Kevin Drum

Cheese-Eating Healthcare

| Tue Jul. 7, 2009 1:06 AM EDT

When I reviewed Jon Cohn's Sick a couple of years ago for CJR, I concluded with this:

The format of Sick almost begs for narratives about overseas health care systems. The book is basically a tour around America, with each of its eight chapters named after the place in which its story unfolds. So why not include chapters on Manchester, Malmö, and Marseilles, each of them highlighting in narrative form both the good and bad points of the British, Swedish, and French systems?

Naturally, then, I'm delighted that Jon found someone to fund exactly that:

Last year, I had the opportunity to spend time researching two [] countries: France and the Netherlands. Neither country gets the attention that Canada and England do. That might be because English isn’t their language. Or it might be because they don’t fit the negative stereotypes of life in countries where government is more directly involved in medical care.

....In the course of a few dozen lengthy interviews, not once did I encounter an interview subject who wanted to trade places with an American. And it was easy enough to see why. People in these countries were getting precisely what most Americans say they want: Timely, quality care. Physicians felt free to practice medicine the way they wanted; companies got to concentrate on their lines of business, rather than develop expertise in managing health benefits. But, in contrast with the US, everybody had insurance. The papers weren’t filled with stories of people going bankrupt or skipping medical care because they couldn’t afford to pay their bills. And they did all this while paying substantially less, overall, than we do.

Forget Canada and Britain.  Neither one is even remotely close to the kind of system we'd ever put in place in the U.S.  France's system, however, is surprisingly American in its basic underpinnings.  And while no system comes out tops in every single metric, French healthcare, as Jon says, is better than ours on almost all of them and does it for close to half the cost.

Now, the fact that the French spend about half what we do doesn't mean that we'd cut our costs in half if we adopted a French-style system.  We wouldn't.  There's too much path dependence and too many cultural differences for that.  But what it does mean is that if we adopted something close to their system, we could certainly achieve high-quality 100% basic coverage — with the ability to purchase extra coverage for anyone who wants it — for no more than we spend now and possibly a bit less.

We won't, of course, because too many people are still convinced that healthcare in the United States is better than it is in France — or anywhere else.  It's not.  It's worse and more expensive.  Somebody tell Max Baucus.

UPDATE: Matt Yglesias says that Max already knows.  I figured as much.

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Quote of the Day

| Tue Jul. 7, 2009 12:26 AM EDT

From Jaci Woods, a real estate broker in Irvine, California, explaining the charm of our little planned community:

"The people that don't like following rules say they can't stand it. I saw a man on a ladder starting to paint the side of his house lavender," she said, noting the color was banned by the homeowners association. "It's the ones like that that we guard against."

True that.  You can't be too careful in these parts.  In fact, my neighbor's air conditioner has been on the fritz for the past few weeks and its racket has become really annoying.  I'm thinking about having him deported with extreme prejudice.

From the Annals of Bad Editors

| Mon Jul. 6, 2009 11:30 PM EDT

I'm not quite sure why I looked this up — I think I was verifying the spelling of Daniel Keyes' name — but this afternoon I checked out the Wikipedia entry for "Flowers for Algernon" and learned this:

In 1958, Keyes was approached by Galaxy Science Fiction magazine to write a story, at which point the different elements of Flowers for Algernon fell into place. On submitting the finished story to Galaxy, however, the editor suggested changing the ending so that Charlie retained his intelligence, married Alice, and lived happily ever after. Keyes refused to make the change and sold the story to The Magazine of Fantasy and Science Fiction instead.

Keyes worked on the expanded novel between 1962 and 1965 and first tried to sell it to Doubleday, but they also wanted to change the ending. Again, Keyes refused and gave Doubleday back their advance. Five different publishers rejected the story over the course of a year until it was taken on and published by Harcourt in 1966.

Seriously?  Did these guys also tell Shakespeare that Romeo and Juliet was kind of a bummer and he really ought to have Juliet wake up just as Romeo was about to take the poison — followed by a backslapping reconciliation between the Montague and Capulet clans and a joyous wedding between the star-bless'd lovers?

Jeebus.  What the hell kind of story is it if you give it a happy ending?  What was up with these guys?

Turning the Screws on Iran

| Mon Jul. 6, 2009 1:30 PM EDT

On Sunday, Joe Biden told George Stephanopoulos that if Israel wants to bomb Iran's nuclear facilities, they can just go right ahead:

Look, Israel can determine for itself — it's a sovereign nation — what's in their interest and what they decide to do relative to Iran and anyone else.

Both Robert Farley and Matt Yglesias read this as Biden distancing the administration from any possible attack.  I have a hard time interpreting it that way, especially when Stephanopoulos asked for and got this clarification:

STEPHANOPOULOS: But just to be clear here, if the Israelis decide Iran is an existential threat, they have to take out the nuclear program, militarily the United States will not stand in the way?

BIDEN: Look, we cannot dictate to another sovereign nation what they can and cannot do when they make a determination, if they make a determination that they're existentially threatened and their survival is threatened by another country.

The normal response from Biden would have been simply to repeat the administration's standard position: we don't expect Israel to attack, we wouldn't countenance an attack, and beyond that we won't engage in hypotheticals.  But for some reason that's not what Biden did, and the change in tone was pretty clearly in the direction of not standing in Israel's way if they decide to do something.

My guess: this is mainly intended to put a little bit of public pressure on Iran.  Everyone understands that Israel would have to overfly Iraq to get to Iran, and everyone understands that they could only do this with American permission — tacit or otherwise.  Nothing has changed in this regard.  America is plainly on the hook as a co-conspirator if Israel does anything, and always has been.

Rhetorically, though, this amps things up.  Biden is basically saying that Israel really might launch an attack, and the best way to avoid that is for Tehran to start dealing seriously with the United States.  "If the Iranians respond to the offer of engagement, we will engage," he said carrotishly — and if they don't, well, there's not much we can do to stop our crazy cousin.  You know how he is.  You're better off dealing with us.

Hard to say if this will work.  But that seems to be what's going on.  This isn't distancing, it's pressure to quit screwing around and instead sit down and talk.

Chart of the Day

| Mon Jul. 6, 2009 12:12 PM EDT

Ross Douthat says that both Sarah Palin's popularity and her notoriety are heavily class-based:

Palin’s popularity has as much to do with class as it does with ideology....Here are lessons of the Sarah Palin experience, for any aspiring politician who shares her background and her sex. Your children will go through the tabloid wringer. Your religion will be mocked and misrepresented. Your political record will be distorted, to better parody your family and your faith....All of this had something to do with ordinary partisan politics. But it had everything to do with Palin’s gender and her social class.

Well, look: Bristol and Levi went through the tabloid wringer because they were practically sent from Jerry Springer central casting.  If you're an unknown candidate for national office sprung on the American public, and a few days later that public discovers that your teenage daughter has gotten pregnant out of wedlock, the tabloids are going to go nuts.  Maybe that doesn't reflect well on America, but it's got nothing to do with class.

As for Palin's religion being mocked and misrepresented, Barack Obama got a wee taste of that too last year, didn't he?  And Palin's political record wasn't distorted any more than anyone else's.  Hell, maybe less.  When you base your whole political persona on an obvious lie about being a sworn enemy of federal earmarks — in a state that's practically the earmark capital of the country — and repeatedly claim to have opposed a bridge to nowhere that you were plainly in favor of, well, the distortion started right at home, didn't it?

Still, all that said, I'd agree that Palin's appeal is essentially based on class resentment.  She gets her biggest applause lines when she talks about liberal elites who look down on regular people; the mainstream media peddling lies and propaganda; government bureaucrats who think they know better than you; and big city intellectuals and their contempt for small town values.  That's all heavily class based.  And yet —

Then some facts intrude.  John Sides presents this chart today showing where Palin's base of support comes from.  And it turns out that there's very little difference between her support among the college educated and her support among high school grads.  That's not a perfect proxy for class, and it doesn't show strength of support, which might well be more fervent in the lower SES groups.  Still, it's not too bad a proxy, either.  Class might have less to do with this than Douthat thinks.  Maybe she's just a loon after all.

Marijuana and Me

| Mon Jul. 6, 2009 11:21 AM EDT

A few months ago we started putting together the July/August issue of the magazine, which focuses mostly on the war on drugs.  (The full package, "Totally Wasted," is here.) When my editors learned that I live the life of a monk — I don't drink, I don't do drugs, and I've never taken even a single toke of marijuana — they were pretty amused.  So they decided I should write a piece on marijuana legalization.  And I did.

There's no simple money graf to pull out of the piece, but you probably won't be surprised at the conclusion:

Going into this assignment, I didn't care much personally about cannabis legalization. I just had a vague sense that if other people wanted to do it, why not let them? But the evidence suggests pretty clearly that we ought to significantly soften our laws on marijuana. Too many lives have been ruined and too much money spent for a social benefit that, if not zero, certainly isn't very high.

The bad news is that, at least for now, the chances of fully legalizing marijuana are essentially zero.  We may continue to make progress toward partial decriminalization, which is better than nothing, but at least in the near future that's about all we can look forward to.  Read the article to find out why.

The rest of the piece is a look at what the likely effects of decriminalization and legalization would be.  Some of them may come as a surprise, some of them won't.  As for the title of the piece — "The Patriot's Guide to Legalization" — well, I'm not really sure what it means either.  I just write the text around here and let other people worry about the creative bits.  I think it's meant to go with the picture, though I have to say that perhaps "The Geek's Guide to Legalization" would have fitted the illustration better.

Anyway, now that that's done, maybe I should try some pot one of these days.  After all, do I really want to go to my grave not knowing what it's all about?

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R.I.P. Robert McNamara

| Mon Jul. 6, 2009 10:56 AM EDT

Robert McNamara has died.  Lots of people a little older than me won't agree with this, but I've always felt sorry for him.  I think part of the reason is that his personality is a lot like mine — it's mine squared or cubed or to the tenth power or something, but still recognizably mine.  And so it's easy for me to believe that if I had been in his situation I might have ended up doing many of the same things he did: overanalyzing the details, burying myself in work, staying too loyal to a cause for too long, avoiding the moral consequences of what I was doing, and then ending up haunted by it for the rest of my life.

That's no kind of excuse, of course.  I might have done what he did in the same circumstances, but I didn't.  He did.  And yet, even at that, at least he figured things out eventually.  That's a helluva lot more than some of the other architects of Vietnam did.  Most of them didn't resign, didn't admit error, and apparently didn't even feel much anguish over their roles aside from the purely selfish anguish of being objects of public scorn.  McNamara's anguish may have seemed rather technical and remote to a lot of his critics, but that's just who he was.  At least it was something.

Anyone old enough to have lived through the 60s as an adult probably won't feel much sympathy for this point of view.  But it's hard for me not to.  He's a cautionary tale for people like me.  R.I.P.

Conservatives on Healthcare

| Sun Jul. 5, 2009 8:57 PM EDT

Two pieces in the LA Times today demonstrate why conservatives are increasingly losing the healthcare argument.  First up is Michael Tanner of Cato, a guy who's practically an op-ed machine on the subject of healthcare, and right up front he says this about healthcare in America: "It costs too much. Too many people lack health insurance. And quality can be uneven."  And he admits that "supporters of the free market" — like him — "have been remiss in positing viable alternatives."

A promising start!  But his solution is bizarre:

There are two key components to any free-market healthcare reform. First, we need to move away from a system dominated by employer-provided health insurance....Changing from employer-provided to individually purchased insurance requires changing the tax treatment of health insurance....For tax purposes, employer-provided insurance should be treated as taxable income.

....The other part of effective healthcare reform involves increasing competition among both insurers and health providers. Current regulations establish monopolies and cartels in both industries.

These may or may not be good ideas.  They might or might not reduce the cost of healthcare.  That much is at least debatable.  But they'd do nothing to reduce the number of people who lack health insurance.  Just the opposite, in fact.  If we took his advice, employers would drop health insurance like hot coals and it's a dead certainty that anybody who's over the age of 50 or has a previous history of anything at all would be unable to get replacement coverage in the individual market.  This isn't debatable at all.  So why does Tanner think any ordinary middle-aged, middle-class op-ed reader is going to support a plan that increases the odds that they'll have no health insurance in the future?  That doesn't make much sense.

But at least Tanner isn't crazy.  Unpersuasive, maybe, but not crazy.  Charlotte Allen, conversely, thinks that in order to free up some much needed healthcare cash, Barack Obama wants to take all our old people and set them adrift on ice floes to die.  Do you think I'm engaged in some bloggy exaggeration for rhetorical effect?  Let's roll the tape:

The Eskimos used to set their elderly and sickly adrift on the ice or otherwise abandon them during times of scarcity, and that, metaphorically speaking, is what Obama would like us all to start doing.

....The scarcity of resources to pay for expensive medical procedures will only increase under a plan to extend medical benefits at federal expense to the 47 million Americans who lack health insurance. So why not save billions of dollars by killing off our own unproductive oldsters and terminal patients, or — since we aren't likely to do that outright in this, the 21st century — why not simply ensure that they die faster by denying them costly medical care?

The rest of the piece is a weird Soylent Greenish hodgepodge of scaremongering about comparative effectiveness research, fear of jackbooted government bureaucrats pulling the plug on grandma, and a revival of zombie "No Exit" agitprop last seen in 1994.  Allen barely even pretends there's any real evidence for this stuff — mainly because there isn't any, I suppose — so instead she just riffs hysterically about what Obama "seems" to believe about how to reform healthcare.  Most weirdly of all, though, at the end of the piece the conservative Charlotte Allen herself seems to suggest that Medicare should be funded with infinite amounts of money and there should never be any restriction on how it's spent.  Either that or she doesn't realize that Medicare is the way most old people in America get medical care.  Or that Medicare is a government program.  Or something.  I can't really make sense out of it.

Better conservatives, please.  These two are hopeless.

Roger v. Andy

| Sun Jul. 5, 2009 2:16 PM EDT

I feel like I ought to have a post about the Federer vs. Roddick match at Wimbledon today, but I have oddly little to say.  The fact is, despite the spectacular final score, it didn't feel like that great a match to me.  Roddick dropping six consecutive points in the second set tiebreaker set a bad tone, and the rest of the match was basically just a serve-a-thon.  That's Wimbledon for you, of course, but in the end it just didn't have the feel of an epic contest.  How is that possible for something that ended 16-14 in the fifth?  I'm not sure.

Still, it was great to see Federer get #15.  If Nadal doesn't get his bum knee back in shape soon, Federer is going to end his career with a grand slam record somewhere in the 20s.  Amazing.

Quote of the Day

| Sun Jul. 5, 2009 1:58 PM EDT

From Sarah Palin, still governor of Alaska for the time being, taking advantage of the power of social networking to continue her self-pity fest on Saturday:

How sad that Washington and the media will never understand; it's about country. And though it's honorable for countless others to leave their positions for a higher calling and without finishing a term, of course we know by now, for some reason a different standard applies for the decisions I make.

Um, what higher calling are we talking about here, Sarah?  Freeing up your schedule to whine more regularly on your Facebook page?

But here's an interesting thought: Maybe she really means this.  Seriously.  Maybe she really doesn't get the difference between resigning your office to, say, accept a nomination as Secretary of State or ambassador to China, and resigning your office just because people are mean to you and the whole governor thing has gotten kind of boring.  This is Sarah Palin we're talking about, after all.