iffy quasi-medical treatment - acupuncture; one genuine but not widely needed medical treatment - fertility treatments; and one cosmetic treatment - hairpieces. But wait. Are there really insurance plans that pay for hairpieces as in what some bald guy wants to buy when he turns 50? Maybe. But I think it’s a heck of a lot more likely that the “hairpieces” Mr. Herrick is so concerned about are actually “prosthetics” purchased for chemotherapy patients who have lost their hair.

It is entirely possible that some States mandate treatments many people are not interested in. But they also mandate that insurance cover items like a certain length of hospital stay after a mastectomy. (Remember “drive-by mastectomies”?) Or allow a mother to stay in the hospital for a certain length of time after a Caesarian section. It may be that you think those are needless luxuries; you’re not one of the people who are horrified by HMO’s relentless focus on the bottom line regardless of what “amenities” they have to throw overboard. Let's think this through.

Say you're fine with the insurance companies escaping all types of State mandates, even the ones that seem like decent ideas. You figure that if people don’t want drive-by mastectomies they can ante up for more coverage. Uh-huh. How long do you think it will be before all the mandates imposed by a very liberal State like New Jersey simply get imposed at the Federal level? Interest groups pressure the government entity with the power. Sell insurance across State lines - especially while we have a Democratic President and Congress - and you’ll find every insurance company in the country required to pay for acupuncture, fertility treatments and hairpieces.

And if by some miracle those Federal mandates don’t happen then we’ve got other problems. The WSJ article says:

This doesn't mean sick people who have kept up their coverage but are more difficult to insure would be left out. Congressman Shadegg advocates government funding for high-risk pools, noting that their numbers are tiny. The big benefit would come from a market supply of affordable insurance.

So after all the hysteria about euthanizing grandma we’re now going to entrust sick people to the government’s tender mercies. I try to imagine a place where the country can find more health care savings than it could by rationing care to those who need it most and I can’t really think of one. Imagine if the government was deciding on treatments for cancer patients, for those with multiple sclerosis or ALS; for those with chronic heart disease; for children born with cystic fibrosis or Down syndrome. And how tiny are their numbers after all? What happened to all the blather about how much chronic illness costs us every year?

But let’s leave aside that problem and assume we are in fact talking about only a tiny group and who cares if the government does them in - think of the money we’ll save! That tiny group is the least of our worries. How about incredibly Balkanized health insurance plans? Like, say, an interstate health insurance plan that covers only healthy single young men between the ages of 18 and 35. Oh, it won’t say that in the plan description. It just won't pay for birth control or yearly gyn exams; won’t pay for Viagra or cardiac care; won’t pay for ulcers or migraines; won’t pay for any childhood illnesses or checkups or vaccinations; won’t pay for much of anything except broken bones from snowboard accidents. Heck, the insurance companies could charge a dollar a year for that kind of policy and make money.

Of course once those 18-35 year old men get “too old” or have children or experience a serious illness, they’ll be shuffled along to another, more expensive policy. Because, you see, the market that isn’t healthy 18-35 year old men will be sliced and diced into smaller and smaller segments with the cheap coverage separated from the not so cheap, the somewhat expensive separated from the really expensive. Which pretty much disposes of this next argument:

Mr. Rother also said "risk selection" is a problem. But the coverage mandates cause that. As more healthy people opt out of health insurance because it is too expensive relative to what they consume, the pool transforms into a group of older, sicker people. Prices go higher still and more healthy people flee. High-mandate states are in what experts call an "adverse selection death spiral."

He’s right about that spiral but he’s wrong if he thinks selling health insurance across State lines is going to magically unwind it. It’s simply going to move the problem. Yes, the healthy 18-35 year old men might - I emphasize might - buy a health insurance policy if it’s dirt cheap. But the other little segments that insurance companies chop their customers into are going to opt out in droves because their policies are going to be full of people just like them: each successive segment defined by the need for more coverage because of age, existence of children, and illness; each successive segment increasingly expensive. This is fair in some absolute market sense but it’s not going to solve the problem of the uninsured. And it will eventually mean more and more people end up in that government funded high-risk pool because they simply cannot afford the insurance plans offered for their age, life-stage, and illness cohort.

Besides if you really want healthy people to leaven your insurance pool then force everyone to buy insurance. That will take care of the opt-out problem. Of course, a mandate like that may well be unConstitutional but we’ve already established that’s not a deal-breaker for this crew.

Sunday, August 23, 2009

It's an ill wind that blows nobody good

I haven’t said anything here about the Whole Foods boycott because it seems so dumb to me. Here’s a company that as far as I can tell is a great place to work and people on the Left are going to stop shopping there because the CEO wrote an op-ed they don’t like. A successful boycott would seem to condemn the employees to unemployment - or at best a job at a grocery chain that almost certainly won’t be as decent to them.

Furthermore, all the Whole Foods’ social conscience stuff - fair trade, organic, local - that Leftists thought was so great hasn’t suddenly disappeared just because the CEO is - OMG - a libertarian. News flash: it took me less than 60 seconds to find a 2005 article in which Mackey is described as “an ardent libertarian”* so it’s not like you wouldn’t already have known about this if you really cared. Before it was, like, you know, fashionable to care.

So now the Left is going to shop at, what, Wal-Mart because even though - according to the liberal party line - they treat their employees like dirt and import poisonous junk from China, their CEO hasn’t written an editorial opposing Obamacare. Oh, yeah, that makes sense.

As dumb as this boycott is, it has had some redeeming social value: Anglachel has come out of retirement - I hope permanently - to blog about it. I disagree with her about almost everything political but she has an incredible ability to cut to the heart of the matter. For the ritual evisceration, read “Whole Foods Nation Betrayed”. For the serious political stuff, read “What do you want?”

Thank goodness for Whole Foods boycotters.


*And read the article if you’re one of the people who decided as a result of his op-ed that Mackey is a soulless capitalist.

Begala and bipartisanship

One of the recurring characters who popped up when I tried to clean up categories on my blog was Paul Begala. He turned up in two posts with similar themes: A Begala canard and Birth of a lie. Shortly after I noticed this pattern, Begala popped up again on CNN (I think it was) talking about the myth of the reasonable, rational Republican. That seems to be his patter these days; he wrote about it for The Daily Beast:

In the four committees that have passed versions of health-care reform, the Democrats have accepted a total of 183 GOP amendments. But that generosity has yet to earn them a single Republican vote in single committee. Zilch. Zero. Nada. Bupkes.

Like the myth of the unicorn, or Sasquatch, or a humble political pundit, the myth of the reasonable, responsible, rational Republican persists. High-minded media elites and goody-goody Democrats want to believe in it; they need to believe in it, and in the face of all evidence, they persist in that belief.

Perhaps the Republicans are negotiating in bad faith. Perhaps not. But in thinking about bad faith, it’s instructive to look at this Slate article by John Dickerson. Written in mid-July and entitled “Obama’s partisan attempt to change the meaning of bipartisanship”, it’s worth reading for its overall review of the Administration’s attempt to redefine “bipartisan” to mean something other then “at least a few people from the other party voted for it”. What I found most interesting, though, was this paragraph:

In The Audacity of Hope, then-Sen. Obama wrote: "The majority party can begin every negotiation by asking for 100 percent of what it wants, go on to concede 10 percent, and then accuse any member of the minority party who fails to support the 'compromise' of being 'obstructionist.' For the minority party in such circumstances, 'bipartisanship' comes to mean getting chronically steamrolled, although individual senators may enjoy certain political rewards by consistently going along with the majority and hence gaining a reputation for being 'moderate' or 'centrist.' "

I haven’t read the book so I can’t speak as to context but that quote does put a whole new spin on what the Administration means when it insists Democrats are honestly seeking a bipartisan bill but the Republicans are being “obstructionist”.

A remarkable resemblance

[This is the second post in my series on “death panels”. The first post is here and contains definitions important to understanding the later posts. All posts in this series are categorized under “Death Panels”.]

While wandering through the landscape of the health care blogosphere, I stumbled upon this remarkably calm, remarkably intelligent article in the Washington Post. Danielle Allen’s “Opponents Are Prejudging Health Reform’s Side Effects” explains why worries about “death panels” and rationing cannot be assuaged by quoting chapter and verse of the legislation. Do read the whole thing but I was particularly struck by these two lines about the thinking of those who oppose Obamacare:

The issue, rather, is that they recognize that the stated goals and structure of a policy may not fully capture its full range of outcomes in practice. [snip]

In asking lawmakers to consider not merely the goals of their policies but also the experiential meaning of concrete realities that those policies may bring, they have a point.

This is remarkably similar to the reasoning behind Comparative Effectivness Research:

An important component of CER is the concept of Pragmatic Trials. These clinical research trials measure effectiveness—the benefit the treatment produces in routine clinical practice. This is different than many regularly clinical trials, which measure efficacy, whether the treatment works or not.

In other words those who are concerned about rationing and “death panels” are focused on what the real-world outcomes of Obamacare will be just as those who support Comparative Effectiveness Research are focused on what the real-world outcomes of medical treatments are. It is hard to understand why the idea that what happens in the real world isn’t always what we intended is so valid a concern in medicine but so ludicrous a concern in politics. If anything, we should expect there to be far, far less discrepancy between the predicted and actual outcomes in medicine than in politics.