Filed under: Health
Here, I pioneer a new blog style: the epistolary. Basically I posted this as a comment on Megan McArdle’s blog and can’t be bothered to translate it into third-person. This blog is all about laziness! Enjoy.
Filed under: Uncategorized
Filed under: Health
For what it’s worth, I agree with Megan McArdle that the people who are currently obese in the US will probably stay that way, and that while efforts to help them lose weight if they so desire are a moral good, they shouldn’t be a major, expensive, or coercive component of public health policy. I think we’re largely stuck with the waistlines we have, give or take a bit of improvement, and that this generation of Americans probably has a rendezvous with diabetes.
What I am concerned with is reshaping incentives in America so that this generation doesn’t get any fatter, and the next generation never gets this fat. Because the next generation of Americans includes these two guys.
Okay, Andrew Sullivan has now called Megan’s post a “must-read“, and I’ve heard from another source that the conservative-libertarian crowed really seems to like it. I have to reiterate: this is ridiculous.
What is the catastrophic outcome Megan is afraid of? It is this: that the government will start trying harder to help fat people lose weight. Seriously. This is the dystopian example that she provides of how increased government involvement in the health market will “curtail future freedoms”.
She provides two examples of the kinds of programs she’s talking about. One is a hypothetical government behavior change communication program for overweight people, which she argues will not work. Again: why is she afraid that the government, when it comes under pressure to save money on health care, will thus be driven to spend money on a program that does not work? The other program would be hypothetical government coercion not to eat fattening food. Again: every single advanced country in the world except for the US has government-supported universal coverage. There is not a single case of a government that forcibly restricts the food consumed by citizens. This is ludicrous, on a Jim DeMint level.
The other harm Megan claims from universal health insurance is that it will destroy innovation in the health care sector. How? Well, “in the absence of a robust private US market” — what? Hold it right there. Who proposed getting rid of private health insurance in the US? Exactly no one. Certainly not the health care reform bills currently in Congress. And if they did, there would still be the private health insurance market in France, the private health insurance market in the Netherlands, the private health insurance market in Germany, and so on, to pick up the slack. In each of those three countries, private health insurance covers almost the exact same percentage of total health spending outlays as in the US! Most countries in the world that have universal health coverage have robust private insurance markets. What health care universe does Megan inhabit?
Even if the above mistakes weren’t enough, there is simply no evidence that innovation in effective health care is mainly driven by the private US market. And when Megan says there’s a crisis in pharmaceuticals innovation going on these days, she’s right. The crisis is this: private pharmaceuticals companies aren’t producing, or even working on, a significant number of new drugs for major health problems. No new lines of antibiotics to fight antibiotic-resistant strains of TB and other bacteria. No new anti-malaria drugs. And so on. The pharmaceuticals companies claim it’s because patent terms are too short. Whatever. If the private US insurance market is supposed to be driving innovation in pharmaceuticals, then the private US insurance market is failing.
Look, Megan’s post doesn’t make any sense. That conservatives of a free-market bent read through it and think that it does shows that they have been conditioned by 30 years of Friedmanite language to react positively to a particular ideological style of rhetoric and set of catchphrases even when those catchphrases have been assembled to form a proposition that is incoherent.
THERE was a pretty illuminating exchange yesterday between Matt Taibbi and Ezra Klein, two pithy guys whose hair is currently on fire. Mr Taibbi was born with his hair that way; Mr Klein’s hair is usually neatly combed, but has finally ignited in despair at the spectacle of inadequate health-care legislation emerging, or not, from the 111th Congress. “This whole business, it was a litmus test for whether or not we even have a functioning government,” Mr Taibbi wrote…
Filed under: Uncategorized
So, part of the reason I’ve been posting rather lightly here of late is that I’ve taken up a new job, as a blogger at the Economist.com’s Democracy in America group blog. I’m very excited to join my two excellent co-bloggers there, Dave Weigel and Roger McShane. Several of the posts I’ve written for DiA are already up, and I will try to cross-post a notice here each time I post anything of significance there.
But I’ll also continue to post here at Accumulating Peripherals on subjects of no particular interest to Democracy in America. So don’t take it off your RSS reader! And if DiA’s not on your RSS reader, put it there!
Filed under: Health
Yesterday Megan McArdle wrote a long post explaining why she opposes universal health care, on principle. It came down to a fear that government bureaucrats will tell her she can’t have more than one chocolate eclair. No, I shouldn’t make light of this; it’s a good post. I disagree completely with virtually everything she says in it, but I’m glad she wrote it. I now have a somewhat clearer sense of what it is I disagree with so completely.
Megan’s overarching anxiety about universal health insurance, the fear she raises at the end of her piece, is that it will ultimately force the government to start restricting behavior in order to control costs.
Once the government gets into the business of providing our health care, the government gets into the business of deciding whose life matters, and how much. It gets into the business of deciding what we “really” want, where what we really want can never be a second chocolate eclair that might make us a size fourteen and raise the cost of treating us.
Let us note here in passing that Medicare has not attempted to ration chocolate eclairs for seniors, nor are these desserts exactly hard to come by in countries like France and the Netherlands, which have universal coverage and much lower costs than the US. (The Netherlands even has comparable obesity rates.) But moving on: the reason Megan thinks this intervention will be heavy-handed is that the government has no real idea how to make people less obese.
When you listen to obesity experts, or health wonks, talk, their assertions boil down to the idea that overweight people are either too stupid to understand why they get fat, or have not yet been made sufficiently aware of society’s disgust for their condition. Yet this does not describe any of the overweight people I have ever known, including the construction workers and office clerks at Ground Zero. All were very well aware that the burgers and fries they ate made them fat, and hitting the salad bar instead would probably help them lose weight. They either didn’t care, or felt powerless to control their hunger. They were also very well aware that society thought they were disgusting, and many of them had internalized this message to the point of open despair. What does another public campaign about overeating have to offer them, other than oozing condescension?
But wait a minute. What Megan is saying here is the exact opposite of the conventional libertarian-conservative line against government restrictions on fatty foods, which is that people who don’t want to eat fatty foods should just not eat them. That line was memorably encapsulated in Morgan Spurlock’s “Supersize Me” by a conservative man in a Stetson hat who proclaimed that anyone who doesn’t want to eat at McDonald’s can just drive on by, and that it’s none of the rest of our business what McDonald’s puts into its food. That was also, unsurprisingly, the position taken by the fast-food industry lobbyists in the movie.
But Megan is saying this isn’t true. She’s saying that overweight people — like, for that matter, pretty much everyone else — are unable to control their eating behavior. And she’s absolutely right about that; in fact, you have to be a bit deliberately dense not to understand that most people do not have full voluntary control of their eating.
And contrary to what Megan writes, obesity experts and health wonks are not deliberately dense: they do not think that overweight people could lose weight if they just tried, or are too stupid to know why they are fat, or that they don’t experience enough social stigma. Health experts, like all behavior change specialists, understand very well that more information about health risks does not usually, by itself, lead to behavior change. They learned that lesson decades ago in the battle against smoking, and re-learned it in the battle against AIDS. Just knowing that something is going to kill you doesn’t make you stop doing it, not if it is deeply embedded in your social rituals, unconscious habits, or sense of self — or, obviously, if it is physically addictive.
And that is precisely why changing health behavior is usually not something that can be done by individuals. It has to entail a broader social effort to create environments in which being healthy is easier than not, and to discourage people and businesses from creating unhealthy environments. Megan writes that the overweight people she knew at Ground Zero “felt powerless to control their hunger,” were “very well aware that society thought they were disgusting,” “had internalized this message to the point of open despair.” The portrait Megan paints of is of people asking for help. They don’t want to be fat. But they can’t control their eating and exercise behaviors on their own. Almost none of us can. We need intervention to make it harder to eat lots of unhealthy food, and to make it easier to eat healthy food and to exercise. These people are essentially saying: “Mayor Bloomberg! Please ban trans fats, before I eat more of them!” And stop subsidizing corn syrup, and pave more bike lanes, and build more walkable neighborhoods, and put calorie labels on chain restaurant menus, and put PE and recess back in the school day for schools that have lost them, and ban deliberate “smell-vertisement” by fast food stores as a public nuisance, and go ahead with whatever other range of programs you think appropriate, some of which may help some people, some of which may help others, to reduce the constant temptation to eat cheap, fattening food that now surrounds us on the American streetscape.
Perhaps Megan thinks none of these interventions will work. If they won’t, it’s not clear to me why she thinks the government will face pressure to employ them to save money. Certainly, I can’t imagine anyone being so stupid as to think one can reduce obesity-related health care costs by further stigmatizing the obese. The US already engages in plenty of ineffective stigma-based ad campaigns to try to stop teenagers from having sex and using drugs, but the motivations are chiefly moralistic rather than fiscal, which is why their proponents don’t care that they don’t work. In any case, though, if Megan doesn’t think anything can help the obese to lose weight, what does she think society can do for them? Stop stigmatizing them? Because that ain’t gonna happen; it would be a quixotic project that would require a lot of, well, government-funded sensitivity training campaigns…
Situations where people are not rational and do not have autonomy over their own actions, or in this case even their own desires, are problematic for libertarians. Some libertarians cope with these kinds of issues by simply pretending that people are always autonomous, responsible actors; they might say that by not controlling their eating, obese people are displaying a “revealed preference” for eating lots of fatty food over being thinner, or something stupid like that. Megan doesn’t engage in that game. But in this situation where people are saying they’re psychologically unable to act in what they identify as their own interests, Megan seems to be unwilling to reach into the social toolkit to help them out, because she can’t see reaching into the social toolkit as anything other than coercive. I’d bet that when she so much as reads the phrase “reach into the social toolkit,” she shudders, even when it refers to paving more bicycle lanes. So what does she think can be done?
I think she thinks that nothing can be done. “Nothing can be done” is not an appealing political program. It doesn’t even seem to me like an appealing way of being in the world. But, in large measure because a lot of congresspeople share these kinds of unexamined quasi-libertarian ideas about health care, it seems possible that nothing is exactly what will get done about health care in the US.
Filed under: Health
It’s come to my attention that if I had moved to the Netherlands from the US this year, rather than 10 years ago, I would have saved less (in percentage terms) on my health insurance premiums. That’s because back in 1999, I was getting a low rate as a then-young healthy person; my premiums were 75% lower in the Netherlands than they had been in the US. But as of 2006, the Netherlands instituted a major systemic reform under which all health insurers must offer everyone in the country exactly the same individual rate for health insurance, regardless of age or prior medical condition. This paper in the magazine Health Affairs by two Dutch health economists explains the details. As of 2007, the average Dutch premium was about 1100 euro, rather than the roughly 600 euro I was paying back in 1999. On the other hand, each Dutch taxpayer (and I was paying taxes) now gets an income-related subsidy from the government to help reimburse health insurance premiums, and that runs up to a 1,464 euro maximum. At the same time, there’s a 7.2% payroll tax to fund the government-run Risk Equalization Fund (more on that below). Employers are required to reimburse that 7.2% fully to employees; but I was self-employed. Of course, in the US, I was paying an equivalent payroll tax for Medicaid and Medicare.
The net impact of all this is kind of hard to figure out. It’s hard to know how much the average 30-year-old would pay for insurance now in the US. The Robert Wood Johnson Foundation says the average cost of an individual policy in the US was $4118 in 2006. But a survey of policies sold through eInsuranceHealth in 2007 showed costs for individual policies ranging from $1200 to $3600 a year. And of course back in ’99 you could get 1.25 euros for your dollar; these days you can get 1.4 dollars for your euro, which makes the idea of moving to Holland to buy health insurance less attractive. And yet, even at today’s exchange rates, and even assuming I could get a decent insurance plan in the US for $2500 a year, I would save almost $1000 a year — 40% — by moving to the Netherlands, even without factoring in whatever government subsidy I got back. (My earnings that first year in Holland were, shall we say, low enough that I feel confident I would have received a substantial subsidy.)
Filed under: Health
I must confess that I’ve found it increasingly difficult to follow the intricacies of the health care reform debate in the US over the past two months as it’s moved through Congress. (I think I’m for putting Medicare compensation rates in the hands of an independent agency rather than Congress, but since Henry Waxman is against it and the Blue Dogs are for it I feel I may be missing something; in any case it’s clear that without being based in Washington I can’t follow the details closely enough.) But I still think it worthwhile to keep posting occasionally based on my personal experience of European health insurance and health care systems.
The system the US is going to end up with if the current House bill becomes law will look something like the system in the Netherlands: a combination of private insurance plans sometimes linked to one’s employer, a public plan, a mandate that everyone must purchase health insurance, and a mix of public and private health care providers (doctors and hospitals). When I moved from the US to the Netherlands in 1999, I switched from an American HMO to a Dutch health insurance plan. In both cases I was buying insurance as an individual on the private market. My premiums dropped 75%, from somewhere over $2000 a year to a little over $500. During the course of the following year and half, I visited a private-practice primary care doctor three times, which was about three times as often as I visited one in the US. On each occasion I saw the doctor the day I called with no appointment. The cost was somewhere between $25 and $50 per visit, I can’t remember the exact figure. The doctor’s office was a spiffy one located in a gorgeous canal house in the center of Amsterdam.
Since leaving the Netherlands to live in first Togo and now Vietnam, our family health insurance plan has come through private insurers paid by my wife’s jobs. Our current plan is with a company headquartered in the Netherlands and, because my wife is Dutch and works for a Dutch employer, functions within that framework. It initially gave us global coverage everywhere in the world except for two countries where health care costs are so far out of line with the rest of the planet that they demanded a higher premium for coverage there. Those two countries were Switzerland and the United States, which also happen to have the most deregulated and private-sector-oriented health insurance systems in the developed world.
Because we spend several weeks each year in the US and didn’t want to run the risk of bankrupting ourselves in case of an accident, we eventually kicked in the higher premiums to get coverage in the US as well. Our coverage includes full reimbursement for all doctors’ visits and prescription medicine, major dental, the occasional pair of eyeglasses, and various other routine expenses that actually entail rather perverse incentives and perhaps shouldn’t be included in insurance plans if one wants to hold costs down. While on this plan, we have had two children in Dutch hospitals. We have had one very serious medical intervention in which my then 9-month-old son had to be medevac’d from Hanoi to Bangkok for a life-threatening respiratory infection. We have had one other hospital visit and minor operation for him, and various other significant expenses. The cost of our all-embracing gold-plated global coverage is in the range of 6000 euro per year for our family of four — currently about 70% of the average cost of family health insurance in the US. That’s at the historically high level of 1.4 dollars to the euro. If the dollar regains any strength against the euro, the plan will look even cheaper.
At some level, I’m not sure why I care whether the US finally gets a sane health insurance system. If people who live in the US want to waste 5% of their annual income on a full employment program for health insurance company call center workers and pharmaceuticals executives’ golf course memberships, that’s their prerogative. But my passport says “United States of America”, I vote in the State of New York, and to make a long story short, it’s my country and I love it. The insanity of the US’s health insurance system, and the inability of the US’s political system to get a handle on problems caused by corporate interests that run against the public welfare, is wrecking the government’s budget and rendering the country unable to act on issues of global urgency. The US needs that money to fight climate change and to fund development aid in Afghanistan. And more broadly, I don’t like it when people from other countries consider my country stupid, and are right about it. It feels much better having a president who people from other countries respect. It’d be nice if on this issue too, when people from Vietnam asked how health insurance works in the US, I could explain it to them as a positive model, not as a warning of how not to do things.
Filed under: Religion
There really isn’t anything at all interesting to say anymore about atheism vs. religion, and hasn’t been since at least the 1950s, if not the 1850s. So instead I’m going to catalog a few of the more spectacularly uninteresting things people are saying on Andrew Sullivan’s atheism vs. religion thread. From Patrick Appel’s post today, reporting some reader responses:
Lots of atheists broadly reject the existence of any God, but casually embrace concepts such as ‘luck’
I have seen people who were losing or had just lost loved ones, and been with them when they heard words from their faith tradition that spoke of all things being in God’s hands, and seen them draw strength from that to deal with their loss. So, yes, religion has to answer for the crusades. And atheists have to answer for having no meaningful words of hope to provide in crisis.
Funny, my dad is an atheist, and I’ve always found him to be full of meaningful words of hope in times of crisis. I mean, I think he’s an atheist; I actually don’t know. Put it this way: Both of us are occasionally practicing but non-believing Jews, and in all the conversations we’ve ever had about moral significance in life, never once has any mention been made of the will or existence of any kind of supernatural being.
I’ve always had room in my head for the acceptability of belief in the existence of some kind of deity, as long as one doesn’t believe that deity has any actual physical influence on the really existing material universe, which would just be ridiculous and superstitious. But recently I was taking a shower, and it occurred to me that saying you believe in the existence of something that doesn’t have any material reality or observable consequences is a pretty empty statement. If something has no effects whatsoever, if its absence would have no consequences, what does it mean to say it exists? One might I suppose place it in the category of values or qualities, which are things we believe in that often have no material existence and in a sense no observable consequences. “Nobility,” for instance, is something I believe in but that doesn’t have any material existence, and one could imagine people from other cultures who didn’t even understand what you meant when you said “nobility”; the world they see is no different from the world I see, but they are not wrong when they fail to perceive any such thing as “nobility”, nor am I wrong to perceive it. In a slightly different way, there are people who argue there’s really no such thing as “altruism” on various emotional or philosophical grounds, whereas I believe there is such a thing. This is an interpretive difference about the nature of the world, and one can argue for the existence or non-existence of these qualities without having to believe in a different material reality, much in the same way that I believe there is much that is good in Stanley Kubrick’s Eyes Wide Shut while others deny the existence of anything good in the same movie. But I’m not exactly sure what a belief in God as a value or quality would look like, and I really doubt it would look much like the religious faith practiced by 99% of the people who identify themselves as believers. Another plausible option would be to believe in God as a fictional character, which is I think what a lot of people are doing when they ask themselves “What would Jesus do?”