Thursday, February 28, 2008

What's wrong with this picture?

Apart from being a little fuzzy, this presents Americans with a dose of reality. Among the 26 developed, industrialized countries of the world, the United States is roughly average on a set of socio-economic indicators that measure quality of life. To see more detailed information, go to OECD Factbook. The above chart is taken from a presentation on the short and long fiscal crisis facing the federal government prepared and presented by Controller General David Walker. Click here to see this and other avaialble presentations.

Monday, February 18, 2008

What a mess we have made of health care!

Why can't we just face the truth? For a variety of reasons, we have wrecked our health care system under the guise of a free enterprise, market-driven approach. Somehow we believed that using the market would result in better health care, that is, better care to more people. After close to 30 years, the results are shameful:
  • We spend more money on health care per capita and a higher percentage of gross domestic product than any other developed country and yet on several key measures such as infant mortality and life expectancy we rank embarrassingly low.
  • 40 million Americans have no health insurance and thus basically no way to cover the expenses of maintenance health care let alone of serious illness.
  • Lack of access to preventive and ordinary care means that more routine illnesses present in more advanced and often chronic form by the time the health care system is accessed.
  • Those of us who have health insurance live with an illusion of security since HMO's achieve their business success by restricting access to care.
  • Increasingly the ability to pay determines the amount and quality of health care one can receive. Those in the top two percent of U.S. incomes can afford whatever health care they desire. The rest of us must often forgo needed treatment because we cannot afford it.
  • What was once a totally not for profit sector has become dominated largely by for profit companies, both health care and insurance companies. Profit companies legitimately seek a reasonable profit. Unfortunately in health care, profits are resources that are not spent on providing health care.
  • While a large proportion of drugs are based on research funded by our tax dollars through the National Institutes of Health, drugs prices in the U.S. are higher than in other countries. We are the source of subsidies at the research and the retail level.
We have taken health care out of the realm of a social goods (similar to fire and policy protection, education, highway construction and maintenance, air traffic control to name a few) and moved into the realm of market goods. This has clearly resulted in a fundamentally flawed health care system. Even attempts to use the insurance model to cover everyone will continue complicity with the profit market model and thus perpetuate the problem.

Why cannot we just do what common sense tells us: Just as public education through the 12th grade, health care should be available to everyone regardless of health history, ability to pay, legal status, etc. As with education, those who desire a different alternative and can afford it would be able to access health care through a market model but no one would be denied quality care because of ability to pay.

I am lucky to live in Rochester NY. New York requires that hospitals be not for profit corporations. While many ancillary services--imaging is a good example--have moved out of hospitals into profit making corporations, the fundamental structure of care remains a not for profit one. In Rochester, the largest health insurer and HMO is a Blue Cross entity that did not transform itself from a not for profit to a profit seeking organization. Now named Excellus, the leadership and board of this non profit insurer did not think it wise for the long term health of their clients to become a profit seeking company. While there are clearly health care issues in Rochester, we have not experienced the horror stories so typical in the operation of hospitals and HMO's in other parts of the country where health care has become a business.

If it is too extreme and perhaps impossible to return to health care system that is not viewed as a business, what can we do to at least begin to get our money's worth out of our private and public expenditures. Here are three possible suggestions:
  1. Change the current law that prevents Medicare from negotiating prices with drug companies. The Veterans Administration is allowed to do this as well as the HMO that covers federal employees. Doesn't it make sense to permit this for those on Medicare who opt for the drug coverage?
  2. Simplify the Medicare drug coverage by eliminating the confusing insurance middlemen. If Medicare can pay health care providers directly, it can easily pay drug providers directly. This would eliminate the money diverted to insurance company profits.
  3. Require that everyone have health insurance coverage and then create incentives for people to use the health care system as often as needed. This will, over time, result in more preventive care which will reduce expenditures in the long run.
These are steps that we can take to move away from the disastrous experiment of converting health care into a market-driven business. Markets are effective at allocating resources for many activities but health care is not one of them. Our experiment has made a few people very wealthy and left the rest of us paying more for health care and getting less.

Tuesday, February 12, 2008

Things Are So Complicated

"Global demand lifts grain prices, gobbles supplies" is the cover story in the Money Section of USAToday for February 12. It is a good example of the way in which our global interdependence can lead to unintended or at least unanticipated consequences. Most would think that the economic development of third World countries is a good thing..and it clearly is. Most of us would think that turning to alternative fuels is also a good thing...and it is. Many think that using corn based ethanol is a good thing...and it might be. However, all these developments are leading to increased demand for food relative to supplies and thus higher prices for food commodities: corn, wheat, soybeans, etc. This is clearly a good thing for farmers both here in the U.S. and in developing countries. It means that especially in developing countries, more people can sustain themselves with agriculture and thus are less likely to migrate to urban areas with there concentrations of people and poverty.

At the same time, however, as prices for food increase, those who are poor and less able to afford food will get less food. Just to take one example cited in the article, the World Food Programme "will need $520 million more to provide the amount of good they had budgeted for this summer." This story is duplicated in other organizations providing food assistance like Oxfam.

As societies develop economically, they tend spend more on food although at a lower percentage of total income. There is an underlying dynamic, however, in that as people develop economically they tend to prefer increase animal protein over plant. Since it take eight times the grain to produce a calorie of animal protein as opposed to a grain protein, the demand for grain accelerates exponentially.

A gas station in Rochester has just started selling ethanol. It seems to be the case that every time a gallon of ethanol is consumed, the bread that I buy will cost more. That is merely an inconvenience for me but could threaten the health of those less well off than I.

It is hard to tell what to do. Switch grass seems a better source of ethanol than corn. The overall carbon foot print of ethanol--regardless of the source--may not be much better than petroleum. Reducing use of and thus demand for energy in the U.S. seems a more responsible way to be a good citizen in this global interconnected world. Increasing personal contributions to food assistance organizations is also a reasonable response for those of us who are so well off relative to our global sisters and brothers.

Friday, February 8, 2008

Isaiah and the Problem of Religious Practices

The lectionary for February 8 contains a reading from Isaiah 58:1-9a that is relevant to much in our lives today, especially as we begin the season of Lent. The people to whom Isaiah speaks were observant. They fasted; they afflicted themselves; they prayed. And yet, they felt that God had abandoned them. "Why do we fast, and you do not see it? afflict ourselves, you take no note of it?" They were following all the rules and did not receive the benefits of their special relationship with God.

They, as I often do, missed the point. Careful observance of religious practices does not somehow earn the favor of God. The loving concern of God is there for the asking, not the earning. In fact, all we need do is accept God's love in a way that changes us in a much more fundamental way than any prayer or practice can possibly do. As Psalm 51 tell us in today Responsorial Psalm, acceptance of God's love results in a "heart contrite and humbled." It is this changed heart that expresses itself in the kind of fasting pleasing to God.

"This, rather, is the fasting that I wish:
releasing those bound unjustly,
untying the thongs of the yoke;
Setting free the oppressed,
breaking every yoke;
Sharing your bread with the hungry,
sheltering the oppressed and the homeless;
Clothing the naked when you see them,
and not turning your back on your own."

As far as I can tell, all the major religions focus on a change of heart that is the source of both religious practices and acting in the world with justice and mercy. It is not that prayers or even acts of justice earn the favor of God but rather that an acceptance of God's life and love in each of us that naturally overflows into prayer and justice. When Jesus spoke of faith without love being as empty as a clanging cymbal, he was recalling this ancient insight. When Ghandi said that he would become a Christian if he had every met one, he was referring to the same thing.

As a Christian entering the season of Lent, I am called to refocus on this fundamental dynamic. Prayer, fasting, and justice are the fruits of faith. The Ten Commandments and other moral precepts are not so much rules to live by as they are descriptions of the life of those who have entered into the life of God. Lent is a time to rededicate myself to this faith and to the ways in which I express this in my daily life. My goal is that this new life "shall break forth life the dawn."

Sunday, February 3, 2008

Clinton or Obama: Final Answer

The Giants won the Super Bowl. Is that an omen?

It is now Sunday night and I have determined to make my decision before I go to bed.

I will vote for Hillary Clinton. This has been a difficult decision. I could vote for either and will strongly support either as the Democrat nominee. I know Clinton better since she has been my senator for eight years. On almost all important issues their positions are essentially the same. I wish that Clinton had voted against the Iraq resolution. Twenty-four senators did. However, all of the senators who subsequently became candidates for the nomination voted for the resolution. Edwards subsequently recanted. Obama was not in the Senate at the time although he gave a speech against the resolution and the war it led to. His position at the time mirrored my own. I am not sure what he would have done if he had been in the Senate and thus his position would have had an impact on the actual policy. It is one thing to give a speech; another to vote on legislation that will impact policy.

Clinton is a strong, assertive, intelligent and savvy woman. That she comes across to some as calculating and self-interested seems to me to reflect more our difficulty in finding categories to judge such a woman rather than the character of her words or actions. As a woman, she also has special difficulties with her spouse. Male candidates typically have spouses who have subjugated their careers or ambition to those of their husbands. This means that the spouses of male candidates are largely attractive appendages. The spouses of female candidates typically have careers and public visibility which can often be problematic. The Ferraro candidacy is an example. Hillary's is another and is probably an extreme example. I can judge her candidacy apart from Bill's record and I believe that others can and should.

Charisma is just not enough for me any more. I want someone as president who begins with policies and proposed programs that will deliver on the ideals we all share. I have not heard or seen many of Obama's television ads but the ones I have seen focus on his personal history and the great ideals of America. I think that Clinton is committed to similar ideals but relies more on her experience in working out the political agreements and often compromises that are necessary to deliver on those ideals.

In the end, I believe that those who share the ideas and ideals of the Democrat party will join a new administration. There might be differences in those who join a Clinton administration and those who would join an Obama administration but I do not think the differences would be in quality.

I am more comfortable with and have more confidence in an approach that relies on persistent and patient work to achieve essential policies than I do in an approach that seems so characterized by enthusiasm. The change that either candidate proposes will take years to achieve and these changes will face opposition and unknown challenges. Success will require the capacity to persist in the face of defeat and difficulties, things which can too easily deflate enthusiasm and popularity. I believe that Clinton is in the political process for the long term, regardless of the outcome of this campaign. That commitment is important to the achievement of the ideals and policies at the heart of this campaign.

I am putting this topic to rest for a while. My next posting will take up something else.

Clinton or Obama: More

It is early Sunday morning in California. I have had discussions with family members from Missouri, Colorado and California. All of them are supporting Obama. Their reasons have nothing to do with policies or positions on issues. Their concerns about Clinton run more to history and her style, variables over which she has little control. Her past experience (Senate) and experiences (spouse of Bill Clinton) are part of who she is today and who she will be tomorrow. Her work in the Senate has been impressive; she has served New York and the country well. She works hard and has been effective working across the aisle. All this would serve her and us well. However, she is also Bill Clinton's spouse. The more active he is in her campaign, the more important that fact becomes. I do not believe that she would be controlled or even unduly influenced by him. She is quite strong and able to make her own way, as she clearly has in the Senate.

The problem, I think, is that his presence recalls his history and people's reaction, especially Democrats' reactions. First, as my sister pointed out, she is angry at Bill Clinton for having wasted an opportunity to make significant changes in our country because of his personal moral choices and the ensuing debacle. That alone would make anyone angry. Hilary cannot change that association or history. She is caught in a situation, not of her own making. Further there is nothing she can do about it. Dumping Bill in any way would not actually change anything.

Second, as my daughter in law in California, pointed out. Clinton would not be able to attract thebest and brightest in the Democrat constituency because of anger about Bill. They still smart from how they were misled, how they believed and supported Bill even as he was lying and manipulating them. This breach of trust has not been healed and seems likely not be healed. The quality of a presidency is due in large part of the quality of those the president can attract to serve in the administration. We have been ill served by the ideological litmus tests of the current administration. We would be further ill served by the failure to attract the very best talent possible. I think this anger and resentment lies behind the endorsements by Ted Kennedy and John Kerry. Obama, on the other hand, would be more likely to attract the brightest and the best in a campaign to change the government and its relationship to its people.

I believe the above is true. Perhaps that is why I began by leaning toward Richardson and then a bit to Edwards. I had a sense that Clinton might not be the strongest candidate. For some reason, however, I never moved toward Obama even after it became clear that Richardson and Edwards were non-factors. The truth is I have a hard time trusting Obama. For me, he is not charismatic. Perhaps I distrust charisma as a basis for choice. But without any clear policy differences, it is reasonable, albeit uncomfortable, for me to make a choice based on style, history, charisma, and the ever slippery political calculation about who would win against likely Republican candidates. It is ironic that in a race where many say we should have politics as usual the final choice becomes essentially a political choice rather than one about policies and positions.

My brother and sister are convinced that Clinton would lose to McCain who they believe will be the Republican nominee. I do not share their certainty but do share their concern.

So with my decision due by the end of the day, I am now leaning toward Obama. I am not ecstatic about it and find a troubling lack of enthusiasm for his candidacy. Perhaps that is a function of my frustration of finally having to apply political considerations to arrive at my final decision.

More later.