Can we learn from international health care systems? Yes we can.

If one were to listen to the media coverage over health care it would be difficult to grasp what the key issues in the debate are. One might easily confuse discussions of death panels, rationing of care, and ferocious town hall meetings to be the lynchpins of reform. Moreover, because a vast majority of the media coverage has revolved around the “he-said she-said” political horserace, the discussion of reforming America’s health care system has had the tendency to come across as beltway inside baseball, where the jostling over political talking points and out smack-talking the other side is an end in-and-of-itself. No wonder recent polling has shown a decline in the public’s interest in reform. Yet reform is desperately needed. Stepping back and looking at the overall figures emphasizes the point.

According to a recent OECD report the United States spends more per GDP on health care than any other OECD country—we spend 16 percent a full 5 percentage points higher than France which comes in second and nearly twice the OECD average of 8.9 percent. Yet 47 million Americans, or one-in-seven people, are left without insurance (also the highest percent uninsured out of OECD countries). Despite our massive spending there are fewer physicians per capita than most OECD countries. In 2007 the United States had 2.4 physicians per 1,000 citizens where the OECD average is 3.1. Life expectancy in the United States stands at 78.1, almost a full year less than the OECD average of 79. Similarly, infant mortality (6.7 per 1,000 births) is higher than the OECD average (4.9) and more than twice as high as that of Iceland, Sweden, Denmark, Luxemburg and Japan.

It is simply astounding to think that, in the country most known for well-oiled markets and economic efficiency, we spend nearly twice the average of other developed countries. And, in one of the richest societies the world has ever known, 25 percent more children die than the international average. The United States' health care system is arguably the largest public policy failure since the Vietnam War (if not even longer). While there is no shortage of ideas for how to repair the disastrously broken system, there is a severe shortage of serious conversations over reform. A good starting point might be to ask—given we so far worse than many other nations—what makes our system so different? Again, depending on whom you ask you’ll likely to get a wide range of answers, but looking at least one statistic might offer at least a conversation starter, if not a solution: Private insurance accounts for 35 percent of total health care spending in the United States, which is significantly higher than that of other OECD countries. Indeed, excepting France and Canada, no OECD country spends over 10 percent on private insurance.

This is not to say private insurance is the only problem with our system or that solving issues revolving around private care (pay for quantity of services over quality, pre-existing condition clauses—something unheard of elsewhere around the world, etc.) are sufficient to mending our system of care. The point is if we are serious about creating a better health care system to care for our parents and to be inherited by our children a necessary starting point is to ask where we fail compared to our international friends and what others are doing that we are not. There is an unfortunate mantra of American politics that we have nothing to learn from the rest of the world, this mentality is unproductive, un-analytical and should be avoided in the health care debate.

Otter Debate: What's Driving Up the Cost of Health Care? It's the Failing of Private Insurance.

What’s driving up the cost of health care for the average American? Duh, it’s the insurance premiums! But why are insurance premiums going up? Perhaps counter-intuitively, it’s because we’re getting smarter about our own health.

Tools from WebMD to home genetics-testing products give unprecedented power to the average citizen; it’s perfectly common for a person to know before they ever set foot in a doctor’s office exactly from what they suffer, and how worried to be about their ability to pay for the treatment. And if I know before my doctor, you can bet I know before my insurance company.

This democratic power is actually crumbling the bedrock of our private insurance industry. Private insurance works best when the folks buying it are both heterogeneous and ignorant. As long as this holds out, the healthy will almost perfectly subsidize the sick and everybody can pay the same, perfectly reasonable premium. But when either the pool of insured becomes more homogeneous or when people get smarter about their actual risks, things get dicier for the insurer—and those counting on the insurance.

Those who have reason to believe themselves healthy face a strong incentive to stop subsidizing the sick by defecting from the status quo and forming their own, new, healthy pool of insured; this will assure that all those healthy folks can pay a significantly lower rate for their insurance. Simultaneously, those who have reason to believe themselves sickly face an equally strong incentive to upgrade to the most generous insurance plan possible so as to receive better service. In this fashion a multi-tiered* system will emerge: healthy people pay almost nothing for almost no services, and sick people pay out the wazoo for everything they could ever need. In fact, this starts to look very much like a system where no one has insurance at all—except that the people selling the “insurance” walk away with a healthy cut of everyone's premiums, and the cost of health-service-provision rises.

The most efficient alternative to the current system—wherein everyone is losing except the insurance companies—is to set up a system whereby as large and diverse a pool of people as possible are insured and the healthy have no means to defect to a cheaper alternative. To those playing at home, this will look very much like a single, national, mandatory health insurance plan. Any compromise or political “solution” that looks different is born of either inexcusable ignorance of economics or inexcusable deference to insurance titans. Fuck that.

* Actually, this will tend to become an infinitely-tiered system wherein everyone pays in a premium that almost exactly corresponds with the amount they will eventually take back out, plus the overhead, profit, and lost-interest that they will generously forfeit to their insurance company.

Otter Debate: What's Driving Up The Cost Of Healthcare In America: It's aging, stupid.

When Sarah Palin talks death panels, it always seems to be Grandma that's getting the shove-off into oblivion. Why can't we pull the plug on Uncle Roy or your friend Jimmy? Because, obviously, the greatest risk of death comes from aging, and we're older than ever.

Despite this, we're also living longer than ever. What do these seemingly contradictory set of facts mean? It means that the main reason health care costs are exploding in America is due to older and older Americans getting better and better care. Just twenty years ago, statins, now a mainstay in cardiovascular treatment, were just on the drawing board. Ten years ago, Herceptin, the breast cancer wonder drug, was just in trials. Are we more medicated than we were before? Yes. But that's because the medication is working. Heart disease and cancer deaths continue their slow decline. This is great news for Grandma. But how are we going to continue to pay for these ever increasing costs?

Plus, if our aging population is the reason for our health care costs, in addition to better and better (yet mind blowingly expensive) treatments and medications to prolong life, why do other countries with even older populations and even higher life expectancies (*cough* Japan *cough*) have lower health care costs?

Insofar as the second question is concerned, I can only offer what a wise old Italian once said, "Europe can be socialist because America is capitalist." In other words, the pre-negotiated rates for drugs and treatments in Europe simply don't cover the research cost of drugs. Yet research goes on because American drug makers (and some European ones) can charge Americans out the ass. American health care might be so expensive because we're subsidizing the wonderful European health care free-ride that some would like to emulate.

You can see this same pattern in Medicare. Medicare currently does not reimburse doctors or hospitals enough for them to break even (like our friends, the Europeans). Instead, private health providers have to make up the difference by charging their privately insured patients more.

So if we can't change the French attitude about screwing American consumers over by giving their population a free ride at our expense, and we can't have the Neitzchean moral clarity to push Grandma off a cliff once she's outlived her usefulness (i.e., either socialistic[government mandated] rationing or capitalistic[ability to pay] rationing), what can we do to lower the cost of health care?

Simple, we go for broke, decide as a nation it's a good idea to live a high quality of life for as long as freakin' possible, and find more effective and cheaper ways to do so. We need to confront the real problem, aging, head on. We need to lower the cost of research by streamlining and standardizing the evidence needed to prove drugs work across multiple markets. If it's good enough for the FDA, it ought to be good enough for the Canadian equivalent, and visa versa. We need government to play it's usual role in a fundamentally R&D problem - set goals of effectiveness and cost with prizes,(and here, and here) in addition to funding publicly published blue-sky research that can serve as a foundation for the commercial sector to boot strap themselves to new drugs and treatments. We need to find more effective ways to bring new research out of university labs into pharmaceutical factories, instead of letting breakthrough results stall for a decade or more. We need to find better ways to deal with the enormous risk of researching new drugs (which make take a billion dollars or more and still fail completely in phase 3 trials) to refocus our pharmaceutical company's efforts on novel and better treatments rather than me-too drugs and inventing new diseases (restless leg syndrome, anyone?)

Grandma is living longer than ever, and she's quite happy to continue doing so. We can either have an existential crisis in which the entire nation confronts its mortality head on and lives in some sort of objectivist paradise that celebrates dying at 75, or we can plunge head long into the thankfully immature and fantastic dream of living longer and better lives through our own hard work and research. This is a nation, nay, a species that has been both to the moon, and the deepest trench on Earth. We've flown many times faster than sound, and slowed light down to walking speed. We've got telescopes probing the very beginnings of the universe and microscopes probing the very beginnings of our own microbiological structure.

You're telling me that a species capable of all these beautiful, fantastic things will forever be doomed to die at 80? Will forever been doomed to be too frail to work after 65? That, despite all of our advances, we still must fatalistically accept our own end - going quietly into that good night?

Fuck that.

Otter Debate: What's Driving Up the Cost of Health Care in America? The McAllenization of Healthcare.

“Medicine has become a pig trough here…we took a wrong turn when doctors stopped being doctors and became businessmen.” While this doctor was referring to McAllen Texas in The New Yorker's recent health care case study, he could have easily been referring to the US as a whole. The New Yorker blames perverse incentives placed on doctors by insurance companies, hospitals, and medical administrators where doctors are encouraged to churn out a steady volume of tests, procedures, patients and profit. In this instance, market forces have proved effective in creating quantity care but have failed to create quality care.

As the New Yorker article points out, more procedures in many cases offer marginal value as all procedures carry risk. Back surgery is a prime example. John Smith comes in for a bad back; doctor refers John to a colleagues boutique back surgery hospital; John leaves crippled with internal scarring and a new case of arachnoiditis. Specialized hospitals such as the one I mentioned in the example can be seen everywhere. Interestingly, the New Yorker mentions my hometown, Tulsa, as a city trending towards McAllenization of healthcare. Growing up in Tulsa, I've seen boutique hospitals pop up everywhere as enterprising Doctors poach high margin customers (ie John Smith) from larger hospitals. In fact, the number of boutique hospitals has doubled in the US since 2001 to nearly 220. As we debate the new Health Care bill, solutions to these problems remain elusive.

The Wall Street Journal recently discussed one--comparative effectiveness research. The Agency of Healthcare Quality Research (AHQR) is flush with $1.1B in stimulus funds and charged with comparing treatments, medicines, and making recommendations. While my most cynical colleagues might claim that this institute will eventually help justify "rationed care," but rationing already occurs every time a doctor opts one treatment over another. While it may seem by my post that I may think doctors are greedy, the truth couldn't be further from the truth--my dad is one. I've seen him work on the front lines as a family practitioner and pass up lucrative opportunities in favor of staying there. He eschews costly questionable treatments and thinks carefully how best he can improve the patient's quality of life. The solution comes from doctors sharing, collaborating, and setting up systems that are geared towards improving patient health. Bi-partisan consensus legislation can play a role in facilitating these relationships with funding for programs such as the AHQR, setting up peer review committees, and funding for research on different systems of care. Sadly, whether the government is writing a check or private insurers are doesn't address this fundamental problem… but that is best saved for another post.

What every American should know

The torture memos.

Thinking about this rationally, to me, the real crime here wasn't just the torture. It was the hidden, secretive abuse of individuals under the guise of protecting the rest of us. Quite honestly, I don't have anything against using all means necessary to get information out of someone that is dangerous to the country.

But the problem lies in only using these methods to withdraw information, and ensuring that there is actual information to withdraw.

A good parallel would be the fourth amendment, which guarantees against unreasonable search and seizure. In our information age, knowledge itself has become something worth searching for. The fourth amendment basically says that to engage in an invasion of privacy, the executive must seek a warrant from the judicial branch of government. So far, this has worked out pretty well - can't we learn something from this? Would people be as against torture if they knew that the accused had a good amount of evidence that he was withholding information, that might save lives, enough evidence that convinced a judge?

Meh. Perhaps. Another parallel would be capital punishment. In our society, we still believe that if a person has committed a heinous enough crime, and it can be proven as such, then they deserve to die. Despite this, we still have been committed to making the execution process more and more humane (although there's a legitimate argument to be made that it could be more humane than it is now). We're not wishing suffering upon the condemned, but simply coming to the conclusion that society can never be safe with his presence.

Likewise, the decision to torture someone can be completely divorced from the decision of how to do so. Extraction of information via pain, whether physical or psychological, is not attempting to inflict pain for the sake of inflicting pain (any more than the death penalty ought to be just to kill someone painfully). It should be centered completely around the outcomes, the information gathered. Techniques like water boarding do actually fill this niche of inflicting the maximum amount of short term, easily reversible psychological trauma most likely to get information from an unwilling suspect without long term physical harm.

Don't get me wrong, it's tragic, but I don't see anything per say wrong with the idea so long as the accused rights are respected - see the warrant gathered above. Any psychologist will tell you torture is good - in fact, too good - at getting people to tell you what you want. That's why it's useless (and morally abhorrent) for confessions and the like. But if we, a priori, have a great deal of evidence implicating a person in a conspiracy or plot in which people are still in mortal harm, enough evidence to convince a judge, and torture is administered for the sole sake of gathering information rather than causing needless pain, exactly what is wrong with it?

I know I'm living in a dream world in which human beings can act reasonably enough not to abuse such techniques, but on the face of it, it's completely ethical. You harm one person to save others from more harm. Assuming protections are in place to ensure that the harm is only the mechanism for gathering information, and that ample enough evidence has been gathered to prove that the accused does contain information that puts others in mortal danger, aren't we morally obliged to act?

Horrible Idea Reproposed

The scapegoating of the obese during the health care debate is almost getting comical. Time and again bad ideas like 'sin taxes' are proposed, and even now the proponents are forced to openly admit they don't work - but let's do them anyway.

Common misconceptions are bandied about like the candy they hope to ban. "We must act!" they implore, "To prevent this generation from having a lower life expectancy than those before them!" Just how much cognitive dissonance does it cause to say that when it's just been reported that we're living longer than ever?

Jon Stewart risks his moral authority

First, watch Thursday's episode of the daily show. Stewart's guest is Betsy McCoy, allegedly the source of the term 'death panel', although she never called them that.

During the financial crisis, Jon Stewart built up quite a reputation as a kind of moral authority for America. Anyone who's seen his massacre of Jim Cramer can attest to this. I felt sorry for Cramer, yet Stewart had clip after incriminating clip on his side. I could tell that Jon took no great pleasure in what he was doing, but that he felt like he had to get the truth out. I respected him for that.

But he seems to have subtly dismissed his role as legitimate debater here, even though he gave his guest the majority of the show's time (a pattern when the issue is important the guest is talking to) when he descended to demanding his debate partner doing something so silly as look up a page in the bill she had with her in a binder hundreds of pages thick, then chided her by singing a song while doing so. It was kind of shallow humor, especially for Jon Stewart.

Honestly, from what I could tell in the show, the specific section could be read by either party's interpretation and both stepped beyond the point a few times. I don't think his guest ever really resorted to the sort of hyperbole you saw come out of Sarah Palin's mouth about death panels, and I honestly think Stewart didn't seem on his best game here. He used the audience too much as a bully pulpit, pressuring his guest, when he's usually far more cool and even defensive of his guest against the audience's displeasure.

I hope this isn't part of a growing trend and that Jon Stewart remains our society's post-modern sense of morality (which of course has to be on a comedy show), but what I saw today was just a sliver of arrogance on the part of a man who's so frequently condemned the hubris of others.

Hear Ye! Hear Ye!

Welcome to the founding of the neglected centrist party in American politics - the Otter Party!

The Otter Party takes its cue from the Bull Moose of those who might be a little fed up with the current state of affairs. Like the Scarecrow from the Wizard of Oz, perhaps it's the current Republican leadership who has no brain. And, conversely, the Democratic leadership who, like the friendly lion, has no courage.

We live in incredibly exciting times, but also trying times. Our Earth is warming, our deficits are growing, our population is aging and the debate over whether Government or Business is more soulless rages on. But our life expectancies grow. Poverty is shrinking around the globe. And new technologies promise to take us from nearly to-cheap-to-meter carbon free electricity and expansive global social networks to cures for cancer and even the stars themselves.

The Otter Party seeks to solve the problems we have today but also freely embraces the solutions of tomorrow. No political party holds the monopoly on good ideas, and we recognize this, thus we look for solutions from both the Right and the Left. With politics, it is too easy for emotions to rage and ad hominem attacks to run free, but real progress takes cooperation from people who's only real shared interest may be the prosperity of this country.

And that is the shared interest of all of us, right?

Bringing you these thoughts are our motley crew of writers. On the left, we have NoExtremists and the UrbanEconomist. NoExtremists works for an economic think tank and campaigned for the current Secretary of State, Hillary Clinton. UrbanEconomist is pursuing his PhD in economics with a focus on Urban infrastructure. On the right, we have TheNewAgeRepublican and SkepticalExtropian. TheNewAgeRepublican is an accountant and amateur historian, while SkepticalExtropian is an engineer and fancies himself a futurist - if there were any money in it.

They won't always agree, and when they do, it may not always be the prevailing wisdom. But they won't let party lines get in the way of writing and advocating for a better America.

Some have asked - why the Otter? The Otter is well known among zoologists as nature's most majestic creature. There need be no more justification than that.

We hope you enjoy our shared thoughts and discussions, and remember, Vote Early, Vote Otter!