Monthly Archive for November, 2007

Using public health care to realign incentives for the private sector

Over at the Archimedes Movement’s blog, a few of us have been sharing stories and talking about the failings and the future of health insurance in the US. Many people have flat out said that insurance needs to go. I recently posted about insurance generally, what it’s good for, and how we can improve it.

I think the the pertinent idea behind insurance is pooled resources to protect against a shared risk. In that sense, I think the government, which we all pay for and which protects us all (or should) is a kind of insurance. Considering how often I feel it fails us, I like having a government really well!

What we need to consider changing is the private management of health insurance. A lot of people think private ownership, and the competition that can result, is necessary to bring down costs, which is an interesting myth because in reality private ownership of health care has made costs skyrocket. Here’s why. When private companies compete, they don’t actually compete to lower costs, they compete to increase profits. In some cases companies compete to increase value, which includes developing a better product and lowering costs to attract more customers, and thereby more profits (profits are still the only real goal here). HMO’s and Private Health insurers haven’t been doing this.

Rather than competing to increase value, the standard has been to sign up as many paying customers as possible, and then hire fancy lawyers to convince as many as possible that they don’t actually deserve what they payed for. The profit incentive is no longer aligned with the better product incentive – more refused care = more profit when you’re just competing to trick the customer. Why has everyone been getting away with tricking the customer?

If every ipod you purchased broke after 3 days, you would teach Apple a lesson by buying a different brand. If all mp3 players of all kinds broke right when you needed them most, everyone would teach the whole industry a lesson by not buying any more mp3 players until producers realized they needed to start competing for value again. The problem in health care is that we can’t decide to stop purchasing health care because it’s not a luxury, it’s a necessity.

So how do we get private companies to start competing for value again? I’ve heard the book Redefining Health Care has some good ideas, though I haven’t read it myself. In my opinion, we use public money, which we already have enough of, to provide for health necessities and let the free market optimize everything else. This would give customers the power to resist purchasing from shoddy providers and realign the sector from an economics of exclusion to an economics of value and price optimization. The basic care must always be sufficient that people feel empowered to stop purchasing from private companies if every single HMO and private insurer in town is just waiting to rip them off.

Regarding the blurry boundary between Free Love and Transactional Sex in Cuba

the malecon

the malecón photo by Isaac Holeman.


The other day I passed part of the afternoon walking alone along the malecón, the seawall pictured above. Built in 1901 by the U.S. during one of their occupations of Cuba, it covers most of Havana’s sea shore and is a hub of people watching and sea sprayed dallying for locals and tourists alike. On one particularly popular stretch I walked past a fairly attractive young woman wearing a modest tank top and long skirt. She was sitting with one hip and a hand on the broad seawall, and I happened to look over right as a gust of wind blew her skirt almost up to her waist. She saw my embarrassed smile and called me back, “hey amigo”.

She was friendly and more forthcoming than most Cuban women I’ve met, particularly after she discovered I’m from the US. Before long she asked me if I had a girlfriend (American women are always asked by Cuban men “do you have a boyfriend?” If yes, “do you have a Cuban boyfriend?” The question is slightly less common from women). No I said, and she smiled and said she was single too, so we could start dating if I liked. She knew I only had 3 weeks left in Cuba, but said we could pasar un buen tiempo (have a good time). I was more than a little stymied, fearing to respond in case I had misunderstood, though I was certain I hadn’t. It got worse when she said, as if to clarify, “quieres quedar conmigo?” The word quedar has various meanings, some of them specific to Cuba, so she might have been asking if I wanted to stop and sit on the seawall with her, if I wanted to start dating her, or if I wanted to sleep with her. After consulting Cuban friends, the last interpretation wouldn’t have been literally accurate but possible as an innuendo, and the second was the most likely, but I had no idea at the time. She then told me about a nice bed and breakfast (casa particular) by the national hotel that would rent a room for $20, did I have 20 dollars? she asked. This is significantly more money than non-famous Cubans my age have for leisure spending in a month, or even a year. As I drifted away, feeling rather odd, I tried to stammer something about not knowing her very well – it almost came out in English.

Here’s a list of my general perceptions about the conversation, including the nonverbal cues.

  • She was interested in having sex with me, pronto.
  • This would have been part of engaging in a relationship, not just a one night stand (one afternoon, in this case).
  • My nationality and her associated expectation of my relative wealthiness played a significant role in her interest.
  • If I had pursued this relationship, she would have expected me to spend money, take her places, and buy her things that were not otherwise available to her.
  • If I had agreed to the relationship but later refused to spend money on her, she would very likely have ended the relationship, but wouldn’t have argued that I had incurred a debt that needed to be paid.
  • She did not consider the proposal a transaction or a purchase.

Again, this is the way it looked from my perspective, they are not indisputable truths about the situation. I am quite confident that she was not a jinetera (prostitute), but I definitely got a bad vibe that felt more sinister than promiscuous and forward behavior alone. This experience left me with more questions than answers. Here are some of the questions.

  • If there were a spectrum of behavior with transactional sex on one end and free love on the other, where the heck would this encounter register?
  • Could I have ethically pursued a romantic relationship with her (not necesarily including sex), knowing that she was probably as interested in my economic status as in me?
  • In this specific instance, would it have felt empowering to her that she could use her attractiveness to satisfy her physical desires AND have material benefits, or would she have felt that this use of her body was an unfortunate only option? Basically, was she going against her morals?
  • Was my impulse to get away from her rooted in an unfair gender bias – an expectation that Cuban women should act more prudently than Cuban men?
  • Did my response to this situation result from an unfair bias regarding her nationality and my assumptions about her economic status?

The second to last question needs more explanation. Young Cuban men are constantly intimating to my female American friends that they would like to have a sex with them. This can be frustrating but it’s “normal” here. My female friends are really put off by this dynamic (I would be too), but it doesn’t cause them to reject every person outright; if they did they wouldn’t have any friends. They just deal with it and remember that they need to be careful about initiating relationships on their own terms.

If this woman had been a man and I a woman, her actions would have been relatively very forward, but not to the extent that they would merit immediately viewing her as much less appealing than any other random stranger. While she definitely did say some things that made it clear she was in the market for a sugar daddy, it’s hard for me to dissect how her nonconformity with the typical gender role might have cauesed me to (in the spur of the moment) focus on the financially motivated comments (creepy) more than any genuine interest in casual sex (not my thing, but not as repulsive as sex for money). It’s probably pertinent that she must have been more aware of Cuba’s gender biases than I, and her words were probably intended to honestly convey all of the things she was interested in. Nonetheless, I don’t like the idea of applying this gender bias when I make decisions. This is one of the dilemmas of being in an environment where I feel like the only norms I can use to interpret the social significance of various interactions are those of a culture that I can’t participate in fully enough to challenge.

As for the last question. There are a lot of gold diggers in the states too. I’m definitely not a fan of them, but I tend to think of it as shallow rather than borderline transactional sex. I don’t think this girl was looking to me to help her meet basic material necessities. At the same time, if she is like most Cubans she probably has almost zero material pleasures beyond those necessities, and very little chance of improving her situation through her own labor (there just aren’t economic opportunities in Cuba). While intertwining sex and material gain may not exactly be driven by desperation in this case, it likewise doesn’t seem quite the same as a person in the US who has access to economic opportunities and is choosing not to pursue them because it’s easier to seduce a rich person.

Overall, it was a pretty strange experience, one that I wouldn’t have been capable of understanding (linguistically or culturally) a few months ago. It’s nice to feel that my Spanish and understanding of Cuban society have improved that much, but at the same time I feel like gaining some insight has left me with more unanswered questions than I had before. Please post a comment if you have ideas about any of my questions.

Important note: Although I have read that sex tourism is often less formal in Cuba than in other places, I have not thoroughly researched the topic. This post is meant to describe some individual responses to economic and social differences. Please do not think I am claiming that everyone who comes from or visits Cuba responds the same way.

Freedom Aint Free: Big Tobacco Purchases Oregon Voters for Record 12 Million

As many of you must know, Oregonians recently voted down a bill that would have provided health care to all 117,000 of Oregon’s uninsured children. While we’re at it, perhaps we should vote to club some baby seals. If I had voted against health care for children, I would have found it utterly impossible to explain my motives to a child.

In retrospect, I would like to offer something of an analysis of what happened. Some people hate kids. They are noisy, they seem to have extra snot, ect. Others claimed to find the goals of the bill agreeable, but were critical of its structure. It would have raised the cigarette tax by 84 and a half cents. In addition to arguing that this unfairly targets a specific segment of the population, I listened to a lobbyist argue that the bill unfavorably targets poor people, because poor people are statistically more likely to smoke (that’s right, he pretended that tobacco providers are advocating for the poor). A more devious neoliberal argument cited research that when the price of cigarettes is raised, people smoke less. In response it would be necessary to raise the tax in order to keep funding the same amount of health care, which would in turn lower the number of people smoking ad infinitum. This was portrayed as a bad thing, because the money would eventually run out. How terrible that we should finally find a way to help people smoke less or quit all together. A final point against the bill was that it would have created a constitutional amendment, a legislative act probably not very appropriate for this effort. Former Governor John Kitzhaber wrote a thoughtful discussion of some of these issues.

Those were the arguments, let’s take a step back and look at the motives. Big tobacco and the stores (mainly Plaid Pantry) who sell a lot of cigarettes in Oregon stood to lose a lot of money. They responded full force, spending a record 12 million dollars. Last year five states had similar measures, so tobacco lobby money was spread thin and 3 of the measure were passed. This year, all the national tobacco money came to Oregon. One commenter on Blue Oregon wrote

So if Oregon children aren’t going to get my tax money for health care…then the tobacco companies sure ain’t gettin’ it either… Let’s tell them that we’ll be keeping the next $12 million, thank you very much… Quitting has made me feel healthier, wealthier, and just a little happier every day, all thanks to (ironically) Phillip Morris and RJ Reynolds. Thanks for playing your “defend the Constitution” fiddle out here in Oregon (referring to TV spots decrying the constitutional amendment)… just don’t mind the door as it hits you on the way back to N. Carolina/Virginia.

Last spring when I testified in favor of the Oregon Health Kids plan before a special joint committee of the Oregon House and Senate, the mood was cheery and hopeful for me and the 3 women (two of color, one with uninsured baby on lap) who testified in favor that day. The five 50’s and older white male professional lobbyists who testified immediately after me seemed almost frantic. Those lobbyists failed to sway the Oregon legislature, but Big Money from Big Tobacco did sway Oregonian voters.

The moral of the story is that freedom most certainly aint free. It cost more than 12 million dollars to purchase freedom this time around. Remember this story next time you get ready to head to the ballot box, and consider looking into who is funding the campaigns in favor and against, what they have to loose/gain, and how those campaigns have influenced your voting behavior.

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