Universal Health Care

Judging by how long it's been since the health reform meltdown of '94, we can estimate the half life of this issue's radioactivity at a little over a decade. Politicians no longer shrivel in its presence. Interest groups like hospitals, doctors, insurers, and retirees no longer find it useful to toss around health reform to one another like a hot potato. Health reform is now mostly inert, though heavy, seemingly unmovable. No one doubts that it has to be put to rest. One sixth of this country is chronically without health insurance, and many more have intermittent, or near-useless coverage. The system is no good for anyone, if you can call it a system.

Before moving forward we need to have a national dialogue on what our system should look like. There are so many options, even the options have options. a First, why universal coverage?

The moral argument: Universal health care is a human right. It's a matter of basic human decency.

...Yes, but not like the right to breathe. It's one that you have to claim. It doesn't come to you, and only go away when things go wrong. Nations (and states) determine when and how this right will be extended to their citizens.

The practical argument: Universal health care saves lives and money (but not necessarily in that order).

...Yes, but you're a cold blooded reptile to try and stand on this argument alone. Nevertheless, this is the way ideas are sold. You can't just be a libertarian and ride in from the ranch to the ER whenever you feel like it. We all pay for that. Car insurance is mandatory because it avoids one party getting the raw end of the deal. The same could be said about health insurance. Insurance is about security in a place where we all share the road.

People in health policy like to say that the way you pay for health care is completely separate from how it's delivered. In other words, to describe any health care system, you have to think of both sides of the equation. Different systems think of it in different ways. What they have in common is that they cover everyone, and that they are heavily coordinated by the government. Here is a brief a la carte menu of health care systems we can debate.

The Canadian/Scandinavian/Limey Insurance Model:

This is what people are talking about when they say "socialized medicine". The state is the big, basic insurer. In some places, they are the only legal insurer, in others, they are legally allowed to insure some things and not others. In England, for example, everyone is part of the National Health Service scheme, but people can buy private insurance as a supplement, and see private providers too. They have the option to buy their way out. Canada is a bit more restrictive in this respect, and the Scandinavians are as well. As far as care delivery, English doctors are mostly contracted by the state, and subject to direct regulation, though reforms in the 90s developed all kinds of market incentives for performance, and ways they could make profits by doing the right thing. Same goes in Scandinavia. They aren't afraid of the market, they just want it to work for them-- all of them. These are the systems where people hear about long queues for non-urgent things like hip replacements, and the occasional horror story about someone dying in line for a heart bypass. These are real complaints, no doubt, but these systems have better health indicators in almost all respects from infant mortality to life expectancy, cover everyone fairly equitably, and cost half as much of their country's GDP's than ours (roughly 8% vs. 16%). They're also working on those queues.

The German/Dutch/Frog Insurance Model:

These systems evolved out of medieval guilds, where all the candlestick makers would pitch money in for a "sickness fund" where one candlestick maker could draw from if they got sick, their wife had a baby, or whatever. During the unification of Germany, Bismarck got involved in all of this, and started to find ways were the candlestick makers could subsidize the ironworkers, even the paupers. Gradually, different industries each got their own insurance companies, and the state redistributed money to and from each of them as necessary. People could take their coverage with them their whole lives, and they could buy into more posh coverage as they moved up the career ladder. The key here is government coordination. They make sure that all of the complicated arrangements work, and that the doctors get paid in ways that make them want to do good work. It's heavily bureaucratic, but the emphasis is on insurance tied to one's employment, however confusing the overall arrangement may be. It's a market, with the state as the referee. France's system has a more private bent to the whole arrangement, but like the others, guarantees comprehensive coverage for everyone. This sytem provides high-quality care to all, but sacrifices some of the power to manipulate public health that comes from the Leviathan paying for everything. These systems cost around 10-12% of their nation's GDP's, and do it better.

What should we do?

This is my opinion. The fact of the matter is that insurance companies do a lot of business in this country, and already have long-standing relationships within the health system, not to mention the political system. Single-payer people (wannabe Canadians) want to make their business illegal. Insurance companies could allow a great amount of consumer choice-- something that is basically an American value. The government needs to ensure that all Americans are consumers, and that all of us consumers are able to choose from essentially the same basket of insurance products. If the rich want more, fine. But we need to get good coverage for all.

We need to do better than "bare bones" coverage too. People need to be able to see the doctor. They need to have affordable medications. The state needs to get involved. Doctors, big pharma, insurance, and yes, we will pay for it, but in the long run it's cheaper to get people in seeing the doctor before they cost $50,000 in emergency surgery, or end up on dialysis. In any sense, it's only fair to have all sides pitch in to this. At the same time, we aren't Scandinavians here; we won't accept a wait in line for the sake of solidarity, but we must accept that covering people is both moral and sensible. There is an American solution to this problem out there, and we can learn much from an examination of our values, and the values that led to the systems that other countries have developed. We can do this our way, but we must do this.

There is a lot more to say about health care, and I imagine we'll hear a lot more from the politicians and talking heads on TV in the coming months and years. I'll probably lay out what I think should be the basic demands we should make on the designers, but I think that as a country it's time we sat down and figured out how to make it happen once and for all. Health coverage is a basic right that is just plain missing here in a place with so much money and creativity. Let's claim our rights.

Double or Something

We're seriously considering sending another 20-40,000 troops to Iraq as a stopgap measure to pacify the place. There's good reason to believe that the psychology at work behind such a proposal may lead towards real biases in decisionmaking. Take this example from Foreign Policy Magazine:

Option A: A sure loss of $890
Option B: A 90 percent chance to lose $1,000 and a 10 percent chance to lose nothing.

"In this situation, a large majority of decision makers will prefer the gamble in Option B, even though the other choice is statistically superior."

If you're going to apply this thinking to our current situation, I think something is missing in this calculus. It's that we're not talking about the difference between $1000 and $890.

First, the currency isn't dollars, it's kids. We're talking about the difference between 3000 soldiers and 4000, or more. Second, we don't know our odds of success. They could be 10%, 50% or whatever. All we have are the opinions of experts, most of whom say that it doesn't look good. Even the players say we'll have to bet more than we're willing to make a difference in this mess we're in.

To leave now (or soon, or something, anything) would mean a sure loss of a war and 3000 lives. As our situation looks ever grimmer, there is a temptation to up the ante, to call and raise, to shoot the moon, whatever cardplaying metaphor you choose, the odds are worse than roulette.

For the same psychological reasons that gambling is so universally popular-- the possiblilty of sweet victory, we are biased towards the unfavorable odds of warfare. Even when we win, it's at a great cost. Even when we have a winning hand, we lose lives in the process. Unlike dollars, lives can never be replaced by the bank.

It looks like this time our leader's poor estimation of risk got us into a sucker's game. Their basic assumptions of the situation, that there was a real threat over there, that we'd be received as heroes were wrong. They mistakened Vietnam for V-E Day... what looked like a slam dunk turned into a bloodbath.

History and psychology show that, right or wrong, in the end war is more often a fool's game than our instincts are likely to predict.

The decision to go to war may turn out to be wise or unwise. History provides examples of both. But for every Second World War, there is a Korea, a Vietnam, a Napoleonic Folly. Sometimes we win, sometimes we lose. But we must make the most impartial calculations possible.

Leave the Texas Holdem poker yokels to TV. Too much is at stake.