Books!!

It is an interesting time to be in Washington D.C., particularly working on issues of health and health care. I look forward to seeing how things play out with so much talk of health reform going around. I recently picked up a few books and reread some old ones that I think help create a good foundation of knowledge about the challenges and possibilities for health reforms in the coming years. I wanted to highlight four that I think are great reads:

The first and probably most approachable book is Critical: What We Can Do About the Health-Care Crisis by Senator Tom Daschle (with Greenberger and Lambrew). This book is a good primer for the upcoming health care debate, and is extremely timely (making it somewhat hard to find at a bookstore...) given that Daschle will likely be the next head of the Department of Health and Human Services. Daschle, an experienced former Senator, brings a unique perspective to the discussion and highlights the plight of real Americans using poignant and illuminating examples from people he has interacted with during his long career of public service. The book does a good job providing a clear overview of what must be taken into account and what reforms should be made. It is written in a very engaging manner and would be a great read for anyone even vaguely interested in one of the possibly largest overhauls to the U.S. government in history.

The second book is Health Care at Risk: A Critique of the Consumer-Driven Movement by Timothy Jost. Jost is a law professor but the book reads more like a thriller (well, maybe not for most people...). He paints a clear picture of the rise of the consumer-driven health movement and highlights its intellectual as well as political origins. While it would seem that consumer-driven health would be the focus of the book, in fact, that is only one part of the overall story. Jost constructs the most clear and concise narrative I have found about the rise of the current U.S. health care system and how truly exceptional (not in a good way, by most accounts) the American system is. He does a good job identifying the common conceptions that people have about health care and the possible solutions. His analysis questions many of these assumptions and forces us to think critically about the goals of health care and what those goals would mean for reforms.

The third book is Governing Health: The Politics of Health Policy by Weissert and Weissert. The book is the best source I have seen that lays out the different actors and interests that play a role in the health care debate. Each of the key players (Congress, the President, interest groups, etc.) is explored at length, including their often contradictory and nuanced stances and perceived interests. Written by two political scientists, the book provides an excellent overview of the factors that are likely to come into play during any health care debate, particularly one that would entail wide-ranging reforms to the system. The actual policy process is also highlighted, something that is often discounted when people talk about what should be done when it comes to health. Taking into account the feasibility of particular reforms will be key for the new administration and any advocates of reform.

The final book is Why Are Some People Health and Others Not? The Determinants of Health of Populations, edited by Evans, Barer, and Marmor. This classic book is a personal favorite. It expands the notions of health away from just health care by examining the importance of how society is structured and its implications for health. The book highlights growing congruence among a number of fields that identify health issues that cannot be explained simply by differences in care or sanitation or wealth. It highlights the importance of factors like hierarchy, genetics, and structural issues that play an important role in determining not just health outcomes but also opportunities for care and even understandings of what it is to be sick. Many of the ideas underlying this book played a key role in my graduate work.

If there are any books that you have found helpful to understand health or health care, please let me know as I am always looking for new sources on the subject.

Hard To Imagine How The NRA Can Spin This

A recent study which was underwritten by more than 300 U.S. mayors has uncovered some extremely damning evidence about the link between lax gun laws and legal guns ending up being used in crimes. The study makes clear that 10 states with lax gun laws are responsible for over 50% of guns used in crimes across the U.S. This number should be staggering and the repercussions swift. This sort of dangerous funneling of weapons to be used in crimes cannot be allowed to continue. While people will continue to argue that it is not the guns that commit the crimes, it is clear that access to guns is providing the ability to carry out many crimes. It is hard to imagine how anyone reading the report could come to the conclusion that gun control does not have a positive effect on reducing the amount of guns in the hands of criminals. Particularly deplorable was the cover-up pushed by the industry to keep this data from seeing the light of day. To know that such data exists and to try to censor it is despicable and calls into question how dedicated to safety those involved really are.

It isn't just purchasing guns intended for use in crimes that is making headlines. In the same days as the above-mentioned report was released, this story came out as well. I cannot imagine how horrible all those involved must be feeling at this moment. It is difficult to imagine such a senseless thing, all because a weapon was being treated as a source of entertainment. Why an eight year-old would be allowed to fire such a deadly weapon is beyond me. I hope people learn to respect the dangers that guns pose and accept that they must be regulated for public safety. Together these two articles highlight what many researchers in a variety of fields (including public health, criminology, sociology, economics, and others) have found, that guns must be regulated and that protections must be in place to keep guns out of the wrong hands. Clearly many states are failing on this issue and must be brought to task.

Dangerously Heightened Expectations

With the election of Barack Obama, a international outpouring of support has increased the already immense pressure on the 44th President-Elect. Congratulations have come from the most unexpected places, including the President of Iran (who now feels spurned by the Obama camp's tepid response). Different groups around the world are placing expectations and ideas at the feet of Obama hoping that he will become involved and help solve problems. On one hand, this invitation to multilateralism is breathtaking. It is amazing to see that even the international community believes that America can and will be better under the leadership of Obama. However, together with the expectations domestically, it is hard to imagine how Obama can make all groups happy within the grace period of his early campaign. Obama stands on the cusp of being the most important president in America's history. The possibility of making the U.S. more accountable and multilateral is a dream that many have hoped for for decades, particularly during some of the recent dark years America has faced. People around the world have placed their hopes and dreams on his administration and it is difficult to imagine how it can meet expectations. 

A recent article by one of my favorite journalists, Ahmed Rashid, author of the recent book Descent into Chaos (which focuses on the war on terror in South Asia, primarily Afghanistan and Pakistan), sheds light on some of the massive expectations Obama faces. Reading through the article I was struck by just how much different factions in different conflicts are focusing on every word Obama says, in hopes of identifying what his presidential and international priorities will be. Particularly interesting was the quote by an unnamed European foreign minister that European countries will be unable to refuse anything Obama asks for in the first six months of his administration. There is such a massive amount of power in that statement. I cannot imagine any president in recent times being charged with such a great and also dangerous burden.

An America I Can Believe In

In what has to be the most historic election in a generation, Barack Obama has become the president-elect of the United States. It is hard to imagine how such an unlikely candidate had such a meteoric rise to success. I will be the first to admit I questioned Obama in the primaries. Initially I was a Kucinich supporter (a long shot, but one of the only beacons of true progressivism in a party bogged down by greed and avarice). After his withdrawal I changed my loyalties to Clinton. Having met her personally and believing that she had the strength, experience, and political capital needed, I felt she would also be the best to face whatever Republican was chosen. Now, unlike many Clinton supporters, I never fell into the rancorous denouncements of Obama and genuinely felt that either would do a reasonable, centrist job as president. I felt safe with either of them but not particularly inspired. Sure they were both historic candidates in a year the Democrats stood a good chance of actually winning, but it is always hard for me to vote for centrism. This country has been governed by the fifty-one doctrine for too long (playing to the middle in an attempt to eek out the election with just enough votes). This doctrine has often meant proving who was the most centrist, the most moderate. As a leftist progressive, this placation often struck me as dumbing down the election, and also hindering a genuine vision of a better future. I began to see that Barack Obama was trying to transcend the old language of elections. He spoke to the youth in a way that didn't seem placating or insulting. He gave people the opportunity to inform themselves on complex issues and expected that they would respond. He called for national service, in a country that is facing hard times and an uncertain future. He made me believe.

It is hard to sum up how amazed I am looking at the electoral map in today's Washington Post. Seeing how many states ended up blue and how many of the red states are closer than anyone could have imagined even two years ago. I was amazed to see Obama do so well in my home state, Montana, a rural homogeneous state. It makes me question my own and many other cynics' interpretations of the possibilities for a sustained grassroots movement in America. Many first time voters must feel empowered by the success of their campaign of choice. It will be important to keep these citizens involved in the process as it moves forward and to get them to understand that democracy is not just voting. Only through a sustained national movement can real change be accomplished. I feel optimistic about politics for the first time in a long time, and I am really excited that I will be in the middle of it.  Heather and I are already making plans to be at the inauguration. It will be exciting to play an important role in the health care debate and to have the real likelihood of actual reform. It is a historic time, and a great time to be in Washington D.C.  As one person who always had a hard time believing in hope, I say this with complete conviction: Yes, We Can!

A Vote For Change

I have always been a bit of a pessimist when it came to politics. Being a political science/sociology major will likely do that to you. Compounded by the fact that my political development happened in a state were if you weren't voting Republican you may as well not show up. For awhile I certainly understood the expatriate movement and why some Americans felt the draw of greener pastures around the world. I still have my fair share of complaints about the U.S. and its position and direction in the world. I have come to see however that everyone in the world wants the U.S. to change, in a myriad of different ways. Only through remaining in the U.S. and being that voice for change can effective reforms be undertaken.

I often hear Americans and residents of other countries say that they didn't realize how good they have it at home until they go abroad. While I can empathize with this comment, it in no way informs my way of seeing the world. There are many good things about the U.S. that I appreciate. The reason I have chosen to remain in the U.S. for the forseeable future is to push for change. Leaving just because the times are bad is an injustice to those left behind. Those who believe that the U.S. can or should be better have the obligation to work toward that change. Only through a truly democratic movement will Americans become engaged and informed. The record numbers of people registering to vote is one sign of light in a very dark time.  We need to realize that democracy is not just voting. Democracy requires active engagement and only the people can keep government responsible.

I cast my absentee ballot today. When I cast the ballot I was reminded of a quote by RFK that informs the kind of communitarian democracy that I idealize:

“Each time a man stands for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends a tiny ripple of hope, and crossing each other from a million different centers of energy and daring, those ripples build a current which can sweep down the mightiest walls of oppression and resistance.”

A vote for change is in the mail. Lets hope we get it right this time.

The Straight Talk Express Is Off The Rails Again

I never realized the "Straight Talk Express" mantra of McCain included slander. After being clearly rebuffed on issues of importance like the economy, the McCain campaign has decided to fall back on the most deplorable and depressing of tactics. While I can't fault them for using every tactic available to them in such an historic election, I am extremely disappointed at this decision. The Washington Post recently reported that the McCain campaign will be focusing on personal attacks on Obama's character.

The opening salvo of this new course was Palin dragging out the tired old line of Obama being associated with terrorism because he happens to live in the same neighborhood as one of the founders of the Weather Underground. Real solid stuff guys. What's next, talking about how the name OBAMA rhymes with OSAMA? I mean seriously, is this the best that the McCain folks can come up with, ad hominem attacks that indicate nothing about Obama.

This new tactic is just another low point for one of the few senators, Republican or Democrat, that I truly respected. Pandering to the religious right, becoming the partisan he said he never would, and leaving behind the issues to instead make personal attacks. McCain's star has fallen quite far in the last six years for me. These actions are not the course of a "Maverick" but of a flailing politician behind in the polls. If you're going to lose, at least do so with some dignity.

Obama's To Lose

After quite possibly the oddest vice presidential pick since Dan Quayle, the presidential race is now Obama's to win or lose. McCain has effectively silenced his greatest criticism of Obama by selecting someone much less experienced as a running mate. Palin has been the mayor of a city of 9,000 and is now the governor of Alaska, a state of only 680,000 and is run largely at the expense of the U.S. federal government. She has no foreign policy experience and is even younger than Obama. The fact that McCain has put her one step from the presidency shows that he is not as truly concerned with experience as he claims. A vice president needs to be ready to take on the job of the president from day one. It is hard to see how that is possible with someone like Palin.

I hear many people say that McCain is trying to reach out to disaffected Clinton supporters with his choice of Palin. While this may seem plausible because of the fact that she is a women, I would hope that McCain would be smarter and realize the women that supported Hillary are much more savvy than that. The fact that Palin appears to be an arch-conservative and opposes fundamental rights for women (anti-choice, against federal funding for family planning) doesn't lend itself to many Clinton supporters switching sides.

The choice of Palin is likely to raise this issue of the extreme sexism that still exists within the Republican party. The traditional and essentialist roles that are ascribed to women in Republican talking points only show how out of touch the party is with changes in society. I would also not be at all surprised if having a female VP hurts McCain among southern white males. It will also be interesting to see if the media continues its sexist tirades that were so common while Clinton was still in the race.

After a couple rough weeks in the polls, it looks like smooth sailing till November now (don't prove me wrong, Obama!).

An Election Without End

As the U.S. presidential election draws near, I am increasingly disgusted by what passes for journalism and democratic participation. It is hard to fathom how such a corrupt and despicable system is not challenged more widely by Americans. Most Americans, liberal and conservative, agree that our government has serious problems. However, instead of addressing them through collective movements, we choose to pick at each other on "hot-button" issues. Responsible and accountable government is not something anyone would oppose. The steps that would need to be taken to create a responsible system are neither easy nor straightforward. Many argue that the presence of massive amounts of money in American politics is the largest source of its problem. While I would argue that money plays a part in making the problems worse, the structure of the legislature and elections also has significant negative effects on representation and public policies that come to be instituted. The current structure enforces the two-party system and the personalization of campaigns. It also greatly hampers the ability to implement reforms. The lack of benefits of voting combined with the lack of risks of not voting create the situation where only around half of eligible voters turn out on presidential years, and even less than that on non-presidential years (let alone the paltry sum that appear for purely local or county elections).

While, for me, some form of proportional representation and changes to the amount of elections we have would be a good start; it is important that other people get engaged with this process. Having people come to understand that democracy requires much more than just voting is important if sustained, realistic change were to be enacted. This isn't something that will be accomplished through a spontaneous uprising of national consciousness. It must be facilitated by groups that people engage with in their daily lives (employers, religious communities, civic organization, NGOs, and the government itself). We as a society have learned to be apathetic, but this social apathy can also be unlearned. Giving people a reason to vote and significant benefits for electing your particular chosen party would create a more vibrant and engaged democracy.

Migration Myths, Journalistic Mistakes: How do Articles Like this Get Printed?

On the front page of MSN today was a link titled "What if All the Illegal Immigrants Went Home". It sounded like an interesting piece so I decided to check it out. Obviously the folks at MSN.com felt the actual title of the article, "What if we threw out all the illegal immigrants,"was not quite appropriate for the tagline. Once I saw the actual title and checked the credentials of the writer (Shirley Skeel, a "print and radio journalist based in Seattle who has written for Bloomberg News, The Seattle Times, the Los Angeles Times, and the Daily Mail and Daily Telegraph in London. She has also produced radio features for National Public Radio and its affiliates"), I was not sure what I would find. I did a quick google search of Skeel's previous work and found some other less than complimentary commentaries about other Skeel articles here.

While shoddy journalism is nothing new at MSN Money, this articles takes lessons learned from an intro to economics course and attempts to apply them to the real world.

"The biggest losers would be middle-class families with two working parents, living in high-immigrant states such as California, Texas, Florida or New York."

What about the twelve million people forcibly displaced? Seems like being tossed back to a variety of countries in Latin America, Europe, and Asia would be more difficult. These workers left for a multitude of reasons (including discrimination), and being forcibly returned would be much worse than someone having to clean their own house. Not to mention that many of those that had to go back to low-income countries would now face extremely difficult circumstance as large numbers of former immigrants would now end up competing for the same jobs that caused them to leave their home country in the first place. Also, the families that would be destroyed by such an event would also be in a worse situation than the guy who has to mow his own lawn. Many families have some family members that are undocumented workers while other members have gained legal status. This could even mean couples being split up and parents separated from children. Skeel touches on the difficulties of deporting so many people, but only as an afterthought (though it seem like the whole article is more of an afterthought, than actual journalism).

Possibly the most insulting part of the article:

"Economists say if [American citizens] agreed to bone meat or install insulation, they could earn 6% to 10% more than the deported workers, as wages rose to lure new workers. That could mean $18,000 to $30,000 in pay a year."

Come on, what "economists" did you speak to? This sort of theoretical armchair economics is the reason most Americans understand so little about how global capital works. These two sentences are riddled with so many problematic and untrue assumptions that it would take more time than I am willing to invest to deconstruct them. However, I will focus on two key points: wage determinants and employment networks.

This statement (and the wider article) makes the fallacious assumption that the "illegal immigrants" are the reason for lower wages. While from a purely theoretical perspective this may seem plausible or even likely, any engagement with the actual literature on wage restructuring points to wider, more structural factors. Aviva Chomsky (2007) notes that wages across the U.S. have either stagnated or declined for low-skill workers, while profits have increased in many sectors. She argues that it is the businesses that target undocumented workers because of their marginal status, which allows companies to treat them abhorrently while not fearing repercussions. This is particularly true in many agricultural industries that rely heavily on undocumented labor. Were they to switch to documented workers with legal rights they would deeply cut into their profits and thus face the wrath of their short-term minded shareholders. This would likely push many companies either to increase their production of goods in other countries (which may not be as profitable as it used to be, due to the high costs of transportation due to higher gas prices) or by directly increasing the prices of goods (something that would create a serious backlash).

For employment networks, most social scientists recognize that it is not simply employment that determines where an individual lives. However, Skeel found someone intellectually lazy enough to believe so (however without evidence, like most researchers at the Heritage Foundation; Rector is a senior research fellow, though research is a strong word for what the Heritage Foundation does)

"Just how quickly would Americans fill the vacated jobs? And at what pay rate? Perryman points to Texas, where he says there are more than 1 million illegal workers, but only 450,000 unemployed residents. 'If you do the math, it just doesn't work,' he says. He doubts that many needy Virginians would move to Texas for often-grueling, low-paying jobs.

Rector disagrees. He says it would take time for 'Cousin Fred' in Texas to phone up his jobless mates in Virginia, but, 'There are a lot of people who work for less than $20,000 a year.' And they would move for a job."

While some people move to find employment, the vast majority of Americans would have no idea where and what types of jobs are available in their own town, even less so in places across the country. The idea put forth by Rector in the above quote relies on the economic ideology that individuals are rational choice robots that have perfect information and are able to weigh the costs and benefits of their decisions. Joseph Stiglitz, a Nobel prize winning economist, has studied informational asymmetries and notes that these naive assumptions of many economists simply are not supported by research. Calvó-Armengol and Jackson (2004) identify that the importance of social networks in determining opportunities for employment has been well-researched and is overwhelmingly supported. To assume that eight million American citizens (the number it would take to replace the employed undocumented workers, from Skeel's estimates) would pick up and move to take part in unskilled and nonunionized work is just ridiculous.

While such hypothetical articles allow us to think about the difficulties of immigration policy, when as poorly researched as this one, it is hard to see how it adds to the debate. Immigration is a complex issue without simple solutions (as can be seen in nearly all countries), however, using simplistic logic and ignoring previous empirical work will not get us any closer to a solution.

References:

Calvó-Armengol, Antoni, and Matthew O. Jackson. 2004. "The Effects of Social Networks on Employment and Inequality." The American Economic Review 94: 426-454.

Chomsky, A. 2007. They Take Our Jobs: And 20 Other Myths About Immigration. Boston: Beacon Press.

Intensifying Violence as a Way of Increasing Safety?

The ruling today by the Supreme Court on District of Columbia v. Heller does not come as much of a surprise but does set a dangerous precedent and shows how out of touch with reality the current court is. The ruling struck down the 1976 Washington D.C. law that banned the ownership of concealed weapons in Washington D.C. Scalia argued that gun ownership represents an important part of the "historical narrative" of the U.S. However, so did slavery, but I don't think his "air-tight" logic will get applied to that. Evidence from those who study gun violence and gun ownership find that while gun ownership among the general population does not increase crime, it does increase the intensity of the violent crime. A recent opinion piece points out the absurdity of the "more guns, less crime" ideology. Ludwig and Cook (2006) argue that this leads to greater likelihood of death from violent incidents and thus a greater risk to the community. Kleck (2004) notes that increased gun ownership by non-criminals leads to increased number of guns in the hands of criminals, through a variety of mechanisms. Luckily, D.C. is still able to create regulations for gun ownership if not ban it outright. Evidence of the effect of the 1976 law was overwhelmingly positive, with a twenty-five percent reduction in gun homicide and a similar reduction in suicide with a gun. Similar declines were not found in the areas of Maryland and Virginia that surround Washington D.C., which did not implement similar measures (Wintemute 2008).

Besides the evidence of the negative social costs in relation to violence, the ruling raises another key issue. The ruling notes that gun ownership is important for hunting and self-defense. On the issue of hunting, clearly the preferred weapon of most hunters is not a handgun. While hunting may be a enjoyable pastime for some, it seems that having measures such as trigger locks or disassembling them should not be a problem, as was required in Washington D.C. prior to the ruling today. For self-defense, Hemenway (2000) found that that criminal uses of guns far outweigh self-defense uses. This casts serious doubt on whether the presence of guns actually makes us safer, even from a self-defense standpoint. Wintemute (2008) also notes the dangers of guns and the likelihood of fatal accidents when fear is a factor, even when there was no actual threat.

While I don't think any amount of evidence can make die-hard gun activists change their mind, I hope that others are more open to the overall effects of guns on society. While a collectivist approach to public policy is not something that many Americans understand, it would provide for a safer future. Fixing the fear of violence through arming ourselves does little to assuage the fear and makes us less safe as a society. Reducing inequalities and creating active, engaged communities would do much more to foster safer neighborhoods than any amount of individual effort.

Citations:

Cook, Philip J., and Jens Ludwig. 2006. "The social costs of gun ownership." Journal of Public Economics 90: 379-391

Hemenway, David, and Deborah Azrael. 2000. "The Relative Frequency of Offensive and Defensive Gun Uses: Results From a National Survey." Violence and Victims 15: 257-272.

Kleck, Gary. 2004. "Measures of Gun Ownership Levels for Macro-Level Crime and Violence Research." Journal of Research in Crime and Delinquency 41: 3-36.

Wintemute, Garen J. 2008. "Guns, Fear, the Constitution, and the Public's Health." New England Journal of Medicine 358: 1421-1424.

Misperception of Intent

When discussing undocumented workers many people on both sides of the argument make the claim that these workers end up in jobs "Americans don't want." However I think this argument places the decision making wrongly in the hands of the average American, who in this fantasy considers themselves too good for farm work or that it is too difficult work. It seems more likely that the reason these jobs are not taken by Americans is because the companies that hire these workers would be completely uncompetitive if they hired Americans (due to their ability to demand better pay and protection). Only through hiring marginalized workers with no formal rights are they able to remain competitive with goods produced much more cheaply elsewhere.

There are many jobs that are much more disgusting and backbreaking than field work but are done by Americans and some are even unionized. This is possible because these industries can remain competitive despite paying reasonable wages due to different competition structures than is present for agricultural work (e.g., copper mines). Many of these companies would have already moved production to another country if possible; but they are unable to, due to the type of product they produce.

While this argument leads some to push for new policies of protectionism, for me it indicates the need to structure trade in a fair way. Protectionism has done little to provide good long-term jobs for Americans. We must come to the point where the lowest cost is not separated from the factors from which the product are produced. Products from countries with substandard quality controls, unethical work practices, and terrible human rights records must be identified as such. By accepting these products despite these problems, we are just serving to reinforce the negative tendencies under which the goods were produced.

Confusing Correlation with Causation

A recent article on MSN Health does a great job showing how the medical view of individuals can miss the social determinants of both health and crime. The article cites a recent study in PLoS Medicine which found that increased levels of lead in children is linked to crime later in life. They article goes on to discuss the dangers of lead and the neurological effects that it has. Even though it notes the connection between lead exposure and poor communities, it completely misses the connection between poor communities and crime. Instead in assumes that the effects of lead on the brain are what lead to crime.

This lack of a larger perspective shows how entrenched the medicalized, atomized version of society is. Individuals who are born into socially marginalized communities often have no real opportunity for engagement and often end up being involved in delinquency. While there is still the presence of agency, it is difficult to disregard the widespread patterns of crimes in marginalized populations worldwide. Nothing links these groups (race, religion, creed, education) except for their marginal status. It is difficult to see how policy makers cannot make the connection that it is not something intrinsic to these individuals but something social that is happening. Social patterning of all aspects of our lives is something continually overlooked by the media and not well understood by those in power. We must learn to look past simple individual level explanations and ask why these patterns are so consistent across place and time. Only then will we be able to find adequate social and economic policies to mitigate the ill effects of poverty and marginalization.

Social Determinants of (Google) Health

Google recently added an interesting new feature to their online empire, Google Health. It has the making of a useful and helpful tool for many people that want a place to keep track of their medical history and required prescriptions. You can enter your personal information, update your existing conditions, and even import your medical history and records from a variety of sources. It can also be used to find a doctor in your area or to seek online medical help.

One area where it is woefully insufficient is on social determinants of health. It would seem a more appropriate name for the site would be Google Medical, because that is its sole focus. The social determinants of health have been found to play a significant and varied role in individual health. Factors that are social determinants of health include things like where you live, what type of social capital the area you live in has, what is inequality like, how much income do you make, what kind of discrimination do you face, etc. However those critical factors are completely absent from Google Health. This reinforces the myopic medical view of health that divorces the health of the individual from the health of others. All health is patterned. Even things we consider random and tragic, like cancer, follow social patterns and gradients across factors like income. Ignoring these issues on a health site is at best ignorant and at worst neglectful of a whole host of factors many people may not be aware of.

More Folly than Fact

John McCain's proposed health care policy is another example of irrational faith in a market that has already failed millions of Americans, particularly the 50 million without any health insurance. The problem is that "the market" and health have an extremely poor track record in all countries that have implemented market-oriented measures. The costs in each of the countries has increased without an increase in the actual services provided or quality of the care. This is the reason (as mentioned at length in previous posts) that Americans spend the most per capita on health but have among the poorest health outcomes for OECD countries. The U.S. government currently covers health for the two groups most prone to health problems: the poor and the elderly. By bringing all Americans into a national health system, the higher risk of these groups could be shared across a larger pool. This would bring down costs per patient overall in the U.S. and would reduce the overhead and bureaucracy needed to run the system. While both Barack and Hillary have imperfect plans for health care they are vastly superior than the "faith-based" plan from McCain. While government may not be the perfect provider of health, we have plenty of examples of more successful programs run by other countries that we could draw lessons from.

Peace Through Torture

It is difficult, if not impossible, to fathom at this point how the Bush administration can justify the actions they have taken. The most recent disgusting example of rampant disregard for the safety of Americans is the veto of the interrogation limits for detainees. While intelligence experts and interrogators continually identify the ineffectiveness of torture, overwhelmingly Americans fail to understand this. This disconnect is dangerous because it has been shown that torture can increase similar acts of violence from those on the other side of the conflict. The American people and those around the world must not let these actions continue. A concerted effort to hold those responsible for torture could be one positive step in creating sustained change.

Another aspect that has been identified as playing a role in the veto is executive power. Like many of the actions taken during his term, Bush has continually attempted to enhance the power of the executive generally and the presidency specifically. This is in direct contrast to the rhetoric of big government as a pariah on society. It is hard to imagine trying to secure your legacy by making the world less safe and free through torture. History will not look positively on the wasteful War On(of) Terror that has been undertaken during this administration. It is even more disgusting that McCain gives the Bush administration nearly a free ride in his discussion of their actions. I have a campaign slogan for him "Making America Less Safe for only Three Trillion a War!" I guess it may be a little too long...

Possible Turning Point

A recent ruling in California on rescinding health insurance will hopefully have a industry wide impact on the way health insurance cases are managed. As the article notes the woman was diagnosed with breast cancer and was undergoing treatment for it. Midway through treatment, the company, Health Net Inc., canceled her policy leaving her with hundreds of thousands of dollars in debt. The reason given was that there was some weight discrepancies on her application and possibly missing information about a heart condition. This type of health care is deplorable and just another example of the dangers of for-profit health care.

The current system has Americans paying the most per capita for health care by a wide margin. (see table below). This massive discrepancy between what is spent in the U.S. and the level of health that is attained is a fundamental contradiction of our system. The fact that 50 million Americans go without health insurance (which often means going without health care) helped to increase this discrepancy. When people without insurance go for care they pay up to four times as much as those with insurance.



Source: uscs.edu

Administrative costs are also a significant reason for this vast discrepancy in spending. The bloated insurance company system makes health care less efficient as opposed to the "common sense" notions that are typically expressed around issues of public versus private. Using simplistic theories from economics may give particular policy prescriptions, but the empirical data often indicates something much different.

Many recent polls indicate contradictory factors in people's perceptions of health care. While approximately two-thirds of Americans support the idea that the government is responsible for providing health care to everyone, only forty percent would like to see the system changed to a single payer system.

The thing that I fail to understand is how Americans don't make the connection between the per capita spending and the cost of a single payer system. When we are paying significantly more for health care and receiving less benefits, it is hard to justify the current system. Due to the cultural fear of taxes present in the U.S., it is difficult to imagine an increase in taxes being a possible method of funding health care. It must shown that an increase in taxes would actually save Americans money. What they pay to insurers as well as the decreased direct pay that they receive due to the cost of company provided health care likely exceeds the tax increases that would be required to fund this system. Overall the expenditures of Americans on health care would decrease under a single payer system for a variety of factors including the ones mentioned above, but also other factors (ability to practice preventative medicine, decreased cost for prescription drugs, and increased risk sharing to name a few).

While the road to a single-payer system is neither simple or clear, it stands as the most likely and successful measure. While many countries are repealing aspects of their health care system, it is largely at the behest of those who stand to make profit. Those who require health care are often the first to decry these cut-backs. Though a single-payer health system would impose problems of its own, it is hard to imagine that it could be anywhere near as bad as the current system for the fifty million Americans without insurance and the tens of millions who are underinsured or likely to be dropped if they do get sick.

An Anticlimactic Ending

The recent departure of Castro from the position of president of Cuba fails to represent the 49 year rule that began with a thunderous revolution. While the results of his rule have been mixed, the Castro doctrine represented a fundamentally different way of viewing the world. It is hard to imagine that Cuba will not end up plodding along within the current globalized economic system much like other countries of Latin America. Their gains in social capital represent a real possibility for facilitating sustained development (in the sense of the capability approach). Hopefully the U.S. will give up our historically messy legacy now that Castro has stepped down. Removing the embargoes and travel restrictions would create the best possible opportunity for allowing actual change to take place in Cuba. Most important for Cuba at this time, in my view, is an implementation of a more democratic and representative system of governance. With it's spiritual and political figurehead out of office this seems more possible than it has in decades. Cuba is already highly globalized with its dependence on tourism and trade in sugar. By identifying and implementing appropriate legal and political changes it could take advantage of the years of progress in social capital that it has sustained.

It will be interesting to see what Castro's legacy will be. Beginning his reign as a fiery orator and general to stepping down decades too late. The gains made in Cuba in areas of health and poverty were often overshadowed by stories of repression and abuses of power (jailing homosexuals and dissidents comes to mind). Will Castro be seen as a revolutionary character that sustained Cuba? Or a petty dictator that kept Cubans from attaining a better standard of living? I assume the polemics will eventually fade and a more nuanced and ambivalent account will be the one taught in years to come. In the battle of "Socialismo O Muerte!" it appears a withering death of Cuban socialism will be the final result of Castro's grand experiment.

An Informed Discussion

As with much of American politics, the current immigration debate is filled mostly with polemics and demagoguery. It is often difficult to find a nuanced discussion of the issues and the wider context in which they exist. Luckily over the holiday break I was able to dive into two books on the subject, both of which provide a very contextualized account of central issues and controversies and where they reside in the course of debate.

The first one I read is They Take Our Jobs: And Twenty Other Myths About Immigration by Aviva Chomsky. It was a great book. Chomsky identifies key myths that are pushed about immigration from both pro and con positions. It places the immigration issue within the larger context of neoliberal reforms. While I wish some of the entries were longer, always good to leave the reader interested in finding out more, the book really stands out as a critically engaged account of the issues. One thing that particularly stood out was the role of marginalized labor and its place in the U.S. economy from the time of the American Revolution.

Ex Mex: From Migrants to Immigrants by Jorge Castañeda, a former foreign minister of Mexico, examines the historical context that situates the current debate. He also provides an excellent discussion of possible policies and the likely proponents and opponents to these policies. Examining the ways immigration from Mexico has changed, but also how it remains remarkably similar to previous decades, helps to identify that what we face is nothing new. Also noteworthy is that it provides a Mexican perspective on the issue, particularly from a person who has had a lot of influence and experience dealing with this issue at the highest levels of government.

While these are just two of many possible books that provide accounts of the current immigration debate, they are both very accessible and well-written. A proper discussion of immigration and its ramifications must start somewhere and these are good resources for that discussion.