Map of life expectancy at birth from Global Education Project.

Wednesday, December 31, 2008

Cross the gypsy's palm with silver . . .

Last year, I predicted we would have a nasty recession. Check. I also predicted that oil prices would stay high regardless. Not so much, although I'm still expecting a rebound. We won't discuss my Superbowl pick.

2009 is a tough year for the prognosticators. The psychics can throw just about anything at the wall and hope something sticks. Yellowstone supervolcano, anyone? Actually I'm not worried about the greatest catastrophe since the emergence of Homo sapiens, destroying Civilizationasweknowit -- not going to happen. However, it's a good bet that there will be a substantial natural disaster somehow somewhere in the US of A. Here's hoping that it doesn't happen before Mr. Obama gets his own team in place at FEMA and he gets unfairly blamed for any screwups. So that brings us to my first real prediction, that whoever he appoints won't have prior experience consisting of investigating alleged liposuctioning of horses' asses.

I'm sure the prognostication everybody really wants from me concerns health insurance reform. Unfortunately, as I have noted many times, the political system is stacked against the changes we really need. The problem, as the Political Scientists say, is one of concentrated vs. diffuse interests. (Political science is not a science. When I pointed this out as a college freshman, my professor, Nannerl Keohane, who had recently married fellow Swarthmore professor Robert Keohane following some sort of rumored love quadrangle [possibly bogus] and then went on to become president of Wellesley College and Duke University [meanwhile my art history professor was changing genders from male to female, but her {formerly his} wife stayed with her so evidently they both became lesbians. It was a regular Peyton Place.] wrote up on the board the word scientia, and asked me if I knew what it meant. I replied, "It appears to be in some foreign language." God, I was insufferable. Actually it's Latin for "knowledge," i.e. science didn't used to mean science as we know it today but just generally knowing stuff, or thinking you know stuff, and that's poli sci.

But I digress. The point is that while the vast majority of Americans would benefit from universal, comprehensive, single payer national health care, for a lot of them it would be, or seems to them to be, only a minor advantage over their current situation, and they have other concerns that seem equally or more pressing. The people who would benefit the most, in fact, have the least political resources and influence. So there just aren't structures that translate this diffuse interest into real clout within the lawmaking institutions.

But for a small segment of the population, which happens to have immense political resources, it's a major threat. For insurance companies, it's life and death; for drug and medical device companies, it's a tragic attenuation of the river of gravy in which they are accustomed to wallow. Both of these industries have very powerful lobbies and own numerous Senators and Representatives. (The medical profession, as embodied in the AMA, for many decades bitterly opposed it as well. Although docs have largely come around, there is still enough ambivalence and dissent within the groves of Aesculapius that the AMA is not likely to be a strong player in this game.) The Free Market™ theology that permeates the political culture is a powerful weapon in the hands of the opposition, since newspaper and TV reporters are too ignorant to know that it's a crock, and it has also been adopted by the right-wing theocrats such as Rick Warren who stuff it into their sheepish followers along with the rest of the horseshit they peddle. All of these powerful actors, including the 43 Republican Senators to whom the pathetic, wimpish Senate Democrats will hand over total control, will fight like pit bulls to stop reform.

Obama's actual proposal, as we know, is modest and incremental. It's fairly similar to the current experiment in Massachusetts and the Swiss system which our friend Ana has described for us, neither of which is entirely successful, to say the least. In fact we're headed for a major crackup here in Massachusetts, where we are about to discover that we just can't pay for it after all. I fear that will become evident before anything moves very far through the Congress, which won't help matters. The lesson ought to be that we need a truly radical reform which can effectively contain costs, but I fear the opposite conclusion will be drawn.

So here's my prediction. What we'll end up with is little more than an opportunity for people to buy into a federally sponsored plan, but with insurance companies sitting in the middle taking a cut for no reason other than they lobbied for it, on a sliding scale which won't really make it affordable for low and moderate income people. Employers could also choose the same plan for their workers. It won't be truly comprehensive and it will have significant co-pays and limitations, e.g. no dental. It will be partially community-rated but will include some age rating, meaning that people in their late 40s through early 60s will be even more likely to be priced out. But it will expand access a little. There will be some other bells and whistles, such as a U.S. equivalent of NICE but with no real powers, just jawboning; maybe some half-decent FDA reform that may last for a little while; and some bargaining between the national plan and the drug companies that will save a few cents on some drugs, mostly just for show.

Then the challenge in coming years will be over the viability of the national plan, whether it can be structured and funded so as to become truly affordable, and outcompete the private plans so as to move toward universality. If the drug and insurance companies perceive it as the camel's nose under the tent, they may stop even that, but perhaps they won't be able to. We shall see.

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