Health Care: Cost effective policy.

This fascinating article appeared in the NYT recently. It discussed the British program called NICE which determines which treatments the National Health Service will cover based on calculations of cost effectiveness. There are many issues brought up that are worth discussion.

First I applaud the efforts of the British government to negotiate prices. While that was not the intended goal of NICE drug companies have increasingly eased prices so that their treatments are covered. This is fantastic. If medicare and medicaid had the power to negotiate prices I'm sure we would save tax payers billions of dollars. Those services represent such a huge share of the market that their power would be profound. And drug prices are so erroneous and exploitive, something has got to be done. Reading this made me wonder why prices aren't tied to efficacy in some way. That kind of price model might in the very least give the drug companies a leg to stand on when they try to defend their fleecing of the dying. I can't imagine this country having the balls to play this kind of hard ball. Even the best solutions put forward this election season for solving the health care crisis are full of consessions to industry. In my optimism I view them as step 1 on a road left.

The ethics of this program are worth discussing as well. If a National budget and health system risks ruin (as I believe ours does) then maximizing cost-benefit for health care may be the only ethical way to insure that citizens are able to rely on a basic standard of care. But deciding that that level of care is going to be less than the highest that our technologies and skills are capable of is a hard pill to swallow for anyone. I don't know if the British ever claim to have the best health care in the world but I know the US certainly does. Despite the fact that we don't. We are capable of delivering great care to the relatively few rich and well insured. But our health outcomes as a nation are embarrassingly behind the rest of the world. Pragmatically, it is imparative that we accept that so far we have failed; that 'slowing progress' which industry threatens may be a necessary concession to save the masses and wallets of all.

Patients in Britain who are on the losing end of NICE, like the patient with kidney cancer, might be best served in the future by a two tier system. This is the system that I ultimately believe the US will be forced to adopt, as it is the only one that I can imaging being both financially tenable and still leaves a place for our precious free market. In this system you have universal health care for everyone that assures an 'adequate' level of health care, and you have a private optional insurance system that people can buy to pick up where universal care leaves off. Because a standard level of care is already maintained this could really work on an old school insurance style model, and possibly serve consumers much better. Fewer people would make claims and things like doctor choice and elective and heroic procedures could more easily be covered. As a future physician I cannot see this as an ethically perfect solution. I believe a physicians ethical obligation is always to provide the highest standard of care they are able to each of their patients. The British NICE deserves a lot of credit for its dedication to egalitarianism.

"After consulting a citizens group, the institute decided that the nation should spend the same amount saving or improving the life of a 75-year-old smoker as it would a 5-year-old." When it comes to life I am definitely a quality over quantity kind of girl. It really bothers me that improving a life is subject to the same cost effective analysis that extending a life is. If a drug fits their criteria of extending a life for 6 months but has horrible and debilitating side effects this too should be considered in the financial analysis. And if quality of life is improved, as for the MS patient mentioned in the article, I find it extremely unsettling to deny the treatment. As policy this gets dicey. Ideally this is the sort of decision a patient should be allowed to weigh in on.

The reality of our situation, in the midst of a war and a financial crisis, is that we are going to be forced as a society to make some tough decisions. Should smokers pay more for health care? Should fat people? But all of it involves making a decision that I'm still not sure we as a nation have made. Barack Obama made me swoon in the second debate when he said, simply and directly, that he thought "[health care] should be a right." Making and embracing this idea emphatically requires that we come up with a quality level of care that is freely available to everyone. Realistically we must also realize it can't be perfect.

Obama's Citizenship Questioned

Sorry It's been a little while since I've written anything in a little while. I'm afraid I've been experiencing something that scares me. I didn't realize how bad it was until I read this article in the Wall Street Journal online. To summarize: people are challenging Obama's citizenship on the grounds his father was a British citizen and the court has never officially established what it means to be a natural born citizen. Many of these suits were filed across the country and the only person to take the suit seriously is dear Justice Thomas. (When I hear his name I always think of Justice Marshall's comment "a black snake is still a snake".) The case now needs the approval of four justices to be heard before the court. My reaction to this farce is hard to express in written form but it went something like this: "OH MY GOD CLARENCE THOMAS IS THE WORST PERSON IN THE WORLD" followed closely by post traumatic flashbacks to 2000. The stolen election flashed before my eyes and hyperventilating and shouting at and with my husband and shouting phone calls to my parents (who annoyingly failed to take it seriously). A friend of mine dug up some more info, I'm not sure from where, and discovered the punch line. Apparently John McCain was not, in fact, born on us soil. His family was stationed abroad and congress quietly passed a law declaring him a 'natural born citizen' before he embarked on his presidential run.

So most people did not find this quite as sensational as I did. This morning I found myself wondering why. Then I realized the problem: I've been happy lately. Politically speaking. Obama has more or less been doing a sensational job. I have not yet been disappointed. My complaints (among them a discomfort and skepticism regarding his appointment of Hillary) are quite minor. I have an open mind and a trust that he knows better than me and I am ready to be proved wrong. So when I stumbled across this citizenship fiasco all this rage and delicious frustration that I just haven't been able to feel lately suddenly felt free.

I realized I don't know how to play this person I now find myself being. For so long I defined myself as a radical leftist dissident. And at the same time I constantly felt frustrated with what I saw as a lack of pragmatism and political savvy on the left which I saw as constantly setting us back. So I was the idealist who worked for Gore instead of Nader and didn't really feel at home in either camp. In short there was always something really substantial to get mad at. Now I'm irked by the obsession about the Obama dog. It's kind of trippy.

I must make one thing clear: I'm not complaining. I am eager to adapt to this new world order. I'm just not sure I know how to do it. (Did you notice OJ is going to jail? It's like the world has been turned upside down!)

Post Election Thoughts

I am exuberantly fantastically happy. The pride I feel is new and exciting for me. Obama's win was decisive. The electoral vote count currently sits at 349 to 163 and his popular vote lead is a stunning 53% to 46%. Obama has a mandate that Bush, for one, never had. And here is where people have started to rain on my parade. It started before the election was even over with Newsweek's cover story cautioning Obama about "center-right nation" he might lead. Tonight on the news I heard Nancy Pelosi talking about starting the new legislative session with a children's health care bill, something she pointed out had been passed under Bush. Her message was one of cautious change and moderation.

Remember when Bush took office? He snuck into the presidency with a popular vote loss and a push from the Scalia and he took office like a cowboy. He appointed people with extreme conservative credentials and he started pushing conservative policies with such swagger you'd have thought he'd had a landslide behind him. And he got away with it. In his eight years he systematically undermined every progressive policy of the Clinton era and constructed an administration that has been an unapologetic disaster not just for their image but for the very lives of American and foreign citizens. Throughout all this, even when Democrats managed to take Congress their protests were meek at best.

Here we have a man who has the most liberal record of any senator. He has the most progressive platform of any presidential nominee since before Clinton. And he won decisively, even easily. He won on a message of Change and of Unity all balanced on a very progressive platform. He wants to tax the rich. He wants a new sustainable energy policy. He wants an economy tailored to narrowing the income gap, not widening it. He said in the second debate he thinks we should have the right to health care; this is a phenomenal and radical idea. How is it that we see a man like this get elected so decisively, at this moment in history where the economy is falling apart in such a big way, and the message, even from leaders in his party, is one of baby steps? Oh I remember, its because his party is the democratic one, the party of the spineless.

I believe Obama will be the leader he promised and has already shown himself to be. I will be happy if he appoints a cabinet with diverse politics and expertise. I want a white house full of discussion and argument and careful decision making. But that said, I want the big changes I voted for. I don't think the discussion of where the country sits politically at this point is actually worth asking. Even if this country has been a center right nation what this vote says unarguably is that this nation is ready to try something else. If Obama seizes his moment with the vision he has demonstrated up to now and fulfils the promise of this election he will make a center-left nation. Now, few know for sure what the effect of his ideas might be. This nation has known little else in my lifetime save a conservative corporate friendly government. This election demands that Obama show us something else. If he doesn't he will go down in history as a disappointment. I hardly dare imagine what consequences that might bring. I think Obama won because he has the fortitude and vision that his party is long lacking. Nancy Pelosi's remarks today reminded me that the change has not come yet. She still suffers from that instinct to just roll over. My biggest wish in the coming months is that she's the only one.

President Barack Hussein Obama

Electional Affective Disorder

Tonight it has reached a climax.

My usual voracious reading/listening/watching of all things media has not led me to anything satisfying. Its the calm before the storm, nothings happening, the candidates aren't doing much worth noting and no one is saying anything about them worth listening to. The satisfaction of reading an article about Obama's lead in the polls has melted away. The same stories that made me elated mere weeks ago now just make me a little more on edge, a little more panicked. I go from moments of blissful excitement to fear and panic and stress. Unfortunately my life of late has been teaching me how to dwell in that stress. I can feel each muscle in my back tighten notch by notch. I need to do something.

I find myself trying to connect, to find ways of passing these next 24+ hours that will make me feel apart of history. I'm throwing a party. Today I've spent all afternoon cooking and cleaning and preparing. I find myself working with a focus and a drive that is so unusual to me in these activities. This is the first presidential election since I aged into the right to vote that I haven't been able to volunteer for my candidate. (Medical School will do that to you.) I tried to make up for this by giving money and telling my friends and family to give money, but all the emails in the world from Barack (who has become my most persistent correspondents) fail to make me feel connected in the same way. This year I feel detached from history. I read to feel empowered but when that failed this blog was born. But whoever said "knowledge is power" really must have been doing something with it. Knowledge without action or voice is impotence. And that's how I've felt through much of this election. Even voting was so unsatisfying, filling out the absentee ballot at my kitchen table. At least I'm voting at home and not here in Vermont, I thought. At least this way my vote might get noticed.

In these past few weeks I've become superstitious. Of course I'd never admit to actually believing that sleeping every night in an Obama t-shirt will hold any sway over things, but it seems the right thing to do. There is an L word I won't say but which I fantasize about. And no it's not 'lesbian.' And yes I do think it really could happen. I think Obama is going to take this thing home. I'd say 'I know' but that too might jinx it. I want him to do this early and I want him to do this big. I want there to be no question that the country is behind him.

I cringe when people say his lead is just about the economy. The last two elections should have been about the economy or we might not have ended up in this mess. I hope this crisis teaches people the folly of 'values voting' and that 'fiscal conservatives' are never what they claim to be. But more than anything I hope Obama lives up to the dreams that I have for him. I was so comforted on this front when he was on the daily show the other night and talked about this moment in history as a time when a leader like himself has the opportunity to make big substantive changes. Those aren't exactly his words but the ones he chose surprised me in their scope. This wasn't the centrist timidity of elections-past. This was what I was voting for. The left has such a bad rap in this country. Sarah Palin tosses the word socialist about like an slur and yet she gives everyone in her state a check from the profits of their shared natural resources. We need a new left. A left that isn't communism, and isn't socialism, but where those words can be used in a conversation of ideas without striking fear. We need a left where belief in the free market isn't as ubiquitous a part of a candidates platform as belief in god. Indeed where either of those are not a prerequisite. And even as I sit, with the happy ending yet to be written, Allan Greenspan doesn't even believe in the free market anymore. I never thought I'd write that, and I've been believing in change now for a long time. I don't think I'll be disappointed.

Sarah Palin

There's been a lot said about Sarah Palin and I don't want to get into rehashing it, but I do want to share a few of my thoughts on this woman. As a jumping off point I'd like to point you towards this article that appeared in The Daily Beast. A democrat and former editor of Ms. Magazine says she knows Palin to be a smart and thoughtful feminist. If she's right I think we have a much scarier situation on our hands. Clearly the main thesis of those on the left has been quite the opposite. Recent ridiculing of fruit fly research has been shown as an example of her disturbing lack of scientific literacy and we are encouraged to conclude from this that her literacy on other important aspects of government and society is equally lacking. If Ms. Lafferty is correct and Palin thinks these things through then I fear we must conclude that this statement was made with deliberate calculation. This would suggest that she is not merely ideologically (or religiously) so skeptical of science that she sees it as an expendable part of the federal budget, but that she might be actively exploiting the ignorance of the American public to promote her agenda of destroying our scientific infrastructure. True this may have been an innocent mistake or the mistake of a speech writer, but there are just too many examples of lying ("I was vindicated!") or vast hyperbole ("Obama palls around with terrorists!") in her rhetoric that a mistake seems much less likely. If she is thoughtful, if she is intellectually curious, if she "asks questions, and probes linkages and logic" as Ms. Lafferty insists then she deserves much more condemnation and outrage then she has hitherto been subject to. I think that thus far she has been able to hide behind the persona of an innocent when she works her crowds into frenzies of racist fear and anger over this dangerous terrorist she claims to be running against. If John McCain did this sort of thing (instead of his meek statements that Obama is a family man) the outrage would be ferocious. But Palin has been getting away with it. If she really was a ditz you'd hope McCain knows that and until he croaks it'd be safe to trust that her capacity for damage-by-ignorance would be curtailed. If she's a brainiac we risk another more radical Cheney.

As far as her feminism goes I find it gross that any democratic woman or Hillary supporter would abandon their party for McCain. Why? Because issues matter. Issues matter so much more than symbols. Geraldine Ferraro was on NBC after the Biden-Palin debate saying that she was rooting for Biden because she's a democrat, but rooting for Palin because she is a feminist. She was happy to see her hold her own because it set an example for her grandchildren that women can do this. I see such perversion in her thinking. Palin should be able to fail on her own, without it telling us that women aren't capable. This idea that any woman in the public eye makes or breaks the image of all women is in of itself a sexist and offensive idea. We are a diverse gender and this seems totally lost on everyone, feminists especially. Palin doesn't represent me. She and I share nothing politically. Unlike Hillary who worked her way to the ballot, Palin was selected. John McCain decided who would represent women in this election on the national stage. Who gave him that right? Doesn't it belittle us to have our 'representative' chosen by a man? Hillary fought for political change, she fought for the middle class, she fought the progressive fight and that fight is the substance that makes Hillary worth admiration. Sure she deserves an extra dose of adulation for getting so far as a woman, but to distill her down to the single dimension of her gender is to insult and patronize her. To phrase Palin merely because of her gender is to insult and patronize her and every other woman whose broken any glass ceiling anywhere.

Occasionally Palin claims to be in support of various women's issues: support for parents of special needs children, or equal pay, or title IX etc. But you don't have to look very far to see the truth that this is mere pandering. Indeed you can look no farther than the above mentioned fruit fly comment. Those very same fruit flies have lead to the discovery of key proteins involved in autism. Remember McCain's enthusiasm for that cause in the last debate? How are you going to help if you cut funding? This is hypocrisy pure and simple.

McCain Style

This campaign is the worst of history repeating itself. This campaign is turning into "guilty by association", "if you're not with us your against us", intolerant, hate inciting, bullshit. When has this happened before? It's called McCarthyism stupid. That disgraceful period of our history is when people were accused of being traitors (that's 50's speak for "terrorist" or "anti-American") merely for being acquainted with people who were thought to be traitors. That's when anyone who dissented from the left was equated with the most extreme left. Dissent is the point of democracy. Dissent is the most American thing we've got.

And while we've mentioned it, I hate this word "terrorist". And before you accuse me of being soft let me say I absolutely detest the killing of innocent people and consider it the highest of crimes. But the word terrorist is brandied about to mean some sort of super evil criminal who is beyond human and beyond rights. Some murderers are criminals because they are heartless sociopaths, some murderers are criminals because they are desperate. Neither one's crime is more forgivable but how you stop them is very very different. I don't know which kind of murderers bombed the world trade center. But I do believe most people are good. I am not so cynical as to think most people fighting us were not at some point in their lives as complicated and human as I am. I believe this is the more moral and optimistic way to see the world, to search for the humanity in our enemy. And even as we seek to punish them and defend and protect ourselves, I really believe that it is this human connection that is our best defense. The word "terrorist" strips people of their humanity. Once someone is labeled a "terrorist" it doesn't matter if they are even guilty let alone why they committed their crime. But if we can't understand their crime how can we fight it, and prevent more? Our hubris has made us forget our own capacity for fallibility, which is why suspects have rights in the first place. If our hubris makes us so short sighted as to strip our enemies of their humanity, we miss and opportunity to learn, we miss an opportunity to understand, and we miss an opportunity to make a case in our defense. This is in no way about appeasing our enemy, this is about thwarting their power to build their movement. If we had put our best, most compassionate, most enlightened, most liberated foot forward seven years ago, our case would have been made. Instead we went to war in a country totally irrelevant to 9/11 and we committed some of the worst human rights abuses in our history interrogating suspects. We embarrassed ourselves. We should be embarrassed to use the word terrorist so flippantly as Sarah Palin does. Recent history has shown we are not very good at figuring out who those people actually are. Especially when we lack intellegence.