The Healing of America and its implications

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T. R. Reid, in his book The Healing of America, notes that Americans pay on average substantially more for health care than other industrialized nations, and focuses on the following factors:

• Health insurance company profit margins
  
• Health insurance company incentives to cheat
• Costs to doctors of dealing with insurance companies
• Doctor debt service
• Doctors' salaries and expected standards of living
• Doctor malpractice insurance

As I've noted elsewhere, in his book he visits doctors in several countries with the same complaint (persistent shoulder pain with limited range of motion), discusses the history of health care funding in each country, describes the general level of health care in each country, and examines at least in passing how each country deals with the problems listed above. These typically include:

• Regulatory requirements on health insurance companies
• Non-profit health insurance companies
• Requirements that health insurance companies cover anyone and everyone, regardless of condition and cannot deny claims
• Government funding of higher education including medical school
• Health care price controls
• Government incentives for preventive care
• Government subsidy or funding of malpractice insurance

And while Reid talks a lot about American exceptionalism, holding it up as a straw man, he never deals with (nearly) unique American conditions, namely

• The role, effectiveness, and cost of American medical testing
• The cost of providing any publicly funded service in a large, sparsely-populated country (the cost of transportation and transportation infrastructure in countries like Australia, Canada, and Russia)
• The cost of other American federal government priorities, including foreign aid, military spending, etc.

He deals with the weaknesses of each of the countries he holds up as offering better care than the United States:

• France is continually renegotiating and restructuring how it pays for health care
• The UK simply doesn't offer some life-saving procedures
• Canada offers poor access to specialists
• Japan pays for lots of high-quality health care for an aging population by squeezing doctors to the point that a certain amount of unofficial payment in the form of a tip or bribe is customary

And he doesn't project where these different systems will be in ten or twenty years, when undoubtedly one or more will be better off and one or more will be worse off.

Reid presents universal health care as a moral choice and a moral commitment, and once he's done that any further analysis has to be done in terms of values, not data, so when he presents data it's hard to know when he's being fair. He also chooses a mix of metrics for comparing different countries, and a reasonable person might fairly question some of his choices. Certainly infant mortality rate is important, but I have my doubts about any metric that attempts to adjust life expectancy by a quality of life measure, or even life expectancy at sixty: the last of these might be a good way to examine and compare populations, its usefulness as a guideline or a prescriptive measure would be limited.

What I'm saying is this: it would be great to have lots of Americans living to the age of eighty-five or ninety, but I'm not sure it's a proper goal when making health care policy decisions.

Now, finally: what do Reid's metrics suggest about the current health care bill(s)? Reid would probably scream at the prospect of requiring all Americans to buy health insurance without doing something to cap the cost of health insurance (he'd suggest the government take all the profit out of the health insurance industry) and he'd probably suggest that the assumption that the free market will bring down costs a sick joke, since if I understood him correctly most health insurance companies function as local near-monopolies: each, in each of its target markets, has lots of pricing power because it has very little competition. Reid would like the restrictions on denying coverage for pre-existing conditions.

And I would guess he'd say what a lot of liberal and progressive pundits have said: this is a lousy start on a good process of increased regulation of the health insurance industry that doesn't do a thing about the health care (providing) industry.

The problem here, of course, is that the Democrats have paid so much for this bill in publicity and political capital that it will likely cost them seats (and power) in the next Congress, so they will be less able to press on to more ambitious goals like price controls and direct public funding of doctors and hospitals. On the other hand, it's hard to imagine the Republicans completely dismantling whatever system results from the current bills.

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No Impact Man

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Colin Beavan's book No Impact Man still merits a wait list at my local public library, but in the spirit of thrift and conservation I got on the list a couple of months ago and waited my turn.

Beavan came to national attention in 2007 on the strength of a single New York Times article by Penelope Green titled "The Year Without Toilet Paper," and to his credit he' s managed the transition from adequately successful but minor author to blogger, lifestyle experimenter, and finally public figure pretty well.

No Impact Man is Beavan's story of his year-long experiment in personal transformation, devoted to the refinement and reduction of his environmental footprint, including:

• Refusing to eat or drink anything in a take-out container
• Using a mesh bag instead of either paper or plastic grocery bags
  
• Taking stairs instead of elevators, biking instead of taking public transport or taxis
• Eating local food (grown within 250 miles of his Manhattan apartment)
• Turning off the electricity in his apartment
• Using a solar panel to power his laptop
• Composting
• Using cloth instead of disposable diapers
• Canceling or consolidating trips
• Getting involved in local natural resource rehabilitation

He's very committed, involves his wife and toddler daughter, and admits the strain the experiment puts on his marriage. He also discusses the emotional, psychological, and dare I say spiritual foundation of his experiment.

I have to admit that while I found Beavan's experiment interesting, I didn't like him; while he wears his "guilty liberal" credentials on his sleeve, and I appreciated his honesty in that department, I found him self-absorbed, self-indulgent, and on the whole not at all likable.

By and large Beavan doesn't do the math: he often raises questions that have answers if he'd just do the math and doesn't answer them:

• Is it possible for New York City to become a sustainable city?
• Does it make sense to wash a dish rather than use a disposable alternative?
• Which is better (or worse): paper bags or plastic?

He also fails to make helpful distinctions; while he's correct that the no-littering campaigns in the Seventies were funded by industrial concerns and misdirected attention from not creating waste in the first place to disposing of litter, and put the burden on consumers rather than producers, he doesn't distinguish between law-abiding polluters and law-breaking polluters. He never talks about the contributions organized crime has made to pollution in the New York City area, for example. And this is not just a quibble: efforts on the part of individuals are dwarfed by the decisions by corporations and industries, and the vast array of government regulations proposed to fix these problems are useless if the regulations are ineffective.

Beavan also tends to deal in soft generalities: everyone understands that market costs fail to capture ecological externalities, and GDP is a poor measure of aggregate quality of life, but the alternatives he proposes are inadequate. Tax-based approximations to real costs tend to leave a government in possession of a vast pile of money that will need to be reallocated for the benefit of future generations. I have to believe that one of the lessons of Social Security and Indian Trust Management is that the Federal government can't be trusted to manage what is effectively a giant pile of cash. The GDP alternatives Beavan moots (including the Happy Planet Index) are volatile subjective measures that don't actually measure what we'd like them to measure: they don't measure ecological capacity to produce happiness, and happiness itself doesn't really have a cash value. Fundamentally, any fundamental transformation of the way people live has political and economic dimensions, and these don't go away just because real prices are hard to measure and GDP is currently misused and misinterpreted.

Ultimately Beavan is engaged in something like a spiritual exercise, and by discussing his other spiritual practices (meditation, reading various religious texts, etc.) he hints at the fact that he's on some sort of spiritual journal and/or search for meaning through this experiment. Unfortunately his spiritual practice is turned entirely inward: he talks about how his appropriation of elements of various religions fit into his view of himself, help him understand himself, etc. and if anything his preoccupation with himself and his own guilt/satisfaction/whatever undercut the primary message of his experiment: he really is engaging in magical thinking about the connection between the paper plate he doesn't use and a polar bear who may or may not drown, rather than a useful discussion about the meaning of moral commitments and environmental policy. In other words, he doesn't care about the planet or even about his fellow-man; he only wants to feel less guilty or less responsible.

I'm grateful to Beavan for making the connection between his experiment (as a spiritual exercise) and e.g. his reading Buddhist teachers like Pema Chödrön (as a spiritual exercise) or his appropriation of Menominee people as spiritual heroes. When various Christians (and I suppose, various atheists) take exception to environmentalism as a religion they typically cast it in terms appropriate to their model of a religion: Christians see it as idolatry in the form of Gaia worship; atheists undoubtedly see it as latter-day cargo-cult style superstition. But Beavan isn't engaging in religion writ large; he's engaging in spiritual practice writ small.

This narrative is the only thing I can think of that explains how Beavan emerges from his experiment with some new habits and engaged in a new conversation, but he's ultimately unchanged: his false comparison between living in Manhattan and going "back to the land" still makes sense to him; he's ready to jump on a plane and travel to a speaking engagement; he turns back on the electricity rather than moving somewhere with more abundant natural light. He emerges thinking better of himself but not actually a better person.

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New Year's Resolution

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In 2010 I will no longer read articles on the Web that are not available as a single page.

Sadly this is one of the big differences between content from professional and amateur (or do we prefer the term "citizen?") sources: commercially-funded content tends to have a hard word limit per page (or worse, only be available as a one-side-per page slide show) and be decorated (read: "interrupted") by lots of advertising. Apart from a handful of newspapers most commercial content does not offer a single-page view; it even seems that a smaller percentage of content even offers a print view.

There's no reason to do this any more, so far as I can tell: the Web isn't the newsstand, the content doesn't need to fit inside the boundary of a printed page (of any size) any more, and we don't measure content in pages any more. There's absolutely no reason to make me click on more than one link to see an article that only talks about one thing.

So I'm done.

Summary of T. R. Reid at Commonwealth Club

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T. R. Reid is a journalist and author of The Healing of America; here's a summary of his prepared remarks at Commonwealth Club of California (mp3):

Reid went and visited a bunch of countries and looked at how they fund health care.

1. Not every modern country uses a socialist scheme: private health care works in other rich democracies.
2. Not every modern country is single-payer; e.g. Japan has 3000 payers, Germany 220, Switzerland has 70.
3. Not all developed countries do the same things.

Of 190 countries there are four basic models; they can be broken down by asking who is the provider and who is the payer:

1. The Beverage model (UK): taxes are high, but they pay half of the what the U.S. does; government owns hospitals, pays doctors, and pays bills. This is real socialized medicine.
2. The Bismarck model (Germany): premiums are split between employers and employees; private insurance purchased through employer. Private doctors/hospitals/insurance.
3. National Health Insurance model (Canada): private providers; government pays. Premiums are paid to provincial governments (Reid did not deal with the question of whether people opt out). Model for Johnson/Medicare plan. Popular in newly-rich countries. Reid singled this approach out for criticism because Canada has limited numbers of specialists and advanced equipment; "lots of waiting" for non-emergency care. A gatekeeper system.
4. Out of pocket model (much of the world). Patient pays at point of service; for some reason Reid spent a lot of time talking about people paying with potatoes.

All four models are in effect in the United States: the military has the Beverage model, the elderly have the NHI model, many employed people have the Bismarck model, and about forty-million Americans pay out of pocket. This differs from much of the rest of the world: most countries have just one model.

Why do most countries have one model? Reid chose to examine Switzerland:

1. It's simpler and cheaper to administer; Reid says in the U.S. we spend 18-25% of our health care dollars on administrative costs.
2. They have a strong incentive for preventive health care; cited many anecdotes from the UK.
3. It is "fairer" to have everyone have the same access to the same health care at the same cost. Reid ended his remarks here by admitting this is a subjective assessment of a moral question and fundamentally reflects a moral value.

During the Q&A Reid said he expects the US to move to a Canadian model.

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Ken Fisher's Five Signs of Financial Fraud

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Ken Fisher is pushing a book, and put in an appearance at the Commonwealth Club of California recently. His book is about Ponzi schemes generally, and the traits they typically share. Here's his list as best I can summarize it from listening to his appearance at the Commonwealth Club:

1. Combines custody with decision-making; this means that your shares are held in-house and not with an independent third party.
2. Numbers too good to be true/fees to low to pay manager/manager making money by "just trading."
3. Investment strategy opaque, not understandable by laymen, or a trade secret.
4. Markets things that don't matter but contribute prestige; has flashy hobbies; makes a big deal of associations with politicians or celebrities. Makes a big deal of impressive family history or impressive resume. Implies that he's offering you a special person or specially connected.
   
5. Does not answer questions; resistant to due diligence; shuts down/out people who ask questions.

Also, Fisher basically says that there's no difference between a politician and a crook, so beware anyone to takes politicians seriously.

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This Little Light

I've been on unintentional hiatus for more than two months now, but I wanted to do the prairie dog thing for just a moment to mention Christa Brown's new book on abusive ministers:

1. Eileen Flynn comments on her weblog
2. Eileen Flynn's column at the Austin American-Statesman about Brown's book

This is Flynn's coverage of Christa Brown's book This Little Light: Beyond a Baptist Preacher Predator and His Gang.

I haven't read this book, but I will probably pick it up when I can find it at a good price and have the time to read it. There really is no dispassionate discussion about abusive preachers, but I'm hoping that Brown takes a more measured tone in her book than she does at her weblog.

See also the promise of a review here and points beyond.

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