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Current Issue

Handbook on State Health Care Reform

by John C. Goodman, PhD

Chapter 2: PRINCIPLES OF REFORM

What are the principles of health reform? One might suppose they are fairly easy to enumerate and command widespread support. As it turns out, that is not the case. Here are five recommended principles. If they are followed, the odds of successful health policy reform will be greatly enhanced.

Principle No. 1: No One Should Be Denied Basic Care because of a Lack of Ability to Pay.

A good society does not withhold basic health care from people because they lack the resources to pay for it at the time of delivery. This does not imply that people have a “right” to free care. If that were the case, everyone would have a perverse incentive to become “free riders,” wastefully over consuming care at everyone else’s expense. Instead, most people should be expected to pay their own way most of the time. But no one should have to forgo basic care because they can’t pay for it at the time of delivery.

Principle No. 2: Health Care Should Be Provided in a Competitive Marketplace.

The economic definition of efficiency is: Whatever is produced should be produced at minimum cost. Some studies lend credence to the idea that one out of every three dollars of health care spending is wasted. This implies that, in principle, the same health care could be provided for two-thirds the cost. Alternatively, there could be 50 percent more care for the same amount of money. In other markets, entrepreneurs spur efficient production by repackaging, repricing and taking advantage of new products

and innovations. Principle No. 2 is not being followed whenever entrepreneurs are arbitrarily prevented from serving this function.

Principle No. 3: The Appropriate Level of Insurance Depends on the Assets to Be Protected.

If Principle No. 1 is followed, people will not need insurance to receive care. Instead, they will need insurance in order to protect their earning power and other assets from unexpected health care costs. Other forms of insurance serve as a useful guide. The purpose of life insurance is primarily to protect earning capacity against the consequences of premature death.

Accordingly, the appropriate level of insurance depends on current assets and expected income. The purpose of casualty insurance is to protect the value of, say, a home or automobile. The appropriate level of insurance depends on the anticipated risk and the replacement value of the home or car. Similarly, the purpose of health insurance should be to protect assets against unexpected medical costs.

Principle No. 4: Health Insurance Should Be Personal, Portableand Renewable.

It is a mistake to have a system in which a change of health plans is virtually mandated whenever people change employers. Instead, health insurance should be portable (traveling with the employee from job to

job). Also, it defeats the whole purpose of insurance if premiums can rise in response to an adverse health event. Life insurers do not get to charge more to the insured who get AIDs or cancer. Insurance exists to transfer risk from the individual to an (insurance) pool. Th e price of that transfer is the periodic premium payment. Once the insurance contract is set, the practice of increasing premiums after an adverse event occurs would be like changing the odds on a horse race after the race is underway.2 Accordingly,

people should be able to buy health insurance that is renewable at rates that are independent of adverse health events. In most states, this is required under the laws governing individual insurance. However, such insurance is generally unavailable in the small group market.

Not withstanding all of the above, from time to time people may wish to change their insurance coverage. At that point they should be able to buy real insurance in a real market. It is to everyone’s advantage to be able to face real prices for risk when making changes in insurance coverage. Otherwise, people who are undercharged will over insure, and people who are overcharged will underinsure.

Principle No. 5: Private Insurance Should Be at Least as Attractive as Health Care Provided at Taxpayer Expense.

For many people, the implicit alternative to private insurance is to rely on charity care paid for by others. For those who qualify, Medicaid and S-CHIP programs are alternatives to private insurance. Perversely,

these alternatives encourage people to forgo private coverage paid from their own pockets in order to take advantage of care provided at taxpayer expense. Rational public policy would create the opposite incentives. At a minimum, government should be neutral — giving people just as much incentive to be in the private sector as in the public sector.

 This book excerpt is found at http://www.ncpa.org/

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Book & Cinematic Reviews

Previous Issue

Movie Review: By James J. Murtagh, M.D.

"Breaking Bad": Character is Fate

Meth-cooking Walt reaches new height of art: No Excuses

 Warning:  spoiler alert. If you have not seen the final episode of  Breaking Bad, do not read further. The episode contains a major plot twist which is discussed in this Op- Ed.

It is fiendishly appropriate that the modern Greek tragedy, Breaking Bad, ends almost exactly 2400 years since Sophocles wrote Oedipus Rex. Breaking Bad, demonstrates the most intense hell on earth, forcing its worst characters to kill the people and things they love best. But unlike any other modern drama, the main character finds at least partial redemption in admitting, "I did it because I wanted to"- a completely novel idea in modern times!

For five years Breaking Bad, like The Shield, like the Sopranos, and "The Wire", shows evil in all its seductive guises. Of these, Breaking Bad was most shocking, even moving its audience to cheer for the central character, Walter White, the average man in this morality play, the chemistry teacher dying of lung cancer who decided that he had no way out and had no choice but to turn to crime and cook meth. His almost-innocent beginning led to worse crimes and eventually he ends up a drug king pin. Even White's murder of innocents- including an innocent child- evoked a morbid fascination. How much could one man get away with? 

But then the twist. Tonight in the finale, Walt made no excuses. This may be a first since the Greeks and Shakespeare- Walt actually took responsibility and admits he has no one to blame but himself. He had been telling himself that he turned to crime to save his family. Tonight he admits, "I did it for myself. I liked cooking meth. I was good at it."

Whoa! No one in the Inferno, or the Sopranos, or the Wire or the Shield, admitted that they had free will. Most, like Michael Corleone justified themselves, "I had to do it for my family."

The average Shakespearean villains, from Richard III to Macbeth blamed the stars or the weather or the witches. Rarely did a villain admit "I am the author of my own suffering". It was the highest form of Shakespearean art when characters transcended and admitted what they did- Hamlet, King Lear and Othello.

Oedipus was perhaps the first to realize his own free will brought him to his fate: "Apollo - he ordained my agonies - these, my pains on pains! But my hand that stuck my eyes was mine, mine alone - no one else - I did it all myself!"

In modern times, criminals blame a series of dominos in their life. Variations on the twinky defense. Lesser Greek characters also tried to blame crime on micro events- "we started the Trojan war because of an argument, a woman, an apple."

Fate reserves circles in hell for treacherous murderers even below simple murderers. Not being caught appears infinitely crueler than being fried by 2,400 volts in an electric chair. There is a deep freeze as cold as great lake Cocytus Dante described at the bottom of the ninth circle of hell, reserved for the great traitors of all time.

Dostoevsky also believed that punishment was essential to redemption of the human soul. Hell's best-kept secret is that we create it for ourselves. Walt connived, threatened, hoodwinked and betrayed to make a bad end. But Walt, at the last minute, realizes, makes sincere contrition and achieves a redemption.

Robert Frost wrote that torment by ice can be much more painful than by fire, metaphorically contrasting passionate torments with death by hatred. Walt's enemy’s fate is death by ice, frozen into a bland cubicle, with no hope of redemption.

In a larger sense, society also had a hand in Walt's demise. Had Obamacare been in place, and Walt had affordable health care, Walt would have had no reason to turn to crime. Is it worse for a hungry man to steal a loaf of bread, or a dying man to ask for medicine? Perhaps worst of all is the society that creates the criminal by making him steal the bread or the drug.

Congress should take note. Can Congress claim that it has no free will?  I hope our lawmakers watched the program and decided to end the abomination of gridlock and the lack of medical care.

Shakespeare granted the release of death as the greatest boon to both homicidal heroes and villains.  Hamlet, Oedipus and Walt all lived in worlds "rotten." The deserts of New Mexico have much in common with Hamlet's Denmark.

"To never have been born may be the greatest boon of all." Walt had few options at the end. He asks his adversaries to end his life.

Not all villains could be punished by no punishment. The Iagos and Richard IIIs delight in escape. Could fitting punishment depend more on the nature of the criminal, than on the crime? For some criminals, capital punishment is devoutly to be wished. For Dante, divine punishment was necessary for the operation of a divine Universe.

Do we, in the modern world, including our leaders, suffer even more because the possibility of punishment often seems remote?

Sophocles heard it long ago upon the Agean, the turbid eb and flow of human misery.

Walt- your end puts you in the company of the greats. We will miss you.

James J. Murtagh Jr. jmurtag@mindspring.com

This review is found at http://www.medicaltuesday.net/BookReviews.aspx

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Book & Cinematic Reviews

Past Issue

Love in the time of Algorithms

Online dating is awash with deviance. There are perverts, scammers and misanthropic entrepreneurs all hellbent on profiting from loneliness. But then there are women like Laura Brashier, a 37-year-old hairdresser from California and a survivor of cervical cancer. Her treatment left Ms Brashier unable to have sex. Rather than endure the anxiety of conventional dating she decided to set up a dating site for people like her. 2Date4Love describes itself as the site for “people who cannot engage in sexual intercourse to meet and experience love, companionship and intimacy at its deepest level. Since its creation in 2011, it has enrolled thousands of members who might otherwise have struggled to find romance.

WSJ Jan 29, 2013, A13 Bookshelf.

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Book & Cinematic Reviews

Past Issue

The American Conservatory Theatre: Dead Metaphor

A.C.T. Presents the World Premiere of George F. Walker's Hilarious Political Comedy
Dead Metaphor

February 28 to March 24, 2013

Directed by Irene Lewis, this dark comedy--from one of Canada's most acclaimed playwrights--satirizes the hypocrisies and politics of postwar living

A soldier returns from the Middle East to find work in this audacious and hilarious dark comedy

SAN FRANCISCO (January 15, 2013)—American Conservatory Theater (A.C.T.) welcomes the . . . world premiere of Dead Metaphor —George F. Walker’s dark comedy that satirizes the hypocrisies and politics of postwar living. When Dean returns home from the war in the Middle East and hits the job market, he discovers that his superior military skills don’t get him very far in the business world. His readjustment to non-bunker life begins by moving in with his aging parents and pregnant ex-(and soon-to-be current) wife. When he is offered a job as poster boy for a crusading politician on her own mission for “truth and justice,” his military ethics collide with the unscrupulous world of national political campaigns—and he discovers that his unique skill set may be his best asset after all. 

Says A.C.T. Artistic Director Carey Perloff: “I read Dead Metaphor all in one sitting—the first scene made me laugh out loud, the second scene was a shocker, and by the third scene I was totally hooked. In the spirit of Bruce Norris’s Clybourne Park, George Walker has an incredible knack for mining dark humor out of impossible circumstances, deploying a kind of vivid satire to make us listen to our own clichés and become aware of our own hypocrisy. And I can think of no one better than Irene Lewis, who staged a brilliant production of David Mamet’s Race for us last season, to bring to life this world premiere by a major Canadian writer. A.C.T. audiences are in for an outrageous ride and a vivid glimpse at the underbelly of modern life and contemporary politics.”

Dan Rubin writes in the program about his conversation with the Playwright, George F. Walker:

In 1971, George F. Walker was a 23-year-old taxi driver from Toronto’s working-class East End. While carting fares around the city, he saw a Factory Theatre Lab poster calling for play submissions by Canadian Playwrights—part of founding artistic director Ken Gass’s visionary “Canadian Only” policy, one of the sparks of Toronto’s theater movement in the 1970s

Walker had been scribbling poems and short stories since high school. Friends from the neighborhood had always said he would become a writer Local writing groups were closed to a working-class kid, however. They were reserved for University of Toronto graduates. And Walker had no idea how approach publishers. Theater in Toronto, on the other hand, “was just getting started,” he remembers, “and they’d take anyone.”

So Walker wrote his first play, The Prince of Naples, and submitted it. A week later, he learned that it would receive a production. On the first day of rehearsal, Walker saw director Paul Bettis’ copy of the script. On it, dramaturg John Palme had written a note: “This guy is a genuine subversive. We’ve got to produce him.”

Where the title of Dead Metaphor came from, Walker explains. There used to be a time when we didn’t send soldiers off to fight wars and then forget entirely about them, like they weren’t even part of our society. Less than one percent of both our populations has anything to do with them. So something that used to mean something—soldiers fighting for their country—is now irrelevant. It is a dead thing. We don’t even know where they are. Off they go and then they come back into our world, many of them in trouble, messed up and with nowhere to go. They come back and they only get noticed when they’re in trouble. And we’re in trouble too.


A.C.T.’s 2012–13 season also features the world premiere music theater event Stuck Elevator (April 4–28), the Bay Area premiere of The National Theatre of Scotland’s internationally acclaimed production of Black Watch (May 9–June 9), and a new production of Tom Stoppard’s ravishing masterwork Arcadia (May 16–June 9).

This play review is found at http://www.act-sf.org/site/PageServer?pagename=events_conservatory

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