Japanese medical system WINS
So, I pushed Sushu in a wheelchair up a mountain for about a kilometer to get to a small country hospital, and then had a very awkward conversation with the reception desk where I explained that I have insurance in America but it probably won't cover anything in Japan, will it, and I know that you can't know this until after we've seen the doctor, but like how much will this cost? 10,000 yen? 100,000 yen? 1,000,000 yen? (I heard an old man in line before us get charged 1,000,000 yen for something, so I was worried our bill might be similar.)
About an hour later we saw a doctor. Even in such a remote location, the doctor spoke English. An X-ray found no fractures. They put Sushu's foot in a cast, gave her a bunch of painkillers and anti-swelling meds and cold packs, and told her to stay off it for 2-3 weeks.
Examination + X-ray + cast + medicine = 15,000 yen. That's $150. This is after we showed up with no appointment and no insurance. Paperwork was minimal. Everybody was quick, professional, and super-friendly.
So, yeah, it pretty much put the American health care system to shame. I would expect a similar treatment in America to end up at least $1,000, if we would even have gotten to see a doctor the same day at all.
Oh, and it was raining when we were done, so I called back to the hotel about ordering a taxi. The hotel sent a guy up the mountain in a car to get us and bring us back for free. He stood out in the rain to hold the door open for Sushu and make sure she got in the car OK. He expected no tip.
Some days Japanese people just amaze me with their helpfulness and understanding in the face of all the weirdness I'm introducing into their lives. This was one of those days.
Why is health care so expensive?
There are a lot of explanations, but another one occurred to me this morning. I am not an expert, so tell me if I'm completely naive, but here goes:
- What keeps prices low in any other industry? Competition, right? If company A raises its prices too much, I go to company B.
- This all assumes a transactional scenario where I buy stuff directly from company A or B and where I have the freedom to switch companies at any time. The medical equivalent scenario is one where I can buy services directly from one doctor, and go to another doctor if the first one charges too much.
- Most people do not pay doctors directly, but go through insurance companies. The insurance company pays (most of) the medical bill; it also limits the doctors I'm allowed to choose from.
- Most people do not buy their insurance directly, but get it through their jobs. The employer chooses the insurance policy.
- The health benefits may be a factor in me choosing where to work, but it's unlikely to be the main factor in my choice compared to location, salary, type of work, whether my boss is tolerable, etc.
- Thus, I don't deal with the doctor directly. There's not just one, but two intermediaries between me and the doctor: there's the insurance company, and there's my employer.
- So if the doctor wants to charge more than I can afford, I can't just walk away and go to a different doctor, because my doctor choices are limited by my insurance. And I can't just switch insurance, because my insurance choices are limited by my job. And changing jobs isn't realistic.
- Besides, nobody will cover a pre-existing condition, so as soon as something is wrong with me, my choices are whatever insurance I've got, or nothing.
- For all these reasons, my ability to negotiate over the price of my health care is effectively nonexistent. I can't pressure anybody into reducing costs because I don't have the freedom to walk away from a provider who is too expensive.
- The doctors don't get paid by me, so they have no incentive to negotiate price with me; they get paid by the insurance company, so their incentive is to charge the insurance company as much as they can get away with charging.
- The insurance company gets paid the same (by my employer) whether they cover my care or not, so their incentive is to deny coverage in as many cases as possible.
It all boils down to the fact that in this system, consumers can't exert downward competitive pressure on the cost of health care, the way they can with services they buy directly.
Of course there are a hundred other reasons that also contribute to the high cost, but I think this is significant.
I don't have a solution to propose; I'm just trying to understand the nature of the mess we're in, so that I can form an informed opinion on the current debate over health insurance reform.
Could the partisan hacks keep it down please, I'm trying to think here
The tenor of this health care debate is pissing me off. And stressing me out.
Reforming health insurance is an important issue; it's not one of my personal hot-button issues, but it's what Obama has decided to focus on first and it's a major part of what we elected him to do. So here we go; the fight is on.
If the government is going to reform health insurance, I want them to get it right. Whatever happens, it's largely going to be decided in the Senate. There are two senators there, Barbara Boxer and Diane Feinstein, who are supposed to represent me as a citizen of California. I have an opportunity to put pressure on them to get them to vote the way I want. (I think Boxer is up for re-election next year, so I can especially put pressure on her.) But first I have to figure out what it is I want them to vote for. If I'm going to pressure my senators for something, I want it to be the right thing. Right now I'm not particularly knowledgeable about the medical or insurance industries. That means I need to educate myself. I think I have a responsibility as a citizen to educate myself.
But the sheer amount of hyperbole and misinformation and screechy partisan rhetoric out there makes it hard to figure out what sources I can trust.
For example, it is impossible to understand anything about the health care debate unless you understand the differences between the various possible levels of government involvement in paying for health care, e.g. the difference between public option, single payer, etc. I have only recently figured out these distinctions myself. I summarize them in the following table, ordered from least government intervention to most government intervention:
- The government does not get any further involved in funding health care; private insurance companies remain the only option for most people (unless you are old enough for Medicare, or in the armed forces, or a veteran) but perhaps have additional regulations or restrictions imposed on them.
- Public option. There is a new, public (i.e. govt) insurance company to compete with private insurance companies; you have your choice between them. This is equivalent to how the postal service, a government-run organization, competes with private companies UPS and FedEx to provide package delivery service.
- Single-payer. The govt pays for all health care; hospitals remain private companies but compete for government money, like military contractors. Medicare is essentially already single-payer health care, but for old people only. Canada has a single-payer system.
- Socialized medicine. Doctors are all on govt payroll, like policemen, firemen, or the army. Britain has socialized medicine.
This is really basic, beginner, 101-level stuff. If we had a functional news media, one that was doing its job, it would be educating people about these things, and the difference between 1, 2, 3, and 4 would be common knowledge. But instead we have a news media that can only communicate sound bites and emotion and conflict, not facts. It's really good at glossing over the important differences and lumping everything together, and many people seem not to know the difference between 1, 2, 3, and 4.
Essentially all of the plans the Democrats are considering are variants of 1 or 2. 3 and 4 do not even seem to be under consideration. (Which is too bad; 3 is unlikely to happen but I don't think it should be dismissed out of hand.)
Yet it seems that the entire Republican argument against reform is based on pretending that 2 equals 3 equals 4 equals jackbooted government thugs coming to your house and euthanizing your grandmother. It pisses me off, not because they're against health care reform, but because they're making the argument in a fundamentally dishonest way, with fear tactics and hysterical exaggeration, taking avantage of people's ignorance. It would be different if they were making an argument like "We can't afford this plan" or "this plan gets the incentives all wrong" or "There are better ways to control medical costs". Maybe they could even propose an alternative plan, maybe something based on tort reform or increasing competition between insurance companies.
And meanwhile, the Democrats seem to be basing their whole argument on "Insurance companies are evil". Well maybe they are and maybe they aren't, but how about explaining how each of the several possible plans would work to make things better? How would any given plan save users money and/or get us better quality care and/or increase freedom to switch doctors and/or jobs? How would the government will pay for it? What will it do to protect user choice and maintain incentives for quality and innovation? Instead we just hear them saying, basically, "Insurance companies are evil" over and over again. Pointing out that the curent situation is bad doesn't automatically prove that your proposed plan is better.
Why is health care expensive, part 2
There are a lot of money-wasting inefficiencies in the system. (CNN article, worth a read.) According to this one of the biggest, and most perverse, is the widespread practice of doctors ordering tests that they know patients won't need, either because they are afraid of malpractice suits (you can get sued for failing to do a test, but not sued for doing too many tests, apparently) or because the doctors are milking the insurance companies for money.
It seems like a big opportunity to get costs down, if we can figure out how to put a stop to needless tests.
"Do you want your insurance provided by the DMV?"
An argument I've heard deployed against government involvement in health care is "Do you really want your insurance provided by the same people who run the DMV??".
The last couple of times I've gone to the DMV I've made an appointment (yes, you can do that), so my wait time was under half an hour. Service was always cheap. Although their rules don't make sense, at least they are clearly explained. The worst DMV experience I've had was a result of an employee not understanding the rules, and was solved by going to a branch in a different town. So while I don't exactly look forward to visiting the DMV, I don't dread it either.
In contrast, I've been trying for the past, like, six months to get my insurance company to add Sushu to my policy and I'm still getting the bureaucratic runaround. This is something that I have been told is within my rights, but I keep meeting procedural obstacles. I blame ClearBenefits, which is some kind of middleman organization between my employer and the insurance companies, which runs a very confusing website.
So no, I'm not convinced that government bureaucracy is inherently worse than corporate bureaucracy. I certainly don't think that replacing one with the other would automatically be some kind of terrifying nightmare.
Why is health care expensive, part 3
Atul Gawande ("He's ranked higher than me on Google" complains my friend Atul Varma) is a doctor who also writes articles about the state of the medical industry.
He recently attempted to get to the bottom of why health care costs so much. He did some investigative reporting into two towns in Texas - McAllen and El Paso. They have the same population, same demographics, same level of medical technology, and one is not noticeably sicker or healthier than the other. But one spends twice as much on health care. Why?
Here's the article. It's definitely worth a read.
Dr. Gawande's conclusion: the main factor to blame is a cultural shift in the doctors themselves. Since the 1990s it has become more and more culturally acceptable among doctors in McAllen to assign treatments on the basis of how much the doctor will earn by doing them. El Paso hasn't had a similar change in attitudes.
Blaming the doctors themselves? Controversial! But you should read the article and see what you think of the evidence Gawande presents.
Gawande contrasts the McAllen situation against the Mayo Clinic, which is known as one of the highest-quality hospitals in the country as well as one of the most affordable. At the Mayo Clinic doctors are paid flat salaries, instead of charging fees per procedure. That means they do not have any incentive to pick more expensive treatments just for the sake of charging more. Maybe that puts them in a better position to find the best balance of price and effectiveness when choosing treatments.
Could moving from fee-for-service to doctors-on-salaries be another part of a long-term strategy to control costs?
Some good introductory/background reading for the health care debate
Remember that there's two subjects here. There's the policy issues of how the health care system could be better, and then there's the political issues of how to accomplish that. For the time being, I'm mostly focusing on learning about the policy issues, because I can't really decide where I stand on the politics until I understand how the system works. I've been reading pretty voraciously in an attempt to educate myself.
Here is a "back of the napkin" slideshow explaining the issues involved. It has cute doodles.
The Washington Post has a slideshow primer with voiceover and animation.
The Economist also has an introduction to the topic here. It points out that the U.S.A. spends 16%, or one sixth of our GDP on health care. We have by far the most expensive health care system in the world. Yet in terms of quality we rank thirty-seventh in the world, so what gives?
They also have a follow-up article about the political process of reform, called This Is Going To Hurt. Shockingly for a magazine that's generally quite free-market-uber-alles-rah-rah-rah, the Economist actually likes single-payer best out of all the options.
A mandate is a law that everyone must have health insurance (if they don't, they'll face some kind of penalty.) Like right now we have mandated insurance for cars (you can't drive without insurance), but not for people.
During the election, Obama said repeatedly that there was no mandate in his health-care plan; he would impose no penalty on people who don't get insurance. (Remember the face that John McCain made when Obama said during one of the debates that the penalty would be zero? It was amusing.)
A thing we tend to forget during presidential elections is that presidents don't write legislation. Congress does. So it's meaningless to talk about "Obama's health-care plan". Even if he'd rather not have a mandate, Congress might pass one anyway. Most of the chatter has been about stuff like the public option, but even if there's no public option in the final bill there could very well be a mandate. It would be a huge change, so I want to understand what it would mean.
So, what's the deal? Why is a mandate something that we would want to pass? I mean, there are a lot of people who can't afford health insurance, right? If you legally punish them for not buying it, that's not magically going to make them able to afford it. You're just punishing them even further for being poor. So what's going on here?
The first thing to understand is the risk pool, and who's not in it.
Among the 45 million Americans who don't have health insurance, there are two groups of people. There's people who choose not to buy it because they are healthy enough that they don't think they need it and/or rich enough to pay out of pocket for anything that goes wrong. The insurance companies would love to have more of these rich, healthy people on board because they make the risk pool less risky, but the people aren't interested.
The other group is people who are poor and/or sickly enough that the insurance company either won't cover them, or that the price it sets for them is more than they can afford to pay. These people would love to be on insurance, and those who see universal coverage as a moral obligation would love to get these people onto insurance. But the insurance companies don't want these people on board because they make the risk pool more risky.
If you believe we have a moral obligation to get universal coverage for the poorest and most sickly, then how do we do that without overwhelming the risk pool? The obvious way is to add the poorest and sickest to the risk pool along with the richest and healthiest, who would balance them out. But we alread know these are people who don't want to join. You would have to force them to. Thus, a mandate.
The other thing to think about is "No more discriminating by pre-existing conditions", i.e. insurance companies can't charge you more or refuse you coverage because you've already got something wrong with you.
"No more discriminating by pre-existing conditions" sounds great, especially if you're one of the poorest/sickest people. But if we passed a non-discrimination law, and did nothing else, think what would happen. You could wait until you get sick and then buy insurance to cover your problem. In fact, there would be no reason to do anything else. Nobody would buy insurance until *after* they got sick. And at that point it's not insurance anymore. Every user of the system would be pulling more out of the system than they were putting into it. The system would collapse.
But if you have non-discrimination law AND you have mandates, then maybe it would work. You can't game the system and buy your insurance after the fact, because you're mandated to have insurance first. The non-discrimination law would make insurance affordable to the sickest people, who would then be able to obey the mandate.
So a mandate by itself would be bad, and non-discrimination by itself would be bad, but together each one could prevents the worst problems of the other, and together they make up something like universal coverage. Next time you hear people talk about mandates, or about not discriminating by pre-existing conditions, remember that neither one makes sense by itself, but they might make sense together.
That's the theory, anyway. Would it work in practice? Is it the right thing to do? Is it even constiutional? I don't know.
The view from your sickbed
A lot of fascinating medical bill / insurance horror stories are collected at Andrew Sullivan's "The View From Your Sickbed" series.
Of course anecdotal evidence by itself isn't something to base policy on. And the individual stories point in all different directions and have competing suggestions for what exactly needs to be changed. But in gestalt they underscore the desperate need for some kind of reform.
Why is health care expensive, part 4
Insurance companies face almost no competition (PDF link).
According to that report, most states are effective monopolies or duo-opolies; regulations prevent companies from competing in other states, and mergers have reduced what was left (400 mergers between health insurance in the past 13 years). 94% of insurance markets are highly concentrated, meaning almost entirely dominated by one or two companies.
When people (or, to be more precise, their employers in most cases) don't have a choice of insurance company, there's nothing to stop insurance companies from raising premiums as high as they want and reducing coverage for anything that would cost too much.
This is why insurance premiums are increasing 4 times faster than wages. Premiums have gone up 87% over the last 6 years.
Is your insurance coverage 87% better than it was 6 years ago? Are you 87% healthier? Has the process of treating the sick somehow become 87% more expensive? I don't think so. I think insurance companies are taking more and more of our money, and keeping it, just becaus they can. Top health insurance companies are reporting amazingly
high profits even during the recession.
While the auto industry and the financial industry have been falling apart and needing to be bailed out by the government, while unemployment has gone up to 9.5%, the top three insurers averaged profits of $2.4 billion each for 2008.
I'm not going to say that we should decide how much profits a company is allowed to make, or say that a company is evil just because it's making a lot of profits, but I will say this: high profits are a sign of low competition. If there was an efficient, competitive market, then more companies would be operating on lower profits and passing the savings back to the customer in order to stay competitive. That's obviously not happening.
If we want to increase competition, and I think we do, one way is to loosen the regulations that prevent companies from competing in other states. Another way is to establish an alternative insurance organization to compete with for-profit insurance companies. This could be the public option, or some kind of user-owned 'co-op' insurance companies as has recently been proposed. If such an alternative didn't have to worry about pleasing shareholders or buying yachts for their CEOs, maybe they can give consumers a better deal, and put some competitive pressure downward on private insurance companies.
Remember, when you hear talk about a public option, that the point is to increase competition. Some people are freaking out about 'socialism' but increasing competition to drive prices down is really the most capitalistic type of reform imaginable. Also remember that the public option is just one means to an end, not the end itself. Competition is the real goal.
Of the one-million-plus personal bankruptcies that happen in America per year, over 60% are directly due to medical bills.
That's a family having a medical bankruptcy every 90 seconds. It has gotten much worse between the last time such a study was done, in 2001, and when this study was done in 2007. Scariest is that 75% of these bankruptcies are from people who had health insurance. I repeat, they HAD HEALTH INSURANCE. It failed them when they needed it most.
From the article:
"Across the US, 25 per cent of employers cancel coverage as soon as an employee has a disabling illness while another 25 per cent cancel it within 12 months."
A common scenario leading up to bankruptcy is that insufficient medical care leads to people getting sicker, until they miss too much work, which leads to them losing their jobs, thereby losing their health insurance, becoming unable to afford care at all, ending up sick, broke, jobless, and homeless. It's a literal death spiral.
So you might hear "Only 15% of Americans are uninsured" and think "Hey, that doesn't sound too bad". But it's not just the 15% of us who don't have health insurance that we should be worried about, it's the other 85% of us too, for whom health insurance isn't doing what we paid for it to do.
Literally the only thing that health insurance companies contribute to society is risk mitigation. They're supposed to be a way to control costs. They're supposed to protect you from having to pay devastatingly high bills in the event of an accident or emergency. If they're not fulfilling that function, then why do they exist?
Health care town hall meeting, IRL
My representative, Anna Eshoo of California district 14, is having a "town hall" meeting about health care next Wednesday night. I'm gonna go to it. My self-imposed homework assignment will be to have a list of intelligent questions ready for her by then.
Why is health care expensive, part 5
Because of fear of lawyers?
83% of physicians surveyed reported practicing 'defensive medicine'. They do procedures they don't think are neccessary because they're afraid of being sued for not doing them. And they pay for malpractice insurance. Predictably, the doctor lobby is strongly in favor of tort reform, while the lawyer lobby is strongly against it.
However, studies show malpractice awards are not the main driver of health care costs, says this article from the Washington Independent. We might save some money by tort reform, but it's unlikely to be the main way to get costs under control.
There's a lot of interesting facts in that article. Apparently the cost of malpractice is calculated as only 2% of overall medical spending, so maybe there's not much savings to be had there. On the other hand, nobody can calculate the ultimate cost of defensive medical treatments. On the gripping hand, Texas already capped pain-and-suffering awards at $250,000 and had "a dramatic decline in lawsuits", but Texas still has some of the most expensive healthcare in the country. 29 other states have also done some sort of capping of malpractice awards, so it's not clear what else could be done in those states. Plus there are concerns that the Texas system makes it hard for people who have been legitimately harmed by real malpractice to get fair compensation for it.
A lot of points of view on tort reform, pro and con, are brought together in this Daily Dish post.
Why is health care expensive, part 6
Acute medicine is always more expensive than preventive medicine. If the doctor can detect something early, it's going to be cheaper to fix (not to mention less traumatic) than if you waited until it's an emergency.
So it seems like common sense that doing more preventive care, less emergency care, would be a way to save the whole country money on health care. Quite apart from any matters of public policy, it's also a choice we can make individually in order to save ourselves money and stay healthier. (That reminds me... after this blog post I should get some exercise and make myself a dentist appointment.)
If our current system is biased towards emergency care and away from providing preventive care, that could be a major part of the country's problem. Is there such a bias? I haven't seen any statistics on it, so I have nothing but a hunch that there may be. I would love it if anybody could point me at any evidence to confirm or deny this hypothesis.
This is closely related to another problem, which is that uninsured people show up at emergency rooms with acute problems. We treat them, because we don't want them to, like, die, but then they can't pay, the hospital eats the cost, and it ends up driving up insurance prices for everybody. Seems like it would be a lot cheaper for everyone in the long run if we could figure out how to get some basic preventive care for those uninsured people in order to deal with their problems before they become emergencies.
The health insurance model " pay into a fund every month, get a pay-out if you have an emergency " is an illogical way to pay for preventive care. Twice-yearly checkups are an entirely predictable cost. The emphasis on fixing insurance may be obscuring things that we should be doing to encourage preventive care.
Would it make more sense to move regular prevention outside of the insurance system entirely, and fund it through other means? Or would it make more sense to incentivize people to take care of themselves by, like, giving them a break on their premiums as long as they are seeing a doctor twice a year? Are there any health-care plans out there right now that already do something like this?
(Whoops, I hit "submit" too early on this post, so it showed up incomplete on the RSS feed. Fixed now.)
For your information, and as a reference for further discussion, here is a summary of House Resolution 3200 (pdf link), the foremost health care reform proposal. This is a section-by-section summary, so it's a mere 35 pages instead of the 1,018 pages of the full bill. There will be many more changes to it before the final vote.
This was sent to me as an e-mail attachment in a mass-mailing from my representative in the House; I'm assuming that it's public domain and OK to redistribute.
I have a long blog post coming up about Wednesday night's health-care town-hall meeting, which was basically a circus of depressing partisanship.
Why is healthcare so expensive, part 7
Because we rely on insurance too much?
I just made a dentist appointment for this Friday, for a routine checkup and teeth cleaning. Of course, the first thing the dentist asked about was my insurance coverage. I read her a mysterious number off of a plastic card that Mozilla gave me, and then she was happy.
Routine dental checkups and teeth cleaning is an entirely predictable procedure with what should be a low, predictable cost. Have you ever thought of how weird it is to that we use insurance to cover entirely predictable costs?
We don't use auto insurance to buy gas. It would be insane. Insurance is for accidents, it's for unpredictable costs. But people use health insurance to pay for routine checkups or monthly pill supplies. You almost have to use insurance because the price of basic services and supplies is absurdly inflated, under the assumption that an insurance company is going to be paying for it. Imagine if gas cost $50 a gallon but your auto insurance paid for it. That's the situation we have with health care. (It's often been pointed out that Americans tend to take better care of their cars than of their own bodies.)
When you pay with insurance, you're paying with somebody else's money. When you're paying with somebody else's money, there's no incentive for the patient to look for a good deal, and there's no incentive for the doctor or the hospital to economize on their costs, as I've pointed out before. The costs all come back to us eventually in the form of higher insurance premiums and more people dropped from insurance coverage.
Why do we have a system where we pay for everything with health insurance? It started, believe it or not, as a way to get around wage controls during WWII. Health benefits were not covered by wage control laws. After the war the wage controls ended but in 1954 Congress created a tax loophole that makes health benefits tax-free - meaning that it is far cheaper for a company to pay somebody a dollar of health insurance than to pay them a dollar of salary. This is the single biggest loophole in the federal tax code and is considered by many economists to have a massive distoring effect on the economy. (You may recall that during the campaign John McCain proposed ending this tax loophole. Not a very popular idea, but it might actually have been a good one.)
This is a really good article here: How American Helath Care Killed My Father, by David Goldhill. Despite the sensationalistic title, the contents are quite reasonable and thought-through and fact-based. It's long (six pages), but read the whole thing. Then bookmark it and read it again tomorrow. There's a ton of juicy information in there, like the fact that America has one health-insurance-company employee for every two doctors, a sure sign that insurance is too big.
Goldhill estimates that if all the money our employers take out of our paychecks to go to medicare and health benefits was simply given to us as cash instead, the average person would be getting back something like $1.77 million over the course of their lifetime; and that if we put this into a savings account and paid for routine care directly, we'd be getting a far better deal. Prices would come down because we'd cut out the middleman, because people would be spending their own money and so would have an incentive to save, and because providers would be directly competing to serve customers.
We'd still need insurance to cover the truly catastrophic events. So Goldhill proposes a system where everybody has a HSA (Health Savings Account) to pay directly for routine care, and is also enrolled in a single mandatory nationwide insurance program that covers only emergencies.
I think there's a lot of sense in that. But there's no political will for anything like that. Right now the Democrats are only talking about expanding insurance coverage, not cutting it back to the places where it makes sense.
I found out the other day that Mozilla actually offers an HSA (Health Savings Account) plan as an alternative to the Anthem PPO health insurance that I have now. I looked into it a bit to see how it works. The nice thing about the HSA is that I could put money into it from pre-tax income. I pay almost 30% in taxes, so this is quite significant. The HSA comes with a high-deductible insurance policy that only pays for stuff over $5,000 (for the family plan) - in other words, it only pays for the truly catastrophic stuff.
However, the reason that I chose not to switch to the HSA plan is that Mozilla would not be redirecting the money that they're currently using to buy me insurance and put that amount into my HSA; instead, they'd just keep it. If I wanted money in my HSA, I'd have to take an additional chunk out of my salary to put there. Because of that, it doesn't make sense to switch, especially when the PPO alternative is so generous.
This is an example of how it's really hard for one person to break out of the system by themselves. It's a collective action problem. Even if widespread use of HSA plans would lead to a better health care economy overall, nobody wants to be the first one to switch because they'd be losing out by doing so. Switching America onto HSAs would require a complete overhaul of the system, a complete rewrite of the rules for employer/employee health care payments and tax deductions.
Anna Eshoo vs. Hecklers at CA-14 Town Hall (Long)
Two weeks ago I went to the health care "town hall meeting" (actually in a school gymnasium, because what town has a Town Hall anymore?) with the representative for CA-14, Anna Eshoo.
It was a depressing circus of rabid hyper-partisanship and grown adults acting like middle-schoolers in a playground fight.
It's taken me two weeks to write about the town hall just because it was such a weird and disturbing experience. I needed some distance from it.
I'm a very non-confrontational person, you know? Raised tempers, confrontation, and people yelling at each other makes me uncomfortable. Being in the middle of about a thousand people angrily booing each other made me feel threatened. I felt like I needed a detox afterwards.
While I didn't see any signs equating Obama to Hitler, there was a group of people outside with a mix of protest signs more or less focused on opposing government intervention. Standing across from them was a group of counter-protesters who were all little old ladies in crazy flowery hats with signs about how much they love their Medicare, "which is a socialist government single-payer program", and how they wish they could share it with everyone. They sang a song about it. I'm serious.
Inside the auditorium it was jam-packed; there were lots of people who didn't get a seat. We all got a stack of question cards on which we could write our name and contact info and a question, and pass them to one of the moderators, who collected them and brought them to Eshoo on the stage. She answered the first question from each person, with promises to answer the rest later, by e-mail.
It was clear from the moment Anna Eshoo took the stage that it was going to get rowdy. It was hard to tell for sure but I estimated about 1/3 of the crowd were vocally anti-reform protesters, mostly older people, who booed and jeered at pretty much anything positive Eshoo said about health care reform or HR 3200 or Obama, shouted out statements contradicting her, etc. Maybe 1/2 the crowd was on the pro-reform side, judging by the fact that they clapped at all the things the protestors booed at, but they weren't nearly as forceful or organized. Complicating matters there was another small but vocal contingent, maybe 1/8 to 1/6, who were die-hard for single-payer, so they would join in on booing the public option but then start up chanting in favor of HR 676.
I thought Anna Eshoo handled herself quite well in the face of this circus. She knew her stuff; she took questions straight from the pile without filtering them, and made honest attempts to answer them no matter how dumb or how hostile they were. She displayed an impressive command of facts and figures while answering difficult questions off-the-cuff, without notes. She didn't let the vitriol of the hecklers damage her composure. Several times when the audience got too rowdy, she tried to shame them into behaving, saying "I don't care if you disrespect me; I know some of you don't like me and that's fine, I can take it. But please have some respect for your neighbors, who have come here to have their questions answered, and quiet down so they can hear."
Man. Sometimes when people act like middle-schoolers, you have to treat them like middle-schoolers, know what I'm sayin?
Eshoo spent a lot of her answers focusing on the fact that the currently uninsured are costing us a lot of money by showing up in emergency rooms, that emergency care is more expensive than prevention, and therefore that we can save money by insuring the uninsured and getting them preventative care. (The point I made in this post.)
"Californians with insurance pay an average of $1400 on their health insurance premiums every year to help offset the cost of health care provided to the uninsured.", according to Diane Feinstein's website. I'd take that $1400 figure with a grain of salt, though, since I don't know how you can accurately measure these things.
A lot of the questions, I'd say the majority, were hostile, based on false premises, or were questions that were not really questions, like:
"Why do you want to destroy the best health care system in the world?"
"What will it take to convince you the majority of your consituents don't want more government control over our lives?"
It was pretty clear that these people were not against specific details of the plan; they were dead-set against having any reform at all. I mean, how the heck can a public option be described as "more government control over our lives"? That makes no sense. These kind of questions were just trolling, trying to get a reaction out of the audience, which they certainly did.
Some questions that were more about the protesters themselves than about health care reform. There were a couple which basically demanded that Eshoo apologize for mean things that other Democrats had said about the protest movement, like calling them "astroturf" or "angry mobs". This is both off-topic and, um, why should Eshoo apologize for something she didn't say? "I don't agree with demonizing anyone" is what she said.
A lot of the questions were pure right-wing memes. You can find the same memes all over any number of blog comments and forum posts all over the Internet right now. For example, there's a meme going around that says the Tenth Amendment puts any health care reform beyond the constitutional powers of the federal government, and thus it would be illegal for Congress to pass any such thing. (By that logic, Social Security and Medicare would also be unconstitutional... is anybody in favor of repealing them?) I was wondering if this meme would show up in a question at the town hall, and it did! Somebody challenged Eshoo with "What clause in the constitution gives the federal government the right to take over the medical system?"
The answer, by the way, is Article 1, Section 8:
"The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States."
Eshoo pointed out that Congress has people whose job it is to check the constitutionality of bills before they're voted on, that opinion in the mainstream constitutional law world is that the bill is legal, and that the Supreme Court is right across the street from Congress and ready to strike down any laws it finds unconstitutional.
This was one of a couple of fun moments when Anna Eshoo schooled the hecklers. Others:
She was asked if she would "promise to read the bill before voting on it". (This is another common right-wing meme: the idea that nobody in Congress has read the bill.) She picked up an actual copy of bill HR 3200 (in a large black 3-ring binder) and waved it at the audience, saying "I never vote on anything I haven't read. Not only have I read it all, I wrote parts of it. Maybe you should try reading it too."
She was challenged on the fact that some of the uninsured are uninsured voluntarily, and that HR3200 would take that choice away by forcing people to buy insurance. (One of the more well-founded criticisms, I think.) She countered by asking everybody in the audience who voluntarily chose to remain uninsured to raise their hand. Not one person did. "Very interesting", she said.
She also said, at one point, "I don't think anybody in this room wants to stand up and defend the practice of recission" ( when an insurance company drops a customer after that customer gets sick and attempts to collect on their policy). Total silence; nobody stood up. She pointed out that aside from the public option, none of the most important things HR3200 (and all the other bills in consideration) does is to make recission illegal, and that this is one of the ways the bill is trying to benefit the currently insured, not just to cover the uninsured.
I like Anna Eshoo a lot. Even though I think HR3200 is a pretty flawed bill (more about that later), I respect how she kept her cool under fire, schooled people with facts, took questions in good faith, and argued both the moral and economic rationales for why we need more coverage for more people. I find myself wanting to come to her defense against the people who were booing her.
Aside from the stupid questions, the other thing that pissed me off was that people just had to politicize everything she said. For example, she mentioned Ted Kennedy, and all the conservatives booed (really? so soon? no respect for the dead at all?), and all the liberals clapped louder to try to cover up the booing. Later she mentioned Ronald Reagan — not to praise his policies, just to establish the time frame of a certain Medicare reform — and all the liberals booed while all the conservatives clapped. Now what was the point of that?
Naked partisanship is an ugly, ugly thing. It's politics as war, as zero-sum game, where winning is not about passing laws that improve people's lives, it's about inflicting damage on the opposing team. It brings out the worst in human beings.
Said naked partisanship doesn't belong soley to the hecklers and anti-reform protestors in the current controversey. It exists on both sides. There was no reason for liberals to boo the name Ronald Reagan, except to, I dunno, express their team spirit, like soccer hooligans. He's dead, and although I don't agree with a lot of the stuff he did, his policies were not the topic of what we were talking about, and booing him has nothing to do with reforming health care.
Similarly, it's easy to dismiss the hecklers/tea-partiers as a bunch of angry cranks who can't get over the fact that their side lost the election last year. A lot of them would be protesting pretty much any serious reform plan by the Obama administration, regardless of its merits or flaws. It's also easy to laugh at them given the absurd falsity and illogic of some of their core arguments.
But you know what? I think it's too easy. For people like me who are generally pro-reform, it is too too easy to dismiss the opposition and, in dismissing them, overlook serious problems with HR 3200 and other proposals. These problems exist. It's fine to point out the stupidity and racism of some of the protest signs the opposition is waving, but doing so isn't going to make HR 3200's problems go away.
I don't know how many other people in the audience were like me — generally in favor of reform, but skeptical on the particulars, not ideologically committed to one particular method, and there because we wanted to ask questions and learn something. But whoever else was in that camp must have been as disappointed as I was that Eshoo had to spend so much time answering stupid troll questions and admonishing people to quiet down.
Two years ago, I said to my previous dentist "Hey could you take a look at my backmost top molar on the right side? When I touch it with my tongue it feels like there's a big hole in it." and he glanced at it and said there was no cavity, only a "ledge". But it still felt like there was a hole there, so last month I had my new dentist take an X-ray of it and she said "Yeah, the cavity is halfway through the tooth, this needs to come out."
Stupid first dentist totally screwed up!
So tomorrow morning at 10 AM I'm going in to get that tooth pulled.
I'm scared. Hold me.
My aunt needs $10,000 of dental surgery to fix a bone infection in her upper jaw resulting from a botched root canal years ago.
Insurance would pay for fixing the bone infection, but it would not pay for replacing her top front tooth, which would need to be removed. She'd be walking around with a giant gap in her smile.
Missing your front teeth is no fun: it makes you a bit of a social outcast, and makes it hard to eat a lot of things, but the insurance company can't afford to think about those things. Their job is to keep prices down for their customer base as a whole. I'm not just being snarky here: if we want health insurance to be able to keep medical prices down (and what other purpose is there for health insurance?) then we should want insurance companies look at things with a "needs of the many outweigh the needs of the few" mentality. Using that cold, Spock-like logic, it makes sense to pay to fix the bone infection, which could be life-threatening in the long term, but not to pay for the front-tooth replacement.
In other words, to ration their payments.
We keep hearing objections to any form of government intervention in the healthcare industry on the grounds that it would lead to rationing, i.e. some government bureaucrat is deciding whether you deserve to have your treatment paid for or not.
And you know what? It's true. There is a finite amount of resources out there that can be used for medical treatments. Government-provided health care (public option or single payer) will involve bureaucrats making decisions about rationing of care. Yes.
But, uh... This is different from private insurance companies how? Bureaucrats employed by private insurance companies are making these same sorts of rationing decisions right now, about my aunt's teeth and a million other things.
There is perhaps an argument to be made that private insurance company bureaucrats have incentives to be more accountable to individual needs than government ones do, because it's easier to switch insurance companies than to switch governments. But you try actually switching insurance companies, or try bargaining with them on rates or coverage, or for that matter try getting a human being to answer the phone, and see how much the insurance company cares about keeping one person's business.
It's pure wishful thinking to believe that any system will be able to give free unlimited medical care to everyone. There are a finite amount of resources to be used to pay for treatments. Whoever is doing the paying is going to have to say "no" to some requests. If you want treatment above and beyond that level you're going to have to pay for it yourself. This is true under any system. Thinking that public-option, or single-payer, care will end all need for rationing, as some reform supporters do, is daydreaming. But to claim we don't already have rationing in the current private market, as some reform opponents do, is to be oblivious to reality.
I got a shot of H1N1 ("swine flu") vaccine on Tuesday.
By Wednesday morning I had a sore throat and mild fever, like I was coming down with a cold. But was it an unrelated cold, or was it an immune reaction to the vaccine?
Today I've still got a sore throat; if I had caught a cold my nose would be running by now, and it's not. So I'm pretty sure it's an immune reaction to the vaccine.
I know that vaccines work by basically giving you a mild, non-virulent form of the virus. But this is the first time I've had anywhere near this bad a reaction to one.
If the vaccine is this bad, I'd hate to have the real thing!
Lately I've noticed that by 4 or 5pm at work my heart is beating way faster than it needs to, since I'm not doing anything more strenuous than sitting at a desk rocking out on my headphones.
I think I might be overdosing on caffeine. The free supplies of coffee and tea on offer at the office are really nice, but I think maybe I should cut it down to just one a day and see if my ticker calms down.
It's not carpal tunnel
Went to the doctor today and found out it's tendonitis, not carpal tunnel syndrome. Her recommendation was basically just to stretch, take breaks, and fix the ergonomics of my working area. So keep doing what I was doing anyway. That's why I'm now typing this on an ergonomic keyboard with my laptop screen raised to eye level, instead of hunching over the laptop like I used to.
My aunt has recently been into an alternative medicine practice called "earthing". It's apparently based on the idea that you'll be healthier if you keep your body electrically grounded at all times.
She asked me, since I know something about electricity, whether there's any scientific basis for it.
"Earthing" advocates talk about the ground as being a reservoir of free electrons; they say your body needs these electrons to neutralize free radicals, and they say that wearing rubber-soled shoes insulates modern man from the ground, cutting off your electron supply.
There's something psychologically appealing here - the modern world does make us feel cut off from the earth, so along comes a claim saying that being cut off from literal physical contact is literally damaging your health, for reasons that sound vaguely scientific. So I can see why people would fall for it.
Look, I totally believe that people who walk around barefoot outside a lot are healthier. But they're healthier because they're getting exercise and fresh air and sunshine and feeling carefree and feeling connected to nature, not because they're electrically grounded. Grounding yourself isn't going to hurt anything, but it's not going to give you "more electrons" than you would pick up from touching random objects all day.
If you're worried you're not electrically grounded, just touch a metal doorknob and you'll find out pretty fast! Getting the electrons you need to neutralize your charge isn't some gentle field of healing energy - it's literally a shock. That's all being grounded means: you're prevented from building up a static charge. In a circuit that uses A/C power and/or delicate electronics this is an important safety measure. But there's nothing special about the earth in this regard; it's just a large neutrally-charged object. Saying that the earth contains a limitless supply of free electrons is technically true, but that makes it sound like an energy source, which it isn't. (If it was, we'd be getting free electricity by plugging into the ground, not burning fossil fuels.)
And finally, if your body contains free radicals but is neutrally charged overall (which it is!), you're not going to pick up any extra electrons from being grounded. (As if extra electrons in your the skin of your feet could somehow find the free radicals in your body to neutralize them, which is extremely unlikely.)
There's a thorough takedown here which points out that neutralizing free radicals isn't even necessarily good for your health.
Earthing fans claim that it's been scientifically shown to reduce blood viscosity, but the abstract of the research paper shows a sample size of ten and it's not clear they even used a control group.
The people pushing "earthing" appear to be profiting from the sale of sleeping pads that plug into a wall socket so you can be grounded while you sleep. So yeah, this is yet another pseudoscientific fad designed to sell people expensive stuff that does nothing (see also crystals, magnetic bracelets, "orgone energy" emitters, homeopathic medicine, etc.)
The lesson here is that anybody can take any random harmless activity and claim it has health benefits, and as long as the claims are vague enough ("reduce aches and pains, sleep better, have more energy") the placebo effect will be enough to convince some people it's working.
And I'm mad at people who peddle this shit, because they're rip-off artists, taking money from people who don't know enough science to be skeptical.
But you know who else I'm mad at? The United States health care system. For failing so many people so badly that those people feel like they're better off believing in fucking magic than in modern medicine. If our health-care-slash-insurance-company system wasn't such a huge, uncaring, impersonal, bureaucracy, if it treated people as individuals deserving of empathy instead of interchangeable parts on an assembly line, maybe fewer people would be driven into the arms of pseudoscience.
After a week and a half of holding out against the flu epidemic, I finally succumbed on Friday.
Or did I? My symptoms aren't nearly as bad as what Sushu had, or what other people have been describing. I just feel like I have a cold, not the flu-of-doom.
Sushu and my mom both reported that after they got the flu, they got better, but a week later had a relapse.
My theory is that there's a milder cold following around in the flu's wake, taking advantage of people's weakened immune systems, like Turks following the Mongol Horde. And I avoided the flu, but then let my guard down and caught the cold.
On Friday, we had dinner at a not-very-good Indian restaurant (it's called Tava Indian Kitchen and it's like somebody was trying to make the Indian food equivalent of Chipotle).
After that we stopped at Trader Joe's to grab bananas and maple syrup. Cashier asked how I was doing and I said I felt like I was coming down with the flu. Then the conversation got very weird.
He said the flu was really bad this year, but "they're making it worse" by distributing flu vaccine shots, which are really a evil plot to GIVE people the flu, and nobody should get flu shots ever.
Yes, he was one of those anti-vaccine guys.
I was feeling too sick to argue, so I just told him that last year I got the vaccine and did not get sick, and this year I did not get the vaccine and I did get sick, so it works for me.
He backpedaled: "Oh, well, you're probably in the right age range and healthy enough to resist it, but they shouldn't give it to babies and old people"
Then I just paid for our stuff and peaced out. If I had been feeling better I would have argued with that idiot, because anti-vaccine hysteria really pisses me off.
Like hey, you ever notice how our generation was lucky enough to grow up in a world without deadly smallpox epidemics? How, if you live in a first-world country, you probably don't know anybody who died as a kid from whooping cough, or was permanently crippled by childhood polio?
All of those are because vaccines fucking work. They are a miracle of modern science.
And there's a very disturbing trend of people not wanting to vaccinate their kids because they heard it caused autism, and they're not only endangering their own kids, they're making it more dangerous for everybody else too by weakening the herd immunity. So I feel like pushing back against anti-vaccine hysteria is pretty important.