What I changed my mind about : academia, socialized medicine

Jan 05 2008 Published by under Politics

This post at cosmicvariance refers to a question at the Edge world question center: "what have you changed your mind about?" It's interesting reading, and I recommend it.

Although I'm not quite a luminary up there with those quoted in Sean's post, I'm going to give two answers.

The first answer, of course, is very personal, and was represented by the huge life change I went through in 2007. Specifically, I decided that a career in the research and teaching of physics and astronomy wasn't worth it. I was at the wrong place (a research University) at the wrong time (when it was getting more difficult to get NSF funding) which made it really the wrong place (the research University was inflexible enough that funding was a tenure veto criterion), and I failed to move to the right place (I interviewed at a few liberal arts colleges I would have loved to go to, but either didn't get offers, or in one case got an offer that was not feasable for me). I loved the teaching of physics and astronomy, and loved the science, but finally was able to admit to myself that it had been a few years since that love justified putting up with the crap. The main reason I hadn't admitted that to myself was that to leave was to be a failure. (Indeed, today, I still feel a bit like a failure because I couldn't make it in academia.) However, I've moved on to something else which I'm finding stimulating and rewarding. I'd thought about letting go a few times before; this was the time when I was able to bring my mind around enough to actually letting go. I'm glad I did it before my hand was forced by being fired. (Many not in academia don't realize that being denied tenure means that you must leave the institution where you are, but that is the case.)

The second answer I have is more longwinded, and is a change of mind that happened over the last six or seven years. Specifically: some form of socialized medicine is necessary for the good of the United States. If you had asked me six years ago my opinions about socialized medicine, I would have repeated a lot of the arguments you hear from others who are opposed to it: freedom to choose your doctor and other health care providers, long wait time for non-immediate-emergency procedures in some countries that currently have socialized medicine, the typical inefficency of anything that is government controlled, the quashing of innovation that comes whenever anything is moved out of the free market and into a centrally controlled bureaucracy.

And, the truth is, I still believe a lot (if not all) of those things. However, until eight or nine years ago, I was in the situation that a lot of Americans are in. I was young and healthy (or healthy enough). I had no major illnesses. I had health insurance through (first) my graduate school or (later) my job, and as such was able to get what care I needed. I didn't worry too much, because if I got a contracting job, or something else that didn't pay health insurance, it was possible to get personal health insurance. (I know a few people who do that.)

What changed?

I married somebody with a chronic illness. Somebody who will not be able to get health insurance-- because it makes no business sense whatsoever to give it to her-- unless she's in a large group plan, where the power of group bargaining is able to bring her into that plan. She also isn't able to work a full time job; the fatigue and restrictions that comes with her illness make it very challenging for her to even work a quarter time. What this means is that I, as her husband, must remain in a job that's got a group health insurance plan, or we're screwed.

For most middle-class Americans without children, I suspect that housing (i.e. mortgage or rent) is the dominant single expense they have. In our house, even after health insurance, medical needs is our dominant single expense. This is part of why I wasn't able to take the job offer I had at a small liberal arts college a couple of years ago; I couldn't afford the 30% pay cut that taking that job would have represented. It is also part of why I'm very anxious and afraid about making any kind of job change. Everybody is anxious and afraid about losing their job, because of the uncertainty and fear of insecurity that comes with it. People like me-- people with uninsurable family members-- have the additional anxiety that we must be able to find a job that includes a group health insurance plan. I worry about getting fired from my current job-- not just for the reasons that everybody worries, but also because I would absolutely need to find a new job as fast as possible that my wife and I wouldn't find ourselves in the financially untenable position of having a gap in insurance that would cause "pre-existing condition" clauses to kick in on whatever policy we had with the new job. This isn't just me; many, many people are in the same situation as my family.

The current situation hurts small businesses too-- the sort of thing that free markets are supposed to be the biggest supporter of. My aunt runs an ice cream store, and has for many years. She often find it exhausting, unsurprisingly. She would love to find somebody she could hire on and keep as a long-term manager, but she's had a lot of trouble doing this. Several years ago, when talking to her about this, and feeling (as I always did) stressed and unhappy with academia, I briefly fantasized about moving to Charleston, WV, working as a manager at an ice cream shop, and having a much lower stress life. The problem is, my aunt can't hire on somebody that is really good enough to be a manager who will stay for long, because she would need to offer them health insurance... and at a store with a handful of employees, that's simply not possible. So, the best people she hires tend to be short-term... students and others who have plans to move on to bigger and better things. Right now, security in health insurance is coupled to having somebody in the family working at a large enough employer to have a group health insurance plan. This means that somebody who might (for other reasons) decide to take a job with a very small business may not practically speaking have the freedom of choice to do so.

The free market is a great solution to many things. It's far more flexible than a centrally managed solution. In many cases, if you try to dictate the solution ahead of time, you ossify your society, writing in strictures for how things work that may not be the best, and may not keep up with the change of society and technology. If you have a free market, the market can adapt to new solutions naturally, without having to convince people wedded to the old ways of doing things to change the laws and government procedures. For a lot of things, this is great. But, to many libertarians, the free market is the hammer that makes everything in the world look like a nail. While the free market may do the greatest good to the greatest number of people in many cases, when it comes to health insurance, working out a good solution for the majority of people mean that those not in the majority suffer and die. It's not a matter of providing the best entertainment options, of providing the kinds of cars people want, of providing the food choices that people are willing to pay for; it's a matter of sickness and health, and of life and death.

And, we don't even really have a free market solution right now. The system we have in this country right now mixes all of the worst aspects of free-market health care and socialized medicine. One of the biggest worries with socialized medicine is that we'd be turning over our health care to the same people who run the IRS, to the same people who run the DMV, to the same legions of politicians and faceless bureaucrats that haven't been able to balance the budget for years. People would end up cogs in the system, without the freedom to make intelligent choices about health care providers themselves. But think about it: how different is that, really, from what we have right now? If you're in a group health insurance plan, you are at the mercy of the "preferred provider" list and the formulary of that plan. If you're like me, and only occasionally have to go to the doctor, you don't notice that the system of insurance we have is saddled with soulless bureaucracies as much as any government agency... but it is. My wife, exhausted already, spends far too much time talking to health care providers trying to figure out how to get this or that thing approved, trying to figure out what changes were made to the drug formulary this year. And, all of the expected symptoms of bureaucratic bloat are there. Byzantine and complicated rules. Different answers every time you get somebody different on the phone. Uncertainty as to whether or not something you need will really be covered. Backtracking as the insurance company screws something up and tries to tell you that what you didn't isn't allowed. And, finally, for some things, paying a full out-of-pocket price because (for example) psychological health care is never covered at the level of physical health care.

In many ways, we've already saddled ourselves with a lot of the bogey men that those against socialized medicine scare us with. At the same time, we have the fundamental problem of a free market health care solution : people falling between the cracks. Those who aren't basically healthy being left behind by a system that recognizes that it is simply not economically sensible to keep them alive.

Now, mind you, we could very easily -- and, I fear, probably will -- do socialized medicine dreadfully wrong. If and when we implement some form of universal health care in this country, I think we should look to how the framers of the Constitution implemented government. We would need some form of separation of powers (with checks and balances), and we would need some explicit declarations of individuals rights. In particular, the organization or agency that pays for health insurance must be explicitly separated from the organization or agency that dictates what is covered. Without that, budget constraints will inevitably lead to the same nightmare of capricious and mercurial lists of what and who is covered that we have in our current system.

If I were president, the very first thing I'd do is outlaw pharmaceutical patents, coupled with a raise in the budget for pharmaceutical research. This would very likely spin the country into a huge recession, because so many of our mutual funds are heavily invested in profitable drug companies right now... but we'd come out a stronger and more moral place on the other side. Pharmaceutical companies argue that drug patents, and the exclusive rights that those companies receive allowing them to sell drugs for the mint they are sold for, are necessary to fund research. Of course, it turns out that those patents are funding advertising more than research. We don't need pharmaceutical companies to develop drugs; what we need are the drug researchers and those who directly support them. If the chemists and biologists who develop new drugs can make a reasonable living doing that with publicly funded research, we will still get the new drugs that we get right now... without having to sign over control over the pricing of these new drugs to a soulless entity (a large corporation) that's only interested in leveraging its assets for maximum profit. As a side benefit, we'd no longer be in the position our country has been in in recent years, having to argue that people in Africa need to die in order to "protect the intellectual property" of the USA. (AIDS drugs can be very expensive, and many impoverished nations in Africa can't afford them. The USA has in the past argued explicitly against ways to provide affordable drugs to these populations, because to do so would have been to allow production of those drugs in violation of the patents granted to the US companies that developed them. This is not the behavior of a moral nation.)

So, yes, many years ago I was opposed to socialized medicine because of (a) fear of ever growing government control, (b) the inefficiency and threat to innovation represented by large bureaucracies, and (c) freedom of choice. It took being married to somebody who really has to interact with our current health care system all the time to recognize that for many in this country, we don't entirely have any of (a), (b), or (c) with our current system... and we do have people left behind by that system.

8 responses so far

  • Mary says:

    Strangely enough, I've changed my mind on those same two issues. On the academic career one, though I'm still be in grad school (in physics) -- I've decided to try for industry jobs first. Because yours isn't the only story of tenure denied that I've heard, and I know a couple of perpetual post-docs, and because I've seen what my advisor has to do to get and keep funding, and don't want any part of it. I do feel a little guilty because I'm female and now going to be part of the "leaky pipeline" though...

    On the health care -- it's my husband's mother who's sick and unable to work, and I hate that we're grad-student poor and unable to help. She lives with her own mother who recently broke her knee, and with neither one able to really walk right now, they're having to call 9-1-1 when she tries to walk on the broken knee to go to the bathroom because she has no other choice besides soiling her sheets -- and neither would be able to clean that up.

    In high school, I read Ayn Rand and bought into the fantasy of a world where everyone was self-supporting, dignified, independent. But now I wonder, if Ayn Rand had ever got the kind of disease where you can't control your own bowels, had been bedridden, would she still have been a such a committed individualist? In the real world, where sickness and age exist, we can't all be self supporting. Even after getting over my fling with libertarianism, though, I was uncertain if health care was one of the things the government should be doing, worried that public health care would weaken innovation, a lot which comes from American companies.

    I agree with you that there are many wrong ways to do public health care, but after seeing what my husband's family is going through and feeling powerless to help, I think it couldn't be much worse than the current system. Most sick people need basic nursing care more than they need new drugs anyway. I've put it in the category of things like "the highway system" and "printing currency" in my mind now -- things that have to exist for society to work, and which the free market won't do right because the profit incentives point in the wrong directions.

    So yeah, same mind-changes.

  • rknop says:

    Re: going into industry, don't feel guilty. It's not your responsibility to fix the problem with an uneven playing field for women in physics! It's your responsibility to choose the life path for yourself that makes the most sense.

    Re: flings with libertarianism, I still sort of consider myself a libertarian. I described myself to a co-worker as a "Howard Dean Republican." He said that made no sense... but I said I was a libertarian in favor of socialized medicine. He started to think, yeah, OK, perhaps "Howard Dean Republican" is about right.

    My politics is all over the map. People who learn my opinion on one thing are often surprised to find my opinion on another.

  • I used to work for an auto glass manufacturer, which sounds irrelevant until you realize it's another heavily insurance-driven industry. There are a whole lot of freaky things that result from that... moral hazards become deeply entrenched parts of the industry. And then there's the whole pharmaceuticals influence (there's probably parallels with the auto industry somehow, but I won't stretch the analogy that far). If it weren't for health insurance, and HMOs, and other "unnatural" influences on the market, I think the medical industry would be entirely different. (Perhaps not better. But wrong in different ways, if not.)

    So yeah, I'm kind of with you: I don't like the idea of socialized medicine at all, but at this point I don't see an alternative given what the medical industry has grown into.

  • Interesting post.

    FWIW, I don't think socialised medicine is *inherently* more incompatible with freedom of choice than non-scoialised systems are -- I think it rather depends on how the systems are set up. For example, in the UK's National Health System, I can chose my GP. That is, I can walk into a GP practice and be regsitered with that GP. If I then decide don't like that GP, I can walk into a different GP's office the next day and request to be registered with the new GP, without having to give any reason, and my notes will be transfered accordingly. That's freedom of choice, isn't it? Equally, if I need to be referred to a specialist, I can ask my GP to refer me to Dr Jo Bloggs if I happen to know of a Dr Jo Bloggs whom I would like to be seen by (assuming s/he is appropriately qualified to treat me).

    By the same token, I know lots of people in the US who have insurance who have limited choice in who they can see -- for example, there might be a very limited list of a certain type of specialist there insurer will cover them for. In those cases, when comparing "like for like" it seems that the NHS system has at least as much freedom of choice as the US system.

    The NHS does have a seriously "postcode lottery" problem, but I don't think that's really inherent in socialised systems -- one could sort that problem (if the powers that be were so inclined) by redistributing funds appropriately.

    As for inefficiency...comparing "like for like" (ie, uninsured people in the NHS with uninsured people in the US system), at least people in the NHS get treated eventually, whereas in the US many people just don't get treated. And again, I think this is a function of the amount of money put into the system, and the contracts etc that are being used. The NHS doesn't have to be as inefficient as it is -- pay rises and decent working conditions for nursing staff etc, would go a long way to helping with the understaffing issue. But that requires better/greater progressive taxation.

    I also have chronic health problems, BTW. I'm not sure that living in the US is a viable option for me, although I am a US citizen. I live in the UK, and I'm very glad that I have access to the NHS, even with all its faults.

    Cheers,
    IP

  • Schlupp says:

    Inefficiency in 'socialized medicine'.... Dunno, I'd perhaps find that argument more convincing, if the US didn't spend roughly twice as large a part of their GDP on health care as most European countries. So, basically, my most important argument against privatized health care is that it's too expensive. Yeah, I know, the market is supposed to 'always be more efficient', but
    1) If a theory doesn't agree with the data, it's the theorist's job to explain that, not just deny the data.
    2) The axioms of the usual market theories may not be fulfilled in health care: Some participants in the relevant market may not be very well able to choose rationally and all that. Because of being ill and frightened.

  • Someone says:

    I tend to agree with your views.

    It does sadden me, though, that many whom I've met with views supporting universal single payer healthcare do so only after relatively personal experiences (e.g. your wife's situation).

    (Note: Wish you had a plugin that allowed commenters to be notified when someone responds to a post that the person commented in - I'll likely never read your response without it).

  • yagwara says:

    I'm coming to this late, but I felt I had to ask a question.

    First, I have to agree entirely with Schlupp: data shows that 'socialized medicine' is vastly more efficient than the current US system. And I have to agree with IrrationalPoint: as a Canadian, I can call any GP or walk into any clinic with no problems. If I don't like a specialist a GP refers me to, I can ask her to refer me to another. My experience working in the US has not been so positive.

    But my question follows up on Someone's comment: why did it take your wife's chronic illness to change your mind? Why were you unable to imagine a situation like yours and your wife's, until you found yourself in it?

    Please don't read that as an attack. Every person I've met who is opposed to socialized health care seems to suffer this same inability to imagine themselves in a situation like yours, and I am honestly struggling to understand why.

    I feel like I could win them over if only I could make this real to them.

  • Moondragon007 says:

    Yagwara -
    Cos, to paraphrase the parable (or whatever), you never really know someone's situation till you've walked a mile in their shoes.

    I looked down on the working poor till I took a vocational class and had a chance to converse with them. Now I know that most of them *want* to improve the situation of themselves and their families, they just need some help.

    I never realized the limitations of our local public transit service till I spent 8 years riding the busses. Thank God I have a car now, but I will never again take mobility for granted.

    And, although MediCal is perhaps not all it could be, it is infinitely better than our county MIA (Medically Indigent Adult) program. For one thing, my primary care doctor actually knows what the heck he's doing. My kidney stone was finally diagnosed after years of wannabe doctors (the county hospital is also a teaching hospital) telling me my back pain was due to my weight and there was no point in doing anything about it.