Medicare for All

I’ve been interested to see how frequently the comments to this blog end up discussing (and debating) America’s health care system–even when the ostensible subject of that day’s post is something entirely different.

(As I was typing the phrase “healthcare system,” I was reminded of a graduate student—a hospital administrator—who corrected my use of that term. “America doesn’t have a healhcare system,” he said. “We have a healthcare industry” and it’s not the same thing.)

I often share insights from my cousin, a respected cardiologist who also spent many years teaching medicine. He recently sent me a thoughtful analysis of that healthcare industry, and the prospects for fixing what everyone realizes is unsustainable. I particularly like his introduction to the issue:

When considering the best way to solve our country’s medical care woes, I am reminded of Churchill’s famous statement about democracy as a form of government, in which he stated in effect: It’s a terrible system, but everything else is worse. This same statement might apply to a single payer system in medical care, for it probably beats everything else, as I explain below.

He noted that a truly effective system will require cost controls, including tort reform, the excessively high cost of drugs, inappropriate use of expensive tests and treatments, and several others. He is convinced that these issues can be resolved, and that a single-payer system (for example, “Medicare for All”) is both inevitable and the best solution:

In an article on why a single-payer system would be our best solution, Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and an architect of the Affordable Care Act (ACA), contended that although the ACA has been “a step forward for the country,” it “does not deal with the problem of waste and complexity in the system,” as he feels a single-payer system would. I can personally attest to the complexity of the system with the many headaches provided by a dizzying array of differing insurance forms pertaining to treatments, hospital admissions and a multitude of other issues.

And James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of the forthcoming book Talking About SINGLE PAYER!, argued that a single-payer system is “a more economical way to use healthcare resources. You could reduce expenses and still improve quality. That’s a tremendous opportunity that you don’t have in many other fields.” Of course, as he pointed out, this would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000. (Maybe these same workers could be involved in more productive work such as restoring our nation’s wobbly infrastructure!) But Dr Burdick also maintains that a single payer system would likely restore doctors’ authority. And those who favor this system say that for all practices, administrative costs would plummet because there would be only one set of payment rules and forms, with the result that prior authorizations, narrow networks, and out-of-pocket payments would be eliminated.

He also reports that there is growing physician support for a single-payer system. For example, a 2014 survey of Maine physicians conducted found that nearly 65% of respondents preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey.

Interestingly, a majority of the population (51%) now supports Medicare for all, according to a national poll released this past year.

In reality, a government-run single-payer system is the only way to provide effective basic medical health therapy and management, but for those who desire a higher level of care—and can afford it—there should be a private-pay system, contrast with the Canadian system. This would, de facto, constitute a two-tiered system. This might be objectionable to egalitarians that wish to have a “one size fits all” system, but would be the most pragmatic approach.

Usually those against single payer system trot out the usual vague objections that we are becoming “socialistic.” But what about our current Medicare system, is that not socialistic? I might add further that I personally have worked at a VA hospital, and, despite all the current noise, found that once patients were able to access the system, the care is quite good. Its main problem seems to be gaining initial entry into an overburdened system in a timely manner. By contrast, it is highly unlikely that a random assortment of for-profit HMOs would do a better job serving the high-utilization health needs of our veterans.

His conclusion–with which I concur:

Whether we like it or not, basic healthcare is like a utility—something everyone needs, and, in the best interest of our society, everyone should receive. Although there are many variations of the general theme as I have enumerated above, we are moving inevitably toward a single payer system. When it finally arrives, I believe everyone will be relieved, if not pleased, even including the Republicans!

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What is with the Fixation on Potties?

Oh, Indiana! You have so many virtues….and so many legislators with questionable reasoning abilities. The legislative session that just began promises to be a bonanza for those who enjoy black comedy and unintentional irony.

For those of us who want adult government, not so much.

A major focus of the upcoming session will be the effort to add four words and a comma to Indiana’s existing civil rights law.  In the aftermath of last year’s RFRA debacle, business and civic organizations have partnered with LGBT organizations and faith communities to lobby for the addition of “sexual orientation” and “gender identity” to the existing list of things (race, religion, gender, etc.)that Hoosiers can’t use as reasons to discriminate against other people.

All of these characteristics should be totally irrelevant to an individual’s right to rent an apartment, enroll in an educational institution or buy goods and services in the marketplace.

Four words and a comma. It’s not rocket science.

Lawmakers who really do want to discriminate but want to pretend otherwise have come up with all manner of convoluted bills to allow disparate treatment to continue. Others have simply abandoned the pretense, offering proposals that, if passed, would tell the world that Hoosier Hospitality is a highly selective concept.

And the world has noticed. This is from Talking Points Memo:

An Indiana rep recently proposed a bill that would hit transgender individuals with a Class A misdemeanor if they used a public restroom that doesn’t conform to their gender at birth.

I can see the signs now: Before using this potty, please deposit your DNA sample with the attendant…..

The whole potty fixation is a mystery to me. I was just in New York—I know, a den of iniquity—and most of the public restrooms I used were “one at a time” facilities available to either gender. (If you’re really worried about who uses which toilet, I have a suggestion: Get a life!)

This bill should die a quick death. Last year, similar bills failed to pass in Kentucky, Florida, Nevada and Texas (hardly liberal bastions), and the Department of Justice has declared that restricting transgender students’ access to public restrooms amounts to sex discrimination under Title IX, but hey–this is Indiana.

Even Georgia doesn’t want to be “the next Indiana.” 

For a legislature dominated by self-described proponents of “limited government,” the bills submitted thus far certainly are a mixed bag. On the one hand, our “small government” Christian conservatives are proposing a bill that would effectively  outlaw abortions (no terminations after a heartbeat is detectable–about the same time most women find out they’re pregnant). On the other hand, it’s hard to square that “pro life” position with the bill allowing habitual drunks to buy guns, the bill removing the need to license guns, the bill to allow guns on college campuses…

Maybe they want to be able to shoot people they think are using the wrong potty?

In any case, if the “wrong toilet” and gun bills pass, I’m moving to a saner state….Evidently, there are a lot of them.

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Yeats Was So Right….

One of my favorite quotes is from a poem by William Butler Yeats, who wrote that “The best lack all conviction, while the worst are full of passionate intensity.”

Science has confirmed the observation, at least with respect to the “worst,” and to the extent that “best” and “worst” refer to intellectual acuity.

In 1999, David Dunning and Justin Kruger of the department of psychology at Cornell University conducted a fascinating study after reading about a man named McArthur Wheeler. Wheeler  robbed two banks after covering his face with lemon juice in the mistaken belief that, because lemon juice is usable as invisible ink, it would prevent his face from being recorded on surveillance cameras.

Earlier studies had suggested that what might delicately be termed “ignorance of performance standards” accounts for a substantial amount of incorrect self-assessment of competence. In other words–as the Facebook meme has it–stupid people are too stupid to recognize their stupidity.

Dunning and Kruger found that, for a given skill, incompetent people will:

  • fail to recognize their own lack of skill
  • fail to recognize the extent of their inadequacy
  • fail to recognize genuine skill in others
  • will only recognize and acknowledge their own lack of skill after they are exposed to training for that skill

According to Dunning, “If you’re incompetent, you can’t know you’re incompetent.… [T]he skills you need to produce a right answer are exactly the skills you need to recognize what a right answer is.”

According to Wikipedia (yes, I know–I don’t let my students cite to Wikipedia, but it’s convenient and generally, albeit not always, accurate):

Dunning and Kruger set out to test these hypotheses on Cornell undergraduates in psychology courses. In a series of studies, they examined subject self-assessment of logical reasoning skills, grammatical skills, and humor. After being shown their test scores, the subjects were asked to estimate their own rank. The competent group estimated their rank accurately, while the incompetent group overestimated theirs.

Across four studies, the authors found that participants scoring in the bottom quartile on tests of humor, grammar, and logic grossly overestimated their test performance and ability. Although test scores put them in the 12th percentile, they estimated themselves to be in the 62nd.

(This definitely explains most of  the students who come in to complain about their grades….but I digress.)

How did Yeats put it? Those who know the least are those with the most “passionate intensity.”

The evidence is everywhere. Just look at Congress, or the Indiana General Assembly.

Or the “Y’all Qaeda” standoff in Oregon…

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Speaking of Infectious Diseases…

It would do us well to remember that chosen ignorance isn’t confined to the uneducated, Fox-“news”-watching, fearful folks who tend to be the butt of liberal disdain.

 A new study confirms its presence in tonier liberal precincts as well.

When it comes to science illiteracy in the form of Creationism, we know what kind of people are more likely to believe it: Those who attend church frequently, the elderly, and people without much formal education.

But when it comes to parents who refuse to vaccinate their children, the demographics are very different, according to a new study in the American Journal of Public Health.

The people most likely to refuse to have their children vaccinated tend to be white, well-educated and affluent.

Although this particular data point was not in the study, I’d be very surprised if the same people who are rejecting the overwhelming scientific consensus about the value of vaccination aren’t also sneering at the “anti-science” folks denying the reality of climate change.

At both ends of the political spectrum, we have people picking and choosing the scientists and scientific conclusions they are prepared to accept. I’m neither a sociologist nor a political psychologist, so I’m unprepared to offer a theory about why liberals choose to reject one set of conclusions and conservatives another, although I have a sneaking suspicion that in each case, tribal identity plays a large part.

And independent–let alone critical– thinking plays very little…..

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The War on Secularism

Can you stand one more meditation about religion and the need for certainty ?

We talk a lot these days about fear–fear of terrorism, fear of change, fear of modernity. But when you come right down to it, the basis of all of these threats to subjective well-being is an overwhelming fear of ambiguity.

We humans evidently have a primal need for bright lines, eternal truths—for non-negotiable and non-relative Truth with a capital T.

The political danger presented by that need for certainty was obvious to the nation’s founders, who intended the Bill of Rights to prevent the “passions of the mob” from extinguishing the rights of those holding nonconforming beliefs.

The deep desire for easy answers in a complicated world explains many of the more troubling aspects of our  political environment. Consider the current “Trump phenomenon.” According to a study referenced in a recent article in the Washington Post,

Interviews with psychologists and other experts suggest one explanation for the candidate’s success — and for the collective failure to anticipate it: The political elite hasn’t confronted a few fundamental, universal and uncomfortable facts about the human mind.

We like people who talk big.

We like people who tell us that our problems are simple and easy to solve, even when they aren’t.

And we don’t like people who don’t look like us.

Much of Trump’s appeal–and the appeal of the many demagogues who preceded him–boils down to this need to simplify, to draw bright lines, to chase away the demons of ambiguity.

Hibbing of the University of Nebraska says this need for clarity is important to understanding Trump’s support.

“People like the idea that deep down, the world is simple; that they can grasp it and that politicians can’t,” Hibbing said. “That’s certainly a message that I think Trump is radiating.

Much the same psychology is on display by the religious conservatives fighting for (their version of) religious rights. (Sometimes, aided and abetted by people who surely know better. Yes, Justice Scalia, I’m looking at you.)

Most of us look at Christian Americans and see people who have been highly privileged by a culture that has long been dominated by Christians. But these religious warriors see themselves under attack, not by a rival theological perspective, but by secularism.

Christian conservatives who are battling for the right to promote their faith in public or official settings see themselves locked in an epic contest with a rival religion. But that rival isn’t Islam. It’s secularism.

However one defines secularism, it represents a diminished influence of religion and religious authority—the blurring of previously “bright” lines.

Secularism terrifies people who need those bright lines, who need concrete authority to obey and whose worldviews are rendered entirely in black and white.

What terrifies me are people who fear ambiguity, who see no shades of gray, and who reject the exercise of moral autonomy.

And those people aren’t all in ISIL.

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