Sunday, August 30, 2009

Health Care and the Jewish Problem

There has just been a birth in the Californian branch of our family. I called the new father to say mazal tov and he described how at the last moment there had been various complications, but everything is alright. So, he summed up, since you've been mentioning healthcare on your blog, Yaacov, you might want to mention that my vote is for the system. It works well.

(Actually, I think he was talking about the system before it changes, i.e. as it already is, so his point may have been different than he meant - but I really don't think this is the moment in his life to be quibbling about politics. His agenda at the moment is way above politics).

Then there was Dennis who slammed into me last week, going so far as to call a post of mine that mentioned healthcare, a travesty.
You rightly criticize those of us here in the United States for doing not understanding the complexities of the Israel/Arab/Palestinian conflict. But you do the same thing when you say that you are agnostic on "who's right and who's wrong, who's fibbing and who's fibbing more."Don't mean to be harsh, because I read you constantly but you have this wrong.

In between Dennis and the new father, I had a chat the other evening with a fellow who lives here but works as a physician in the States (you'd be surprised how many such extreme commuters there are). He told me that philosophically he's all for revamping the American health system, and would even be willing to take a financial hit if it would be for the general good, but in his opinion nothing being discussed right now will make things any better, and probably they'll get worse, though he expects his income to remain unaffected.

This blog is not about American health care. It's mostly about Jewish stuff, though from time to time I jump around. Yet it occurs to me that the healthcare metaphor really can be useful, precisely because it demonstrates how impossible it is for an outsider to really understand what's going on.

I have no doubt that were I was prepared to spend six solid months studying the matter I could form an educated opinion, unless I'd need 12 months, or 24. If I didn't think so I couldn't be a historian, since historians have the fundamental conceit they can understand times and places they've never been to. Yet short of dedicating oneself totally to really understanding, I'm here to report that following the media doesn't work. These folks swear by their narrative; those folks swear by the opposite one. These chaps admonish that there's an imminent danger; the other blokes shrilly warn of a whole different set of apocalyptic threats. These guys quote statistics; the other ones wave different ones. Somehow there are Nazis involved on both sides of the argument, though I haven't been able to figure that out at all.

Not to mention that the single most important part of the story is not visible through the media at all: what's it like living in the system? I don't mean, which horror stories each side trots out. I mean the regular living part of the story. What's it like right now to live in the present system, what's wrong with it, and how ought it be different. What do you do when your kid has the sniffles? When she has something worse than sniffles? When, heaven forbid, she has something radically worse than sniffles? How does it work? What decisions need to be made, by whom, under which constraints?

This type of understanding cannot be had merely by following the media. Can't.

Which brings me back, unsurprisingly, to the things I do know about, such as living in this conflict-torn land. Or being a Jew. Without wishing to be arrogant, I expect these issues are more complicated than health care in America; they've certainly been around a lot longer... Anyway, you see where I'm going with this...


Yaacov said...

I saw, Aviv, but didn't see any reason to believe these people are any more non-partisan than, say the NYT. Even the Economist, which isn't American and might hopefully by non-partisan, is only partially helpful.

joseph said...

Dr. Lozowick,

Since Israeli issues are something you do know about, could you comment on this issue:
The article is from the local Jewish newspaper.


Anonymous said...

What is it like here? It is great if you can afford insurance. It is terrible if you can't.

40 million people do not have insurance. If they stay healthy, it's fine. If they don't, it's a disaster.

You can lose your insurance for all kinds of reasons. Something needs to be done to make it affordable.

And, btw, too many people here have brains "like dining room tables," and so Nazi has become the epithet du jour, unfortunately making the word meaningless.


Anonymous said...

There are a lot of really complicated problems with the health care system, but the post just above sums up the part of it that amounts to social crisis, as apposed to various issues related to the performance of the system.

Health care access in the US is based on your job. Increasingly, however, people have non-traditional jobs or work a collection of part time jobs and don't have access that way. If they're not overweight and don't have any other pre-existing conditions, access is still not totally out of reach, although it's expensive.

But if the insurance companies can exclude people or price them out on any basis at all they will do it, and this is what has become a crisis for a lot of people who, as Bill Clinton used to like to say, work hard and play by the rules.

A narrow fix is possible here, but that would mean forgoing the opportunity to exploit the crisis to push other agendas.

The narrow fix would be to require Insurance companies to market their products in a non-discriminatory fashion. One price for all customers and all products available to all customers. Insurance companies will object because they'd prefer to micro-manage their risk, but these rule changes would be more fair while still allowing them to price their products according to rational risk assessment. The only difference would be that their risk assessment would be based on a total national sample.

A gov't run system, by the way, would accomplish the same thing, but would bring with it all the absurd political baggage, corruption and management inefficiency of a gov't run system. It seems awfully stupid.

Anonymous said...

Yaakov, I have been a lurker on your blog for about a year now so I am familiar with and admire your caution in expressing an opinion on questions about which you have little knowledge or experience. In fact, I have found myself emulating your caution even though, being in my mid-fifties, I am not easily influenced to change my intellectual habits.

However, I think that you really are off-base here. There *are* questions where the obvious facts really do determine where any decent person should stand. The abolition of slavery and Nazi antisemitism are obvious examples as well as, in our lifetimes, civil rights for racial minorities (in the US but also elsewhere).

In this case, the facts of the matter really are very clear. Medical care here is fantastically expensive. Private insurance is also extremely expensive, much too expensive for the large majority, and is unavailable at any cost if one has a chronic condition or a history of serious illness. (In other words, if you are already sick, you cannot buy insurance.)

The vast majority of those who have insurance receive it as a benefit from their jobs. If they lose their job, they lose the insurance. There is an option to continue the insurance for 18 months by paying the entire cost oneself, but the large majority that are unemployed simply do not have the money to continue coverage. Even if they do, they have to seek private insurance after 18 months. Of course, they may be uninsurable (see above), in which case, they are simply out of luck.

It is true that, for the truly destitute, there is Medicaid, which provides insurance for the poor. But, the coverage varies widely between states, with many bureaucratic barriers that can be impossible to navigate if you are already ill. In addition, many health-care providers do not accept Medicaid. In any case, you cannot get it if you have any significant income or assets. In other words, if you do not have insurance (see above) and have large medical expenses, you must first spend yourself into poverty before you can get any government aid.

Given the basic structure of the system, if is not surprising that there are countless tragedies. People either do not receive medical care at all or are forced to choose between forgoing care or leaving their families in poverty.

The numbers affected are huge. Even before the current recession, something like 40 million or more were uninsured at any given time; millions more were uninsured for some period during any given year. Millions have been bankrupted by medical costs -- except during recessions, medical costs are usually the biggest cause of personal bankruptcy. I, personally, had a friend who died, in large part, because of lack of insurance. I have known others who were chained to their jobs because chronic conditions or previous medical history made them unable to get private insurance (even assuming that they could have afforded it).

The fact is, these things simply do not happen in any other developed country. Allowing it to happen here at all, let alone to millions, is simply barbaric.

There is a lot more I could say, but I will leave it at this for now.

David E. Sigeti

Thomas Lowinger said...

Mr. Sigeti,
Having health insurance as a benefit of being in the workforce increases the participation in the workforce and productivity of the country. If the govt. is requiredt o provide sustenance, housing, health insurance, why would people want to work?. 40 million out of 300 million is not such a great number and some of these 40 million are uninsured by choice. You should provide some reference to millions gone bankrupt because of a need for health care. The truth is there is a need to cover everybody but many avoid getting isurance (or trying to until they get sick)

Yaacov said...

Joe -

I wrote a section about this in Right to Exist. I think I've written about it here, too, but I'm not finding it right now so maybe I haven't.
Anyway, my sentiments are similar to those of Gideon Saar, and even Netanyahu. With 7.5 million Israelis, we can afford to find a way to let these 1,100 kids and their parents (in most case, single moms) stay here if they wish to be Israelis, too. That means they serve in the army when their time comes, and then they merge into the rest of society and live their lives.

Philo-Semite said...

Sigeti is correct. My family has experienced healthcare in a dozen developed countries, and in the USA the value/price ratio is the lowest. Even South Korea, Taiwan, and Israel provide better healthcare than the USA.

Further, the public-private mix Obama proposes works very well in Switzerland and Holland.

Lowinger and in fact the entire American right wing have adopted a position which is barbaric and verges on the insane.

I'm wary of Obama's views of the Mideast, but on healthcare his success would be the greatest mitzvah of the past half-century on the American continent.

Anonymous said...

Mr. Lowinger,

I find your post very confusing. At one point you say that, "The truth is there is a need to cover everybody," but earlier you argue that health insurance should be contingent on having a (presumably paying) job. Which is it -- do you think that coverage should be universal or not?

I also have no idea why you believe that we need to "increase participation in the workforce". I think that almost everyone who studies the well-being of American children thinks that we would be better off if we decreased participation in the workforce by encouraging families to have a full-time homemaker if they have children under a certain age. Such a shift of workers from the commercial economy to the household economy would not decrease productivity, unless you think that the only labor that is productive is that which is performed for an employer.

In any case, the biggest effects of having health insurance depend on employment lie in reducing the incentive to hire and in reducing job mobility. Employers are reluctant to hire because each new employee comes with the (more or less) fixed overhead of an insurance policy. Instead, employers have an incentive to work their current employees overtime, thus reducing employment and (often) stressing their employees. Employees are often reluctant or unable to switch jobs because of problems with existing medical conditions, changes in coverage, or just the risk of losing insurance if the new job does not work out.

No one here mentioned providing "sustenance, housing," or anything other than health insurance and the US does not come close to guaranteeing any of these to its citizens. However, there are many countries that effectively guarantee the basic necessities of life to all their citizens. For the most part, they do not have a major problem with people not wanting to work. People want more than the bare necessities, and they want the social status of being self-supporting.

How you can say that 40 million uninsured (about half of whom are children) is "not such a great number" is absolutely beyond me. (I suppose that one could have said in 1960 there were only 20 million African-Americans so why did we need civil rights laws.) In any case, you seem to have completely missed my point that the things that happen here -- people denied essential medical care for lack of insurance; people forced to choose between forgoing care and seeing their families reduced to destitution; people getting sick, loosing their jobs as a consequence of being sick, then loosing their health insurance when they need it the most because they lost their job -- should not happen at all and do not in any other developed country. Do you honestly think that we should allow these things to happen to our fellow citizens when we can easily avoid it?


Anonymous said...


Mr. Lowinger,

(Sorry, I left my signature off the preceding post. It was me.)

On the question of "millions" bankrupted by health care costs, I picked "millions" but not "millions per year" because it seemed a conservative estimate. The statement about medical costs being the leading cause of personal bankruptcy except during recessions has been around for some time now and I have read it repeatedly in the papers. It is possible that this statement is an exaggeration. I do not have time to do a careful investigation but an advanced Google search on the words "bankruptcy" and "medical" in the ".gov" domain produces some interesting links. This one:

estimates that "between 1.850 million and 2.227 million debtors and dependents experience medical bankruptcy annually". Note that the authors are including all members of the household.

This one:

claims that rates of medical bankruptcy have been exaggerated, although that I do not think that the author estimates a number (I just skimmed the article).

The second link is from a conservative think tank. I do not know about the orientation of the authors of the first link.

If you have time to investigate this question, I would be very interested in the results. Obviously, for something as complex as bankruptcy, the question of the "cause" will be based on one's methodology. Just changing the way you lump causes into categories can drastically change "the leading cause". Do you count "credit card debt" as a cause or do you count the credit card finance charges and the things that were bought on the card separately? If you have the time, have at it and I would be very interested to see your results.

David E. Sigeti

Anonymous said...


Thanks very much for your support. I agree with pretty much everything that you say except for lumping Mr. Lowinger in with "the entire American right wing", unless you have knowledge that I do not about Mr. Lowinger's opinions. From his post, it is not at all clear to me that he opposes universal coverage. (See my answers to him above.)

David E. Sigeti

Anonymous said...

Mr. Sigeti -

thanks for taking the time to write these long posts about health care. I find it fascinating that Mr. Lowinger assumes that if you don't have health care, then you don't have a job. I also find it fascinating that as one of the proposals in the health care reform is to require all employers, even McDonald's, to provide health care, an anti-healthcare reform talking point is that requiring employers to provide health care will reduce our workforce by causing layoffs and businesses failures!


Thomas Lowinger said...

Mr. Sigeti and others,
I am not prepared to go into the debate about health care on this blog, but let me mention a few things;
The united States has lower unemployment then other western countries France, Germany etc. Countries with extensive social welfare setup are monoethnic societis. The US being a multi-ethnic society based on somewhat different principles that have worked to make it the freest most democratic and most powerful nation on earth. Even people from countries with full medical coverage (such as Hungary, where I was born) are desperate to immigrate here. And by the way, many universal health coverage countries, such as Hungary in the 80's did not cover open heart surgery for those over 65. I am employed in the health care, being a medical physicist for over 20 years. I do not know of a single case of a person not getting the radiation therapy they required. And that includes undocumented aliens. (OK, It may be different in places out of NYC). Finally, I consider myself liberal but not a leftist.