Cuba: A look into the perils of communist health care

Whenever I hear people discussing the perils of socialized medicine, I think of three countries immediately. Japan, Sweden, and Cuba. Japan and Sweden I immediately think of because these are two of the indisputably healthiest countries.

Sweden has universal almost-free health coverage, where the state pays for about 98% of all costs; in Japan, health coverage is mandatory and either supplied through an employer, with the government providing coverage for students, elderly, farmers, and the self-employed. We could consider Japan the exemplar for the private model and Sweden the exemplar for the public model; in either case, the far less healthy United States is getting far less bang for its health care bucks than either.

However, I think of Cuba because Cuba is actually identified as communist. Nobody is going to dispute that Cuba is communist - nor will anybody mistake Cuba for a rich country. The CIA World Factbook estimates that Cuba's GDP per capita, by purchasing power parity, is only $9500, barely more in total than what we spend per capita on health care.

Cuba spends even less - the WHO estimates 7.6% of its GDP - and due to Cuba's particular economic and trade relations situations, Cuba is short on many modern medical supplies, and this is reflected in the number of Cubans dying from causes we consider easily preventable.

Here's where the Cuban system falls short. Maternal mortality - perhaps noncoincidentally, this ratio is matched by the rise in the number of c-sections performed. Tuberculosis - detection, treatment, and prevention. Child deaths due to diarhorreal disease or pneumonia - which would be especially easily solved with a little more money for drugs and sanitation infrastructure.

Cuba also has noticably - albeit not as dramatically - higher deaths due to cardiovascular problems, something that may be linked to Cuba's substantially higher tobacco use rather than a specific deficiency in care, but that pretty much covers all of it.

Life expectancy in Cuba is quite similar to the US. Infant, child, and adult mortality are overall lower. And what does it say about us that we spend twenty times as much on health care (ref) and yet get so little, as a population, out of our health care system? How much would it cost us to match Cuba's infant and child mortality rates?

I am sure there are many specific procedures that are simply not available in a poor country like Cuba - but how can a rich country like the United States fail so badly with basic care that all the advanced procedures in the world barely let us catch up to our poorer neighbor on the demographic level?

The oddity of the informed middleman

On a certain level, salespeople tend to bother me a little. Not so much personally - although one of the people at my undergraduate alma mater I found the most reasons to personally dislike ended up working as a car salesman for a little while - as in terms of the general concept of the role. The line between salesperson and scam artist can be very slim, and it's difficult to see, sometimes, just what they add.

There are two elements that combine to make salespeople hazardous. One is working on commission; the other is informational imbalance. If you work in sales, you probably are paid on commission, even if you work as a middleman between two parties (as, say, real estate agents do) rather than working directly for some manufacturer.

I can think of several scams that involve trying to hook lots of amateur sales-interested folk by requiring them to buy expensive samples or the merchandise they will sell, and then doling out a narrow commission. I say "scam" because some of these operations make their real money selling sample kits to would-be salespersons rather than moving merchandise through those salespersons. The commission is a powerful motivating tool.

Now, when combined with the information gap, a salesperson on the ground has every reason to outright lie to uninformed customers if it will get them to purchase something marginally more expensive, to incrementally stretch bit by bit their intended budget, and since little of it is written down, there's often little recourse for a consumer who has been deceived with a personal sales pitch.

I've been lied to by sales folk more than once myself. And by and large, the consumer is in something of a bind: They need an expert on computers, cell phones, etc that they can talk to, who will explain all the features they don't quite understand - but while the salesperson is such an expert, and a remarkably easy to find one, there's every reason not to trust them.

Oddly, my experience is that when there's no commission in play and a generous returns policy, employees working for a wage are perfectly willing to dish out honestly about which products do what and what you probably need for what you want to do. Remember all the jokes about used car dealers? The grain of truth in them is why I so tend to distrust salespeople. It's nothing personal, salesfolk; it's simply that I'm pretty sure your interests and my interests are as close to orthogonal as they could be given that we're talking about the same kind of product.

A secession scenario, part II

Continuing from where we left off last time, we divided the USA up based on a hypothetical Republican-led, anti-Obama secession movement, and then looked at the composition of the ASA (the "anti-socialist" seceded states) and RSA (remaining states). Today, in the second part of the series, I'd like for us to explore what the major obstacles to a secession movement would be in a number of these states and regions.

The Old South

There are a few common problems in this region that present an obstacle to secession attempts, one being that a Republican-led secession movement would probably struggle in Democratic state legislatures in Louisiana, Mississippi, and Alabama. A powerful reason across the entire region is that 29% of the population of this region is black. Percentages range from 37% in Mississippi to 26% in Alabama, and while you can find a number of Southern whites who will say that states' rights and secession are things that have nothing to do with race, you would be hard-pressed to find Southern blacks willing to agree. And that's with secession in general; an anti-Obama secession movement would inflame racial tensions to heights not seen since the 1970s even if it failed. In the event any of these states were to secede from the rest of the US, I would expect to see things get very ugly in a hurry for the reasons of race and history.

Georgia

Georgia is the largest and most prosperous state in this region. However, while Georgia's state government is firmly in Republican hands, Georgia is also the state in this region that gave Obama the highest percentage of the vote - a full 47%, his third-smallest percentage loss in the country behind Montana and Missouri. This would present a major obstacle to any secession movement in Georgia; Obama simply doesn't have the net negatives in Georgia that he does in the rest of the South. Georgia has also spent the most effort reinventing itself as part of a new South; Atlanta, as the center of the "New South," would represent a powerful center of opposition to secession.

South Carolina

South Carolina is one of the two states in this region whose state governments are controlled by Republicans. South Carolina also is the state with the longest history of secession threats, and did so in December 1860, before any other state in the Confederacy. It was also the site of what is widely regarded as the first battle of the Civil War (Fort Sumter) and for these powerful historical reasons, a secession movement starting in South Carolina cannot avoid being compared to the Civil War. Also, two practical points to consider: If Georgia does not secede, South Carolina would be surrounded; and South Carolina's economy relies heavily on the tourism industry, something that is likely to take a sharp nosedive even in a peaceful secession.

Mormon Triad

Three of the most heavily Republican states, with three of the four lowest Obama vote percentages, are also the three with the highest percentages of Mormons in their population, which helps me come up with a handy name that doesn't sound like it should include Colorado and Montana. Utah is much more Mormon than Idaho, which is much more Mormon than Wyoming; the three of them combined are close to half Mormon, with around 2.3 million LDC members out of a combined population of 4.8 million. However, the name is much more than that; it's a reminder of how influential the CLDS is within the Republican party, especially in Idaho and Utah. If there are any three states in which the opinion of Church elders will matter, it will be these three states.

An interesting historical fact: During the civil war, an assembly of the Mormon church sent a petition to Congress to join the United States. I know very little about the inner workings of the current CLDS, but I expect secession to be controversial enough that it will matter what is being said within the CLDS, and I do not expect these three states to secede on their own account - if and only if Republicans across the nation are clamoring for secession. However, in these states, and in the Plains states (the column running down from North Dakota to Oklahoma), we don't expect white-black racial tensions and the history of the Civil War, Reconstruction, and the Civil Rights Act to be as important.

Montana

Montana, I should note, is something of a special case that I tossed in on the secession side without a very detailed explanation. Montana is increasingly Democratic, and McCain edged out Obama in Montana by barely more than 2% of the vote. I included Montana for two reasons, and two reasons only. The first is that increasingly Democratic or not, Montana has a powerful libertarian tradition and a lot of very independent-minded folk, and the justification of this scenario was that the country would split over health care. The second is that if the Mormon Triad and the Northern Plains states (Nebraska and the Dakotas) all secede, then Montana will be completely surrounded by seceded states, at which point secession would start to sound a lot more reasonable.

We can expect, however, that Montana would be likely to secede only in the event those six other states all seceding - and it is not guaranteed even then.

Texas

Texas is an interesting state, even more so within this collection, because we actually have seen polls run gauging the popularity of secession in Texas. We've seen polls run for two reasons: One, the governor was talking about. Two, Texas probably is the most likely state to secede. It's a large state with a significant population, a large economy, lots of natural resources, and an unusually strong identity. Texans identify as Texan. The forum post inspiring this exploration assumed Texas would lead any secession movement - and even so, polls have suggested that secession struggles to reach majority support among Texas Republicans, and is unpopular within the general population.

So when we talk about Texas... we cannot help but see how unlikely any secession scenario is in the near future. It makes for some fun stories to talk about, and perhaps by closely watching the continuing saga of Governor Perry, we might see what it would take to have another period of secession from the Union.

Nonlinear history

A long time ago, I got into writing online quizzes. My masterpiece was a monster on the topic of how history gets revised for popular consumption. It's been a long time since I updated it, or checked to see if it was still working, but one of the key themes I noted in putting it together is this:

History is very nonlinear. It's not only nonlinear - different things change at different rates - but in every dimension it is non-monotone. Technology does not always move forward. New farming techniques are not always better. Sexuality has not steadily become more relaxed over time, but instead, has cycled through different eras of prudishness, puritanism, and permissiveness.

The Victorian era is a prime example. It was probably the height of sexual repression (as we commonly consider the term) in England - but while the stiff standards of "proper" female behavior marched forward, that does not mean the pre-Victorian era was even more prudish. In fact, the 17th century was a very earthy century in England, as we know from Shakespeare.

Another prime example that is especially worth noting is the Antikythera device - a mechanical computer dating back to around 150 BCE, which in sophistication, rivals the mechanical computing machines of the early 19th century. It would take almost 2000 years until western Europe recovered the sophistication of the Greek clockwork devices.

And then the mind just boggles. On some level, when I was young, I absorbed the lesson that history was a kind of progress. You always moved forward. And then, slowly, I absorbed a different lesson: History is nonlinear. Dramatically so, not just in the eyes of wild-eyed fans of ancient alien visits, or apocalyptic doom-bringers, but in the cold eyes of rational respectable historians.

Forces for progress exist, but as is normal in nonlinear dynamics, they are very difficult to model, and there are areas where they behave oddly, local anomalies, and oscillatory behavior.

Snap judgment

One of the most difficult things in the world to do, for me, is withholding judgment. It's something I have to constantly work at, to train myself in, and for a scientist or a mathematician looking to discover the untested truth of propositions, one of the most important.

The moment I look at a proposed theorem, or a math problem, or read the description of a court case, I want to be able to say "Well, obviously, it's this." I want to know that man is definitely guilty, I want to know that the proposition holds for all x>3, I want to be able to tell immediately if a fuel is a thermodynamically viable carbon-neutral energy vessel. I'm impatient like that, and growing up with the ability to answer nearly any of the "math" problems posed to me within seconds probably didn't help.

I mean, I sped my way through the SAT, taking less than half the time allotted on each section, just because I wanted to say I knew answers immediately, to make snap judgments. It didn't matter that it was important for college admissions, and it probably didn't help that the one time I actually went back and made myself check my answers, telling myself the test score was important, I got a 1480 that was almost exactly the same 1480 I'd gotten the previous year (740/740 vs 760/720).

But the thing is, I also hate being wrong . I just have to be right, and being wrong would be even worse than having to wait for the answer. So I learned - slowly and painfully - to withhold judgment. The study of philosophy has been very helpful for me in developing that patience, and I've withheld judgment about many things that few people hesitate to fix in their mind. I'm comfortable with being an agnostic; I push myself to try foods that I was sure I disliked; I understand how to take a hypothetical position and work up a whole tree of contingent conclusions while keeping my assumptions in clear sight.

It's not what I really wanted - to know the answer now - but if I can only either be sure I'm right, or have my answer now, I'd rather be sure.

A secession scenario, part I

Today, a poster on NationStates posed the following hypothetical: Suppose Texas and a majority of "red states" threaten to secede from the Union in response to Obama and the Democrats nationalizing health care. What would you do? Well, I thought it was an interesting question.

My first thought, naturally, is to explore the scenario a little more carefully to determine what states are involved. An anti-Obama secession movement will be almost strictly Republican; thus, we should start with those states whose state governments are entirely Republican controlled. There are eleven of these. I'll subtract Florida - since Obama won Florida's electoral votes - and add the overwhelmingly Republican Oklahoma and Wyoming, which have Democratic governors but posted the lowest percentages for Obama. Finally, I'll throw Montana in, since they just got surrounded, to make 13.

In red, we have the Anti-Socialist States of America (henceforth the ASA) and the Remaining States of America (henceforth RSA) are in blue.

After looking at the map and thinking about it, I'll introduce a group of "border states." Kansas: It's been a long time since "bleeding Kansas," but it's in something of a strategic spot. Politically, it's similar to Wyoming and Oklahoma in having a strongly Republican state legislature and a Democratic governor; it's also a state in which Obama enjoys surprisingly high approval ratings, considering he lost it in the fall.

Louisiana, Alabama, and Mississippi in the Deep South are also strategically positioned, and an area in which Obama polls low numbers. However, they are also states with significant black populations that their Democratic state legislatures rely on heavily. These four states are possible candidates for a second wave of harder-fought secessions in this scenario, but also states in which secession would be more politically difficult. These are battleground states in this sort of scenario, and are keys to either the RSA or ASA having a more contiguous territory.

And that's the first thing we really notice about this map, as opposed to a map of the Union-Confederate divide in the Civil War: The CSA (grey) and the Union (blue) were both contiguous territories, and the disputed states/territories whose membership is less clear are all on the border. Our hypothetical ASA and RSA divide the continental US into five separated chunks - three ASA chunks and two RSA chunks on my first map, or one contiguous continental ASA dividing the RSA into four pieces with the "second wave" states.

I think that's a very important lesson to draw: Our political interests, as a nation, are not as sharply divided regionally as they used to be. We've seen some electoral maps that seem to show sharp regional divisions, but the interior of this country is not exactly politically uniform. The situations from state to state, right at this moment, defy an easy division of the country into a Republican region and a Democratic region.

Let's look for a minute at the characteristics of the two freshly-divided nations. We're assuming that this is somehow an amicable parting of ways.

First, the RSA is staggeringly Democratic, and the ASA staggeringly Republican. The Senate keeps at least 52 Democrats and loses at least 19 Republicans, for example. On the federal level, both have a clear supermajority in one party - which means that we should expect major political shifts, possibly the rise of new (or newly prominent) political parties.

Second, the two hold about the same land area (between Australia and India. with one 6th and one 7th place in the world, depending on who gets the border states), but the RSA has most of the people:

RSA: 235 million, 4.1M km^2 land
ASA: 58 million people, 4.5M km^2 land
Border states: 15 million people, 600K km^2 land

Neither one is exceptionally richer than the other; the "border" states are a bit poorer than the rest of the country, on average. The RSA remains the world's largest economy, while the ASA goes somewhere in the area of 5th-7th place, depending on the details of how we measure things and whether or not it gets the border states:

RSA: 2008 GDP $10.8 trillion, $45,000 per capita
ASA: 2008 GDP $2.6 trillion, $44,000 per capita
Border states: 2008 GDP $590 billion, $39,000 per capita

So the ASA would be about the population and wealth of one of the major European countries - somewhere in the range between Italy and Germany. We wouldn't expect anything much larger than the ASA plus border states to secede even in a political atmosphere favorable to secession.

The wealth of nations

As of 2008, three of the major GDP estimations agree on the list of the ten richest nations on Earth. First is the US, then, with close to the US GDP between the three of them, Japan, China, and Germany; the lists then all proceed with France, Italy, and the UK (in that order). The final three, which the different lists rank differently, are Brazil, Spain, and Russia.

In a moment of curiosity, I decided to plot these with respect to population... land area... there's not really anything in common with the list. It gets worse when we go a few more places down, which pulls in India and Mexico.

The only thing that's really clear on these lists is that the wealth of nations is still fairly concentrated. The 800 million people in the EU and US control half the world's economy; the 2.5 billion people in China and India control a tenth of it. Mostly that's China speaking, there, India is part of the 2.8 billion population unit that only accounts for 5% of global GDP.

India. The Tiger. The rapidly developing, technologically savvy country. Rapidly growing economy or not, a rising reputation for churning out talented engineers and programmers or not, they're still quite poor in terms of cash dollars.

When I think of all the things I bought, there's very little in terms of durable goods that came from the US or EU; some fencing equipment, some odds and ends, some books - and when I read the 538 post near the end of June (see link above) talking about how to take out about 40% of the world's population for the small price of 5% of the world's GDP, I have to wonder if we aren't undervaluing the contribution these countries make to the global economy when we choose to rely on GDP as a measure of it.

I also have to wonder if it's a question of the value of their labor being truly different, or if it's really more of a product of how money moves. Or doesn't move, as the case may be. Some evidence suggests that the supply and demand for money - and therefore, currency exchange rates - are a large piece of the picture, for when we look at GDP(PPP) figures - measuring local purchasing power - the EU misplaces about three trillion dollars and China picks up a similar amount, rocketing past Japan.

India shoots up from 12th (1.2$T) to 4th (3.2$T). The local goods and services available in India would be worth about three times as much on the European market as Indians actually buy/sell them for. It's amazing, and more than a little bit disturbing, to think that the difference in the value of money is so terribly significant.