The Answer Guy Online

Providing information to unwitting victims on a "don't-need-to-know" basis since 1974.

Saturday, June 26, 2004

Girl, You Have No Faith In Medicine

I sat on this post for months and months, partly because small pieces of it were cribbed from ideas found on comment threads to blogs I was reading a lot back then (no time these days) and I couldn’t possibly attribute them properly, partly because I was never happy with its overall tone, and partly because while still tinkering with this post (but well after I had essentially the entire thing written) I worked on a case involving the health insurance industry. There’s obviously nothing in here that reflects confidential information, but I figured I would inform readers that my opinions on this topic were the same before, during, and after this work.

As if I needed further confirmation that something is awry about the way we deal with health care in this nation, one of my close friends has recently had a bout with a brain tumor, and may or may not be on the hook for an astronomical bill.

When it comes to health insurance, yes, I’m unfashionably socialist.

For starters, I’ve always thought that the idea of basing insurance coverage around employment was inherently silly, especially in a 21st Century where everyone is constantly changing jobs. Furthermore, it strikes me as a kind of tax on job creation and accelerates the idea of a “permanent temporary work force” that hasn’t a clue where it’s next paycheck might be coming from. And of course more and more employers, if they can get away with it, aren’t providing health coverage at all.

But I think the problem is bigger than that.

The original social purpose of insurance – any kind of insurance - was to spread risks across the general population. Those who sold insurance generally made a profit doing so, since rates were presumably set in such a way as to recoup costs, plus opportunity costs.

Somewhere along the line, it occurred to someone that while one could make a profit spreading risk, one could make even more profit by appearing to spread risk while in fact avoiding risk. The more knowledge one gained of potential risks, the greater the opportunity of an insurer to avoid risks themselves. Actuarial science is by and large based on risk avoidance.

This fact reflects a system that is not so much immoral as it is amoral. Insurance companies do not exist to make the world a better place – they exist to make money, and if the investment dollars of those who own insurance firms could make more money doing something else, they would.

Now when it comes to, say, auto insurance, I’m not going to lose much sleep over this. If your record as a driver is bad enough that you can’t afford insurance, society is arguably better off if you’re forced to take the bus.

Health insurance is a different matter.

Despite efforts by well-funded think tanks to pontificate otherwise, some things are not commodifiable. Health is not a commodity, mostly because it is not, strictly speaking, excludable. If your city or town has people that for whatever reason leave their diseases untreated, you could get them too. Virsues, bacteria, and protozoa do not truly know geographic or economic boundaries, particularly as our globe grows smaller by the hour.

We have found - for better and for worse - risk factors for the health of many of our citizens. For some people, health care is so expensive that no rational profit maximizer would ever insure them. We can argue over whether at least some of those people brought such conditions upon themselves, but once you start down that path, it’s difficult to stop. Furthermore, the fact is that there are plenty of people who are in such a position through no fault of their own. Think babies born with severe birth defects, or the children of Love Canal. Consider people with MS or some other degenerative disease.

For those in expensive groups to get "coverage," either an insurance company has to charge a prohibitively high premium or someone has to lump them in with lower cost people. The simple fact is, for these people risk pooling is the only reasonable solution, unless we’re going to have them go without coverage.

Now there are and have been societies that make their own cost-benefit analysis and conclude that they are better off cutting simply some people loose entirely, for the presumptive good of society. None of them, however, is anywhere near the most affluent society the earth has ever known.

And another thing – scientific knowledge about the human genome is getting more sophisticated every year. Imagine what the insurance companies will do when and if they get that kind of power to avoid risk. Imagine how many more people will be left out in the cold, due completely to the DNA with which they were born. It is still the stuff of nightmarish science fiction – today.

Well, what about a halfway measure, you ask?

A mixture of markets and a public sector risk pool won’t work either. What is a market actor going to do? If the market actor has the ability and know-how to do so, the actor is going to cherry pick - to serve only the low-risk and high-profit people. And since the insurance industry will only get better at risk avoidance with time, their cherry picking will become ever more exact. Which is going to leave the public sector with only the high-risk population. Which in turn will leave us with the same situation we find ourselves in at the present time.

Medicare, which generally services people that the insurance industry would consider high-cost, has been able to succeed - to a point - for three reasons.
1. It’s been able to take advantage of group purchasing in bulk, the same principle that allows Costco to charge lower prices to its customers who by large quantities of stuff.
2. It has a politically powerful seniors’ lobby behind it, which makes it difficult for government to walk away from providing Medicare even if it were so inclined.
3. The care it has provided has not generally been quite what the private sector can furnish to those willing to pay for it themselves.

Contrast this with Medicaid. Its constituency is often not only generally high cost but politically disenfranchised. It’s always targeted for deep cuts, and providers are frequently abandoning the program.

And for the rest of us, including many poor people who are too “rich” to qualify for Medicaid, there’s generally no system at all.

Eventually even Medicare becomes problematic. Ironically, it is the most cost-efficiently managed health program in this country, giving the lie to the claims that the government would destroy healthcare if allowed.

The ironic thing about it is that the costs aren’t likely to go up much, if at all. We do give out free health care, as it happens – in the emergency room, by which time the uninsured patient’s condition has likely degenerated to the point where he or she requires much more expense than if whatever condition he or she might have had were detected earlier. So the uninsured patient gets the bill, often for an astronomical sum of money, which the hospital generally has to eat. Meanwhile, the patient is walking around with a debt he or she could never hope to pay, which has other social costs.

Simply put, the market will fail to provide for our common health, just like a market would fail to provide for our common defense. A unified system can be reasonably efficient, equitable, and humane.

I’m not sure what this makes me in today’s political landscape and marketplace. A relic of a time when we all felt as if we were in the same boat, perhaps.

Would there be sacrifices? Of course – no decision is without sacrifice. (Although they are not as great as some may at first think.) But seriously, perhaps the nation that spends the most in the world on its health care while having by many metrics the unhealthiest population in the industrialized world ought to be doing something different with health care.

Friday, June 25, 2004

A Frank Exchange Of Views (a.k.a. "Go Fuck Yourself")

I have a secret admiration for PR flacks who can craft nice euphemistic phrases like the one above to describe Dick Cheney's Senate floor outburst at Sen. Patrick Leahy yesterday.

In all honesty, profanity has never bothered me all that much - I imagine I have a higher tolerance for it than most people. Not that I think it should be coming from the halls of Capitol Hill or anything, but my mood is not one of righteous indignation.

As fun as it is to mock an administration that claimed that they were going to "restore honor and dignity to the White House" and "change the tone in Washington" for disproving once again that "the adults are in charge," this is nowhere near the thing Cheney and Bush has done that most deserves negative publicity.

It's not even worse than calling a reporter a "major league asshole" for telling the truth about your record.

It might be worse than replying "Big Time" though.

Just for the record, no, I do not think that this was staged as a rationale for replacing Cheney with someone else as Bush's running mate. Presumably, if they were going to do it, it would be better from their standpoint if it didn't look like they were doing it mostly because they thought Cheney was a political liability.

UPDATE: Apparently, Cheney feels no remorse for his indiscreet use of language, as eviedenced by this article, amusingly titled "Cheney Felt Better After F-Bomb." Cheney strikes me as the sort who'd feel better after dropping a bomb of any variety, verbal or otherwise.

Wednesday, June 23, 2004

Media Play

I had no interest in purchasing Bill Clinton's new book. I tend to avoid memoirs by still active politicians, since, even if they were written by the person, they tend to be boring affairs that don't produce much in the way of genuine revelations. Words are calculated, carefully chosen so as to preserve the political viability of the author.

However, via Atrios comes this intriguing passage:

I was genuinely confused by the mainstream press coverage of Whitewater...One day, after one of our budget meetings in October, I asked Senator Alan Simpson of Wyoming to stay a moment to talk. Simpson was a conservative Republican, but we had a pretty good relationship because of the friendship we had in common with his governor, Mike Sullivan. I asked Alan if he thought Hillary and I had done anything wrong in Whitewater. 'Of course not,' he said. 'That's not what this is about. This is about making the public think you did something wrong. Anybody who looked at the evidence would see that you didn't.' Simpson laughed at how willing the 'elitist' press was to swallow anything negative about small, rural places like Wyoming or Arkansas and made an interesting observation: 'You know, before you were elected, we Republicans believed the press was liberal. Now we have a more sophisticated view. They are liberal in a way. Most of them voted for you, but they think more like your right-wing critics do, and that's much more important.' When I asked him to explain, he said, 'Democrats like you and Sullivan get into government to help people. The right-wing extremists don't think government can do much to improve on human nature, but they like power. So does the press. And since you're President, they both get power the same way, by hurting you.' I appreciated Simpson's candor and I thought about what he said for months. For a long time, whenever I was angry about the Whitewater press coverage I would tell people about Simpson's analysis. When I finally just accepted his insight as accurate, it was liberating, and it cleared my head for the fight.

Did Alan Simpson really say this? I don't know, and, from my perspective, I'm not sure how much I care if Alan Simpson really said this. It's as good an explanation of why the allegedly liberal media doesn't act liberal - even before you consider their corporate ownership and the biases inherent in such ownership - and why reporters were so nasty to Clinton even though most of them probably voted for him.

Tuesday, June 22, 2004

Running To Stand Still

Great post here from Crooked Timber about what's wrong with this economic recovery as compared to previous ones.

The downside to the flood of articles touting how "productive" American workers have become is the fact that Americans are working more and more, harder and harder, with longer and longer hours, for less money, or at least less in terms of real purchasing power.

It's as if the worker is on a treadmill that's being turned up.

This problem is even worse if the increased price of certain commodities - oil in particular - leads to across-the-board price inflation not accompanied by wage inflation. The price inflation could exert upward pressure on interest rates, which would put the squeeze on many who are already mortgaged to the hilt.

It's not especially strange from an economic standpoint that an employer would attempt to pawn more risk on their employees (in the form of fewer job guarantees, benefits such as pension and health coverage.) What is strange, in my view, is that those who lead the public sector are advocating exacerbating the problem of pushing off more risk on those least able to afford it. They advocate shifting tax burdens towards employees and away from employers and holders of wealth. They push for eroding worker protections and shredding social safety protections.

Though there are not by any means masses starving in the streets, there are almost certainly more people who are one accident, one illness, one bad day from being in truly dire straits.

How will workers exposed to ever more risk respond to all this being dumped into their lap, when it becomes to difficult to ignore? There are a number of possible answers to this quandry, and none of the answers paints an optimistic picture of our nation's future.

Wednesday, June 16, 2004

Counting Chickens

Bush declares victory over terrorists in Afghanistan.

This statement probably comes as news to most people in Afghanistan outside of Kabul, in lands controlled by various warlords with shifting loyalties and various Islamist groups ready to strike.

The question that's on everyone's mind is whether Bush wore a flight suit to make such a delcaration.

Tuesday, June 15, 2004

Un-American Sentiment #1

Some people have too much freakin' money.

Monday, June 14, 2004

This Mortal Coil

If you're anything like me, dear readers, when you see a headline like "Death Plunge Over Rotten Dumplings," you just have to look at it.

Turns out the article is about the head of a food manufacturing company in Korea who committed suicide by jumping off a bridge after it was discovered that his company and several others were using rotten ingredients in their dumplings. (I guessed before looking that the article was about Japan; turns out I was off a little.)

I don't want to sound like I'm in favor of suicide, but can you imagine an American CEO doing something like this, no matter what his or her company did?

Instead he would find someone, anyone, else to blame. Maybe he'd pay some token, slap-on-the-wrist fine, and if it was bad enough, cool his heels for a few months in a Club Fed. Someone else would have to clean up after the mess, preferrably the taxpayer. (Ever notice how in this country, even more than others, we privatize success and socialize failure?)

We don't really know what this person's motivations were, but I think we might be a lot better off as a society if the head of a company who did something like this didn't want to show his face in town anymore. Not because I like the idea of CEOs offing themselves in dramatic fashion, mind you, but because I'd rather see less business malfeasance in the first place.

Friday, June 11, 2004

In And Around The Lake...

Had to pass this one on.

Apparently, a man-made 23-acre lake in the St. Louis area disappeared virtually overnight, likely caused by a sinkhole that resulted from a crack in some surrounding limestone.

I've heard of eutrophication causing many a small pond in New England to become a swamp or even a meadow. (One main culprit is nutrients flowing into the ponds from fertilizers or phosphate-contatining detergents feeding aquatic plant life that clutters up the water.) But I can't recall hearing about something like this...

Thursday, June 10, 2004

Rest In Peace

Music legend Ray Charles has passed away at age 73.

His records were played often in the house where I grew up, even though my parents were a full generation younger than Charles himself. He wrote many fine songs, but made a number of songs from sources as disparate as blues, country, gospel, and Tin Pan Alley eternally his. Any list of classic Charles tunes would seem incomplete, except that I will note that his rendition of "America the Beautiful" is the most beautiful rendering of any patriotic song I have ever heard, due both to its uniquely American rhythm and complete lack of the bombast and pomposity that mar nearly all national songs.

My grandfather, who unfortunately had some tendency to harbor less-than-fully-enlightened attitudes regarding race relations, was especially touched by his music. I have some truly fond memories of spending an afternoon transferring all of my grandfather's old Ray Charles records to casette tapes so that he could listen to them in the car. Charles' inspired piano playing and distinctive voice could always cut through the hissing of even the scratchiest, most worn vinyl and speak directly to the heart.

His death will be mourned by music lovers everywhere, and he and his voice and his spirit will be missed.

No Scrubs?

It's widely assumed that if you're poor and/or out of work, the opposite sex (particularly if you're a guy) wants nothing to do with you.

If there's any validity to this story, that assumption may not be true. Turns out that the unemployed have no less sex (and with more partners to boot) than the rest of us, and that sexual activity does not correlate with income.

Now there are some confounding factors here, the first one that comes to mind being that I would guess that people classified as "unemployed" are probably on average younger and less likely to be married than the general population.

Nevertheless, good news for those of you down on your luck, I guess.

Monday, June 07, 2004

Funeral For A Non-Friend

Former President Ronald Reagan passed away Saturday afternoon. I've avoided reading what I'm sure are lavish and maudlin tributes to Reagan and his legacy in various newspapers.

And I'm left with the quandry of what to say when some public figure that one has a deep aversion to passes away.

I'd refrain from speaking ill of the dead, since a dead man can't defend himself... except that this dead man already has a legion of hagiographers and other various admirers, producing one encomium to Reagan and his record after another. Which is perfectly fine, except I wish they would stop trying to put Reagan's name on anything and everything they can think of; they couldn't even wait until his heart stopped beating to push for all these namings and renamings.

There's an aircraft carrier named for Reagan. He also has a Presidential Library, and a freeway that runs near it in Simi Valley, California, is also named for him. The Ronald Reagan Building and International Trade Center downtown is notable for being loud, garish, and grossly overbudget (how's that for a perfect metaphor for his presidency.) I have no particular quarrel with any of these.

I wish they'd have left our local airport - and the Metro station that serves it - alone. And now they're coming for the dime. And, supposedly, Mount Rushmore. I don't think I exaggerate much when I wonder if I'll be commuting to the District of Reagan sometime soon.

But I suppose we have a lot to thank him for.

We can thank Reagan - or the people pulling his strings - for a lot of things... massive deficits, dirtier air and water, the demise of the small family farm, the steady decline of the real purchasing power of ordinary working people, the explosion of the homeless population, deliberate neglect of the growing AIDS crisis, an escalation in the War on Drugs that scarred inner cities nationwide, wasteful Pentagon bloat, Islamic terrorist networks, Latin American death squads, Ed Meese, James Watt, Sam Pierce, Justice Scalia, and the notions that trees cause pollution and that ketchup is a vegetable.

His formidable ability to connect with the American people, to get them to believe in themselves, was matched only by an apparent indifference to those who fall on hard times that led to an unraveling of much of the unstated social contract that held America together through the turbulent years of the 20th century.

Who knows how much policy would have been turned over entirely to the plunderers, oligarchs, theocrats, and unreconstructed neo-Confederates that dominate the modern Republican Party if Reagan had not been stuck with a Democratic-run House and a closely divided Senate for eight years?

We may yet find out the answer to that question if things keep trending in this direction.

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