Understanding What's Going on with Healthcare

This post is going to examine in shallow depth a lot of what's going in with Healthcare reform right now. I feel like the confusion that a lot of people are feeling is making them risk-averse (at least that's my impression among friends and family), so I'd like to take a stab at explaining things.

There are two major issues with healthcare in this country that Washington is attempting to fix. 1) Healthcare costs 16% of every dollar made in America and the cost is growing faster than inflation, which is unsustainable and too expensive already and 2) we're the richest country on the planet and many people in this country can not afford sufficient healthcare. Since the lack of coverage problem appears to be less present to people than the financial issues, it is useful to reformers to note that getting universal coverage will help to reduce the cost of the system.

Healthcare costs are increasing for many reasons. High priced and cutting edge treatments is just one cause. The system is tilted toward doctors spending more money (since they get paid for each test they run, rather than for successful results, quick fixes are discouraged even if they're the better treatment). The insurers take a large percentage for profit. Every service essentially has a tax built in for the uninsured as we need to subsidize the costs of emergency room treatments.

It is known that a large number of people are uninsured. The White House claims it is 46 million people, reform opponents say it is much lower - but that entirely misses the point, I believe. This is the United States, richest country in the world and in all of human history; and we are not the top in the world in providing care for our citizens? The Declaration of Independence does state: "We hold these Truths to be self-evident, that all Men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness." However, even beyond the general understanding that there is a problem, people always think it's someone else's problem, since most of us do have insurance. However, that's because most people don't realize how easily they could lose their insurance. Whether being fired or changing jobs, we can easily find ourselves without insurance and excluded due to a pre-existing condition.

So how can we solve these issues... There is much saving that could occur if we bring uninsured people into the system. Emergency care is the most expensive type of care, but the only type available to the uninsured. If we get everyone insured, emergency costs will decrease greatly. We can also save money by taking away doctors' incentives to order extra tests. Certain institutions (like the Mayo Clinic) have gotten great results putting doctors on salaries so that they are not rewarded based on the number of tests they order, but instead by healing their patients. However, this is only going to amount to some of the cost (estimated at $100 Billion a year) required to fund the new covered people. We'll need to raise more money from some other sources, possibly 1-3% taxes on earners making over $1 million a year. However, the way the system is currently designed, if we institute reforms the savings will just disappear into the insurers pockets, costing citizens the same amount. That is the purpose of the public option (explained below).

Under the reform plan, all citizens will be required to have insurance. If you can't afford it, then the government will pay for it for you. You can choose any plan that is available for the value of the government subsidy, whether public or private. The public option will be based on Medicare. Medicare guarantees all seniors in this country a minimal level of coverage. If you (or your employer/former employer) can afford more or better coverage you are welcome to it, and many people do. However, if all you can afford is Medicare, then that is usually sufficient. If you can afford insurance and don't have it, the government is proposing penalizing you. The current penalty appears to be half the cost of the public option (likely around $2,000).

One of the most common arguments I hear against government involvement is that this threatens the free market, the driver of all innovation. The first point is, if the free market is more efficient than the government plan, then people will stay with private providers and there won't be an issue. However, if the government is more efficient then that undermines the argument.

And that is the bigger point here. We use the government's size and reliability to do many things in this country where they are more appropriate than private business. Public transit, roads, army, the courts. Just because healthcare has been a non-governmental function in the past, doesn't mean that's appropriate. Moreover, free markets don't really work for healthcare. For one, most people never think of the cost of healthcare, especially those that spend the most on it. People have their workplaces take care of all or part of it and rarely if ever choose employers based on healthcare. Also, humans are very bad at rationally understanding large numbers.* Free markets only work when there is full information available to all. Since citizens can't really conceive of healthcare's value to them until they actually need it, they are not rational actors when they purchase healthcare - making an inefficient market, exploited by healthcare companies.

The bottomline here is that the system is unsustainable as is and we know this. The current proposal will address the need for cost controls, give universal coverage and not alter most people's coverage. Ignore the fearmongering, it's simple and it's needed.

Please comment on this post if you'd like me to clarify or explain anything further.

*I'm currently at home with a knee healing from an ACL reconstruction. My surgery likely cost my insurance company $40,000. What are the odds that you'll tear your knee in the next month? (I have no idea what the answer is, but it's pretty low) Now how much would you pay to insure against that happening?

No More Torture

Yesterday, President Obama released four memos outlining the legal jujitsu and gymnastics the lawyers in President Bush's Office of Legal Counsel came up with to justify turning our CIA agents into torturers. You can see the memos obtained by the ACLU here.

And you all should take a moment to look at them for a second. Lawyers for the President explain how 'extreme pain or suffering', as forbidden by international treaties, does not apply to our techniques because our torture doesn't take too long, or cause permanent physical impairment. So, it's ok for us to throw people into walls, slap people around, put them in stress positions and (yes) waterboard the terrorists.

There's nothing particularly newsworthy here, we've just kept our heads in the sand for so long about what really happened that I'm interested to see if documentary evidence of the depravity that took place will raise peoples' consciousness.

It seems like the consensus in this country is to leave the past in the past. This is bullshit. Just this week, the US agreed to deport a purported Nazi war criminal. Yet, we have no need to look into the mirror at ourselves and our countrymen at the atrocities they committed?

For all of our country's shortcomings at taking the moral high ground, we are different than others, have been different than others, and should remain so. Papering over this incident is despicable. But, I'm spitting a lot of strong words here, so let me explain:

1) We broke international laws and treaties, blatantly. There's no excuse here, the international law is clear, we've attempted to judge others by this standard and reestablish an international community following the Bush debacle. We need to stand up for what we allowed to happen.

2) Torture is ineffective, any experienced interrogator will tell you so. Moreover, these memos lay out the fact that these aren't some Jack Bauer wannabes. The torture outlined here was not about obtaining information. It was about abusing our enemies. Abu Ghraib is a direct consequence of behavior like this, and it blows my mind that most of these memos were issued after Abu Ghraib. How was the lesson not learned?

3) Moving forward is not an option. We will not defeat Islamism without international support, however we have minimal international credibility. Showing that we are addressing our past will bring our allies with us. As proof, as recently as Tuesday, Spain was vocally investigating war crimes charges against some of Bush's lawyers who authorized this. When it became clear that these memos would be released, Spain backed off and let us handle our own business.

4) Ever since Ford pardoned Nixon there has been a complete dereliction by the American public to hold our executive officials to the legal standards they are meant to defend. First Nixon gets pardoned. Then Bush pardoned the Iran Contra operatives. Then Scooter Libby. Meanwhile, anyone with half a brain knows that the Bush administration broke many laws in their singleminded pursuit of the war on terrorism (you can claim that they were worth doing, but you can't deny that they were breaking laws left and right - at least you can't deny it credibly as shown by how outlandish these memos are), yet we are even considering letting everyone off the hook, except the frontline soldiers who got caught?

We need to begin to believe in ourselves again, and we can only do that by addressing our failures and proving ourselves better than it.

John Yoo who is the most well-known of the Bush hacks who authorized torture is today a teacher at Cal Berkeley. Teaching law each and every day. This is outrageous and depressing and shows our nation's failure to confront these criminals and make them pay for their crimes.

I know everyone wants to move and forget the past, no need to stir up confrontations. That's bullshit, our country can never heal unless it addresses its failings and I fear we'll fail ourselves again.

An Open Letter to President Obama

Mr. President (and staffer),

I am a strong supporter of yours. I rented my own buses to Pennsylvania to bring volunteers to your campaign and spent a week working in Pennsylvania.

That said, I believe you need to seriously consider letting Mr. Summers resign. You fought against the corruption of the revolving door in your campaign. Mr. Summers defines that. I understand that he is intelligent and a confidant, but you need someone who is untainted.

I believe that there has been too much focus on preserving the institutions on Wall Street for their own sake, rather for the sake of the economy. This also extends to our behavior with AIG. We don't NEED AIG or Citi, we need them not to collapse and damage those affected. However, there is no implicit need for these companies to exist.

I believe this gets back to people in your administration having preconceived notions of the permanency of the financial system as it is now. It is outsized to our economy and therefore exerts an outsized influence on you and your administration. Having someone with such clear conflicts as Mr. Summers does (as shown in the Washington Post article today), inhibits him from making truly neutral observations. He is not a bad man, but he is compromised.

Furthermore, having these types of figures around you only gives opportunities to those who oppose you. Don't give them the opportunity. I also reject the notion that everyone who is qualified may be compromised. That is a cop out. You're the President, millions would jump at the opportunity to advise you.

I also wanted to note that this is the first time I've emailed you with a complaint since you capitulated on FISA immunity last summer. I am not one to write about every issue of the day, but your own reliance on the people and institutions that brought us this mess concerns me greatly.

I hope you are able to broaden your circle of advisors in light of this conflict and recognize that I am not some partisan attacking but a concerned citizen.

Thank you,

William Finkel

My Thoughts on Tax Situation (late breaking, Daschle withdraws -phew)

I have a few thoughts on the 'tax situation'...

1) Nancy Kileffer - Doesn't this sound like Bernard Kerik? Fess up to a smaller crime and withdraw when no one is paying too much attention? I know it's pure speculation on my part, but her offenses hardly seem worthwhile to withdraw over - so I assume there's something we don't know.

2) Geithner - I understand why one could say his transgressions are more serious than Daschle given his standing as chief enforcer (and overseer) of tax collections. But in his case, I think this actually does show how complicated taxes can be and might help the case for simplification (which I firmly believe could and should be a nonpartisan issue, however, if you think the debate over social security is considered the 3rd rail, wait till they take away deductions for interest on home equity loans).

3) Daschle - This is where I have a problem. I can (kinda) understand that he is given a corporate car and driver and fails to recognize that as income.

However, the problem is that he was accepting a car and driver as a consultant. There is no meaningful distinction here with the forbidden class of 'lobbyist' and he's been involved in this game for years (his wife's been a consultant for decades). Obama's loyal to Daschle as Daschle has been a mentor to him, but exceptions to rules need to be meaningful - and I don't see a reason why Daschle NEEDS to be the pick for HHS. Is he the only one who can get health care reform passed?

With the person given the waiver in DOD, I can understand saying that he is the ONLY man for the job - Daschle is not the only man for the job and he is tainted by the revolving door. Barack doesn't need him, but apparently his talk of cleaning up DC ends when his friends are the topic. I'm embarrassed. (and now I'm relieved he's gone...)

How Obama Leads

So I've been gone a while...I trust most of you know what I was up to during the election (running my own buses down to Doylestown, PA to help the Obama campaign), maybe one day I'll feel up to writing more fully on the experience. In the meantime, I've noticed something very interesting in the way that Obama has chosen to lead, and I felt compelled to share it.

Quite simply, Obama leads from the center and as someone who admits his own limited information. Given his own limited information, he expects to be lobbied by the citizens to correct flaws in his actions. This is a marked difference from the Bush administration and (from what I recall) the Clinton administration. Obama isn't concerned with being first and being right, he is concerned with being right at last...

There are three incidents in the past week that back up my belief and show the importance that citizen engagement is going to have on the Obama administration.

1) In early December, Obama announced that Pastor Rick Warren would give the convocation at his inauguration. Warren is one of the biggest names in evangelism and marks a significant conciliatory shift from the fire and brimstone of previous leaders such as Jerry Falwell. However, he is an evangelical leader and embraces many views that I (and liberals generally) oppose - in this case, most notably he opposes gay marriage. Obama supporters smarting from the passage of Prop 8 in California (which made gay marriage illegal) and Warren's role in the passage were outraged. Obama held to his guns, defending his politics of civility to those with different opinions. However, the attacks and howls of betrayal continued.

Just last week, Obama announced that he would be having Gene Robinson a gay Episcopal bishop give the commencement address at his inauguration. In doing so, Obama showed that he was susceptible to citizen pressure and that the rules applied for everyone. As much as us liberals and progressives were opposed to Warren, so too are conservatives against Warren's participation. The President-elect is showing that his rhetoric of a United states is not just rhetoric, but that he may need to be kept honest.

2) Over the past few weeks, the administration announced its plan for a recovery program. It's plan was smaller than most economists called for and included tax cuts that did not seem to have much impact on the short term economic needs. Fears spread that Obama was ceding the debate to Republicans by coming in with a plan aimed to placate them, but lacking the teeth needed to save the economy. Senators Harkin and Kerry (both Democrats) publicly expressed their concerns. Liberal economists chimed in. People began to worry whether the President-elect would fight for what's needed over what's politically expedient.

However, the President-elect was not done. He stated during an interview that he was open to anyone with a plan that might work. He also stated that this was a starting point as he expected the bill to grow. Then a few days later, he announced that due to overwhelming opposition, he was removing his plans for a business credit for each new job created (apparently the program would have been ripe for abuse and impossible to oversee). This proposal had been his alone, and he has let it go in response to the opposition from his OWN PARTY.

Since Obama had to cede ground to his own party, he was there representing the opposition to his party. By being the target of democratic doubts, he marginalized the true opposition.

3) Just last Sunday, Obama appeared on ABC and was asked about closing Gitmo, a promise he made during the election. Apparently, the transition process has revealed many of the difficulties in just shutting down the installation immediately, although he remains committed to doing so. In the interview he stated that he can not promise that it would be closed in 100 days.

A cry of outrage went out from various bases all opposed to our mistreatment of prisoners and abuse of international law that took place there. On Monday, the transition office made a statement that an executive order will be issued on Inauguration Day ordering gitmo closed. Another victory for our right to speak back to the President.

And all of a sudden, these pieces came together for me. I'm here in New York struggling to keep interest and support going among the people who volunteered with me in Pennsylvania. And I keep wondering, is the Obama team ever going to come up with a plan for us? Then it comes to me, keeping the President honest will not be opposed to what he wants, it is what he wants.

During the transition, many entrenched DC folks have taken on prominent roles in his cabinet. I'm not opposed to this, the President-Elect has recognized that they are the technocrats but that their thinking can be stale. He intends for us to pay attention to what is happening in his administration and let him know when the insiders are wrong. This isn't second guessing him, this is helping him.

Also, another interesting aspect is how the President has seemed to take a centrist position but is in fact taking a watered down liberal version. The spending bill, more progressive churches (such as Warren's) and closing Gitmo are all to the left of traditional discourse in this country. If Obama had fully embraced these issues then he would be seen as ruling from the left. Instead, he cedes a little to the right to rule from the center. Then, when his base opposes him on it, he is forced to move to the left to placate them, making it still appear as if he rules from the center, as he has embraced the left's views. He has made himself the leader of the rational right and put himself in opposition to the left - essentially cutting the entire far-right out of the debate. I don't know if it was done on purpose, but it's brilliant.

So, how gullible are we?

Why I believe Obama will win

Some people ask if I really believe Obama can win. Maybe they're worried about entrenched racism being too much to overcome. Or perhaps they bought into the Hillary line about him not being able to win the swing states. Either way, I feel very confident (though that's happened before).

There are two reasons I believe in Obama's potential - substantive and situational.

Substantively, Obama has made the right decision to stop running away from Republicans on 'Republican Issues'. Since the late 60s, Republicans have won on foreign issues, while Dems have dominated on domestic issues. Democrats so internalized this divide that a generation of Democrats have been ashamed to speak their mind on foreign policy. Hillary exemplified this by voting for the war in Iraq and attempting to prove her Commander in Chief qualifications by tying herself to John McCain. She would constantly cede the foreign policy ground and attempt to change the subject to domestic policies. However, times have changed and Americans have realized how the republicans have done us poorly in their neo-imperialistic posture. Obama recognizes this and will run on principles. The principle that Republicans royally screwed up in Iraq (from hype, to concept to execution). The principle that being afraid to speak to adversaries will lead us to more wars. Obama has never been afraid to challenge McCain on this, so he is now forcing the media to question their assumptions here as well. Of course, we still dominate on domestic policy (even if Obama has shown weakness in articulating his economic policies). I believe the American public is ready to have a sustained discussion about our role in the world, and by addressing the Republicans assumptions, he can show a Democratic spine - something that's been missing.

Situationally, this country is trending Democratic after a sustained conservative strength starting with Reagan's election. There are several pockets across the country that Obama has the power to flip. Virginia and (to a lesser extent) North Carolina both have a large creative class as well as a large blue collar workforce relocated from the Northeast. In the mountain West, the Republicans have disappointed a lot of libertarian small government conservatives and (at the least) Obama can make those states closer (for example, Montana's governor and both Senators are now Dems). Additionally, there is the liberal small government West (New Mexico, Nevada and Colorado - as well as Arizona if McCain weren't running). These states are highly energized by his campaign and may also shift Democratic this time around.

So yes, Obama may have problems in Florida and Appalachia, but the new parts of the country that he has opened up give the Democrats to build a new majority, not a temporary reprieve by being Republican Lite. This is exciting and why I think he will prevail.