Saturday, January 29, 2011

Scribbling the Cat

I’m not sure what to make of this book.  On the one hand it shed light on a place I know next to nothing about, southeast Africa.  On the other hand I came away with the distinct feeling that the less I knew about that place the better.  What must that have been like for the author, traversing the roles of contemporary american housewife and…  travelogue reporter going through one of the shittiest places on earth?

I want to make fun of it, to point out that there is something profoundly off about an African travelogue where the only characters that matter are white.  But doing that misses a key point- the characters are aware of that very fact, are aware that their story is somehow contrived and displaced, they know very well that they are screwed.  They are who they are, and there isn’t much they can do about it. 

Sometimes living requires accepting uncertainty and contradiction, even in ourselves.  What are we but a reflection of a world we cannot hope to understand?

Andrew Bacevich Column

There is a posting at Tom Dispatch of an Andrew Bacevich op-ed, on why the political posturing threatening to cut military spending is a farce.  I don’t agree with everything Bacevich says, but he is always worth reading.

Sunday, January 23, 2011

Health care financing <> Health insurance

From Richard Thaler via the NY Times:

Perhaps the most unpopular feature of the health care legislation now in place is a provision that requires nearly everyone to buy insurance. It is known as the mandate, and it is the aspect of the bill that could end up before the Supreme Court. In contrast, nearly everyone seems to approve of the provision ensuring that pre-existing medical conditions won’t prevent you from finding affordable insurance, as well as the rule that prevents insurers from dropping you if you get sick.

Unfortunately, it is hard to have the popular features without some version of the mandate. A health insurance system cannot work unless most healthy people participate.

Actually, there is a really simple way to cover those with pre-existing medical without imposing an insurance mandate.  Use a tax instead.  Either way, the low risk majority is being asked to subsidize the high risk minority.

Why not use insurance where it makes sense in health care finance and use something else where it doesn’t?

Cortright & Company Editorial

I finally got around to reading the editorial from Joe Cortright & company in last week’s Oregonian.  I liked the substance and philosophy behind it.  Particularly the proscription to attend to details:

Statistics can too easily mask the story that we really need to understand: what makes each company and each worker in the Portland region successful -- or not. We need to ask why a company founder came to or stayed in Portland, what prompted her to start her company and what factors made her successful -- and what would make her leave or quit. We need to understand what makes a successful worker want to be here, what will make them stay and what will improve his value to the company and the broader society. Those stories -- which will have different nuances for each profession and industry -- can't be told by the statistics alone, regardless of how we slice and dice them.

I consider myself a successful worker, here are my answers to the questions posed.  What made my wife and I move here was the progressive social culture and political values, the relatively low cost of living, and the perception that Portland Public Schools offered acceptable educational opportunities for our kids.  What would make us leave is Portland’s peculiar relationship with the past.

While Portland’s nominal political values are unabashedly progressive, there is knee-jerk parochialism when it comes to growth and development.  From Memorial Coliseum to the proposed Wood Village Casino and many things in between, it seems that every proposal for economic development is met with fear and loathing.  Portland suffers from a form of collective hoarding syndrome.  It risks drowning under mounds of once useful but now purposeless buildings and structures, preferring mindless nostalgia to the uncertainties of change.  I don’t see how the city can thrive in the 21st century with that attitude, it affects everything from jobs to education.

Sunday, January 2, 2011

Health Care Cost Inflation: Copayment Cards

Here is a story demonstrating how health care costs get distorted.  Things to note:

  • First, note how much patients can influence what they are prescribed, despite nominal physician control.
  • Then look at the cost benefit analysis (or absence of it).  Were doctors previously prescribing the wrong treatment, or are they now wasting money?  One or the other is true.
  • Third, notice how this defrays the pricing distinctions copays create.  If a 20% copay incurs the same cost as no copay, expect them to be priced the same.  That eliminates an option for cheaper insurance, making insurance more unaffordable.

The story is specifically about drugs, but I suspect the problems exist for a broad range of treatments.  More evidence that insurance reforms alone will not improve health care access, the key problem is at the provider level.