The socialized medicine we already have

The public dialog surrounding health care has become fairly frustrating to me. There's a generation gap, an information gap, a comprehension gap, and not only that, but plenty of hypocrisy and misinformation going around.

First: No, the US health care system is not the best in the world. We may have the best experts on some diseases, and very good health care, but the overall quality of care, system-wide, is no better than tenth in the world. Even Forbes magazine - hardly a bastion of socialism - puts the US at 11th healthiest. In 2000, the WHO put the US health care system as 15th best - 37th accounting for how much we spend.

No matter what anecdotes Fox News, the Wall Street Journal op-ed pages, or anybody else spout about the horrors of socialized medicine, the fact of the matter is that nearly every serious look at the data tell us that Canada, the UK, Sweden, etc have far better health care systems.

Second: The US already has government-provided health care. For 2005, the WHO calculates total government spending on health care in the US at $2,862 per capita (out of a total of $6,350 - yes, both figures have risen substantially in the last 4 years). In other words, between Medicare, Medicaid, the Veteran's Administration, and other government provided insurance and health care systems, Uncle Sam pays directly for about 45% of all health care.

I don't believe that counts the employer tax break, which as an indirect subsidy amounts to about $500 per person, and Medicare spending has grown sharply in the last four years. Government insurance programs cover directly more than a quarter of the population directly, and the subsidies affect half the population.

The result of selectively covering the poor, elderly, and disabled is one of the most expensive (and least efficient) government health care systems in the developed world. The US government, in 2005, spent more money per capita on health care than the Canadian government, the German government, the UK government, the Swedish government, and most of the other European governments you hear about when people start talking about socialized medicine and universal health care.

Iceland, Switzerland, and Denmark's governments all spent more than Uncle Sam in 2005 - in nominal terms, but in terms of purchasing power parity (everything is more expensive there), they spent less than our government. Austria pretty much matches us in PPP terms; so far as I can tell, the French and Norwegian governments alone spent more money on health care than our government did.

In fact, US government spending on health care is about the same as total health care expenditures - public and private - in the countries I usually use as examples, Japan and Sweden. (Anyone think that Japan has a recent history as a bastion of socialism?)

So if "government provided health care" is a form of socialism ... ladies and gentlemen, I present to you the United States: The world's third or fourth most socialized medicine on the planet - and the only one in the top 20 that can't manage to cover all its citizens.

Third: The generation gap. What a lot of people don't seem to understand is that employer health benefits are on the downslide. And that matters a lot more for us young folk, who are part-timers, new hires whose contracts don't have grandfathered care, entrepreneurs, subcontractors, self-employed, and generally get the short end of the stick when it comes to government subsidies and government-provided coverage.

I'm 25. Mortality and disease and high health care bills are pretty uncommon in our age bracket - but there aren't many of us who don't realize that skimping on preventative care now will cost use when we're older, or that one accident, one unusual disease will completely wipe out our pocketbooks and put us in the hole. Not only that, but we probably won't even be able to get care until later in the course of a disease or long-term condition if we aren't covered, and that means it'll get a lot worse.

And so most of us are strongly in favor of health care reform. It's not surprising; we're right there. We can see our self-interest, and we can see our taxes fueling a system that spends enormously and inefficiently on everybody else. And when I hear about all the older folks hollering and protesting at "town hall" meetings about "socialized medicine," I can't help but think: There is someone who probably benefitted from government-subsidized health care for several decades of their life, and is probably covered directly by Medicare now.

And I think to myself that they are probably more than a little bit of a hypocrite. They have socialized medicine. They're probably afraid it'll get cut if the government stretches out to pay for everybody - something I think about a lot when I look at how older folk respond to intimations of Medicare cuts. Those young people, they don't need insurance, most of them are really healthy - so many of the older generation seems to think.

And who is going to be paying for this, paying for the growing national debt, paying for any health care reform? Most of today's retirees aren't going to be paying many taxes twenty or thirty years down the road. Most of today's young people will. So when I see members of the older generation fighting health care reform tooth and nail, I look at the demographics and the statistics and I think to myself that it looks like most of the protesters are engaging in an exercise in hypocrisy.

But back to the issure of young people needing coverage. Here we come to the comprehension gap. Because when it comes to having health care, it's do or die. And so when it comes to insurance, you need coverage that will handle a major emergency, which in a market where the government is paying for most of everybody else's ticket, in a market where you can't shop around between more than a handful of providers, in a market where bloated middlemen work hard to make their share larger, in a market with an enormous information gap, means that you're completely fucked if you're a little fish on your own shopping for coverage.

I happen to have gotten lucky in that my graduate school actually provides health coverage as part of my funding package, and it might even be adequate coverage in the event of a major medical emergency. I don't know yet. There's always a lot of fine print, and I haven't spent several weeks reviewing it - not that I could afford to buy adequate coverage on my graduate stipend. I don't exactly have a choice there.





So. That turned out to be a longer rant than I expected, and there's so much more I could talk about, but I'll leave you with the summary and the recap. First, other countries do actually have better health care systems. Second, the US government is already spending enough to provide universal coverage and better coverage. Third, your experience and understanding of this country's health care is going to vary radically based on age and socioeconomic background.

At the risk of sounding like a teenager, many of you making loud objections really just don't understand. The holes in the system are a lot more visible to those of us living in them, and to those who trip over and fall in one.

Bows and guns

A little military history and a little lesson about technology.

Guns and cannons replaced bows and catapults in Europe and Asia beginning in the 13th century, and ending in the 16th century; that is to say, by the time the 16th century ended, the bow as a military instrument was considered largely obsolete.

Why? It's easy to see how artillery was replaced; it was much easier to throw massive objects with chemical, rather than mechanical, energy; cannon were far superior for reducing fortifications and smashing through human bodies, from the very start.

The mission of a musket is different. It's to kill some particular person. Military guns of the 16th century are smoothbore weapons, muskets and arquebuses; they're terribly inaccurate compared to bows. With much lower rates of fire, and in this era much less reliability, the gun was a more dangerous weapon to use. Backfires and accidents with slowmatches were quite common. The Mongolian horse archer of the 13th century would probably have been able to handily trounce a pistolier from the 16th century - probably, individually, deadlier than any of the types of soldiers fielded across Europe in the 16th or 17th centuries.

The typical Mongolian bow, with close to a 160 pound pull, fired an arrow with around 160 joules of kinetic energy (ref); for reference, tests playing a ~80 joule arrow at point blank against 15th century armor show it to be capable of just barely piercing period armor. There exists a raging debate over how effective the less powerful (100 pound typical pull) English longbow was against the very best plate armor, developed after the famous Battle of Agincourt.

Expert opinions range from "only at point-blank on a good direct hit" to "any shot within the effective range of the longbow that lands squarely," but the Mongolian bow is more powerful; accurate to about 80 meters in the field, the range at which large, round, and comparatively soft musket balls with a higher muzzle energy (but poorer ballistics and a larger surface area) could threaten plate, it can be expected to pierce plate armor with nearly every square hit at that range.

The fact that it could deliver 3-6 hits in the time that it took a musketeer to reload just about makes up for the fact that only a square hit would pierce; the gross inaccuracy of the musketeer means the Mongolian bow is almost certainly deadlier than the musket even against targets with good armor.

And good armor was not that common. I sometimes go as far as to suspect that a tumen of Chinggis's finest could quite possibly defeat a like number of 17th century German mercenaries in the field. So why, if the archer was better at killing more people in a hurry than the musketeer and the best bow of the 13th century was in many ways better than the best guns of the 16th, did the musket replace the bow so quickly?

The answer is complex. One factor is that when two armies face each other, accuracy is no longer as important; a poorly aimed musket ball or arrow is deadly no matter who it hits, and it will hit someone. Another factor is logistics: Musket balls and powder are easier to carry, and are easier to manufacture in large quantity. A third is training: A 16th century musketeer required no more than a few weeks to familiarize himself with his weapon to use it as accurately as anyone else could, while the deadly longbowmen of England's 15th century armies, and the deadlier horse archers of Mongolia's 13th century armies, required years of specialized athletic training.

And because of that, the bow was prohibitively expensive to use in armies, compared to the gun. Some would still use it to great effect once in a while, but it never regained ground as a battlefield weapon. In time, the greater kinetic energy of the gun was coupled with better ballistics, armor-piercing ammunition, rates of fire, and great advances in accuracy, outclassing the bow on all fronts; but to replace the bow as a weapon of war, it needed only more convenient ammunition and greater ease of use. Even allowing that a 15th century English longbowman, firing ten arrows a minute, was deadlier than the musketeer replacing him against all but the most heavily armored men, he was many times more expensive, and harder to replace.

And so the bow was replaced by the gun, in the far east and in the west. Here's where I generalize today's lesson on technology: The better technology is not always superior in all regards. It's even possible to go backwards in some respects - and yet still render the old technology "obsolete" quite authoritatively.

Long term; short-term

Some days, I wonder how many of the people I meet are putting their long term interests or their short term interests first.

Being aware of both is another thing that many people don't do well, whether planning for a party or running a major corporation. Unfortunately, we put many people in positions where they are unlikely to look for long term interests - traders looking to make the new smarter quicker buck, a CEO hired to make immediate changes in the short term profit numbers, politicians looking to win this year's race.

And while it's foolish to neglect your short-term interests completely, it's possible to focus a little too much on the long view, but it's much easier to go for the immediate reward. And I can't help but think that when people looking only at the short term results get that immediate reward, they're being trained to keep doing that. Something about psychology and positive reinforcement.

Nixon's southern strategy won the Republican party the South for a generation - and alienated the non-white voter for at least as long. George III found the colonies a quick and easy source of additional revenue. It is usually a perfectly rational strategy that is the worst mistake of all. Just dump it in the river, and watch it catch on fire after decades of dumping; save a few million now by privatizing prisons, and watch prison populations climb at a faster rate; throw out the rules of war, and wonder why your opponents do likewise.

This is the real reason I don't trust in the invisible hand - and the reason, too, why I try to be so careful in my decisions these days. Everything has consequences stretching into the long term.

Occupation and representation

Every so often I am reminded of Puerto Rico. It comes up in political discussions, and I've known a few people from there, or who have family from there. And every time it comes up, I wind up feeling like there's something wrong.

A dozen generations ago, Benjamin Franklin, Thomas Paine, and company were grumbling about being subject to a sovereign who they had little influence on. Parliament representation was not for mere territories.

Now, here we are, continuing to return the favor. I know - Puerto Rico gets a lot out of its relationship with the US. But it's a real affront to democracy for us to be sitting here on the mainland and handing down decrees. It's not a pressing security issue or some kind of wartime emergency; we just own it and rule the 4 million or so people there in a state of legal limbo - neither an independent country nor one of the states making up the United States proper.

There's also Guam, American Samoa, the US Virgin Islands, and the Northern Marinaras, which are a good bit smaller - between the four of them, they have a little less of a population than Wyoming. Each is individually large enough to be admitted as states under the Constitution, of course. And while many people on both sides of the affair find the status quo a reasonable compromise, I don't.

If we're ruling over you, you deserve representation in our government. "Territory" should always be a temporary status, and it should be one that's revisited regularly. Puerto Rico was taken over by the US about the same time as Hawaii and the Phillipines. Hawaii has been a state for fifty years; the Phillipines were granted independence sixty three years ago. Puerto Rico deserves to get its hands on either full statehood or independence; so, too, do the four smaller territories I mentioned.

As small as they are, Guam, American Samoa, the Northern Marinaras, and the US Virgin Islands still deserve to participate in every level of government they are subject to.

Markets want to be conservative?

The other day I said something that should strike a reader as odd: Markets want to be conservative. And in that, I did not mean "conservative" as a collection of political positions that some pundit might want to assign to the term; I mean the much older and more literal meaning of the term. The sort of market economy we have today resists some types of change.

It's not an inherent property of the market itself. It's a product of social influence. With the creation of each market, each service, each industry, a special-interest group is created. The invention of the personal automobile lead to the automotive industry - and all those involved in the manufacture, sale, and maintenance of the automobile have a vested interest in consumers using cars, and will try to influence policy to fit.

The only change that the market embraces is one that makes someone more money; privatizing prisons, for example, has backfired by creating a lobby - one with, in many cases, pre-existing ties to state legislators that landed them the contracts in the first place - with a vested interest in increasing the prison population. Insurance companies have a vested interest in preventing health care reform - because successful reforms would obliterate their bottom line.

In a land where everything is for sale - including legislative access and the publicity needed to get into office - the market provides incentives for parties to fight against change. We've seen it with the tobacco industry; we've seen it with state-run lotteries; we're seeing it now, once again, with health care. In each case, the profit motive of the private sector puts the brakes on changes in public policy.

When I look at the privatization of prisons, I am not surprised that some states may achieve short-term savings in higher efficiency operations; I am also not surprised that in the long term, it comes back to bite them in the tail, as suddenly there's a group that benefits if recidivism rises, if indeed crime rates rise, and fundamentally if prison populations rise - a motive that does not exist in a publicly run prison.

Slavery

Today was Juneteenth, and so the historical ending point of slavery in the US has passed through more minds than it usually does this week. And yet, archaic institution or not, slavery captures a lot of creative thought.

There are several modern arguments hidden in the corners of the moral and ethical spectrum of opinions that favor slavery. All - well, almost all - are unwilling to say that the institution of slavery as practiced in the US was a-OK. Hereditary racially-based lifelong slavery in which the owners have unlimited rights to dispose of their property as they see fit? Certainly not!

But while I think that the wrong was in the humans-owning-other-humans part, others would suggest it is in the other details. Why, if it is entered into with agreement by the party being enslaved, appropriate rights left to the slave, has nothing to do with racial oppression, what of it? Shouldn't people be free to enter into such a contract?

It is a perfectly libertarian turn of phrase. If slavery is a transferable contract, shouldn't it be legal? Leaving aside the sticky issue of people being pressed into slavery under duress, false pretenses, et cetera. There is a subtle point in the works. While undoubtedly there are those foolish enough to sign themselves onto an open-ended transferable contract - and some of the more clever transferable labor contracts look something like that - there remains the freedom to walk away from a contract at any time - throw up your hands and walk off the job. You may be out money; you may even be liable for financial penalties; but you retain that liberty.

Perhaps most importantly, it retains a sharp distinction between people and property, which is a dangerous line to blur. And perhaps we should carefully look at the things that look like slavery - prison labor to fill pockets, transferable contracts, and the penalty clauses allowed to labor contracts - and ask ourselves "What is the difference between this, and some nicely cleaned-up version of slavery?"

And those of you in the BDSM crowd who are into the master-slave relationships and roleplay on a purely consensual basis, who can end it at any time? You can ignore all that.

Retroactive reason

We are very fond of speaking of ourselves as rational creatures, but I cannot be sure that even I am more rational than rationalized. As methodically and carefully as I approach life, and making the decisions that I make, it is very difficult to be sure that I have arrived at a decision through the rational process, or whether I simply use the rational process to justify the decision I want to make.

Every once in a while I catch myself at it - usually a little late. You rationalize a little bit, then you rationalize a little bit more, and then the data come around and slap you in the face and say Yo, you're wrong! This is why I'm very leery about claiming to know things - careful critical examination of the justification is required to be sure it's not just a pleasant rationalization with a giant hole in the middle.

I, Agnostic

Occasionally, I tell people that I am an agnostic. This seems to provoke some discussion, now and then, as the devout Christian or equally devout atheist would like to know just how I could be indecisive.

I'm not being indecisive, I reply, and so begins my long story. I'm not an agnostic because I haven't seen the arguments presented by either side, and can't make up my mind; I'm an agnostic because I refuse to believe something I can't know. I can't know there is a God; I can't know there isn't a God. Or Goddess. Or some number or combination of divine, semi-divine, near-omnipotent, or other supernatural beings.

That doesn't mean I don't make contingent judgments, or moral judgments, or ethical judgments, or that I don't have my own peculiar fanatical beliefs. I don't need to believe in a God, or know punishments or rewards await me in the afterlife, to decide what I should and should not do; to be the best person that I can be, to do good as best as I can, is its own reward. Nor do I need to deny others their own leap of faith in declaring there is - or is not - some God out there. For practical terms, one good leap of faith is worth quite a bit of philosophizing.

For myself, I am content to muddle along on judgments, logic, and philosophy, knowing there are things out there that I cannot know.