Friedrich von Blowhard writes:

Dear Blowhards,

I happen to be in the process of reading Thomas Ferguson’s Golden Rule: The Investment Theory of Party Competition and the Logic of Money-Driven Political Systems (1995, University of Chicago Press). The title’s a mouthful, I grant, but it’s a pretty interesting book.

But as a consequence, when I picked up the L.A. Times today, and my eye fell on a column discussing healthcare reform (“Healthcare debate framed by fear-mongering ads” by David Lazarus), my recent reading of Mr. Ferguson sent off a few sparks.

Mr. Lazarus in the L.A. Times says:

…a key problem here is that most of us aren’t taking the time to understand the various parts of this admittedly complex equation. Instead, we’re leaving it to interest groups to call the shots, and the debate has devolved into a pathetic shouting match between partisan camps.

This certainly struck a chord with what I had very recently read in Golden Rule. To briefly summarize, Mr. Ferguson begins his discussion of the 'investment theory' of politics by quoting Anthony Downs on the prohibitively high cost of gathering the information necessary for the ordinary voter to meaningfully participate in the political process:

“The expense of political awareness is so great that no citizen can afford to bear it in every policy area, even if by doing so he could discover places where his intervention would reap large profits.”

Mr. Ferguson then goes on to argue that:

…in a political system like that of the United States, where even highly motivated voters face comparatively enormous costs when they attempt to acquire, evaluate, and act upon political information, effective electoral control of the government process by voters becomes most unlikely.

He continues by asking:

…if ordinary voters can’t afford to invest [the necessary large sums required to first understand what's at stake and then to influence] American political parties, then who can? And by virtue of their unique status, do not these “big ticket” investors automatically become the real masters of the political system?

Mr. Ferguson explains that such big ticket investors normally amount to businessmen who can draw on corporate resources to pay for political activity and who have a large financial stake in the outcome that justifies the expenditure (unlike the Average Joe).

This ‘mastery’ of the political system by large investors does not, of course, imply that voters are irrelevant. But according to Mr. Ferguson:

…in situations where information is costly, abstention is possible, and entry into politics through either new parties or existing organizations is expensive and often dangerous…large investors try to assemble the votes they need by making very limited appeals to particular segments of the potential electorate. If it pays some other bloc of major investors to advertise and mobilize, these appeals [will] be vigorously contested…

Gee, that “vigorously contested” sounds a lot like, um, what’s been going on in Florida.

It has dawned on me that it would be of nice to have a detailed explanation of who the big ticket investors in the healthcare reform debate are, what they have at stake, and what their positions are. If that information wouldn’t necessarily allow voters to actually control the process, it would at least let those of us who are not 'mobbed-up' be able to handicap the most likely outcome.

So far, however, the news media seems to be largely viewing the fight as a Democrats vs. Republicans donnybrook or a Democrats vs. Democrats donnybrook, possibly reflecting the rather simple-minded idea that politics is to what politicians do -- no more, no less. For example, in this story (“Obama fights back as bid to reform US healthcare stalls” from Paul Harris of the U.K. Guardian) pretty much reduces the sound and fury we're seeing to partisan politics, i.e., a battle between political parties, or between professional politicians:

The tactics of Republicans, conservative protest groups and healthcare lobbyist-linked organisations have been decried by many commentators. Though Republican leaders and other conservatives have claimed the protests are a genuine outburst of anti-healthcare reform feeling, there have been instances of activists being caught red-handed.

According to Professor Ferguson’s view, this is falling for the oldest game in the book, where the magician distracts you with legerdemain while he gets on with his real business unnoticed by the audience. As the good Professor puts it:

Investment theory takes care never to confuse investor/employers with politician/employees.

Granted, the Guardian story does eventually get around to discussing, at least in vague terms, who is really manipulating the puppets (i.e., the politicians) from behind the curtain, even if it does so only after dragging in yet another the confusing assumption: to wit, that U.S. political parties actually stand for something. As a consequence, the activities of the Blue Dog Democrats seem quite perplexing...like grabbing the football and running towards the wrong goalpost...at least until we get to the second paragraph:

Ironically, Obama's main problems lie with his own party and with his desire to reach consensus on the healthcare issue rather than to dictate a reform programme. He has insisted on Republican involvement in the drafting of new legislation. He has also paid heed to the "Blue Dog" group of Democratic politicians who represent conservative-leaning electorates and who have pushed aggressively for him to water down his healthcare proposals by, among other things, taking out the public option.

At the same time, as anti-lobbying watchdog groups have pointed out, money has been flowing to the group's members from the healthcare industry in the form of campaign contributions. Blue Dog Democrats have collected more money than any other congressional grouping this year, with more than half the cash coming from healthcare businesses or the insurance and financial services sector.

Ah, well, that begins to clear things up.

As for Obama’s motivation in pushing healthcare reform? Just guessing, but so far the Obama administration has been so corporatist in handing over aid-and-comfort to specific favored industries while withholding it from others that it makes me wonder if he views universal healthcare to be a bone to throw at the ordinary Joe. I'm sure the administration pollsters have picked up on the fact that Mr. Average Joe has begun to resent exactly how rigged (in favor of the big-ticket investors) politics in the U.S. has proven itself to be during the current downturn. If that line of thinking starts to proliferate, something bad could happen to the big ticket brigade. But I don't claim to be very well informed here, and I'd like to know more.

Do any of our brilliant readers have more detailed sources that can provide a coherent discussion of which industries have a dog in this fight (pro, con, otherwise), and in what groupings they are assembled? I’d love to read it. Any other fans of Ferguson out there?

Cheers,

Friedrich

The most surprising thing is that neither side -- from the lowliest protestor right up to the President himself -- seems to have the slightest idea what's in the bill. The bill itself is rather opaque (although I have read through the bits of it I thought applied to me, i.e. not the Medicare + Medicaid bits). But the CBO did put out a helpful summary of the major provisions in its mid-July letter on the House bill, and that summary provides more information than most of the key participants here seem to have got.

The fact that everyone genuinely seems to be ignorant about the real content of the bill as it stands at the moment has made for a singularly unenlightening public debate. Proponents mostly make the (easy-to-make) case for "reform," as a general concept, without any argument for why the particular reforms the bill incorporates would be worthwhile, and opponents reply the bill is a government takeover of health care.

Posted by: Taeyoung on August 9, 2009 3:15 PM

I'm inclined to think the focus on what people or organizations have one kind of economic stake or another is too narrow.

It's sort of like the "greed" argument that has been presented since Reagan was elected. Greed always seems to do with money and therefore is a bad thing. Yet there also is greed for power -- political power. And, to my mind, that can be far more dangerous than strongly seeking riches. (Of course, both kinds of greed can be manifest in the person or group, thus adding to the intensity and stakes.)

As for the health care debate, I want less government involvement, not more. And if this thought aligns with the position of the most rapacious insurance company ... well, I don't care, because it's still my genuine opinion.

Posted by: Donald Pittenger on August 9, 2009 4:28 PM

Donald: "...Yet there also is greed for power -- political power. And, to my mind, that can be far more dangerous than strongly seeking riches..."

But how often is political power decoupled from money power? You can't get too far in terms of political power in this society without the bucks.

Donald: "...As for the health care debate, I want less government involvement, not more. And if this thought aligns with the position of the most rapacious insurance company ... well, I don't care, because it's still my genuine opinion."

So you would hold such an opinion even if it goes against your interests? That's your right, of course, but I suspect most people think otherwise. I don't want my insurance company deciding less than 24 hours before a long scheduled, expensive but routine procedure is to be performed that they suddenly aren't really sure how much they're going to cover, so we then have to scramble to come up with the whole thing before hand and wait to see what they'll do--or *if* they'll do. That's what happened to my husband this week. If it takes government involvement to set some limits and ensure some basic consumer rights then I'm all for it. Actually, a single payer system is what I'd really like to see. For me, it's a matter of productivity, competitiveness and a healthy workforce. It's something that is worthy of national investment. At any rate, you might find PBS' Bill Moyers' Journal interview of Wendell Potter, former Cigna executive, interesting.
We have an expensive, screwed up medical system in this country--dealing with the extended illnesses, hospices and deaths of 3 elderly parents in a span of 4 years amply demonstrated that reality to my husband and I. We actually need much more than just health care funding reform, but it starts there.

Posted by: KR on August 9, 2009 6:35 PM

The bill is more than 1,000 pages long. Any bill that is too long to read is too long to be passed. It should be automatically rejected.

Posted by: kurt9 on August 9, 2009 7:11 PM

Sorry KR, but I do not think that the "single payer" option is in my best interest at all. I have a pretty good health plan and having worked for various governments for more than 21 years, I have a good deal of confidence that a government plan will result in worse health care for me. I hate to sound selfish, but since I'm likely to have only one life, I want to control as much of it as I can and not leave decisions in the hands of competition-free government bureaucrats.

Yes, our health care system isn't perfect (which one is?). But why is the only solution a form of Socialism from which there is no escape for most citizens? Wouldn't it be better to fix any defects individually rather than doing everything at once where the resulting prospect of future change is minimal?

B. Moyers and B.H. Obama can say "Trust me" all they please, but I don't find them (and Big Government) trustworthy at all.

Posted by: Donald Pittenger on August 9, 2009 7:28 PM

Excellent post. But I believe the hc reform bill is also corporatist. From a July 25 AP article on hc reform -- look who supports it:

"The drug industry, the American Medical Association, hospital groups and the insurance lobby are saying Congress must make major changes this year."

http://tinyurl.com/ljgwdw

In any case, this is all just one more reason for the Bill of Federalism. Let's pull the plug on D.C.

Posted by: Kirsten on August 9, 2009 7:38 PM

Donald: "...I have a good deal of confidence that a government plan will result in worse health care for me. I hate to sound selfish, but since I'm likely to have only one life, I want to control as much of it as I can and not leave decisions in the hands of competition-free government bureaucrats..."

So you'd rather your life and your health be in the hands of the corporate shadow government making decisions based on how little health care they ration to you? I just don't get this at all. At least we have some semblance of control of the traditional government in terms of our votes. There is no way we can hope to control corporations short of the 'R' word (regulation). I do not believe for one minute that corporate America is subject to any greater competition. They can do whatever they please.

"...Yes, our health care system isn't perfect (which one is?). But why is the only solution a form of Socialism from which there is no escape for most citizens? Wouldn't it be better to fix any defects individually rather than doing everything at once where the resulting prospect of future change is minimal?"

The problems are derived from it being a 'for profit' system. The only way to fix that is to extract it from that system. My mother and my in-laws had no problem with our established form of geriatric health care 'socialism,' i.e., Medicare--thank God for it! They didn't wish to escape from it, in fact they sang it great praises. It was all the rest that was the problem.

"...B. Moyers and B.H. Obama can say "Trust me" all they please, but I don't find them (and Big Government) trustworthy at all..."

And so you trust the corporate shadow government? Unbelievable.

A tangent: Has anyone noticed that those conservative astroturf 'protesters' who have been interviewed on network T.V. opposing health care reform all weigh about 300 or 400 pounds? I've seen 2 of them interviewed on T.V. this week. These people with obvious pre-exisiting physical conditions are millimeters from a catastrophic health crisis, yet they're convinced that their private insurers will do right by them. Good luck!

Posted by: KR on August 9, 2009 8:09 PM

I'd like to clarify that my intent here is NOT to take any stance, pro or con, on "healthcare reform" in this post and certainly not to express an opinion on any particular legislation. That's a whole separate discussion. I'm talking about political theory here.

To be more specific, I've seen lots of discussion about who doesn't like this bill or who is opposed to healthcare reform. The list mostly recites the familiar suspects: doctors (no public option for us, thank you), big pharma (don't negotiate the prices of our drugs), hospitals (don't cut our Medicare & Medicaid reimbursement or force us to collect comparative effectiveness data), medical device manufacturers (don't stifle innovation), labor unions (dont' tax our benefits), U.S. Chamber of Commerce (don't tax employers if they don't offer health insurance)...etc., etc.

What I want to know is what powerful interests are pushing for it, because they've got to be out there. I'm guessing that a lot of employers are hoping to cut the costs of their employee healthcare benefits by, one way or another, offloading them on the public purse...but I don't know that for sure. I suspect the pressure in this direction is much more indirect, but I don't believe that the US political establishment would be tackling anything this controversial without prodding from their 'patrons.'

On a different point: Donald, I'm puzzled when you say you want a reduced government presence in healthcare. Do you mean you want the government to stop funding Medicare? Or to stop licensing doctors and hospitals? Or to stop subsidizing two-thirds of the cost of doctor training? Or to stop allowing employers to deduct the cost of healthcare benefits instead of treating them as compensation? Or to stop providing low cost financing via tax-free municipal debt and other finance programs for healthcare facilities? The current system is not exactly laissez-faire. Counting government and insurance money -- both socialized payment mechanisms -- healthcare is already 85-90% socialist on the demand (payor) side; it's only on the supply (service provider) side that it remains stubbornly private and for-profit. I agree that one way to "reform" healthcare would be to eliminate all licensing requirements and all socialized payment mechanisms and force people to pay the cost of their healthcare out of pocket; that would cut costs by at least half (and maybe more) within a year or so. But is this what you're driving at?

Posted by: Friedrich von Blowhard on August 9, 2009 8:10 PM

KR and Friedrich, I am not a policy wonk (obviously!) and, like most folks, go through life operating mostly on the basis of rules-of-thumb ("heuristics" for any grad students in the audience).

One rule-of-thumb I believe in is that government changes slowly, is inefficient, monopolizes force and is permanent, for most practical purposes, whereas businesses (unless they become de facto government) are comparatively fragile and short-lived because they face competition and cannot sustain monetary losses indefinitely; therefore government should be minimized to the greatest extent possible because it holds the greatest potential danger to personal freedom.

So I have no particular opinions regarding one detail or another regarding this policy or that or where a government-non government line gets drawn if it comes to pushback against government intrusion.

This does not mean that I'll never have detailed opinions. But presently we are in a situation where an entire, extremely complex system is at stake, and no one can really grasp all the implications. So I say kill the health care push and look at details in isolation. Perhaps under those conditions I might be able to respond to Friedrich's question: From a practical standpoint, government involvement/interference cannot be avoided, so we enter the realm of wonkiness and the drawing of lines.

Sorry that I don't buy into the "corporate shadow government" worldview. Even if it as fearsome as some might think, its danger can't hold a candle to the risk of jackboot totalitarianism.

And apologies to authors of future comments, but I've said most of what I plan to say on this issue for now. I don't happen to have a detailed, foolproof health policy in my back pocket ... only a set of principles I'll cart into the poling booth.

Posted by: Donald Pittenger on August 9, 2009 9:14 PM

Another one, Friedrich: as I'm sure you know, Walmart is for it, and has apparently invested a nice chunk of its PR budget in making that clear.

http://www.latimes.com/news/columnists/la-fi-lazarus5-2009jul05,0,4358896.column

Of course all we know is that they're supporting it, not why. What seems most logical to me is that it's a matter of "keeping your enemies closer." Walmart, the insurance industry, etc. have decided that if they're in the same bed as the politicians they can influence the legislation to give them a competitive advantage of some kind.

Other possible motives: looks good from a PR perspective; perhaps federalizing hc delivery gives some of these industries cover from a liability standpoint as well. Last point is pure speculation . . .

Posted by: Kirsten on August 9, 2009 9:19 PM

The problems are derived from it being a 'for profit' system. The only way to fix that is to extract it from that system.

You know, this is a far more complex problem than people realise. Any change in the health care system is going to generate winners and losers, and I imagine that the people lobbying congress are the affected parties with the funds to exert political influence. Drug companies, health funds, doctors lobbies etc.

The problem with the debate is that it is complex and simplistic solutions frequently generate more problems than they solve.

Take for instance the profit motive. Get rid of that and you get the U.K system of health care, where you can get ultrasound after waiting 4-5 weeks for free or you can't get one at all.

Take drug costs. It cost a about billion dollars to develop a commercial drug. This is private money a drug firm has to invest with the risk of loosing all of it. The patent laws only give the drug company a small amount of time in which to recoup its investment(if the drug is approved) and to make a profit to keep it going as a going concern. Cutting down on drug company profits means less research is going to be done. It's not rocket science.

Lifestyle factors. Why should the community pay for poor lifestyle choices. Why pay for smokers health costs, or obese peoples health costs? Would people be healthier if they new the gov wouldn't pick up the costs of bad lifestyle choices? But then could a culture that believes everyone else is responsible for your problems afford the cost of providing health care to all.

Government funding means a third party( not necessarily acting in the patients interests) enters into the doctor patient relationship, this comes with both pros and cons? Do you want the government to decide that you qualify for certain cancer therapies as is the case her in Australia?

The mess that is your health system is as result of your laws, legal system, health system and culture. Everyone is champing at the bit to have their special interest forwarded, no one looks at the big picture: Which means the big picture suffers.

Your system is a bad system but I feel a socialised version of it will be worse.

Posted by: slumlord on August 9, 2009 11:44 PM

The way to understand what is coming is to break it down simply.

We will have a national health care system with a single payer--the government.

The way that the government achieved this monopoly was to enter a segement of the market (medicare and medicaid), and then underfund these programs. The costs were passed onto the private sector, making insurance more expensive. The did the same thing with mandating treatment of people who could not (or would not) pay the bill. Private insurance costs are now through the roof.

Now they are saying there will be two systems, but in reality, they will underfund the government system, pass on the unpaid bills to private insurers, and completely drive private insurance out of reach of all but the most wealthy.

Then they will ration care, and the quality of care will fall. The state will also mandate treatments, even if the patients don't want them. Say goodbye to that freedom you have now.

The big drug compainies will become fully government-protected cartels who will lobby the state to mandate their new drugs and treatments to patients. It will be hyper-corporatism.

So we will have a sort of socialist/fascist model for health care, and the care will never be affordable, but rationed and mandated, and worse than it is now.

Nice.

Posted by: B on August 10, 2009 12:48 AM

Significant numbers of doctors DO support reform, including some sort of public option. Wal-Mart's support may well be related to the fact that the company pays low wages with few benefits; a system that decouples health insurance coverage from employment might be seen as making competitors who now do provide health insurance less attractive alternatives for employees.

It continues to amaze me that we have a system that fails so spectacularly by the pertinent objective metrics ... infant mortality, life span, total amount of GDP spent on health care, etc. ... and is yet defended so vigorously by so many. For those who support the system as it is with only slight tinkering is it fear that they'll somehow lose an elevated position, a stock portfolio heavy with pharmaceutical stocks, belief that God works by giving wealth and health to those who most deserve it? I am particularly amused (or angred depending on the day) by the "rationing" rationale levied against having a public option. What is having 45 million uninsured (or whatever the figure is now up to) unable to access most health care options if not "rationing"?

We have a political system that serves the elite. It is beginning to appear that for all the cries of "socialism" and the tinfoil hat brigades looking for Obama's birth certificate that this health care reform is going to end, not in any public option worthy of the name and not in less expensive insurance or health care, but rather in a requirement that we all MUST patronize the insurance industry, regardless of whether we can afford it or not. It seems that the entrenched interests are going to be successful in subverting the roughly 70% of the populace who want to see a public option at the least and preferably universal coverage (aka socialized medicine).

Posted by: Chris White on August 10, 2009 7:58 AM

What I want to know is what powerful interests are pushing for it, because they've got to be out there.

Health insurance companies, obviously. The CBO has already calculated that it's a $1 trillion subsidy to individuals to purchase health insurance over the next 10 years -- essentially, a $1 trillion subsidy to the health insurance industry. What's more, under the current bill, both individuals and businesses will be hit with a penalty tax if they fail to buy the health insurance companies' products.

Posted by: Taeyoung on August 10, 2009 8:16 AM

For 30 years my father-in-law worked in a senior management position for a health insurance company.

And he simply says the only way to fix the current problem is to take the profit motive out of it.

In a capitalist system, is this even possible?

He says there are established best practices for this industry that have been completely thrown out for profit's sake.

He says any gov't run program would simply follow best practices that have been established for the industry. He also said the government would try to enforce best practices on private insurance companies.

From a practical standpoint I would assume this means more scrutiny across the board, which means it will take longer for people to receive only the care they need.

I think most people don't really understand why costs are so high. My feeling is most people think cutting costs means cutting prices.

What it really means, for instance, is preventing that doctor(s) from running a battery of exams and tests just to be safe. It doesn't mean simply slashing the prices of all those exams and tests by 50%. It doesn't mean lowering the price of those pills.

As usual, most people know the problem, but they don't know the causes. If they knew the causes were excess based, I wonder if they would feel different?

As slumlord says, increased socialization would introduce a new set of problems.

Posted by: Steve-O on August 10, 2009 9:55 AM

It continues to amaze me that we have a system that fails so spectacularly by the pertinent objective metrics ... infant mortality, life span, total amount of GDP spent on health care, etc. ... and is yet defended so vigorously by so many.

One reason I'm not swayed, personally, by these metrics is that I'm not persuaded that they accurately portray what's going on out there.

E.g. infant mortality. Data has to be controlled for how live births are counted.

Money spent as percentage of GDP: seems to me the real issue here is our value system. In a society where the individual is prized, spending on healthcare is going to be high.

From the 2007 Congressional report that is the source of your assertions (http://assets.opencrs.com/rpts/RL34175_20070917.pdf):

one poll found that 34% of Americans thought that modern medicine could cure almost
any illness, whereas only 27% of Canadians and 11% of Germans thought this.

We believe in it, we want it, we spend money on it.

From the same report: after we in the US reach age 65, our life expectancy is 11th & 13th highest for men & women, respectively, out of the 30 countries covered in the survey.

So the picture isn't so clear-cut as your comment suggests: our current system isn't a "spectacular failure." It has flaws, but so do others. Look at "wait times" in the report. We're also 3rd highest in percentage of people who self-report our health as being "good," "very good" or "excellent."

Posted by: Kirsten on August 10, 2009 1:53 PM

Those of us who have health insurance I think are quite happy with the quality and access to it, if not the cost, paperwork and dealing with dodgy insurance companies. The issue here is twofold: insuring the uninsured, of which the onus to do so is not obvious to everybody, and de-coupling health insurance from the workplace, which I think a vast majority of people would be in favor of as long as the quality of care would not suffer.

So for those in favor of health care reform, the hurdle is convincing the tens of millions who have health care and are generally happy with it to take a leap of faith in changing how that care is paid for and delivered.

I've historically been in favor of something like nationalized health care, but recently I've started to question that. On the one hand, I think it would be more efficient. My father has been a private practice physical therapist for 30+ years and says billing Medicare and Medicaid patients is vastly easier that dealing with private insurance companies. He doesn't make as much from those patients, but has said he makes up for it in less hassle and time on the phone. On the other hand, I can't see how access to medical visits would not be impacted negatively from a nationalized program. I VERY MUCH like the fact that I can call my doctor and be seen that day, usually. I am absolutely not willing to give that up. With any other service, I'll wait, but not when it comes to my or my family's health.

Now, I'm not a heartless bastard, and have personally spent many, many months with me and my family uninsured. It sucks and it's scary. So I'd love to see a program that covers those currently without health care. As long as it doesn't negatively impact my and my family's health care. Give me that plan, and pay for it, and I'm in.

Posted by: JV on August 10, 2009 2:21 PM

btw, I'm willing to pay a bit more, either in taxes or premiums, to fund a program that would extend health care to the uninsured while maintaining the quality and access of my own health care program. And I'd pay even more if such a program could untether my health care from my employer. However, I'm lucky in that my monthly premium for myself, my wife and my 3 kids is 180 pre-tax dollars. A friend of mine pays out 800 bucks a month for health insurance through his employer for a family of 4, which is outrageous.

Posted by: JV on August 10, 2009 2:35 PM

Lifestyle factors. Why should the community pay for poor lifestyle choices. Why pay for smokers health costs, or obese peoples health costs? Would people be healthier if they new the gov wouldn't pick up the costs of bad lifestyle choices? But then could a culture that believes everyone else is responsible for your problems afford the cost of providing health care to all. - slumlord

(Btw, not picking on you slumlord, just using your statement of this issue for context.)

I find this angle to any debate about health insurance - whether it's private, provided by an employer, or govt. healthcare insurance - is specious. The point of healthcare insurance is that costs can be mitigated for everyone by everyone paying in.

The simple, basic, indisputable fact is that everyone gets sick once in a while, and as you get older more things go wrong.

Thus it can be argued that MERELY BEING ALIVE is a "lifestyle factor."

Excluding someone because they, in theory, do or did something that puts their health at greater risk ignores the basic fact mentioned above. (And, if you want to be really forthright about it (if not a little evil and cynical), some of those who have "lifestyle factors" actually to manage to kill themselves sooner than they would have, thus actually help out on the cost side of things.)

Therefore I would like to suggest a "Those of you who have not sinned" approach to this.

You cannot bring this up this topic at all if you have ever:

- Smoked anything (pot, tobacco, punk wood, second-hand smoke, smoke from a fire)
- Eaten anything that is bad for your particular metabolism
- Don't spend at least 15 minutes per day out in the sun without sunscreen
- Spent time out in the sun past the 15-minute mark without sunscreen
- Had unprotected sex with anyone other than your spouse, or have ever had anal sex at all
- Served in the military
- Ridden a motorcycle
- Walked alone in an urban setting after dark
- Skied or snowboarded
- Driven or been in an automobile, particularly on the highway, and particularly at night
- Consumed alcohol
- Consumed any pill or drug (legal or illegal) that has known and possibly dangerous side-effects or taxes any organ
- Climbed a mountain
- Eaten food you have not picked and prepared yourself
- Engaged in any sport or activity that has the potential for bodily harm
- Been too thin
- Been too fat
- Are left-handed
- Are shorter than 4' 6" as an adult
- Are over 6' 10" as an adult
- Birthed a child

Posted by: yahmdallah on August 10, 2009 3:46 PM

(Btw, not picking on you slumlord, just using your statement of this issue for context.)

Likewise.

Look, there is a clear distinction between exposure to risk and deliberate self harm. A motorcycle rider is exposing himself to risk of injury. The smoker is actually injuring himself. I feel it's quite reasonable to treat a smoker who has stopped smoking, or a fat person who is making progress in loosing weight, but it's a different matter of community paying for the treatment of cardiac disease while the patient continues to engage in behaviours which make the cardiac disease worse. Why treat people who are making their condition worse?

We know for instance, that type two diabetes can be put into remission by loosing weight and exercise, not to mention the whole host of other benefits that such an approach brings. But why the hell should the community pay for diabetes medications when the individual himself is not prepared to put the effort in for their well being? It is a continual source of perplexion to me as to why we should be providing expensive partially efficacious treatment when excellent cheap treatment is available but not chosen.
Why not go for the cheap option first?

I'm sorry, but the intellectual premise behind your argument is that individual has to be catered for by "society"; no demands should be put on them. This is the sort of premise that sends health care costs skyrocketing and ultimately makes it unaffordable for everyone.

The hideous expense of the American medical system is partially based upon the premises by which it operates. I mean should 95 year olds get by-pass surgery? What are the limits of treatment? The problem of socialised medicine is that these problems move from the realm of ethics and culture and become the subject of political struggles. That is a universally bad thing. It is very hard to stop treatment under the current system because of the legal and cultural premises by which it operates. The only thing that puts the brakes on the system is when people run out of money, but when the government is paying, you either get health costs that spiral out of control or you get rationing. Which politician is going to have the balls to say we are not paying for 90 year old heart by-passes? I mean imagine if the really hard core right to lifers got political power, does everyone get put on the ventilator at the public expense? Does it suddenly become a right?

These issues need to be nutted out because the premises by which the current American system of medicine operates are deeply flawed, and an open cheque book is not going to fix the problem. There is a good tradition in American medicine of abdicating responsibility from the individual by giving them a disease for their moral failings. Who decides if sex addiction is a disease? What are the criteria? I know a lot of shrinks and I'm not all that confident with their insight and independence? Because if it is a disease, the amount spent on treating the condition is dependent on where these shrinks draw the line.

As for mountain climbers and other people who want to push "extremes", what is the problem with them taking supplemental insurance by paying for it? I mean if want to climb mountains and expose yourself to increase risk, how about putting a bit more into the till?

Posted by: slumlord on August 10, 2009 11:26 PM

The larger point is that everyone is going to get sick a few times in their lives; therefore, everyone will need healthcare. That fact alone should render the debate moot.

But, since it hasn't, and the denial (or mandatory extra cost) of healthcare for people who put themselves at greater risk of health issues for the sake of saving money is a real issue to some, we debate.

To me, this issue is the poster child for the "slippery slope." If you posit that some activities will require the use of healthcare dollars that otherwise would not have been spent, then you have the problem of where the line's drawn.

However (to simplify), let's assume that we somehow find the 10 most logical, reasonable, but also pragmatically compassionate people in the world, and we hand that decision to them. They might decide that pregnancy - a completely avoidable condition that's expensive - by all common sense will of course be paid for.

But what do they do about heart disease? A LOT of research points to the fact that high cholesterol is not a primary indicator of heart disease, yet that is the current trope, as you state yourself in one of your examples.

Tom Naughton's wonderful Fat Head presents a lot of compelling evidence that we don't really have a handle on what obesity may exacerbate and what it may not. (Even the official definition of "obese" is specious.)

Fat Head also shows how a thin person can still eat in such a way that they can develop type 2 diabetes. Therefore, if you have a good BMI, but get that type of diabetes, you get treatment, but otherwise you should shop around for a good deal on a cremation?

Ok, let's go one worse. What if you're genetically predisposed towards a disease? Should you have to pay more? (i.e. Do you think "Gattica" is a feel-good movie?)

You can be genetically predisposed to both diabetes and heart disease. If you pass the genetics test, meaning you have the markers for diabetes, you get treatment, but the fat-ass next to you in the waiting room (who fails the test) doesn't get treatment?

And on down the slope.

Our 10 unanimously chosen experts would, I believe, not have such cut-and-dried decisions to make as your post implies.

However, I think it comes back to this:

Why treat people who are making their condition worse?

Because the alternative is immoral. Any sense of morality pretty much assumes that we don't allow people to die if we can prevent that death, even if they are exacerbating their condition.

Consider this: say you've gone to the doctor because a mole on your arm looks funny. Tests prove it's malignant. Then you get a letter in the mail from your insurance carrier (whomever that may be - Aetna, Uncle Sam, etc.) that says, "Melanomas are entirely preventable, according to recent studies, therefore we will not pay for any treatment related to this particular cancer. Have a nice day!"

Is it your fault, or your parent's fault, that you ran around as a kid (or now) without sunscreen? And what if you were sunscreened religiously yet still got melanoma, but, too bad, it's been deemed preventable.

Your reaction to that should pretty much determine your views on the matter.

(One small P.S...
A motorcycle rider is exposing himself to risk of injury. The smoker is actually injuring himself.

Every single person I've ever known who rides a motorcycle regularly has been in an accident significant enough that required a visit to an emergency room. (Informally poll your friends and neighbors and I bet you'll find this to be true.)

I've also known more people than I can count who've made it into their 70s before they have a life-threatening complication from smoking tobacco. (Don't get me wrong, I think smoking is ridiculous and dangerous.)

One take-away from the great "How We Die" by Sherwin B. Nuland is that if you make it to your mid-70s, regardless of medical reason you may die from (assuming you die of a disease or medical condition), you really die of old age. Therefore, 100% of motorcycle riders will cost my insurance provider money (and didn't have to), but a (significant?) percentage less than that who smoke will not.

Given that, should we not insure anyone who has a license to ride a motorcycle?)

Posted by: Yahmdallah on August 11, 2009 4:25 PM

The problem here is that there is not simply enough money in the till. The U.S will not be able to honour its current social commitments, let alone any new massive burden.(David Walker)

If you posit that some activities will require the use of healthcare dollars that otherwise would not have been spent, then you have the problem of where the line's drawn.

Correct, but the line has to be drawn somewhere.

Ok, let's go one worse. What if you're genetically predisposed towards a disease?

Nope. You have no choice in the hand that life deals you. I'm happy to insure against misfortune, not stupidity and sloth.

Because the alternative is immoral. Any sense of morality pretty much assumes that we don't allow people to die if we can prevent that death, even if they are exacerbating their condition.

Whose morality? There is plenty of people who will disagree with you on that position. What is the problem with people taking the consequences of their actions? What moral system states that its fine to take away income from a hard working man in order to spend it on a self mutilator? The other problem with such a morality is that it is the morality of busy bodies. People who know what's good for you and are going to make sure that you get it.

"Melanomas are entirely preventable, according to recent studies, therefore we will not pay for any treatment related to this particular cancer. Have a nice day!"

There is no activity in life that is risk free. In Australia we have had a rather successful program at reducing the incidence of melanoma only to find that we are now having an epidemic of vitamin D deficiency. Life is inherently risky.

All human endevour is a balance between risk and benefit. But the trade off for taking increased risk was the great benefit that would be gained by the action. Until recently normal people though that there was a duty of care to themselves and that people should not take undue risk without a corresponding benefit. The problem is however when people engage in risky behaviour without benefit to themselves.

Take motorcycle riding,it has both its pros and cons but on overall balance it is perceived to be a good thing(just). What are the benefits of obesity? Or smoking? Or bungee jumping? In the latter case it is an exchange for an extremely intense emotional experience vs the risk of death and serious injury. Is it worth it? Not in my books. Should I have to pay for a lifetime of health care because some idiot chose to seek cheap momentary thrills? On the other hand, I've got no problem with paying for the care of a window cleaner who accidentally falls to the ground. His job is inherently risky but it comes with worthwhile benefits. He has been prudent and suffered and accident, while my bungee jumper has deliberately walked into harm's way. My obligation to care for you starts when you are unable to care for yourself, not when you have been negligent and not chosen to take care of yourself. There is a difference.

Is it your fault, or your parent's fault, that you ran around as a kid (or now) without sunscreen? And what if you were sunscreened religiously yet still got melanoma, but, too bad, it's been deemed preventable.
1) Melanoma can occur without sun exposure.
2) While you were young, you were under the care of your parents who were responsible for your care.If they did not look after you properly, you can't be held responsible for their actions. I'm happy to pay
3) If you did apply sunscreen religiously and suffered melanoma, that would have been a misfortune, since you would have take all prudent measures to avoid the disease. I'm happy to pay.
4)But if you decide to spend your time on a tanning lounge, with big signs saying this activity will increase your risk of melanoma. The cough up, because I don't want to pay.

Posted by: slumlord on August 11, 2009 9:54 PM

The quesiton asked by Donald in his original post was: [W]hich industries have a dog in this fight (pro, con, otherwise), and in what groupings [are they] assembled?

Apparently Australian landlords feel they will suffer economically if the U.S. adopts some type of universal coverage (government run single payer, government option plus private insurance, or mandates requiring all to carry insurance from private carriers) because those who take unnecessary risks will be covered, thus costing more than it might for those who live blameless lives. Now, exactly who decides what activities are going to be considered risky for whom remains to be seen. Would it be a panel of government experts (we know how folks feel about those) or the insurance companies (we know how folks feel about them as well)? Perhaps it would be a panel of average citizens who live blameless and risk-averse lives and have the authority to determine whether your particular elevated risk factors are fully voluntary or the result of unavoidable genetic or parental malfeasance. (Although something like that might also be described as busy bodies. People who know what's good for you ...) If kids who are fed too many corndogs become obese, develop corn allergies, or get type II diabetes do you cover them, but perhaps remove coverage from the parents to teach them a lesson in good parenting? So many questions, so few answers.

The bottom line remains that by virtually all metrics from infant mortality through life expectancy, and on to cost per person or as a percentage of GDP, the U.S. fails relative to other industrialized nations when it comes to health care coverage and outcomes. It seems to boil down to a tug of war between those whose first impulse when considering the nation and their fellow citizens is e pluribus unum and those whose first impulse is let me live free or die. Those of us who think in terms of all, working together as a nation for the good of all, are inclined toward universal health coverage while those whose allegiance is first and foremost to the individual favor the status quo.

Posted by: Chris White on August 12, 2009 8:13 AM






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