The nebulous nuts and bolts of health care reform

How is that "health care reform coming? New York City's Mayor Michael Bloomberg, a savvy businessman with a long and successful career, is skeptical regarding the pending health care reform bills. This is what he had to say on Meet the Press today:

MAYOR BLOOMBERG: You know, if you really want to object to something in this bill, number one, I have asked congressperson after congressperson, not one can explain to me what's in the bill, even in the House version. Certainly not in the other version. And so for them to vote on a bill that they don't understand whatsoever, really, you got to question how--what kind of government we have. Number two, when they talk about bending the curve, as, as the governor said, bending the curve is a flimflam euphemism for increasing costs, but we're going to say we'll do it at slightly lower rate than we would have otherwise.

GOV. PATRICK: That's not what I'm talking about.

MAYOR BLOOMBERG: I understand that. But they are not talking about reducing costs, they're talking about chancing the first derivative.

MR. GREGORY: Slowing it, right.

MAYOR BLOOMBERG: Slowing the growth down. And when you look at where the cost savings are going to be, well, they're going to cut something out of Medicare and Medicaid. Now, anybody that runs for office will tell you, you don't do that.

MR. GREGORY: Right.

MAYOR BLOOMBERG: I mean, the bottom line is it's so politically explosive, it really would be a first time in the history of the world if they ever cut anything out of either of those two programs.

I suspect that based upon the utter inability of any credible knowledgeable person to frankly state the cost of "health care reform," that Americans are in for a rude awakening. Consider the starting point: the terrible financial condition of Medicare. Here's how bad it is:

The present value of unfunded obligations under all parts of Medicare during FY 2007 over a 75-year forecast horizon is approximately $34.0 trillion. In other words, this amount would have to be set aside today such that the principal and interest would cover the shortfall over the next 75 years.

No private non--criminal corporation would submit operating budget this insane. Yet this is the type of program that we have come to expect from Congress, and it is based upon scores of accounting tricks. These sorts of tricks and traps are exactly what has been alleged about the current proposals for "health care reform." Consider the arguments articulated in the November 13, 2009 issue of Reason.

Congress is using "every budget gimmick in the book" to conceal hundreds of billions in healthcare-reform costs that will lead to "massive tax increases" and higher insurance premiums, one of the country's leading healthcare experts warns.

Early on, Obama originally pledged that his plan would save the typical American family $2,500 a year in healthcare costs. The main purpose of health care reform was "cost control." (see Obama's State of the Union Address from February 2009). Where is this cost control in the current bills? How can we possibly cover tens of millions of people who can't otherwise afford coverage, yet save lots of money for those who are paying their way? Both of the current proposals both depend on a government-funded free-market program administered by for-profit insurance companies. Paul Krugman has argued, however, that the free market doesn't work regarding health care.

[Y]ou don’t know when or whether you’ll need care — but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor’s office; and very, very few people can afford to pay major medical costs out of pocket. This tells you right away that health care can’t be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can’t just trust insurance companies either — they’re not in business for their health, or yours.

The second thing about health care is that it’s complicated, and you can’t rely on experience or comparison shopping.. . .

We are a country filled with people who abuse their bodies and then depend upon the health care system's expensive treatment. The annual cost of obesity alone in the U.S. is $200 Billion. In fact, we spend less than one percent of total health care spending on prevention. Where is the "stick" (or the "carrot") in the current proposals that will actually make obese, chain-smoking and otherwise reckless Americans change their wasteful and destructive ways? These are my concerns about the current proposals. Well, those concerns and these and these and these . And now we have the business-savvy mayor of NY stating that he has yet to find a member of Congress who understands how the current proposals would really work. And we have a Congress with a history of not actually dealing with fiscal catastrophe, but only putting it off for a few years. We have a system that has yet to explain how it will force Americans to live healthier life styles, in order to save that money. We have competing 2,000 page proposals loaded with lots of stuff that will only be revealed AFTER "reform" is passed. I can already hear it: "We didn't catch that obscure language inserted by [financially interested corporation] that will cost taxpayers an additional $40 Billion every year"). What sustains the momentum is that we will purportedly be insuring thirty million more people, even though it is not clear what we will be giving up in order to do that. Things that motivate the idea of "health care reform" are some low-hanging fruit such portability and restrictions on denying coverage for pre-existing conditions. I've advocated that we should pass laws regarding these obviously needed measures separately, so that we can then really look carefully at the rest of the proposal separately, to just it on its own merits, if we can cut through the morass of accounting gymnastics that apparently serve as the backbone of most of the package. Another thing that motivates passing "health care reform" is the name of the legislation itself. Who could possibly be against "health care reform." A good title does wonders for ramming through indecipherable legislation. This is the current health care "reform," as best I can discern it. It's not looking promising, because it's not looking financially sustainable.

Continue ReadingThe nebulous nuts and bolts of health care reform

Attenuating friendships

At the Chronicles of Higher Education, William Deresiewicz writes about our long-evolving idea of friendship, and it's not a good thing. The more friends we claim to have, the more we are diluting the idea of friendship. Deresiewicz makes many worthy observations along the way, including the suggestion that the classical idea of a committed friendship conflicts with the expanding notions of freedom and equality. When I commit in real-life ways to particular friends, I seem to be acting in an exclusionary way toward all of those people who didn't make the cut. In modern times (says Deresiewicz), deep and committed friendships make some of us uneasy. "At best, intense friendships are something we're expected to grow out of." The comments to the article divided rather evenly into those that found the article poetic and inspiring versus those that found the author to be verbose and "howling at the moon." Reading this piece, I repeatedly thought of Robin Dunbar's research regarding friendship. We are not physiologically capable of having more than 150 good friends at one time. But networking tools certainly seem to expand our contacts (if not our friendships) well beyond 150. How should we really describe those people to whom we are linked up, but not in a deep way or a flesh and blood way? Reading this article, I was also reminded of several friendships that I would absolutely positively claim to be deep meaning friendships, that were started and maintained through the Internet. None of these are mere Facebook "friends"; they each involved substantial amounts of private email and, eventually, some face-to-face discussions. I mention this to fend off any suggestion that "real" friendships should be limited to those relationships maintains primarily through flesh and blood encounters. Here's a bit more from Deresiewicz' thought-provoking article:

If we have 768 "friends," in what sense do we have any? Facebook isn't the whole of contemporary friendship, but it sure looks a lot like its future. Yet Facebook—and MySpace, and Twitter, and whatever we're stampeding for next—are just the latest stages of a long attenuation. They've accelerated the fragmentation of consciousness, but they didn't initiate it. They have reified the idea of universal friendship, but they didn't invent it. In retrospect, it seems inevitable that once we decided to become friends with everyone, we would forget how to be friends with anyone. We may pride ourselves today on our aptitude for friendship—friends, after all, are the only people we have left—but it's not clear that we still even know what it means.

Continue ReadingAttenuating friendships

Gifts that tell good stories

Geoffrey Miller has written an extraordinary book, Spent, that challenges us to recognize that our ubiquitous efforts to decorate ourselves and others with goods and services are primarily to project image and status. (and see here and here) "Many products are signals first and material objects second." The result is that we often engage in a vast orgy of spending mostly to look good in the eyes of others. What does this have to do with Christmas? We humans are also creatures who are always looking for shortcuts. Many of us have deliberately chosen to work long hours as part of "career" choices in order to make more money. Most of us who have who have made extra money as a result of those long hours at the office would much rather burn off some of that money at a store than to spend our severely limited amounts of time creating goods or providing services. We'd like to believe that our gift-giving is a display of our good intentions and of who we are, but as Miller points out, the store-bought gifts so many of us buy serve only to display only a narrow range of qualities regarding who we are:

Buying new, real, branded, premium products at full price from chain-store retailers is the last refuge of the unimaginative consumer, and it should be your last option. It offers low narrative value--no stories to tell about interesting people, places, and events associated with the product' design, provenance, acquisition, or use. It reveals nothing about you except your spending capacity and your gullibility, conformism, and unconsciousness as a consumer. It grows no physical, social or cultural roots into your local environment. It does not promote trust, reciprocity, or social capital. It does not expand your circle of friends and acquaintances. It does not lead you to learn more about the convention, manufacture, operation, or maintenance of the things around you. Retail spending reveals such a narrow range of traits: the capacities to earn, steal, marry, or inherit wealth, and the perceptual memory and media access required to spend the wealth on whatever is advertised most avidly now.
(p. 271 ff). Those who procure gifts with a moment's thought or two, and with the help of credit cards, often fail in their attempts to impress. Retail spending pointedly fails:
[a]s a costly, reliable signal of one's dedication to a particular person (in the case of gifts), or to a particular acquisition (in the case of things bought for self display).
Miller reminds us that creating something yourself speaks much more loudly than a premade thing purchased at retail. The proof is that gifts which require personal time and creativity make much better "stories" to tell to family and friends. I largely agree with Miller, though I think that retail spending can make a compelling story in some circumstances. For instance, what if someone has limited financial means, yet digs deeply in order to purchase a nonfrivolous gift that another person truly needs (e.g., assume that someone of limited means provided a student with books that were desperately needed for a coming semester). During the Christmas season, however, Miller's version of retail spending is a common occurrence. Most of us patronize retail stores in order to send out ready-made gifts. This much is not disputed. What can be disputed in an interesting way, is why . Many people would claim that we give gifts to each other because we "care about" or "love" each other. Miller's writings dig several levels deeper, recognizing that we are human animals who have come equipped with deeply felt needs to display our traits to each other, and that we resort to retails gift giving to serve these deep urges. In other words, Miller resource to biology rather than folk psychology:

Biology offers an answer. Humans evolved in small social groups in which image and status were all important, not only for survival, but for attracting mates, impressing friends, and rearing children.

(p. 1). During this Christmas season, and at all other times of the year, it is fascinating to re-frame the widespread displays of gift-giving as anciently-honed and deeply-rooted biological impulses geared to ensure survival. For more, consider this post, entitled "Shopping for Sex" and this post on The Church of Stop Shopping.

Continue ReadingGifts that tell good stories