Uninsured in America

Megan notes that the president has "downgraded" the number of uninsured Americans to 30 million -- most likely because the more commonly used statistic (45 million) includes immigrants, who will not have access to public insurance under the new plan.

Depending on how you look at it, the real number of uninsured is probably even lower than 30 million, since many of the uninsured are either eligible for some kind of public health insurance or wealthy enough to purchase coverage on their own.

Health Care Speech: The Good and The Bad

I didn't get a chance to watch the president's speech, but I read a pretty lengthy synopsis. From what I gather, Obama did an excellent job selling his proposals and dismantling some of the more transparent lies disseminated by conservative opponents of the bill. (Here is a good roundup of some of those lies.)

If nothing else, Obama definitely deserves credit for trying to put Congress back on track.

And it goes without saying that Congressman Joe Wilson should be ashamed of himself for his awful outburst. Kudos to John McCain for calling Wilson out. Wilson's comment was even more ridiculous because his claim is false. Obama is right. The bills being considered by Congress would not cover illegal immigrants.

Having said that, I do think it's important to address some of the (relatively minor) falsehoods that the president was peddling tonight:

1) Despite what the president says, preventative care is not likely to save money -- in fact, it may end up leading to higher spending overall. I've addressed this point in a previous post.

2) The House bill would allow abortions to be covered under the public plan. The president keeps insisting that this isn't true. He's either fudging or he's genuinely ignorant.

3) It's at best misleading for the president to insist that everyone who is currently covered will be able to 'keep what they have.' The truth is much more complicated and uncertain.

4) As one of Megan McArdle's commenters pointed out, Obama's reference to the highly-concentrated Alabama health insurance market is a bit odd and incoherent. Blue Cross Blue Shield Alabama -- which has come to dominate the market in that state -- is actually a not-for-profit insurance company. Since Obama has repeatedly argued that profit motive is one of the things stifling competition in the industry, the Alabama case seems to undermine his point.

Health Care Thought for the Day

It's often said that there are three major problems in American health care reform: cost, availability, and quality.

Unfortunately, I think there is really one major problem: People disagree over the relative importance of each problem.

Cultural Influences on Poverty in America

In his column today, David Brooks points to this article in the recently-launched National Affairs magazine. The author, Ron Haskins, paints a complex picture of poverty and economic inequality in the United States.

Haskins's ultimate conclusion:

[A]lthough there is room for government to help advance the cause of economic mobility in America, it can do so mostly by encouraging personal responsibility. Poverty in America is a function of culture and behavior at least as much as of entrenched injustice, and economic mobility calls not for wealth-transfer programs but for efforts that support and uphold the cultural institutions that have always enabled prosperity: education, work, marriage, and responsible child-rearing.

Thus, the inequality debate is not nearly as relevant to the more important question of mobility as it sometimes seems to many advocates and politicians. Inequality is a cloudy lens through which to understand the problems of poverty and mobility, and it does not point toward solutions. Great wealth is not a social problem; great poverty is. And great wealth neither causes poverty nor can readily alleviate it. Only by properly targeting poverty, and by understanding its social, cultural, and moral dimensions, can well-intentioned policymakers hope to make a dent in American poverty — and thereby advance mobility and sustain the American Dream.

I think one of the problems with contemporary liberalism has been its unwillingness to seriously acknowledge the destructive cultural factors that hinder economic mobility in some low-income communities. Many progressives behave as if "institutional inequality" is the only thing limiting the available opportunities for low-income families. But conservatives rightly point to the importance of personal responsibility and family stability.

Indeed, it often seems as though the liberal "model" of society has failed to account for the vast array of government-sponsored social welfare and social justice programs introduced over the past several decades -- most of which have failed to remedy the problems that they were designed to address.

Unfortunately, we now have a conservative movement that is more interested in browbeating the president over a simple "stay in school" speech than challenging him to more seriously address issues like parental involvement.

Update: Here is a good article explaining why conservatives should've been supporting Obama's speech to school children.

Anecdote of the Day

From John Kingdon's excellent Agendas, Alternatives and Public Policies:

One example of the principle of equity as the driving force [in the policymaking process] is the case of the government's renal dialysis program. As soon as the technology for convenient dialysis was perfected, it became clear that some people were receiving this life-giving treatment and others were not. The selections of patients to receive treatment were made on the basis of ability to pay, qualification for experimental study groups, proximity to the few centers where dialysis was being performed, and the happenstance of personal health insurance coverage. Gripping stories appeared in the popular media about "death committees" of physicians that were charged with deciding whose lives should or should not be saved.

Such a fundamental, dramatic difference of treatment was more than decision-makers could bear. The Senate passed a short rider introduced right on the floor which provided that renal dialysis and kidney transplants be financed by Medicare, and the House quickly followed suit. So compelling was the inequity that had thrust this item onto the agenda that Congress really did not consider the cost of the program in any detail, a cost that exceeded a billion dollars within a few short years. As one knowledgeable respondent summarized the forces that lead to such sudden agenda status and passage, "When there is serious inequity, that is politically and socially unstable. Once a technology is developed, everybody will want it." The moral pressure to avoid letting people die, when a procedure was available to save them but for a cost, was simply irresistible.

Another great example of why the "death panel" protesters are missing the real problem with increased government intervention into the health insurance market . . .

American Health Care Wants

Ross has a really good article in today's NYT on the morality and practicality of physician-assisted suicide. He writes:

There are many good reasons to oppose assisted suicide. It transforms a healing profession into a killing profession. It encourages relatives to see a loved one’s slow death as a problem to be solved, rather than a trial to be accepted. And as Emanuel noted in his 1997 essay, its “beneficiaries” are far more likely to be suffering from psychological distress than unbearable physical pain.

But in the profligate, Promethean United States, it probably won’t lead to rationing-by-euthanasia. It’s just as likely to become one more “intervention” that we insist every health insurance plan should cover — on our way, perhaps, to a rendezvous with fiscal suicide.

I agree with Ross's ultimate conclusion. The furor over government-sponsored "death panels" isn't just silly and distracting -- it's totally missing the point.

The problem with increased government intervention into the American health care system isn't rationing. (In fact, as regular readers of this blog know, I think that some sort of rationing is essential from purely practical point of view.) The problem is that Americans want unlimited care at unlimited expense. We also want unlimited choice, as Ross points out.

In the United States, the number of state mandated benefits has risen steadily over the past few years. (Here is a helpful old post by Tyler Cowen considering the economic implications of state mandated benefits.) We continue to call on our lawmakers to force health insurers to cover more -- not fewer -- medical services.

Americans want to have it all. We want to maintain our high wages. We want to keep our costly fee-for-service insurance plans. We want to be able to choose our medical providers. And we want access to the most expensive, cutting-edge treatments available.

We just want someone else to pay for everything.

Random Thought for the Day

There are essentially two way of looking at the legislative process:

1) You can belittle it. You can argue that our Senators and representatives are too beholden to constituents, special interests, and public opinion polls to ever effect real, substantive change on big-ticket policy issues. From this perspective, the process is inherently flawed, with an array of backward incentives that discourage intelligent large-scale reforms.

2) You can embrace it. You can choose to see all the bickering, partisan incrementalism -- the messy "consensus-building" -- as reflective of a society with conflicting moral and social priorities, where no one has a monopoly on truth, but where we slowly move toward some kind of positive collective agreement. As Immanuel Kant allegedly put it, "out of the crooked timber of humanity, no straight thing was ever made."

I suppose you could also do both of these things -- or, perhaps, you could see it in a totally different light -- but I think most people tend to fall into one of these two camps. Either you belittle the process or you embrace it.

So, which camp do you think you fall into?

Brooks on Health Care Reform

David Brooks responds to Gail Collins's questions on the unraveling of the health care reform bill. I really do enjoy "The Conversation." I think that Collins and Brooks balance each other out very well.

Anyway, I think Brooks makes some excellent points. He writes:

Most Republicans say the Democratic bills are radical and socialist. My problem with them is they are modest and timid. The Democrats say the current health care system is dysfunctional, then they preserve and extend it. They don’t touch the fee-for-service system. They don’t touch the employer-based system. They don’t alter the runaway costs.

. . .

The problem is that incremental reform doesn’t work. We have to go back and redo the system. My big takeway from this whole mess is that incremental reform doesn’t work. We have to go back and redo the system. I’ve said it before and I’ve said it again, the Wyden-Bennett approach is the way to go. It has bipartisan support. It is consistent with traditional American values, emphasizing individual choice, not top down control. It reins in costs in the only way acceptable to American voters, through competition not executive fiat. It would liberate us from the employer-based system that is dying anyway.

. . .

Two other random points. First, the political gridlock right now has nothing to do with Republicans. Democratic moderates are now firmly against the public option and I suspect generally against the Obama approach, because it will cost so many of them their jobs. The House is gridlocked, and it is under total Democratic control. The Senate is too, and would be even if Ted Kennedy’s seat were filled tomorrow.

Second, it should be said that most of the special interests are wildly in favor of the Democratic approach. The lobbyists are spending far more to support it than to defeat it. Big pharmaceuticals spend more money on TV ads than John McCain spent in his fall campaign. And despite this avalanche of money the public is still leaning against reform, at least as currently envisioned by the White House and the Congressional leadership. The public isn’t always right, but the majority views are at least worth taking seriously. Especially if you want to win elections.

I Got the Rationing Blues . . .

Julian Sanchez writes:

It's one thing to say there's a shared obligation not to let people suffer or die when we know how they could live many years longer, or in much less pain. I find it a whole lot less compelling to suggest that people are entitled to public provision of, say, Tacerva—which . . . was approved to treat pancreatic cancers because it improves survival time by a whopping 12 days at a monthly cost of $3,500.

This, I think, is the basic problem with health care reform. If you were dying from pancreatic cancer and you could pay $3,5000 to extend your life by 12 days, wouldn't you do it? I certainly would. From an individual perspective, this seems like an entirely rational decision. But from a social perspective, does it really make sense?

If we want to consider health care reform, I think we have to begin talking about rationing. Unfortunately, Republicans are only interested in using the idea of rationing as a scare tactic, while most Democrats refuse to even speak the word . . . .

Update: Megan McArdle has a long-winded post on this. I think she's right that it's a bit silly to frame the question this way -- these drugs don't expand everyone's live expectancy by 12 days, rather they extend the average life expectancy by 12 days.

Thus, some people may enjoy a few extra months of life, while others may die sooner because of an adverse reaction to the drugs. The point is that when you're facing death, a chance to prolong your life even by a few days (and possibly a few months) is probably worth it. The possible upside benefits of the treatment far outweigh the potential side-effects. And it's not easy to deny people drugs that could potentially extend their last few days of life.

McArdle writes:

I'm not saying that this is the standard we should adopt. But I actually think that it has a fair amount of emotional resonance, which is why appeals from cancer patients are so effective when they're denied marginal treatments.

I'd say that's true. And I suspect cost becomes less of an issue for these patients as they approach the end of their lives.

Katie Roiphe Clashes With Feminist Bloggers

Katie Roiphe -- who I think it one of the most brilliant opponents of rape-culture feminism around -- defends herself against the absurd criticisms of her recent piece on the joy of motherhood.

Conor Friedersdorf also jumps to Roiphe's defense.

From what I gather, Roiphe's detractors are upset about the subtitle of the article ("Why won't feminists admit the pleasure of infants?") . . . which Roiphe did not select.

I've been a fan of Katie Roiphe for a little while now. She's an excellent writer and thinker. Here is an old piece where Roiphe attacks the alarmist and self-contradictory ideology of rape-culture feminism . . .