The Surreality-Based Community on Health Care

I have read a couple of debates on health care recently, by crowing members of the “reality-based community” who, in those posts, say that anyone who disagrees with them is “dumb” or “delusional” (those are direct quotes). Somehow they view themselves as different from Republicans. Behaviorally, I see little distinction.

There’s an amazing amount of simple dismissing of economists, because the conclusions they come to do not square with ideology. This is a perfect mirror for conservative attitudes toward evolutionary biologists–and yet the opposition to biology was brought up as somehow having to do with the value of markets in regard to health care.

Several times I saw these points brought up in the discussion as “refutations of right-wing canards that have been disproven time and and time again.”

  1. Markets do not work in regard to health care, so market-based arguments are irrelevant. “First off, markets don’t work in health care.”
  2. Price information is impossible to achieve in health care, so a market-based solution cannot function, even if markets applied to health care, which they don’t. “The provider community has resisted, and will continue to resist, price transparency. Lotsa luck getting them to agree to post their prices in a way the consumer can use.”
  3. Health care is not substitutable, so there is no competition in health care markets. You must have all services immediately upon falling ill, and there are no choices in treatment. “Every ecomonic law I am familiar with has, at it’s heart, a rational actor. Well, I can’t think of a less rational economic actor than a mother with a sick child, can you?” “the heart attack victim who is brought in, unconscious, on a stretcher, is in no position to ask questions about the army of practitioners and laboratory full of machines that is brought to bear in saving his life. Rational decisionmaking is gone.”
  4. Implicit in these critiques is the idea that our current system is an unfettered market system.

The first three can be partially refuted by looking at eye surgery to improve vision. It’s substitutable–you can get contacts or eyeglasses. Price information is frequently touted on the radio. And, as it is regulated only to the extent of quality and not for provision (it is not covered by any insurance or government program), prices have declined over the same period that prices have risen for healthcare generally. It also helps refute the fourth: if you compare the procedure to get LASIK versus insurance-covered medicine, there’s not a great market at work in insurance-covered medicine.

Of course, it is optional, and therefore fails to meet the time-dependency test of the third objection. To respond to this, I want to take two tacks: first, such conditions are not unique to health care, and second, most healthcare is not provided in that severe a crisis.

If you are a homeowner, and a pipe breaks, and you do not know where the shutoff valve is, do you shop around for quotes from a plumber? Or do you call the first number you can find to have someone come out and deal with it, and pay them whatever they ask? Of course it’s the latter. Does this mean there’s no market for plumbing? Should we have National Pipe Care? And do you call the most expensive plumber, or do you first call the plumber you’ve felt has a good price and only not go with them if they’re not available?

Of course, most plumbing calls are for leaky faucets and repair work after an emergency has been dealt with. Similarly, non-life-threatening diseases form the bulk of primary care. Most mothers with good insurance bring their little tyke in for every sniffle, even though the vast majority are viruses that will pass in a week, with or without treatment. They demand antibiotics anyway–otherwise, there would be no antibiotic crisis in the First World. So clearly, incentives matter to mothers with sick children. When they don’t have such insurance, they don’t bring them in as often, because they have to trade off the money for a useless antibiotic versus just letting a cold run its course–and since it’s non-life-threatening, a child who doesn’t get better can come back for further treatment if the cold doesn’t go away. Even when the disease is life threatening, moving into the more expensive areas of medicine, the progressions are rarely fast enough to prevent a day’s worth of price versus quality comparison shopping.

Of course, with employer-provided insurance, you never see the price or make the decision of where or whether to get treatment, or whether a less expensive treatment will do you well enough. So doctors have no incentive to post prices. That gets us back to whether what we have is a true market. Why do we tie insurance to your job? Because a long time ago, the government put in place wage controls. So to compete for workers, employers would offer insurance. The government allowed it by making such “contributions” tax-exempt. That basically distorted the market in favor of third party payment for health.

So that brings us to the final Surreality-based objection: any criticism of single-payer or government-provided health service equates to a defense of the current system. Not even close. I want lots of changes to our current system, and I’m far from sanguine about it. One reason national health systems are cheaper than hours is that they don’t attempt to be heros all the time: they ration care. Canadians have far fewer MRIs per capita than Americans. Not all headaches require MRIs, folks. Of course, if Americans payed directly for their MRIs, they’d probably opt for more cost-effective treatments. The biggest problem in any market system is getting people to go to preventative care, when it’s most affordable. I think allowing catastrophic care insurance (which is what really should be covered by insurance) to require the insured to get regular physical exams (and gym memberships?) and charge discriminatory prices based on controllable risks, such as weight or smoking, would go a long way to addressing that problem.

But the blinkered gainsaying, straw-manning, and ad hominems that are practiced in the Reality-based community while simultaneously posturing themselves as the “smart ones” who are “sane” (and they say libertarians are elitist…) pretty much earns them a spot right next to Tammy Faye Baker on the next Surreal Life.

I’d love to see some more progressives who admit that the market does things well and who explicitly accept and identify the tradeoffs of efficiency versus other values they’d like to make–including an acknowledgment of the pain they will cause people, especially poor people, before their justification of why that pain is necessary for their other value. That’s a conversation I could have much more readily than trying to dissuade somebody who believes that nobody involved in health care responds to incentives.

I Plodded Up the Side of Hawksbill Mountain…Again

Another Sunday, another mountain…er, the same mountain as described in Ginger’s post, actually. But it’s a nice trail to see the change of seasons. This season is deer mating season, and I saw a doe running up the mountain with a buck hot on her tail (quite literally). Then I saw them go the other way, and I just imagined a slo-mo picture of it with “I’m in the Mood for Love” in the background, possibly the Alfalfa version.

Other than the weather being very nice and the valley below at peak or near-peak leaves, the only other notable thing was meeting my friend Missy’s new mare prior to the hike. Unfortunately, Gertie was just coming off a bout of some disease related to Rocky Mountain Spotted Fever, and wasn’t in her best mood–plus she was annoyed that Sam, the pony, was hogging all the attention. I gained instant backwoods cred, though, as said pony was nudging me for more petting and had quite a bit of mud on him. So I didn’t start up the mountain as a fresh-faced city boy. He and the other horse, Jack, were quite fascinated by some smell my shoes had. It had been a while since the shoes had met with doggie doo on the sidewalk, so I’m not sure what was so fascinating about them that wouldn’t be true of any other piece of clothing I have (Squeak’s down adds a bit to my dust load in the apartment).

So I have shoes that smell great to horses and saw a ruttin’ deer. Bet you feel enriched knowing that.

I Have My First Hater

Surely this will catapult me into the ranks of big time bloggers like that guy from flyover country, the gay Republican, or some political hack. My more commented-upon Canadian-themed post got quite a lot of hate comments from Canadians who failed to read the substance of the post (or, as I judge from the quality of the spelling and punctuation, may simply have been unable to read it). It then also drew quite a lot of counter-hate hate comments from Americans. Ever one to enjoy watching Canadians act in opposition to their self image, I just sat back and watched.

But when a couple of 14-year-olds (or their mental equivalents) began bashing one another the thing got tiresome. As long as they were bashing one another based on their country of residence, I didn’t much care. Then the (self-identified) American began simply just posting potty mouth words without a lot of point to them. Now I’m quite a fan of potty mouth words (fuck, shit, Jerry Seinfeld, crap, children, dickweed, and Canada, just to name a few)–I just require that they be in the service of something. So I just deleted those posts but left up the juvenile name-calling. That caused outrage, so I banned the commenter’s IP address. He came back and resumed the name-calling, and all was well.

Then the (again, self-described) Canuck failed to recognize that a spammer bent on selling him magic beans for his beanie-weenie had simply used a bot to post some innocuous bit of nonsense, and replied to it. I of course deleted the spam, causing much anguish on the Canuck’s part. I replied that as this is my private propertah, all will respect my authoritah, and I’ll delete whatever the fuck I want for whatever reason I want, or no reason at all. Generally I’m pretty liberal about what I’ll let pass, but sometimes I’m just feelin’ the need for delete.

This caused the American to launch into a paroxysm of abuse. So, of course I deleted it, since it had nothing to do with hating (or not hating) Canada. He returned, full of accusations of treason, etc., etc., and I deleted those. Eventually I got tired of the thing and just turned the comments off that post, since most of them even before the juveniles got involved had been fairly stupid anyway. Canadians seem to have a lot of time on their hands and get a wee bit defensive about being a real country (funny how real countries never feel the need to get defensive about their existence). This caused quite a pause, since neither of them seemed to know that a “blog” has “posts” of which their favorite was simply one among many.

So today, while I spent the day out in the warm sun enjoying nature’s plenitude, the American troll was in his dank cave manually spamming as many posts as he could (geez, write a bot like every other script kiddie). I returned to find them, and promptly deleted them. The Canadian troll managed to bang out a couple of insults between bouts of shivering, but as autocratic and random as I am, I elected to let them stay. I’m just kooky that way.

No doubt my American hater will come back with all sorts of things as soon as the public library opens again and he manages to rediscover how to work the automatic door. They’ll probably be deleted and that IP address banned. Since I have very low readership, I don’t mind banning most of SBC’s IP space. They’re pretty lame, anyway.

But I’m so glad I have a hater. Clearly, I’m coming up in the world.

Oh, Yeah, I Did Get a Degree In That Once Upon a Time

I spend so much time playing at being a geek that I forget I once got a degree in international relations. But other people remember, so I got this email a couple of days ago:

I had a choice between two essay questions on the exam I was taking in a Global Politics class. The questions essentially flowed thus:

1. What should poor countries do to encourage their own development?

2. Have the IMF and World Bank had a positive or negative influence on global economics?

In my opinion, question 2 was harder to answer than question 1 and I felt a bit insulted that the prof would even put question 1 on the exam because it not only contained really lame phrasing but it also seemed just way too easy to answer. I chose to answer question 2 for this portion of the exam because I thought I would be able to put more thought and substance in question 2 than I would have in question 1. Dave said that question 1 was the really important one and that you would be able to explain to me why.

I’ll spare the casual reader my reply. If you’re curious, International Political Economy in 1000 words or less follows after the break.

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Browser and CSS Technique Updates

Jason notes the release of Firefox 1.5 RC 1. Turns out the Safari team has been busy, too, and included in this week’s OS X 10.4.3 release is a version of Safari (and any application that uses WebKit for rendering) that passes the Acid 2 Test.

I confirmed it, and it’s pretty cool.

(Not shown: the nose turns blue when you hover over it.)

Also of note for the future of such advances in esoteric CSS, Eric Meyer notes the holy grail of table-free design: effortless, semantic, order-agnostic equal-height columns, created by Alex Robinson. Do I dare hope it supports flexible widths? He also has a table-free grid layout, too. And apparently this works in all current browsers.

That would be great–I would love to finally separate design from code. My criticisms to date have been for those who have made George Bush-like claims about turning the corner in the development of table-free designs. All of them were severely limited and they brushed over the real difficulties involved for real-world application.

Given their history, I’m going to wait and see before going out and adopting this. Unlike many of the evangelists, I have paying clients that only care that their website works in whatever browser they’re currently using and that their bosses are currently using. Or whatever browser a complaining user is using. I prefer elegance, but they pay only for results, elegant or no.

But it would be quite a relief if true. Since I’ve been working with HTML emails I have felt anew the pain of development pre-CSS. I was actually an early adopter, because it meant never having to search and replace font tags again. That CSS works all the way back to Netscape 4.x. But it doesn’t work in *^%!$*&@ Lotus Notes.

iPodding (though I have no iPod) Memeing

Radley Balko has caught Tyler Cowen’s meme of asking for recommendations for new music. Radley did one better and at least provided up front some of his likes, which actually makes it possible to determine whether anything you listen to will appeal to him. (In light of Tyler’s more recent listings of his suggestions, I sincerely doubt he’ll like anything I listen to–and I kinda doubt Radley will get a lot out of mine, either, though you never know.)

But I think just listing some suggestions and inviting people to track back isn’t a bad idea. So consistent with the iPod theme, though I own no iPod, here are some key ones I think more people ought to love, linked to the iTMS when possible.

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