Map of life expectancy at birth from Global Education Project.

Friday, December 02, 2016

Here's a letter I wrote to my colleagues . . .

. . . along with one of them.



This is a critical time for the future of health care policy, and all policies affecting public health in the United States. The incoming president and congress have promised to take actions that will profoundly change our health care system, along with environmental regulation, immigration policy, labor policy, and much more that will affect the health and well-being of the population. Some of the rhetoric in the recent campaign has also affected the social and political culture of the nation with unpredictable but likely worrisome consequences.
            We were deeply concerned by the scarcity of informed and even accurate discussion of public policy in the recent campaign. It appears that voters have little understanding of what government does or how government policies and practices affect their lives. The news media largely failed to explain the facts and controversies underlying policy choices, and allowed empty rhetoric and personal questions about the candidates to dominate the communal discourse.
            We believe that we, as experts in policy issues that are of the greatest importance for our nation and its citizens, can and should do more to contribute to the public discourse beyond our traditional focus on publishing in journals that are read only by our peers. We believe that we need to define an expanded role for public health researchers that brings our science out into the world and engages with people from all communities and walks of life. Voters cannot make appropriate decisions if they cannot meaningfully evaluate what candidates say and promise.
            We hope to join with our colleagues, starting within the department but perhaps expanding to the entire school of public health and ultimately beyond to other institutions, in an effort to democratize our work. By this we mean listening and engaging communities in helping us to understand what matters to people, and how we can best serve the public interest through our scholarly work, but just as importantly o through effective dissemination of knowledge and empowering people to be informed civic actors.
            We have discussed a few ideas about what some components of this effort might be. We do know that it calls for re-examining the institutional expectation for how public health scholars will focus their time and how their accomplishments will be evaluated. But there is much we can do now, that we believe we should be doing as a matter of urgency. We hope that some of you will join us in discussion leading to action. Please let either or both of us know if you want to join us, and we will convene those interested.
I'm not the only one who feels this way -- for example there's the well-publicized open letter from MIT faculty -- but I'm not just talking about writing open letters or op-eds. I'm talking about working with community-based organizations to engage people directly in understanding the facts underlying policy choices and how government matters to their lives. We cannot survive in a post-factual world.

Wednesday, November 30, 2016

Not exactly news . . .

The Commonwealth Fund has done the latest in its series of surveys of 11 countries (western Europe, Canada and the U.S.) and, well, you already know:

  • Adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs. One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs. This percentage is down from the 2013 survey (37%). [But it's about to go back up!] As few as 7 percent of respondents in the U.K. and Germany and 8 percent in the Netherlands and Sweden experienced these affordability problems.
  • U.S. adults were also the most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.
  • Half of U.S. adults struggled to get health care on the weekends and evenings without going to an emergency department. Between 40 percent and 64 percent of adults in the other countries reported the same. The Netherlands had the lowest rate on this measure, 25 percent.
  • Adults in the U.S. (19%) and France (24%) were the most likely to say that their medical records or test results had not been available at the time of an appointment or that duplicate tests had been ordered in the past two years. These problems were reported less commonly in the other countries.
  • Fourteen percent of chronically ill U.S. adults said they did not get the support they needed from health care providers to manage their conditions. This was twice the rate in Australia, Germany, the Netherlands, New Zealand, and Switzerland.
So the Republicans take over and vow to make all this worse -- much, much worse. My question is simple: what is the constituency for this? Why do we so passionately want to hurt ourselves?

We'll be in for a lot of this . . .

Sam Stein and Matt Fuller for the Puffington Host report on the 21st Century Cures Act, which appears likely to pass. Believe it or not, it does some things Democrats want to do, including providing some additional funding for NIH and money to the states to combat opioid addiction.

But of course, there's a high price to be paid. It also makes it easier to get medical treatments approved without demonstrating that they are safe and effective. Senator Warren has denounced this as a corrupt bargain. The Democrats in congress will be offered more of these corrupt bargains in the coming years, such as the phony infrastructure plan that really consists of giving away public goods to capitalists. The Republicans haven't been afraid to obstruct everything for the past 8 years -- how will the Democrats behave now?

Stay tuned.

Monday, November 28, 2016

Speaking of scams . . .


While the new president and his minions are busy selling out the country for personal enrichment, the pharmaceutical companies will not be left behind.

This is a slightly complicated scam, so you might want to read the essay in NEJM by Dafny, et al. For those with short attention spans, I will try to explain. There are lots of medications available to treat most conditions. The FDA has to approve them if they are safe and effective, but they don't have to be superior to existing treatments. Comparative effectiveness research doesn't always get done, but sometimes we know that a less expensive drug works as well as a more expensive one, at least for most people. Also, of course, once marketing exclusivity expires there are often cheaper generic alternatives to brand name drugs.

So, insurance companies put drugs in different "tiers" with consumers facing higher co-pays for medications the insurers want to steer people away from, because they are more expensive or less effective, or both. This helps them make money, sure, but it also helps keep premiums down for all of us. So what do the drug companies do when they want to keep selling their more expensive brand name drugs?

They pretend to be doing you a favor by giving out coupons that cover the co-pay. But they aren't doing you any favor, they're screwing you. Let's say a drug costs the insurance company eight times as much and they give you a coupon for a 20% copay? You use the brand name drug instead of the generic, which might have a much smaller copay but with the coupon the brand name drug is free. But the cost to your insurance company is much higher. The drug company gets their ill-gotten gains and ultimately, it comes out of your wallet anyway in the form of higher premiums.

I wouldn't count on your friends in congress to do anything about this.

Thursday, November 24, 2016

The New Normal


Simon Maloy thinks Trump's corruption will sink the Republican party. To which I say, poppycock.

According to the New York Times and the rest of the corporate media, Hillary Clinton was the corrupt candidate. Can you imagine if Clinton had just settled a fraud lawsuit for $25 million, or the Clinton Foundation had admitted to self-dealing? My imagination can't even encompass what the news coverage would be like.

But they are doing their best to ignore Trump's blatant and proven corruption -- one brief story on each revelation, and we move on. What makes Maloy think that's going to change?

Saturday, November 19, 2016

Theories of History


There are several approaches to understanding and writing about history. There is the Great Man (rarely Woman) school, which consists largely of biography. There are grand theories that explain history as a process shaped by large forces in which the choices of individuals have little weight, from Marxism to the inevitability of neoliberal dominance of the planet. The latter didn't exactly have a name but lots of people believed in it.

Then there are those who say, sure, there are grand forces -- technological change, climate, resource depletion, demographics -- but against that background, a lot of shit  just happens. Call this the "for want of a nail" theory of history. Well, it's true.

No-one can enumerate the links in the causal chain that led to our present disaster, but we can spot a few that are both necessary and basically stochastic. Hillary Clinton actually won the election by quite a substantial majority, but thanks to the historical anachronism of the electoral college, it doesn't count. There is no argument that I can see that makes this the right result. A few thousand votes in a key state tips the whole thing. In past elections that has been consequential but in this election it puts the country on a path completely opposite to what would otherwise have been.

Another necessary link was the Comey letter. There is plenty of evidence that it flipped the election, and probably the Senate. This of course would not have happened in the corporate media hadn't been obsessed with the completely bogus non-issue of Hillary Clinton's e-mails to begin with. But they were, and Comey  knew it.

Comey could not have played his dirty trick, however, if he didn't have Anthony Weiner's computer. Ergo, if the ridiculous and ridiculously named Anthony Weiner did not have an incorrigible habit of tweeting his junk, Hillary Clinton would be preparing to assume the presidency and appoint a young liberal justice to the Supreme Court.

In other words, this whole thing doesn't mean shit. It's a horrible accident. Jessica Williams (a Daily Show regular with John Stewart for those who aren't with it) said, "The first rule of politics is, Don't Tweet Your Junk," which presumably Weiner would have learned when it cost him his congressional seat. He did not, causing him to lose his chance to be mayor of New York and prompting Williams to say, "The second rule of politics is, Don't Tweet Your Junk."

Apparently we need a third rule. "Don't Tweet Your Junk."

Monday, November 14, 2016

Resistance


So, Paul Ryan says his first priority in 2017 is to phase out Medicare. He'll give people vouchers that will cover part of the cost of private insurance instead, but obviously the whole point is that they won't be sufficient. Medicare is much more cost-efficient than private insurance, because it doesn't have to pay for marketing, multi-million dollar executive salaries, or profits. And insurance companies have all kinds of ways of avoiding the most costly customers and screwing people out of benefits. Read the linked post if you want more details, but . . .

What is most strange about this is that it has almost no constituency, apart from a few extremist ideologues and plutocrats who don't want to pay taxes. Retired people and people who will retire depend on the program (as do people with disabilities). Doctors and hospitals get most of their revenue from it. The only way Republicans can advance their agenda is to lie to people, which is what Ryan is doing.

It seems to me that now that Republicans have total control over the federal government, and it actually comes time for them to do everything they have promised to do, it's suddenly going to get difficult. The first thing George W. Bush said after he was reelected was that he wanted to privatize Social Security. Funny thing about that, it didn't happen.

We need to resist everything, everywhere, with maximum energy. There is still plenty of life in the American republic and the progressive vision. We will win in the end.

Thursday, November 10, 2016

How worried should we be?


I commend to your attention this essay by Ezra Klein. Before I try to very briefly summarize his argument (but do read this, although it's long form) I want to pull this:

He is a man who routinely praises dictators. Of Vladimir Putin, Trump said, "He's running his country, and at least he's a leader, unlike what we have in this country." Of Kim Jong Un, Trump said, "You've got to give him credit. He goes in, he takes over, and he's the boss. It's incredible." Of Saddam Hussein, Trump said, "He killed terrorists. He did that so good. They didn't read them the rights."
It’s not just that Trump admires authoritarians; it’s that the thing he admires about them is their authoritarianism — their ability to dispense with niceties like a free press, due process, and political opposition.
Trump has promised — in public, and repeatedly — to bring this hammer to American governance. He stood in a nationally televised debate and vowed to jail his opponent if elected. He has proposed strengthening libel laws to make it easier to cow the press and antitrust laws to punish Jeff Bezos and Amazon for the Washington Post’s coverage of his candidacy. In a recent speech at Gettysburg meant to preview his first 100 days in office, Trump said he would sue all of the women who accused him of sexual assault. 
During rallies, Trump has exhorted his followers to assault protestors, and has promised to pay their legal fees if their thuggery leads to arrest. He has warned that the only way he could lose the election would be if it is rigged, and has suggested he may refuse to concede.
And all this ignores his more basic flaws. He is cruel, lazy, and reckless. He knows nothing of policy and has not bothered to find anything out. He is easily baited, reliant on sycophants, and prone to conspiracy theories. He is a bigot who slimed an American-born judge for his Mexican heritage and a misogynist who boasted that his celebrity gave him license to commit sexual assault. He has cast doubt on America’s commitment to the NATO alliance and offhandedly encouraged Saudi Arabia and Japan to build nuclear weapons. His business is rife with conflicts of interest, and his campaign has been amateurish and poorly managed.
 Klein wrote this before the election, when he expected Trump to narrowly lose. (Actually, he did lose the popular vote, and it wasn't particularly close. But the problem of the electoral college is for another day. He got plenty of votes.)

Klein's basic claim is that the gatekeepers who once had control of the nominating process -- party elites, mostly, but corporate media as well -- have completely lost influence. But while the parties are institutionally weak, the public is more partisan than ever. The result is that once Trump got the nomination, Republican voters stuck with him despite whatever doubts some of them may have had. And party elites could not afford to abandon him lest their voters retaliate against them.

We can forget about checks and balances because soon, far right extremists will control all three branches of the federal government. They will do whatever they want, and believe me, New York Times editorials won't slow them down.

Friday, November 04, 2016

Gross Domestic Problem


Back when I was a 22 year old Nader's Raider I heard Hazel Henderson speak at one of our conferences and she was already saying what Edoardo Campanella apparently thinks is a radical new idea, which is that Gross Domestic Product is not a valid measure of well-being, and not even a valid measure of economic activity.

Hazel was not the only person to figure this out 40 years ago and plenty of people have kept hammering on the fairly obvious truth of it since, but it's just pissing into the wind. The corporate media and political leaders continue to treat GDP growth as the measure of a "healthy" economy.

The reasons why this is wrong are so many and so gross that nobody should be arguing about it, but apparently we have to do it anyway. Here are a few:

GDP does not account for externalities. You know, air pollution, stuff like that.

It treats resource extraction as production, even though the resource is gone.

It treats harms as goods. For example, a hurricane that destroys houses becomes economic growth because the cost of rebuilding them is counted as a positive while their destruction is ignored. Same with automobile crashes, disease (which leads to health care spending), basically anything that goes wrong and has to be fixed.

As a corollary, saving money is bad. Preventing disease, avoiding disasters, improving public safety - these are all negative for GDP.

It doesn't properly account for the value of technological advances. As the same goods and services get cheaper, we still have the value, or even greater value, but the contribution to GDP goes down.

It takes no account of inequality. If one person gets all the loot and the rest starve, it doesn't matter.

It takes no account of any activity that doesn't involve exchange of money -- from household work to volunteering. Take care of your elderly parent yourself, zero contribution. Hire somebody to do it, GDP. 

More money flowing around does not translate into human happiness. No account of community, friendship, the value of common space, free concerts on the green, mutual respect, you name it.

Do we really need to keep having this pointless discussion?

Tuesday, November 01, 2016

The grotesque corporate media


Jesse Berney and Matthew Yglesias have posted very similar essays, which means they are channeling a collective consciousness, not that one is stealing from the other. As Berney puts it:

You start with the assumption that Hillary Clinton is corrupt. After all, there have been whispers and accusations and investigations and allegations and scandals with ominous names like WHITEWATER and BENGHAZI for years. Even if you can't describe exactly what she's done wrong, there must be something to all these stories, right?
Or, in the words of Yglesias:

The latest Hillary Clinton email revelations arose out of an unrelated investigation into Anthony Weiner’s sexting. The best way to understand this odd hopscotch is through the Prime Directive of Clinton investigations: We know the Clintons are guilty; the only question is what are they guilty of and when will we find the evidence?
Berney:

When I fired up the New York Times app on my phone Saturday morning, I had to scroll through four full screens before I got to a headline that wasn't about FBI Director James Comey's letter to Congress that the bureau had discovered emails on Anthony Weiner's computer that possibly maybe perhaps might be related to its earlier investigation of Clinton’s private email server. With zero information about what is in those emails, zero information about any connection to Clinton, zero new allegations of wrongdoing, the Times and much of the media treated this story with the kind of wall-to-wall coverage usually reserved for the first moon landing.

Yglesias:

There are several rules that govern media coverage of the Clintons, but this year the Prime Directive has dominated them all. Network news has devoted more minutes of coverage to Clinton’s emails than to all policy issues combined, even as email investigations have not uncovered any wrongdoing. It’s inexplicable news judgment, unless you simply assume there’s a crime out there.
On their editorial and opinion pages, the corporate media from the New York Times to CNN all say that Trump is unqualified to be president and that his candidacy presents an unprecedented risk to the republic. But in their news pages all they ever talk about is phony Clinton scandals, while Donald Trump's innumerable very real scandals are completely ignored, even when they are reported by credible single sources such as  David Corn, David Farenthold and Kurt Eichenwald -- as are issues of public policy.

I am very puzzled by this.

Also, too, what Digby says.

All of this raises a question The Washington Post’s Paul Waldman raised two months ago: How is it possible that Clinton’s email brouhaha has marked her as thoroughly corrupt and dishonest, while Trump’s monumentally nefarious past, present and future are overlooked? Waldman’s assumption is probably the correct one: The narratives were set early in the campaign cycle, with Trump being the bigoted, crazy one and Clinton being the corrupt one. That’s just how the media frames the contest. They got it wrong. Yes, Trump is the crazy, bigoted one. He’s also a misogynist and worse. But he’s also the corrupt one, perhaps even more than most of us who had already understood that ever imagined.


Thursday, October 27, 2016

Something vs. Nothing ought to win every time . . .

. . . but it's uncomfortably close. The New England Journal of Medicine informs thusly:

The editors invited the Democratic and Republican presidential nominees, Hillary Clinton and Donald Trump, to answer the following question for Journal readers: What specific changes in policy do you support to improve access to care, improve quality of care, and control health care costs for our nation? Secretary Clinton responded. Mr. Trump did not respond.
I expect he found it difficult what with his 200 word vocabulary. Anyway, you can read Hillary Clinton's response here. Sure, there's a lot of rhetoric in there and some non-specific promises but there are also some very specific, real and progressive items. Of course, they won't get through Congress unless Nov. 8 is nuclear, but for what it's worth here are a few highlights:

  • Enhance tax credits to make insurance on the exchanges more affordable
  • Public option in every state
  • Medicare buy-in for people 55 and older*
  • Streamline approval of generic drugs
  • Require drug companies to justify their prices
  • Allow Medicare to negotiate drug prices
  • Expand payment reform
  • Promote integrated medical and mental health care
  • Expand funding for community health centers
  • Assure access to affordable contraception and abortion
  • Increase investment in medical research 
This is a real, progressive platform that would make a huge difference in people's lives. You can vote for it, or you can vote for nothing.

*Sets up the slippery slope to single payer national health care, in case you didn't get that.

Monday, October 24, 2016

The 60s


The death of Tom Hayden is a timely reminder of a previous turbulent time in our history. I was a teenager, and I just missed the Vietnam draft. (I turned 18 in the last year of the draft and had a high lottery number.) To me, and in my circle of friends and acquaintances, it as just normal and natural to view the U.S. as war in Vietnam as a crime against humanity, to see the government as largely an agent of plutocrats, the society as fundamentally racist, and capitalism as fundamentally exploitive.

I haven't really changed those views, but of course I'm more jaded now. The revolution never came, though we did make some progress. The 1960s left was male dominated and took patriarchy for granted; women were largely placed in a subservient role. As Hayden's obituary notes, he was part of the problem, and he eventually got slammed for it as feminism rose up within the left. Nowadays we see gender equality -- and gender equality going beyond the binary male/female categories we took for granted -- as being essential to progressivism.

George W. Bush got his illegal war of aggression but there was much more resistance early on than there had been to the Vietnam atrocity. We learned the hard lesson that the widespread resistance to the Vietnam war that eventually emerged was driven in considerable part by the draft that threatened middle class white kids. With no draft, the Iraq war, while controversial and ultimately repudiated by most responsible commentators and the public, generated far less passionate dissent.

Women and gender minorities have come a long way since the '60s, we did get Medicare and Medicaid, but the plutocrats still rule. In fact inequality has only increased. Racism is less socially respectable but I'd be hard pressed to say there is a whole lot less of it. The military-industrial complex is as entrenched as ever and we can't say the national surveillance state is less intrusive than it was in the days of J. Edgar Hoover. And what progress we've made on environmental protection faces continual rearguard action and we're pretty much neglecting the existential crisis of civilization facing humanity.

An extremist ideology has taken over one of the two major parties and managed to insert some false premises into the conventional wisdom, particularly that the national debt is an urgent problem and we need to cut entitlement spending, threatening the gains of the New Deal and Great Society. (Viz. Krugzilla.) Voter rights are under assault once again. I'm not sure whether Hayden looked back on his lifetime of advocacy with some small degree of satisfaction or if he felt essential despair. My own feeling is that progressive ideals generally have wider currency but do not have proportionate political effectiveness. I wouldn't say we've gone backwards but we're climbing the ratchet of progress very slowly.

Monday, October 17, 2016

Providence, RI exercises common sense


Our previous Director of the state health department convened an Emergency Medical Services working group, consisting mostly of fire chiefs and EMS personnel but also including me as the token academic. It was fun. I would wear the firefighter jacket I inherited from my father.

Anyhow, one of the big issues for EMS is what they call Frequent Fliers. I forget the exact percentage, but the majority of ambulance runs transport a small number of people who ride anywhere from once a month to, seriously, one guy who was transported 235 times in 2014. How can this be, you may ask? Well, a lot of them are incorrigible alcoholics. The problem for EMS is that they had no place to take them but the emergency department. There were legal and financial issues involved, as well as the simple lack of an alternative. As you presumably know, emergency departments are expensive and they have a lot of what drunks don't need and nothing that they do need. They'd just sit there until their blood alcohol went down, get kicked out, and come back a few days later.

So, it required an act of the legislature to do three things: protect EMS from liability for transporting people elsewhere than the ED; allow them to be paid for doing so; and create the place to take the drunks. The place hasn't opened yet but it's under construction. The people will get counseling and other services. Whether that will lead to any of them getting sober is unclear, but it will save the city and state some money and who knows, maybe it will actually help some people.

The strange thing is that it took so long to figure this out, and that most cities still operate as Providence has done until now. We just get stuck doing things the wrong way, it seems.

Friday, October 14, 2016

Back to the Knitting


Haven't posted for a couple of days because it felt like, what's the use? The world has gone insane. But what the heck, we're still here and there are still problems that matter so let's talk about some of them.

This week's NEJM puts the focus on serious mental illness -- the people who used to be in what were called "insane asylums" but are now more commonly living on the street or in prison. Lisa Rosenbaum discusses the history and the dilemmas created by the current situation. In a companion essay, Christine Montross discusses mentally ill people in prison.

You probably have heard about conditions in mental hospitals back in the day. They were indeed totalitarian realms in which patients were often degraded and abused. When antipsychotic drugs became available that could control symptoms of severe mental illness, a movement sprang up to move people out of mental hospitals and into supportive community settings. Everybody thought that was a great idea so they largely closed down the state hospitals and moved the people out. However, they didn't do part B, which was to create the supportive settings in the community. Part A saved a lot of money, or seemed to; part B would have required spending money.

So homeless shelters and prisons, rather than group homes, ended up replacing the asylum. Many people with severe mental illness can't behave the way prisoners are supposed to behave so they end up in solitary confinement. People who are (maybe) lucky enough not to be in jail are sleeping on the street. If you live in the city you see them all the time. And no, we aren't saving money. Prisons are expensive, and so are hospital emergency departments which people with serious mental illness land in with sometimes astonishing frequency. (Providence EMS, I am told, transported one individual more than 200 times in 2014.)

We might have a discussion of these issues in our political campaigns, or so you might think.

Friday, October 07, 2016

Threatened Sanity


As I may have mentioned once or twice, I have a long commute. I have what I am increasingly deciding is a bad habit of listening to National Pubic Radio under the misapprehension that I am making some positive use of the time.

Currently they are doing the common lazy journalistic stunt of rounding up random nobodies-in-particular and getting them to talk about why they are going to vote for candidate A or B.. In this case 50% of them are going to vote for the Cheeto dusted megalomaniac.

These people all have one thing in common. They are blithering idiots who presumably are able to dress themselves or they wouldn't be out in public, yet that seems implausible. I discovered that I cannot listen to their drivel so I have to turn the radio off for a couple of minutes until I'm sure it's safe.

Many people are now questioning the viability of our electoral republic. The tolerability of letting idiots vote is dependent on the proportion of idiots in the population and it is evidently much too high. Of course there is a disease vector for the epidemic of idiocy -- the corporate media.

There are signs that some editors are waking up to the horrific danger they have created. The New York Times has improved a bit in the past couple of weeks, although they are still gasping desperately for balance, as with a recent long-form piece discussing Bill Clinton's extramarital adventures. But even the victories are Pyrrhic. We're talking about how the candidate insulted a former beauty queen and whether he pays taxes. As Krugzilla notes, we aren't hearing a word about the crisis facing industrial civilization; and I could add, pretty much anything else of substance. Apart from the border wall and the Muslim ban, both of which may or may not currently be operative, the people don't know anything about policy differences. Well, okay, one candidate doesn't really have policies but he will sign everything that Paul Ryan and Mitch McConnell put on his desk and appoint Rush Limbaugh to the Supreme Court.

The discourse is so debased and depraved that it makes you wish for a philosopher king.

Tuesday, October 04, 2016

Why premiums are rising on the ACA exchanges -- and the deeper meaning


Health economist Uwe Reinhardt professorsplains it for you.

There are a couple of moving parts to keep in mind here. The first is that for any given health care service or product, the price is higher in the U.S. than in the rest of the world. It just costs more to deliver the same amount of health care here as it does elsewhere. There are a couple of reasons for this, which I'll mostly leave for another day, but this is a hard problem to fix because obviously those high prices are going into the pockets of people who are politically influential.

The next point, which Reinhardt shows you in graphic form (do lick link) is that 50% of people account for 97% of all health care spending, and the top 10% account for 65%. That's okay -- that's the whole reason why we have health insurance at all, because very few people in the top 10% have even a fraction of the income they would need to pay their own way. Health care is completely unlike other basic goods. We all need about the same amount of food, and the cost of basic shelter and clothing are about the same for everybody.

Now obviously if you're well off you can buy fancier food and clothing and bigger houses, but that's pretty much beside the point. Few of us want to consume more health care than we need -- with the exception of a very small number of people with psychological disorders, it's no fun at all, in fact it's often painful and otherwise unpleasant. And vanity cosmetic surgery is not paid for by insurance so that's also beside the point. Those people who are consuming a lot of health care need it.

So the way civilized countries solve this problem is that they give everybody basic health care coverage and finance it from some sort of a universal levy that has people paying a share they can afford -- simplest is a system funded from a progressive income tax, but some countries use kludgier systems just because.

Before Obamacare, people generally either had coverage through employment; or through government -- Medicare, Medicaid, military service and veterans' benefits. People were eligible for this coverage regardless of their need for health care, which meant broad risk pools including people who consumed relatively little health care, making the whole thing affordable. But people who didn't have coverage through these means couldn't buy insurance if they happened to be sick and actually need it, because it would be very expensive, precisely because otherwise uninsured people who were healthy would not choose to buy insurance and therefore they would be joining a very expensive risk pool.

So the Affordable Care Act forced participating insurers to issue policies to all comers, and to offer them all the same premium. The individual mandate was necessary to force young and healthy people into the pool, but for political reasons, the penalty was set much too low. Therefore insurers discovered that policies sold through the exchanges were costing them more than they expected, therefore they are jacking up the rates (or getting out of the market), which is just going to cause even more relatively healthy people to forego insurance and pay the penalty and so on. This is called the death spiral.

Solutions:

A) Jack up the penalty for not buying insurance. Stat.
B) Pay for universal health care through the tax system. Yes, that means higher taxes but you won't be paying insurance premiums, so you'll actually save money. (And if you get health care through your employer, you're paying for it whether you know it or now.)

But we have a weird, ideological aversion to anything called taxes. We want what they buy, but we don't want to pay for it. Because Freedom.