It’s always good to have a story, especially one that upholds your political beliefs.  So, imagine my reaction upon reading Good Calories, Bad Calories by Gary Taubes.  I don’t know if Taubes himself has any leanings in the direction, but his book is the most compelling libertarian story of the past 50 years.

There are some basic principles of the libertarian critique of governmental policies designed to solve Pressing Problems.  These are, that those government policies often:

• mis-diagnose the problem
• makes decisions based on political realities instead of scientific ones
• crowds out competing (and potentially more accurate theories or solutions) either directly, by criticizing them, or indirectly, by denying them funding
• end up making the problem worse, or exacerbating a different problem via unexpected side effects
• cause a legion of special interest groups of corporations to arise to take advantage of (as well as reinforce, through their own interest) the government’s potentially wrong decision

If you’re not particularly disposed to these ideas already, this all sounds like wishful thinking about government incompetence.  Yet this is exactly the story presented by Taubes as the history of the fat vs. carb nutrition debate in the US over the past 50 years.

To sum up, without all the science (read the book, it has all the data you need), the story goes like this: about 50 years ago, a few prominent scientists, particularly Ancel Keys, decided, based on incomplete evidence, that fat was the cause of heart disease, and that carbohydrates were a good replacement for it in our diets.  Unfortunately, not only was the decision premature, it also was wrong, and here’s the most important part: it was wrong even based upon the evidence they had at the time — they simply ignored or dismissed it.  This isn’t a case of science improving and rendering an old government policy wrong, this is government policy making the wrong choice despite the evidence.

The anti-fat movement (led by Keys) then convinced the government and the media of the correctness of their case, which was then enshrined as policy by a government panel: fat bad, carbs good.  This is partly why the food pyramid’s base, the largest section, was all carbohydrate-rich breads and pasta.  The low-carbohydrate movement (the opposition of the anti-fat movement), despite having an increasing body of evidence that stated that fat was not bad, and carbs were not good (each subsequent study failed to prove the anti-fat hypothesis), were pushed aside, labeled as cranks or corporate stooges of the companies that produced high-fat food.  Billions of dollars of NIH funding flowed into anti-fat research, food manufacturers touted the heart-friendly effects of their products, and groups like the CSPI arose to plug anti-fat agendas.  Government policy and millions in advertising now set, Americans duly changed their diets to become more “healthy” — ushering in a wave of all the “diseases of civilization” that low-carb advocates predicted: diabetes, obesity and various forms of cancer.

Then, once the obesity epidemic (if not directly caused by the high-carb policy, certainly exacerbated by it) became the new threat, established policy and scientists blamed it on fat as well.

You probably could not invent a story that fit the libertarian critique so well.  Confirmation bias alarm bells went off the entire time I was reading; but the Taubes book is exhaustively researched and annotated — not just with the data (often based on studies that examined the results of low-tech societies, which ate mainly meat and other high fat diets, transitioning to the higher-carb diet of Western societies, and their subsequent explosion of diabetes and obesity — and cancer) but with the specific charges leveled at each by the anti-fat movement in an effort to erroneously discredit them.  Some people will write a book based on the results of a single paper, and present its conclusion as definitive proof.  This book presents the results of hundreds of papers and studies, all of which disprove the anti-fat hypothesis or support the low-carb one — every one dismissed and ignored.  It is also a devastating critique of academia, which, once a theory was established as the conventional wisdom, had no interest in examining data that might undermine it.

To recap: the government picked some bad science and enacted incorrect policies based on it, which damaged the health of millions of Americans, costing us billions of dollars in healthcare bills, millions of lives (here I merely repeat the government’s claims about the damage of the “obesity epidemic”) and did little to actually prevent the problem for which it was designed.  They suppressed, ignored and slandered those who disagreed, who had the data on their side both at the time, and today.  Then, when the damage reports came rolling in from their actions, promptly demanded that they were the only people capable of fixing this problem, and confidently prescribed the exact same medicine which had caused the problem in the first place: the low fat, high carb diet*.

How is this not the centerpiece of the libertarian argument for a less-activist government?

* – to be fair, they also advocated good things, such as an increase in exercise, and a decrease in the consumption of sugars and soda.  The latter again points out the crazy logic of advocating high carb diets: those carbs roughly translate into the same end result in your body as the sugar.

Wow, I completely agree with this:

So here’s a modest proposal: Instead of spending $400 billion on Medicaid in 2010, let’s spend $300 billion, but instead of spending it on Medicaid, or even on vouchers, let’s write checks to the poor. Instead of filtering $9,815 per Medicaid enrollee through a cascade of government employees, let’s send $7,361 in cash into the mailboxes of impoverished individuals, to spend on whatever is most important to them and their families. It achieves more efficient wealth redistribution than does Medicaid, and allows the poor to afford high-quality, private-sector health insurance.

Uhm, yes?  It’s amazing how programs designed to help the not-so-well-off so rarely consider just giving them money and letting them decide.  It’s almost like people don’t really respect their autonomy very much.

I accept that this post isn’t really arguing for 100k a year max incomes, as Matt says:

Similarly, one important reason high-end consumption items are so expensive is that the people who buy them have so much money. If there weren’t all these rich people around, that house on the Hamptons would be much cheaper and you wouldn’t be so desperate to earn enough money to buy it. These points are important, underappreciated, and should shape our thinking about policy to a greater extent than they do, and I think the Grief piece is a welcome contribution to dramatizing that fact even if the specific proposal has some problems.

Some problems still remain, though.  Though surely the wages of some CEOs are driven primarily by prestige competition, what about doctors?  Medicine is actually a field where the income is necessary (and 100k a year is not enough) to compensate the doctor for the immense losses (both financial and otherwise) they have suffered on the route to becoming a physician.

- Educational costs: Now,  on some level, the prices of education, both undergraduate and medical school, are driven by the higher wages one can expect to reap as a physician, but it’s still going to cost a lot.

- Hours worked/work conditions:  100k seems like a decent hourly salary at 40 hours a week.  It’s not so nice at 80 hours a week, especially when you consider that those extra 40 hrs are probably worth a lot more to you as luxury time.  Plus, what’s the cost of literally having people’s deaths on your hands?  Even the best doctor will one day, have a patient die that they could have done something about.  One of the best features of my job is that I don’t have that kind of responsibility, and it would take an immense amount of money (much higher than the difference between my salary and 100k) to get me to change that.

- Opportunity cost:  you could have earned a lot of money working, instead of the 4 years of medical school, or having a part-time job in college (you may not have time for that as a pre-med),  and the 3-4 years as a resident, during which you make a very small amount.

- Intangibles: what’s the proper wage for someone who has sacrificed personal relationships or time with kids to the extent that a doctor has?  I’m not sure that I can put a price on that, but I’m pretty sure it’s high.

- Value of what they’re providing: certain surgeons actually can save lives that no one else in the world can.  Now, I’m not saying that we should compensate them at the going insurance rate for life-years or whatever, but I think most of the people in the world are fine with the idea of people who save lives making more than 100k.

So yes, I accept that for some jobs, the high salary is driven by competition instead of real compensation.  But there are quite a few where it is not — there are “real” as opposed to positional reasons for their paychecks.  I know Matt’s not actually recommending the max income policy, but it’s hard to imagine any policy that we might propose that reduces the positional component of a CEO’s pay without similarly affecting doctors, who may have little or no positional income.  After all, it’s hard to show off all your conspicuous consumption if don’t get home until after all the other Maserati owners have gone to bed.

Here’s how insane our definitions have become in the area of healthcare.  From Michelle Obama:

[... ]right now, too many people aren’t getting the check-ups or the screenings they need to stay healthy. Twelve percent of kids haven’t seen a doctor in the past year. And 59 million adults — and 11 million children — depend on an insurance plan that does not cover basic immunizations.

Without getting into whether or not government should or should not provide these services, read that closely.  People have “insurance” that doesn’t cover basic immunizations.  This is a medical “procedure” that every single American should get and even follows a predictable schedule, in that you know that a 6 month old should get immunization X, and a 2 year old should get Y.  This isn’t just pedantry — there is a real difference in providing low cost services that everyone should get on a predictable schedule, and insuring against ones that are low probability but high cost.  One should be covered by insurance, and the other should be covered by, well, anything but insurance.  That is why our fire insurances policies don’t cover our gutter cleanings.  And you wouldn’t want them to, either, because they would by definition charge us more than we would pay if we contracted those services ourselves, because otherwise why would they offer it at all?

Immunizations are not expensive.  They are not unexpected.  They should be universal — if you want to talk about a mandate, it should be here.  This violates the entire purpose of insurance, which is to cover expensive, unexpected, rare events.  Why on earth would we expect “insurance” to cover it, and then present their failure to do so as a reason for government to provide it?  If you don’t have enough money for the immunizations that really, truly have a very good chance of preventing your child from dying — then you don’t have money for anything else, and should already be on extensive assistance from the state, and you can use that money to pay for them.  There are reasons the healthcare industry does not function very well, and this is one of them.

Another, like I mentioned in the previous post, is employer-based healthcare.

Peter Suderman says that lots of companies are going to end their healthcare plans under the new system:

Many businesses, especially those that employee fewer individuals, will choose to drop health coverage for their employees. Indeed, the CBO projected that about 3 million individuals would be shifted off their current employer-provided insurance, and many experts I’ve spoken to recently think that number is likely to be low.

[...]

AT&T, for example, calculated that it could save $1.8 billion by shifting its employees into a public program. Now, not every business will immediately kill health coverage under the law, but as time goes on, and the potential savings add up, it will be tougher and tougher for businesses, small and large, to keep offering coverage.

This seems bad, and it indeed would be better if these companies kept insuring these employees, because the PPACA (is this acronym we’ve decided on, guys?) is going to have trouble covering all of them.  But taking a longer view (and please do not take this as support for the bill), getting people off employer-based healthcare insurance is something that needs to be done.  It’s not the only thing, certainly, and I don’t think transferring them to government-based healthcare is an improvement, but it is a necessary step in actually useful healthcare reform.

From Mr. Harsanyi at Hit&Run:

The uplifting tale of the hard-boiled immigrant, dipping his or her sweaty hands into the well of the American dream, is one thing. Today we find ourselves in an unsustainable and rapidly growing welfare state. Can we afford to allow millions more to partake?

When Nobel Prize-winning libertarian economist Milton Friedman was asked about unlimited immigration in 1999, he stated that “it is one thing to have free immigration to jobs. It is another thing to have free immigration to welfare. And you cannot have both.”

I completely agree with the sentiment.  But do the facts of immigration back this up?  Immigrants across the only border that people ever talk about “guarding” are generally young and looking for a job.  It may be possibly true that they would be net recipients of welfare (i.e. get more welfare than they pay taxes on their work), but what about Medicare?  Medicare makes welfare look like pocket change — and it is a primarily generational tax transfer; that is from working young to the old.  In this case,  immigrants look less like freeloaders and more like suckers.

Given the way the demographic numbers are pointing, with the percentage of young, working Americans declining, and the percentage of old, not-working Americans increasing, we may need a ton of immigrants (who are overwhelmingly in the first category) to make this work in the long term.  I am convinced that even if immigrants are free-riding on welfare, the fact that they (and illegal immigrants moreso) are net contributors to the Medicare redistribution more than makes up for it.  If there is a program that is going to bankrupt America, it is Medicare — not welfare.  Therefore I can’t get angry about young, relatively healthy workers coming here and helping put off our financial apocalypse.

Update:

I honestly don’t care how much people want to police the border, or crack down on illegal immigrants.  I want the completely legal routes to working here to be made much wider.  I want the world to actually resemble the one the crazy build-a-wall people imagine: where the only ones trying to sneak across the border are criminals — because anyone who is just trying to get a job has an easy and low-cost method of getting in.

Conor F. has more on the “let more people in and we don’t care how you police the border” idea.

This is the kind of shit that drives me up a wall:

The Food and Drug Administration is planning an unprecedented effort to gradually reduce the salt consumed each day by Americans, saying that less sodium in everything from soup to nuts would prevent thousands of deaths from hypertension and heart disease. The initiative, to be launched this year, would eventually lead to the first legal limits on the amount of salt allowed in food products.

Except for one little problem: salt isn’t bad for you — if you have normal kidney function.  It isn’t bad for you.  Say it with me again, all together now: salt is not bad for you.  The entire premise of this massive intervention is wrong — and the only person they thought to interview to say this was the “Salt Institute” rep.

Also in health news, awhile back there was this article out of China bemoaning how fat their kids were getting, because they wouldn’t be able to die gloriously in service of their stupid government.  I scoffed at them, arrogantly assuming that my country couldn’t be so horrible.  Obviously I was an idiot:

School lunches called a national security threat

WASHINGTON – School lunches have been called many things, but a group of retired military officers is giving them a new label: national security threat.

That’s not a reference to the mystery meat served up in the cafeteria line either. The retired officers are saying that school lunches have helped make the nation’s young people so fat that fewer of them can meet the military’s physical fitness standards, and recruitment is in jeopardy.

Yup, the reason the military recruitment quotas are in jeopardy isn’t because kids don’t want to get their legs blown off in Iraq; it’s because their school lunches make them fat.  That’s totally it.

What kind of fucked up, insane world do we live in where this is not an Onion headline?  How is “school lunches a national security threat” not instantly laughed off the stage?  What kind of twisted person looks at the pudgy 8 year old and sees a wasted military resource?

For the MSNBC Health “News” Shit Trifecta:

Going tanning as addictive as drinking

1 in 3 college students who tan could be hooked, study says

Some people’s indoor tanning habits qualify as an addiction similar to being hooked on alcohol or other addictive substances, a new study suggests.

Let me issue a carefully reasoned, well-researched rebuttal: No, it isn’t.  You are stupid for printing this tripe.

What the heck?  Stop making my healthcare posts look stupid only a few weeks after I put them up.

This is great stuff:

We lost.   They won.

We are:

Progressives who favor a single-payer system

Libertarians who favor HSAs

Moderate economists who favor cost control to free up money for other societal goals

They are:

Doctors

Pharmaceutical companies

Hospitals

Private prepaid health plans (for some odd reason referred to as “insurance companies”)

Medical device makers

And many other special interest groups

Minor quibble with “doctors,” as certain specialties will benefit and certain ones will not, but still, that basically covers it.  What’s most interesting (at least for me, because confirmation bias is lots of fun) is his comments on the (completely insane) idea that regular health maintenance (doctor’s visits, normal drugs) and catastrophic care (car accidents, cancer) are still being treated as the same thing:

Private prepaid health plans (for some odd reason referred to as “insurance companies”)

[...]

The way to achieve this is with a combination of HSAs and catastrophic insurance.

His “odd reason” above highlights the insanity: insurance is for low risk, high cost events.  It should not cover doctor’s visits or birth control.  This is not to say that you can’t (or shouldn’t) have a plan that pays for those things, but it is emphatically not insurance, and should be treated and regulated differently.

I also like his proposed alternative (take that, reformers who say no one else has any better ideas!):

Sometimes I think the two political extremes blew an opportunity.  Let Medicare take over catastrophic insurance for everyone, and let HSAs cover 95% of health care bills.  Then provide a subsidy to low income workers’ HSAs.  Voila, no private insurance companies.

That would work, (the vital component is the different treatment of maintenance and catastrophic healthcare) but again, at the risk of being nitpicky, I’d split the “catastrophic” care segment, by establishing some dollar amount “medicare opt-out” that you could elect to take.  That way, if you felt like you could do better on your own, you could go that route, but you’d be ineligible for medicare forever.  Oh, and no healthcare reform (well, you know, other than the one we just passed) is complete without repealing the current bias in the tax code for employer provided insurance over individual provided. Still, these are minor nitpicks.

What it comes down to is this: libertarians warned that this hallmark of progressive policy making would end up getting completely corrupted by precisely those groups progressives hate most, to great financial and political gain.  And they were right. But then, maybe I just want thousands of poor people to die, so who are you to believe?

The CEO of Cleveland Clinic gives a Newsweek interview.  Some things were pretty good, some were bad, and some were insane:

Cosgrove declared this year that if it weren’t illegal under federal law, he would refuse to hire fat people as well. The resulting outcry led him to apologize for “hurtful” comments. But he has not backed down from his belief that obesity is a failure of willpower[.]

The problem is — being fat (up to a point) isn’t unhealthy.  Being sedentary and inactive is — and to his credit, the Cleveland Clinic does encourage people to exercise more.  If Cosgrove really wanted to improve the health of both his employees and his patients, he’d do well to focus more on activity and less on weight.

The main thesis of the article is that the Cleveland Clinic might be a good model for the rest of the country — and I agree.  But there aren’t enough rich Arab sheikhs with heart problems to fund all of the rest of the hospitals.

Yell louder, Mr. Fisher.  The craziest part:

The federal government effectively controls the number of residency positions through the Medicare program, which pays a subsidy of $8.8 billion to hospital training programs. In 1997 Congress determined the country had enough doctors and capped the number of slots it would pay for at around 98,000.

Yup.  Too many doctors!  That’s Congress for you.

He does miss one point in his byline question of “why is it so hard to get primary care physicians through residency programs?”  A major factor is “because their residency programs are so grueling.”  He gets the specialist pay issue, but lifestyle is becoming an even larger determinant, I think.

Go now. Via Marginal Revolution.

“Health care reform is absolutely on a collision course with the doctor shortage. Something has to be done about it, and it is spelled GME.” (Graduate Medical Education)

Everyone’s plans for healthcare reform are pretty irrelevant in the face of not having enough doctors to execute them.

“Women physicians these days are increasingly dropping out of practice altogether in their 40s or early 50s. And men are seeking better lifestyle arrangements, too.”

This is because the medical profession is not very forgiving to part-time employment (there are high fixed operating costs). You can’t phase out slowly like you might be able to with other jobs — and being a physician in your 50′s means you have been working very hard for at least 28 solid years. The “lifestyle” issue is very big for both men and women.

As we value leisure and lifestyle more and more, becoming a doctor is becoming less and less appealing. Not everyone is willing to accept major curtailment of friends, family, hobbies, relaxation, sleep, dating and kids during the best years of their life — and make no mistake, that is what you accept if you are going to medical school and residency. Especially during internal medicine residencies (the one all those “primary care physicians” we want to have will be enduring) you are looking at 70-100 hour work weeks (yes, it’s “capped” at 80 hours officially, but that’s like saying drugs are illegal, so no one will have them).

At the most competitive residency programs, working 100 hours a week doesn’t mean just losing the things above, it means losing things like sitting down, eating, any sleep at all, and going to bathroom when you need to. If you want some scary statistics, look up how many residents abuse alcohol, prescription drugs, are on anti-depressants, are in therapy, etc…

The only reason we’re not facing an even more massive shortage right now is that residency programs are highly incentivized (up to including yearly 6 digit bribes from medicaid/care per resident) to retain residents they’ve conned into coming to their programs, and so have erected very high barriers to exit, or even changing specialties. Plus there are natural barriers, such as the sunk cost fallacy that “all those years would be wasted if I left” and your student loans, which can range up to a quarter of a million or more.

The takeaway from this is this most claims of “cutting costs” are bunk.  Every time you cut costs in the healthcare market, there are going to be doctors getting paid less.  Sure, you can try to make sure that some of those burdens are born by insurance companies or just those evil specialists, but it’s not so likely.  But we’re rapidly reaching the end of salary reductions for the “regular” doctors and pediatricians — we simply can’t pay them much less and have them make enough to repay their student loans.  It’s already to the point that salaries are so low that anyone who can is going into a specialty.  Decrease that any more and you won’t get any more — and those who exist will retire or be forced out of business.

The thing that everyone harps on; the rising cost of healthcare, is not going anywhere.  You can slow it (and you should) by removing waste/fraud/abuse, but that’s never as easy as you think, because one person’s waste and abuse is another’s healthcare.  Healthcare costs are going up, no matter what.

Wait, what the hell, did people really not know this?

I’M NOT sure how the blogosphere managed to collectively miss this, but very little attention was paid to this piece last week in Slate by cardiologist Darshak Sanghavi which explained how Medicare and most private health insurers set reimbursements for different kinds of physician procedures. Okay, maybe that doesn’t sound so exciting, but it’s actually very, very weird.

It’s almost impossible to believe, but according to this article in Annals of Internal Medicine (cited by Mr Sanghavi), it appears to be true: in setting the price for a procedure, Medicare doesn’t consider how much healthier it makes the patient, any more than the old Gosplanconsidered whether anyone wanted to buy the USSR’s cruddy steel. Amazingly, private insurance companies have followed suit, basing their reimbursement rates on the same RVUs set by the AMA. The article points to the way this system has resulted in artificially high numbers of specialists and a shortage of primary-care doctors, but the problem goes deeper: this kind of pricing would obviously lead to the kinds of distortions Atul Gawande found in his celebrated New Yorker article this summer, on why America spends so much on health care.

I am honestly not trying to sound condescending here, because the reason I know this is not because I’m smart or well-read, it’s because my wife told me — but I just kind of assumed it was one of the major features of the healthcare debate that people would know about.  Also, the part is bold is extremely important.  It is not “amazing” that private insurers do this, it’s pretty obvious that they have to.  If you reimburse for less than Medicare, doctors will (over time) just bill Medicare for the procedure.  If you reimburse for more, doctors will bill you for it, and you’ll pay out much more than your competitors.  And unless the price-setting geniuses at Medicare and the AMA pick the precisely right price (ha ha, especially since they have a financial incentive to go high) then there’s going to be some problems.

And the source of this cushy, Soviet-style pricing scheme appears to be the monopoly power of America’s doctors’ association. Now, this is the first time I’ve ever read about this system, and it’s possible that I’m completely missing something here. But it seems to me that if anyone is really worried about socialism in America’s health-care system, they should be taking a close look at the AMA’s RVU Update Committee and why it is allowed to set the wages that doctors are paid.

Well, duh — this one of the key features of why I’m (and I assumed lots of other people) are against the healthcare reform being proposed.  The more government control of this sector, the more important that pricing scheme becomes, and the more incentive doctors have to lobby to inflate it, and then everyone’s costs go up, including the people on private plans.  I thought the “Medicare determining private insurance reimbursement rates” concept was front and center in the healthcare debate.  I guess if it’s not, it should be.  It’s a prime example of how the level of government involvement in healthcare is already making the system worse. (more…)

Megan McArdle managed to last a week longer than me before declaring healthcare debate pointless:

It’s a judgement call.  Not all values are commensurable.  There are multiple theories of politics.  And justice.

So why talk any more?  I can’t believe how nasty this debate has gotten.  I can’t believe that people who claim to value a classically liberal market society, on the one hand, and people who say that all they want to do is help people, turn into such screaming, hate-filled lunatics when the subject comes up.  A debate over health care should not remind me so much of a debate over the Iraq War.  I write thousands of words on innovation, and John Holbo boils my concerns about lost years of life down to “indifference to the poor”–as if, first, the poor will not be helped by new treatments, and second, we should do anything at all, no matter how horrific the results, as long as it helps the poor.  Well, and third, as if the poor weren’t on Medicaid, but that’s another rant.  This is about as useful as my saying that John Holbo’s basic philosophical premise is a desire for my grandchildren to die young.  I devoutly hope that if any of his freshmen said anything remotely this silly in a paper, Mr. Holbo would flunk them.

This is why I think Yglesias’ wish that we focus more on the moral/ethical component of political issues, while perhaps a good idea if everyone were calm and rational, is probably a bad idea in practice.  Mr. Holbo has decided to state that McArdle doesn’t really have real objections to healthcare reform, but is motivated primarily by a desire to see poor people die.  I wish that were an exaggeration to cast him in a bad light, but it isn’t:

Philosophically, there just isn’t a case to be made against reform unless it’s this simple one: if you don’t have any money, you shouldn’t be entitled to any medicine. McArdle is very indignant when people accuse her of indifference to the fate of the poor, but – honestly – if it isn’t that, then it’s nothing. At the philosophical level.

This is what we get when people bring the moral and ethical component to policy debates.  ”The opponents of my chosen policy are evil and wish to see poor people die.”  What’s especially hilarious about this is that we explicitly have a policy already in place that provides healthcare for people who “don’t have any money” and nothing she has ever proposed involves removing it.

If healthcare reformers were merely proposing expanding medicaid coverage, that would be one thing.   But they seem to insist that opponents of their plan are opponents of medicaid, when they are not.  The reason for this is that they have well-honed their rhetorical skills against these people, whom they believe to be evil.  Fair enough.   But this is, in reality, a debate about a massive reconstitution of the healthcare industry as a whole.  There are bound to be many who have substantive issues with this, but they are more difficult to cast in an “evil” light, which subsequently makes it harder to rally support and denounce foes.  It might not be intellectually honest, but they certainly feel it is productive in a political sense.  So, they’ll continue to do it — though I would be remiss if I failed to note that many opponents of reform do exactly the same thing.  So people who have honest objections to healthcare reform get disgusted and go do things that are more likely to produce results, like smashing their fingers with claw hammers.

Here’s some healthcare reform I can support, at least more than the current monstrosity being proposed:

So what to do? Leonhardt then looks at various proposals to increase choice and competition, including one by Sen. Ron Wyden (D-Ore.).

In the simplest version, families would receive a voucher worth as much as their employer spends on their health insurance. They would then buy an insurance plan on an “exchange” where insurers would compete for their business. The government would regulate this exchange. Insurers would be required to offer basic benefits, and insurers that attracted a sicker group of patients would be subsidized by those that attracted a healthier group.

The immediate advantage would be that people could choose a plan that fit their own preferences, rather than having to accept a plan chosen by human resources. You would be able to carry your plan from one job to the next — or hold onto it if you found yourself unemployed. You would never have to switch doctors because your employer switched insurance plans.

The longer-term advantage would be that health insurance would become fully subject to the brutal and wonderful forces of the market. Insurers that offered better plans — plans that drew on places like the Mayo Clinic to offer good, lower-cost care — would win more customers.

Can this really be in the New York Times, much less on its front page? Have I somehow entered an alternate universe in which economic sanity reigns?

I take back all the bad things I said about Mr. Leonhardt.  Well, no I don’t, but I will temper them with praise for this piece.

I’ll add my own personal hobbyhorse: make sure to divide the voucher up into catastrophic insurance and non-catastrophic health care (arbitrarily divided by some relatively high dollar amount), since the markets for these two products are (or should be) much different.

If I try to talk about how I think torturing people is bad, people on the right go crazy and tell me I like terrorism.

If I try to talk about how I think maybe expanding government roles in healthcare is a bad idea, people on the left go crazy and tell me I’m a racist militia nut who likes watching people die.  (Not trying to conflate these two issues in any way, other than they are both things I get yelled at for believing.)

If I try to talk to people who already agree on these two things, there are a lot smarter people than I saying it already — and no one listens to them, either.  Sometimes it just feels like lots of people think they get to play with different rules to political discourse — and it’s not much fun to discuss the issues with them.  Especially with the people who think they can just declare things like “torturing people” within bounds, but “complaining about doing it” out.

Most Americans are familiar with the idea of “every time you buy gas, you’re sending money to Saudi Arabia!”  Those who are familiar with the Cleveland Clinic are aware of a reverse situation: where oil-rich Saudi (and similar individuals from other countries in the region) sheikhs come to America for expensive medical (especially cardiac) procedures, (and are overcharged, and pay in cash) which subsidize the care given to poor Americans.  The practice has become so lucrative for the Clinic that they decided to open a branch in Dubai.

Does this have an impact on the healthcare debate?  I don’t know.  But it’s interesting.

I can’t actually figure out if this Bill Maher piece (via MR) is for or against the healthcare reform currently being proposed:

Sarah Palin says she would never apologize for America. Even though a Gallup poll says 18% of Americans think the sun revolves around the earth. No, they’re not stupid. They’re interplanetary mavericks. A third of Republicans believe Obama is not a citizen, and a third of Democrats believe that George Bush had prior knowledge of the 9/11 attacks, which is an absurd sentence because it contains the words “Bush” and “knowledge.”

And these are the idiots we want to weigh in on the minutia of health care policy?

So, does this mean that we shouldn’t have the government run healthcare because it’s made up of the same group of idiots as these average Americans, or at least idiots elected by this wider group of idiots?  Or does this mean we should have the government run it, because if the average American is this dumb, they can’t be trusted with making healthcare decisions either?

I thought it was “against” until I read this: (and the user comments)

And if you want to call me an elitist for this, I say thank you. Yes, I want decisions made by an elite group of people who know what they’re talking about. That means Obama budget director Peter Orszag, not Sarah Palin.

Yet you can easily get two people (both with credentials as impressive as Orszag’s) to disagree violently about healthcare reform, or even the budgetary analysis produced by him.  If the debate were between experts with PhD’s in one camp against geocentric idiots, that would be one thing.   But it’s not — and neither side has a monopoly on idiots or experts.  Sometimes being smart isn’t enough.

This article doesn’t have a bias at all, no sir:

LONDON, England (CNN) — Britons including Prime Minister Gordon Brown have leapt to the defense of their creaking healthcare service after President Barack Obama’s plans for a similar system in the United States were branded “evil” by Republicans.

Tens of thousands of people have joined a Twitter group expressing pride in the UK’s National Health Service (NHS), which offers free taxpayer-funded medical care to all British residents, while leading politicians have spoken out in support.

Leading politicians spoke out in support?  Shocking!  To be honest, though, the “death panel” thing is kind silly:

Republican former vice-presidential candidate Sarah Palin earlier this week condemned Obama’s plans to introduce a public heath insurance scheme as an “evil” move that would result in “death panels” deciding who would live or die.

I have no idea why anyone listens to her, but she actually demonstrates a really good point, if not intentionally.  Of course no one is going to say “sorry, grandma, time to die.”  But that’s the problem — if everyone thinks that it’s horribly immoral to officially deny people care, and voters can vote people into power who can promise them more care, then there is no way on earth we are going to control costs.  It’s fine if you consider giving people more care a feature, (as I do) but then the whole saving-money thing goes right out the window.  And we can’t afford a national healthcare plan that doesn’t massively cut costs, at least not without spending cuts that not a single politician is proposing.

Healthcare reform that will provide more healthcare to those who want it will cost more than we can afford to spend without massive spending cuts in other areas, which are not being proposed.  Reform that cuts costs to the extent that is necessary will be too unpopular to be sustained, or will drastically curtail individual freedoms with regard to what you eat, what you risk, and how much you exercise.  Reform that provides better results will cost increasingly large amounts of money, and will be popular enough that people will vote themselves more of it.  Anyone proposing reform that does all three is operating on the same reality level as magical flying unicorns.

Finally: if we spend too much on healthcare, we risk causing financial problems that will damage the well-being of Americans more than not having healthcare.  The moral debate about reform is another issue.  Right now, we can’t afford it.