Monday, November 2, 2009

Good Intention and Hard Economics: Is There A Compromise?

This is my final post on the health care bill (unless something really interesting happens). I've come to the conclusion that health care needs to be reformed - how that goes about happening is a nuanced matter.

I. Two Possible Beasts of Health Care Reform

Adding a government competitor in the private sector would indeed force insurance companies to lower their rates, but there are two problems that may come of this: either the government will put private companies out of business (by providing Low Cost, Good Quality, and Good Access all at the same time, likely requiring taxes to go above 50% of our income), or it will just become a bigger and meaner Medicaid- Low Cost, Good Access, and better-than-no-insurance quality/hopefully better-than-old-Medicaid-quality - so, it would compete with insurance companies, but with slightly lower quality so it doesn't put them out of business completely. Among the problems facing Medicaid which we've already pointed out is that since Medicaid is a last resort, it doesn't have to compete with anyone (you only use Medicaid if you can't afford the other ones). Thus it's inefficient, full of bureaucracy, and, worst of all, habitually discriminated against by doctors because of insufficient coverage. Either choice (government takeover of health care or Big Medicaid) does attempt to address the needs of the disenfranchised, however, and therefore the intentionality is good and is perhaps a first step to sustainable reform.

If this bill passes, I'm going to cross my fingers and hope for the lesser of the two evils - the latter (Big Medicaid)- since the former would cause the wealthiest, most resource-rich country in the western world to end up like the USSR, go bankrupt and owe China more money than we could ever pay back, which is not even remotely a good idea. Even Dr. Powers, who is a huge advocate for health care reform, backed up that probability. Or, in a not-as-bad-but-still-pretty-bad scenario, we end up like Europe - great access to basic health care but high complacency and almost no innovation whatsoever; there's a reason we lead in medicinal research, and there's certainly a place for innovation not just in health care, but in the healthy psychology of a responsible citizen. We must understand that the US Government cannot provide low cost, high access, high quality health care without transforming our economic system into an entirely different creature.

I am going to go ahead and assume that no one wants to revert to a communist system, because it's a bad idea to give any group of people that kind of control over information and basic needs of citizens. If you disagree with that, we have bigger fish to fry - but before you argue with me, do me a favor and pick up a history book. We do want what Communism aims for, though - economic justice and equal dignity for all human persons.

II. If the Government Doesn't Beat Out All Other Insurance Companies and Operates Within a Budget, How Do We Make Sure The Quality Is Better Than Current Medicaid?

So *if* the bill turns out to not take over the private sector in health care, it will be because it has become Big Medicaid (low cost, good access, medium-low quality health care). Think about it - the cost is going to be less than private businesses - so the only way it won't completely bankrupt them is if their quality of coverage isn't quite as good. Big Medicaid isn't necessarily a bad thing if it provides better insurance to more people than the current Medicaid system does. If Big Medicaid allowed better access and lower cost of health insurance to low-income earners, one further reform would have to take place to improve quality as much as possible *without* taking out of taxpayers' wallets or increasing the deficit.

If the Health Care Bill fixes cost and access, it should leave quality up to another reform: requiring hospitals to set salaries for their doctors to reduce overdiagnoses (take away the commission on keeping people sick). In the case of extraordinary procedures that would cost above a certain amount of money, a review board would have to sign off on it to ensure that the money is not ill-spent. That, in and of itself, would attack the heart of discrimination between insurance policies in hospitals - the doctor doesn't personally financially benefit more depending on which insurance policy he gives more attention to. Thus, more quality care will be given to those who benefit from Giant Medicaid than it would otherwise, because doctors will be more willing to treat them in the first place.

Some argue that this would require a government takeover of hospitals; I say that's silly. We already tell businesses how much carbon emissions they're allowed before they get in trouble, for the good and health of all citizens. Oh, hey, wait! We just intervened in private business without taking it over! Look at that!

Telling hospitals to eliminate the commission system for doctors will not be the end of the world; they're just telling them to operate like a normal business, not a sales business - and also, of course, to recognize the humanitarian nature of their chosen field.

So here we're closing the gap between cost/access and quality. Whereas previously high quality necessarily correlated to high cost, and low quality to low cost, instituting salaries would hopefully compromise by offering medium quality for low cost (doctors wouldn't discriminate at least, but if the person can never cover their share of what Big Medicaid can't, the hospitals will possibly start putting the pressure on doctors to decline them service in the interest of business sustainability. Not perfect, but sustainable and better than what we have now, which is discrimination based on perception, not financial history). Hence, I'd identify the quality they offer as medium - not great, but not bad either.

On the flip side, then, there are ways to narrow the gap on the other side - offer high quality for medium cost. There are ways to drive down costs of insurance policies that already are guaranteed good quality without pouring too much money into the system. Once again, I'd like to draw attention to the Mackey Op-Ed that spells out a way to work within our economic system to competitively drive down insurance costs (it truly annoys me that liberal media summarized this article as "anti-health care" since it's really pro-health care, it's just smart about it. Think outside the box, people! Also, wake up and realize that the government's pockets are not bottomless.) Thus, the highest quality health care of Blue Cross/Blue Shield would become more affordable simply as a result of competition with other private health insurance companies.

III. A Realistic, Sustainable Solution to a Pressing Moral Problem

This is by no means a permanent or perfect solution. It doesn't eliminate the gap in health care between income levels, but it does narrow the gap to a more palatable degree. It is, however, sustainable, which is just as important as a bill being morally right - what's the point of a morally correct bill if it dies out or bankrupts the society it intends to fix? We need to find a compromise between sustainability and morality, and we need to be much more cautious about it than we currently are. The government cannot, by the admission of public health experts, offer all three elements - cost, quality, and access - without an enormous shift in how much money goes into the government, and how much control the government has in the private sector - we have seen time and again that a communist state deprives the individual of innovation and sense of personal responsibility. There is a way to implement morally good ideas in our current economic system, a system that we know works better than a communist one.

We must take into account that we have an enormous national deficit, that security-wise we really really don't want to owe money to a country that's very high on the list of possible wartime enemies in the next two decades, and that we're in a recession where people can't handle the exorbitant tax hike that this would require.

IV. Other Concrete Changes that Must Take Place in Order for the Bill to Maintain Moral Integrity

In terms of the health care bills currently on the table, the following concrete reforms must happen (as well as an admission that we cannot provide the same level of quality as Blue Cross/Blue Shield without bankrupting America):

None of the health care bills on the table leave room for conscience rights of doctors - that is, the bill does not explicitly protect doctors from being forced into engaging in acts that they find morally abhorrent - specifically performing abortions.

The intentional absence of this clause is worrying, especially in light of the dramatic increase of federal use of tax dollars to fund abortions, indicating a very leftist lean within the bill itself. The silence of the bill on conscience rights is therefore deafeningly loud, and must be explicitly addressed within the bill.

Furthermore, the 50% of Americans that now morally oppose abortions should not have their hard-earned money going to fund privately-owned abortion clinics.

Finally, provisions must be made for health care for immigrants; this has not been a priority so far and must be made explicit within the bill.

Saturday, September 5, 2009

More Health Care Resources

Upcoming documentary: Money-Driven Medicine

"Atul Gawande's excellent analysis of high-cost, low-quality care in one town (with low-cost, higher-quality neighbors)": (Thanks to Vienna Teng, Ivy League grad and my favorite singer) -

The Obama Perspective:

Blog on Politico: Parallels between clinton's health care plan and Obama's -

Facebook Statuses the New Town Hall? Blog

An Economic Perspective Blog:

GoogleBooks: Money Driven Medicine:

Redefining Health Care: Creating value-based competition based on results:

Your Money or Your Life: Strong Medicine for America's Health Care System (GoogleBooks)

Catholicism and Health Care Reform

Summary of Catholic Church's Stance:

US Bishops criticize Federal funding of abortion currently included in Bill:

Collection of USCCB letters to Congress regarding the bill:

Thursday, September 3, 2009

Health Care, Step 1: Does the System Need Reform?


Before any of us can form solid opinions on the health care bill, we should probably understand the essential nature of the health care system.

I recently sat down with a man who worked as a doctor for 20 years before he became frustrated enough with the system to pursue a Master's of Public Health; here's a summary of our conversation, which he described as "A semester of Public Health in an hour":

There are three ways to measure the Public Health system in a given country: Cost, Quality, and Access.


1. The US as a whole - government and citizens - spend $2.5 trillion per year on health care - drastically more than any other country on the globe. About $1.2 trillion comes from the US government, and about $1.2 trillion from individual citizens. It comes out to about $7,000 per person, which pulls about $2,000 per person more than the next leading country, which would be somewhere like Switzerland or someplace with excellent health care.


2. Despite this incredible investment of money, the US health care system is not among the best in the world - in fact, we're generally ranked between 25 and 50 internationally on any given standard of measurement (usually decided by the World Health Organization, generally recognized as the main authority in these matters). We are not #1 in anything, and we are behind Western Europe in almost everything. (*Note: I asked about our level of research here - we are #1 in the world in novel innovations - but he said that we are dealing with public health costs/care, not research. I'd be interested in seeing if the two are financially linked, i.e. if cancer research would suffer from funding being cut for the sake of free checkups - which would be an entirely different ethical discussion)

3. One of the reasons that we, according to Dr. Powers, will never be #1 in the world in anything, is our diversity of population. We have much more to worry about than any other country because of our genetic, ethnic, and socioeconomic disparities are so pronounced.

Genetic diversity: We must worry about sickle-cell anemia and the flu, diseases crossing borders through immigration and intra-city passing of diseases. We have a distinct set of challenges to customize medicine to unique persons, whereas Europe generally has a homogenized culture.

Cultural/Religious Diversity: It is difficult to pass any sort of standard of medicine without offending someone.

Socioeconomic diversity: we are more capitalist than Europe. One could debate the pros and cons regarding this - in fact, that would constitute the heart of the health care debate - but a certain result of this is a more dramatic difference in health care depending on one's socioeconomic class. Take infant mortality, a common measure of the standard of health care in a country: a white woman in the suburbs of Chicago would have a very low infant mortality rate - in fact, one of the best in the world, perhaps #1 or #2. Take a Hispanic woman in the inner city of New York, and the infant mortality rate skyrockets - those in the inner city "drag our statistics down." And why? Often for lack of basic prenatal treatment: ultrasounds, prenatal vitamins, regular checkups, which cost more overall for someone without health insurance than someone with insurance (Insurance companies get a discount). Which brings us to


In the US, there are about 300 million people. Around 200 million have access to health insurance and affordable care. The remaining 100 million are either uninsured or relying on a Medicaid program which is typically inadequate to meet health needs.

Of those 200 million, most have employment health insurance, and the rest are on Medicare or are entitled (Veterans or in the Military). In the 1960s, the elderly were among the poorest and sickest, so they developed Medicare. Now, the elderly are among the healthiest and wealthiest. In terms of employment health insurance, jobs and health care have historically been connected since World War II. Some quick history:

During WWII, America had a worker's shortage, since all of its young men went to war. Businesses, striving to stay alive, started competing with each other to offer higher wages to attract more workers. What started to happen, was that big businesses could afford to pay very high wages, drawing workers away from small businesses and overall hurting the economy. So under FDR, a cap was put on excessively high wages. Now the businesses needed to find another element to make them more attractive - and that thing was benefits. They started offering health care benefits along with their employment, beginning the tradition of employment-based health insurance plans. The government supports this system by allowing health care obtained through employers to be tax-free - employers and employees cut the cost of health care about 50/50, easing the burden of health care on the steadily employed.

Now, the other 100 million citizens do not have health care access. About 50 million are unemployed, or work minimum wage jobs. Another 50 million are underemployed - that is, their jobs neither pay enough to cover a cost of living, nor provide health care coverage. Some of these people have access to Medicaid, but, according to Dr. Powers, the Medicaid system is hopelessly flawed.

Under Medicaid, the burden is placed almost exclusively upon the hospital (remember, a private business) to cover health care costs. They are simultaneously required to offer things like emergency assistance to anyone who comes in, regardless of their ability to pay. Well intentioned, but the system is flawed - Dr. Powers worked in the ER for 20 years, and consistently saw hospitals overlook and delay treatment to Medicaid holders, and give preference to Blue Cross/Blue Shield and other insurance providers. Hospitals, like any business, needs to maintain a profit margin, and being required to pay hundreds or even thousands of dollars on a patient is not likely to encourage good or effective service.

Moreover, hospitals are likely to "milk" good insurance policies through excessive health care costs. As Dr. Powers puts it, a patient could come in complaining about how when they eat spicy foods, they get really bad heartburn; when they take over-the-counter medicine it goes away, but it consistently happens after meals. He says that a doctor could do one of two things: he could say "Well, this sounds like a classic case of acid reflux disease - take these meds and come back in a month if the symptoms persist." and bill the insurance company, and get $50-$70. Or he could say "This could be, well this could be bad. I think we need to run some tests - do a biopsy, maybe take an MRI, to make sure everything's okay." And if the patient hears that, of course they'll believe the doctor - he's a doctor! If they go through with it, then the doctor can bill the insurance company $700. So what, then, should stop a doctor from overdiagnosing? And sadly, Dr. Powers said, many doctors do. In other words, doctors are financially benefited not to cure their patients, but rather, in a sense, receive a commission on keeping them sick.

In fact, Dr. Powers speculated that there's already enough money wasted in the system to cover any health care reform needed, if it was redistributed, but that would take a drastic total reformation of the health care system that would take several years - and a government takeover of hospitals. (*Note: I'm unconvinced here: governments control big businesses without taking them over - can't they lay down guidelines in salaries to prevent these kinds of abuses?) One very interesting venue to explore would be whether moving doctors onto fixed salaries would stem this kind of thing - right now, doctors receive a "commission on sickness." Pay a good doctor $125,000-$150,000 a year flat, and let the costs of health care go entirely to the hospitals to cover basic preventative medicine for lower income levels. Or would overdiagnosis drop so drastically that there will no longer be that excessive money "in the system"? That's a question for an economist to deal with.

Based on the conviction that basic health care is a right, not a privilege, Dr. Powers suggests that perhaps government-subsidized medicine wouldn't be too bad. People claim that it's "socialist," but in reality the government already subsidizes half of American health care.

Back to Cost, Quality, and Access - he calls it the "Iron Triangle" - but at any given time, only two of them can thrive. You've either got low cost and good access, but poor quality, good quality and easy access, but only if you've got the money to pay the high cost, or good quality and low cost health care (say, in the military), but limited access (gov't can afford to provide only to military personnel). Obama's mistake, said Powers, is that he tried to say that the US can have all three at once - which is only possible if our economy ends up like the USSR's.

No matter what, says Powers, we need to operate under the knowledge that our current health care system is not sustainable. In just a few decades, the cost of Social Security, Medicaid, and Medicare are going to consume the entire federal budget if the status quo stays the same. Dr. Powers suggests that Medicaid is revamped (it's all pretty much wasted money), and excessive health care spending on overdiagnoses get cut. One way or another, health care needs to be reformed - it's just a matter of how it happens.


Overview: Health care should be evaluated by Cost, Quality, and Access. If one seeks to improve cost and access, people fear quality will be neglected. Access is currently rationed according to socio-economic class under a capitalist system; in response to the arguement that government "rationing" is dangerous, the liberal would argue that health care is already rationed according to socio-economic class.

Hospitals waste insurance money on overdiagnoses; this is the heart of excessive spending with little quality to show for it.

Other issues not discussed with Dr. Powers - impact of lack of competition between health insurance companies - partial monopolies = health insurance companies doing what they want.


In conclusion - these are simply impressions dutifully reported from the perspective of a Pro-Obama doctor with a Master's of Public Health and 20 years' experience in the field. They do not reflect my own viewpoints. I'm looking for a conservative alternative perspective. Until I get a chance to find one and buy him/her a coffee, we will settle with the now-famous John Mackey Wall Street Journal Op-Ed Article (which deals more with the solution than the problem) - for some reason liberals got pissed about this, which makes not a lot of sense since he's acknowledging there's a problem, but has experience with money and understands that the government's pockets are not bottomless:

The Whole Foods Alternative to ObamaCare

anyone else is welcome to add their two cents.

Monday, August 24, 2009

Ethanol and the Food Crisis

Resigned myself to the reality that I don't have time to condense this. Read it in all of its original glory . Good to write, even better to read :p

Wednesday, March 4, 2009

A Closer Look at Haiti and the US' Continued Role in the Food Crisis

A woman prepares mud cakes to sell for food. Mud cakes, made by mixing oil, sugar, and mud, have grown in popularity as a means to take the edge off of hunger. Associated Newspapers (UK), August 2008.

Haiti by the Numbers

GDP Per Capita: $573.70 (about $1.57 per day)
On average, Haitians spend 75% of their income on food alone
In the US, if you spend over 1/3 of your income on food, you are considered impoverished.
80% of Haitians live in abject poverty(2003)
Haiti also has one of the largest wealth disparities in the world
Following the debt crisis of the 1980s, Haiti now owes $1.5 billion dollars in loans. For all of the aid money flowing from the US to Haiti, more of it is flowing back to us in the form of debt payment
66% of Haitians are farmers although it only comprises 30% of the GDP.
Literacy rate: 52.9%, the lowest in the region. Only 20% of children make it to high school

Haiti has always been unstable – most lately, the riots that broke out last April reinforced the notion that Haitians need to “get their act together.”

April 8, 2008:

"UN Peacekeepers fired rubber bullets and used tear gas to control mobs rioting over rising food prices in Haiti... for months, Haitians have compared their hunger pains to
"eating Clorox" because of the burning feeling in their stomachs" - The Guardian, UK

April 18, 2008:

Marc Lacey of the New York Times publishes a compassionate article for the victims of the spike in food prices, but says "Haiti, its agriculture industry in shambles, needs to better feed itself."

Before 1986, Haiti was self-sufficient in rice production

Nineteen Eighty-Six

January - February: Dictator Baby Doc is ousted by the US government. He flees, taking with him all of the money in Haiti's treasury

April: American Rice, Inc., succeeds in lobbying Congress for subsidies on their rice. They can now sell rice that costs $400 to produce for only $250

December 30, just eight months later, the International Monetary Fund, influenced heavily by US businesses, offers a $24.6 million loan to Haiti - with the stipulation that they would cut public spending and liberalize their trade policy - that is, virtually take away their tariffs on imported goods. Haiti, about to default to bankruptcy, accepts.


Subsidized US rice floods the country. Haitian consumers rejoice at the low prices. Within two years, most subsistence farmers are put out of business.

The newly-subsidized American Rice, Inc., gradually secures its monopoly over the Haitian market. Haiti becomes the #3 importer of American rice in the world.

No longer producing its own food, Haiti transforms from a net exporting country to a net importer. It becomes very sensitive to changes in the global food market.

Millions of people move from rural areas to urban areas to find work. In cities, all food is purchased, not grown, leaving the urban population especially sensitive to the globalized economy.

Now, Haiti is sensitive to the global food market. When prices rise, people starve, and then riot. It is stuck in debt, imports more than it exports, and its political and economic policies are indirectly controlled by the people they owe money to - notably, the World Bank and the IMF

Why Did the IMF include stipulations to liberalize the economy?

Theory #1: The IMF believes int the "free market theory" and that capitalism is best for all. Providing cheap rice to impoverished people can't be bad, right?

Theory #2: The US wanted to flood Haiti's market with rice so that we (and American Rice, Inc., which was struggling in the international markets) could gain a major importer of our goods

Theory #3: The IMF, created after WWII to regulate the international currency to the gold standard, lost its mission in 1971 when the gold standard was suspended.

Since then, it has been looking for a reason to exist. It established itself as global economic policeman. It began with loans during the oil crisis of the 1970s, to more powerful loans during the debt crisis of the 1980s.

The IMF has emerged as one of the most powerful organizations in the world, powerfully influencing the political, social, and economic policies of virtually every developing country in the Western Hemisphere.

First-Hand Accounts of the Impact of Subsidized Rice

"American rice invaded the country. It was sold for so little that we could not compete. There was a very serious struggle. When they brought the [American] rice up from Port-au-Prince, they had to escort it in military convoys, to prevent us from seizing it. By 1987 and 1988, there was so much rice coming into the country that many of us stopped working hte land," - Charles Suffrard, rice farmer.

“Within less than two years, it became impossible for Haitian farmers to compete with what they called ‘Miami rice.’ The whole local rice market in Haiti fell apart as cheap, US-subsidized rice, some of it in the form of ‘food aid,’ flooded the market. There was violence, rice wars’ and lives were lost.” – Dr. Paul Farmer

“In the 1980s, imported rice poured into Haiti, below the cost of what our farmers could produce it. Farmers lost their businesses.
People from the countryside started losing their jobs and moving to the cities. After a few years of cheap imported rice, local production went way down.” – Fr. Gerard Jean-Juste

Recent History

March, 2000 - 60 rice farmers and their families pool their money and buy a rickety boat to sail 150 miles north to some British islands to escape their poverty. The boat capsized, killing everyone on board.

In Haiti, most former farmers are living in the slums of the city.

“I come here every day in the hope that one day there will be work, but there never is. When I leave the house, my children
hope that I will earn enough money to come back with food. But very often, I have to walk home because I don't have enough money for a bus.” - former farmer living in the slums of Port-au-Prince

With employment down, and importation up, urban Haitians are very sensitive to changes in food prices.

From 2007 - 2008, the price of basic foodstuffs went up 40%.

Two factors contributed to the outbreak of riots around the world in April - an announcement of new subsidies for the biofuel industry, and a spike in rice prices.

The US is a central exporter of rice and corn, two basic foodstuffs. The price of both have risen drastically in the last few years.


Next - Ethanol and the Food Crisis

Tuesday, December 23, 2008

City of Williamsburg, by the numbers has more numbers than you'll ever need for any city you could ever want to know about. There's data for both the City of Williamsburg and Williamsburg the county.

Some interesting/relevant tidbits:

(Williamsburg city)

Population in July 2007: 12,434. Population change since 2000: +1.7%

Estimated median household income in 2007: $46,254 (it was $37,093 in 2000)
Williamsburg: $46,254
Virginia: $59,562

Estimated median house or condo value in 2007: $427,735 (it was $182,000 in 2000)
Williamsburg: $427,735
Virginia: $262,100

Mean prices in 2007: All housing units: $500,825

2008 cost of living index in Williamsburg: 104.6 (near average, U.S. average is 100)

According to our research there were 64 registered sex offenders living in Williamsburg, Virginia in early 2007.
The ratio of number of residents in Williamsburg to the number of sex offenders is 194 to 1.

Daytime population change due to commuting: +9,499 (+79.2%)
Workers who live and work in this city: 2,212 (52.2%)

Williamsburg household income distribution Williamsburg home values distribution

Unemployment in September 2007:
Here: 4.1%
Virginia: 2.8%

Residents with income below the poverty level in 2007:
This city: 18.3%
Whole state: 9.6%

Residents with income below 50% of the poverty level in 2007:
This city: 9.3%
Whole state: 4.3%

There's a whole page with numbers on the poverty levels in Williamsburg:

(We will definitely talk about this on the first morning).

Next, if you type in "poverty in Williamsburg virginia" in Google, this memo will show up:

One little bit from there caught my eye:

Income and Poverty

  • The Census Bureau¹s model-based estimates for income and poverty should be used with caution. Still, they reflect the existence of a relatively intractable segment of the population in poverty in both James City County and Williamsburg.
  • Poverty is more prevalent in Williamsburg than in James City County. Part, but not all, of this trend can be attributed to William and Mary students.
  • Black youths are especially likely to live in poverty. This trend is most noticeable in Williamsburg where 49% of black youths were in poverty in 2000.

If you're very interested in the issue of affordable housing, here's a site that might be worth a look. Every year they have the "Va Governor's Housing Conference," a major gathering of everyone involved in the area. The presentation powerpoints can be found here (most are very technical):

Out of all the presentations, those of you living in NoVA will find this one particularly relevant, as it details the unusually high number of foreclosures in the NoVA area:

Food crises and US policy

This article explains how subsidized US rice, sold to Haiti, undercut the local Haitian farmers and precipitated a food crisis. Shows how good intentions can sometimes go awry.

This article, "Manufacturing a Food Crisis," details the role that the WTO, IMF, and US played in exacerbating hunger abroad, with particular emphasis on Mexico and the Philippines.