Progressives: Don't Get Hung Up on Single Payer

As a health policy wonk, whenever my vocation comes up among people of a progressive stripe, the conversation inevitably leads to (and usually ends with) the refrain, "if only we had single payer." Having dealt with the American health care system both as a consumer and as someone who reads hundreds of pages of its rules and regulations on a weekly basis, I understand the allure. Health care in America is an unholy pain in the ass. I would love to be given a card that lets me go to any doctor I want any time I want for free. But that's not happening, even in the rosiest scenarios,

Yes, we can and must do better, but "single payer" isn't some holy grail. If we just handed out Medicare cards to everyone in the country tomorrow, we'd still have to choose between traditional Medicare and Medicare Advantage. We'd still have to choose a Medicare Part D plan if we want prescription drugs. We'd still face 20 percent coinsurance and a litany of copays, meaning that we'd probably also shop for supplemental coverage.

Even if we somehow swept the Canadian system of paying for care down from the North, we'd still have to deal with the endemic perverse incentives of hospitals who are paid by the procedure, medical malpractice, fraud and abuse, the profit motive, and a good number of other aspects of American health care that are untouched by who pays for it. If the politics of enacting single payer above insurance companies' objections is tough, it's nothing compared to all the pharmaceutical companies, device manufacturers, hospital and medical associations, all demanding that the tax payer float the costs of every new, expensive thing without prejudice.

Imagine all the ads on TVs for scooters and diabetic testing kits if everyone had insurance that was guaranteed to pay for anything and everything with only a doctor's note. That's America.

I don't like our health insurance system, but consider this: every year these captains of industry don't take a growing percentage of our health care dollar. It's steady. It may be 10 percent, it may be 25 percent, but it doesn't change. At the same time, hospitals and doctors are paid more and more and more annually. Put those two facts on a curve and the math it pretty clear that health care costs are going up, and it's the cost of health care (not health insurance) that drives it. We could save money with single payer, but the pressures to spend more and more on the newest gadget, or the guy with the fanciest medical degree will remain. Medicare deals with this in the same way that private insurance does, and faces real political and regulatory constraints. It's health care that's expensive, not health insurance.

That said, even people with really good coverage must sort through a morass of deductibles, copays, preferred providers, pharmaceutical tiers, and who knows what else before a claim is either paid out based on some hidden algorithm, or it's rejected by some mysterious technicality. Forget it if you're poor, have crappy coverage, or can't be bothered to learn the rules of a game whose rules are both arbitrary and capricious. In my work, I'm constantly exposed to a regulatory structure that's designed to both encourage a functioning, competitive market and reduce abuses of the consumer that are often a result of that competition. I have to be familiar with dozens of federal, state, and private rules, and am supposed to have some wisdom about how they all interact. I'm reminded again and again that one person's policy pet peeve is another's cash cow, and that even with the best intentions, the everyday consumer is powerless against this deluge of legal jargon. The market can help here, but not without some strong, sometimes complex, sometimes controversial protections for regular people. We can and must do better.

Single payer would be simpler to deal with. It'd probably be somewhat cheaper too. Had we gone for it in the 60s, when Canada and other nations did, before medicine got so expensive and profit-driven, it'd probably have been a much better decision than any alternative proposed since. But here we are today. Health care is far more complex and costly than it was in 1965. With the power and economic influence that health care has amassed, I doubt that even Canada would be able to pass today what it did back then.

It's possible that a few states will move ahead with legislation, despite the recent setback in Vermont. It's even possible that Single Payer will spread like wildfire until some day decades hence, the Alabama legislature approves CrackerCare to become the 56th state in the union with a fully public system. But progressives can't just sit around and hope.

Right now, all the energy in health reform is on the conservative side. All the model legislation bandied around statehouses calls for greater "consumer participation," where larger deductibles and copays, an ever growing stack of confusing insurance products each with its own shell game, and fewer regulations is somehow supposed to lead to a utopia of Joe Consumer shopping for his chemotherapy from a number of willing, transparent bidders, each vying for the shrinking balance in his Health Savings Account. That's reality, and it's happening now. The progressive answer to complex, though thoroughly bad legislation with a good chance of passing cannot be "yeah, but Single Payer." It has to be complex, good legislation.

So what are some progressive ideas that might work within the confines of today's health care system? A few general principles are a good place to start.

1. The consumer should be freed from having to think about whether they're better off going for the cheaper or the more expensive chemothreapy. That's a job for doctors and insurance companies. As a consumer, I can shop for those with the right tools. I can't be expected to decide how best to treat my cancer.  
2. If it's cheaper health care you're after, deductibles and copays are a waste of time. A $5,000 deductible keeps consumers away from doctors who might prevent a problem early on, and then, once it's a $100,000 life-threatening problem, doesn't really affect the consumer's decisionmaking. It's the quintuple bypass surgeries that make health care expensive, not the visits to the cardiologist.
3. The government should set rules for negotiation between doctors and insurers. It should ensure that a neutral third party is available to appeal an insurance decision within  24 hours.
4. The consumer should be able to deep-six any insurance plan that gives them the run-around any time they want (within reason). That's consumer-driven health care.
5. The government should provide and publicize good evidence on what's good and what's a waste of money, regardless of who stands to make money off of it. Insurance companies can do with this what they will (within reason).
6. If we're going to have private insurance companies, they need the same bargaining power that the state would have. Much of Europe has private insurance. The difference is that everyone has it, and the companies bargain collectively. Let the insurance association sit down with the medical association and come up with a fair price for things.  
7. Insurers should pull from the same risk pool. Right now, plans are carefully crafted to keep sick people out. They might not offer a particular drug, or have a higher copay for a given condition. If insurers' risks were adjusted across the whole population, they'd compete on who offers the best service, not who has the cheapest patients.

There must be a clear progressive alternative to the status quo in the post-ACA era. Progressives need to get better at talking a big game while playing small ball.  Single Payer is a nice, simple idea, but it's not the only way to achieve better health care for more people for cheaper. We can't wait around for a perfect alignment of political forces to usher in some new, magical era of free health care for all. We can't expect its opponents to take it lying down. We need to work on the system as it is, today, before someone else does. We need to do this now.

    

Just because it itches...

Back in Junior High and High School there was this sort of guy who could reliably be made to fight almost anyone, almost at any time. The Spaz. All anyone had to do was walk up to him and say something like, "yo mama better stop wearing that rainbow lipstick because when..." and he would spaz on command, running headfirst at the guy who says it, or as a bank-shot move, the guy that the spaz thinks said it. Looking back at it, he was probably deeply traumatized by events of his past or the realities of his present. It was probably the only way he knew how to react. He always came back for more.

The Spaz is a modern allegory for us-- America and many others aside. This isn't middle school. It's the Middle East this time, and all we do is spaz, spaz, spaz.

"...We are continuing this policy in bleeding America to the point of bankruptcy...All that we have to do is to send two mujahedeen to the furthest point east to raise a piece of cloth on which is written al Qaeda, in order to make generals race there to cause America to suffer human, economic and political losses without their achieving anything of note other than some benefits for their private corporations... Every dollar of al Qaeda defeated a million dollars, by the permission of Allah... As for the economic deficit, it has reached record astronomical numbers estimated to total more than a trillion dollars."                                                                                                                                                            --Osama bin Laden                                                                                      

When this started out, we charged into the Middle East headfirst in a righteous fury. A bunch of Arab guys had run several planes right into our nation's most enduring symbols. Thousands died, and the rest of were deeply shaken by what they did. So we went to Afghanistan, who only recently had finished with the French, British, and Soviets. The Arab guys who first came up with the whole idea were holed up in some caves in the middle of nowhere there. So we killed almost all of them, and many others aside. We spilled our lives and torched our money there.

Then we notice Iraq, who may never have cared for suicidal Quran-banging hillbillies, but was somehow supposed to have nuclear arsenals fit into overhead-bin-sized suitcases, thermoses full of VX gas, and tubes of toothpaste full of plague, all headed our way. So we went there too. And we killed almost all of those guys and many others aside. Lives and money were everywhere traumatic, ignoble wastes. And for nothing but a cabal of desert sadists, some old Russian tanks, some decent oil fields, and a hundred thousand dead, largely blameless, faceless people. We saw existential threats there and everywhere.

Eventually, most of us didn't like what we'd done over there. Here in America we were poor and shell-shocked. So a new president was voted in, and we mostly left Iraq and Afghanistan, somehow still hemorrhaging lives and money over there. Then other Arab guys, and many others from Central Asia and East Africa, who mostly learned from the earlier guys' run-ins with us, tried to smuggle bombs in Gatorade bottles, shoe soles, and underwear. They set off some nasty bombs on European public transit a couple times. They nearly got us in Times Square. And we mostly held back from all-out war.

Since then, several European countries, America and other allies have stopped many, many of these guys. A few have gotten through, and people in the West have died, but we were paying less and less attention to Iraq and Afghanistan, focusing here on ourselves as a nation than as vengeful occupiers of others. Then there were a few civil wars across North Africa and a few in the Near East, with all their associated atrocities and injustices didn't seem to raise our hackles like before. We mostly held back. So they took hostages and they start posting their grizzly deaths on Facebook, Twitter, YouTube and a thousand other sites, each with their own millions of viewers, watching agape. And we can no longer hold ourselves back.

Now we're going back into Iraq. We're talking about bombing Syria. We're making secret handshakes with Iran and greasing the palms of generals and sheiks. We're getting pressured to "leave everything on the table" in certain quarters here at home. But we know we're being taunted again. The overall threat of those behind ISIS might be vastly diminished from before, but they are taunting us with every last tool still available to them, scaring the world with viscous, horrific images, doing everything they can to drag us headfirst back onto the battlefield.

Let's be clear. Terrorists can hurt us. Even from afar, with only an IPhone, a kitchen knife, and a black mask, they can disturb us down to our soles. But nobody anywhere these days talks about these guys on the awful scale of nuclear annihilation. Let's not forget that just before we started getting involved in the Middle East, we had passed a generation under the real possibility of billions of lives gone in a final conflagration. Before that, a generation had gone to a war against total world domination, just after a massive economic collapse of their own. Before that there was only more of the same, and worse by many measures before that.

How can we compare the horrors of slightly more distant past with the events of the past thirteen years? It's been nearly an entire history of violence, and our traumas have left us punch-drunk, angry, and afraid. Terrible things may have happened to us in the past, but all it takes is a mama-joke now. These weak, almost childish enemies can get us playing their unending game. This time we have to see that the whole world is no longer at stake here-- there is no need to spaz. 

Listening to Dictators

One thing about dictators is that they're usually the most brutal in countries that were made up by others in the first place. Take the atrocities of Saddam Hussein, who was allowed to run roughshod over his straight-lined piece of desert because of other people's desires for oil and cold wars. We even encouraged him to gas people when we were fighting the Iranians.

Another thing about dictators is that when their authority is questioned, they usually say that the country will fall apart without them. If there's one thing we've learned in the 21st century, it's that they're usually right. We don't have to like them, but they're not stupid.

As a nation of immigrants ourselves, America has no natural ability to understand what sectarianism really means to people whose families have been killing one another for generations. Our collective boat ride over the proverbial ocean erased those instincts from our psyches, and replaced them with clear borders and a constitution that we hold sacrosanct. So we're left with pious theory. In come the neo-cons; people whose lack of instinct and skillful amnesia could only come from America. Denial is not just a river in Egypt. It flows right through our own country. 

Watching events unfold in Iraq, Syria, and to a lesser extent in other parts of the middle-east, I sometimes imagine the raspy laughter of Saddam Hussein, followed by endless "I told you so's." I can easily picture just how absurd it must have seemed to him for our haughty generals to believe that we could replace what he controlled only through great bloodshed with peaceable, pluralistic, semi-secular democratic institutions.

For those who think that if we'd just stayed longer, dug in deeper instead of "cutting and running," it's worth considering now not whether nominal peace could have been assured in Iraq, but whether we could have achieved it without the level of tyranny that men like Saddam Hussein believed necessary. The tyrant has a natural constituency, speaks the local language, and has everything to lose by his defeat. These are inborn advantages to running a highly fractious, largely contrived nation that no amount of military hardware can surmount.

Others can relitigate the decision to go into Iraq. I'm actually grateful that the matter is up for discussion once again. It's the only way we have any hope of not repeating its mistakes. I'm more interested in what we should do now. While it was apparently news to some a decade ago, we know by now that in the Levant and Greater Mesopotamia there are several ethnic and religious groups that have never gotten along. Why should we force them to live in the same country?

Yugoslavia came into existence in the same era as Iraq and Syria, and for many of the same reasons. Once the dictators fell, it wasn't long before a nasty civil war broke out, followed by a plodding though eventually successful political resolution. Its progress strikes me as an excellent model for foreign involvement in a seemingly intractable ethno-religious conflict. Perhaps if the Kurds, Alawites, Christians, Sunnis, Shi'ites, and a handful of others had their own states, they'd relax a little.

Perhaps those who live in nations that aren't ethnically their own would be viewed less as separatist enemies, and more as minorities that deserve protection. Nations with large separatist factions might even consider giving the separatists what they want. The Kurds of Turkey might drop the freedom-fighter bit if there was an actual Kurdish homeland, instead of a theoretical one that must still be fought for. If I was Turkey, I'd even donate some acreage, perhaps in exchange for a sweetheart oil deal.

My belief is that people who have a long history of hating one another might be better served by having their own borders, and answering to their own leaders. It's not to say that nations can't be very diverse. Perhaps levels of economic development or cultural heritage play roles. Whatever the case, when people start hurting one another, these sorts of solutions ought to be high on the list of anyone interested in stopping it. 

The World Doesn't Owe You a Thing

Mass-Killings. Gun Rights. Mental Illness. These issues will be thoroughly argued over, forgotten, and rehashed when the next 20-year-old opens fire on innocents. What hit me about this most recent tragedy is the raw narcissism at its root. Here is a man who believed that his failure to attract the opposite sex is due to some systemic failure in the nature of all of humanity. It wasn’t he who was untalented, unattractive, or just plain unlucky. Despite his obvious superiority to anyone who ever had any actual success in getting laid, his failures all came down to unerringly shallow women who were universally attracted to brutish men. The cosmic order of things was simply skewed against men like him. The only solution was for them all to die. How can anyone think that way?

Despite the headlines, most troubled young men don’t end up as mass murders. Some become criminals or recluses. Some just kill themselves. Some get over it. The solutions are manifold. Experts have toiled over identifying some algorithm that predicts who is who among this most dangerous group, and how to stop them. Take all the guns away and surely there will be fewer deaths. Public vigilance might head something terrible off. Improve mental health care and surely someone will get the help they need. But none of those decisions alters the fact that any one mass shooter represents thousands of others who don’t quite have all the pieces in place to commit such a reprehensible act. Certain policy changes may alter the odds of one particular tragedy, but they will do little for the related but subtler forms of suffering present in all quarters of our society. What is it about these men? What does it mean for the rest of us?

Maybe someone who harbors these feelings of self-hate, or hatred of others will read this. If so, the one thing I want you to hear is that the world doesn’t owe you a thing. No amount of rage or retribution will bring you peace. Get all the help you can, but in the end, it’s up to you to heal.

The tragedies that bring about suffering are irrelevant. Suffering is suffering, whether it’s because the Khmer Rouge tortured and killed your whole family, or because some girl rejected you in the eighth grade. In both instances, people are left with the simple choice of how they react. Do we blame others or is it somehow our own fault? Ultimately, are we capable of overcoming suffering or will it destroy us? Will we find it just to take others with us?

In my limited experience, despite some chemical imbalance or series of genuine tragedies, the most resilient people are the ones who believe that the world doesn’t owe them anything; that injustice happens and that the only question is what we do with what we have. Given the same variables, different cultures lead people to different choices. We can and should help those in need, but for real healing there must be some sense that in the end, it’s up to us to improve our own lot. Maybe it’s with the help of family or friends. Maybe it’s religion or some other social order. Maybe our cultural shortcomings are due to the erosion of traditional institutions, or the growing mountain of self-referential role models present in our torrent of media, but it’s not just about the next 20-year-old mass shooter. Something is lacking in many, many of us.

Malaysia 370: All Right, Good Night

Something about the disappearance of Malaysia Airlines Flight 370 is utterly captivating. Pings off of a geosynchronous satellite tell us that the plane was last on one point of a vast arc that covers a significant fraction of the globe, including both the wilds of central Asia, and one of the emptiest stretches of deep ocean in the world. That’s the last we know.

Before 1999 turned to 2000, people believed that even TV remotes wouldn’t work after a mysterious bug in its and all electronics’ programming took hold in the moments we rang in the new year. Many were confident that the whole world would fall into chaos as power plants shut, traffic lights went dark, and phones went dead. Whatever happened or didn't happen, none of those beliefs mattered once the event came and went. In the hours after 9/11, people believed it was right-wing crazies, left-wing nuts, radical vegetarians, or terrorists. We all wanted to know, “what are their demands?” though that seems beside the point in light of the continuous war that must have been the real demand of all sides concerned.

Sitting where I am in time, I know that Malaysia 370’s fate will probably be known someday soon, even if ten days seems like a long time for a jumbo jet to remain missing. It may return as some horrific vehicle of destruction at the center of a terrorist plot. It may be at the bottom of the Indian Ocean. But right now, nobody knows. It’s during times like these, before all the mysteries are revealed, that capturing thinking on what happened is of underappreciated importance. In our era of information collection few new mysteries are made. Too little is not captured in some database or closed-circuit camera. Once all is known, conjecture collapses into cold fact; the stories end, and the remaining carcass of truth is picked apart by analysts.

For this window of time before all is known about such a globally witnessed event, there is a space for public imagination, and that in itself is valuable to people in the future who want to understand the veins of thought at work in today’s collective unconscious. Some groups with high profiles, have raised the possibility of alien abduction. Many look at the potential flight paths to central Asia as a reason to suspect that the plane touched down safely in some mountain redoubt to be repurposed for something terrible. Maybe it’s the Uighur separatists-- the East Turkestan Liberation Front. The Chinese say no.  Then there’s the Malaysian Al Qaeda informant who spoke of a 9/11-style plot back in 2012. Or maybe it’s pirates, intent on taking the 777-ER to a chop-shop in some non-aligned state, or selling it at a markup to someone who prefers not to order directly from Boeing.

For myself, I'm pretty confident that the plane crashed somewhere in the south Indian Ocean, after an electrical fire or some other cataclysm onboard led the pilots to make a sharp turn for a nearby runway, and take their communications offline to isolate an errant circuit. Autopilot could have been programmed and engaged before the pilots lost consciousness and the plane would then have continued on a southern heading for many hours until its tanks went dry and it fell into an unimaginably massive expanse of unpatrolled ocean, somewhere in the lonely landlessness west of Australia and north of Antarctica. I also want to believe anything but that simple, sad likelihood. 

   

We want to believe that the 239 people onboard that plane are somehow still alive, held captive by terrorists or pirates, to be released when the time is right. Others want their beliefs confirmed that it’s Muslim terrorists as usual. A few want to ascribe the plane’s disappearance to aliens, benevolent or otherwise.  These are the thoughts that are in today’s mass psyche; the thoughts that will be mothballed and forgotten in internet archives once the truth is almost inevitably known. There’s a value to those ideas, a sense of how people in a given moment respond to something that hasn't yet reached its conclusion, or perhaps never will.

As time compresses with our expanding capacity to capture and analyze everything everywhere, these mysteries will shorten in their duration or disappear altogether. Would Amelia Earhart still remain missing if she had set out today? Would people still be free to imagine her living out her days on some desert island these past 75 years?

Mystery, even when couched in tragedy, is a rare, precious thing. We should all try to remember what we used to think before we knew everything. It's the key to understanding belief.