The Testy Philosopher

An open letter to the 170K+ people who have forgotten the meaning of 'outrage'

2011-10-06T20:06:00.000-07:00

RE: $5 debit card fee found outrageous

Dear Molly and outraged BoA members,

I was almost one of you, putting my name on the petition. I too have a BoA debit card that I use on occasion, and enjoy - on some subconscious level - not having to pay for it. Like you, I would really prefer to not pay $5 a month to continue to do so. Moreover, as I like... to think of myself as an 'activist' on some small level, signing petitions and such, I was obviously tempted to join you. But you see, I happen to read the petition (1st paragraph), and so instead here I am pompously giving a simple lesson in English usage.

$5/month for a service, any service, is not outrageous. 'But they want to charge me to get my own money' you say. Yes it's called providing a service. Costco charges ~$4.50 a month for you to shop there. That's right - they charge you to take your money! Let's write a petition to Costco!

There is of course a visceral kernel of truth in your claim - the charge seems frivolous, unjustified. This has been free (for the short span of our memory anyway),
and now you suddenly want to charge us for it? What gives? But lo, you are not powerless in the face of this heinous injustice. Turns out, BoA is not a monopoly! There are in fact other banks who will be happy to provide you with free debit cards - both large and small.

Of course, customers banding together to protest a corporation's behavior is a core element of market capitalism and a proven method of achieving real economic and social change. Threatening to go to another provider is an excellent strategy, something I really wanted to join.

But outweighing the prospect of keeping $5 a month is the harm you perpetrate on the public sphere by diluting the meaning of 'outrageous.' This may not sound like much, but in a representative democracy, outrage really is the central mechanism of keeping the system accountable. Outrage is the best motivator of people; it is a precious, precious resource, that you waste so recklessly (and here I also mean you, change.org)! You know what is outrageous?

-University tuition costs have tripled in just a decade
-10's of millions of Americans cannot afford health insurance
-9/11 First responders still can't get coverage for job-related cancer
-The federal gov't can't seem to get its shit together to halt global warming
-The new banking regulations that were supposed to prevent a repeat of '08 were watered down into meaningless-ness by those very banks that caused it in the first place
-State-perpetrated murder is slowly morphing into a civil war in Syria as nations look on
Etc.,

Don't spend your outrage on small personal grievances, save it for what really counts.

/end rant/

King Market - Reframing Freedom

2010-02-25T11:57:00.000-08:00

We are accustomed to thinking authority must be centralized. Even after Foucault, the idea that we are more ‘ruled’ by distributed forces or actors like the corporations in the market is difficult to grasp – it does not fit in our linguistic frame of ‘authority’ and ‘power’. To say that corporation X is oppressing us or has undue control over our lives I think would be a lot easier to comprehend and accept than the claim that ‘the market’ is. We don’t think of it as an actor, particularly one whose influence needs moral evaluation, and yet, that is exactly the case. Think of it this way: If you are walking in a labyrinth and you meet a guard who blocks your path, what is the stronger influence on your ability to move – the guard or the walls of the labyrinth?

We need a new linguistic frame that allows us to understand authority and domination (infringement of ‘autonomy’ if you will) is systemic. The reason it is so difficult to transfer our conceptions about limits of power from the political domain, where the constitution limits actions of the government, to systems like the market (but not just the market, climate and society might need similar evaluation) is that key elements of the frame – the authoritative/powerful actor – is missing. We are used to individuals wielding power from the beginning of our lives in childhood. Personifying the government is easy – the executive is a single person; other bodies are small groups of people. But how can we do this with ‘market forces’? This we tend to assimilate to luck or nature - forces beyond our control that we learn to not accord moral relevance as we grow up. Even Mill could only articulate the majority as a tyrant when it controlled the means of coercion – government (contrast this with accounts of social oppression of conformity in Ibsen and Sinclair Lewis).

One might respond that the real reason we don’t talk about the market the same way we do about government is that the latter coerces, while the market merely provides choices, or, at most, structures our choices. Government is thereby in a class of its own as threat. This sounds plausible because 'coercion' a part of the authority frame mentioned above. To notice it, we need to see an authority figure – we can’t imagine coercion without a coercing agent. In fact this response has strong appeal because the term itself (rather than just the frame within which it operates) has come to require intentional action.

However, the response misses the point because what is at stake is not coercion, but impingement on our life choices -- on our freedom. Centuries of having the government as the greatest threat to individual freedom has driven us to identify (intentional) coercion as the primary danger, but today, in many societies, this is no longer true. We are only concerned about coercion because it negatively affects our freedom – the latter is what matters. Coercion is sufficient, but not necessary to restrict our freedom. So let us recognize the new sources of this influence, such as the market, and come up with new linguistic frames that do not require a single authority figure and give us a clearer picture of reality and what affects our lives.

Lobbying as a symptom of our social problems: King Dolla

2010-02-10T14:22:00.000-08:00

Why are business associations consistently more effective than groups like environmental organizations (besides the fact that it is easier for smaller number of interested parties to act)? Because monetary effects (e.g. costs to business) are easily quantified and related to by all, businesses and the public, especially by the consumers that we have become. Environment or health concerns can subjectively matter more to people than a potential regulation does to a company (esp. to the middle class in the developed world who do not really have to worry about tangible basics like nutrition, shelter, or even internet connectivity) – but they are harder to quantify and thus think about.

The market has reached far into our lives, but it cannot accommodate many things – which are dutifuly left by the wayside. What does it mean that 'we have become consumers instead of citizens', the recent slogan of progressives? It is not just that we hold consuming more important in our mental world than political participation, but that we apply a consumer metric to everything we deal with. We consume healthcare, beauty of the environment, fresh air. But a ‘consumer’ is a market participant and a consumer metric is a monetary one. Thus, for instance, consumption in the domain of health can only describe services provided (which have market-set price) not the potential health benefits to the person (except through perversions like lost productivity). A consumer orientation equates value and price – which do align in goods that really are commodities, but do not and cannot in domains like health or nature. The old mantra "you can't put a price on X" today has the sad undertone that X will be simply ignored.

People naturally gravitate to heuristics. When Clooney's understudy questions his use of stereotyping in Up in the Air, he responds, "it's faster." Simplify, streamline -- we are powerless to argue against these commands (and where does their appeal come from? Exactly). Price offers just such a heuristic.

The climate crisis could be an excellent opportunity to drive this point to public consciousness, and demonstrate that universal commodification is a recipe for disaster. Unfortunately, the left has capitulated to business interests and has started to argue for emission regulation in market terms – in monetary comparisons of instituting and foregoing regulation now, instead of considering the true “costs” – loss of land and livelihood whose market valuation does not capture its true value.

There is an alternative. We have plenty of other ways to talk about the things that matter to us besides their price and cost. Quality of life; sources of (national) pride (e.g. parks, national monuments, just social arrangements); social responsibility; what we leave for our children; the social compact (this one is a bit antiquated, but is making a comeback). All these kinds of frames express judgments of value without drawing on market terminology or mental orientation.

This shift is inescapably difficult. "If we do this we will leave the next generation a $10 trillion debt" is so much more alarming and obviously actionable than "If we don't do this, the arctic icecap will melt", or "50 million of faceless Americans will lack access to healthcare." And nothing spells doom faster today than a prognosis of difficulty. But we have to do it anyway.

The Ethics of Designer Children

2008-01-10T14:43:00.000-08:00

Some time ago I happened to record an interview on NPR with Michael Sandel, a Harvard philosopher about the ethics of genetic engineering (he recently published a book The case Against Perfection). It got me thinking, and I thought I might share some ... thoughts.

In the last two decades, our rapidly developing biotechnology has brought us into the realm of human genetic engineering. We are now able to not only screen for many diseases and a few genetic characteristics, but are on the verge of being able to select characteristics of a child. So far this has been limited to the sex of the unborn (for $10-20K), but these will soon expand.

The ethics of this new technology has - as is traditionally been the case – lagged behind the scientific capability. Despite the engagement of prominent intellectuals -- Jurgen Habermas, probably the most important living Continental philosopher wrote a short tract on it a few years ago (The Future of Human Nature), and now so has Michael Sandel -- a truly public debate has not materialized, aside from brief flashes over Dolly the sheep and stem-cell research.

In his discussion, Sandel brings up several fundamental issues: the role and importance of choice as such, the distinction between medical treatment and enhancement, and perfection of species as such. These slippery topics will hopefully make the following discussion more interesting.

Genetic alteration of children remains the locus of the discussion with Sandel, and there are two big points there:

1) in a classically Marxist line, Sandel argues from the point of view of the parents - if they can choose the characteristics of a child they will treat it no different than produce – as a commodity. According to him, such an attitude is simply inappropriate when it comes to children, who, like other relatives (say, parents) should be loved for the relation, not their qualities. As an example of this view taken to the extreme, he points to parents who choose to bring to term a child with Down's syndrome.

But Sandel has to fudge a lot here, blurring together relatively neutral cosmetic characteristics -- hair, eye color -- and 'merit qualities' - (predisposition to) intelligence, musical talent, height, build, etc. While customizing a child like a weekend sports car seems ethically dubious, one can't condemn parents for choosing a smarter or taller than average child on these grounds, for they can reasonably say they are doing it entirely for the child's good. We are assuming fairness does not enter the picture here – that everyone would have equal access to these technologies.

So instead, Sandel is forced to rely here on his distinction between medical treatment and 'enhancement', which distinguishes ensuring a child has higher intellectual potential as reprehensible, while screening for diseases is ok. I will address this distinction below; at this point, we should just note that the moral status of genetic engineering will hinge on this distinction for Sandel.

2) Jurgen Habermas, on the other hand, argues against human genetic engineering because of the effect on the child - the awareness of having been engineered by another person, rather than just fate. Now, rather then a purely philosophical question as he characterizes it, it is in fact an empirical psychological one, similar in nature to the effect of discovering that one is adopted. However, its not a priori clear what effect a revelation of genetic tampering would have, especially in a society where that is fairly commonplace. In fact, not having had good genes arranged in a society where that is common would likely prove even more psychologically damaging. In any case, I'm insisting the question is empirical rather than an abstractly metaphysical.

In contrast to the two philosophers, I would say my position is more practical, which brings me back to Sandel's distinction of medical and enhancement (negative and positive) treatment.

“Treatment vs. Enhancement”

Is there a real (moral) distinction between medical treatment and enhancement? Sandel argues yes – medical treatment restores 'natural human functioning' (for example, growth hormone deficiency resulting in exceptionally short height) while enhancement is more like a consumer good. But how does one define ‘natural human functioning’? The condition of the average human? This widely depends on the environment – what is a 'natural human environment' – savannas? Jungles? Certainly not the living conditions of 99% of contemporary humans.

Ultimately such a distinction can only refer to the below/above average human condition in a given society - from which it is much more difficult to extract a moral argument. What is the significance of this? Well, when it comes to practical policy issues, it's not too great. So, for Sandel, plastic surgery is a 'non-medical consumer good', not a public good like regular medical services, hence they should be treated differently. This may include decreased health insurance coverage, forcing (non-reconstructive) plastic surgeons to repay any federal grants/scholarships they received while in medical school, etc. Overall not particularly controversial, because it addresses a compromiseable, ‘linear’ issue.

Choice

However, if we deny moral weight to the “treatment vs. enhancement” distinction, Sandel is on shakier ground when it comes to parents selecting genes of their children. And this is the case because another moral factor comes in – choice. A reasonable (in America) rejoinder to Sandel is that choice is a fundamental right, of parents among other instances. In the radio program that I refer to, Sandel brilliantly replied that while choice is important, it is not absolute or even a self-standing good (“choice is not an altar we should all worship at”). This is a particularly appropriate response for him, given his communitarian concept of freedom, which emphasizes context and social links over absolute notions and rights like a naked ‘right to choose’.

One problem with allowing such choice for parents is that it inhibits them (and society more generally) from learning to accept things about children – it takes away the ‘gift of human nature’. In this case, according to Sandel, the right to choose would be trumped because, given the enhancement distinction, choice for enhancement is morally lower than choice for medical treatment and doesn't place it above other considerations (those discussed above). But if the distinction doesn’t hold as a sharp line, his reply is no longer valid, especially when we acknowledge the difference between neutral “customization” gene selection -- or something like abortion conditional on genetic quality -- and enhancing the genetic stock of one’s child to improve their potential in life. In that case, it would be difficult to justify restraint on the latter opportunity from the point of view of a single family. Choice is no longer obviously morally less important. So perhaps at this juncture we should widen our scope to consider the policy for society as a whole – i.e. eugenics.

Eugenics

If gene selection is not objectionable for a given parent within society, it implies society as a whole accepts genetic selection of children and its likely outcome (given social pressure) – accelerated genetic drift in a steady direction, i.e. uncoordinated eugenics. What is the problem with making explicit and coordinated? As Sandel notes, we often object to eugenics because it has historically been bound up with coercion, so perhaps there is nothing wrong with it if is voluntary (for the moment treating the choice of a parent considering whether to assure his child high intelligence in a society that discriminates against the unintelligent as still voluntary). But he argues that such a program would be pure hubris – we would presume to know what is best for humanity. We would be playing God. Not to mention (as Sandel does), the danger of ‘inscribing in genes' present prejudices, something bound to happen when genetic engineering is done on a wide scale.

Clearly, organized (or wide-scale) endeavors in human genetic engineering is quite hazardous. There is also the possibility that (international competition aside) there is little to be gained from genetic improvement on a national scale. What do we gain if the US population becomes a little stronger on average, a little taller, or even a little more predisposed to intelligence? “Subjective welfare” studies clearly show that growth of per capita GDP in Western societies does not correspond to growth in subjective well-being. This is in part because many characteristics we hold important are inherently relative – they are “positional goods” (basically, goods whose value derives from factors external to the good itself). Just as the benefits of wealth above some threshold are relative to one’s peers, so would be genetic endowment.

Midway conclusions

Based on the considerations so far, I would argue along with Sandel that programs that encourage genetic enhancement in a particular direction are a bad idea. Private ventures, like a recent attempt to propagate the genes of Nobel laureates, are less censurable largely because of their smaller scale. But when it comes to individual parents and doctors, I would disagree with Sandel. The argument so far shows there is nothing morally wrong with parents selecting their children’s genes as such, at least when it would not reasonably seem to be against the child’s interests. While enhancing a child’s height or intellectual potential may not improve their life, it is unlikely to be any more damaging than myriads of other choices parents currently make for their children, from the music lessons they force on them, to their diet, to their schools.

In practice, certain limits would need to be placed on the types of genetic choices allowed, but social rather than legal means, acting both on the doctor and the parent, should minimize the more shady genetic meddling, like choosing hair or eye color, to prevent the commodification of children. This is not the domain for hard government regulation. Rather, these choices should be guided by how we understand the nature of the person, and it is in this respect that a discussion of enhancement in sports is timely.

Enhancement in Sports

On this issue, Sandel finally leaves abstract categories, and says we must consider this issue on purely functional grounds. As he says, the deciding criteria when considering the morality of enhancements in sports (whether chemical like steroids or physical like bionic limbs) is the purpose and ultimate goal of the sport. The legitimate enhancements ones are those that perfect rather than obscure the qualities and talents that the sport is meant to demonstrate – and is thus sport-dependent. Racket improvements in tennis or running shoes for runners (his example) do not interfere or obviate the participants’ skills but rather allow more fine-tuned performance. In no sense do they corrupt the sport. On the other hand, field and track athletes who are thus able to achieve unprecedented feats are distinctly less interesting. A shotputter on steroids is much like a drag race – perhaps an interesting show, but hardly a sport as such. The distinction is subjective but rooted in what we imagine to be the purpose of sports in general and a given sport in particular: exercise of skill, elegance, determination, endurance, etc.

Returning to the case of the parents, most crudely put, what is the purpose of children or particular characteristics for them? Or, rather, how do we think about character traits and other human qualities – to what extent do they impact on our self-image? Is musical ability just a ‘faculty’ (as Plato would put it) or is it part of our very self?

In Conclusion

So the moral outcomes rest on a fine distinction – are we adding characteristics – say mathematical talent – to a given child? Or are we creating a child to spec, like playing SimChild, with intelligence x, height y, language ability z? We have to think about the nature of self, how we construct our identity. The former primarily engages the eugenics question and I think only becomes problematic on the grand scale, while the latter is potentially subject to most of Sandel’s and Habermas’s objections… but how convincing are they?

On the one hand, the idea that parental participation in determining their children’s genes will have terrible effects on the child’s self-image (a la Habermas) blithely ignores the tremendous role parental influence in all its forms already plays in a child’s growth. Habermas in particular seems to be completely oblivious to the widely accepted role ‘nurture’ plays in the process, as if living in a 19^th century pre-Freud world that imagines genetics to be uniquely indelible. On the other hand, now that we know genetic factors have similar influence to childhood environment, his insight might instead suggest that we should curb already existing parental influence through childhood rather than allowing that influence to extend into the child’s genetic make up.

My point here is that there are no a priori philosophically deducible answers to be had on this question for the individual. It is not morality which should guide us here but empirical psychological data which illuminates how the self-image and child-parent relationships are affected by the application of these new technologies. If we find that parents fundamentally view their children differently (for the worse) as a result, this would be a decisive argument against them. If nothing of the sort manifests itself, I argue we have no philosophical reason to hold back. Of course, the necessary experimental data may be difficult to obtain, but the point is that any limitation should be justified on practical, psychological grounds, not mere speculation; we’re dealing with a question of discipline competency, as it were. So, for one, in regard to Sandel’s point about commodification of children, as much as I agree that choice is at times harmful, so many other factors are to be considered that this effect may entirely disappear. And if I was in that position, I would push for the best damn genes money can buy.

California Healthcare reform - the panacea that is SB 840

2007-08-07T11:13:00.000-07:00

Having been advised recently of some horrible truths about the condition of our healthcare system (by those that paid good money to see Sicko), I decided to see if anyone else was as discombobulated as I.

Lo and behold, the legislature in our wonderful state of California is in fact trying to push through a bill to address virtually all of the current problems (SB 840 proposed by Senator Kuehl). Naturally, the governor is opposing it, pero quiza si suficiente muchos hombres saven la verdad, actual progress may happen.

This is not the post to convince you of inadequacies of the current system (particularly in California). There are enough sources out there for that, not least Michael Moore's opus mentioned above. Start with the fact that 16% of the population is completely uninsured. For the libertarian in all of us, there's also danger of being denied payment by the insurance companies (which happens all the time for expensive procedures), denial of coverage for pre-existing conditions, loss of coverage with loss of employment, etc.

No, this post merely analyzes the said bill, as its ramifications are difficult to understate. I'm going to try go beyond the standard "think of the children vs. commie socialized medicine" bullshit and hopefully convince you this is something worth supporting. And support it actually needs, because despite an upcoming rally in LA
(http://upcoming.yahoo.com/event/226563/) the governator still seems opposed to it. So here goes.

----------- ----------- ----------- ----------- ----------- ----------- -----------

Note: (PP) below marks issues that are not resolved to my knowledge. Numbers like 140xxx refer to section number in the bill text.

A short summary is available here. Basically, "the bill creates one plan and one public trust fund which pays all health care bills and collects all the monies already being spent on health care and insurance plans, which is called a "single payer" system." (onecarenow.org) It replaces all insurance companies and creates a single insurance provider run by the state headed by the Commissioner ('the Comish'). It is funded by an employer/employee tax that replaces current premiums.

Select substantive provisions of the bill

Structure

The bill provides for a state-wide commissioner to head an agency and office that supervises a dozen regional directors who implement his policies. This does raise the specter of central planning. It is unclear if this is worse than the present insurance market in any meaningful way (where the plurality of insurance companies hold all the power - not the providers). The problem is particularly acute, however, in regard to capital investment - which would be directed from the center. (PP)

The bill also provides for a creation of extensive statewide electronic infrastructure for management, supervision and information exchange. This is nice.

Healthcare delivery/covered benefits

"Covered benefits will be defined under the bill to include all medical care determined to be medically appropriate by the patient's health care provider," (Senate analysis) This includes dental care, acupuncture, chiropractors, vision. The bill excludes cosmetic medicine and providers not licensed by the state. It provides for the Commissioner to extend benefits not currently described/covered as funding allows. Primary care providers may apparently be changed at will (no stated limitations on this) - unless they are in "integrated healthcare provider" systems (like Kaiser?) in which case it is more difficult.

Those few service that are not covered (like elective cosmetic insurance) may still be covered by private companies (onecarenow.org)

Referrals are necessary to see specialists without co-pays/deductibles, unless that specialist is your primary care provider. It may be annoying, but this reduces costs and lowers fraud based on experience of other countries. It is also a standard practice in many current insurance plans.

The system will provide insurance for those who are temporarily out of state (unlike many current plans). For periods of greater than 90 days the Commissioner will determine eligibility.

Enrollment/eligibility

All eligible residents (those physically present with intent to reside) will be enrolled – provided with identification that can be presented to healthcare providers.

"In the event of an influx of people into the state for the purposes of receiving medical care, the commissioner shall establish an eligibility waiting period and other criteria needed to ensure the fiscal stability of the system."(Bill Text). While nothing is really said about how eligibility will be checked, the question is really how effective could a verification system possibly be? (PP)

On illegal immigrants:

The bill itself does not specifically mention illegal immigrants. However, onecarenow.org writes
"[They will be covered]. It costs California less to insure undocumented immigrants than to exclude them. People without health insurance don't get preventive care and, consequently, use expensive emergency rooms and hospital care when they get sick. It is estimated that if every Californian got preventive care we could save $3.4 billion dollars a year. Most undocumented Californians are employed in essential jobs and our immigrants pay $80,000 more in taxes and fees over a lifetime than they will receive in local, state and federal benefits in their lifetimes. And it's good public health policy to insure the entire population. It helps control epidemics or outbreaks that could expose everyone to disease.” (onecarenow.org)

More directly, this simply transfers and lowers the already hefty bill we're paying for the uninsured when they are treated by state hospitals and their emergency rooms. "Emergency rooms will no longer be crowded with uninsured patients who should be with primary care doctors, at a much lower cost. Rural and inner-city hospitals and trauma centers will no longer be closing because of high proportions of non-paying patients." This really happens, state hospitals run enormous debts because of having to treat the uninsured - which then fall on the tax payers of the state. "There will be no need to resort to collection agencies to collect bills. Patients will not be forced into bankruptcy by medical bills, at a loss to hospitals." (onecarenow.org)

One could say - why should we pay for the illegals and reward them, etc - but rationally, economically - it is simply the case that everyone would be better off.

Copays/deductibles

There will be no deductibles or co-payments in most situations for the first 2 years of operation – after which these may be instituted. However, these combined, may not exceed $250 per year (!). In any event these may not be established for preventive care (the bill is touted as pushing preventive care - unlike the present system - as fiscally wise). I think lack of any co-pays is a serious problem, but hopefully this will be changed during implementation. (PP)

Other

A number of exemptions are spread throughout the bill that diminish the monetary impact on individuals (i.e. waivers for collective bargaining agreements, etc).

The bill only becomes operative once the Secretary of Health and Human Services determines there are sufficient funds to initiate the transition (i.e. within several years)

Financing

Financing for SB 840 is explicitly provided by a separate bill (SB 1014 (Kuehl)) that will fund the healthcare system primarily via "a health care coverage tax on the wages of an employee that would be paid by both the employee and the employer" (Senate analysis) – which would be transparent to the employees as the tax would stand in place of current payments to insurance providers.

The plan is that NO NEW SPENDING (taxes) are created by the bill. The premium/funding structure is to remain roughly the same as now (with respect to gov't/employers/employees shares). The current expenditures should cover universal healthcare. In fact, a single statewide plan – instead of the current selection of 6000 plans - would actually cost $8 Billion less than the current expenditure of California last year:$186 billion, 5.14% of state’s GDP (estimated by the Lewin report). The same report estimates that the plan will actually save $44 Billion in the first 10 years of operation.

The money would be acquired by efficiency savings. More specifically --

“ 1. Reducing Insurer Administration by about 69%- saves $9.686 billion in 2006
2. Reducing Hospital Administration by about 22%- saves $3.56 billion in 2006
3. Reducing Physician Administration by about 30%- saves $6.614 billion in 2006
4. Bulk Purchasing of Prescription Drugs - saves $4.418 billion in 2006
5. Bulk Purchasing of Medical Equipment - saves $786 million in 2006
6. Increasing Primary Care - saves $3.408 billion in 2006
7. Reducing Provider Fraud - saves $783 million in 2006”
(onecarenow.org)

More details (mainly from the Lewin report) here.

They argue that the increase in utilization of the system would be offset by "$20 billion in administrative savings and $5.2 billion in bulk purchasing savings." (Assembly Committee analysis). Kuehl in fact claims that 30-50% of the money in the system is currently wasted or misspent (Assembly Committee analysis?)

It would be nice to find an evaluation of the Lewin group (PP). It has done many such studies across the country, but its accuracy is unclear, though it is regularly used by congress and other states, so presumably they're as good as it gets.

But the claim is fairly plausible on its own. True, normally we don't think of government agencies as being efficient, but when it comes to insurance, this is not necessarily true. Medicare actually has far lower administrative cost (the measure of efficiency) than private insurance companies. Even a critical study has found this to be true -- at most 8% for Medicare and at least 9% for the private insurance (Matthews 2006). Plus, the system will have the benefit of the insurance companies' profits. The last several years have been lucrative for the insurance companies, the five major HMOs have earned over $11BILLION in profit a year, spending over a Billion just on marketing in 2006 and donating over $3 Billion to politicians since 2001 (emaxhealth.com). The California Blue Shield by itself earned almost almost $400 million in profit in 2006 (blueshield.ca). Not to mention the spending on litigation. All of this money will now go directly to the health providers and consumers, instead of their share holders. Finally there are considerable gains to be made from the introduction of state-wide electronic infrastructure that will streamline the operation

Potential problems

(In addition to those marked throughout this post with ‘PP’)

Fraud detection

Any entitlement service provider must deal with the possibility of fraud. This is one of the weaknesses of the proposal (TBOMK). The bill does provide for the Inspector General (of the system) to investigate fraud, abuse/misuse of the system and its benefits. While this mitigates the threat of denial of coverage we face with the present for-profit system, it likely errs on the other side, creating the potential for extensive misuse, since the checks on it are so distant (performed by a separate branch of the service).

This is particularly problematic as the bill prevents co-pays outright in the first two years of operation.

Conflicts with federal regulations

The bill acknowledges there may be conflicts with federal regulations and the Commissioner is charged with resolving these. What are the potential conflicts and their impact?

Arguments against

One of the most telling arguments in favor of the bill is that the list of supporting organizations runs for 5 pages – but there are only about 2 dozen opponents, most of them insurance industry related and a few chambers of commerce. But let's consider some of the arguments made against the bill.

A. CMA makes two cogent arguments:

1. The bill allows a decrease in benefits (compared to current plans) to cover revenue shortfalls.

This is true - when a significant revenue shortfall is evident, a number of 'cost control' options are available to the commissioner, including - among many other less drastic measures - (sec 140203c):
"temporary decrease in benefits"
"postponement of planned capital expenditures"
"imposition of copayments or deductible payments"
If these are not sufficient in the longer run, premium payments may be increased.

While this is not surprising, given the present uncertainty of the future fiscal situation, no one wants to see "decrease in benefits" as an option.

However,that option requires approval of the legislature - and clearly will not be granted lightly (140203).

2. The bill concentrates all decisions about plans and policies in a single commission.

However, it does however establish several boards and advocacy groups for oversight. It provides for impeachment and removal of executive officers.

B. Opponents cite the following statistics about Canada -

"More than 1.3 million Canadians (out of a total population of 26 million) are waiting for medical services, including 212,990 who are waiting for surgical procedures; 45% of Canadians who are waiting for services describe themselves as being in pain; Canadian patients wait an average of six weeks after referral from a primary care physician to see a specialist, and then wait another 7.3 weeks on average before they receive treatment; and 63% of Canada's x-ray equipment is out of date." (Assembly committee analysis)
Their system also tends to delay introduction of new techniques (thus it has a 1/10 of per-capita MRi machines of the US) - though the # we actually need is probably in between.

While some of this data is questionable, it is in fact common to have multi-month waiting periods for elective procedures (but everyone truly has access for urgent procedures).

However, Canada has actual socialized medicine - where the state owns the providers too. In addition, Canada spends considerably less on healthcare than California, even per capita: $4,411 USD (combining public and private sectors) vs. $5100. We also have the benefit of considerably greater capital investment to date. And to be honest, comparisons like this - which ignore demographics, absolute quantities, use & spending patterns really aren't worth the photons used to display them on your screen.

C. Verity of fiscal claims

Opponents also claim that administration costs will not be slashed and large taxes will be required.

However, as argued above, there's reason to believe the extensive analysis cited by the supporters. The opponents however cite no studies or evidence for their critical claims TBOMK.

Arguments pro

All California residents will be safe from the fear of losing their health insurance (when they lose their job, or get one of many that doesn't offer full benefits) or being unable to afford it (as the premiums continue to get ratcheted up). There will be no exclusions of pre-existing conditions. There will be no more bankruptcies from medical costs. About half of personal bankruptcies today are due to medical expenses - and 75% of those had medical insurance when their illness started. We will no longer have to be afraid of this. Personally I think this is an overwhelming reason to reform the status quo -- the other reasons merely support the choice of this particular bill.
This bill provides excellent coverage of high quality. Benefits covered are equal or better than virtually any plan on the market. There are multiple provisions for oversight of policies and care delivered, including the creation of a Chief Medical Officer who would head the Office of Health Care Quality. Everyone will have the chance to choose any primary provider they wish.
Greater access to emergency rooms as the uninsured and under-insured are diverted to ordinary care providers.
There are good reasons to believe the plan will actually save money for the consumers and employers over the current system.

Find more details on the benefits this bill promises here.

In Sum

This is not a perfect solution. It brings challenges, from ensuring proper policies and sound investment by a central agency, to preventing an influx of out of state immigrants. While the financial outlook is good, economic predictions are inherently uncertain.

However, the bill goes to a great length to build incentives and checks within the system to combat the inherent problems of bureaucracy, and is flexible enough to deal with the inevitable unforeseen. It has been supported by an extensive financial analysis. It carries the support of most of the legislature and virtually everyone organization that is not tied to the insurance industry. It addresses a major and urgent social problem without increasing taxes - and it actually has a shot. Give it a chance. If nothing else, think of the children won't you?

References

Onecarenow.org. http://www.onecarenow.org/sb840.htm

Bill Text. http://info.sen.ca.gov/pub/07-08/bill/sen/sb_0801-0850/sb_840_bill_20070710_amended_asm_v96.pdf

Senate analysis. http://info.sen.ca.gov/pub/07-08/bill/sen/sb_0801-0850/sb_840_cfa_20070604_103241_sen_floor.html

Assembly committee analysis. http://info.sen.ca.gov/pub/07-08/bill/sen/sb_0801-0850/sb_840_cfa_20070702_100653_asm_comm.html

Matthews, Merill, Ph.D. 2006. Medicare's Hidden Administrative Costs. http://www.cahi.org/cahi_contents/resources/pdf/CAHI_Medicare_Admin_Final_Publication.pdf

Emaxhealth.com. http://www.emaxhealth.com/124/13925.html

Blueshieldca.com. https://www.blueshieldca.com/bsc/aboutbsc/download/A18066-OL_4-7AROnline2006.pdf

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I will attempt to resolve some of the questions marked above and post an update shortly. Until then, bad spellers of the world, untie!

(Update 8/08/07)

First post!!

2007-08-06T13:34:00.000-07:00

woot!