President Obama is going to Capitol Hill tomorrow to try to convince legislators, and the associated national audience, to support health care reform. He's got a tough battle in front of him...in part because of people's fears about what that change might mean. We might lose the health care and choices we have now. We might have to wait to see doctors, or to have operations. And so on.
But all of that presupposes that we (we being the working, insured population of America) have something worth keeping, choice, and access now. And the option, if reform doesn't happen, of keeping our insurance and service delivery the same.
Neither of which is necessarily true.
The company through which I get my health insurance was recently acquired by another corporation. The new HR department told us that while we would have a new insurance carrier, our plans would be rolled over into a similar kind of coverage at the new company. But when I went to arrange a doctor's appointment, I was told that I now needed to see a primary care physician first, because I'd been switched from a Preferred Provider Organization (PPO) to a Health Maintenance Organization (HMO). There's a big difference between those two types of health care plans. (In a PPO, there's a network of preferred providers, all of whom can be in individual, private practices. Reimbursement for using that network (providers who've agreed to the insurance company's reimbursement rates) is higher than going out of network, but you can go to anyone you want, at any time, and get some compensation. In an HMO, you need to see a primary provider first and get a referral to someone else in a very structured network, all associated with that HMO company. And you have to use a physician in that HMO network in order to get any compensation.)
I called the benefits person and said there had been a mistake, and I wanted to change my health insurance back to a PPO plan, even though I recognized that it would cost me more in premiums.
"You can't do that," she answered. "We don't offer a PPO. We only offer an HMO."
"I don't have any choice at all?" I asked.
"Sure you do. You can opt out in the next open enrollment session, which is in three months."
"Opt out of our health plan altogether."
"So then what insurance would I have?"
"You wouldn't have any."
I called the benefits folks at the old corporate owner, just to make sure I wasn't imagining that I used to have it better. If I recalled, I told the woman I spoke with there, we'd had several types of plans to choose from, back in the days when they were in charge.
"Well, we actually discontinued that. Now we only offer people one health plan, too. It's just that the plan we offered happened to be the one you had anyway."
So despite the fact that I'm a gainfully employed, working adult with supposedly "good" health insurance, I actually have no choice about the kind of health care plan, and therefore the kind of health care, I can get. What's more, the type and quality of that insurance coverage obviously can be arbitrarily and summarily altered, at any time, without any input from me. So ... even if an overhaul of our health care coverage reduced choice and control (which is not at all a given), it wouldn't really be any different than what I'm facing now.
As a matter of fact, my parents, who are on the government-run system called Medicare, have more choice and control in their health care I do. Of course, when my dad needed a knee replacement, and I found the doctor who seemed best for the job, I was told, in July, that the first office appointment available was in early November, and the first potential surgery date would be in late January. So even when we have reasonable choice, we don't necessarily have reasonable, or easy, access.
Which leads me to wonder, what the heck are people so afraid of losing?
James Surowieki offered some interesting potential answers to that question in last week's New Yorker. Multiple psychological studies he referenced have apparently shown that most humans are susceptible to something called the "endowment effect," which means we tend to over-value things we own. We wouldn't imagine selling old Aunt Martha's silver collection for less than $5,000, for example, even though we wouldn't pay more than $500 for an identical set from someone else's attic.
So we tend to think our insurance is better than it is, simply because it's ours. But Surowieki thinks there's another psychological effect at play, as well: something known as the "status quo bias." In short, we fear losing more than we care about gaining, so we fear changing what we have for an unproven "other," even if what we have isn't so terrific. Nobel prize winners Daniel Kahneman and Avos Tversky called this inclination "Prospect Theory," explaining that people had to feel like they would gain far more than they stood to lose before they would gamble on the outcome. Which, in the context of health care, means that in order to get enthusiastic about changing the system, the perceived benefit would have to be not just equal, or a little bit better for less money, but several times greater than any perceived cost, risk, or negative trade-offs. That's a pretty high bar to clear.
We also are susceptible to a clear and simple fear of the unknown. Known misery, or "the devil you know," is more comfortable to us, in many ways, than the great unknown, even if the unknown offers the possibility of far greater improvement or rewards. It's why so many people stay in bad relationships or jobs. Among other things.
Important to note, however, is that all of those effects are irrational tendencies, not recommended strategies. We may overvalue the status quo and fear changing it, but that doesn't always lead to a happy ending ... especially when the world is changing around us, or the status quo is a sinking ship.
And that's the other important point worth considering in all of this. It's not even a matter of changing the status quo. The status quo is changing itself. So we don't really have the option of not changing. Not because the system is broken, or will bankrupt our children, but because our insurance is being altered on us now, whether we like it or not. Employers are cutting back benefits and options, and that trend isn't going to reverse itself without some serious restructuring.
So ironically, the only way to keep our health care from changing is to change the system; take the control of our choices away from our employers and give us more choice in what kind of insurance we opt in for. Or as Surowiecki put it: "if we want to protect the status quo, we need to reform it."
Note: I will be offline for the next week, returning September 18th. Photo Credit: Flickr User Oswaldo Ordonez (Orcoo)
Trump’s attacks on the free press don’t just threaten the media—they undermine the public’s capacity to think, act, and defend democracy.
Are Donald Trump’s latest attacks on the press really that bad? Are they that out-of-the-ordinary, given the famous record of complaints nearly all his predecessors have lodged? (Even George Washington had a hostile-press problem.)
Are the bellows of protest from reporters, editors, and others of my press colleagues justified? Or just another sign that the press is nearly as thin-skinned as Trump himself, along with being even less popular?
I could prolong the buildup, but here is the case I’m going to make: Yes, they’re that bad, and worse.
I think Trump’s first month in office, capped by his “enemy of the people” announcement about the press, has been even more ominous and destructive than the Trump of the campaign trail would have prepared us for, which is of course saying something. And his “lying media” campaign matters not only in itself, which it does, but also because it is part of what is effectively an assault by Trump on the fundamentals of democratic governance.
Jewish Community Centers around the country have been bombarded by menacing phone calls. For the most part, people are sad, not scared.
The Nashville Jewish Community Center has now gotten so many telephone bomb threats that the dates run together, said Leslie Sax, the executive director. The first call came on January 9, when Nashville was one of the first 15 JCCs to get threats. The next call was January 18, accompanying yet another national wave. The latest was just this weekend, on Presidents’ Day, when 11 JCCs around the country were threatened, according to a spokesperson for the national organization. The Nashville facility, more full than usual with people exercising on the holiday weekend, was evacuated before security gave the all-clear.
“Most people just feel sadness—they’re sad that this is happening,” Sax said. “Everyone keeps saying they’re disheartened and frustrated.” But even though people are upset, they don’t seem to be scared. “I haven’t heard fear,” she said.
Plagues, revolutions, massive wars, collapsed states—these are what reliably reduce economic disparities.
Calls to make America great again hark back to a time when income inequality receded even as the economy boomed and the middle class expanded. Yet it is all too easy to forget just how deeply this newfound equality was rooted in the cataclysm of the world wars.
The pressures of total war became a uniquely powerful catalyst of equalizing reform, spurring unionization, extensions of voting rights, and the creation of the welfare state. During and after wartime, aggressive government intervention in the private sector and disruptions to capital holdings wiped out upper-class wealth and funneled resources to workers; even in countries that escaped physical devastation and crippling inflation, marginal tax rates surged upward. Concentrated for the most part between 1914 and 1945, this “Great Compression” (as economists call it) of inequality took several more decades to fully run its course across the developed world until the 1970s and 1980s, when it stalled and began to go into reverse.
Joe Moran’s book Shrinking Violets is a sweeping history that doubles as a (quiet) defense of timidity.
The Heimlich maneuver, in the nearly 50 years since Dr. Henry Heimlich established its protocol, has been credited with saving many lives. But not, perhaps, as many as it might have. The maneuver, otherwise so wonderfully simple to execute, has a marked flaw: It requires that choking victims, before anything can be done to help them, first alert other people to the fact that they are choking. And some people, it turns out, are extremely reluctant to do so. “Sometimes,” Dr. Heimlich noted, bemoaning how easily human nature can become a threat to human life, “a victim of choking becomes embarrassed by his predicament and succeeds in getting up and leaving the area unnoticed.” If no one happens upon him, “he will die or suffer permanent brain damage within seconds.”
Experts on Turkish politics say the use of that term misunderstands what it means in Turkey—and the ways that such allegations can be used to enable political repression.
Over the last week, the idea of a “deep state” in the United States has become a hot concept in American politics. The idea is not new, but a combination of leaks about President Trump and speculation that bureaucrats might try to slow-walk or undermine his agenda have given it fresh currency. A story in Friday’s New York Times, for example, reports, “As Leaks Multiply, Fears of a ‘Deep State’ in America.”
It’s an idea that I touched on in discussing the leaks. While there are various examples of activity that has been labeled as originating from a “deep state,” from Latin America to Egypt, the most prominent example is Turkey, where state institutions contain a core of diehard adherents to the secular nationalism of Mustafa Kemal Ataturk, which is increasingly being eroded by the government of Recep Tayyip Erdogan. Turkey has seen a series of coups, stretching back to 1960, as well as other activity attributed to a deep state.
The preconditions are present in the U.S. today. Here’s the playbook Donald Trump could use to set the country down a path toward illiberalism.
It’s 2021, and President Donald Trump will shortly be sworn in for his second term. The 45th president has visibly aged over the past four years. He rests heavily on his daughter Ivanka’s arm during his infrequent public appearances.
Fortunately for him, he did not need to campaign hard for reelection. His has been a popular presidency: Big tax cuts, big spending, and big deficits have worked their familiar expansive magic. Wages have grown strongly in the Trump years, especially for men without a college degree, even if rising inflation is beginning to bite into the gains. The president’s supporters credit his restrictive immigration policies and his TrumpWorks infrastructure program.
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By replacing Mike Flynn with H.R. McMaster, President Donald Trump added one of the most talented officers the U.S. Army has ever produced to his team.
Let me be as clear as I can be: The president’s selection of H.R. McMaster to be his new national security advisor is unambiguously good news. The United States, and the world, are safer for his decision.
McMaster is one of the most talented officers the U.S. Army has ever produced. That sounds like hyperbole but isn’t. In the Gulf War, he led an armored cavalry troop. At the Battle of 73 Easting—a battle much studied since—his 12 tanks destroyed 28 Iraqi tanks, 16 armored personnel carriers, and 30 trucks. In 23 minutes.
In the next Iraq war, he led a brigade in 2005 and was among the first U.S. commanders to think differently about the conflict and employ counterinsurgency tactics to pacify Tal Afar—one of the most wickedly complex cities in Iraq. He excelled at two different echelons of command in two very different wars.
The Border Adjustment Tax, a proposal favored by House Speaker Paul Ryan, has aroused serious opposition from Republican senators.
Donald Trump is feeling good about taxes. In his gonzo press conference last Thursday, he assured Americans that “very historic tax reform” is absolutely on track and is going to be—wait for it!—“big league.” The week before, he told a bunch of airline CEOs that “big league” reform was “way head of schedule” and that his people would be announcing something “phenomenal” in “two or three weeks.” And at his Orlando pep rally this past weekend, he gushed about his idea for a punitive 35 percent border tax on products manufactured overseas. The magic is happening, people. And soon America’s tax code will be the best, most beautiful in the world.
But here’s the thing. What Trump doesn’t know about the legislative process could overflow the pool at Mar-a Lago. And when it comes to tax reform, even minor changes make Congress lose its mind. Weird fault lines appear, and the next thing you know, warring factions have painted their faces blue and vowed to die on the blood-soaked battlefield before allowing this marginal rate to change or that loophole to close.
“I’ve never seen anything quite like” Trump’s approach to national security, says a former counterterrorism adviser to three presidents.
Updated on February 20 at 4:40 p.m. ET
President Donald Trump has made national security a centerpiece of his agenda, justifying policies ranging from a travel ban to close relations with Russia. But the United States is now more vulnerable to attack than it was before Trump took office, according to the man who served as George W. Bush’s crisis manager on 9/11.
“In terms of a major terrorist attack in the United States or on U.S. facilities, I think we’re significantly less ready than we were on January 19,” said Richard Clarke, who served on the National Security Council in the George H.W. Bush, Bill Clinton, and George W. Bush administrations. “I think our readiness is extremely low and dangerously low. Certainly [government] agencies at a professional level will respond [to an attack], but having a coordinated interagency response is unlikely given the current cast of characters [in the administration] and their experience.”