Good Journalist Hunting, Part 2: Drugs, Sex, and American Healthcare

Background

In Part 1, I conveyed my experience in Target Corporation's stockroom to explain Amazon and Costco's success and said I'd discuss insurance companies and opioids in a subsequent post. 

The War on Drugs Results from Government's Desire to Monopolize Revenue Streams

Fewer than 0.06% of Americans between 15 and 64 years died from any kind of drug overdose in 2017. Why, then, are U.S. politicians so enamored with the drug war and opioids in particular? 

If you're a Chris Rock fan, you already know the answer. 

We got a horrible drug policy... The government always says drugs are illegal because they're bad for you and they're trying to protect society... [but] the government doesn't [care] about your safety... They don't want you to use your drugs, they want you to use their drugs... So every night, you see a drug commercial... trying to get you hooked on legal [stuff]... 

The reason cocaine and weed are illegal in America [has nothing] to do with your safety. The reason cocaine and weed are illegal in America is because the best cocaine and weed aren't made in America. If they made the good [stuff] here, there'd be a "Cocaine and Weed" restaurant on every corner [like Starbucks]... The government will never legalize drugs in America... because the government makes way too much money putting [black people] in jail. [Never Scared (2004)]

What you may not realize, however, is why the government is so keen to protect its own pharma revenue stream. 

Simply put, it costs a lot of money to develop new drugs. According to Bill Bryson in The Body (2019), on average, a billion dollars invested will get you one-third of a new drug, not even a complete one. 

Innovation within such a front-loaded system generally means only "Big Pharma" can participate, and research focuses on chronic illnesses like cancer and mental health issues--not life-saving new antibiotics, which work too quickly to generate recurring revenue. [Andrew Lo's Adaptive Markets (2017) proposes better ways of funding pharma R&D, but his ideas haven't caught on.]

America's funding paradigm incentivizes unnecessary diagnoses of mental health issues, autism, and other long-term conditions; worse yet, attaching the imprimatur of science to greed reduces the credibility of experts as well as academics.

Let's talk about how I found myself in a psychiatrist's office playing word association games at a rate of 300 to 400 dollars per hour. I've had weak ankles since a teenager, and after another swollen twist, I mentioned my despondence. My doctor, hearing Pavlovian bells of negligence, asked if I wanted to be referred to a psychiatrist. Having more free time due to an inability to play basketball, I agreed. Under the ACA, each state may create its own "competitive" marketplace, and mine is called "Covered California." Members can choose from platinum, gold, silver, or bronze plans, but the older you are, the more prohibitive the costs of anything above bare-bones bronze. In the beginning, insurers tried excluding mental health coverage to offer better cost-benefit propositions or more than de facto catastrophic coverage.   

Unfortunately, California's state legislature nixed the mental health and substance abuse opt-out, which it could do because once again, states dictate the terms and conditions of insurance coverage on state exchanges, not the federal government. (Incredibly, inclusive mental health coverage is more common than useful dental coverage, a distortion caused by pharma R&D costs being subsidized through insurance reimbursements, plus government's intent to delegate mental health and addiction issues to Big Pharma and religious entities rather than asylums, prisons, or clinics.)

Had insurance companies capped physical rehabilitation treatments to twice per month or not covered epidurals during childbirth, governmental intervention would be welcomed, but almost all medical coverage categories are general, figuring doctors should determine treatment, not legislators. Here, national legislators devised a healthcare program covering all Americans at reasonable prices, only to see courts and state legislators whack insurer flexibility and federal enforcement, thus reducing cost-effective options and oversight. 

A dysfunctional dynamic within government increases complexity and the likelihood of divided realities, especially when few Americans understand the law; conveniently, such ignorance leads voters to blame faraway Congress instead of nearby state and local politicians.

I believe that today, the average person is overwhelmed by the complexity of life because it got more complicated... I barely know an adult who isn’t on some kind of drug, either prescribed or otherwise, to deal with anxiety. -- Scott Adams, on "digital disease" (2018)

The general population doesn't know what's happening, and it doesn't even know that it doesn't know. One result is a kind of alienation from institutions. People feel that nothing works for them. -- Noam Chomsky (1993)

Yet, both sides, even their extremists, reflect one of three crystal-clear images: 

1) frustration with well-intentioned government programs no longer resembling their original conception as they trickle down to local levels and multiple special interests; and 

2) a sincere belief that more centralized (aka national) governance will reduce multi-layered bureaucracy as well as local resistance to implementation and change; or

3) a sincere belief less government and a more direct relationship between buyer and recipient will improve accountability.

All three choices are correct and also equally wrong. Whether a program works depends on the individuals administering it and incentives for questioning orthodoxy, not whether the program is corporate or governmental. It may be true some governments are inept at hiring, but so are many corporations (e.g., Enron, WeWork, Theranos, and Wirecard). If multi-national corporations have an advantage, it is mainly because they can hire non-citizens, meaning their talent pool is not only global, but able to gauge workers' skills at lower wages before bringing them onshore. (Government unions, especially teachers and police, don't help, but that's another matter.) 

Additionally, the lines demarcating private and public healthcare are often so blurry, they cannot be found. Take the Covered California website. It's possible the state created the website itself or the contractor who won the RFP (by bidding the lowest) hired only American citizens or onshore workers, but once up, de-bugging and security likely went offshore. Either way, I had to visit a private benefits office in person to show identification, because the state's website refused to accept my license or passport uploads. (Side note: economic data is easily manipulated; for instance, if the government's deficiencies create private sector "clean up" jobs, such jobs are given the same weight as meaningful jobs in the unemployment numbers.) 

Once registered and referred by my primary care physician to a psychiatrist, I drove to a private office complex, walked upstairs to a private office, waited about 10 minutes, and was shown into a lightly furnished room. The psychiatrist asked me a few questions, then began a modified version of the Rorschach test, where he displayed words on index cards and prompted for associations. If he showed you the word, "police," you could say "blue" or "Black Lives Matter" or "law" and so forth. After about 30 minutes of this ridiculous game, he decided I was bipolar and prescribed lithium and follow-up sessions. If I remember correctly, I attended two more sessions, which were similar, then stopped. The sessions, which my insurance paid, cost about 1,000 dollars. No solo practitioner in the legal field could ever get away with such lucrative billing for similar levels of work, but most independent lawyers do not have an insurance company paying their bills. The lesson? Insurance coverage raises prices with no guarantee of competent service, regardless of whether governmental or private actors are involved. Furthermore, inserting a third party between buyers and sellers increases risks of corruption, especially if the category of reimbursable services is ambiguous. 

Governments Must Be Allowed to Successfully Compete against Mafia Influence

Besides insurance, why are legal drugs and the process for obtaining them so expensive? First, you have to understand why governments exist. Government's primary function is to create, whether directly or indirectly, better alternatives to the informal economy while allowing reasonable inflation. Without inflation, debt becomes exquisitely burdensome for borrowers; and without debt, most legitimate businesses could not have been created or could not have survived economic cycles. (Amazon and Walmart are turning economic theories on their head, but both are inherently multi-faceted and trans-national, meaning they can accept lower profit margins and pass along cost savings by targeting billions of global buyers and sellers.) When considering the billions of dollars of banking loans to major pharma corporations, every illegal drug deal harms the flywheel of pharma R&D by reducing insurance reimbursements as well as healthcare premiums, making it harder for operators to pay back debt or to set up new labs at hospitals, university research facilities, or Merck and Co. headquarters. 

Now imagine an empty lot fifty miles from your house. 

From Sabrina (1954): 

Linus Larrabee: What’s money got to do with it? If making money were all there were to business, it'd hardly be worthwhile going to the office. Money is a by-product. 

David: What’s the main objective? Power? 

Linus: Agh! That’s become a dirty word. 

David: Well then, what’s the urge? You’re going into plastics now. What will that prove? 

Linus: Prove? Nothing much. A new product has been found, something of use to the world. So, a new industry moves into an undeveloped area. Factories go up, machines are brought in, a harbor is dug and you’re in business. It’s purely coincidental of course that people who've never seen a dime before suddenly have a dollar. And barefooted kids wear shoes and have their teeth fixed and their faces washed. What’s wrong with a kind of an urge that gives people libraries, hospitals, baseball diamonds and movies on a Saturday night?

If the mafia buys the lot instead of a mall, office, or factory developer, the city will not only receive less tax revenue, but will likely see its police force outgunned and outwitted, making neighborhoods less attractive to families and PhDs. More importantly, a mafia-influenced city--where violence exacts efficient payment and coercion--attracts different kinds of businesses and thus unreliable accounting as well as diminished transparency. Whereas most businesses seek to grow through superior service or products, the mafia grows as a way to evade taxation and to launder money.

In the EU, where the "Las Vegas" development model is being used to incentivize legitimacy, several blocks in Eastern Europe (aka former Soviet Union) have more dim-lighted casinos, wagering rooms, and upscale bars than Starbucks and McDonald's. In the United States, after "obscenity" charges became passé, content-neutral "time, manner, and place" restrictions required strip clubs, night clubs, hookah lounges, and other drug dealer hangouts to be away from schools, suburban moms, and anyone else with an 11 o'clock bedtime. 

Despite attempts at reasonable regulation, our ever-increasing levels of police funding and mafia growth--both of which reduce fertile ground otherwise able to foster economic diversity--indicate the balance of regulation has failed. 

Lawyers, Judges, Police, Politicians, and Teachers Have Used Governmental Influence to Create Jobs but not Meaningful Economic Alternatives, Allowing Mafias and Nepotism to Prosper 

Somehow, laws designed to give politicians and police greater ability to shape communities have caused the mafia and informal economic actors to become more respected. Such a result is only possible if government has misused its powers to create an antiseptic or equivalent existence, rendering the mafia the more interesting one. This anti-hero script explains the tragedy of Western governments, which have delegated social services to religious institutions, especially the Catholic Church; divided themselves by litmus tests of abortion and death penalty rights; and promoted separate and unequal compensation and disciplinary terms favoring existing employees and fellow churchgoers, with the occasional minority highlighted to mislead taxpayers, results be damned. 

In 2008-09 California’s [government] teachers were predominantly white (70.1%) and female (72.4%), quite a different look from the student population that was 51.4% male and had major ethnic categories of 49.0% Hispanic, 27.9% white, 8.4% Asian, and 7.3% African-American.

Setting aside global tax reform, you'd think a decent education would be the antidote, and it's not as if American K-12 education lacks money--the California teachers' pension fund alone has 242 billion dollars--so the absence of an informed public must be attributed to journalistic abdication and institutional corruption. 

In fact, American education is so terrible at producing competent voters, few adults realize state constitutions exist or that only governmental activity falls under the 1st Amendment. 

The Free Speech Clause prohibits only governmental abridgment of speech. The Free Speech Clause does not prohibit private abridgment of speech. - Supreme Court Justice Gorsuch, Manhattan Community Access Corp. v. Halleck (2019)

(I count myself as one of America's neglected--when I graduated law school, I didn't know about state constitutions, which typically extend rights beyond the federal Constitution, or even the location of the local courthouse.) 

In Western countries where governments haven't ceded education and social welfare to the Catholic Church and other "nonprofits," they, too, have failed to create the appropriate balance between regulation and opportunity. For example, according to journalist Stig Abell, Britain's NHS is the "fifth largest employer in the world." Mr. Abell's pride in his country's subsidized healthcare system excludes important details: when the NHS was created, research assumed shorter lifespans for most citizens, as well as higher birthrates to support tax transfers into a national healthcare system. If America has a military-industrial complex, then Britain has a healthcare-and-pension complex, and both require so much debt to occupy their economic spaces, efficiency and accountability by any means necessary look increasingly attractive to voters. (Meanwhile, if one enters a mafia-owned strip club or massage parlour and pays cash, one can usually get service without queuing or being assigned to a waiting list.) 

And so, however one looks at Western healthcare and secondary education, failure looms, and exceedingly complex failures are exactly why most Western politicians can focus on opioids and other outliers without fearing logical retort or upsetting the status quo. Worst of all, the honest politician who tries to re-enact Mr. Smith Goes to Washington (1939) on the local level must contend with other cities and states of lesser moral fiber capturing lobbying and other dollars on the sound principle that if they do not accept inertia's largess, someone of even lesser moral fiber will. Given such circumstances, one can be forgiven for elevating a mafia don or high-level confidential informant above a politician or lawyer who makes promises s/he cannot keep without becoming a banker's whore. 

The creatures outside looked from pig to man, and from man to pig, and from pig to man again; but already it was impossible to say which was which. -- George Orwell, Animal Farm (1945) 

The Path of Least Resistance

Now that you better understand the miasmatic cauldron of corruption and general depravity through the lessons of Western drugs, healthcare, and education, you can vote more responsibly. Will your heightened civics knowledge make a difference when the only consistently good Western politicians are Scotland's retired Gordon Brown, Australia's retired Paul Keating, and Czechia's dead Vaclav Havel? Probably not, but democratic governments were never meant to be better than the citizens within them. In fact, though democracies tend be more transparent, transparency combined with complexity spanning multiple levels of governance is no guarantee of clarity. Thus, despite much progress, we have returned to where we were centuries ago, mucking about, unclear which direction to go, side-eying our neighbors, and praying a pandemic doesn't wipe us out. If this be progress, I'll take the whore, and you can keep the teachers, priests, politicians, lawyers, and made men. 

© Matthew Mehdi Rafat (2020) 

"Men will never be free until the last king is strangled with the entrails of the last Catholic priest." - attributed to Denis Diderot

Bonus: as Adam Gopnik, New Yorker (2017) explains, John F. Pfaff makes reasonable counterarguments regarding Chris Rock's statements above: 

"During the great wave of incarceration—generally thought to have begun around 1980, and cresting about three decades later—state prisons added something like a million inmates, with about “half that growth coming from locking up more people convicted of violence,” Pfaff calculates. Nonviolent drug offenses accounted for only around a fifth of the new incarcerations... [Emphasis mine.] 

So what makes for the madness of American incarceration? If it isn’t crazy drug laws or outrageous sentences or profit-seeking prison keepers, what is it? Pfaff has a simple explanation: it’s prosecutors. They are political creatures, who get political rewards for locking people up and almost unlimited power to do it." 

Bonus: Good Journalist Hunting, Part 1 is HERE. Part 3 is HERE. 

American Hubris, or Why Revolutions Usually Focus on the Educated Classes

In America, the two federal legislative bodies are trying to reform a healthcare bill passed by a previous administration. The old bill increased premiums, especially for younger people, and didn't sign up as many people as expected in some states.

I'm seeing a lot of Americans encouraging people to vote on the healthcare bill who don't realize the terms are not yet final. The CBO report--issued by a nonpartisan government agency--relied upon by the media addresses the last version of the bill, not the latest negotiations.

In response to the CBO report, Congress is attempting to resolve inconsistencies between the House and Senate bills. The House bill received more support from the CBO, causing the Senate to revise its own version. If someone tells you to vote "No" on the healthcare bill as of July 7, 2017, s/he is missing the key point: there is nothing final to vote on.

Too many Americans have the hubris to encourage others to vote a particular way without knowing the facts, which is a pattern among modern-day Americans with high levels of education: they like to encourage supportive acts that make themselves feel good, but without any substantive understanding of the issues. Such hubris has torn the country apart and allowed Trump to flourish.

When choosing between a team that thinks it knows enough about healthcare to encourage voting a particular way on a bill that hasn't even been finalized, and a team actually trying to reduce long-term healthcare costs--which sap resources from younger generations--it doesn't take a Ph.D to figure out which side makes more sense.

Bonus: Nothing prevents states from raising taxes, borrowing money, or taking other actions to make up any shortfall in federal healthcare funding. For example, if Medicaid was completely eliminated, California has Medi-Cal and would still be able to provide any service currently subsidized by the federal gov. States want unlimited or ever-increasing funds from the federal government, a paradigm that masks the true costs of gov programs; keeps taxes artificially low; causes national security risks by putting future generations in debt to foreign creditors; reduces state and local gov flexibility by increasing dependency on the federal gov; and reduces accountability. 

Healthcare in America: Symptom of Overall Decline

I just ordered a new hearing aid. I bought it from the same entity I pay health insurance to. Hospitals may be non-profit or for-profit, but the label isn't very helpful because any entity with salaries and overhead must focus on getting money or go bankrupt.

Americans are confused about "for-profit vs. non-profit" because they're not used to seeing actual sticker prices for healthcare services and because insurance has allowed diffusing ever-escalating costs. Such a system works only if more people are added to the same insurance pool each year, which gets trickier if true competition exists. 

On paper, a for-profit entity has more incentives than a non-profit to be efficient and better at preventative medicine, thereby lowering long-term costs. Yet, even that basic premise is questionable if a non-profit has leadership that rewards employees for efficiency and reducing the number of unnecessary third-party tests. The trick is getting the balance between efficiency and customer service right.

Why do other countries seem to handle healthcare better? Reasons might be counterintuitive or simple. For example, they could be dealing with a population that drives less because of better public transportation, which increases daily walking time and therefore decreases heart disease rates. Maybe people are less stressed because they have less debt or more free time. Perhaps fewer people engage in excessive drinking or prefer wine to beer. (Even the "wine vs. beer" factor requires more analysis because the main difference might be that most wine is more expensive than most beer, encouraging less consumption and therefore fewer negative health effects.) Is the climate extremely hot, encouraging more showers and therefore more cleanliness, reducing disease transmission? Or does a hotter climate make it harder to walk more, increasing health risks? 

The more we analyze complex problems, the more it becomes obvious that nothing can be fixed on a national level in any large country, and one reason smaller countries like Singapore are so successful is because they are smaller and can act locally and more quickly when problems arise. (Note: "democracy" isn't necessarily the answer to anything once you realize any system that encourages local solutions, accountability, and more humility works.)

Back to my hearing aid purchase. I've been severely hearing-impaired since birth. American health insurance doesn't fully cover hearing aids, even if medically necessary. Also, tax write-offs require such a high level of medical expenses, almost no one actually qualifies. (Meanwhile, a dollar spent on advertising creates an automatic, above-the-line deduction--the best kind of tax break.) I will be paying 1200 USD out-of-pocket for the most basic Oticon aid, labeled as "entry" level. I probably need two more functional aids costing 2600 USD each, but I tend to spend a lot of time alone (cue the chicken or the egg debate), and I'd rather use my money for more pleasurable experiences like eating out or even giving it to a friend who can pay off high-interest consumer debt.

Why do I share my experience with you? I want you to get a sense of why American healthcare is so problematic and why labels like "single payer" or "for-profit" don't help. When I made the appointment to purchase the new aid, I already had the benefit of a previous visit, where the audiologist explained the different options and price points to me. I was given a standard half-an-hour appointment, but I saw the system scheduled the next patient in 20 minutes, creating an incentive to minimize the time spent with me.

Not knowing about the 20 minute scheduling until my follow-up visit, I brought another aid I use as a back-up, which needed a simple tubing replacement. The audiologist looked at it and told me it's not common for Kaiser to work on an aid not purchased through its own service. She turned the aid over a few times and finally left for three minutes and returned with a tube.

A tube is just a piece of plastic attaching the earmold to the electronic aid that goes behind the ear, but if the five cent piece of plastic isn't replaced regularly, the expensive aid won't work optimally. Before Kaiser, I had a private audiologist, and it was standard procedure to clean or replace the tubing if requested. Unlike Kaiser, the private audiologist doesn't get an automatic stream of customers referred from the overall insurance pool, so it has incentives to treat customers well. It is a for-profit entity, while Kaiser Permanente is one of the nation's largest non-profit health plans. Before I go further, I want to say I like Kaiser. It has an integrated-care model, which is the future of healthcare--if we get it right.

Interestingly, the audiologist told me Kaiser's hearing aid unit was "for profit." I'm not a tax lawyer, and the idea of a non-profit entity with a for-profit subsidiary sounds odd, but it's possible the audiologist isn't a tax expert and mis-spoke. Later, I realized the audiologist's use of "for profit" might have been a way to subtly get out of performing a basic medical service. If you only have 20 minutes a patient, and if you don't need to attract new patients because they're part of an existing insurance network, why do extra work? What is the incentive to treat the patient as a whole person, regardless of whether your corporate structure is for-profit or non-profit?

Such problems aren't unique to healthcare. Even mid-sized law firms now require associates to charge 10 or 20 cents per copy, limiting copy machine use by requiring an electronic client billing code. In the past, firms would also charge an inflated flat rate to send faxes. As you might suspect, the incentive to nickel-and-dime clients in a for-profit system is high, which leads many people to advocate a non-profit system where the culture can, in theory, focus on seeing the person as a whole human being. Yet, here I was, in a non-profit entity, and the incentives clearly discouraged an audiologist from assisting me in a simple way. The lesson? Tax structures don't tell you anything about employees or their dedication. They don't tell you whether the employee is burned out or if she feels like a meaningless cog. They don't tell you if the employee wants to help you but is constrained by policies discouraging common sense.

A for-profit system might be better if it attracts the most ambitious, hard-working employees, especially if a non-profit system pays less or attracts burned-out employees. Indeed, even a non-profit system must manage patients efficiently, and software now handles day-to-day operations for most large entities, restricting flexibility and personal initiative. 

Remember going to a doctor's office and waiting for 20 to 30 minutes after your appointment time? What if that inefficiency allowed the doctor to listen to patients more and give everyone the benefit of more personal service? What if technology has sacrificed our ability to feel useful and to take care of people in ways that build lasting relationships? What if tolerating technological advances that limit personal flexibility but increase efficiency has seeped into other parts of American culture, limiting our ability to think long-term?

I don't know the answers to the above questions, but removing personal discretion from employees and increasing hurdles to long-term customer relationships aren't the solutions. To be fair, the audiologist did give me extra options that answered other questions I had. However, by the time she showed me a catalog with useful add-ons, I didn't know if she was genuinely trying to help me, or if she had a sales quota. 

Dealing with American healthcare is enough to make a diehard capitalist into a committed socialist. That should scare us all. 

Bonus: "Despite all the false positivity, I find Americans to be generally the most stressed out and unhappiest people on the planet. Despite all the resources, and all the money they have, they are sadder than people I know who can barely make ends meet in other countries, but still know how to live in the moment." -- Benny Lewis 

Debate on Health and Healthcare

Status Update from Lawyer/Solo Practitioner: Eff you, Kaiser. I'm not paying $352 a month for health insurance in 2011. I don't smoke, I exercise, I'm not involved in any risky activities, and I avoid liquor. You people saw me about five times in 2010 and don't even provide me with my hearing aids or dental work. Does anyone have any advice for other health insurance options?

P.S. The biggest long-term medical expenditures will be on Medicare. Do you see what I mean when I say that current American society is financially stealing from the young to benefit the old? Do you really expect us to continue to be the world's superpower when we spend ever-increasing resources--already about 50% of federal tax revenues--on senior citizens? Money is finite. One dollar spent on senior citizens--who've had their chance to save money, have families, and buy homes--is a dollar not spent on the young, who have yet to have families, buy homes, and utilize compound interest.

Rob: Do you drive a car?

Lawyer: Yes, and I have the med pay option on my car insurance.

Older people drive, too. Why not let them pay a higher share of overall insurance costs, given that they've had an additional 30 years to save up for it and have also benefited from the real estate boom--unlike most people under 35 years old? Americans don't understand that the real threat against our way of life isn't Al Qaeda, Iran, or Iraq--it's older people and government workers voting in benefits for themselves at the expense of the young and unborn.

Trent: I have great insurance. Don't use it..have a DR/Hospital phobia. Only go if injured.

Laura: I feel ur pain. I was looking to switch from Anthem BC to Kaiser but rates at Kaiser were slightly higher..

Roger: Start smoking and drinking and engaging in risky activities.

Mary: I've got to point out that I'm certain there are plenty of elderly Republicans reaping the healthcare benefits for which you hold all Democrats responsible.

Lawyer: yes, but the GOP is trying to cut universal healthcare coverage while the Dems passed it, which has caused my premiums to increase drastically over the past three years. I will now have to get a reduced benefit health insurance plan b/c of the Dems. You want me to give them a medal for passing lame, watered-down, insurance-company-friendly legislation? I'd rather cut programs Tea-Party-style if it means I save money.

BTW, isn't it lovely being in a union, where taxpayers like me pay for fed, state, and local gov employees' benefits even as our own costs increase? Ah, those Dems--looking out for their unions. You want me to support a party that doesn't care about small businesses, young people, families, or inflation? I'll take the war-loving whack-jobs over the alternative, b/c the GOP has promised to cut spending and government programs. And Obama's pay freeze on federal gov workers doesn't go far enough--he should have cut salaries by 15% for anyone making more than 75K/year, including himself.

Mary: Oh, and we opened up 3 [police] dispatcher positions today. Check out the CalOpps link on my page, I encourage you to apply.

Lawyer: Re: dispatcher positions, so the government is expanding while the private sector and consumer spending is declining? This will totally work...as long as the laws of economics and math don't apply.

Mary: we aren't expanding. We are perpetually shortstaffed. As a matter of fact, I'm finishing up day 2 of 6, with a 68 hour workweek. For lack of a more appropriate term, I am dog arsed tired... So please, apply, and encourage others to also. I'd love to have my weekends...in all seriousness. I'm thankful for job security, but this still is no cakewalk. :-(

Lawyer: no well-paying job's a cakewalk. If we keep inflation under control, have a balanced budget, and stop relying on accounting gimmicks and constant bond issues, we can hire more gov workers. The private sector is getting more squeezed than the public sector--I've never seen so many hi-tech working so hard b/c of job cuts. Many engineers I know are working 19 hour days...with no job security, pensions, or lifetime medical benefits. The real problem is that so much of our taxes are going into the pockets of retired gov workers, which leaves your department with less money to hire workers now. Why can't more people see this simple fact? Public pensions cost current jobs and are unaffordable during a recession.

Also, if the private sector economy improves, the issue of gov benefits will not be at the forefront of budget discussions. Thus, the best thing gov workers can do is help the private sector get back on its feet.

Until just recently, the Dems controlled Congress for the last four years. All I see is my costs going up and my income getting more and more unstable. In fact, I've begun representing more gov and union employees now than ever before. It's scary to think that I am getting fewer calls from private sector workers because they just aren't enough of them working anymore, and the ones who have jobs are probably not willing to rock the boat under any circumstances. Sigh.

Mary: I credit divorce :-)

Lawyer: It's all a big mess, isn't it?

Mary: So in a way we are paying your salary too then?....

Lawyer: yes, except it's completely voluntary, and if I don't perform well or provide a service better than my competition, I don't get paid. Also, my services create no long term, unpredictable costs to taxpayers, and my fees are negotiable. Oh, and I have no job security or guaranteed income stream from taxpayers. So yes, to an uninformed person, it's exactly the same thing :-)

In the gov world, if you're incompetent or if they don't like you, they tend to reduce your duties and stick you in a corner somewhere until you retire. In the real world, if you don't perform, you get fired, and I might be able to get you a severance package, perhaps between three and twelve months. (It's usually easier to get a severance if you see a lawyer before you get fired, BTW.) Unlike the gov, the effects of a bad employee in the private sector are finite and definite.

Mary: I will absolutely agree with you in that sense. It is infuriating and a slap in the face to all of us that DO come to work and give our jobs and the public our all when we see substandard employees retained and given the same pay.

FWIW, the union really doesn't do everything in the best interest of even its members. I'm fighting what seems an uphill battle on right vs wrong, negligent retention and nepotism...not to mention favoritism and inappropriate relations among ranks. The union's stance is, "well let's see how it pans out." Um, for the $1,000 I pay you each year in membership fees alone, that answer isn't gonna fly! So I applied for the job in question when it opened...my interview was yesterday.

Lawyer: Some unions do a great job protecting their workers, but some are terrible when it comes to protecting the rank and file, especially in some California county hospitals. That's why some union members come to me for advice, even though their union should be the one assisting them. (Hey union reps, you might want to return a phone call once in a while and keep your members appraised of deadlines, including the deadlines to file grievances. I'm just sayin'.)

British Citizen: I love the NHS [national healthcare system in the U.K., which is free for British citizens.]

Rick: I cannot believe I'm attempting to defend Obama, but blaming Obama and fed govt employees for the high cost of your crappy health insurance is just silly and childish. Let me get this right; G.W. Bush and the Republican policies (dragging our troops into Iraq costing us billions of dollars a year, deregulating banks and insurance companies allowing multi billion dollar profits for those companies and their CEOs at the peril of poor and middle class Americans, and more...) took this country into the worst recession in our history since the Great Depression. Now, Obama has been trying to get the country out of recession, stabilize our economy, and yet help millions of Americans who lack any type of health insurance (a very sad condition for any civilized country) and regulate those greedy bank executives. There are many wealthy corporate executives, including the ones at insurance cos, that see their corrupt money-making ways endangered, hence are raising the cost of your less than adequate health insurance to compensate for it. If there are blames to go around, it should be directed to greedy and corrupt corporate executives and their lobbyists and Republican policies, not federal govt employees and the new Health Care law.

Lawyer: it's perfectly consistent to criticize Bush II and also increased healthcare costs. My comments were directed at Congress, which has been in Democratic hands for the last four years. Bush II was a moron, but like any American president, he doesn't have much control over domestic spending. Outside of of a war situation, an American president is just the mouthpiece for his party, especially if his or her party controls Congress.

I don't think the Dems realized that insurance companies would jack up policy premiums so quickly. And I still don't see any plan on their side to deal with the increased premiums.

[Speaking of unfinished business, we also need better financial regulation--we still have not solved the "too big to fail" problem, which is actually worse than before (all the big banks got even bigger).]

With respect to health care, I remember our president saying that the expanded coverage would be paid for by cutting the fat from programs internally, especially Medicare. I supported that and continue to support anything that will cut long term, unpredictable fiscal obligations. I never heard our president say anything about me paying 10 to 15% increased premiums each year for the past three years.

I recently got a pain in a tooth. I have no dental coverage, b/c individual dental coverage plans are generally worthless. (There aren't enough individuals buying dental insurance to make the plans beneficial or worthy of consideration.) I am going to India soon. I am not sure if I should wait to go to India and get dental care there on my vacation, or just pay up here. I am going to take Advil and see what happens in the meantime. It's a bit astounding to me how our country talks so much about small businesses and entrepreneurs and yet does nothing to assist us except when it comes to retirement plans (like individual 401ks, SEPs, etc).

Rick: I completely share your sentiment re rising cost and lower quality of health and dental insurance. Our president and the Congress need to address the outrageous cost of living, including dental and health insurance costs. It's incredible that US corporations are making record breaking profits while unemployment rate and cost of living continue to rise, and the average American is hurting. And then, there are elected politicians who argue less govt and more tax breaks for the wealthy. Meanwhile our country stands in a mountain full of debt which if not properly addressed will break our back. But hey let's give the wealthy more tax breaks so they can enjoy their yachts, luxury cars, and Tiffany & Co jewels, because the rich can stimulate the economy better than average Americans. And let's deregulate big banks, insurance companies and other large corporations and let them make more profits for their executives while they treat their employees like slaves...advantages of smaller government and less regulations.

Lawyer: this post was never about "smaller government," which is a different discussion. My post was about a poorly conceived healthcare law that has caused my premiums to increase 10 to 15% annually over the last three years, when the Democrats controlled Congress. The Dems passed a healthcare law that was supposed to be paid by cutting spending, not increasing premiums. They apparently did not anticipate insurance companies increasing premiums quickly or did not pass a healthcare law properly drafted to protect the young and middle class.

Insurance companies are a necessary evil that keep healthcare costs in check. Without them, our long-term healthcare costs would be even higher. We ought to have better procedures for contesting denials of care and reimbursement, but we shouldn't lose sight of the fact that insurance companies prevent healthcare costs from spiraling out of control.

Democrats like to joke that Republicans want older people to die quickly, and the GOP talks about rationing and death panels, but no one is questioning the wisdom of paying billions of dollars annually to give grandma and grandpa an additional 6 months of life and all the morphine they want. How did healthcare costs increase so much in 30 years? Is it b/c we used to let older people and people with terminal illnesses die comfortably instead of doing everything we could to prolong their last six months of life? How did Americans survive 30 years ago without Xanax, Prozac, etc.? Are we a more healthy society than we were 30 years ago?

The medical doctor who helped draft the original healthcare bill knew that healthcare expenses during the last six months of a patient's life were outrageous and needed to be reduced. In other words, the Democrats did in fact try to pass a law rationing medical care, which would have been a significant achievement. But insurance and drug companies quickly realized that the original bill would cut their profits and watered down the legislation using GOP scare tactics of "death panels." Now, instead of paying for universal coverage via spending cuts, people like me, you, your children, and the middle class will be paying for it. And it's b/c Americans were too naive to understand that rationing over the last six months of a patient's life is necessary to control healthcare costs.

Rick: I agree with end result of your proposal, but the way to get there should be better articulated than to cut govt employee salaries or reduce the size of govt agencies. Now, if studies prove wasteful spending in certain areas of govt, then yes they should be cut off. Govt should be here to protect the citizens not to waste their tax money.

Matt Miller on Heathcare

Matt Miller on healthcare, from The Commonwealth (June 2009, p. 16):

General Motors famously spends more on health care than it does on steel. And Starbucks spends more on health care than it does on coffee. [Nice margins on coffee, eh?] Workers are left in a situation where, because of the nature of employment and benefits being tied [together], we've got 50 million uninsured and maybe 30 million additional folks [underinsured] in tremendous anxiety. It doesn't work anymore.

According to the same speech, in 1960, healthcare cost 5% of GDP. Now it costs 20%. Did we get completely out of shape in just 49 years? If so, the short time frame indicates no permanent difference, meaning we may be able to change our habits and return to a healthier society. I suspect, however, that the real problem is the way healthcare companies, including hospitals, get paid by insurance companies.

When I was in college, I remember going into the ER for some stomach and head pain--I had slept for about 21 hours in a row and was feeling terrible and nauseous. I'd never slept that long before, and I was afraid something had happened (and no, I did not drink the night before--I have never really liked alcohol because I like sweet drinks, and I hadn't discovered Drambuie yet). An ER doctor checked me out for five minutes and saw nothing wrong. Since I was already there, I asked him to check out a small growth on my calf. The doctor looked at it for five seconds and declared there was nothing serious.

As a student, I was still covered under my dad's health insurance policy, but it refused to pay the bill--the insurance company said my nausea and weariness were not true emergencies, and therefore I should not have gone to the ER. The insurance company said I should have waited until Monday to see my regular doctor, but I didn't have a regular doctor in my college town--I was a freshman, and I rarely went to a primary care physician anyway.

I got the bill from the hospital and was able to see the full charges. In addition to the normal ER fee (which is normally quite high), the doctor had charged me around 200 dollars for the five seconds it took him to check my leg. That's right--the doctor had classified my simple question as a completely new healthcare issue. Even lawyers have to account for their time, so they can't charge outrageous amounts for five seconds of work. I don't want doctors to account for every six minutes of their time, but the current system is too easily manipulated. When I received that separate charge for around 200 dollars--a princely sum for a college student back in the mid-90's--I knew there was something morbidly wrong with the American healthcare system.

There is a happy ending, if my memory serves me correctly. My mom called my dad's insurance company day after day, and I believe it finally paid the bill. I wonder what people do if they don't have a determined person who can call and argue a bill over and over. As a full-time college student, there was no way I could have paid that bill. And what's the point of having health insurance if you can't go to the doctor when you're feeling absolutely horrible and terrified about about a brand-new, sudden problem?

In any case, if you believe healthcare companies won't be forced to change their inefficient ways under an Obama administration, you may want to consider Vanguard Health Care Fund ((VGHCX) and the Vanguard Healthcare ETF (VHT).

Disclosure: as of June 29, 2009, I have no positions in any funds mentioned above.

Universal Healthcare--A Different Perspective

Zeke Emanuel, Chair, Dept of Bioethics, NIJ Clinical Center, came up with a plausible solution to the health care crisis in this month's Commonwealth Club Magazine (page 43, March 2009). I don't have a link to share, but the title of the article is, "Scrapping the System." Mr. Emanuel has a book, Healthcare, Guaranteed.

Bonus: Of course, there's a blog: http://www.healthcareguaranteed.org/blog.cfm

Ronald Reagan on Libertarianism

If you analyze it I believe the very heart and soul of conservatism is libertarianism. I think conservatism is really a misnomer just as liberalism is a misnomer for the liberals — if we were back in the days of the Revolution, so-called conservatives today would be the Liberals and the liberals would be the Tories. The basis of conservatism is a desire for less government interference or less centralized authority or more individual freedom and this is a pretty general description also of what libertarianism is. Now, I can’t say that I will agree with all the things that the present group who call themselves Libertarians in the sense of a party say, because I think that like in any political movement there are shades, and there are libertarians who are almost over at the point of wanting no government at all or anarchy.

From Interview with President Reagan, published in Reason July 1975

http://en.wikiquote.org/wiki/Ronald_Reagan

One of the American public's worst misconceptions is that libertarianism calls for no laws. As I explained in my review of Milton Friedman's Capitalism and Freedom, Mr. Friedman himself stated the need for government: "The existence of a free market does not of course eliminate the need for government. On the contrary, government is essential both as a forum for determining the 'rules of the game' and as an umpire to interpret and enforce the rules decided on." See

http://willworkforjustice.blogspot.com/2007/08/capitalism-and-freedom-by-milton.html

Thus, anyone who states that libertarianism means anarchy or no laws is incorrect. Libertarianism merely means that you agree that interference with your ability to lead your life as you see fit--assuming your actions do not interfere with others' freedom--should be reduced as much possible.

More on government debt and the money we pay to the government: Richard Carmona, former U.S. Surgeon General (2002-2008), says that "75 cents of every tax dollar that you contribute [to health care] is spent on chronic disease, much of which is preventable" (The Commonwealth magazine, June 2008, page 44). Mr. Carmona singles out smoking and obesity as two of the largest scourges of health. One issue with having universal health care is how we regulate chronic disease--does an obese man get a free gastric bypass, or a free diet book? I wish I knew the answer.

One way to reduce the burden on any proposed national healthcare system is to have government workers use the premium + pay-as-you-go system (similar to Kaiser's HMO), while non-government workers use a separate, heavily subsidized health care system (similar to Britain's NHS). With most government workers not being "at-will" and therefore harder to terminate, they are best positioned to budget and pay monthly premiums. This type of carve-out is not unprecedented--postal and other federal workers, for example, do not get the same federal retirement benefits private citizens do because federal workers don't pay certain taxes. With more than 1.8 million civilian employees, the federal government, excluding the Postal Service, is the Nation’s largest employer. If you add in local and state government workers, you would have enough members to incorporate into a "closed system" of medical care (similar to Kaiser's HMO). In fact, you could probably leave the current HMO/PPO system intact, and then work with existing hospitals to provide heavily subsidized health care to private citizens while also investing in new hospitals. (There's no reason Thailand should have more hospitals than America per capita.) The out-of-pocket and insurance reimbursement system would shift to government members rather than private citizens, private citizens, especially blue collar workers, being the ones most required to be healthy so that they can be productive and pay taxes to sustain the government.

[Note: this post has been updated from its original content.]