Cancer

This article in today's paper is incredibly moving. I don't want to bias anybody's reaction, so I am not going to comment other than to say it shows why "it is what it is" is my favorite quote on my Facebook page. And why today is a great day.

Afghan Policy

This New York Times article pointed out just how blatantly corrupt the Afghan government is, from top to bottom. Nicholas Kristof points out that support for the Taliban is often in response to this corruption and that the country is deeply divided ethnically. Steve Coll makes the point that we need to think about what our goals are in Afghanistan. In his mind, they are preventing the Taliban from taking over again and getting rid of Al Qaeda. The former is unlikely and more troops in Afghanistan are largely irrelevant since Al Qaeda is in Pakistan and elswhere. Coll also makes the point that counterinsurgency measures do not work unless there is local government cooperation. I think that any increase in troops to help Karzai police his country should be preceded by steps he takes to halt the corruption, which should start with the new election on November 7. The fact that there is going to be a new election is the result of Obama not doing what Dick Cheney thinks he should do. And let's get over the idea that this is a win/lose situation. That was part of the folly of the Bush position in Iraq. We can only expect incremental gains in Afghanistan and those will only happen if their government limits corruption. It is not our job to make every country better if only because it is impossible.

Insurance Companies

There seems to be an undue amount of sympathy for insurance companies these days from the right, in spite of the fact that they are exempt from antitrust laws. As a lawyer, I periodically deal with them. Workers Compensation carriers routinely deny claims when treatment gets expensive, requiring claimants to litigate. In long term disability insurance, the federal ERISA statute has preempted state law. If you appeal a denial of benefits, the first level is an appeal to the insurance carrier, and then you have to go to federal court under ERISA, which is heavily slanted in favor of the insurance companies. In medical insurance, claims are also routinely denied, forcing providers to appeal. And insurance companies work hard to get rid of those who are bigger health risks, even to the point of rescinding contracts on the basis of some minor mistake on the application. Think of all the expenses insurance companies have in working to deny claims. And all the expenses medical providers have in employing people to deal with the insurance companies, each with their own set of rules. This money seems wasted. I'm in favor of markets where they work, but this one doesn't seem to work. Joe asks why shouldn't we just have Medicare for everyone? I don't see that as a panacea, but that question deserves it's own separate post. The first question I'd ask is how that would deal with rising Medicare costs, which threaten to overwhelm the budget?

History

I just finished a wonderful little book by Margeret MacMillan called Dangerous Games; The Uses and Abuses of History. She has lots of great contemporary examples of using and misusing history, from the Chinese government's emphasis on their recent history of humiliation to promote nationalism to the oft-repeated justification of our policies by referring to the appeasement of Hitler or other bad guys (you can see a version now in right-wing attitudes about Afghan policy). At the end of the book she asks the question what can history teach us? Some quotes: "Since history relies on a skeptical frame of mind, whether toward evidence or comprehensive explanations, it can also inculcate a healthy propensity to question our leaders." It can teach us humility. "One of history's most useful tasks is to bring home to us how keenly, honestly and painfully, past generations pursued aims that now seem to us wrong or disgraceful." "History also encourages people in the present to reflect on themselves." "Bad history ignores...nuances in favor of tales that belong to morality plays but do not help us to consider the past in all its complexity." She also has a lot of interesting things to say about nationalism, a state of mind that has historically only recently existed, and how leaders use this impulse of group solidarity.

Ideas on health care costs

Here Tim Harford argues for catastrophic coverage and health care savings accounts. This argument appears in a longer version in one of his excellent books. Ezra Klein notes (yesterday's blog at 11:55 a.m.) some troubling findings for those who believe that exchanges which allow consumer choice will lower premium costs. Tyler Cowen makes a good point about the availability of health care outcomes (as Atul Gawande has done). These raise some questions for me. Suppose we gave a tax break for medical savings accounts and let people choose only catastrophic coverage on the exchanges. What are unintended consequences? Why hasn't competition between insurers worked? As to the former, would this not affect the power of the mandate that everyone be covered? On the other hand, doesn't the problem of those free-riding on the current health care system really come in when they have a catastrophe? Regarding competition between insurers, isn't the place where we are likely to see the most gains competition between providers? Giving people a choice of plans is good in itself. And further, shouldn't we expect health care costs to increase? We not only have new expensive technology, but more treatments. For instance, 100 years ago my exaccerbation of ulcerative colitis probably would have led to death, which is much cheaper than treatment. 30 years ago they would have just taken the colon out right away, which also would have been more likely to result in death. Four years ago, when I got sick, they tried to treat me with drugs for quite some time, allowing me to at least improve enough to lessen the risks of surgery. Some of these drugs were expensive. For instance, Remicaid was $4000 a dose. Because we have more possible treatments for more medical conditions, costs rise. This leads me to a point a friend made some time ago: the discussion really needs to get to what the basic level of care we are going to give those who get treatment relatively free of charge, like the old or the poor. We cannot afford to pay for everything they may want at any given time. As it is, Medicare and Medicaid are going to swallow up the federal budget.

Partisan self-deception

Apparently there has been a lot of discussion on the right about the falling dollar. Megan and Tyler both have interesting things to say about why most of it is silly from an economist's perspecitve. But Ezra has a good post about the underlying dynamics, and cites a very interesting study that that shows that the more "informed" voters believed more things that weren't true but fit their preexisting biases. This should be a very interesting finding. These discussions also make me wonder how anyone can be so silly as to want to peg the dollar to gold again. Have any of these people studied the depression? I would suggest The Lords of Finance by Liaquat Ahamed as a starter. And how about Ron Paul's book about getting rid of the Fed. Oh my goodness, where do these people get their silly ideas from?

The Mayo Clinic

Along with Obama, I have been impressed by the quality of care at the Mayo Clinic and how much cheaper they are than many institutions. And so it is easy to slide into the view that we should model health care in a similar way. Here is a good article on why the issue is more complicated (also see the very good comments). Complicated problems often do not have simple solutions. I also recently had a client who got shoddy service at the Scottsdale Mayo. I found striking errors in the report on my client's condition.