Dual Citizenship

Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place. ~Susan Sontag, Illness as Metaphor, 1977

In this week’s Sift:

  • A Logical Guide to Healthcare Reform. Three factors will shape any healthcare bill: What makes sense, what can be made to sound good, and what lobbyists are willing to pay money for. A public option makes sense — but will that be enough?
  • Que Sera, Sarah. Don’t look at me. I wasn’t expecting her to resign either.
  • Short Notes. New Zealand Air has nothing to hide. Antidisestablishmentarianism in Illinois. The glory days are over at the Washington Post. But the revolution in Iran may not be over for a long time.

A Logical Guide to Healthcare Reform

Almost all the debate about Obama’s healthcare plan centers on three issues:

  • How close will it come to covering everybody?
  • Will there be a public option?
  • How much will it cost?

Let’s take them one-by-one.

Coverage. The Census Bureau has estimated that 47 million Americans lacked health insurance in 2006. That number was trending upward at the time, so it was probably higher than 47 million even before last September when the economy began collapsing. Of course, that isn’t the same 47 million people from one month to the next; Families USA estimated that 86.7 million Americans were uninsured at least temporarily between the beginning of 2007 and the end of 2008.

Even that number doesn’t capture the full extent of the problem, because many people who have some kind of health insurance aren’t insured for their most serious illness, which their insurance company considers a “pre-existing condition”. In March, Time magazine writer Karen Tumulty told the story of her brother Patrick, who had been insured continuously by the same company for six years. When Patrick developed an expensive kidney condition, the company refused to pay. Why? His policy renewed every six months, and at each renewal he was considered a new customer. Since it took his doctors eight months to diagnose his problem, it was already pre-existing by the time his treatment started. Tumulty estimates that 25 million apparently insured Americans would be in a similar position if they happened to get sick.

Of all possible health plans, only single-payer (the government covers everybody) completely solves the problems of uninsurance and under-insurance. But that is off the table, because Congress is afraid that single-payer would turn us into a totalitarian state like Canada.

A second-best approach to coverage is mandate-and-subsidize: The government forces people to buy health insurance, and helps out people who can’t afford it. Massachusetts currently does this; you pay a penalty on your state income tax if you can’t prove you have health insurance. It’s not perfect, but their rate of uninsured people has dropped from 6-10% to about 2.6%. Mandate-and-subsidize, however, is considered too heavy-handed for a federal plan. (After all, the Massachusetts plan is left over from the socialist regime of Governor Mitt Romney.)

So we seem to be stuck with a third-best approach: subsidize and hope people are smart enough to recognize a good deal. Subsidize-and-hope only sort of works: The first Kennedy-Dodd proposal would have left 37 million people uninsured by 2019. And it has been revised because it was too expensive.

Public option. The most heated debate has been about whether there will be a public option. In other words, will the plan only include private health insurance or will one choice be some sort of Medicare-for-everybody? This is the most naked special-interest vs. public-interest issue, so it has the most confusing rhetoric. Your representatives can’t just say: “I’m against a public option because I need money from drug companies and insurance companies to get re-elected” or “I’m counting on making a bundle as a lobbyist after I leave Congress, so I need to keep the corporations happy.” So they need to come up with other explanations.

The basic problem is that a public option would be too good. Medicare

  • has low administrative costs;
  • doesn’t spend any money on advertising, multi-million-dollar executive salaries, or stockholder dividends;
  • is big enough to demand that healthcare providers accept reasonable prices;
  • doesn’t cancel anybody’s policy.

So if Medicare were an option for everybody, everybody might do the smart thing and choose it. And that would be a sneaky, back-door path to a single-payer system, which (as I already pointed out) would end America-as-we-know-it and make us just like the Soviet Union or Australia.

The focus-group-tested code phrase for this possibility is “government takeover of health care”. Missouri Congressman Roy Blunt, head of the Republicans’ Health Care Solutions Group, puts it like this:

If there’s a government competitor, in the very short term, you wind up with no competitors. When voters begin to understand that the government takeover of health care is really the end result of a government competitor in the marketplace, they’re not going to like that.

That’s because voters don’t want the option to pay lower rates for more secure coverage — at least not if it means that health insurance companies won’t have profits they can contribute to the campaigns of congressmen like Roy Blunt or many foot-dragging Democrats.

In his June 23 press conference, President Obama pointed out how nonsensical this rhetoric is:

Why would [a public option] drive private insurers out of business? If private insurers say that the marketplace provides the best quality healthcare, if they tell us that they’re offering a good deal, then why is it that the government — which they say can’t run anything — suddenly is going to drive them out of business? That’s not logical.

Yes, he sounds like Mr. Spock when he talks that way. But he’s right.

Everybody understands that we need to control healthcare costs. Our current system is tremendously wasteful. Already in 2003, we were spending nearly twice as much per person as Canada or France (which is widely believed to have the world’s best healthcare system — see this comparison by the Dallas Morning News or the World Health Organization ratings). A more recent survey didn’t include France, but estimated that we spend $6697 per person each year while Canada spends $3326 — and Canadians on average live more than two years longer than we do. (If only we had their warm, healthy climate.)

Numbers don’t quite match up from one study to the next, because it’s not obvious what to count as “healthcare spending”. (Dental? Eyeglasses? Breast implants?) But just about everybody pegs our total annual cost over $2 trillion. The unimaginable scale of that number creates opportunities for rhetorical sleight-of-hand, because it’s easy to put forward plans that sound convincing and actually would cut costs, but on an insignificant scale.

Malpractice suits, for example, cost billions each year. But that’s actually a trifling part of our healthcare bill. Statistics are hard to lay your hands on for some reason, but Kaiser estimated that there were about 11,500 paid malpractice claims in the United States in 2007, and an average payout of $310,000 in 2006. Blindly multiplying those numbers together gets you an annual cost around $3.5 billion. (I don’t fully trust that calculation, but ten times that number would still be a drop in the bucket.) And on the wider question of “defensive medicine” — unnecessary tests ordered by fearful doctors — the Congressional Budget Office found “no statistically significant difference in per capita health care spending between states with and without limits on malpractice torts.”

Not all costs are equal. Even more important, we need to understand that a lot of very different things get lumped together in that simple word cost. The cost of healthcare is made up of four factors:

  1. The cost of providing the care that people need in the most efficient way.
  2. Inefficiency in providing the care that people need. For example, a late and expensive treatment for a disease that could have been spotted and treated much earlier, or treating something in the emergency room that could have been handled by a general practitioner.
  3. Overtreatment, i.e., providing care that people don’t need and may even be damaged by. Overtesting falls into this category also.
  4. Costs that have nothing to do with treatment: advertising, profit, administration, and so forth.

The best way to cut costs, if you can manage it, is to eliminate 2, 3, and 4, and then do research to come up with even more efficient ways to do 1. The worst way to cut costs is to leave 2, 3, and 4 alone and cut 1 — in other words, you make sick people go without care.

That, in a nutshell, is why I’m a liberal on this issue. If you look at conservative cost-cutting proposals, they inevitably cut 1 and increase 4.

Any proposal that calls for increasing competition in the private sector is a boon to the advertising industry. You know the ad wars between Viagra, Levitra, and Cialis? (If you watch TV at all, I’m sure you do.) Well, imagine if every piece of the medical industry had to establish a brand and compete for individual consumer attention. Do you know the difference between Laboratory Corporation of America and Quest Diagnostic? You would. They’re the duopoly that dominates lab testing. They could advertise like ATT and Verizon.

Liberals and conservatives also have different approaches to decreasing overtreatment, because they have different explanations of how overtreatment happens. In the conservative narrative, overtreatment is your fault: Because insurance is picking up the tab, you go the doctor for every little sniffle.

This is one of those rhetorical sleights-of-hand I talked about. Yes, everybody remembers a time when they took their toddler to the doctor for something that turned out to be nothing. There was an office visit and perhaps an antibiotic, and maybe it cost your insurance company $100. If every single person in America could eliminate one such episode a year, that would save $30 billion annually — which is a round-off error when you’re talking about $2 trillion.

The importance of that Atul Gawande article I linked to a few Sifts ago is that it pointed out the real culprit in overtreatment: the corruption of doctors who are either paid by the procedure or get kickbacks from the testing labs. In short, it’s a capitalist problem, not a socialist problem. Making our system more capitalistic will increase overtreatment, because it will turn doctors into healthcare salesmen.

In the conservative vision, individuals cut costs by being hard negotiators and looking for the best deal. Picture it: A doctor tells you that your daughter will die in a day or two unless he does a liver transplant. And naturally you react the way you would if a mechanic said your car needed a new transmission. You wonder if he’s just trying to make a buck, so you take her to another hospital to make sure, and then you shop around to get the cheapest possible liver transplant. Maybe you even pretend to walk away so that they’ll cut their price.

Is that going to happen? Really?

What about computers? Whenever you challenge the free-market model, somebody is bound to start talking about the computer industry. Yes, they advertise and pay high salaries and make profits, but still competition forces prices down and performance up. Why couldn’t the same thing happen in healthcare?

Now think about the difference between buying a computer and buying health insurance. You and the people you trust are going to buy many computers over the years, and you can start judging them as soon as they come out of the box. Are they fast? Convenient? Reliable? When something goes wrong does the company make it good? Even in the store, the specs are well-defined and meaningful.

Health insurance isn’t like that. Sure, you use your health insurance fairly often. But you don’t really test it. Do you know how well your insurance would perform if you got cancer or some expensive long-term condition like ALS? Or just some mysterious pain the doctors couldn’t quite diagnose? Probably not. That coverage is what you’re really paying for, why you really need insurance, and you have no idea whether you’re getting it or not.

That’s not like a computer at all. Competition in health insurance is not based on performance, because by the time you need performance, it’s too late to change your brand loyalty. (Now you have a pre-existing condition.) So competition is not going to improve performance. It’s just going to improve marketing.

My conclusion. If a single-payer system really is politically impossible (which nobody really knows, because no national leader has ever made a serious case for it) then we have to make sure that we get a real public option, one that isn’t artificially crippled with rules that make it “competitive” with private plans. If that happens, then I expect the public option really will drive the private plans out of business, because a public plan is just a more efficient way to deliver care. If I’m wrong, and the free market really can improve the efficiency of private plans, then so be it.

And I know there will be scary commercials against any plan that includes a mandate, but I think we need to try it. If we’re not willing to let the uninsured suffer and die — and I hope we’re not — then they really are being covered at least to some extent. We need to make that coverage visible rather than hiding it in the inflated costs that the rest of us pay for everything medical. When the true costs of things are visible, we can try to deal with the situation logically.

Isn’t that right, Mr. Spock?

Que Sera, Sarah

There’s still no good explanation for Sarah Palin’s announcement Friday that she’s going to resign as governor of Alaska. What she said in her rambling public statement made no sense even to other conservatives or members of her family, so we’ve been left to read tea leaves. Cenk Uygur takes you through the various possibilities.

The timing is the biggest clue. She made her announcement on a Friday between Michael Jackson’s death and the Fourth of July, so it’s clear she wanted as little coverage as she could get. Also, the absence of stagecraft made the announcement seem hurried. Given time, any good high school journalism student could have written a clearer statement. And the small audience (who look confused in the reaction shots) suggests that she just called a few friends, got a TV crew, set up a podium in her back yard, and went for it. Why so fast?

My best guess: Either she’s getting out in front of a scandal we’ll hear about soon, or her resignation was part of a deal that will keep something secret.

To me, the most puzzling thing about Palin and her fans is their conviction that she was/is persecuted by the media. The working title of a pro-Palin biography is The Persecution of Sarah Palin, for God’s sake.

I hope the book compares Palin’s treatment during the 2008 campaign with that of all the other previously unknown VP candidates whose teen-age daughters turned up pregnant in the middle of a national campaign. Wait — there isn’t anybody else like that, is there? We used to take for granted that a scandal of that magnitude would sink a candidate, but Palin was allowed to ride it out.

From my point of view, Palin has gotten unusually soft treatment. She was never asked any hard questions during the campaign. It just looked that way because she fumbled so many easy questions. I doubt Katie Couric thought she was going in for the kill when she asked what newspapers Palin reads.

When conservative blogs fulminate about satirical articles or images of Palin, the commenters almost always say that if this were done to Obama, no one would stand for it. In truth, worse stuff is done to Obama every day, and he ignores it because (1) he’s got class, and (2) he takes his job seriously, so he’s got no time for this nonsense.

Look at, say, this image. Or this one. Or maybe this or this. I could go on and on. And there are countless videos arguing that Obama is the anti-Christ or satirizing the Obamessiah. Photoshop on, wingnuts. Nobody cares.

BTW, I think this anti-Obama video done to Cake’s song “Comfort Eagle” (“we are building a religion…”) is actually pretty good.

On the other hand, Vanity Fair doesn’t like her very much.

This video of Palin telling Hillary not to “whine” about the media is priceless. And just in case her career really is over, TPM collects their top 10 Palin videos.

Short Notes

New Zealand Air has come up with a novel way to make its safety video interesting: The crew is actually naked; their uniforms are body-painted on. Strategically placed arm rests, safety belts, and life jackets avoid an R rating.

An Illinois minister celebrates Independence Day by writing a newspaper column calling for a Christian Revolutionary War: “We must not relent until our Christian heritage is established again in every aspect of society.” What do you know? A real, live antidisestablishmentarianist.

Truth-teller Dan Froomkin is gone from the Washington Post. More and more the Post opinion pages are becoming a home for neocons in exile: Charles Krauthammer, William Kristol, editor Fred Hiatt, as well as an occasional op-ed by Paul Wolfowitz and various other war criminals. When I looked at the Post ombudsman’s article about Froomkin’s firing, I counted eight approving comments. I added the 557th disapproving one.

I was already thinking I was done with the Post. Commenter mmadd summed it up: “the Post that I loved is gone.” Froomkin was just the last straw; the Watergate glory days have been over for a long time. And then they did this.

The pot continues to boil in Iran, with a major group of clerics declaring the officially re-elected government “illegitimate” and the major presidential contenders continuing to publish reports of election fraud.

Still, no popular nonviolent movement can topple a government that retains both its will to resist and the loyalty of its military. The Shah went down because soldiers and police began tearing off their uniforms and throwing their weapons into the crowd. At Tiananmen Square,
on the other hand, soldiers followed orders and the Chinese government weathered the storm. So far, the Iranian theocracy seems to be weathering the storm.

But it’s way too early to declare a winner, because in Iran these things play out over years. The major anti-Shah demonstrations started in 1977, and his government didn’t fall until 1979.

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  • kim  On July 12, 2009 at 8:24 pm

    On health care, next time someone says that a public option would ruin the insurance industry (so?) I'll say, “the post office didn't prevent private delivery services.”


  • By If Not ObamaCare, What? « The Weekly Sift on June 18, 2012 at 12:39 pm

    […] sound good but are basically empty, like capping malpractice awards. (I’ve explained before why I think this will accomplish very little. Short version: Malpractice awards themselves are a trivial part of the overall healthcare budget, […]

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