Today I Learned...

I have had many criticisms of Obamacare. I thought it was a sop to insurance companies and could only control costs by destroying innovation. But even I was not so cynical as to realize it was in fact another attempt to force the poor to subsidize the middle class.

The Obamacare plans, even the gold plans, have very high deductibles. I should be in favor of this, because low deductible plans are just prepaid health care, not insurance. But there's a wide range of health care that's...discretionary. There's my long health slog, of course, but you'd be surprised what becomes discretionary when you can't afford it. Urgent care for a heavily burned finger that will probably heal on its own. An ER visit when you're almost certainly not having another heart attack. A tooth ache.

Obamacare plans make some preventative care free. But otherwise it doesn't cover anything until you reach your deductible, and is pretty expensive until you reach your out of pocket maximum. The insurance doesn't really pay off unless you spend a lot. Who has the money to do that? By definition, the richer you are, the more money you have, the more likely you're going to reach your out of pocket maximum.

I think the poor are still covered in the event of true catastrophe, because you don't have to spend your out of pocket maximum, you just have to incur it, and hopefully the hospital will extend you credit on that after you've been hit by a bus. But the people this law was supposedly trying to help? They can't afford the premiums on the plans where they can afford the out of pocket maximums, even with the subsidies. Which means the subsidies are not going so much to them as to the people in their risk pool with the resources to meet their deductible (whose premiums are being artificially lowered by community rating and the premium ratio cap). Saying they have equal coverage is insulting and a break from reality.

But adults with wealthy parents can stay on their insurance until age 26, which is nice.

[reminder: I've been against Obamacare since it was proposed]

I always knew Obama's promise that no one who liked their health insurance would have to change it, that everyone could keep their doctor, was bullshit. It would have been bullshit even if the law didn't expressly forbid some existing forms of insurance, because even if everything was technically legal, Obamacare changed the incentives and people respond to incentives. I knew that what he meant was "we're not instituting the NHS, your choice of doctor will still be between you and your insurance company." Nothing in the law *demanded* providers shrink their networks, but it would be criminally negligent if no one crafting the bill thought of that as a possible thing insurers would do when faced with a demand to provide more care for less money. So yes, Obama either lied or is so profoundly stupid it's amazing we're not giving farm subsidies to water crops with Gatorade.

That said, I think the insistence that Obamacare be a Pareto improvement over the status quo led to a lot of the worst parts of the bill. They reinforced the link between employment and insurance. Let me repeat that: THEY REINFORCED THE LINK BETWEEN INSURANCE AND EMPLOYMENT.



I have just about the shiniest, most employer provided insurance you could have. And I use it. I would definitely suffer financially if the link between employment and insurance was weakened. And I still think it's a travesty they didn't. I can't even use words to describe this, just more My Little Pony gifs



If they had been willing to let some people suffer temporarily, they could have ended up with a much better bill. One that, say, taxed insurance as regular income and thus removed the incentive to pay people in the form of health care, which they then overconsume. Or at least didn't reinforce the link between insurance and employment.

Speaking of employment and insurance and taxes, let's talk about the Cadillac Tax. Rather than, say, tax the cost of the insurance as income, thus weakening the link between employment and insurance, they have this weird excise tax that is higher than the top marginal rate for income tax (although to be fair, not quite the top marginal income tax rate + payroll tax), based on some weird moralism that person A having really amazing insurance is prima facia hurting person B. I had naively assumed that a plan was considered Cadillac because it had a low deductible or co-pay. This turns out to be wrong. It is considered a Cadillac plan if it costs more than a certain amount. Since premiums vary based on demographics, health status, and risk factors like smoking, this is essentially a tax on being high-risk.

Or at least, it should be. Another problem with Obamacare is that it limits the spread between what young people and old people pay, to a ratio far lower than the expected cost for each group. And it bans considering health status entirely. The explicit goal is to have the young and healthy subsidize the old and sick. Government action making one class of people give money to help another is called a tax, except it's going through a private company and is obfuscated by semi-enforcable demands to purchase a product. I hate taxes as much as the next puppy-kicking neocon, but given that we're going to pay them, I would at least like to pay them to the government. Involving a theoretically unlimited number of private companies to collect the tax and distribute the benefits is a gross violation of every reasonable set of principles I can think of.

It's like someone looked around the country and realized that we pay farmersing conglomerates a lot of money to not grow crops, and the return we do get is less and less like real food every year, and trying to fix it by giving the farming conglomerates more money and forcing everyone to pay a portion of their income to their choice of McDonalds, Wendys, or Burger King. And then claiming all the problems are solved because Consumer Choice.

My digestive system and my immune system are at odds, and it is annoying me.

My immune system hates wheat, milk, and eggs. If I eat them, my lymph nodes swell and I feel generally sluggish and icky.

I don't produce enough digestive enzymes. If I don't supplement with HCl and digestive enzymes, eating anything with real nutritional value, like vegetables and meat, makes me feel ill. I can feel it sit in my stomach and rot. In my stomach's ideal world, I live on bagels and pasta, but of course that is not good for anyone, and is especially bad for people with wheat sensitivity.

I'm sick. My digestive system is even more sluggish than usual, to the point that real food makes me feel icky no matter how many pills I take. My stomach could handle small amounts of simple carbs- but my immune response to wheat hasn't gone away. There is nothing I can eat that will make everyone happy right now. The compromise has been marshmallows and dark chocolate, which are are easy calories that are nonetheless gluten free. You can tell my nutritionist is cool because she said that was not an ideal long term solution but a perfectly good way to cope with the situation at hand.

The health care debate has gotten very, very muddled. Most of my reading on the subject is by progressives (writing either for other progressives or for a general audience as an attempt at conversion), or by libertarians for libertarians. There is a pattern I have noticed that I think is worth addressing: progressives tend to see either One Big Healthcare Issue, or lots of issues with the same solution. Libertarians (as personified by me) tend to see hundreds of small issues that are going to need individual solutions. Which is interesting, because it's the reverse of the usual pattern, in which I think everything could be solved by introducing competition and progressives think we need an expert to tailor a solution to the specific problem.

So here are some of the individual problems I see, and short versions of my preferred solutions.

Problem: People can't afford health insurance/health care.

Give them money. To be fair, this is my solution for all problems relating to poverty. It sounds glib, but I'm being sincere. If we want to place a floor on the consumption of adults, we should just do that. If people are not using the money on the things we want them to, we should reevaluate our wishes or their ability to take care of themselves. Alas, this gets considerably more complicated if children are involved.


Problem: Health insurance is too expensive/increasingly expensive.

Insurance profits are reasonable and have not been rising in recent years. What you are seeing is a rise in the price of health care itself.


Problem: Health care is too expensive/increasingly expensive.

This is sometimes called "health care inflation", which is misleading, because much of the increase comes from the introduction of new things to buy. It's like saying we've had smart phone inflation since 2000. You could make the problem go away by not buying new things.

Some of it is that we're consuming more things. I am maybe the only person who liked Obamacare more after she heard about the death panels, because the alternative was everyone deciding for themselves how much of other people's money they wanted to spend on their own health care. Also, it's still not inflation in the technical sense of the word, any more than we experience produce inflation when I double my banana consumption.

However, some of it is genuine inflation , brought on by Baumol's cost disease (short version: if you have two sectors, and one gets more labor efficient, the other one experiences inflation). There are three solutions: pay workers less for the same job (which every politician ever has promised not to do, because health care professionals are sympathetic, have money, and vote), shift work to lower-wage workers (which we are trying, via things like nurse practitioners and physician's assistants. I am in favor of this but think it bears monitoring before we declare it a total success), or invent labor saving devices (which we have actually done some good at, but since in many cases the replacements are themselves expensive, we won't see returns until they go off patent). I am totally in favor of investment, both public and private, in labor saving devices. But we can't do that by wishing really hard, we have to work with the market we have and adjust if it improves later.

Problem: Wait a minute, you skipped over a possible solution. We could just pay less for the new things.

Okay, technically that's true, but it's a one time savings. Profits are what motivate pharmaceutical companies to make new things that let me live longer. I think our patent system actually does an excellent job here, providing some time to make money and then providing the drugs nearly at cost for all eternity (I have no opinion on the proper length of that first period).


Problem: why don't we just cut out the middle man and do it ourselves?

That is a good idea. There are definitely inefficiencies in the current model. But how do we do that? University research isn't directly translatable into usable drugs. There are many possible improvements to this model, and I am fully in favor of government funding for them as pilot projects, but I would like to see them work before we shoot the old model in the back of the head.

Problem: Even if the increase in insurance costs are due to care costs, couldn't we get a one time boost by removing their inefficiencies?

Yeah, maybe. There certainly are inefficiencies introduced by having 40 different billing systems. But considering that the government's systems are the most complicated and time consuming of all, I don't see them fixing it.

Problem: Health insurance is linked to employment.

Yes, this is deeply stupid. There are two causes: one is that the government subsidizes employer-provided insurance by not taxing it as income. This is stupid and they need to stop doing it.

The second is that employment is a way to get around adverse selection and the resulting insurance death spiral. This one is harder to solve. We probably can't fix the information asymmetry, which leaves mandating everyone purchase insurance. There are two problems with this: done by the federal government, it is either unconstitutional or stretches the commerce clause to the point that it can do anything. State governments can do it constitutionally, but still risk what happened in Massachusetts: originally advertised as mandating only catastrophic (i.e. true) insurance, the bill bloated until it mandated all kinds of care (because lobbyists bought the clauses), raising the premiums considerably. (My impression is that the conclusion progressives draw from this is lobbyists and/or money has too much power over politicians. The conclusion I draw is that we should minimize the number of things government can mandate so that there's no point in bribing politicians).

Note that Obamacare introduced mandatory issue (insurers must insure everyone that asks) and community rating (insurers may not charge more for riskier people) years before mandating purchase (everyone *must* purchase insurance). This is the worst possible thing.

So it's a stupid system, but it will be very hard to transition to something else.

Problem: what was that snarking about "true" insurance?

Insurance means insulating you from rare, extremely costly, unpredictable events, like car accidents and cancer. What gets called insurance today is often just 3rd parties paying for routine care, like vaccines and annual check ups.

Kathleen Sbelius, United States Secretary of Health and Human Services, got this exactly backwards .

Problem: but preventative care lowers the costs for the insurance company, so it still makes sense for them to pay for it.

This is just not true. Very little preventative care lowers the total cost of care over someone's life, because we just keep treating you until you die. Everyone dies of something, and the causes get more interesting and expensive the older you get. Even if the cost was exactly the same, you've been alive for longer and sucked up more money for annual care. The only things proven to actually lower costs are vaccines, dental care, and pre-natal care. You can argue about preventative care being a more cost effective way to raise life span or Quality Adjusted Life Years, but that is a different issue. To the extent that it is true, the gains don't accrue to the insurance company. This doesn't mean preventative care isn't an excellent thing, but excellence and money saving are not synonymous

Problem: The same care costs a lot more when you pay out of pocket than when insurance covers it, and with a lot more uncertainty and anxiety too.

This is a big problem. I don't know how to solve it and am interested in hearing ideas.

This is all very hard to argue at cocktail parties. The other side has some very good visuals and easy to explain solutions. I have a lot of graphs and arguments about highly distributed long term consequences.

As I mentioned in my review of The Abyss, I am horribly affected by pets being hurt, killed, or threatened in stories. Cat deaths are especially bad (see: Battle Royale, Rifter's Trilogy, and The Filth, all of which are about truly awful socities), but I got emotional watching the fish deaths in A Fish Called Wanda too. It's not so much a trigger as a place completely without armor.

I think part of what bothers me is that 1. pets are our responsibility and the trust us and 2. we (I) can't explain what is happening to the pets, which Peter Watts covered better than I ever could in this eulogy for his cat Banana:

He tried to run, you see. Something happened, inside; something broke, and he felt it but he had no way to parse it except that somehow there was a mortal threat and he wasn’t equipped to tell the difference between the things that kill you from the outside and those that kill you from within. All he knew was that his life was in danger, and he reacted the only way he knew how: he tried to run away.

. The fact that something I pledged to love and protect is suffering and I know what the stress chemicals are doing to it but I can't fix it- may even be causing it- tears me up every time.

I was discussing health care and end of life care with a friend today, and realized that this is really present in my feelings on dementia as well. One day you're an entity (or caring for an entity) that can think and plan and rationalize short term pain for long term benefit, and then you're not. And you're left with something that looks like a person but is missing one of the hallmarks of humanness, who is just aware enough to know they're missing something but not what or how to get it. I would be less afraid of Alzheimer's if it didn't make you so mean. Losing your mind is terrible, but senility led to Down's syndrome like behavior, it would bother me less, because you're happy and, while there's some burden of care on your loved ones, they're receiving love and kindness in return. Alzheimers, most other forms of old age senility and dementia, and most forms of mental retardation leave you just aware enough to get angry and hurt the people who love you the most. And I don't see why anyone wants to maintain that, much less force others to do so.

One of the accusations frequently lobbied against organizations like the Pink Ribbon Foundation is that their corporate ties lead them to focus on cure over prevention- in the worst case, partnering with companies and even specific products that contain carcinogens. I kind of feel the same way about government and public health. I've talked before about how ridiculous it is to cover organ transplants for 80 year olds but not dental care for children, but I think it goes even deeper than that. The US government not only allows but subsidizes meat raised on a diet of grain and antibiotics, to the detriment of our health.

I don't think medical companies (or farmers) are evil for wanting to make money. It's what they do, and a lot of good comes out of it. And I don't think people who fight for cures for the specific disease they have, as opposed to general prevention, are evil either. It's human nature to overweight things that affect you.* But left unchecked, these things lead to a highly reactionary approach. Preventing the tragedy of the commons is an excellent use of governmental authority and I'd like to see us get good at that before we start trying to do stuff like decide exactly how much tamoxifen we're willing to buy for an individual 75 year old.

You know, I started this trying to explain that I wanted something else in place of what we're doing, but the more I think about it, the more I realize that this misallocation of energy really is what keeps me from getting behind Obamacare in particular and socialized medicine in general. It's like putting a crown on a tooth needs a root canal: technically some helpful in the short term, but it will need to be torn out before you can fix the real problem. I need to devote more thought to this, but it's entirely possible that if we mastered the fundamentals of not poisoning ourselves, I would not only be okay with socialized medicine, but championing it.

*See: me and dental care.

A while ago I was filling out a new patient form for a doctor's office, and saw an "other" option for both gender and sexual identity, and a "polyamorous" option for relationship status. As it happens I don't need any of those boxes, but I still felt better for seeing them on the form. At first I thought it was because if the doctor considered these sometimes heavily stigmatized states of being to simply be information she needed to know to do her job, then there was reason to believe she wouldn't judge me for my non-standard interests. It made it easier to talk freely without fear of judgement.

But now I think maybe there is more than that. I was watching For The Bible Tells Me So, a documentary on use of the Bible to justify hatred of homosexuality. And it occurred to me that they never say "I hate men having butt sex" or "I hate two men being in love" or "I hate women getting off without a penis involved", or anything specific. The talk about abominations, and perversity, and sickness. Which is a good strategy on their part, because there is nothing homosexuals specifically do that could possibly justify that amount of hatred and fear. But it makes me think that some of what was so comforting about that intake form was the willingness to explicitly name things that many people would not acknowledge.

People, including people who pride themselves on being open minded and accepting, including me, sometimes complain about the extra time it takes to not use "woman" and "vagina haver" as shorthand for each other, to not assume an anonymous internet is a woman because they mention having a husband, to not say "mom and dad" when you mean "parents" and not say "your parent" when you mean "grown up who is mostly responsible for your raising." It makes sentences much longer, ruins comedic timing, and it's a lot of effort for such a small portion of the population. But taking the time to draw these distinctions helps more than trans women and men, gay men, and children being raised by their gay grandfathers. By talking explicitly about things often left implicit due to discomfort, they help everyone whose life is even a little nonstandard feel more accepted and less afraid. And that is worth doing.

This is the story of a woman carrying a fetus that was self-evidently non-viable, but still had a heartbeat. The heartbeat is used as the definition of life for the purpose of Chicago laws. Right now, this means that she had to listen to a doctor explain what abortion was and sign consent forms 24 hours in advance, and that her insurance carrying wouldn't cover it. If abortion was banned, or only allowed for dead fetuses, or only in cases of imminent deadly threat to the mother,* she would have had to carry a dying fetus inside her until she spontaneously miscarried or went into labor. This could have left her infertile, or killed her. If it did none of those things, she would still have to carry around a reminder of the child she wasn't going to have, fake happiness for strangers or share an intensely personal story, and suffer the usual risks of pregnancy.

Individual pro-lifers may not want this to happen, but the laws they advocate predictably lead to this result. They can either admit that this is an acceptable cost to them, or they can advocate for something else.

Anesthetic.

I am lucky to have always had access to frequent top notch dental care. I give dentistry a hard time for handling my trigeminal neuralgia so poorly, but the truth is that without electric toothbrushes and 4x/year cleanings by very good hygienists, I would be in constant oral pain until I died at 40. It's one area I just lost the genetic lottery in.

My dentist talked me into a cleaning with local anesthetic. I kind of thought this was bullshit: we weren't hitting the limits of my pain tolerance, we were hitting the limit of the hygienist's ability to listen to my pain. Which then lowered my pain tolerance because she would stop working and make me reassure her that I was fine, which broke up my attempts to process and not notice that someone was repeatedly stabbing me in the gums. But I agreed, and it turned out to have been a really good idea. Judging just by the amount of blood, She really got in there. Sober, I couldn't have sat still if i wanted too. Numbed out on lidocane, it was basically the world's worst manicure. I'm not having fun, but it is nice to have an hour where nothing is expected of me. I am really lucky to be able to get both the cleaning and the anesthesia without having to sacrifice in other areas.

Money probably does this in a lot of other places too. Even if a rich person and a poor person are suffering nominally the same thing, money lets you escape some of the consequences. Everyone has to go to the DMV, but it's a lot easier when you have flextime. Anyone can use the unemployment office's online system, assuming they have the money for a computer. And so on.

Suppose I could afford the cleaning but not the anesthesia. After the last anesthesia-free cleaning, I was useless for an entire day. I was just too pained and too pissed off at the dental office to accomplish anything. After the anesthesia cleaning, I felt fine. I still took the day off because I already told work I was going to do it and I had a lot of anxiety going in to the appointment, but it wasn't necessary.* I don't enjoy losing a day's pay, but I can afford to do so. Presumably I wouldn't have done that if I absolutely needed the money. But cope is a limited resource, and if I hadn't been able to get it back by staying home and watching Once Upon A Time, I would have found some other way. Alcohol. Abdication of parental duty. Putting off other necessary work. You pay for it somehow.

So I have two points here. First, if you have the money, totally use it to drug yourself during teeth cleanings, even if you have to pay for it out of pocket. I refused for a long time out of some sort of misguided puritanism, plus I was insulted that my dentist kept implying I needed it. Now? I would ask for narcotics if I didn't find them horribly unpleasant. Let modern medicine do one of very few things it's actually good at. Also, don't let your dentist try to talk you into an hour and a half if your back starts complaining half an hour in and the anesthetic lasts an hour. Just come back another day.

Second, it's good to consider what else you're able to buy yourself out of. You don't have to stop doing it, because suffering is not zero sum, but it's good to be aware

*Which is good, because the hour we spent was enough to do exactly one quandrant of my mouth, and I need at least three more of the same, and possibly another cycle after that, at which point I *might* be able to go down to every three months, although it'll take eight appointments because we'll have to do top and bottom separately.

Everything I know about the new potential prophylactic HIV cocktail I learned from this Savage Love Podcast. I'm very willing to believe that Dan Savage (or his doctor co-host) did not deliver a full and accurate reporting of the research. But my thoughts on the topic are so general I'm prepared to plunge in without learning more.

The reported efficacy is 40-60%, with perfect use. Let's pretend everyone uses it perfectly: that's still not high enough to produce herd immunity. Herd immunity is when you've manipulated the environment (through preventatives or treatment or simply sufficient numbers of the susceptible people) such that the average infected person infects fewer than one person. The disease can't propagate at that point. From a public health standard, it's herd immunity or nothing: anything else is nice for the individual but irrelevant.

But everyone won't use it perfectly. People don't take drugs perfectly even when they're immediately helpful. A preventative drug with nasty like effects (which this is) is going to have severe compliance problems.

Some people are arguing we shouldn't release the drug because it will give people a false sense of security and decrease condom use. I don't care. Adults get to make their own choices even when they're stupid. What concerns me is that intermittent use of preventatives against an entity that can evolve is the perfect way to evolve resistance. You couldn't design a better way to create drug-resistant AIDS if you wanted to.

I think the FDA has no business telling people what drugs they can or cannot take and does a lot of harm in trying. But that's for things affecting individuals. Antibiotics and antivirals are public goods, and degrading their efficacy for a small chance at dodging HIV is exactly the sort of thing government should prevent.