Good move, Obama.

So politicians can learn! Something new everyday...

If we have to have corporate health care, better Obama's than McCain's version, but there are still people working for HR 676.

My copy of Maggie Maher's book 'Money Driven Medicine' arrived recently, and once my exams are over, I'm looking forward to reading it.

Can any one recommend any other books on this issue?

Health care is one of the things that makes me very glad to be Australian (thanks Gough).

p.s. I'm also looking for an interesting book/website to help with my grammar, if such a beast exists. For me, good grammar is like Justice Potter's take on obscenity- I (generally) know it when I see it, but I don't know what all the different bits are called.

I'm very encouraged by seeing Elizabeth Edwards come on-board the Obama campaign, and in this position. It's going, I hope, to move Obama's position a little closer to single payer.

Kate (#4), in reply to your postscript, as someone who decided too to learn to use grammar, I think the more important thing than 'what things are called' are the simple bits, capitalisation, spelling and punctuation most importantly, especially in this internet age where correct placement of apostrophes is out of vogue.

BUT, if you insist on knowing your subject from your predicate, this site might help you with your definitions (http://www.unisanet.unisa.edu.au/07118/grammar.htm), and the Blue Book of Grammar (it's available on Amazon and in bookstores in Australia) is a good one to use. Also the professional writing guide, although that focuses on essays etc.

Damian @ 7:

One of the more annoying corollaries of Murphy's Law is that one inevitably makes a spelling error when pontivicating about spelling and grammar.

Kate,

I recently had a grammar book recommended to me, and have actually been enjoying it: The Deluxe Transitive Vampire by Karen Elizabeth Gordon.

@6, 8.

Thanks. Kayjayoh's suggestion looks the most promising. Any book that is about grammar and also has as a key phrase 'ogling stevedores', is enough for me.

I'll order one very soon.

@ 7. Ha.

shit, my Transitive Vampire has gone missing (just looked around for it, it should be in the bookcase on my desk...).

Search tomorrow.

Kate @ 9: If you enjoy The Transitive Vampire, you might also enjoy Lynne Truss's Eats, Shoots, and Leaves: The Zero Tolerance Approach to Punctuation. It's a bit British, but it's also lots of fun.

The Zero Tolerance Approach to Punctuation

I don't claim any grammatical expertise, but "Zero Tolerance" without a hyphen seems really wrong to me. Did this change without anyone telling me?

Also, the title is Eats, Shoots & Leaves (ampersand, no serial comma), which is defensible, but not my preference.

Mary Francis @ 11:

That book was quite popular in Australia too, and it's on my vast 'books I should try and read at some point' list.

Kate @9, et al: I can also recommend ... well, pretty much everything Karen Elizabeth Gordon has written that I've read. There are several more books in the Deluxe Transitive Vampire series; The Well-Tempered Sentence (now The New...) is on punctuation, and there's also Torn Wings and Faux Pas on grammar and style (which I don't think I've read).

There's also Paris Out Of Hand, which is a guidebook to all sorts of fictional places in Paris -- the sorts of things that ought to exist, or would be delightful if they did. (As I recall, there is a hotel in which one must give up one's watches and alarm clocks, but when one awakes -- refreshed, from a good night's sleep -- it will be the precise hour at which one needs to awake. The book has a small selection of comments from the guestbook.) It is really a wonderful book, and though apparently it was marketed as "humor", a far better designation would be "fantasy".

Apparently, she's also written a cookbook, which if I came across a copy I would page through before purchasing merely because I have insufficient self-restraint to wait, not because I would expect it to affect my decision to purchase it.

On the topic of presidential health care plans, I'd like to breeze in and out with a one minute rant:

Could someone please, pretty please, create a fictional person with McCain's health profile--other than change his age to 61 years--and run it by insurance companies to see if anyone would insure him for any price?

Because I don't think he knows what it's like to attempt to get individual insurance in the U.S.

When one C-section can make you uninsurable, when one single chronic condition can make you uninsurable, when the High-risk plan costs 3-4x a standard plan*...

Anyways, this needs to be done, because he doesn't seem to know.

/rant
--------------
* a friend of mine--younger, a bit less healthy--got caught by the high-risk category. They pay roughly $12,000/year for just the insurance, plus a 20% co-pay. I pay a fourth of that (with fixed co-pays). The price gets much higher with increasing age.

Kathryn, a Medicare HMO is comparably quite reasonable. Of course, when you're in my situation, nobody else will ever insure you, so you must live where this HMO practices.

Kathryn,

7 years ago I got caught in the dot bomb and got a Warn Act layoff, with COBRA coverage. The insurance cost $800 / month for two of us from the state safety net program, the Oregon Medical Insurance Pool. That was about half of my unemployment benefits. Now it would cost about $1150 / month. And the out-of-pocket deductible was something like $300 per person per year, IIRC. Good thing I had a lot of savings.

Bruce Cohen #17,

In a similar case* I did Cobra, and then switched to self-pay**, and my rate has been reasonable. But if you can't switch, California's high-risk group is hideously expensive, and that 20% co-pay... ick.

--------------
* Did they do a real Warn Act? The dot bomb I was at went ahead and did layoffs 32% at a time, spread 61 days apart (Warn Act kicks in for layoffs of 33% or more employees within any 60 days).

It was obvious what they were doing, but
1. no recently unemployed person wants to pay for lawyers, 2. n.r.u.p. wants to be seen suing a past employer. Awkward in the job interviews. And 3. No agency has any enforcement powers for Warn Act violations.

** it helped that a friend of the family is an insurance expert and could tell me exactly what phrases to use/ not use to describe things. Tiny changes like "seasonal allergies"= insurable, "hayfever"= noninsurable.

@ 14 Brooks Moses:

She wrote Paris Out of Hand? That book is on my much shorter "I must read this book before I die" list.

I read about it about a year or two ago, and it absolutely captivated me- it's exactly the kind of book I love. But I've been busy and poor and never got round to purchasing it.

However, I did recently come in to a small windfall, which I decided would be spent on books and music, so I think I shall have to order four or five of her books from my local bookstore.

Looking at her other books on Amazon, 'The Disheveled Dictionary' reminded me of both Ambrose Bierce's 'Demon's [or Devil's] Dictionary' (for the title), and Peter Bowler's 'The Superior Person's Book of Words, which is hilarious and beautifully illustrated (as are his other books).

Careful not to step into the beartrap that is discussing grammar, I just thought I should point out that "Eats, Shoots, and Leaves" should not really be recommended as any kind of prescriptive rulebook. I read it, and enjoyed it, but to me it was more entertainment than education. Granted, I do study linguistics, so I'm not Joe Average, but I'm really not that good at punctuation, and even I found a cart load of mistakes in the book. Louis Menand does a better job at telling you why her book sucks as a grammar guide.

One of the most frustrating things about studying grammar is that, very often, there is no right or wrong way of doing things. Linguists differentiate between descriptive and prescriptive grammars: grammars that try to tell you how things are done in a language, and grammars that tell you how things should be done. This is an ancient struggle, no less epic than PC vs Mac, but for what it's worth, I've always found descriptive approaches more interesting.

The book we used at university was this one: Longman's Student Grammar of Written and Spoken English. It's firmly in the descriptive camp. You'll get lots of colourful charts and numbers telling you how often this and this kind of structure appears in journalism, in fiction, etc. This is as in-depth as any sane person could want, so it's probably too detailed for someone looking for a simple introduction, but do consider getting it anyway. I found it very simple to read and use.

Excuse me for indulging in this digression. As for the topic at hand, I used to live in Germany and now live in Ireland, and I really don't see what the big problem is in maintaining a good health system. ;) In Germany, your health insurance is all but invisible. You must have one; it's not legally possible to be uninsured (I'm still trying to convince my German insurance that I am now safe and insured here in Ireland so I can quit the German insurance). In Ireland, most any job comes with health benefits of some form. My current employer pays a 100% of a very good health insurance for me and 50% for a reasonably priced dental plan. I think my contribution for a 6 month period to that dental plan is 50 euro bucks, so absolutely trivial. I do hope you guys get something like this up and running, too. The idea that poor people are allowed to die because they can't afford an operation they positively require to stay alive just sounds so dystopian to me, even after all these years that I've known about it.

I saw a story in the paper recently which they seemed to think was a drugs/crime story, but which was clearly a health-care story.

66-year-old grandmother, running drugs up and down I-95. Why? Because she had about $25,000 in outstanding medical bills -- treatment for a blood disease and for reconstructive surgery for her daughter (who'd been badly injured in a car crash). She'd had no insurance. Drug running seemed like the only way she was ever going to make that much money.

We need some change. What we need is single-payer, and for healthcare to be treated as a right rather than a luxury good. I liked Clinton better on health care because she wanted to mandate that everyone get insurance, but even that I don't think goes far enough, because I think the for-profit insurance model is busted. However, her plan would still be better than this. I hope Elizabeth Edwards pushes Obama in that direction. More, I hope Obama offers Clinton the VP spot and she takes it, and pushes her health care plan from there.

Kathryn from Sunnyvale @ 15:

A C-section makes me uninsurable? I know there is a higher instance of complications in subsequent pregnancies, but really? That's insane. (As is probably obvious, I haven't changed insurance since my son was born. This could prove problematic very soon.)

Paula Helm Murray @ 10:

Actually, I just looked around, and I can't find my Transitive Vampire either. Are two instances of missing vampires enough to call it a conspiracy?

Kathryn #15: I don't think he knows what it's like to attempt to get individual insurance in the U.S.

Really? I do. It doesn't matter what you know if you don't care about it.

On the general topic, I agree with Caroline and will that any solution that keeps the for-profit system in place is not nearly good enough. But barring some sort of miraculous 180 in the way everything works, that won't ever happen here. Therefore: leave the country while it's still legal.

In his speech, Obama repeated his pledges to make available the same healthcare plan that members of Congress get, to reduce insurance premiums by $2,500 a year for the typical family, and to prevent insurance companies from discriminating.

That will be a hat trick--I'd love to see some implementation detail.

The problem is that a "typical" (I'll assume that means median) person has insurance costs that are less than half the average (mean). Reducing discrimination AND reducing costs to the median person is going to be very hard.

A good (minimal) start would be (a) to require all health insurance companies to take all applicants without pre-vetting, at a flat universal one-size-fits-all rate -- i.e. to criminalize cherry-picking -- and (b) to impose a punitive, prohibitive corporate tax on for-profit health insurance companies, coming in over a 2-3 year period to give them time to re-arrange their affairs as non-profits. For a desert topping, allocate a fund to buy up any such insurers entering Chapter 11, and place them under public ownership.

The ultimate goal should be a single-payer non-profit system, but you're not going to get that instantly without a lot of corporate push-back. Salami-slicing to herd them in the right direction is going to be difficult, but it's probably more do-able than out-and-out nationalization (which is what it really needs).

You don't need to nationalize the medics; just form a universal insurance monopsony and the hospitals will have to fall into line.

A good (minimal) start would be (a) to require all health insurance companies to take all applicants without pre-vetting, at a flat universal one-size-fits-all rate

Ahh--the tried-and-true $500-a-month-each plan. That would increase a typical person's health insurance costs by a factor of 5.

Robert Reich had a great blog entry about the Obama, Clinton, and Edwards plans:

Democrats Should Stop Squabbling Over Healthcare Mandates

Sam: the idea is to drive the insurance companies into bankruptcy as quickly as possible. Capping at $100 a month seems reasonable to me ...

PS: $6000/person/year on healthcare is ridiculous. France gets by on 11.1% of GDP to the USA's 16%, and has pretty much the best healthcare system in the world; they do that on under $3000/person.

A lot of your money is being poured into the pockets of, for want of a better word, parasites. (And I maintain that an industry that profits on the back of human illness is parasitic, in the classic blood-sucking-leech sense of the word.)

Well, the US spends $6000/yr/person now--of which less than 5% goes to malpractice premiums and insurance company profits. So what is it you propose cutting to get spending down to $3000/yr/person?

#30
Sam, read what Charlie said again. It's pretty clear to me.
I suspect a lot of doctors would agree with him: they have problems with the insurance companies, too.

Daniel Klein @20 said "In Germany, your health insurance is all but invisible."

Well...there are lots of good things about it, but anyone looking with longing eyes at any European healthcare system needs to look hard at all sides of it.

Currently, German health insurance rates run 12-16% of taxable income; employers and employees pay in an equal sum. Spouse/partner and children may be included in this plan at no additional cost. (This is the [extremely simplified] framework for 'public' insurance*; it is also possible to choose a private insurer, but this has its own pros and cons.) BTW, currently around half of all outlays in the public system are going for the care of retirees; this is, of course, bound to go up.**

You are allowed to choose your 'public' insurance company. They do not differ dramatically in terms of price or coverage, but there are some major differences in their operational costs. Some of them are frankly disastrous, and there are no checks and balances to enforce fiscal efficiency. Instead, when they run deficits, they are shored up by a fund paid into by companies running a profit.

The system as it is now is neither fish nor fowl, neither completely free-market nor completely nationalized, and an easy solution isn't in sight. Patients from Holland come over here because they can choose which specialist they'd like to consult. German physicians move to Norway because the working conditions are better there. (PJ Evans @31 -- boy oh boy, do physicians have problems with the system here!)

The idea of a single national insurance company, as Charlie Stross proposes, does have its attractions. But the devil is in the detail, and I am quite sceptical of monolithic, monopolistic bureaucratic structures.

*for want of a better term; the German is "gesetzliche Krankenkasse"
**info in this paragraph from German Wikipedia.

Sarah @22,

on C-sections, there was just a good article in [Major Paper (don't have access from here)] on this topic.

If you apply for new non-large-group insurance, having had one can be a problem, or make "pregnancy" not covered for the first while of the coverage.

Charlie @25, and others
Minnesota already has the requirement that health insurance be non-profit. We're *slightly* better off for it - but United Health in Minnetonka has a CEO raking in millions, for example. Maybe as a short-term transition, it would improve things slightly for health insurance to be non-profit, but the executives will figure out way to get their big bucks. We need single payer. NOW.

I realize the insurance companies will fight this tooth and nail. Perhaps we could have Medicare for everyone, and let them sell the "medigap" policies until we improve Medicare to where those policies are no longer necessary.

I really, really, don't want to be required to buy health insurance - the insurance companies will find some way to turn it into a bonanza for themselves.

Kathryn from Sunnyvale @ 18

Did they do a real Warn Act?

Oh, yeah. (bwahaha!) The startup I worked for had been acquired by a German company the year before. Our new German overlords thought they were the hottest of sh*t, and didn't bother trying to run our part of the new company (or their own, for that matter) with any semblance of business acumen. So they never bothered to check with their lawyers about layoff laws in the US, just assumed it worked the same way as in Germany. They laid off about 80% of our company at once, which qualified as a geographical site, so the Warn Act kicked in. On top of which, I was in the hospital that day, just a day after back surgery, still heavily sedated, so they ended up giving me 2 months extra medical coverage under the original corporate plan rather than try to explain to my lawyer that they didn't really lay me off just because I was in the hospital.

Those German managers were really bozos. They bought our company for USD $280 million in paper (inflated stock from their own company, which they valued at USD $4 billion). Then when the layoffs came, they sold it back to a consortium of our old managers for USD $1.25 million. And when the new owners went through the books, they discovered the bozos hadn't been collecting license fees; there was over $3 million in outstanding accounts receivable (well past 90 days due) that they could collect immediately, paying them back for buying the company immediately, and providing several months worth of operating capital as well.

dot idiots.

Caroline @ 21

That suggests a really elegant solution to the health care problem: legalize drugs, dismantle the DEA (and the Drug Czar, but scrutinize his organs carefully before using them to make sure the corruption hasn't gone too far), and tax the drug providers to pay for health care. Come to think of it, that will also take some of the obscene profits away from Big Pharma, since they provide a lot of the drug makers' precursor chemicals (IIRC, the amount of ephedrine manufactured in the US and Switzerland is more than twice the amount needed to supply existing legal channels; the rest gets shipped to Mexico for the illegal meth market.)

Following up on my #18,

If you are applying for self-pay insurance, it is really helpful to
1. have a person who'll explain exactly what words to use and not use
2. do a careful check to not apply to a company which automatically denies a condition you have ( After Caesareans, Some see higher insurance costs, because one denial can itself cause another.

For 1, if you don't directly know a person who speaks insurance, there are insurance brokers who can help, if you find the policy-wonk sort. I found this out the good way years ago, when one of them spent a good part of an hour finding a plan and telling me exactly how to apply.

Daniel @20: "The idea that poor people are allowed to die because they can't afford an operation they positively require to stay alive just sounds so dystopian to me, even after all these years that I've known about it."

It's not actually quite that bad, which is a good part of why it's so hard to get anything done about it.

See, if you absolutely positively require the operation in order to stay alive, then there are laws that kick in that say that a public hospital (as opposed to a private one) has to treat you, pretty much at their own expense. They can probably wipe out any meager life savings you have, but they have to treat you.

But what's not covered under those provisions is pretty much anything else -- including routine testing to insure that you don't have any conditions that would cost a little bit to deal with now and a lot to deal with in the future when they became actively life-threatening. Or treatment for such a condition before it got worse, if they were to be discovered, if I understand correctly.

(And it occurs to me, as I think about it, that this may only apply to "emergencies". Gosh, I hope not....)

Brooks Moses @ 38: Well..no, it really is that bad. Families under the poverty line have been essentially denied dental care because the few dentists who would take them were too few and far between, and the families don't know where they are, even when they're aware that there's dental care available.

Deamonte Driver, a 12 year old boy in Prince George's County (Maryland) died of a brain infection that was directly related to an infected tooth, and that in turn was directly related to lack of access to health care. His mother was on welfare (and homeless, IIRC, for a short period of time); the family's cricumstances led to their being denied access, information, and basic health care.

I'm all for some sort of system, whether it's based on the Canadian model or some other country -- we are taxing our poor people into the grave, and we have a system that eliminates access based on income level. Those of us who can afford health care are paying too much for companies and not enough for actual medical preventive care.

We could do a lot by just providing free care for some of the most common easy-to-prevent, expensive-to-treat problems: immunizations, prenatal care, diabetes care, blood sugar and blood pressure screens, dental cleaning and extractions.

For example, there are about 86,000 amputations per year in the US due to diabetes. Some of those could be prevented, saving a lot of money and productivity into the bargain.

And, as has been said before, universal health care is a Homeland Security issue. After all, if we're going to be watching out for terrorists or rogue states attacking with biological weapons, we'll need to be able to detect, map, and treat the disease as soon as possible no matter who's caught it first.

How small of a fraction of the cost of the invasion of Iraq would be enough to set up a real system for this, which would actually make America safer instead of giving people reasons to want to attack?

(Of course, it looks like our tomato industry has already successfully attacked the US.)

Charlie Stross @ 29: "A lot of your money is being poured into the pockets of, for want of a better word, parasites. (And I maintain that an industry that profits on the back of human illness is parasitic, in the classic blood-sucking-leech sense of the word.)"

Ezra Klein puts it well: "One man's waste is another man's profit margin."

heresiarch @ 42

That's too mild a way to put it. I'd say, "One man's death is another man's windfall."

Bruce Cohen @ 43: "One man's death is another man's windfall."

Perhaps in the narrower case this is accurate, but what I like about Ezra's version is that it elegantly demonstrates that the inefficiencies of the healthcare industry aren't accidental misfortune, they are calculated strategy. Any attempts to make the system more efficient are going to have to go up against the ones who are making money from those inefficiencies. Death/windfall captures the maliciousness, but not the calculation.

Bruce, well said. The point of commercial health care is commerce, not health care.

One problem with the USA system, as I see it, is the cost inflation which tends to go along with insurance-payed medical care. I dislocated my shoulder while on vacation in the USA. My holiday insurance had to pay out about $2,000 - 3,000 (eight years ago). It was crazy: a couple of X-rays, a bit of sedative and muscle relaxant, associated needle, syringe etc., a sling for my arm afterwards, and personnel time (maybe about 10 mins receptionist, 30 minutes radiographer, 10 minutes doctor, 10 minutes nurse). I don't remember all the details, but I do remember the 2 mL vial of saline at $18. That's insane. Yes, I know about overheads etc., but it's still insane.

dcb @ 46: I still owe the hospital $1400 for five minutes' use of their laser to zap my right eye. That wasn't the total cost of five minutes' use of their laser, mind you, just my share after my insurance company paid the bulk of it.

Kate @ 4

I don't have a book to recommend you, but a couple people here have already mentioned Ezra, and his blog spends more time on both policy and political issues around health care than any other I know of.

http://www.prospect.org/csnc/blogs/ezraklein

Brooks @ #38: I was worried I'd get the details wrong, and I knew about acute emergencies always being treated, but I don't think I got the basic fact wrong that sometimes people have medical conditions that require a certain procedure to give them a much better chance to survive which they are denied because they can't afford it.

Being a metal head myself, I know the case of Chuck Schuldiner, a visionary in the field of progressive Death Metal. Chuck had a brain tumour. The original operation went well and he was recovering. Years later, the tumour came back, and he would have needed another operation right away. However, the first operation had completely wiped out his family's savings, and he did not immediately undergo the procedure. He did have it lateron; I don't recall now if his friends and family managed to raise the money for him or if he deteriorated to the point where his case was deemed an emergency. At any rate, he died the next year. Would he have survived had he had the operation right away instead of waiting? I don't know, but from my limited medical understanding I'd say that he'd have had a better chance. I hear that "wait and see" is not the preferred treatment for life-threatening cancer.

As for the cost of German insurance, yeah, it's not that cheap. Still: in Germany, whether you work or not, a certain standard of living is guaranteed, and having a roof over your head and receiving medical attention whenever you need it is simply part of that. Hell I'm not saying the German system is great. I didn't have to deal with it a lot since I was a student for almost all of my time in Germany, and from what I heard from people who already worked full time, the system can be very frustrating. It's just that I prefer "can be very frustrating" over "could kill you".

heresiarch @ 44

I understand what you're saying, but I'm not convinced that's a "narrower case". From what I've heard the insurance company's main strategy for reducing the impact of payouts for catastrophic illness is to stall on the claims, hoping the patient dies before they have to make a large payout. That's far more evil than profiting from waste.

Bruce @ 50: "I understand what you're saying, but I'm not convinced that's a "narrower case". From what I've heard the insurance company's main strategy for reducing the impact of payouts for catastrophic illness is to stall on the claims, hoping the patient dies before they have to make a large payout. That's far more evil than profiting from waste."

I'd agree that your example is clearly evil. But it's also absolutely deliberate--how can it qualify as a "windfall?"

When I say that "One man's waste is another man's profit margin" is a wider case, what I mean is that Ezra's example also encompasses something like, say, construction workers slacking off in order to get more hours from the same amount of work. From the contracter's pov, that's waste. From the worker's pov, it's free money. See what I mean?

The larger point is that the death and suffering caused by the current healthcare system isn't due to the particular immorality of the people running it. Rather, it's an emergent property of market principles--if you use a free market system in this application, this is what will result.

heresiarch @ 51

if you use a free market system in this application, this is what will result.

I'm in violent agreement with this statement. For-profit operation of health care systems is a clear case of conflict of interests. It requires the system to be adversarial with respect to patients, which is exactly 180° out of phase with the way medical treatment needs to work.

For-profit operation of health care systems is a clear case of conflict of interests. It requires the system to be adversarial with respect to patients, which is exactly 180° out of phase with the way medical treatment needs to work.

That's the most succinct way of saying this I have yet to see. Thanks, Bruce.

Bruce Cohen @ 52: Exactly. Adversarial systems work really well in some applications. Not so well in others.