The Long View 2007-01-09: Anti-Freeze Life; Ethical Racket; Charles Fort Lives; Towards Universal Health Care; Steyn on Russia

John Reilly had a minor sideline in Fortean phenomena, named after Charles Fort, strange and uncanny events sometimes described as being outside of what science can explain, but often better seen as low frequency events that are difficult to describe. In that vein, the recent juvenile humpback whale found in a mangrove swamp in Brazil is an excellent example. Not quite far enough from the water to be truly inexplicable, but strange nonetheless.

Small whale in Mangrove forest

Small whale in Mangrove forest

There is also a line in this post which I’ve thought about for a long time, and I think I finally understand what is going on.

If the California system is implemented, we can expect it to work better than the plans in the New England states, for the simple reason that California has a younger population. There are more workers to support the system. Still, I do not expect any of the state plans to be altogether satisfactory. As I have remarked before, health insurance may follow the pattern of bank-deposit insurance. That had been tried in a few states in the early 20th century, but the insurance systems kept collapsing because the the risk pools were not big enough. As an afterthought, Franklin Roosevelt included mandatory national deposit insurance among the bank reforms at the beginning of his administration. To everyone's surprise, the insurance restored popular confidence in the banks immediately.

John thought that the difficulty with universal healthcare systems in the United States was that the risk pool wasn’t big enough. That never seemed quite right to me, but it took a long time to figure out why. There are plenty of healthcare systems in the world that cover smaller and older populations than many US states. For example, in 2005, Sweden had just over 9 million resident. Massachusetts at the time had about 6.4 million. It is at least conceivable that the extra 2.5 million people would make the difference, until you look at the population pyramids.

Massachusetts population pyramid 2000  By No machine-readable author provided. WarX assumed (based on copyright claims). - No machine-readable source provided. Own work assumed (based on copyright claims)., CC BY-SA 2.5, https://commons.wikimedia.org/w/index.php?curid=973229

Massachusetts population pyramid 2000

By No machine-readable author provided. WarX assumed (based on copyright claims). - No machine-readable source provided. Own work assumed (based on copyright claims)., CC BY-SA 2.5, https://commons.wikimedia.org/w/index.php?curid=973229

Population Pyramid of Sweden 2016  By Central Intelligence Agency (CIA). - CIA World Factbook, 2017., Public Domain, https://commons.wikimedia.org/w/index.php?curid=64345478

Population Pyramid of Sweden 2016

By Central Intelligence Agency (CIA). - CIA World Factbook, 2017., Public Domain, https://commons.wikimedia.org/w/index.php?curid=64345478

Massachusetts is relatively younger, even though smaller. In theory, this should make your healthcare system, especially if seen in the insurance model, work better. However, universal healthcare didn’t work out as well in Massachusetts as it does in Sweden, because it cost more than expected. Pseudonymous blogger Random Critical Analysis provided me with the reason why: Americans spend much more on health care than Swedes because we are a lot richer, and people don’t understand this and keep being surprised.

John Reilly always insisted that healthcare wasn’t a right, but rather a matter of public order, but I think he was missing some critical quantitative details that would have really made his case better.


Anti-Freeze Life; Ethical Racket; Charles Fort Lives; Towards Universal Health Care; Steyn on Russia


We can probably bet against this ingenious speculation:

Two NASA space probes that visited Mars 30 years ago may have stumbled upon alien microbes on the Red Planet and inadvertently killed them, a scientist theorizes in a paper released Sunday....Dirk Schulze-Makuch...a geology professor at Washington State University. ...In the '70s, the Viking mission found no signs of life. But it was looking for Earth-like life, in which salt water is the internal liquid of living cells. Given the cold dry conditions of Mars, that life could have evolved on Mars with the key internal fluid consisting of a mix of water and hydrogen peroxide, said Dirk Schulze-Makuch, author of the new research.

Perhaps the paper addresses this issue, but there are many places on Earth where an anti-freeze biochemistry would be very useful, yet we do not find it here. That strongly suggests it is not possible.

* * *

When I see this kind of story (from the LA Times, in this case), I think "racket:"

Dark cloud over good works of Gates Foundation:

Ebocha, Nigeria — Justice Eta, 14 months old, held out his tiny thumb.

An ink spot certified that he had been immunized against polio and measles, thanks to a vaccination drive supported by the Bill & Melinda Gates Foundation.

But polio is not the only threat Justice faces. Almost since birth, he has had respiratory trouble. His neighbors call it "the cough." People blame fumes and soot spewing from flames that tower 300 feet into the air over a nearby oil plant. It is owned by the Italian petroleum giant Eni, whose investors include the Bill & Melinda Gates Foundation.

Could someone be gingering up a law suit against the foundation, or are we dealing here with honest idiocy?

* * *

Fortean phenomena should stay off the frontpages, but we have had a flurry of prominent ones in the past few days. Yesterday we had the Manhattan gas incident that interrupted some underground train service and caused buildings to be evacuated, plus the bird die-off that closed much of Houston. That brazen (as in "bold," not "made of bronze") UFO actually visited O'Hare in November, but we heard about only last week. The odds are that all these things, including the UFO, probably were caused by weather conditions that really are unique in our not-very-extensive records.

Regarding the gas smell, I could hear the fire department vehicles looking for the source here in Jersey City, but I could not smell it: I'm getting over a cold.

On the other hand, National Public Radio saw fit to advise its listeners of this development:

Poems, songs, and stories praising Saddam and lamenting his death are popping up all over Arab Internet sites. A few mosques in Baghdad announced that an image of his face could be seen on the moon, and people spilled into the streets this week for a glimpse of their former leader in the night skies.

It's much too early in the year for Silly Season stories.

* * *

In the realm of sober public policy, we see that Governor Schwarzenegger has proposed a state health-care system that would add California to Maine, Massachusetts and Vermont as states that require universal coverage. The plan looks plausible, but I note that almost half the funding would come from new federal money to which the state believes it would be entitled under existing federal rules. I am not pleased that at least some of the funding would also come from new payroll taxes, but that could be a wash in terms of the business climate, since a state with universal coverage is going to be a more attractive place to work. The great red herring in the debate over the Schwarzenegger Plan is going to be its coverage of illegals. The objections to that rather miss the point of the exercise: this is a matter of public order, not social generosity.

If the California system is implemented, we can expect it to work better than the plans in the New England states, for the simple reason that California has a younger population. There are more workers to support the system. Still, I do not expect any of the state plans to be altogether satisfactory. As I have remarked before, health insurance may follow the pattern of bank-deposit insurance. That had been tried in a few states in the early 20th century, but the insurance systems kept collapsing because the the risk pools were not big enough. As an afterthought, Franklin Roosevelt included mandatory national deposit insurance among the bank reforms at the beginning of his administration. To everyone's surprise, the insurance restored popular confidence in the banks immediately.

* * *

Even the House of the Seven Gables demographics of New England looks perky compared to that of Russia, as Mark Steyn recently noted:

The Toronto Star (which is Canada’s biggest-selling newspaper and impeccably liberal) recently noted that by 2015 Muslims will make up a majority of Russia’s army...

The Litvinenko murder is only the first of many stories in which Islam, nuclear materials and Russian decline will intersect in novel ways.

Which brings me, alas, to the Iraq Study Group. This silly shallow report, of which James Baker, Lee Hamilton and the rest should be ashamed, betrays no understanding of how fast events are moving. It falls back on the usual multilateral mood music....By 2050, Russia will be the umpteenth Muslim nuclear power, but the first with a permanent seat on the UNSC. Or maybe the second, if France gets there first....forget the extrapolations: already, domestic Muslim constituencies are an important factor in the foreign policy thinking of three out of the big five. Are Baker and Hamilton even aware of that?

I suspect that France will be the first European country to pull out of the deathspiral. The question is how much discontinuity there will be with mid-20th century liberal modernity. In Russia the problem is more serious, but Russia has fewer inhibitions to overcome in order to solve them.

Now that was a scary sentence.

Copyright © 2007 by John J. Reilly

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The Long View 2007-01-02: Overdiagnosis; Literature Maps; Starship Jesus Conversion from Islam; Spengler's Deal; Shabby Hanging

I do agree with John here that our diagnostic tools often don’t improve health, and that the definitions of “disease” are often too broad, but I disagree about why healthcare doesn’t do much as you might think to improve our health. I definitely don’t blame administrative costs, although I wouldn’t be surprised if you could find something to cut there, it wouldn’t make healthcare in the US cost half as much. Universities are another matter.


Overdiagnosis; Literature Maps;
Starship Jesus Conversion from Islam; Spengler's Deal; Shabby Hanging

The smartest thing anyone has said in years about the US health-care system appears in an editorial in today's New York Times by members of the VA Outcomes Group of White River Junction, Vt.:

For most Americans, the biggest health threat is...our health-care system..more and more of us are being drawn into the system not because of an epidemic of disease, but because of an epidemic of diagnoses...First, advanced technology allows doctors to look really hard for things to be wrong. ...These technologies make it possible to give a diagnosis to just about everybody: arthritis in people without joint pain, stomach damage in people without heartburn and prostate cancer in over a million people who, but for testing, would have lived as long without being a cancer patient...Second, the rules are changing. Expert panels constantly expand what constitutes disease: thresholds for diagnosing diabetes, hypertension, osteoporosis and obesity have all fallen in the last few years. The criterion for normal cholesterol has dropped multiple times. With these changes, disease can now be diagnosed in more than half the population.

It's perfectly true: doctors will keep ordering tests no matter your physical condition until you tell them to stop. This practice is particularly pernicious in the case of the trusting and fragile elderly. That's half the explanation for the runaway insurance costs. The other half is bloated and duplicative (and triplicative) administration.

* * *

And if we must do tests, the best personality test I know of is to look at the books in the subject's home library. We soon learn that certain books belong in the same bookcase. Now comes Marek Gidney and his ingenious literature map, essentially a search engine where you input the name of an author and then see what other people who read that author are likely to read. (There are parallel engines for film and music). If this engine to be believed (and we should take it no more seriously than the "recommended books" feature at Amazon), communities of taste are not what we supposed. For instance, there is strangely little overlap between the readership of JRR Tolkien and that of CS Lewis. Tolkien fans favor high-concept science fiction; CS Lewis, to judge by this search engine, is read mostly as a devotional author. I also see that, if you read William Shakespeare, then quite likely you also read HP Lovecraft.

* * *

I don't believe it literally true that there are Millions of Muslims Converting to Christianity, but the reports to that effect multiply:

Around a million believed in Jesus over the past decade in Egypt. The Egyptian Bible Society used to sell about 3,000 copies of the JESUS film a year in the early 1990s. But last year they sold 600,000 copies, plus 750,000 copies of the Bible on tape (in Arabic) and about a half million copies of the Arabic New Testament. "Egyptians are increasingly hungry for God's Word," an Egyptian Christian leader told.

Does anyone have any hard information about this? And if so, why haven't you told me? What don't you want me to know?

* * *

Asia Times Spengler, seeking, no doubt, to annoy me in particular, suggests in his latest that President Bush's fortunes could be about to improve so dramatically that yet another Bush might successfully be elected to the White House in the near future:

[B]rother Jeb, about to step down as governor of the state of Florida, will be elected president of the United States in 2008, thanks in large measure to the rebound of the current president's standing.

For one thing, Spengler notes, the US position in the world is far better than the political class in advanced countries have reason to admit:

Asians cannot earn money to be saved without selling to the American consumer, and they cannot invest their savings except in United States. ...For all America's embarrassment in Iraq, none of its fundamental interests is impaired by Iraq's misery.

The real problem in that part of the world, as Spengler exhorts us every other Monday, is Iran:

There is no point negotiating with the present regime in Teheran...

This is because the current regime there knows its oil exporting period is nearly over, but has dealt with that fact by turning to apocalyptic fantasy. In contrast, we are told, China and Russia will pursue their real interests with sober good sense:

Securing Russian and Chinese cooperation with US strategic objectives, I believe, is a far simpler proposition than is portrayed in the myth of US imperial decline...

China must settle perhaps 15 million rural migrants in cities each year, while building infrastructure and employment in the interior and correcting urgent environmental problems. To do this, China requires stability and predictability in its foreign economic relations.

What does Russia want? Stability on its borders, often at the expense of the aspirations of peoples who have the misfortune to occupy the Russian near abroad, and a free hand in arranging the economic affairs of the Russian state.

According to Spengler, the US should and will drop its fancy notions about spreading democracy universally, but especially in the Russian Near Abroad. Similarly, the US should let it be known that it will stop pestering China about the yuan-dollar exchange rate. Then, Spengler assures us, the US would have all possible options for dealing with Iran, some of them much better than a speculative strike against Iran's nuclear facilities.

Henry Kissinger believed during the Vietnam War that the Soviet Union was offering to give the United States a free hand in Vietnam, even to invading and overthrowing the government in the North, if the US would acquiesce in a preemptive Soviet strike against China. Then Secretary of State Kissinger and President Nixon showed the proposal no favor.

In this they did wisely. Deals of this sort are like multilevel marketing schemes. They sound like good idea, but they aren't.

* * *

Speaking of impending atrocities, Anthony Sacramone at First Things has alerted an incredulous world to this project:

In this month’s Empire magazine Paul Verhoeven opened up about his upcoming project based, perhaps surprisingly, on the life of Jesus.

Verhoeven is a director with many films to his credit, but he holds a special place in the hearts of Heinlein fans for his 1997 adaptation of Starship Troopers. Anyone who is familiar with both the Heinlein story and the movie knows that we need not take Paul Verhoeven seriously about any book in the world.

* * *

Mark Steyn has some cutting things to say about the recent execution of Saddam Hussein, but not least about the official European reaction to it. We read:

According to a poll published in Le Monde, the majority of Spaniards, Germans, French and British were all in favor of executing Saddam. ...When Die Zeit and The Times and all the rest say that "Europe" condemns the death of Saddam, what they mean is that a narrow, remote, self-insulating politico-media elite condemns it....Whatever one's views on capital punishment, that's not what it's about. Hardcore dictatorships have to be not just politically but psychologically liberated. When one man is so murderously powerful, incarceration cannot suffice - because as long as he lives there will always be the possibility that he will return. ...

On the other hand, the hanging was not all we might have wished:

Unfortunately, when the US handed him over to the Iraqi authorities, the "authorities" did their best to look entirely unauthorized. Saddam was dispatched in some dingy low-ceilinged windowless room of one of his old secret-police torture joints by a handful of goons in ski masks and black leather jackets.

Steyn suggests that someone from the US embassy, or at least the military, should have been on hand to advise on the proper protocol. To that suggestion, I reply that the execution really was not supposed to be public. American executions these days are normally short on pomp and circumstance, too.

On the other hand, the addition of the ceremonial of public executions to the education of the diplomatic corps would add a whole new dimension to Foreign Service School.

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---John J. Reilly

Copyright © 2007 by John J. Reilly

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What works in healthcare?

Short answer: almost nothing.

I’m being flip about a very serious subject, but at the same time I am in fact serious. Modern medicine probably works a lot less well than you probably think it does.

How could I say such a thing when you look at graphs like this?

Maternal mortality over time Our World in Data Global Health https://ourworldindata.org/health-meta

Maternal mortality over time
Our World in Data Global Health https://ourworldindata.org/health-meta

I say it because that is precisely what the evidence shows. If you look at Cochrane, the world’s preeminent aggregator of medical statistics, it is hard not to come away a bit disappointed. Effect sizes [usually the difference between the test group and the control group scaled to standard deviation units] tend to be rather modest.

Here are a few examples:

You can amuse yourself by finding your own examples. There are a few things that genuinely work well. But even for things like MMR, the evidence isn’t as good as you might think.

I suspect what is going on is that medicine works, just barely, on average. You get things like the long slow decline of maternal mortality from the confluence of lots and lots of little things added together. If you look at anything else, heart disease, or cancer, you will see the same pattern. Vaccines are an exception. Disease rates for things with effective vaccines just drop off immediately.

Polio dropped right off

Polio dropped right off

Heart disease is on a long, slow decline

Heart disease is on a long, slow decline

Which brings us to my motivation for bringing this up at all. Random C. Analysis just published an updated argument that healthcare spending in the United States isn’t badly out of line with the rest of the world, once you take into account how much richer we are than just about everyone else. We have more, so we spend more. According to RCA’s data, when income goes up 1x, healthcare spending goes up 1.6x.

My contribution to this is to suggest the reason for this is we purchase more and more healthcare is precisely because it doesn’t work very well. At lot of modern medicine treats symptoms better than causes, because we don’t understand the causes very well. You buy as much symptom relief as you can afford. Even when treatments are genuinely curative, the success rates are often low. For example, the controversial statistic number needed to treat attempts to quantify how many patients need to be treated in order to produce one cure.

This number is often quite large, often on the order of 50 to 100. Even for a really good treatment with an NNT of 10, 9 times out of 10 it isn’t better than the alternative it is being compared to. That is a lot of wasted time, effort, and money.

We just don’t know how to predict the 1 time it works, so we treat everybody and hope for the best.

You can find speculation like this from Goldman Sachs that you can’t make enough money curing disease as compared to offering palliative care. I’m sure there really are businessmen who would gladly milk you for everything you are worth, but I don’t worry about in reality because no one understands how to cure most of the things that ail us. It isn’t like miracle cures are being withheld, or even that research is being directed away from cures. We don’t know enough to do that.

If we really wanted to limit costs for healthcare, it might be possible if we ruthlessly limited access to only things that really worked. We would get 80% of the benefit for 20% of the cost. But people would be pissed. The other 20% of the benefit does actually work, sometimes. I don’t think this is possible, or even really a good idea. Any real solution will involve technology we don’t currently possess.

The Long View 2002-10-02: Wellstone's Wake

It really is the conventional wisdom even now that lower turnout helps Republicans, but who now remembers that 2002 saw increased turnout in the midterms and a huge Republican victory?

This was an occasion where John praised President George W. Bush for at least having some ideas of how to govern, although he didn't seem to think much of these ideas, except that W. did seem to take national security seriously.

John was on record encouraging the Republicans to adopt some kind of universal health insurance as a party platform. Over time, I came to see that he had a point. John thought healthcare was a public good, not a public right, which makes a major difference. Good health isn't something owed to you by others, which is a right. Good health is good, and we are all better off if the health of our fellow citizens is better, but how you frame it makes a major difference.

John's point-of-view was that offering public healthcare as a "right" was a frequent trick of the despotic regimes of the world in the twentieth century to claim that they offered many "rights" to their subjects that Western democracies could not or did not. The fact that many of their people were in fact in poor health wasn't the point. After all, who could fault them for their poverty.

The point here is that political rights do not truly depend upon wealth, or at least they shouldn't. If you are going to have a trial, the right to not incriminate yourself or the right to confront your accuser can simply be part of the standard procedure. All of the pieces are already in place, you simply have to do it. Healthcare isn't like this. You need an incredible infrastructure of equipment and trained personnel to make it happen, along with a distribution network for the supplies needed. If the truck broke down, do you lose your rights?

The most obvious rejoinder to this argument would be that the rich have greater relative access to their political rights than the poor. This is correct, although one should keep in mind that access to rights in modern societies is also available to the clever and hard-working, and being rich has become very strongly correlated with those things in the modern world.

The affirmative response would be the cultures that have developed political rights in the modern sense also developed the traits that are most effective at producing economic growth. These cultures were not always the richest or the most powerful, it simply happens that the political rights developed in the same place that produced the greatest wealth, over a very long period of time. Compound interest tends to add up, if you have a culture that can avoid the economic crises that destroy savings.

Finally, while the Simpsons remain incredibly popular, the data we have is that the series was at its best in the 1990s, so John's dyspeptic comment has some empirical vindication.

Wellstone's Wake

 

To tell you the truth, I was not greatly offended by the pre-election memorial service for the late Senator Wellstone of Minnesota. That was the one that turned into a political rally at which Republican dignitaries were booed, including Wellstone's colleagues from the Senate. The family was actually being tactful when they asked that Vice President Dick Cheney not attend. Paul Wellstone had his merits, among which was a fierce-but-fair partisan temper. A wake that consisted of a rally of 20,000 Democratic activists would have been just what he wanted.

The problem was that it was not what the voters in Minnesota wanted. Had the memorial service been held three weeks before the election instead of just one, the odor of rancor would have dissipated, and the candidacy of senator-emeritus Walter Mondale would certainly have benefited from the boost that the event gave to the morale of the faithful. As it was, people voted on the basis of their exposure to real politics, rather than to the smooth marketing of a normal campaign. The irony, as more commentators than I have noted, is that the memorial rally not only won the election for the Republican, Norm Coleman, it also lost the Democrats control of the US Senate.

 

* * *

Does this really tell us anything about the state of the Democratic Party? Some people made merry at the Democrats' expense, pointing out that both of the emergency replacement candidates for Senate races in 2002 were old, very old, war horses. The short answer may be that, although Mondale lost, Frank Lautenberg won in New Jersey, beating the invincibly obscure Republican, Douglas Forrester. (As we say in New Jersey, Forrester is such a bad campaigner he could not even get indicted in this state.) Personally, I think that it is something of an asset to a party to have a supply of old geezers in the freezer, in case something goes wrong. Real morbidity is when you nominate the geezer in the first instance, as the Republicans did with Bob Dole in 1996.

The problem with the Democratic Party is that it is getting, well, wistful. We see this in the alternative universe to which so many Democrats have retreated, the NBC show The West Wing. In last night's episode, President Josiah Bartlet humiliated his stupid Republican opponent with the Southwestern accent, racking up huge gains in Congress amidst subplots about the difficulties of voter registration. Probably, when the episode was written, the producers expected that it would mark the beginning of a reconvergence of their alternative universe with the real world; hardly anyone expected the Republicans to do as well as they did last Tuesday. As it was, the show was an instance of instant nostalgia

Christian Slater put in his first appearance, by the way, as a naval officer assigned to the White House. He joins Lily Tomlin, who is now President Bartlet's lovable dragon-lady secretary. When Mr. Rogers becomes Secretary of State, we will know that the time has come for NBC to find a replacement.

 

* * *

A more serious example of the Democratic disconnect was also offered around election day, by New York Times columnist Thomas Friedman. In a strange column entitled "American Idol," Friedman describes the huge, enthusiastic reception that Bill Clinton received on his recent visit to Berlin. Friedman argues that America and Americans are not unpopular in Europe these days. Europeans continue to admire American optimism, as represented by the former president, even as they patronize it. Their dissatisfaction is confined to the grumpy old Republicans who happen to run the United States today. The Republicans, Friedman argues, are practicing just the sort of Realpolitik that the Europeans so recently outgrew, and which they therefore loathe. He implies that the way for America to endear itself to Europe is to wear a Clintonian face.

You don't have to be a Clinton-hater to suspect that there was something a little perverse about presenting Bill Clinton as the model American abroad, just as election returns were showing that the candidates lost for whom he had campaigned heavily. (Peggy Noonan called the effect "The Clinton Thud.") There really is a stratum of the Democratic Party that is best understood as a section of "transnational society" ("tranzies," for short) who will not be happy until there is some authority they can appeal to above the heads of the American voter. Such an attitude cannot be good for any democratic party (note lower case).

 

* * *

And what of the Republicans? There has long been an assumption (which I sometimes shared) that Republicans do better when turnout is lower. That was not the case with the recent elections, however. Turnout last Tuesday was about 39%, up two points from the admittedly dismal 37% of 1998, the last midterm election. The higher turnout was largely the product of a few, highly contested races. The most important of these was the reelection campaign of the president's brother, Governor Jeb Bush of Florida. The Republicans won that race, as well as most of the other high-profile races around the country. This makes it hard to argue that the Republican gains were the result of public apathy.

There is no point in getting elected if you have no ideas about governing. The elder President Bush did not understand that, but his son George W. Bush does. One may like or dislike his agenda, but he does have one, and it is far from merely symbolic. The great merit of the current Administration is that it understands that the chief focus in this era must be national security. That said, though, the Administration also needs to be cured of the illusion that the whole of fiscal policy consists of tax relief, and that the whole of tax relief is lowering the capital-gains tax. A demand-side tax cut is in order. They should talk to Senator Corzine of New Jersey; I am sure he would be happy to talk to them.

The Republicans should also reconcile themselves to the fact that some form of universal health insurance is inevitable. It can be done well or badly. If it happens under a Democratic Administration, it will be a perpetual subsidy for the psychiatric industry and for Planned Parenthood. If the Republicans do it, it can be a manageable catastrophic-illness program that will remove much of the pressure on private insurers for higher premiums. The president has only to broach the matter to deprive the Democrats of 60% of their agenda.

Then there is the matter of election reform. Living as I do in a largely Democratic state, I am keenly aware that the Electoral College is a perverse incentive. George W. Bush lost the popular vote in 2000 because, logically enough, he campaigned to win the electoral vote. This meant concentrating on lightly peopled states in the Midwest, while the Republican Party in states such as California and New Jersey were left to their own feeble devices. This neglect is hard to make up for during midterm elections. Even with the recent Republican successes, the campaigns that Republicans mounted in these voter-rich states were disheartening, to say the least.

I fully agree with the arguments against simply abolishing the Electoral College; imagine a very close race, and a national recount like the one in Florida in 2000. The solution, surely, is to tie the electoral votes to individual Congressional districts, and not to states. This preserves the many advantages of a winner-take-all system, while at the same time ensuring that the winner will have at least a plurality of the popular vote. We should fix this as soon as we can.

 

* * *

There is one venerable institution that deserves to be retired before it disgraces itself further. Did you see The Simpsons last Sunday? That was their eagerly awaited Halloween show, delayed after the holiday itself because the FOX network carried the World Series the Sunday before. It was not worth the wait. The writers repeated old jokes and scenarios, particularly in the middle story, in which do-gooder Lisa once again disarms Springfield just before an armed threat appears. Then there was the last story, a take-off on H.G. Wells's Island of Dr. Moreau. That had nothing to do with Halloween. In fact, none of the stories did; only the wrap-around story even featured a ghost. This is inexcusable, since several very good supernatural thrillers have appeared in the last year or two. The show is choking on film-school sensibility.

Surely the time has come for a final TV movie?

Copyright © 2002 by John J. Reilly


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The Reversal of the Great Risk Shift

John Reilly has an excellent post up about the recent federal health care bill.

The enactment of the new federal health-insurance system this week marks the beginning of the reversal of the Great Risk Shift that has characterized American society since the late 1970s. There is now reason to hope that American society can return to something like its historical condition, in which it was possible to change jobs and geographical location without taking your life into your hands. Wages may again be able to rise, since all new money that becomes available for personnel costs will not automatically be eaten by insurance-premium increases. More generally, the subtle loss of morale generated by a system that, for the first time in American history, made a physical necessity problematical will begin to abate, with a consequent rise in personal initiative and national cohesion.

Like Reilly, I too am sanguine about the effects of the passage of this bill, and I see it as an ultimately positive development. This may seem a little strange, because by political temperament, I ought to be bitterly opposed to this enterprise. However, John Reilly was instrumental in convincing me otherwise. He is one of the most reasonable men I know, and he exemplifies the virtue of hope, which makes for a critical difference in perspective.

Reilly has been making the argument that a reform of the health care system in the United States will be a liberation. His reasons for saying so are fundamentally conservative, which annoys pretty much everyone involved, but I believe he is on to something. He has been arguing that the current system limits our free market system by tying people to their jobs which offer good benefits, and making businesses bear the brunt of funding health care, when our foreign competitors do not need to do so. He also insists that health care is not a right, and cannot be. It is rather a matter of public order and entirely practical. Rights-talk is far too absolute to be productive.

One of the chief difficulties with the American system is its opacity. The quality of the health care is really quite good, and it is a vicious calumny to say that the uninsured have no health care in America, rather, they get all their care at the Emergency Department, which is both expensive and inefficient. The rub here is that the people who don't have insurance often wouldn't go to the doctor until they are really sick anyhow, so there is only marginal improvement to be made here. From my time working in the local hospital, I know that the truly poor often simply don't pay their medical bills, which means the service is subsidized by those of us who do pay. It would be better if we did this up front, instead of persisting in sending overdue notices to people with no means or intent to pay anything.

The pricing is the really bizarre thing. If you look at a bill for any medical service, you see a ridiculous value that is invariably cut by half or more if you have insurance, but it is nearly impossible to find out what this value is beforehand. The actual cost of medicine in the US is practically a trade secret. Billing codes are actually copyrighted by the American Medical Association, and guarded fiercely. The Magistra needed hand surgery recently, which was covered well by my excellent insurance, but we actually were unable to find out beforehand how much it would cost.

No business can run this way. Not only can you not determine the cost beforehand, the matter can take 3-6 months to be paid in full. Costs would go down in American health care if only the accounts receivable were smaller! One of the best experiences I ever had was when I went to the ED and forgot my insurance card. When I got the bill I forwarded it to my insurance company, and then I paid the negotiated price directly and got reimbursed. I carry a large savings balance, so this kind of thing is easy for me, but if this is the best to offer the system needs work.

Since I work in the medical device industry, I know that the prices that the manufacturer ultimately sells for in different countries are not all that different. The US is the single biggest medical market in the world [followed closely by Japan], but medical devices still make plenty of profit in the various and sundry health care systems in the rest of the world. I have to laugh when the claim is made that switching to some kind of national health care system in the US will inevitably stifle creativity and innovation. It is certainly possible, depending on how stupid the system is, but all medical device manufacturers compete globally, with a majority of our customers being in allegedly stifling systems already.

The pharmaceutical companies may be in a different boat. I've been of the conclusion that Big Pharma is in trouble for a while now. Actual innovation there is slim, most recent drugs seem to have worse side effects than the things they treat, and R&D costs are ridiculous for new drugs. Don't mistake me, R&D on a medical device can easily cost hundreds of millions of dollars, but I think the results are actually better, and you don't have to worry about generics stealing your market once the patent runs out.

There is a lot of room for cost-improvement in the American health care system, but the really interesting thing is that this political development will not result in creeping socialism, but rather presages the return of a more traditional society. The Age of Autonomy, and both right- and left-libertarianism is ending.