These Nuns Are Bitchin'!

One of the crazier elements of the health care reform debate has been the discussion around abortion. The catholic bishops have opined that unless we specifically prohibit funding for abortions in the bill, they cannot support it. Never mind the help it would provide to millions of poor Americans. And besides - since when do catholic bishops write our legislation? Alas, they apparently do - and so the House healthcare bill included provisions that specifically prohibited abortion coverage on the newly created exchanges. The Senate bill didn't go quite so far; however, it made sure that anyone seeking abortion coverage had to pay out of their own pocket and couldn't get one paid for by Federal funds. This would ensure that the new exchanges abide by the Hyde amendment - which bars such federal funding. (Color me totally confused but doesn't the federal government subsidize abortions with a massive tax subsidy for healthcare coverage for employers, the vast majority of which include abortions in their health care plans?) Anyhow, it was encouraging on some many levels to read this letter from leaders of catholic nuns:

The health care bill that has been passed by the Senate and that will be voted on by the House will expand coverage to over 30 million uninsured Americans. While it is an imperfect measure, it is a crucial next step in realizing health care for all. It will invest in preventative care. It will bar insurers from denying coverage based on pre-existing conditions. It will make crucial investments in community health centers that largely serve poor women and children. And despite false claims to the contrary, the Senate bill will not provide taxpayer funding for elective abortions. It will uphold longstanding conscience protections and it will make historic new investments – $250 million – in support of pregnant women. This is the REAL pro-life stance, and we as Catholics are all for it.

Go Reform Yourself.

Health policy being the most interesting part of my job, I have for some time fantasized about the idea of studying health policy in grad school. Health care is so fascinating! So complex and rich with nuance! So, well, broken!

In the last 12 months as the debate around health reform unfolded in DC, the area has become a painful one. I cringe almost every time the topic comes up - the misrepresentations, the half-truths, the simplifications, the half-baked partisan talking points - so much of it is quite insufferable .. and yet, I rarely miss a chance to read another article, watch another hearing, listen to another pundit on TV opine on the topic. On the one hand I continue to be immensely drawn to the subject, on the other hand, the more I witness the current debate, the more quixotic my interest in health policy seems. Given the frustrating politics of health reform, what good will it do for another person to study health policy, other than to satisfy some intellectual urge?

I guess I gradually came to this conclusion internally, but reading this post by Uwe Reinhardt, a health economist at Princeton, today I am compelled to finally say it out loud: studying this area is a complete waste of time.

The Summit.

What a fun way to spend a day at work! Anyway, just 2 moments to point out now that the transcript is available:

1. In response to the argument that the government should not be regulating minimum insurance standards because .. the government shouldn't be regulating things, period:

THE PRESIDENT: We could set up a system where food was probably cheaper than it is right now if we just eliminated meat inspectors and we eliminated any regulations in terms of how food is distributed and how it's stored. I'll bet in terms of drug prices, we would definitely reduce prescription drug prices if we didn't have a drug administration that makes sure that we test the drugs so that they don't kill us.

But we don't do that. We make some decisions to protect consumers in every aspect of our lives. And we have bipartisan support for doing it, because what we don't want is a situation in which suddenly people think they're getting one thing and they're getting something else -- they're harmed by a product.

2. And a funny moment:

THE PRESIDENT: Let me just make this point, John, because we're not campaigning anymore. The election is over.

SENATOR McCAIN: I'm reminded of that every day.

On a related note, this is a great piece by Ezra Klein about the "philosophical" differences between the two parties that people kept bringing up.

...just as many people discover religion in the face of tragedy, the GOP appears to have discovered philosophy in the face of a Democratic majority.

Truth With An Error Range.

A recent article by Megan McArdle cause a mini storm in the health blogging circles. Moved by the assertion made by Ezra Klein back in the fall that Joe Lieberman was willing to cause the deaths of hundred of thousands of people by threatening to block reform, McArdles goes on to examine the link between mortality and health insurance and after finding various reasons to ignore or disqualify various studies on the issue, she concludes that while there might be some effect, it's hard to tell how big it is and because it's hard to measure exactly how big it is, it's probably too small to matter.

Needless to say, McArdle has been attacked from all sides (actually, mostly from the left) for this article and it's easy to see why. While her article doesn't insist that health insurance is irrelevant and she does say "even if we did agree that insurance rarely confers significant health benefits, that would not necessarily undermine the case for a national health-care program" by launching a pedantic attack on a statistic, she helped to undermine what many would consider a "logical" case for expanding health coverage to everyone.

There are two reasons why I find this whole debate incredibly annoying and offensive.

First of all, by making a reasonable case that the effect of health insurance on mortality are hard to determine precisely she then goes on to argue that we can't say how large it is. If one study says 50, another study says 200, it could probably as well be 0, seems to be the argument. The truly annoying thing about this argument is that from everything McArdle says, she doesn't seem to actually believe that there is no relationship, but she is suggesting that it might be small and either way no one can claim with any certainty what exactly it is.

I guess McArdle deserves credit for correctly identifying a problem with the studies of this sort - they aren't perfect and they aren't precise. However, does it mean they are thus entirely irrelevant? That's what she seems to be suggesting in her concluding paragraph: "we should have had a better handle on the case for expanded coverage—and, more important, the evidence behind it—before we embarked on a year-long debate that divided our house against itself." Translation: why didn't you pro-reform morons get your facts straight before wasting everyone's time with this non sense for a whole year?

Therein lies the insane contradiction of what McArdle is saying: on the one hand, she discredits the assertion that expanding health insurance saves lives by showing how evidence is hard to attain; on the other hand, she says we need better evidence to show exactly how many lives were saved by health insurance. Unless we have an exact measurement, it's useless; if it pretends to be exact and precise it's probably wrong.

McArdle's sophistry is equivalent to asking a man on a boat in the middle of an ocean how deep the water underneath is. The man clearly sees that the water is very deep but he has no good way to measure it until he realizes that he can tie a heavy rock to one end of a thread, drop it in the ocean and measure the length of the thread until the rock hits the bottom. Of course the bottom of the ocean is uneven, so multiple measurements will result in different results. Faced with this imperfect technique and variation in results, McArdle would probably say that we can't conclude that the ocean is very deep. Even though it is intuitive and obvious to all the rest of us that the ocean is very deep, because one can't measure exactly how deep, she would suggest there's some likelihood it's shallow, and maybe we're all just imagining the ocean in the first place. In the case of health care, McArdle's logic would suggest that because we can't exactly measure the link between insurance and health outcomes, we shouldn't be so obsessed with providing insurance to everyone. In the case of our man on a boat, McArdle would probably send the man without an oxygen tank to find something on the bottom of the ocean because he can't prove exactly how deep it is. Despite the preponderance of logic, common sense, intuition and countless anecdotes of people who lose their lives because they can't get the care they need, McArdle is totally unmoved and declares the deep ocean of the problems that uninsured have a mere mirage.

The other reason why this debate is incredibly annoying is because it's entirely besides the point. Yes, it would be great if we could say with total certainty how many people die each year because of lack of insurance and it would be awesome if we could therefore accuse someone blocking reform of killing hundreds of thousands of people. But even in the absence of that, the case for reform is no weaker. In fact, disproving (or undermining) any one "estimate" does not change the fact that the system is incredibly broken and unfair. And while it might be fun to play around with statistics to make a case one way or the other, the truth has an error range and no estimate or projection can be relied upon with absolute certainty. Ultimately, this debate is about values and trade-offs and I wish those hiding behind pseudo-statistical analysis would debate it as such.

False Choice.

According to Brooks, "we face a brutal choice. Reform would make us a more decent society, but also a less vibrant one. It would ease the anxiety of millions at the cost of future growth. It would heal a wound in the social fabric while piling another expensive and untouchable promise on top of the many such promises we’ve already made. America would be a less youthful, ragged and unforgiving nation, and a more middle-aged, civilized and sedate one. We all have to decide what we want at this moment in history, vitality or security."

It is strange to conclude that reforming health care is a simple trade off between vitality or security from the fact that the current bills do not bend the cost curve (and never could, by Brooks' logic), when the principal reason why this is so is because Republicans, the great conservative minds, did everything in their power to strip serious cost containment out of every version of the bill (eg, independent Medicare payment commission, "death panels", strong public option etc.).

Yes, Brooks is right to point out that the current bills would do little do contain costs, but that doesn't necessarily mean that we should ask ourselves if we want to give up growth for security. The question we should be asking ourselves is if we are willing to give up what he calls "a more decent society" only because the current system is phenomenally resistant to change without even asking ourselves why that is so and what can be done about it.

Suprise!

Americans don't give a flying monkey about bipartisanship, when it comes to getting the public option.

"Which of these would you prefer – (a plan that includes some form of government-sponsored health insurance for people who can’t get affordable private insurance, but is approved without support from Republicans in Congress); or (a plan that is approved with support from Republicans in Congress, but does not include any form of government-sponsored health insurance for people who can’t get affordable private insurance)?"

Fifty one percent said they preferred the public option; 37 percent said they preferred a bill with some support from Republicans in Congress. Six percent said neither and seven percent expressed no opinion."

Good to know that Americans care more about the substance of the bill than they care about holding hands with their evil twins on the other side of the political spectrum. Because, really, bipartisanship doesn't pay your health care premiums when you get fired and the insurance companies denies you coverage because you're pregnant or diabetic.

And as Tapper points out, this might embolden the Democrats to go ahead with the public plan with no Republican support and, maybe, this means we can end the obsession with Olympia Snowe. Unfortunately, I don't think it's that simple: the reason why they might need at least one Republican vote - and Snowe's seems the most likely to come on board - is because there are some Democrats and Independents who might vote to filibuster a bill with a public option in it.

Health Reform in America – Why It Should, Could and Probably Won't Happen

A super belated installment of my article in Zahranicna Politika. It was meant to be a "US Health Reform 101" for readers outside the US who may not be familiar with the problem. Of course a few things have changed since the time it was written but the conclusion still rings true, especially when one looks at the Senate Finance Committee bill.

Health Reform in America – Why It Should, Could and Probably Won't Happen

The story of US health reform is a complicated one and a thorough analysis of the topic is beyond the scope and scale of this column. However, it has become increasingly difficult to ignore given the prominence it has risen to in the last few months. Not only has it become the number one domestic issue that the president, lawmakers, lobbyists, news reporters and policy analysts are occupied with, but it is also quickly becoming the gauge for the Obama administration's success and potentially one of the determinants of the mid-term Congressional elections (in November 2010) and the next presidential election (in November 2012). Even more broadly, it has been a fascinating study in the functioning (some would say, malfunctioning) of the US political system and its many quirks. In short, for anyone interested in US politics, there are many reasons to care about health reform.

So what is all the fuss about? Why all the talk about reforming a system which is defined by spectacular innovation and some of the most advanced treatments and therapies? The standard answers to that question typically involve three aspects of the system: access, cost and outcomes. Quite simply, with all its high technology and innovation, the US health system leaves many people uninsured, and despite being the most expensive in the world, it produces worse outcomes. Specifically, while almost a fifth of non-elderly Americans don’t have any health insurance, the cost per capita is roughly twice that of most developed countries, and yet life expectancy is remarkably below average while infant mortality is astonishingly high. Underneath all these characteristics lies the fact that health care in America is an amalgam of disjointed systems of financing and delivery with little coordination of care, no incentives for prevention and wellness and plenty of room for duplication and errors.

(Source http://ucatlas.ucsc.edu/health/spend/cost_longlife75.gif)

If this brief description of the complexity of US health care and its flaws in and of itself doesn’t make it obvious how much of a fool’s errand trying to revamp the system is, consider the fact that during the last reform effort, led by Hillary Clinton, the backlash from all stakeholders was so strong that for the last 15 years most lawmakers treated health care like a bag of toxic waste they wouldn’t touch with a ten foot pole. And yet, given the ambitious nature of Obama’s agenda, it seemed almost natural that he would try to find the Holy Grail.

Interestingly, despite the obvious difficulty of the task and the discouraging historical precedent, as recently as in June, there was a widespread sense of confidence on Capitol Hill that this time around things are different and something will get done. For starters, in the 15 years since the last attempt, healthcare spending has ballooned 160%, while the ranks of the uninsured have swelled from 41 million to 47 million. In fact, according to the CNN exit polls from the presidential election, while the economy was the number one issue for the vast majority of voters, healthcare ranked as number one for as many as did the issues of terrorism and Iraq. Even more specifically, two thirds of voters said they were worried about health care costs (and 60% of them voted in favor of Obama). In addition to having an apparent mandate and greater urgency, the new Democratic administration was also equipped with an expanded Democratic majority in both chambers of Congress - the first time such power alignment occurred since 1993. Perhaps more importantly, unlike in 1993, there seemed to be an agreement among key stakeholders, including the for-profit healthcare industry, about the need for reform. This was a major difference from the Clinton era, when the lobbying and advertising efforts of the health insurers, pharmaceutical manufacturers and doctors killed reform in its infancy. The new administration, trying to prevent Clinton’s mistakes, kept the process as open and collaborative as possible so as not to ignite hostile opposition from any of the key groups, instead making deals with each of them. The premise was that if we can fix the system and expand coverage, all of the participants will benefit and should therefore contribute in their own ways towards making the overhaul affordable. In short, for a very long time it seemed like the stars were aligning for the impossible to occur.

In hindsight, it was only a question of time when the fairy tale would turn into a mean fight. Once the committees in Congress started drafting bills – there are 3 of them in the House of Representatives and 2 in the Senate with jurisdiction over health care – the details got in the way of noble goals. The reality is that while most agree on the need for reform, there are numerous starkly different ideas about both how it should be accomplished and paid for – and each of them has a different set of proponents and enemies. The obvious goal is to find a solution that upsets the smallest number of participants – which isn’t very consistent with the objective of revamping 16% of the US economy. To make matters more complicated, the differences of opinion do not necessarily fall along party lines, rendering the Democratic majorities in Congress largely useless. As an example, a major portion of the debate has been around the possible introduction of a government-run health insurance option that would compete with private health insurers. While progressive democrats perceive this as an essential part of the reform, the conservative block of the party is vehemently against it. Recognizing the complexity of these diverging interests, Obama has been smart in keeping his demands as vague as possible and instead putting out broad parameters for reform – it has to expand coverage, improve quality and save money. This strategic vagueness, however, didn’t prevent the opponents of reform from poking holes in the proposals and the proponents of different solutions from engaging in hostile debates.

And so here we are in August and the whole reform effort appears to be on life support. Why? If reform fails, history books will probably trace its death to the August congressional recess. The recess is a month-long break during which lawmakers typically go back home to meet with their constituents. Early on in the month it became clear that having a bunch of health care proposals sitting around for a month was like leaving a carton of milk on the table for a few days. The news became quickly dominated by reports of contentious town hall meetings in which lawmakers encountered anger and even violence, often fueled by outrage over the supposed attempt to nationalize healthcare and over particular provisions in the health care bills, some of which were completely made up. The famous example was the rumor that Obama’s reform would create government-run “death panels” that would determine which patients are worth living – which turned out to be a gross misrepresentation of actual proposals to include funding for voluntary end-of-life counseling. Another example of populist hysteria was the accusation that the reform will force preferential hiring of homosexual hospital administrators and includes funding for sex change operations, when in fact none of the proposals include any such language. Absurd or not, these protests have a good chance of making lawmakers uneasy about their support for reform especially if they are Democrats in conservative districts or states and thus vulnerable in the next election.

So does this mean that health care reform is dead? Probably not entirely. Obama has made the issue so central to his domestic policy that a complete failure could harm the future prospects of both his party and his own. However, given the lack of legislative will and mounting opposition in the electorate, the most viable alternative is to settle for some smaller incremental changes such as expanding some public programs like Medicaid to cover more poor people and children and pay for it by cutting spending in a few targeted areas. This would be very far from a comprehensive reform of financing and delivery of care, and it will certainly anger the progressive Democratic base. However, faced with the prospect of getting nothing at all, the progressives will likely take whatever “reform” they can get. In the end, it seems quite possible that this will all have been yet another exercise in the realpolitik in the US legislative process and perhaps another lesson for those who believed in Change: it’s slow, painful, full of compromise and ultimately not very satisfying.

Dear Mr. Collier,

I read about you in the New York Times and I have to say I am truly perplexed.

Your situation as you describe it would seem to position you as one of the fiercest advocates of health reform. Your wife's experience with the system is nothing if not exemplary of everything that is flawed in it: your insurer denied payment for your wife's radiation treatment because they were deemed "experimental" (even thought they are pretty much the standard of care for breast cancer as far as I know), presumably to avoid paying for the $63,000 bill (which you ended up not having to pay only because of the kindness of Emory Healthcare). Your insurance premiums have been going up 15% per year - I would imagine much faster than your income - and your deductibles have quadrupled. More importantly, God forbid the cancer were to recur (and in the best case, there is about a 10% chance it will) and you happened to lose your job, your wife would be uninsurable, due to her pre-existing condition.

And yet, you oppose health reform which aims to control the growth in cost of care, prohibit insurers from discriminating among people based on pre-existing conditions, and would give you a safety net to fall back on in case you lose your job or your employer simply decides to no longer provide health coverage for employees, or their spouses (it's a recession, after all).

What I don't understand at all is your reasons for fearing health reform. You say about Obama "he wants to centralize everything. He wants to take over the car companies. He wants to take over the banks. Now he wants to take over health care." Leaving aside the fact that the government didn't simply decide to take over car companies and banks (they begged for and survived thanks to government intervention), I simply don't get what about any of the current proposals says anything about the government taking over health care. And even if it did, why is that necessarily a bad thing compared to what happened to you? You worry about the government rationing care and skimping on the elderly. Instead, you prefer to be in a system, where your insurance company can simply deny payment for a procedure which, according to medical research lowered recurrence risk of your wife's cancer by more than 50%, because it is considered "experimental", even though your doctors recommended that treatment. If that isn't rationing and intruding into medical care decisions made by your doctor than I don't know what is. But I guess having those life-threatening decisions made by a for-profit entity at least feels more American?

I suppose I can understand one reason why you want to keep the system as it is - that against all odds and thanks to a combination of luck and other people's charity, you got what you need out of it. Your wife is OK now and, however expensive it may be, you have health insurance. In other words, the system sort of works for you, so why mess with it?

All of which is to say, go read James Surowiecki's brilliant article in the New Yorker about why we tend to want to stick with things that suck.

Finally.

Some time ago I was walking with a friend and the topic of health care reform came up. The friend stated: "clearly something has to be done .. there are so many uninsured people."

I may know a lot about health care but being caught off guard on a hungover Saturday morning, my response probably wasn't as succinct or clearly stated as I would have liked it to be. And the response I think is the most appropriate is that the uninsured are not the problem with the system but rather a symptom of the problem.

Here's what I mean: with some notable exceptions (like illegal aliens and young healthy people) the reason why there are so many uninsured people in this country is because health insurance has become prohibitively expensive for many employers to offer and for many individuals to buy. The real issue in America is not access but rather cost. As health insurance premiums have grown at double digit rates every year over the last 2 decades (all the while incomes haven't changed much, if anything, they have gone down), people are increasingly faced with an ugly trade off between health coverage and other spending. This has transpired in a few ways: many businesses have either stopped offering health coverage or increased the employee portion of the cost. To the extent that employees are faced with larger portion of the premium, it has clearly provided a disincentive to buy coverage (so called "take up" rate). And while other employers haven't asked their employees to foot a greater portion of the bill, almost all have shifted their employees to plans with higher out-of-pocket expenses - effectively leaving many "underinsured". And so, even if you still technically have coverage, chances are that when you get to the hospital, you now have a large deductible and a co-pay. In other words, the precipitous growth in health care costs (which drive premiums) has left many people out in the cold.

The reason for making this distinction between access and cost (ie, the uninsured are not the problem, but rather a symptom of a problem, which is skyrocketing costs) is twofold:

1. By focusing on the number of people without health insurance the implication could be that you could solve the perceived problem of access by simply throwing trillions of dollars to those who don't have coverage and get them insured. This would, at least temporarily, make everyone happy. I say temporarily because without addressing the underlying problem of cost and "bending the cost curve" (a popular expression these days), the problem would reemerge as further increases in costs would make insurance increasingly expensive to employers and employees (ie, right where we started) or, in the case of government funding, would lead to ever increasing deficits.

2. The focus on the uninsured also makes health care reform less appealing or relevant to the average voter. While there are unacceptably many uninsured Americans, the majority is still insured and the majority likes their health insurance. By talking about reform through the perspective of access, it is hard to inspire much urgency or support when the majority of people don't have an access problem. Other than feelings of sympathy, the horror stories of those who lack health insurance are not particularly motivating to those who do. In reality, however, even those that have insurance today and are happy or OK with it, are not immune from the underlying problem of cost growth. At a minimum, their premiums and out of pocket costs are rising at incredible rates year after year. More importantly, however, unless those trends are muted, the pool of uninsured and underinsured is ever expanding - and it is this threat that should make the need for reform very personal even to those who are currently covered.

On a related note, by focusing on costs rather than access, the problem becomes not only personally relevant to everyone but also inherently less partisan. It is easy to see how a conservative would not be particularly moved by the idea of "universal coverage". And it is also easy to see why my friend, who I mentioned in the beginning of the article, would relate the notions of health reform and uninsured in his liberal train of thought. Indeed, the very need for health reform is often questioned by some in the Republican party, on the grounds that there is nothing inherent about the right to health care. However, by focusing on the real problem - costs - reform suddenly sounds like a fiscal imperative, something that is surely more appealing to conservatives. And certainly, for a problem as big and complex as health care, it is useful to think about problems in ways that people across the ideological spectrum find appealing.

So, to conclude this little diatribe, because cost is the true problem that we should be addressing, I found it heartening that recently the public discourse has finally shifted in that direction. Not only in Obama's press conference on Wednesday but also in a recent slew of articles and op-eds on the topic (here, here and here). I really hope that the message is resonating - not just with the public but also with the lawmakers who are in charge of the sausage that is the legislative process around health reform.

Health Reform Op-Ed Extravaganza.

You can tell that an issue is heating up when you get a slew of columns on it in one day.  Today we got one from Krugman, Douthat, and Will.  All make solid points, even though they see the problem from very different perspectives.  After following the issue up close for the last few years, I could probably write an novel about it, so one of these days I should at least squeeze out a longer piece here.  Stay tuned.

Follow Ups.

It's turning out to be a rich day on a variety of fronts, for many issues that I have written about in the past, so why not simply round it all up in one post?

Immigration:  How timely that there is a new study out from NCPA about the $52 trillion in government program liabilities from Medicare and Social Security.  Their conclusion?  "Social Security and Medicare can be reformed so that each worker saves and invests funds for his own post-retirement pension and health care benefits. The burden for the current generation of workers would be substantial: saving for their own benefits while at the same time paying taxes to fund the benefits of current retirees. However, over time Social Security and Medicare would be transformed from pay-as-you-go programs in which each generation is dependent on the next generation of workers/taxpayers into funded programs in which each generation pays its own way."  Or, as I suggested, you could also expand the pool of young bright attractive (kidding) workers by importing them.  

Gay right and useless NY democrats:  Via JMG, we're hearing that we will be, after all, shafted by the Democrats in NY state senate.  "And thus ends our hope for marriage equality in New York in the near future. In 2010 there will be a redistricting in New York state, a process that the Democrats will at least now be able to control. Therein may lie our hope for marriage equality in 2011."  Really, no comment at all except to say that I pray every night for the Republicans to magically transform into a decent party and kill the Democrats in the next election.  

Healthcare: Ezra Klein and Andrew Sullivan have spent the last 2 days exchanging jabs on the topic, and it's delightfully full of clashes: progressive vs libertarian, personal vs theoretical, American vs British.  One of the ironies in the exchange is that Klein, an American, defends the UK system of healthcare, while Sullivan, a Brit, likes it Americana style.  It started with this post by Klein about rationing, and it quickly got personal when Sullivan responded: "I prefer freedom and the market to rationalism and the collective. That's why I live here."  Klein comes back saying the Brits are more satisfied with their system than Americans are with theirs, ergo it must be better, to which Sullivan goes all metaphysical: "there is a cultural aspect here - Brits simply believe suffering is an important part of life, especially through ill health. Going to the doctor is often viewed as a moral failure, a sign of weakness.. It was one of my first epiphanies about most Americans: they believe in demanding and expecting the best from healthcare, not enduring and surviving the worst, because it is their collective obligation. Ah, I thought. This is how free people think and act. Which, for much of the left, is, of course, the problem." Of course it doesn't stop there and it goes on and on.  The beauty is that while Klein tries to argue with data, Sullivan operates with ideology, personal anecdote and cultural relativism - and yet Klein continues to humor him - with reason and data - for which he deserves some props.

Veganism:  OK that one has been completely neglected here for a long time, but there's a nice article over at the American Prospect about the environmental benefits of eating less meat - and the unpalatability of the argument: "Why are environmental groups and even politicians willing to tell Americans to drive smaller cars or take the bus to work but unwilling to tell them to eat less meat?" 

Robot.

Ezra Klein has a good post up about surgical robots,  a topic I have briefly touched on here with a similar general conclusion.

Writing and thinking about robots has reminded me of a good piece of trivia - the origin of the word robot.  It was introduced by a Czech writer Karel Čapek in a play RUR.  It is derived from the Czech work "robota", which means "labor".  Incidentially, anyone remotely interested in science fiction should read his books RUR and War with the Newts if only to see how much of the current science fiction was concieved as early as 1920.

READ: Health Care and Baseball

Today's NY Times op-ed by Billy Beane, Newt Gingrich and John Kerry is a good example why it is pointless if not dangerous to discuss an issue as complex as healthcare in short format.  They try to make the case that the problem in US health care system is the lack of evidence-based decision making. 

Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology. Instead, most care is based on informed opinion, personal observation or tradition.  It is no surprise then that the United States spends more than twice as much per capita on health care compared to almost every other country in the world — and with worse health quality than most industrialized nations.

The implication seems to be that other countries spend less on their health care because they are much better at determining what works and what doesn't, which strikes me as somewhat misleading.  Other countries spend less on healthcare per capita than the US simply because they either cannot afford to or do not want to.  And their outcomes are better on average simply because their healthcare system is more equitable.  The best care in the US is still by far the best care anywhere; the problem is just that fewer and fewer people are able to access it.

I am not saying here that evidence-based medicine is not the right way to go.  I just don't think we should be expecting magic.  There are many serious structural problems in the US health care and lack of data and evidence is only one of them and cannot be addressed in isolation.  

More practically, however, even if we agree that evidence-based medicine is what we need more of, I struggle to see how that can be achieved in the disjointed system of US health care where decisions, financing and delivery of care all exist in their own silos.  The authors suggest:

Working closely with doctors, the federal government and the private sector should create a new institute for evidence-based medicine. This institute would conduct new studies and systematically review the existing medical literature to help inform our nation’s over-stretched medical providers.

However, that seems a touch idealistic.  A lot of review and evidence already exists and is routinely ignored both by payors and providers alike.  Take the example of surgical robots which cost $2 million a piece, have questionable comparative quality outcomes, yet hospitals are tripping over each other buying them and not because they believe the robots are such good medicine.  When I talk to hospital CEOs and CFOs they often express downright hate for the robots.  They cost a lot, they lose money on every procedure they perform, yet - to stay competitive - they know they need to have one.  In a competitive market place there is always the temptation if not actual incentive to do more with more fancy technology, no matter what the evidence says.  

In fact, I am almost starting to wonder if the real argument here is that unless payments, care and decisions are somehow centrally coordinated, we can't ensure they will be both appropriate and economical.  And that, ladies and gentlement, is how this blogger would make an argument for government-run healthcare.  Or as McCain would probably put it, socialism.  Boo!!

READ: I Care, You Care, We All Care About Health Care

For an issue I know and care so much about, I have neglected health care suspiciously on this blog. This neglect partially stems from the fear of boring the reader; much greater part of this hesitation is really my appreciation for the complexity of the issue that is preventing me from trying to spit out quick and dirty entries I could never consider complete or comprehensive enough.

But I guess I have to give in at some point and we can thus consider this the virtual popping of my health care blogging cherry. And it all started when Ezra Klein pointed me to an op-ed in the Boston Globe today by Jeff Jacoby saying that health care shouldn't be linked to employment. The premise of the piece is that the skyrocketing costs can be attributed to the hidden true costs of care and lack of consumerism in health care. Break health care away from employment and voila - the patient-consumer seeking cheaper better care will magically curb the growth in health care costs.

Ezra, while agreeing with the idea of de-linking employment and health coverage, objects to the notion of consumerism by pointing out that there is a great asymmetry of information between the patient and the provider. While that is a valid point, I do think there is a role for consumerism in health care. For one, even if the patient has to rely on the doctor to figure out what his health care needs are (ie, he cannot - in a truly consumeristic manner - simply decide what he wants and needs), encouraging consumer-driven approaches to finding the best and most appropriate sites of care (ie, the $500 surgery center vs the $5,000 hospital surgical suite) should not be dismissed entirely.

My problem is with the implicit assumptions behind Jacoby original thesis, namely that (a) de-linking health care from employment is necessary to induce consumerism, that (b) lack of consumering in health care is the sole (or biggest) cause of rapid growth in health care costs and (c) the individual somehow has greater power or incentive to drive down health care costs that his employer doesn't. Addressing these points one by one:

(a) consumerism in health care is entirely feasible even under the current employer-based system and is actually quite explicit in many plans based around flexible spending account.

(b) many other culprits can be name that lead to rapid growth in health care costs, among them the cost of new technologies, cross subsidization of less profitable payments in health care and rapid growth in the key health care input such as nurse wages.

(c) under the current arrangement the employers actually exercise a lot of negotiating clout on their employees behalf when negotiating insurance premiums of providers rates, which individuals would never be able to obtain on their own in the market place.

I just reread this entry and I see how it's both too technical and too superficial at the same time but I will develop these ideas further in the next few days but right now work is calling.

READ: The "C" Words

Cancer.  When I meet people through work they are typically middle aged overweight white guys exploiting the latest scheme to make money off of government funded healthcare programs.  But today I met someone different.  Her name is Dr. Chang and she is a radiation oncologist - in short, she treats cancer with radiation.  She described her work at the radiation center - patient assessment, care planning and then actual treatment - emphasizing the importance of empathy and making the cancer patients feel well informed, cared for, and.. hopeful.  That, in combination with her intelligent yet humble, sweet voice was so disarming and inspiring.  At some point it hit me - this woman encounters so much suffering and pain - and helps heal much of it - and you could never tell.  

Change.  In another meeting, 2 lobbyists from a prominent DC law firm discussed the legislative outlook for healthcare.  One point they made put the election in a whole new light for me:  every company in healthcare that depends on government funding should pray for McCain to win the election.  Why?  There is no better way to guarantee the status quo - and no disruptive healthcare reform happening - than by having one party control of the Congress and the other one in the White House.  Here's a perfect example of how that pans out in practice.  Conversely, put the democrats in charge and suddenly the prospect of laws being passed without a veto makes everyones stomach contract a little.  Taking that little observation a step further - and this is not an opinion but rather a procedural observation - the only way to achieve "change" - is to elect a democrat into the White House.  Similarly, the best way to accomplish paralysis in these critical times, is to have an expanding Democratic majority in the congress - which seems all but certain come November - presided over by a Republican.  Good luck getting anything done in that mad house.

And so, here I am, constructing a case for veto-proof single party rule.  Ugh, I hope I won't have to regret it.

READ: Why Elections Rock!

As the years that separate me from the glorious days on the high school debate team have accumulated, the frequency of thinking and arguing about fundamental issues has dropped sharply. Ironically, despite being one of the most cultured and diverse melting pots on the planet, the social life in New York is not particularly designed to encourage discourse, at least in my experience. We all work hard and in the little spare time we have we want to have fun, a concept that for a quarter-aged gay male typically favors drinking in a bar full of beautiful strangers in place of discussing the broken healthcare system or the merits and drawbacks of big government. Besides, as one gets increasingly accustomed to - or perhaps comfortable in - the way the world operates, the urge to question is muted as is the perceived ability to do anything with the entrenched status quo. Sometimes I nostalgically look at the pictures of the long-haired Hair-singing Kerouac-reading teenager from Slovakia and wonder: "What happened?" (The answer lies, roughly speaking, here.. and here, here, here and here.)

Which is why it is refreshing to have the elections as a reason (or an excuse) to once again think, discuss and opine - to believe that how we vote can actually change how we live (not that I can vote, but I can certainly discuss and opine enough to more than compensate!). It is all the more frustrating when, given all the great pressing issues of the world we live in, gas prices are the only one that seems to be getting significant attention from the news media and the presidential candidates. Sure, it is an important issue that affects this country in more than one way, and naturally, it gets acute attention from everyone who doesn't live in Manhattan, because it is so present in people's everyday life and the choices they make. However, the attention it draws in the context of the election seems undue for two reasons: (1) Neither candidate can do much about it and it is questionable whether one would do anything dramatically different from the other especially as the grinding machine of the campaigning process is slowly blending their "solutions" via multiple double-sided flip-flops into one big gassy mess. (2) Every other issue seems to be pushed to the side, in particular issues where the candidates could actually take positions that differentiate them from one another. And they are different - and not just in age, race and height; they just don't talk about it a whole lot.

Which brings me to Krugman, the man who made my day by once again highlighting an issue that I think does not hit the radar often enough given how important it is. In his op-ed in NY Times today he talks about the likelihood of healthcare reform. It is, in my opinion, one of the most fundamental questions that this country has to face, for a variety of reasons which I do not want to get into right now. The point is it's not an issue that is sexy, it doesn't affect everyone every day and therefore it needs disciples who will keep it alive and somewhere close to the forefront. And I think the challenge for us, readers, citizens, voters (however pompous that may sound!) is to adopt an orphan issue, one that is important yet neglected and to try to understand it inside out, because when the candidates talk, the only way to know a difference between them and to see who gets it is to get it on your own.

PS: Incidentally, with regards to healthcare, Obama may mean well but Clinton had him dominated on the issue - a point that probably escaped those who do not pay much attention to it or do not care. Ironically, now that the contrast on real issues between the candidates should be ever more vivid, people are seemingly falling back on abstract proxies for success like "experience" and "comfort", or at least that is the conclusion that some draw from the closing gap between the two candidates. Now, if ever, is the time to read the blue print.