Health for the next America.

Nic Kristof owns an important point. The rest of the article is similarly exquisite.

“Why is it broadly accepted that the elderly should have universal health care, while it’s immensely controversial to seek universal coverage for children? What’s the difference — except that health care for children is far cheaper?”

a.j.m.

Filed under: Health , †ime

Two more fortunate truths about health care.

First, David Leonhardt points out that collective bargaining has created a class of exorbitant health care plans that do not make those who hold them appreciably healthier, but do contribute to the spiraling proportion of our gross domestic product that we spend on health care. Because the government does not tax the proportion of salaries that goes to employer-provided health care, the United States essentially subsidizes these very expensive plans. Leonhardt explains:

If an employer pays a worker an extra $100 in income, the worker may keep only $75 of it, while the government will get $25 in taxes. But if the employer puts that $100 toward health insurance, the worker will get all of it.

This tax break causes us to buy more health insurance than we would if the playing field for taxes were level, much as the tax breaks for housing helped inflate the real estate bubble. In effect, the tax-free treatment is a subsidy for health insurers, doctors and hospitals. It encourages wasteful spending — the extra M.R.I., the brand-name drug that’s no better than a generic, the cardiac-stent procedure that has no evidence of extending life (but does have some risk).

Because these plans often eliminate co-pays, it would re-incentivize doctors and individuals to take more responsibility for patents’ health rather than simply firing off needless tests and treatments. Lastly, a tax on expensive plans would transition people out of them, raising their wages because employers will spend less overall on those expensive plans. There is even good evidence that individuals don’t particularly feel like they need these plans, making the issue fully positive-sum for everyone except lobbyists who orchestrate the collective bargaining. (That’s win win win win, for those of you keeping track at home.)

Second, NPR has a really cool story about Safeway’s popular and successful plan to discount health care for healthy employees—that is, those who are not obese and don’t smoke. This incentivizes good lifestyle choices and internalizes the externalities of poor choices. Why the latter?

“In our particular case, when we have an elevated premium for a smoker, that premium goes into our health care fund with the ability to take care of that employee 10 to 15 years down the road, should they develop lung cancer.”

And did I mention the plan is popular?—to the tune of 78 percent of employees. (& be sure not to miss the elbow NPR throws at the end.)

What’s the point of all this? Easy: Americans do respond well to reasonable incentives to improve the quality of their health care, and enjoy doing it. Of course, they also respond to incentives to spend money and make themselves less healthy. Put together, this is an argument for transitioning health care away from a model in which politicians spend time trying to mirror weakly-held and uninformed opinions, and more time doing what’s best for the country and for the health of American citizens.

a.j.m.

Filed under: Health , positive sum

Pollan on food & health care.

I hope you all got a chance to read Michael Pollan’s New York Times op-ed from a week ago about the relationship between food and health care. I just got to it, and I’m glad I did.

The gist is that the way we eat drives health care costs up precipitously—the CDC estimates that three-quarters of health care spending is aimed at “preventable chronic diseases.” Smoking falls in this category, but so do many expensive diet-related ailments—obesity, diabetes, and so on. Redressing this problem, he says, is even more difficult than reforming health insurance because there is no-one to stand on the side of reform and against the food industry—for now, there’s no real money to be made in feeding people better.

The surprising upshot is that the healthcare bill could change that. Requiring insurers to cover everyone, without respect to existing conditions, gives them every reason to back reform: Type 2 diabetes can cost $400,000 to treat over the course of a lifetime. That’s a lot! We probably won’t see teams of claims assessors-turned-commandos raiding the local McDonald’s, but maybe we can get some momentum going for public education campaigns, better school lunches, and repealing farm subsidies. One of the best points that Pollan is now making is that the government is now footing both sides of this fight, by subsidizing unhealthy food and then having to pay to keep people who eat it from dying. And it certainly makes their lives worse in the meantime—how’s that for government intruding on your happiness?

It goes to show that one of the best things you can do for your country is to feed yourself well. It’s trite, but I love that Pollan encapsulated it in a mantra. I think about it a lot, actually:

Eat food. Not too much. Mostly plants.

a.j.m.

Filed under: Health , food, pollan

Child Mortalities Decline Globally

An article from The New York Times today titled Child Mortality Rate Declines Globally is well worth a look. As expected, it is well worth a look, partially because the news is better than the title lets on. Here are the first two graphs:

MPATA, Malawi — The number of children dying before their fifth birthdays each year has fallen below nine million for the first time on record, a significant milestone in the global effort to improve children’s chances of survival, particularly in the developing world, according to data that Unicef will release on Thursday.

The child mortality rate has declined by more than a quarter in the last two decades — to 65 per 1,000 live births last year from 90 in 1990 — in large part because of the widening distribution of relatively inexpensive technologies, like measles vaccines and anti-malaria mosquito nets.

Why such good news? First, because a decline of that magnitude—some 30%—in two decades is astonishing progress. Second, the rate of decline is so high that even with high fertility rates, the absolute number of child deaths is declining. We should be careful in the coming years to continue this trend, and not to pay attention solely to the mortality rate. This planet owes Bill Gates a great deal—more than enough to excuse him for sub-standard software.

a.j.m.

Filed under: Health , Gates, IMR

Why so much health care on The International Interest?

It’s a blog about international politics—what gives? (Or, if you will, wtf?)

Without tipping my hand too much, diligent readers may have pieced together that an unusual theory of American hegemony has been developing gradually. This has been an American hegemony for a world that is basically safe and generally improving—a leadership for a progressive world. This view of hegemony requires a sensitivity to the balance of perceptions globally, the balance of that which is persuasive. This is a progressive hegemony characterized by offshore balancing, tacit deterrence, and a devotion to the international interest. Of course, more on this later.

The question of health care falls into the first category. In a world in which more states become democratic by the year, international security concerns put less pressure on domestic polities to centralize rigidly, and the rising capabilities of the world’s citizens mean that more of them are entering politics, the capacity of states to exercise reflexive reason over their foreign policy behavior is increasing. This means that nations will gain more discretion over their behavior, as structural pressures to balance the Soviet Union, say, decrease. For this reason, American hegemony cannot look like British or Roman hegemony, which succeeded in putting in place a system of structural economic and military, constraints on state behavior. If American hegemony is to preside over a system of states possessed with agency, American policy must alter the balance of that which is persuasive to citizens abroad.

Progressive hegemony is one way this can occur: if most people abroad think of the United States as leading an international community of states toward a world that is healthier, safer, more prosperous, their willingness to contribute to the hegemonic order increases correspondingly. On the other hand, if America is seen as an inherently obstructionist, regressive country seeking to maintain hegemony only for its own primacy, that hegemony will be increasingly tenuous. And, of course, convincing the world that we are dedicated to building a healthier world means starting at home. As the only advanced democracy that does not offer some system of universal health care, the prospects for progressive hegemony are dim indeed.

Building a healthier world, and a more compelling international order, starts at home. Accepting an obligation to the welfare of foreign citizens means first accepting an obligation to the welfare of our own. No country in the history of the world could do more to improve the welfare of the world’s enduring poor than we can right now. Making the leap from domestic responsibility to cosmopolitanism that the next generation of progressives will be pleased to fight—but right now we don’t even have the rhetorical and moral substrate to build on. America’s struggle for health care is important for international relations, because in this case, as goes the United States, so goes the world.

a.j.m.

Filed under: Health, Who We Are , progressive hegemony, TII, saarr, autonomy

Principles of health care reform.

Jonathan Cohn, in the New Republic yesterday, writes another excellent article that succeeds in conveying what a weird amalgam the current health insurance proposal is. The guiding principles of the current debate are these: (a) reform should be as bipartisan as possible, (b) it should push as much insurance as possible through employers (the “you can keep the plan you’ve got” clause), and (c) it should be revenue-neutral. The difficulty, of course, is that both of these principles make for worse policy—fewer insured, less choice, higher costs, worse care.

Because we are trying to claw our way gradually up a continuum to a sustainable solution (single-payer health care, for example), we end up with this bizarre and universally suboptimal middle-ground. Take the case of the exchanges, which I’ve written about before. The current plan will establish a marketplace through which individuals could purchase insurance from both public and private providers; the exchanges are regulated, exclusion because of pre-existing condition is prohibited, subsidies are provided to low-income families entering the exchange, and so on. The trouble is that the current plan would prohibit any individual who currently receives coverage from their employer to enter the exchange. This makes employers unhappy because small businesses will have to provide costly health insurance; it gives consumers worse care because they’re prohibited from entering an efficient market that drives down costs if they so desire. And even if the exchange does attract a significant number of uninsured Americans, they may not have the benefit of a competitive public option now, or this public option will be made worse off.

The long and short of it is, the principles that Obama has put in place to guide the debate make for worse policy, no matter how much maneuvering is done within those guidelines. The guidelines, not just political opposition, prohibit reasonable options from rising tot he surface. Notice that there is a perfectly simple middle-ground between a single-payer plan and the current proposal: allow any American to enter the exchange or keep their current option as they please. Those who don’t want a public health care plan because they’re worried Obama is going to come into their homes and put a pillow over their children—just don’t switch. It would be difficult for those who do leave their employers’ plan, join the exchange, and opt for the public option to argue that they are being coerced simply because the government can offer better care. You will have ever liberals’ heartfelt condolences for being enticed into health. This is not even what many experts feel is the optimal solution, a single-payer plan; this is a simple adjustment to the current compromise that would provide better coverage.

So here is the point: more and more it seems like health care is not an issue that this polity can cope with adequately. There is too much vitriol, too much opposition, too much fascination with democratic procedure to accomplish anything worthwhile. The Democrats botched this thing from a start: you can’t fight hyperbolic fire with an ongoing negotiation. Health care reform is one of those things that should be negotiated by technocratic, bipartisan experts, behind closed doors, with access to every shred of information and data available to the American populace, and then voted on by congress, yes or no, in one fell swoop. Health insurance is not a point for compromise and posturing: health insurance is one of the basic duties of a civilized populace, and one the United States currently does not live up to. Health insurance should be expensive for its government, unabashedly successful, so capable it becomes transparent, and this accomplished by any reasonable political means necessary. Our government do what it takes to ensure that none of us have to think about health care again—because it is one of that scant handful of things a government must do for its people.

a.j.m.

Filed under: Domestic, Health, Practicing Politics , single-payer

The next American cities.

A couple of days ago, this marvelous little page on frumin.net was going around pretty hard. The page describes the contents of a report from the New York Met. Transportation Council that gives traffic numbers for various routes into Manhattan, which are staggering. The summary is well done, so I’ll simply quote it here:

Just to get warmed up, chew on this – from 8:00AM to 8:59 AM on an average Fall day in 2007 theNYC Subway carried 388,802 passengers into the CBD on 370 trains over 22 tracks. In other words, a train carrying 1,050 people crossed into the <CBD every 6 seconds. Breathtaking if you ask me.

Over this same period, the average number of passengers in a vehicle crossing any of the East River crossings was 1.20. This means that, lacking the subway, we would need to move 324,000 additional vehicles into the CBD (never mind where they would all park). [...]

At best, it would take 167 inbound lanes, or 84 copies of the Queens Midtown Tunnel, to carry what the NYC Subway carries over 22 inbound tracks through 12 tunnels and 2 (partial) bridges. At worst, 200 new copies of 5th Avenue. Somewhere in the middle would be 67 West Side Highways or 76 Brooklyn Bridges.

More complete numbers are available on that site and, naturally, on the report itself. He goes on to calculate roughly the additional amount of space needed to park all the cars that the subway saves from coming onto the island, which leaves massive black blocs down that stretch from 3rd Ave to 9th and take up three times the size of Central Park.

What the author neglects to note is that the continuum does not run between the current situation and this counterfactual New York made up of huge black blotches—in fact there are possibilities that extend in the opposite direction. Right now New York is in a large part made up of those huge black boxes, it is just that they are split into a capillary grid that covers the entire city. When the streets are punctuated by blocks, it is difficult to see just how much city space is taken up by surface streets. So I got curious.

The images below were hacked together very casually and unscientifically in Photoshop, without any help from my seventh-grade art teacher. They are in no way precise or accurate—but they are illustrative of just how much precious urban space is taken up by surface streets. That’s a lot of space! And yes, we do make use of it, but think of the opportunity cost—could we make better use of precious urban land that we mostly use for baking asphalt.

I’ve said it before on this page and I’ll say it again—the first day an American urban area prohibits private cars in its limits will be a great day for the human race. Note that not every street would have to vanish immediately, to provide for access for emergency services—but every other one perhaps could be closed to provide space for public markets, parks, playgrounds, gardens, what have you. Public transportation could expand to drop nearly everyone within a short walk of their home, and covered bike thru-ways could be expanded. Private cars could be parked on the outskirts, but if high speed rail is expanded, rapid regional downtown-to-downtown transport would make this option less and less palatable over time.

As far as I’m concerned, it looks like another of those win-win-win possibilities: shared common spaces could encourage communities to form, gardens and doing away with cars could encourage public health (through exercise, diet, and respiratory benefits), the environmental impacts would be unimpeachable. And, perhaps best of all, we wouldn’t all have a strip of asphalt mini-mall outside our homes. Not all of us have cobblestone streets like Georgetown—but obviously even they could fare better.

I’m being a little dreamy, I understand—but I bet it’s closer than you think, in places like Portland, Seattle, San Francisco. We already regularly impair the efficacy of private cars, with speed bumps, one way streets, cul-de-sacs, dead ends, and so on—and for good reason. And, of course, bicycle ridership has been up this depression (they were already 75,000 on average daily in New York, or 8.6% of all traffic by number, by 1992; 20% of everyone who go over Portland’s Hawthorne bridge are on a bike). It’s a smaller step than you might think.

a.j.m

Filed under: Health, cities, sustainability , bikes, food, roads

Good reads today.

• Greenpeace has up with more than its fair share of absurd and counterproductive strategies of resistance in its history, but its recent tack is a clever one. Aiming at the enormously destructive practice of bottom trawling, in which boats drag nets across the sea floor, leaving huge, barren scars and killing large quantities of both wanted and unwanted wildlife, Greenpeace is sinking large 3-ton boulders into the ocean at strategic intervals to try to prevent the practice. In the past, the organization has struggled to find productive uses for its capabilities (like many environmental groups), but this seems particularly clever: if the governments of the world refuse to regulate overfishing in their waters, they certainly shouldn’t regulate a group moving some rocks around. Ho hum. Don’t mind us.

• The New York Times has an excellent article today about a survey by health insurance companies that intends to highlight exorbitant doctors’ bills, particularly for out-of-network procedures. $20,120 for a knee operation for which Medicare pays $584; $72,000 for a spinal fusion procedure that Medicare covers for $1,629—and so on. This dovetails with Atul Gawande’s influential piece in The New Yorker that points to collective culture among doctors as a culprit in spiraling healthcare costs. These kinds of statements belie the Republican talking point of government-run healthcare coming between patients and their doctors: with very little accountability for what tests doctors order and how much they charge for them, a room that holds just a doctor and a patient has no actor with the knowledge and the interest in holding down unnecessary costs that don’t improve the patient’s health.

a.j.m.

Filed under: Health, sustainability

Choice is good for health care.

Ezra Klein (best), Jonathan Cohn, and David Leonhardt, three of the best, all weigh in favorably on Ron Wyden’s Healthy Americans provision that would open the Health Insurance Exchanges to Americans already covered by their employers’ insurance plans. As it stands in the bill currently, only Americans whose employers do not provide health insurance could visit the Exchange, compare private and public policies, and select their preferred option. Employers whose workers wish to leave their plan would be compelled to provide them with a voucher for what they would have been paying for that workers’ plan anyway. That sounds awfully American.

As it stands, the Democrats’ talk about “giving Americans a choice” about health insurance is only true for the 50 million uninsured Americans; Wyden’s plan would open the market to wider competition, allowing people to move away from inefficient plans that happen to be provided by their employers and provide for Americans with particular needs. As it stands CBO Director Doug Elmendorf told the Senate last month that health care reform will cost money: this provision is just what is needed to allow health care reform to save some of the enormous sum of money that isn’t making us healthier. And isn’t that what this is all about?

a.j.m.

Filed under: Health , health care, Leonhardt, Wyden

Health care is a family value—the cost of giving birth.

President Obama’s press conference last night on the health care reform bill has everyone up in arms. And while I’d be happy to spend my life fighting this fight, I’m not the guy to do it. But I have learned a great deal that I didn’t know—including this.

A post on reddit yesterday said the following: My wife recently had a baby, this is the bill….

• Wife with previa placenta, c-section, 9 days hospital – $50k+

• Son 3 weeks immature, 3 weeks in NICU – $140K+

Welcome to American health care. I do have insurance so with that it will be about $20K out of pocket for me. And most importantly my son is now 5 weeks old and thriving.

A commenter to that post is well worth clicking through to read: a Canadian, his wife had a pre-existing condition that caused a doctor to recommend a cesarean-section, three weeks before the due date. He writes: “I paid for parking. I paid to get some photos of the ultrasound in a cutesy envelope, and I paid something like $10 or $15 so my wife would have a phone in the hospital room. I never saw a bill. I don’t know how much all this cost. I’d never think this is all that remarkable except that I keep hearing that it is.”

I’m quite young. It had never occurred to me that childbirth could cost so much money, but I believe it. What I don’t know is whether those kinds of costs are at all typical. The March of Dimes found in 2007 that the average cost of giving birth in the United States was about $8,000—$11,000 for c-section (the rates of which continue to rise). On average, private health care services paid for all but $500 or so of these costs. Now, this isn’t a median, so it’s difficult to know what the distribution of people is like within this, but clearly a large number of people pay quite a bit more.

My point is this—if you care about any recognizable notion of  ’family values’ you would never, ever condemn an inchoate family to years of debt while they are also trying to nourish, clothe, and teach their child. Universal, efficient, and public health care is a family value because it is a human value.

Imagine a young couple, not long out of college, newly married, with no or partial health insurance. The woman becomes pregnant a few years earlier than they expected, but they decide to go ahead anyway. There is no earthly reason why that couple should be exposed to that kind of liability for starting a family. Assuming the couple has an immaculately average experience, and leaving aside the cost of the nine-month pregnancy, there is no reason why they should have to foot a five figure bill, and perhaps a great deal more.

If Karl Rove were framing this, he’d say our health care system imposed a birth tax. If a liberal academician were framing it, she would point out that this situation is precisely the kind that Rawls had in mind in proposing a system of justice as fairness. No country cloaked in a veil of ignorance about their social, economic, and health conditions would consent to a system that exposed young couples to that kind of risk, for something as arbitrary and capricious as a pregnancy complication.

Health care is a family value because it is a human value; it should be an American’s right because it is a human right.

Filed under: Domestic, Health , health care, values