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.

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.

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.

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.

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.

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.