To the extent that this country has had a commitment to anything like universal health care, that commitment has focused on children. And the current decision to extend health care for low-income children in California makes it clear that the commitment is, at least in some places, bipartisan.
But something is missing from the calculations that justify public health care only for low-income children. As a housing advocate in western Pennsylvania, I routinely saw human examples of this failed calculus. Working homeless parents who had serious health issues but lacked insurance and were over the (very low) income limit for Medicaid would tell me on intake that they h ad personally not seen a doctor for the past two years, although the last one they saw mentioned that they had hypertension or diabetes.
Some reported health-related problems at work. The boss was threatening to fire one father because he passed out when he picked up heavy bags of concrete. A mother was having trouble keeping her fast food job because her leg went numb if she stood too long.
The good news was that these parents had children who were up to date on shots and had seen a doctor right on schedule. The bad news was that these healthy children had parents who were chronically ill.
Ugly ironies turned up daily. There was the single mom who brought her child in so that I could help with filling out the paperwork needed to get braces for his crooked teeth. The state's low-income insurance program for children would pay for the braces once the right boxes had been checked. The mom had been about to lose the family's trailer when her hours got cut at the gas station where she worked. Then she had a spot of luck- she got hired on part-time at Walmart. With two jobs, she could just manage.
But, as always happens in the low-income world, things went south again. The local Walmart notoriously found reasons to fire cashiers who lost front teeth. Too-visible dental problems gave a poor impression and upset the customers. The mom, who hadn't been to the dentist in more than eight years, bit into an apple one day and left a front tooth in its flesh. Mom was still on probation at Walmart. She had no dental insurance, made too much for Medicaid, and lost her job.
As I filled out the paperwork for her child's braces, the family was heading into the sort of semi-homelessness common in the low-income world. Mom, her son, and his new braces would have to move out of their trailer. They would be joining a former sister-in-law and her three kids in a single-wide, one and a half-bedroom trailer in the worst trailer park in town.
Cancer was worse. Some of the uninsured low-income parents who came for housing help had advanced stage cancer- they hadn't been to the doctor for years, nothing was ever caught early Sometimes you could solve the problem of providing income if they couldn't work, but that did little to solve the real problem. Too many children were faced with the possibility that mom or dad might die in the near future and, while waiting to die, mom or dad was usually too shell-shocked and ill to do much effective parenting. Early detection, of course, would not have prevented all these scenarios, but the thing is this: Our country doesn't even try.
The really amazing thing was that no uninsured parent, no matter how ill, ever made the obvious comparison between his or h er lack of medical and dental care and the services available for his or her children. No-one ever expressed envy, became angry, or questioned the arrangement- there was just acceptance of the situation, and pride that the kids had their immunization paperwork in order and had a regular doctor.
It is not just these parents who are at risk of serious untreated illness, however. The society that permits these untenable choices is on the critical list and on the way to an ethical flat-line.
Showing posts with label health care reform. Show all posts
Showing posts with label health care reform. Show all posts
Friday, September 4, 2009
Sunday, August 23, 2009
Protests and Paradigms
In today's Wall Street Journal, John Goodman explains the town hall protests against health insurance reform, arguing that these protests are not "organized" but represent an outpouring of genuine popular opposition. The truth of his assertion depends on how one defines organization.
In fact, the current health reform debate is simply the most recent iteration of a long term organizing project. This project has been a resounding success: it has generated a paradigm that organizes virtually all discussion about inequality in the United States.
Paradigms are powerful precisely because they are invisible. They define what questions can be asked and what answers are acceptable. They organize data, true, but are more important in that they organize the way that data are gathered.
Paradigms are like invisible fences: you don't notice them as long as you stay inside, but if you try to move beyond them, you will be unpleasantly reminded that they exist. The current health care debate has moved too close to the edges of the paradigm: the public protests are, like electric currents at the edge of invisible fences, intended to shock us back inside.
In the United States, the development and implementation of social policy is organized by a paradigm that privileges differences over similarities. It specifies that the first question to be asked by social policy ought to be "can we do without it?" and that the second ought to be "if we have to have it, how can we limit its benefits to the smallest possible number of recipients?" Just as the Aristotelian/Ptolemaic view of the universe meant that questions that began "but what if the earth revolves around the sun..." were either heretical or silly, the American social policy paradigm selects against universalist questions that begin "but couldn't we provide service for everybody?"
The current social policy paradigm emphasizes small payoffs to selected groups of the needy, and large payoffs to selected groups of the more affluent and more powerful. An example: the internal revenue code offers mortgage interests deductions to virtually all middle-class homeowners, but housing assistance programs for low-income individuals and families are managed through programs that operate more like public assistance, making them relatively scarce and relatively hard to access. The prevailing social welfare paradigm consequently rewards cleavages and penalizes unity.
Once in place, paradigms are "sticky": like bad house guests, they hang around long after they have ceased to make a positive contribution. The United States social welfare paradigm has political implications- it guarantees that the most influential players will continue to be those that require the least assistance from social policies. And this, in turn, means that the future distribution of sticks and carrots is unlikely to change.
The American paradigm has another unfortunate feature. It structures the process of comparison. This is evident in the rhetoric of the current health care debate: protestors do not compare their situation to that of less fortunate individuals and ask what could be done to assist them. Rather, they compare their current situation to that which might prevail in some feared future. Similarly, protestors - and even policy analysts like Mr. Goodman- do not compare the United State's provision for low-income individuals with that of other nations. Rather, they focus on their personal satisfaction.
The operation of this paradigm is evident, for example, in Mr. Goodman's assertion that 84% of the individuals in a recent survey were happy with their health insurance. A genuinely comparative perspective would ask questions about this report: Was the sample comprised only of insured individuals? If not, were the uninsured respondents happy with their situation as well? Did the respondents understand the implicit choice to be one between their insurance and no insurance? Were they given the option of choosing between their insurance and the more comprehensive and less expensive plans offered, for instance, in nations like Switzerland?
This brings us back to the town hall protesters. They turn out to be organized after all: they are kept in line by the invisible paradigmatic fence.
To see Goodman's article, go to:
http://online.wsj.com/article/SB10001424052970204884404574362333085067364.html
In fact, the current health reform debate is simply the most recent iteration of a long term organizing project. This project has been a resounding success: it has generated a paradigm that organizes virtually all discussion about inequality in the United States.
Paradigms are powerful precisely because they are invisible. They define what questions can be asked and what answers are acceptable. They organize data, true, but are more important in that they organize the way that data are gathered.
Paradigms are like invisible fences: you don't notice them as long as you stay inside, but if you try to move beyond them, you will be unpleasantly reminded that they exist. The current health care debate has moved too close to the edges of the paradigm: the public protests are, like electric currents at the edge of invisible fences, intended to shock us back inside.
In the United States, the development and implementation of social policy is organized by a paradigm that privileges differences over similarities. It specifies that the first question to be asked by social policy ought to be "can we do without it?" and that the second ought to be "if we have to have it, how can we limit its benefits to the smallest possible number of recipients?" Just as the Aristotelian/Ptolemaic view of the universe meant that questions that began "but what if the earth revolves around the sun..." were either heretical or silly, the American social policy paradigm selects against universalist questions that begin "but couldn't we provide service for everybody?"
The current social policy paradigm emphasizes small payoffs to selected groups of the needy, and large payoffs to selected groups of the more affluent and more powerful. An example: the internal revenue code offers mortgage interests deductions to virtually all middle-class homeowners, but housing assistance programs for low-income individuals and families are managed through programs that operate more like public assistance, making them relatively scarce and relatively hard to access. The prevailing social welfare paradigm consequently rewards cleavages and penalizes unity.
Once in place, paradigms are "sticky": like bad house guests, they hang around long after they have ceased to make a positive contribution. The United States social welfare paradigm has political implications- it guarantees that the most influential players will continue to be those that require the least assistance from social policies. And this, in turn, means that the future distribution of sticks and carrots is unlikely to change.
The American paradigm has another unfortunate feature. It structures the process of comparison. This is evident in the rhetoric of the current health care debate: protestors do not compare their situation to that of less fortunate individuals and ask what could be done to assist them. Rather, they compare their current situation to that which might prevail in some feared future. Similarly, protestors - and even policy analysts like Mr. Goodman- do not compare the United State's provision for low-income individuals with that of other nations. Rather, they focus on their personal satisfaction.
The operation of this paradigm is evident, for example, in Mr. Goodman's assertion that 84% of the individuals in a recent survey were happy with their health insurance. A genuinely comparative perspective would ask questions about this report: Was the sample comprised only of insured individuals? If not, were the uninsured respondents happy with their situation as well? Did the respondents understand the implicit choice to be one between their insurance and no insurance? Were they given the option of choosing between their insurance and the more comprehensive and less expensive plans offered, for instance, in nations like Switzerland?
This brings us back to the town hall protesters. They turn out to be organized after all: they are kept in line by the invisible paradigmatic fence.
To see Goodman's article, go to:
http://online.wsj.com/article/SB10001424052970204884404574362333085067364.html
Saturday, August 15, 2009
Let Them Eat Tofu: Whole Foods CEO On Health Care Reform
John Mackey, the Whole Foods CEO, channels Marie Antoinette in his 8/11/ 09 Wall Street Journal editorial on health care reform. Marie, at least in the apocryphal story, was told that the peasants had no bread and responded "let them eat cake." Mackey has updated Marie's message, but retained her logic.
In Mackey's updated version, uninsured Americans substitute for hungry French peasants. The alternatives to reform that he suggests substitute for cake. The cake has three main ingredients.
First, Mackey argues that adjustments to the tax structure would solve a great deal of the problem. Legal obstacles to health care savings plans could be repealed. Individual contributions to help the uninsured could be incentivized through the tax code. The tax status of individual and employer-provided plans could be equalized.
Each of these propositions has its own difficulties. HSA's, first of all, are rarely provided by low-wage employers and they are rarely attached to temporary jobs and, secondly, would not be particularly useful for families where virtually all income goes toward housing, utilities and food.
As to the role of the tax code in stopping the stampede of well-off Americans who would otherwise be contributing to health care for the uninsured...a determined philanthropist would hardly be put off by existing arrangements. And, finally, Mackey does not tell us in what direction he would like equalization to occur--should individual plans (which are not affordable for many families in any event) become deductible, or should employer-provided benefits be taxed?
Mackey's second set of suggestions involves providing more assistance to a truly beleaguered sector - the insurance industry. Insurers, he opines, are hampered by their inability to compete across state lines and by federal mandates that require them to provide coverage for certain individuals who are at higher risk.
The last point, of course, is just silly: granted, rates might decrease somewhat if risks could be excluded, but what about the people who are insured only because of these mandates? Wouldn't their repeal increase rather than reduce the number of the uninsured? As to the first point, it is possible that competition might occur, but given the relatively small number of insurers and the strength of their common interests, it seems more likely that this would increase the probability of cartel-like behavior that would further harm consumers.
And so we come to Mackey's third line of argument. This is quite innovative: people who become ill have only themselves to blame. Individuals who eat a healthful diet and maintain a healthful lifestyle are unlikely to become ill, he assures us. Well, sometimes this works out, although often it does not. Does Mr. Mackey, who is presumably the poster child for this line of argument, bother with insurance for himself and his family? After all, they would hardly need it.
This argument does, however, provide an anodyne for any lingering idea that we might, as a society, have any obligation to help those in need of medical care. Of course, those uninsured low-wage single moms who drag themselves home after 8 hours of, say, lifting, turning, and bathing patients in a nursing home may not have the energy to fix a tasty, plant-based, low fat meal for themselves and the kids, even if they had the money to buy the ingredients or a way to the nearest organic market. And they might even be a little stressed from the various difficulties in their lives, although Mr. Mackey does not factor in this empirically-verified cause of health difficulties.
But never mind. Mr. Mackey is not making an empirical argument at all. His concerns are normative. He is, after all, both CEO and political philosopher, as we discover at the end of his argument. " Many promoters of health-care reform," he tells us," believe that people have an intrinsic ethical right to health care—to equal access to doctors, medicines and hospitals. While all of us empathize with those who are sick, how can we say that all people have more of an intrinsic right to health care than they have to food or shelter?" And he assures us that a "careful reading" of the Declaration of Independence and the United States Constitution will demonstrate that no such right exists.
Now, I'm no political philosopher, but I recollect something in one of them about the right to "life", right there with " liberty" and "the pursuit of happiness." Is it just me, or is it hard to sustain life without food, shelter or medical care?
Cake, anyone? John Mackey has lots for sale, and some of it is even organic.
To read Mackey's editorial see
http://online.wsj.com/article/SB10001424052970204251404574342170072865070.html
He responds to the furor over his article in the following selection from his blog:
http://www2.wholefoodsmarket.com/blogs/jmackey/2009/08/14/health-care-reform-full-article/#comments
For my money, this response simply makes things worse!
For a report on the demographic characteristics of the uninsured see
http://aspe.hhs.gov/health/reports/05/uninsured-cps/index.htm#Conclusion
In Mackey's updated version, uninsured Americans substitute for hungry French peasants. The alternatives to reform that he suggests substitute for cake. The cake has three main ingredients.
First, Mackey argues that adjustments to the tax structure would solve a great deal of the problem. Legal obstacles to health care savings plans could be repealed. Individual contributions to help the uninsured could be incentivized through the tax code. The tax status of individual and employer-provided plans could be equalized.
Each of these propositions has its own difficulties. HSA's, first of all, are rarely provided by low-wage employers and they are rarely attached to temporary jobs and, secondly, would not be particularly useful for families where virtually all income goes toward housing, utilities and food.
As to the role of the tax code in stopping the stampede of well-off Americans who would otherwise be contributing to health care for the uninsured...a determined philanthropist would hardly be put off by existing arrangements. And, finally, Mackey does not tell us in what direction he would like equalization to occur--should individual plans (which are not affordable for many families in any event) become deductible, or should employer-provided benefits be taxed?
Mackey's second set of suggestions involves providing more assistance to a truly beleaguered sector - the insurance industry. Insurers, he opines, are hampered by their inability to compete across state lines and by federal mandates that require them to provide coverage for certain individuals who are at higher risk.
The last point, of course, is just silly: granted, rates might decrease somewhat if risks could be excluded, but what about the people who are insured only because of these mandates? Wouldn't their repeal increase rather than reduce the number of the uninsured? As to the first point, it is possible that competition might occur, but given the relatively small number of insurers and the strength of their common interests, it seems more likely that this would increase the probability of cartel-like behavior that would further harm consumers.
And so we come to Mackey's third line of argument. This is quite innovative: people who become ill have only themselves to blame. Individuals who eat a healthful diet and maintain a healthful lifestyle are unlikely to become ill, he assures us. Well, sometimes this works out, although often it does not. Does Mr. Mackey, who is presumably the poster child for this line of argument, bother with insurance for himself and his family? After all, they would hardly need it.
This argument does, however, provide an anodyne for any lingering idea that we might, as a society, have any obligation to help those in need of medical care. Of course, those uninsured low-wage single moms who drag themselves home after 8 hours of, say, lifting, turning, and bathing patients in a nursing home may not have the energy to fix a tasty, plant-based, low fat meal for themselves and the kids, even if they had the money to buy the ingredients or a way to the nearest organic market. And they might even be a little stressed from the various difficulties in their lives, although Mr. Mackey does not factor in this empirically-verified cause of health difficulties.
But never mind. Mr. Mackey is not making an empirical argument at all. His concerns are normative. He is, after all, both CEO and political philosopher, as we discover at the end of his argument. " Many promoters of health-care reform," he tells us," believe that people have an intrinsic ethical right to health care—to equal access to doctors, medicines and hospitals. While all of us empathize with those who are sick, how can we say that all people have more of an intrinsic right to health care than they have to food or shelter?" And he assures us that a "careful reading" of the Declaration of Independence and the United States Constitution will demonstrate that no such right exists.
Now, I'm no political philosopher, but I recollect something in one of them about the right to "life", right there with " liberty" and "the pursuit of happiness." Is it just me, or is it hard to sustain life without food, shelter or medical care?
Cake, anyone? John Mackey has lots for sale, and some of it is even organic.
To read Mackey's editorial see
http://online.wsj.com/article/SB10001424052970204251404574342170072865070.html
He responds to the furor over his article in the following selection from his blog:
http://www2.wholefoodsmarket.com/blogs/jmackey/2009/08/14/health-care-reform-full-article/#comments
For my money, this response simply makes things worse!
For a report on the demographic characteristics of the uninsured see
http://aspe.hhs.gov/health/reports/05/uninsured-cps/index.htm#Conclusion
Friday, August 14, 2009
Health Care Reform and Musical Chairs
A great deal of the public behavior surrounding the health care debate can best be described as "childish". When six year-olds do this sort of thing, any responsible adult will respond firmly with "you need to learn to share."
And, in fact, the political economy of American health care is structurally similar to an extended version of a children's game- musical chairs. Musical chairs, remember, is the game in which there are fewer chairs than players. The players circle the chairs to music- I remember "Pop Goes the Weasel" as the usual tune- and when the music stops, they scramble for one of the scarce chairs. Without careful adult supervision, the scrambling can become quite ugly.
Think of individuals who currently have insurance- through government-funded programs, individually-purchased policies, or employment- as those who have chairs. For one reason or another, they have resources that allowed them to win the insurance game as it is currently structured. Those without insurance are the losers. The music has stopped, and they have no chairs.
If the number of chairs is fixed- that is, if there are only so many chairs to be had- then this arrangement is what game theorists call "Pareto-optimal." Optimal sounds good, doesn't it? But what it means here is that for anyone to become better off, someone has to become worse off. There are only so many chairs, so a loser can get a chair only by displacing a winner. Why would a winner voluntarily give up his chair? That would be silly.
Now for the political part. Assume that everyone who has a chair has resources that he or she can use to pay guards to stand around their chairs so that, if the music starts up, the losers will still be unable to get a seat. The resources in real life include campaign contributions, votes, media contacts, and so on.
When the music starts again, the guards swing into action- they know what to do in order to make sure that the winners keep those chairs. The guards, in fact, have routines that they regularly use to keep things as they are. The distribution of chairs has become "institutionalized." There is a structure that supports the status quo.
And there is one more thing. The winners all sit together, all have the same advantage (the chairs) , all agree that they want to keep it, and all know that in order to stay seated, they just have to make sure that things keep working the way they always have. The losers mill around, are dispersed, have different ideas about how to get chairs, and have trouble concentrating-their feet and backs hurt from standing all the time. The people with chairs, in other words, are better-organized and more focused than those without them. This is a "collective action problem" and it makes the the effects of institutionalization even stronger.
It gets worse. Some of the winners sit in chairs that the losers have helped to pay for. If we were talking about, say, health care reform rather than musical chairs, this would mean that people who were receiving government assistance with health care (like Medicare) would be showing up at town meetings to complain that the losers might get the same deal.
If this were a real game of musical chairs, there would be some easy solutions. The winners could stay seated and send the guards out to get some more chairs, using resources that were being spent on other, less necessary things. Or the rules of the game could be changed- everyone could agree to share chairs, figuring that it was better to be a bit uncomfortable than to have some people standing all the time.
Of course, it couldn't be that easy. In fact, if we were indeed discussing health care rather than musical chairs, there would be entire industries dedicated to insuring that it never would be that easy.
And, in fact, the political economy of American health care is structurally similar to an extended version of a children's game- musical chairs. Musical chairs, remember, is the game in which there are fewer chairs than players. The players circle the chairs to music- I remember "Pop Goes the Weasel" as the usual tune- and when the music stops, they scramble for one of the scarce chairs. Without careful adult supervision, the scrambling can become quite ugly.
Think of individuals who currently have insurance- through government-funded programs, individually-purchased policies, or employment- as those who have chairs. For one reason or another, they have resources that allowed them to win the insurance game as it is currently structured. Those without insurance are the losers. The music has stopped, and they have no chairs.
If the number of chairs is fixed- that is, if there are only so many chairs to be had- then this arrangement is what game theorists call "Pareto-optimal." Optimal sounds good, doesn't it? But what it means here is that for anyone to become better off, someone has to become worse off. There are only so many chairs, so a loser can get a chair only by displacing a winner. Why would a winner voluntarily give up his chair? That would be silly.
Now for the political part. Assume that everyone who has a chair has resources that he or she can use to pay guards to stand around their chairs so that, if the music starts up, the losers will still be unable to get a seat. The resources in real life include campaign contributions, votes, media contacts, and so on.
When the music starts again, the guards swing into action- they know what to do in order to make sure that the winners keep those chairs. The guards, in fact, have routines that they regularly use to keep things as they are. The distribution of chairs has become "institutionalized." There is a structure that supports the status quo.
And there is one more thing. The winners all sit together, all have the same advantage (the chairs) , all agree that they want to keep it, and all know that in order to stay seated, they just have to make sure that things keep working the way they always have. The losers mill around, are dispersed, have different ideas about how to get chairs, and have trouble concentrating-their feet and backs hurt from standing all the time. The people with chairs, in other words, are better-organized and more focused than those without them. This is a "collective action problem" and it makes the the effects of institutionalization even stronger.
It gets worse. Some of the winners sit in chairs that the losers have helped to pay for. If we were talking about, say, health care reform rather than musical chairs, this would mean that people who were receiving government assistance with health care (like Medicare) would be showing up at town meetings to complain that the losers might get the same deal.
If this were a real game of musical chairs, there would be some easy solutions. The winners could stay seated and send the guards out to get some more chairs, using resources that were being spent on other, less necessary things. Or the rules of the game could be changed- everyone could agree to share chairs, figuring that it was better to be a bit uncomfortable than to have some people standing all the time.
Of course, it couldn't be that easy. In fact, if we were indeed discussing health care rather than musical chairs, there would be entire industries dedicated to insuring that it never would be that easy.
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