I'm just a bill, yes I'm only a bill

An incredibly hostile FAQ about healthcare reform (aka, HCR):

What is the key issue to remember when discussing HCR? That Congress is broken, and to the extent it works, it's generally to funnel money to the lawmakers themselves.

Wait, what about HCR? We're getting there, hold on a sec...

OK, why is Congress so broken? Well, one party acts like we have a parliamentary system, where party discipline is king and there is no need to negotiate across the aisle, whereas the other is famously disorganized, full of corporate sellouts, and actually does take no steps to maintain party discipline, as Chairman Lieberman can attest. The House passes stuff, but is full of idiots from both parties who don't even understand the work of the committee they chair, speak loudly without saying anything, and needless to say the one nuclear scientist in the room must often feel like he's talking to the furniture.

Wait, if they are so useless how do they pass stuff? Two answers: Nancy Pelosi and lobbyists. In Pelosi's defense, her job is to pass decent legislation, and the house does do so. To go into more depth, congresspeople don't write legislation, they put their names on lobbyists' legislation. Their job is to choose which lobbyists get to write it. I'm pretty convinced lobbyists earn their money not by being evil, but rather by appealing in broad ways to the interests of sitting legislators and then working in sweet deals fro their clients at the margins of bills. I can say for darn sure that the average house member has no concept whatsoever of the content of an average bill, even if they wrote it. Think of it like a university research time. The legislator (professor) is busy with meetings and other important functions, so they hire a team of aides (postdocs) who do know their stuff, but can't handle all the volume of what they have to do, so much of the grunt work is done by lobbyists (grad students), who work for peanuts (large comissions) and scrape by (live comfortably) based on leftover free food (hefty payments by their clients). See, it's a nearly perfect analogy (not a perfect analogy).

Anyway, what about the Senate. How does it work? Bribery. Mary Landrieu was bought off for $100 million, which is pretty cheap considering that they really needed her vote. Ben Nelson got such a sweet deal that he's now actually embarassed by it. Lieberman is just a prick.

So the bill is a product of corruption and idiocy? Yes.

So we should hope it goes down to defeat, right? WRONG!

We should support it, because it is a product of corruption and idiocy? No, as we established, all Congressional bills are like this, but this one happens to help millions of Americans get health insurance.

Why shouldn't they blow up the current bill and start from scratch on a better one? Naive sucker, Congress. Congress, naive sucker. It never gets better, it's Congress. It only gets worse over time. To draw a historical analogy of which my wife is fond, Lincoln was attacked viciously during the civil war because the Emancipation Proclamation was seen as overly compromised, not freeing all slaves in the country. I think his judgment looks OK in hindsight, because it was better than not doing anything.

Why should we make people buy insurance with an individual mandate? Because that's how social contracts work, people. The whole point of insurance is to have the healthy pay for the sick, otherwise, we wouldn't need it. Something has to make the healthy overpay, on the chance they might become sick, or otherwise the sick have to pay the full amount, and that's really not a good thing.

What about the increase in the stock prices for the health insurance companies? They think it's a great deal for them... The stock market is driven by people not much more accurate than Jim Cramer over the long run. They basically put a finger to the wind and then say to buy if some idiot on CNBC says he has a hunch. It's also been pointed out that food stamps are a great boon to supermarket chains and the tycoons of companies like ADM, who are hardly liberal heroes, but that doesn't argue for cutting off food stamps.

I still want Medicare for all. Why can't I have it? Congress! How many times now? It takes $100 million to bribe a powerful senator, and much less for the average congresscritter. For any issue that could cost an industry more than several billion dollars, they will generally be able to bribe their way into getting what they want, since it is in their economic interest to act that way.

Medicare-for-all pretty please? Look, I agree with you, which is why they should have pushed for lowering the eligibility age over time down to 55, maybe by 1 year per year or two. They didn't, and instead the public option was basically stripped of all its power in the house, then killed completely by jackass centrists in the Senate, and then Lieberman poked a stick in everyone's eyeby pushing for, then against, the Medicare buy-in option.

I'm depressed, we should blow up the whole system and rebuild something better from the ashes... This was actually the argument of a popular post at Daily Kos, arguing that the "technocrats" like Ezra Klein (who along with Jon Cohn and Nate Silver are the three people everyone should consult on this issue on a daily basis) were wrong about Iraq, while the Dirty F'in Hippies were right, and the same split is playing out on the left over Health Care reform. Unfortunately, the argument is backwards. As a general rule, it is very worrisome when people agree to risk immediate harm to others in return for some greater good in the future. In Iraq, we were fighting for some sense of security in the future (read: oil profits) that was never really at risk (read: oil profits going to other countries instead!). Those many deaths were traded for the broken and illusory promise of a brighter future, which remains a moral stain on our nation and will continue to do so long into the future.

With healthcare, we have the chance to make a tangible gain now, admittedly one that falls far short of what many of us would have liked to see. Blowing that chance up for some possible future healthcare panacea is just as immoral in a priori terms, as there are real people who will suffer while we place our trust in the American healthcare system to break down and then Congress to step in and fix it. Needless to say, while the former is certainly decent bet, the latter is pure fantasy. While imperfect, the current bill helps a great number of people, an that is the true standard on which it needs to be judged.

Now when arrows don't penetrate, Cupid grabs the pistol

Happy Valentine's day, from me and some gentleman from Atlanta (note the video was made by a fan, and is not an actual music video...which should be really obvious after about three seconds). Tonight, I learned a crucial romantic lesson: if due to the combined effects of bad weather (we covered this yesterday), changes in planning (my wife had a meeting in Peoria today that got cancelled last minute), distractions (my car got stuck half in/half out of the parking spot in the snow), and all around failures on the part of a husband to arrange a Valentine's Day dinner for his wife, hope is not lost. Pick a nice restaurant in town (Biaggi's in this case, an somewhat upper midscale Italian chain, but this is Champaign, after all) and get there early!!! 5:30pm does nicely, getting us a 20-minute wait at what actually passes for a nice restaurant around here. Tiramisu for dessert will make sure that dinner ends happily for all involved.

A brief bit of history: according to the Wikipedia, Valentine's day as we know it was actually not invented out of whole cloth by Hallmark, like Sweetest Day (may those who invented it and ask us to celebrate it be accursed through the ages), but rather by Chaucer. Apparently, he made reference to a non-existent Romantic holiday in May to commemorate the first anniversary of King Richard II's engagement on May 2, the saint's day of Valentine of Genoa. This was confused with the feast of St. Valentine, on February 14, which fell coincidentally near a Pagan holiday, and was eventually used to mirror it, much like Christmas/Yule.

I'll note that starting tomorrow, dkon is welcome to name the second Rooted Cosmopolitans Charity of the Month, which will be features in our right-side sidebar up at the top. In honor of the final day for Kiva.org, I finally made my promised donation to Christina Schuster of Samoa, who is trying to expand the store that allows her to lead an independent life and support her family. I ponied up my $25, and all she needs is $50 more to get her loan. C'mon people, it's Valentine's day, so show the love to her and all the other people who want the chance to live a better life.

Just so I don't forget it, Ezra Klein has a summary from McKinsey about why the US healthcare system is so frickin' expensive. Essentially, they find we pay too much for basically everything. From the blog post:

The very short answer is that we pay more for units of care. McKinsey estimates that it is not higher disease prevalence. Differences in health account for only about $25 billion of the variation -- a drop in the bucket. The difference really is that we pay higher doctor salaries, higher drug costs, higher operation costs, more per day in the hospital, etc, etc. In essence, we're getting a terrible deal.

With that, peace and love to all y'all and remember to be nice to people and especially not to kill anyone if you can avoid it. My New Year's resolution is still going strong (click the link and scroll all the way down if you've forgotten about it)!

Day or night he'll be there any time at all, Doctor Robert

It was brought up in comments that the US seems to prioritize access to healthcare services more than countries with national systems. It doesn't translate into higher life expectancy, and we have a particularly high infant mortality rate, but what about overall satisfaction? We're good at that, right? Not so much. From the Organisation for Economic Co-operation and Development:
Public’s satisfaction with health care system, seventeen countries, 1999-2000
Country Percent satisfied with system
Austria 83
France 78
Belgium 77
Denmark 76
Finland 74
Netherlands 73
Luxembourg 72
Sweden 59
U. K. 56
Germany 50
Ireland 48
Spain 48
Canada 46
U.S.A. 40
Italy 26
Portugal 24
Greece 19

To quote my great-grandparents: For this you pay twice as much? To be as satisfied as Southern Europe? You must be meshuggeneh.

Anyway, there is a class of Americans who aren't so dissatisfied with their healthcare. From Kevin Drum at the Washington Monthly's blog Political Animal, commenting on the numbers above:

It takes a bit of interpolation to extract all the numbers, but that's not hard to do. So with that in mind, here are the percentages of Americans who say they are "fairly or very satisfied" with their own health system:

• Poor: 45%


• Elderly: 61%


• Everyone else: 34%

This is pretty remarkable. First, the elderly in America, who are covered by a state-run national healthcare system (Medicare and Medicaid) are way more satisfied with their healthcare than everyone else. As it happens, the elderly in other countries also tend to report higher satisfaction levels than other people, but usually by just a few percentage points. In America, where the elderly are covered by a national system and others aren't, the elderly are more satisfied by a whopping 27 percentage points.

Second, even the poor are more satisfied with their healthcare than the rest of us. The poor generally rely on a combination of Medicaid, emergency rooms, and free clinics for their healthcare, a system that's hard to beat for sheer inefficiency and appalling service. But even at that, the rest of us, who are mostly covered by employer-provided health insurance, are less satisfied than the poor. The system of health coverage provided to the vast majority of American citizens is so bad that we like it even less than the jury-rigged system the poor are forced to use.

Similarly, the VA system typically ranks higher in satisfaction than private care. To recap, we pay twice as much to be half as satisfied with private insurance, and only those currently in the national systems seem to like it.

My friend works for the National Health, Doctor Robert; Don't pay money just to see yourself with Doctor Robert

I know tonight is the big Iraq speech, but until we have a serious President willing to treat us like adults, I'm not going to waste my time on half-baked recyclings of quarter-baked plans that will fail again for the same reasons they've failed before, dooming countless more American troops and Lord knows how many Iraqi civilians to blatantly unnecessary deaths. If I was even vaguely religious, I'd say God have mercy on the souls of all of us poor bastards, but I'm not. If you happen to be, you may want to consider including humanity in your prayers. We need it desperately.

Instead, let's go over a topic where the situation is just as fucked on the ground, but we can at least maintain some hope: healthcare. Just to set some parameters, people in the US spend more per capita on healthcare than any country in the world. From the Kaiser Family Foundation:

It is reasonably well known that for some time the United States has spent more per capita on health care than other countries. What may be less well known is that the United States has had one of the highest growth rates in per capita health care spending since 1980 among higher income countries. Health care spending around the world generally is rising at a faster rate than overall economic growth, so almost all countries have seen health care spending increase as a percentage of their gross domestic product (GDP) over time. In the United States, which has had both a high level of health spending per capita and a relatively high rate of real growth in that spending, the share of GDP devoted to health grew from 8.8% of GDP in 1980 to 15.2% of GDP in 2003 (Exhibit 5). This almost 7 percentage-point increase in the health share of GDP is larger than increases seen in other high-income countries.

...

Despite this higher level of spending, the United States does not achieve better outcomes on many important health measures.

Let's be clear here: since we are the only major Westernized nation without some kind of national healthcare system, Americans spend vastly more money privately on healthcare than anyone in the world by a vast margin. On top of this, our government also spends more money than any other government in the world. The total amount ends up nearly double that of any other country, as this table shows (BTW, a side note: this link goes to Ezra Klein's blog. He's one of the writers at The American Prospect, with a focus on healthcare and labor issues, and nearly everything I say here can be found in much greater detail over there).

There is some progress on the state government front, with the Governator proposing a statewide private universal healthcare plan in Cali, which is generally but weakly supported by Kevin Drum and Ezra Klein, but knocked by Atrios for being a half-assed vehicle toward the eventual goal. Both sides make some important points about what really is no more than a halfway-measure toward an eventual solution, but I may have to steal some insight from the gay marriage debate and suggest that getting the ball rolling anywhere is important, and there is plenty of time to improve the system as you go. Let's go over the good and bad:

Good: Universal mandates are good. Some people worry about being "forced" to pay for insurance, but Ezra rightly points out that under ordinary circumstances, we call these payments "taxes":

In fact, there is absolutely no universal health care system that wouldn't include a mandate of some kind -- that's how you make it universal. Indeed, without a mandate, you can't have a decent health system: If the healthy can opt-out until they get sick, coverage will be unaffordable for everyone. For a risk pool to work, it needs members at low risk.

The secret is to do what we do with taxes: exempt those whose incomes fall below a given level. California wants to use 250% of the poverty line. Ron Wyden has a plan in Congress with a more attractive and expensive 400% (soak the rich!), but at least we're on the right track, and everyone is covered.

Community Rating: This means that they can't just boot you for having a pre-existing condition or a "dangerous" job. In California, they deny all coverage to firefighters, athletes, and people taking Celebrex and any number of other medications. This is rather obviously a crucial bit of a universal system, and one of the main weaknesses of the current system, which punishes people for proactively discovering and treating medical conditions.

Bad: Private insurance companies are horrifically inefficient. Their goal, as corporations, is to make money, primarily by insuring young and healthy people who will have low medical expenses, and denying coverage to older and sicker people, who actually need the insurance in the first place. Healthcare costs are incredibly unevenly distributed, with costs concentrated amongst small populations. Insurers can ditch these people, insure the rest, and make huge profits, all while defeating the purpose of the system treated as a whole, For a more recent example, consider the fact that insurers pay hundreds of dollars, if not thousands, to find each new Medicare plan signee. The money they make must be greater than this amount, and it comes from taxpayers and the Medicare clients themselves.

Employer-based insurance is no longer viable. I am at my third job in my twenties, with a new one coming up in the not-too-distant future. Each time I move, I need a new insurance company. God forbid I ever have a pre-existing condition. In fact, there is a huge incentive for me not to find one until I get a permanent job. This is not a good medical incentive. Even worse, academics have among the most stable career paths out there. In today's more transient working society, the old employer-based model doesn't work (it's also killing off a few American companies, like GM). This is the key to the Wyden plan, which would eliminate employer-based insurance. For this reason, it is currently considered fanciful, and will eventually be considered so obvious that our children will wonder how their parents ever managed to tie their shoes or feed themselves.

The obvious solution is single-payer, in which everyone pays into a central pool, and the national system pays out to doctors (like Medicare or the VA system). At this point it's damn near inevitable, but for the fact that it would put insurance companies out of business. Someday, the outcry against the ridiculous system will force us into change, but at least a few big states passing half-assed measures have made this a respectable debate again, a decade after the Clinton plan was unfairly savaged by the insurance industry. We'll close with Paul Krugman, to whom one is wise to listen, but for the fact all his columns in the NYTimes now require a subscription. From the NY Review of Books:

So what will really happen to American health care? Many people in this field believe that in the end America will end up with national health insurance, and perhaps with a lot of direct government provision of health care, simply because nothing else works. But things may have to get much worse before reality can break through the combination of powerful interest groups and free-market ideology.

In a nutshell, we currently do everything wrong. We eliminate economies of scale by having too many companies provide the same service to their own smaller client bases, and in doing so manage to unpool the risk from the population back onto smaller groups, which defeats the whole purpose of insurance in the first place. The future can't arrive soon enough.