Tag Archives: Health Care

Monday’s Mtg: How far should the government go to encourage healthy lifestyles?

The more I think about this one the more complicated it gets. OTOH, a lot of what the government does to prevent and treat what are called non-communicable diseases (like cancer, diabetes, anorexia, Alzheimer’s, and hypertension) is widely supported by most Americans. The public loves govt funding basic research on chronic diseases, Medicare and Obamacare subsidies, and govt-enforced safe food and water.

But, when Americans perceive that other people’s illnesses are due to poor lifestyle choices things get controversial. How far should, for example, regulation and taxpayer-supported health insurance go in protecting people from their own bad choices?

It’s not just a moral judgment, either. As the first article below points out, it is hard to attribute many chronic conditions to specific behaviors. This is true even for health problems they’ve been studying for decades like cancer and diabetes and (it seems to me) is probably even more true for behaviors that public policy is newly targeting, like obesity. How can we know what interventions are cost-effective if we don’t know how a lot of the science works?

Oh, and what constitutes a bad lifestyle “choice” exactly? Not all decisions about what to eat and where to work and live are equally voluntary, especially for children but also in a sense for people too poor to afford healthy choices.

Along with these issues, here are some other basic questions we might consider on Monday. I will be back from my vacation, BTW.

DISCUSSION QUESTIONS –

  1. Rationale: Why should the govt try to prevent/minimize bad lifestyle choices?
    — Why: General public interest? Externalities (effects on other people)? To help the economy? To prevent needless suffering? To fulfill international obligations?
    —  When: Scientific uncertainty.
    — Who: Federal govt v. state/local concern?
  2. Targets: Which behaviors?
    — Smoking/drinking, other drug use and vices.
    — Diet: Obesity/sugar, child nutrition/school lunches, “food deserts” in poor areas.
    — Violence and accidents: Guns, hazards. At work/home.
    — Health care: Insurance, Obamacare carrot and sticks.
  3. Tools: It’s not just regulation.
    — Taxation/subsidies.
    — Information and advocacy.
    — Market regs: Restrictions on buying/selling, food service, product safety regs, etc.
    — Health care.
    — People under govt control: School kids, prisoners, soldiers…
  4. Limits:  How much govt action is too much?
    — Who should decide?
    — Where has govt gone too far or should do more?

SUGGESTED BACKGROUND READING –

NEXT WEEK: Does foreign aid work?

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Monday’s Mtg: The Uses and Abuses of “Pop Economics.”

Rich suggested this topic. I wish I had, because I think it is one of our most important topics in years. The way basic, introductory-level economics has been abused to make bad national policy has been a pet peeve of mine for many years.

Sure, all rhetoric in politics is kept sound bite and bumper sticker-friendly. (Not to a fourth grade level like Trump’s rhetoric, perhaps, but still.) And, everybody does it. “Our borders are unguarded/open.” Liberals aren’t patriotic. Neoconservatives love war.

But, when it comes to rhetoric –and policy, too – concerning economics, something much, much more pernicious goes on. It has been called the problem of “Econ 101ism” or “Economism.” Economism, to quote the coiner of the term, is “the misleading application of basic lessons from Economics 101 to real-world problems, creating the illusion of consensus and reducing a complex topic to a simple, open-and-shut case.” For years I’ve seen way too many politicians (and their pundit and journalist enablers) use over-simplified – and thus often inaccurate – Econ 101ism as a kind of Gospel that fully explains how the world really works. They use its “lessons” to show what correct government policy has to be and anybody that disagrees doesn’t understand economics.

Everybody does Economism sometimes. Liberals sometimes indulge in it when thinking and talking about international trade and, less often IMO, about macroeconomics (govt spending levels). But, as the articles below explain better than I will on Monday, there is something about Econ 101’s easy, breezy, oversimplified analysis of how markets work that easily seduces conservatives.  All those pretty supply and demand curves leading to ideal equilibriums without ever a need for government interference.

Again, I don’t mean this topic to be about economic polices and rhetoric that I think are wrong.  I mean it to be about those that are wrong for one particular reason: They are based on a belief that the highly simplified textbook explanations of how markets work should tell us all we need to know about what policies should be.  Econ 101ism, to me, is too often a shield for preferences that based on other things, like ideology and moral beliefs. .

I’ve tried to keep the linked readings fairly easy and, well, breezy. They oversimplify, too, but get the idea across.

DISCUSSION QUESTIONS –

  1. What does Econ 101 teach about how markets and govt interference in markets work? What important things does it gloss over?
  2. In what big ways can well-meaning political advocates misinterpret the lessons of Econ 101?
  3. How do the lessons of Econ 101 get misused by politicians; i.e., what is Economism?
  4. What are some good examples of Economism in action on the Right and Left?
    –> In tax policy? Financial regulation? Trade? Wages and labor markets? Health care? Education?
  5. How can seductive rhetoric based on Economism be effectively countered?
  6. What’s the “other side” POV here? Is Econ 11ism not a big thing?

SUGGESTED BACKGROUND READING –  

Conservative use of Econ 101ism

Liberals use of Econ 101ism –

Special Topics in Econ 101ism –

NEXT WEEK: What beliefs have you changed since you were young?

Monday’s Mtg: Is Obamacare Working? What’s Next?

We last talked about the Affordable Care Act/Obamacare in July 2013 (great links!), as parts of it were still being rolled out.  Three years later all of its major provisions have begun to operate and experts are starting to get an idea of where the law has been successful at achieving its goals and where results have been disappointing and why.

Non-experts like us have a hard time getting any sense of it at all. Obamacare is only dimly-understood by most Americans. The law had to be grafted onto the existing, highly-complex American health care system, so it is very complex. The law’s affects also are nearly invisible to most Americans, largely by design. Complexity and invisibility left a huge opening for clever propagandists to trash the law and attribute every negative development as the beginning of Obamacare’s imminent collapse.

This is a bummer for a lot of reasons, not the least of which is it makes it hard for us to see through the complexity and opacity to draw our own conclusions about the law’s good parts and bad parts (both exist). To help us out a bit, I will start our meeting on Monday evening by reviewing two key contextual points:

  1. The major problems/shortcomings of the status quo ante health care system that Obamacare was designed to fix; and
  2. How the ACA was supposed to do that.

Then, we can go one of several ways. We could discuss each major part of Obamacare in turn, such as the state insurance exchanges, the law’s many new consumer protections, and Medicaid expansion. As we talk I can sketch out some of the latest good news/bad news in each area. Or, we could go big picture and explore whether the ACA has succeeded so far at its three big, broad goals: Achieving near-universal health insurance coverage, controlling health care costs, and improving the quality of medical care. Very ambitious goals.

As we talk, I think it is very important for us to do two things that news stories on Obamacare implementation almost never do.

  • Look at the entire law – not just some piece of it that has experienced recent good or bad developments; and
  • Compare its results to a realistic alternative – either one based on where our health care system was heading before Obamacare or to Republican alternatives (to the extent they even exist – see links).

If you want we can get into GOP alternatives and Hillary’s plans to protect Obamacare’s gains and fix its flaws or expand it. And, yes, there is yet another lawsuit probably heading to the Supreme Court that is aimed at one of the ACA’s major provisions and bringing the whole thing crashing down.

There’s one more thing. The ACA’s shortcomings are particularly tragic, and not just because health care matters so much. Unlike other laws Obamacare cannot be amended at all because Republican lawmakers will not allow it. They want the ACA to collapse so they can “repeal and replace it.” To my knowledge, no major law has ever been held to this standard, expected to work perfectly in its first iteration. Major laws are amended all the time to correct mistakes and adapt to new conditions and unanticipated or even unanticipatable problems. For example, Medicare’s basic fee structure was completely overhauled less than 10 years after its 1965 passage because it wasn’t controlling costs very well, and the program has been modified thousands of times since then.

So, however brilliant or dumb the Affordable Care Act is, we are stuck with it as is. Any insufficiencies in the law (or unexpected adaptation by consumes and businesses) must either be addressed administratively or left to fester, or, if a GOP-controlled Congress is elected, solved or ignored their way.

DISCUSSION QUESTIONS –

  1. Review: How was Obamacare supposed to solve the major problems in our health care system?
  2. The Parts: How has implementation of each major moving part of Obamacare gone? What caused any failures and how was implementation of the law adjusted to compensate?
  3. The Whole: Can we declare overall success or failure (or making good/bad progress) on the 3 major goals of ACA: Helping the uninsured, making HC more affordable, improving quality of care?
  4. The Divide: Do liberals and conservatives define “success” differently?
  5. The Future: What’s next in U.S. HC reform?
    • Latest GOP lawsuit.
    • Dem/HRC plans to fix/expand?
    • GOP plans to repeal/replace?

SUGGESTED BACKGROUND READING –  

It’s succeeding:

It’s a mixed bag or it’s failing:

The Future –

 

NEXT WEEK:   Does the “historical Jesus” matter?

Monday’s Mtg: Why Do So Many Americans Draw Disability Benefits?

Did you know that October is National Disability Employment Awareness Month and that 2015 is the 25th anniversary of the Americans with Disabilities Act? Me neither, when I chose this topic. I picked it, with its specific focus on government spending on the disabled, because the rapid rise in the number of Americans on disability in the last 25 years has made the disabled into another political football to be kicked around. Conservatives point to the increase in spending as evidence of widespread fraud and/or some sort of runaway “entitlement society” mentality. As Paul Krugman said, the disabled have become the new welfare queens. Progressives are outraged, etc.

Yet, it’s a complicated issues. The sharp rise in the number of Americans on federal disability income supports is mostly explainable by benign demographic factors, like an aging population. A lot of the money state and local governments spending on the disabled is intended specifically to reduce society’s burden of caring for them by helping them get an education and a place to live so they can find work and stay employed. But, when you add up all of these costs it is fairly expensive for our society to provide the full range of services that allows disabled Americans to survive and thrive. There may be legitimate issues here.

Which ones should we discuss Monday night? Like last week’s meeting on the transgendered, my first goal is a little education. I’d like us to learn some basic facts on who in America is disabled, why, and what is done for them at public expense. We could then get into how well these programs work and whether more should be done or less. Also, last week’s big budget deal that prevents national debt default (but not, BTW, a govt shutdown, which is still likely) included some reforms to Social Security Disability Insurance. I will briefly explain those changes in my opening.

As always, I expect (and encourage!) us to debate the core philosophical concern at issue: What is our moral responsibility to act as a community to care for the least fortunate among us.

Discussion Questions –

  1. WHAT: What does it mean to be “disabled?” How do the govt and others define the term? How many Americans are disabled and how and why? What are the trends here?
  2. GOVT: What assistance with living do disabled Americans need? What government programs exist to provide it? How much does it all cost and who pays for it?
  3. EFFECTIVENESS: Do these programs/services “work?” Big gaps, wrong focus, vary by state, etc.?
  4. TOO MUCH? Why have the disabled rolls grown sharply in the last 25 years? Are the reasons innocuous or have these programs turned into a de facto safety net?
  5. TOO LITTLE? Alternatively, do we spend too little helping the disabled and/or should more be done to support their ability to work?
  6. ADA: How effective has the Americans with Disabilities Act been? At what cost?

SUGGESTED BACKGROUND READING –

Next Week: Do we need more or less government regulation of business?

Monday’s Mtg: Are We An Over-Medicated Nation?

Bruce, our group’s doctor, will take the lead on this topic. (Bruce is a neurologist. CivCon probably needs a psychiatrist, but nobody wants that job.) The topic I had in mind had to do with our  – probably – growing problem of prescription drug over-prescribing and abuse.  But, Bruce may prefer to take us a variety of directions, such as:

  • Pain medications: The recent sharp rise in opioid addiction in the Unt4ed States, related to the widespread prescribing of Oxycodone. The big issue, aside from just reducing addiction, is how to balance the need to treat chronic pain with safety issues.
  • Psychiatric drugs: Their alleged overuse by both adults and children.
  • Illicit use of prescription drugs by teenagers and children.
  • Whether widespread legalization of marijuana would make our addiction problems better or worse.
  • Others.

Below are some articles on these and other “are we an over-medicated society” issues. I will add others that Bruce brings them to my attention. I’ll see everybody on Monday night.

LINKS –

Next Week:  Are Americans Too Deferential to their Military?                          ?

Monday’s Mtg: Should We Legalize Euthanasia?

Oops.  I may have used the wrong term in the title of this topic.  I meant for us to discuss the Right To Die movement, the movement to pass “assisted suicide” and “physician-assisted suicide” laws. An assisted suicide is just what it sounds like: Suicide with help from another person.  In an assisted suicide, someone helps, but the person to be killed administers the instrument of their own death themselves.  It becomes euthanasia only when a doctor directly commits the killing.  No U.S. state allows for euthanasia.

However, the assisted-suicide movement has become more popular in recent years.  We all remember Terri Schiavo, the brain-dead coma patient from 10 years ago that the U.S. Congress tried to interfere with (link below).  Since then, five U.S. states and several countries have adopted versions of assisted suicide in cases of terminal illnesses – and, in some cases, when an illness is not terminal.  I thought the many ethical and practical issues raised by assisted-suicide would make for a good Civilized Conversation.

I don’t know much about this issue, so my opening remarks will just be a brief framing.  I’ll probably just summarize the U.S. state laws and the Dutch and Swiss statutes on assisted suicide and explain what they do and do not allow.  Then, I’ll try to make sure that our discussion covers the major moral and medical and political issues surrounding assisted suicide.

DISCUSSION QUESTIONS –

  1. What are the general pros and cons of assisted suicide and euthanasia?
  2. Five U.S. states allow assisted suicide, and six other countries allow either it or euthanasia.  What do these laws do?  What have their effects been?  Are their publics happy with the laws?
  3. Do you support these laws?  If so, under what restrictions should they operate?  How could any such laws be written so as to address opponents’ religious and moral objections?
  4. Is lousy end-of-life medical care a part of the problem?  How could end-of-life care be improved in the United States?

LINKS –

Next Week:  The Future of Marriage in the United States.

Monday’s Mtg: What Is a Psychiatric Disorder?

What constitutes a psychiatric disorder has always been somewhat controversial.  (Homosexuality was considered one until 1973.)  The mental health profession uses the Diagnosis and Statistical Manual of Mental Disorders (DSM) to define mental disorders, and a major revision to the manual has just been completed.  Apparently it’s very controversial.  The guy who headed the last revision called the day the new team voted on the recent revision the “worst day” of his professional career.  DMS-5 made “vast” changes to the definition of a mental disorder, and a lot of people thought they made some bad inclusions and exclusions.  For example, hoarding is now a mental disorder and Asperger’s Syndrome no longer is.

Don’t even think this isn’t important.  The DSM affects what insurance companies will pay for and gives science’s imprimatur to an illness.  What’s considered a mental illness and what is not arguably affects more people than a lot of the topics we discuss.  The greatly expanded DSM-5’s definitions mean that millions of Americans will either (1) be labelled as mentally ill when they are not, or (2) will ge the help they need, depending on one’s point of view.

Also, I think this topic raises broader questions about medical care and how science should operate when it intersects with politics.  Given that science is under assault from both Right (climate change, evolution) and Left (vaccines, other junk science), I’m glad we’re doing a science topic again.

Bruce suggested this topic and, as our resident (ha) doctor, he will  present and run the meeting.  Below are some basic discussion questions and some links that I suggest we all try to read.
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DISCUSSION QUESTIONS –

  1. What is the DSM and how is it revised?  Who gets to make these decisions and what is the process?
    .
  2. What big changes were made to DSM-5 and why were they controversial?
    .
  3. When should laypeople second guess the judgments of the scientific community?  Is “never” really the right answer?
    .
  4. What kinds of political pressures is science – and especially medicine – subject to?  Is this really so bad?  What can be done?

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LINKS –

  • DSM-5 entry at Wiki.  Summarizes major changes and the basic controversy.
    .
  • Brief news account of the controversy over DSM-5.
    .
  • Long Scientific American article explains whole thing.
    .
  • In Psychology Today, the “worst day of my life” guy explains his objections  – but also the limits to the damage the new DSM may inflict.
    .
  • Honestly, I had trouble finding a defense of the revisions, but there are two sides to everything.  Bruce, do you know of any or have any other links?  Put them in comments and I’ll elevate them to this spot.
    .

Take a chill pill and join us there!

Monday’s Mtg: “Conscience Clauses:” Faith and Obeying the Law

When does having a strong moral objection to the law allow you to refuse to obey it?  Not very often – try it next time you’re stopped for speeding.  But, “conscience clauses,” provisions in law that allow people to refuse to obey it if they have a religious objection, have been around for years.  This is as we’d expect in a religious country founded on secular governing principles.  But, conscience clauses are making a big comeback, thanks to conservatives.  GOP-controlled states are stampeding to pass laws that carve out religious objection exceptions to laws concerning contraception access, GLBT equality, and other areas where the religious right is losing the broader culture war argument.

This topic has been in the news a lot lately.  Some employers have sued over the Obamacare requirement that their health plans cover contraception.  Some religious employers already are exempt from the requirement, but not enough are to please many conservatives.  I’ll explain what’s going on.  But, just being in the news is not enough to merit being a weekly topic in our group.  I think conscience clauses have a bigger importance than just how they relate to Obamacare implementation.  I believe that the idea that people should be exempt from some requirements of laws they don’t like  is edging towards becoming a core belief of modern conservatism.  To me, this idea that some duties of citizenship are kind of, well, voluntary, is a real slippery slope.  That’s why I wanted conscience clauses on our schedule.

On Monday, I’ll open by explaining (1) what conscience clauses are and their history; and (2) the latest developments in this area (it’s not just Obamacare).  Then, I’d like us to discuss whether today’s conservatives really are trying to redefine the notion of citizens’ responsibilities, or if it’s just the old federalism philosophy being dusted off for an era when they don’t control the national government.

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DISCUSSION QUESTIONS –

  1. What is a conscience clause?  What is the history of this legal idea and its justification?
    .
  2. What is the latest in the fight over conscience clauses?  What is causing the renewal of interest in them?  Is it just Obamacare and contraception, or is something else going on?  Will the courts side with conservatives on this?
    .
  3. More broadly, do conservatives view the duties of a citizen to obey the law and contribute to the well-being of their fellow citizens differently than do liberals?  Are conscience clauses a part of this, or are they just a sui generis thing related to reproductive issues?
    .
  4. Is there common ground to be found on any of this?

 .

LINKS –  

Monday’s Mtg: Should We Keep Increasing Longevity?

Bruce, our neurologist, will present and Carl will moderate in my absence.  I’ll be back for the next meeting, on targeted assassinations on October 8, which is a great — and underreported — topic.

The direction the longevity meeting takes will depend on Bruce, of course.  The links below focus on the political and social policy implications of an aging society.  The costs and risks of an older population have been widely discussed, but – see the links – are easy to exaggerate.  Still, there is no question that an older society is a different society that will require a different mix of services and supports from its government(s).

You also could focus on the personal aspects of extending longevity: The ethics of extending life versus ending life and the morality of spending so much of society’s resources on the elderly rather than the young.  Remember: America’s elderly already live in a kind of socialist paradise; it’s our working age citizens that live without a high level of social support.

Links –  (Bruce: Add any you want in comments, and I’ll put them in the post)

I’ll see you all in two weeks.

Monday’s Mtg: Is Medicare Safe Or Doomed?

Welcome to the heart of the 2012 presidential campaign!  Both the Obama and Romney campaigns swear that they want to protect Medicare and the other side wants to gut the program.  The one that persuades the public wins the White House (probably).

So, who’s telling the truth and who’s lying?  Or, is the truth somewhere in between?  One thing that’s not in dispute is that Medicare faces serious financial problems down the road unless real cost-cutting reforms are put in place.  (Note:  Medicare is NOT “going bankrupt.”  That language is highly misleading, as this explains).

Obamacare tried some Medicare cost-cutting measures.  These reforms include the famous $716 billion in “cuts” that Republicans keep hammering on.  The House Republican (a.k.a., Paul Ryan) budget would have made even more drastic changes, turning Medicare into a voucher to buy private insurance.  Romney, always hard to pin down, has embraced a somewhat less drastic plan for Medicare’s future.

On Monday I’ll open with a short lecture on the basics of what we’re talking about here.  I’ll quickly explain :

  1. What Medicare does, how it’s funded, and why it’s going broke;
  2. How Obamacare will change Medicare; and
  3. The fundamentally different way(s) that the GOP would reform the program.

Remember – you can hate the Republican proposals all you want to and call them all liars (I think there’s a lot of truth in that).  But, at the end of the day, someone has to do something to control Medicare’s cost growth.  The question is how to do that in ways that would (a) work, (b) be fair, and (c) attract public support.

DISCUSSION QUESTIONS –

  1. What does Medicare actually do and how is it funded?  Why is the program running out of money?
    .
  2. Democrats and Republicans seem to have chosen drastically different ways to fix Medicare.  What are the two basic approaches and why were they chosen?  Is the GOP way just a covert attempt to privatize Medicare?  Is the Democrats’ way realistic?
    .
  3. Obamacare:  What changes did Obamacare make to Medicare, especially the $716b in cuts to providers?  Why did they do this?
    .
  4. GOP ideas:  How would the Ryan budget have altered Medicare?  What is Romney’s plan?  Is this privatization?  Is it fair?
    .
  5. What is the evidence that increasing competition in medical care for seniors would be more efficient and lower costs without gutting quality?

LINKS –   

Easier

Harder/Longer/Wonkier:

  • The Medicare Bind:  Why the program is in trouble and how to save it in the long-run.  I recommend.
    .
  • Why vouchers and other conservative plans to use private markets to lower Medicare costs probably would not save as much money as Republicans claim (by a former OMB director).

I don’t want to spend the entire night debating numbers.  What really matters here, IMO, is that Left and Right have a profound philosophical differences on whether government-guaranteed health insurance should even exist!  Let’s debate that, too.