The Price We Pay

What Broke American Health Care--and How to Fix It

[Amazon Link]

I was tempted into getting this book via the author's appearance on Russ Roberts' EconTalk podcast back in Februrary. (I would have gotten to it before now, except for the Portsmouth Public Library's extended Covid-19 shutdown.)

Marty Makary, a doctor affiliated with Johns Hopkins, describes various ways that "we" (as taxpayers, health insurance customers, and/or patients) are being gouged by the health care system.

  • Some hospitals have "list prices" for their services that are stratospherically higher than normal; not only do they gouge, they go after slow-payers aggressively with collection agencies and garnishments.
  • "Health Fairs" that are setups to steer unwary attendees toward expensive and unnecessary services.
  • Surprise billing for participants in your care who are "out-of-network".
  • Ground and air ambulance services are notorious overchargers.
  • Some OB-GYNs aggressively seek out women in labor and persuade them to get unnecessary (but lucrative) cesareans.
  • Doctors (through greed or ignorance) gravitate toward more expensive procedures, out of whack with prevailing practices in their fields.
  • Doctors overprescribe, especially opioids. Probably that's less of a problem these days. But Makary admits do doing it himself, out of ignorance.
  • Middlemen, like pharmacy benefit managers (PBMs) and "group purchasing organizations" (GPOs) can skim, and sometimes a lot more than "skim".

And I got tired of typing, so I'll stop there.

Makary's style is informal, first person, often reporting in detail about his research interviews ("I landed at the Omaha airport and immediately saw a big Omaha Steaks shop in the airport terminal.") Hence, the book is largely anecdotal. That has pluses and minuses. Plus: the stories are grabby and rage-inducing. Minus: there's not a lot of quantitative data. For example, he (sensibly) thinks kickbacks from pharmaceutical manufacturers to PBMs should be banned; but how much would that save? Big problem, medium, or tiny?

Markary is also kind of weak (imho) on the promise made in his subtitle: how to fix it. The basic problem (to which he alludes over and over) is that health care doesn't work like a market. To a first approximation, the reason is pretty simple: someone else is paying, not the consumer. Consumers are insulated from the gory details, and so why should they care about the vast sums flying around that they never see?

Of course, they're paying. Sort of. Through paycheck deductions, mostly. But they have little control over that.

But Markary doesn't go so far as to advocate radical free-market reforms. And I don't think he even touches the over-regulation and over-licensing in the field.

My deep thought about why market reforms aren't coming to health care: we don't want them.

Markets are wondrous mechanisms, but there's one nasty fact: they will provide some things you can't afford.

We don't worry about that in most areas. Can't afford filet mignon? Fine, I'll grab the sirloin on sale. Can't get a Tesla? Honda Civic, baby. No problem.

But with health care, we want the best. We are entitled to the best. And if we can't have the best, then our inner egalitarian takes over: if I can't have it, then nobody else should have it either.

That's ugly, but very understandable. And that's why we can't have nice things.

ADDED slightly later: Markary blames doctor overprescription for the increase in opioid overdose deaths. I don't buy that. See, for example here.


Last Modified 2020-07-08 10:57 AM EDT

Confessions of an Innocent Man

[Amazon Link]

This is another book off WSJ reviewer Tom Nolan's Best Mystery Books of 2019 list. Six down, four to go.

Tom has a pretty broad definition of "mystery". There's a negligible amount of whodunit content here. But that's OK. It's a page-turner.

Right from page one, we learn that the first-person narrator, Rafael Zhettah, is keeping a couple of people, Sarah and Leonard, locked up. A countdown timer shows how much time is left on their "sentence" (initially 2,444 days). Rafael provides them a TV (stuck on CNN, 16 hours/day, now that's cruel and unusual punishment). And he addresses them as "your honors". Hm.

How did that happen? We find out eventually. Pre-kidnapping, Rafael was on death row, convicted of the brutal murder of his billionaire wife. He's innocent (see the title), but thanks to a lazy investigation, zealous prosecution, and a weak alibi… sorry, Rafael, get ready for your Pentobarbital injection.

Given the prologue, we know that Rafael gets out, and (somehow) decides to exact revenge on Sarah and Leonard, and the path is a twisty one.

The author, David R. Dow, is an active opponent of the death penalty, founder and director of the Texas Innocence Network. So there's some advocacy here mixed in with the plot. Depending on your own feelings about capital punishment, you can either roll your eyes or punch the air in agreement.

As said, the book's a page-turner, but strains credulity at times. The biggest disbelief-suspending hurdle for me: Rafael just happens to own a bit of Kansas property that has an unusual plot-critical feature, undisclosed until page 167. No spoilers here, but geez, I said, isn't that convenient?

The Life and Afterlife of Harry Houdini

[Amazon Link]

I put this on my get-at-library list after hearing Russ Roberts interview the author, Joe Posnanski, on the Econtalk podcast last year. Russ's opening comments called the book "very strange and delightful", and I concur. And I'm not much of a magic fan.

(Although I did watch that Tony Curtis movie when I was a young 'un. Posnanski debunks that pretty thoroughly.)

Although Posnanski did tons of research, lots of interviews, it's not really a scholarly tome, or a biography. It's a very personal exploration of the Houdini phenomenon, and why, of all magicians past and present, Houdini still grips our imagination today. We do get most of the details of his life along the way, roughly in chronological order. But (for example), Posnanski finds Houdini's late-career interest in debunking spiritualism boring, and zips over it in a single chapter. A "real" biographer wouldn't do that, but that's OK.

An interesting and recurring theme is the tension between other magicians and Houdini, which continues today. Strictly as traditional magic goes, Houdini was not that great. Plenty of others, then and since, out-illusioned and out-tricked him. But his fame relied on his specialty: escaping from handcuffs, straitjackets, sealed cans and boxes. That seemed to catch the public's imagination and catapulted him to his fame.

We also get a picture of Houdini's milieu, the popular entertainment of his era. I made Mrs. Salad laugh by reading some of the acts Houdini performed with. Texas Ben, the phenomical cowboy pianist who never took a lesson but can play any classical piece after hearing it only once. Leah the Whittler. John Rauth, the man with the longest head. Thardo, defier of snakes.

It was an interesting time. And Houdini was an interesting guy. But Posnanski is also very good at exploring Houdini fandom. Probably the most famous one is David Copperfield, who is probably the closest to Houdini in terms of fame; Posnanski hangs out with him quite a bit, and that's interesting too. (Over the years, Copperfield has bought and squirreled away a lot of Houdini paraphernalia, and he takes Posnanski on a tour.)

And there's a lot of interesting stuff that has nothing to do with Houdini. The actor Patrick Culliton is an obsessive Houdini fan, but he told Posnanski a pretty funny story about Robert Preston's reaction on hearing about the death of Yul Brynner. No spoilers here!

All the Light We Cannot See

[Amazon Link]

This went on my get-at-library list quite a while ago, based on a recommendation of which I have only a dim recollection. Someone at National Review, maybe? I can't find it now.

It also won the 2015 Pulitzer Prize for Fiction. Does that mean it's insufferably arty and politically correct? A book where nothing much happens, but there are a bunch of insufferable self-obsessed angsty characters?

No, it's pretty good, honest. A page-turner, actually.

Set around the horrors of World War II, there are two protagonists: Marie-Laure LeBlanc, a blind French girl who's been evacuated from Paris to the "safety" of Saint-Malo. And German orphan Werner Pfennig, whose talent for fixing radios brings him to the attention of the Wehrmacht. These two crazy kids are set on a collision course: Marie-Laure's relatives become associated with the Resistance, and an old radio is used to broadcast information about Nazi activities to the Allies. And Werner finds himself on a small team of soldiers using sophisticated (for the time) triangulation methods to track down and (violently) silence such clandestine broadcasts. Uh oh.

And there's a lot of other stuff going on. Marie-Laure's father is a museum worker, skilled at woodworking, and he builds scale models of their Paris and Saint-Malo neighborhoods to help her visualize her environment. But he's also entrusted to keep an incredibly valuable diamond out of Nazi hands. That makes him (and his family) also a target of von Rumpel, a German agent tasked with looting the riches of occupied Europe.

Anthony Doerr's writing is pretty good, going right up to, but never crossing over into that too-arty territory. I believe (but I may have gotten this wrong) the title refers to the minor miracle that our perception of the light-filled world is entirely within the brain, which is locked inside the total and eternal darkness of the skull. Funny that.

Trivia: page 83, Werner performs one of his genius acts, bringing a Philco owned by an upper-level Nazi back to life. The lady of the house exclaims: "He fixed it just by thinking!"

Wait a damn minute. That's a Richard Feynman story! From America, no Nazis involved.

I was about to accuse Anthony Doerr of ripping off this story, but as it turns out, Doerr gracefully acknowledges the Feynman source in the end matter. Good for him.

The Monkey's Raincoat

[Amazon Link]

I started a new reading project: the novels of Robert Crais. Back in the day, I read his early stuff via Dover (NH) Public Library, then switched over to buying them as they came out. About time for a retrospective. I grabbed the Mass Market Paperback edition, and…

It's the first (1987) outing for wise-cracking L. A. private eye Elvis Cole and his taciturn partner Joe Pike. He's hired by Ellen Lang, who is missing her husband and young son. Hubby is a struggling Hollywood agent, and he could be mixed up with some nasty types. A sordid tale of drugs, gangsters, and violence unfolds. It's an excellent page-turner, and it's interesting to contrast Early Elvis with Modern Elvis. Early Elvis is funnier, and arguably less ethical. But that's OK.

It occurred to me that if an Aspiring Young Writer wants a free lesson in how to build suspense with a violent climax: study chapters 34-37.

Consumer note: there were a few glaring typos in this 2019 edition. Example, page 266, where Elvis is considering options for an assault on enemy territory: "It was through the door or across the fawn." I think you mean "lawn", Elvis. (This error doesn't appear in the pirated Russian version. Just sayin'.

Or is this some kind of publisher's gimmick? Where they can search for this mistake on the web to nab the intellectual property thieves?

Second consumer note: I don't get the title. It's from a haiku by the Japanese poet Basho (1644–1694), but … no monkeys, no raincoats. I suppose I'm dense.

Friday

[Amazon Link]

Continuing on the Rereading Heinlein project. (Just 23 to go!)

The Amazon link picture isn't the copy I have. I have (ahem) a 1982 first printing. Assuming I paid list price (I don't remember), it set me back $14.95. Ah, the days before I was a senior citizen on a fixed income and felt flush enough to splurge that way.

Although if Heinlein were still alive and cranking out books, I might…

The eponymous heroine is an Artificial Person, grown in a lab with a genome granting her enhanced strength, speed, and sensory acuity. There's widespread bigotry toward APs, so she doesn't advertise her origins. She has a job as a courier for a secretive organization, run by an old guy Friday calls "The Boss". In this scenario, interplanetary travel is a given, interstellar travel is just getting started. But traditional governments have broken up and become balkanized, and corporations have stepped into the power vacuum; it's kind of a mess.

Friday has a dangerous job in a dangerous time and place. She feels she has to, and does, kill a guy on page one, paragraph one. But she's captured by a gang of bad guys on page 7, Raped by page 9. But (spoiler) eventually rescued. (Her lackadaisical attitude toward this attack drew some feminist ire back in the 80s, I recall.)

And things proceed from there. There's not much of a plot; it's basically stuff that she does, and what happens to her. But for me, it kept the pages turning. Friday's first-person narration is Heinleinesque, take it or leave it. Lots of observations and opinions on society, politics, and sex.

The Origins of Virtue

Human Instincts and the Evolution of Cooperation

[Amazon Link]

I bought this 1996 book from Matt Ridley awhile back, but it got shuffled off deep into the TBR non-fiction stack. Thanks mostly to the closure of the two libraries I borrow from, I've been checking out such moldy oldies. And this is pretty good.

It is a polymathic assault on the problem of (roughly) why we humans act as decently toward each other as we do, given that evolutionary "selfish gene" theory demands that our behavior should be entirely governed toward the goal of sending our DNA into the future via our biological offspring.

(You know how that works, right? I don't need to explain it? Good.)

Matt draws his discussion from an impressively large number of fields. Genetics (of course), anthropology, economics, game theory (especially Prisoner's Dillema scenarios), history, theology, psychology, animal behavior, …. Really heavy on that last one: under B in the index we have baboons, beavers, bees, birds, bison, blue tits, blue whale, bonnet macaques, bonobos, bottlenose dolphins, and bumblebees. Something to learn from everyone. And you'll be guaranteed to learn something you don't already know.

Ridley is no Pollyanna: he knows that evolution has also encouraged the (literally!) beastly behavior we too often exhibit. I wish (however) he'd been a little more clear about how we (when at our best) are pretty good at recognizing virtue and differentiating it from vice. Although, as current events are never far from demonstrating, we're too seldom at our best in that regard.

Exit Strategy

[Amazon Link]

This is a sequel to The Second Life of Nick Mason, by Steve Hamilton. That previous book described how Nick was coerced into being the "samurai" (aka, hitman) for imprisoned Chicago crime boss Lucius Cole. Nick is a hitman with scruples, however. He only goes after his designated targets, taking pains to use only non-lethal force on others.

Nick really wants out of this situation. (See the book title.) But until he figures out a way to do that, he has to go along with Cole's current scheme to get out of prison. Which involves (corruptly) forcing a retrial, and having Nick murder the witnesses that testified against him in the original trial. Some returning characters from the previous book, a couple new ones, notably a sociopathic Irish killer who was the previous holder of Nick's current position. And he's pissed at just about everyone.

There's an awful amount of ludicrously-staged mayhem (seemingly written for eventual transition to the big screen) and bad language. Despite the glowing blurbs on the dust jacket, I thought it was pretty perfunctory, but a decent page-turner. Does Nick succeed in his quest to get out from under Cole's thumb and resume a semi-normal life? No spoilers here, but if you look at Steve Hamilton's book list, you'll probably figure that out for yourself.

Open Borders

The Science and Ethics of Immigration

[Amazon Link]

I've been a Bryan Caplan fan for awhile now. I enjoyed his take on why we can't trust voters to generate rational public policy and his look at "why the education system is a waste of time and money".

But, on those topics, Bryan was "confirming my priors"; I was kinda leaning his way before I opened the books. But in this book, he sets out to recommend his titular policy: open borders. Next to no restrictions on foreigners making their way into this country to work. I'm, like, really?

But (spoiler alert) he pretty much convinced me that's the way to go. The moral and economic cases are pretty clear for a libertarian: you have people who want to work, other people who want to employ them, how dare you step between them and ban this capitalist act between consenting adults? And (no question) this is a positive-sum transaction, making both parties better off.

Bryan also handles the (numerous) objections: expanded immigration is not a drag on the welfare state, the cultural differences between Us and Them fade out after a generation, etc.

I should mention the biggie: it's a comic book. The illustrating is done by Zach Weinersmith, the force behind the Saturday Morning Breakfast Cereal web comic. (Recommended, if you're into that sort of thing.) This works pretty well, too. And I got more than a couple chuckles along the way. (There's a "Notes" section at the end if you want more words than pictures on a certain topic.)

[Amazon Link]
And I should also mention that immigration is one of those topics on which I'm easily persuaded by the last thing I read. See (for example) my take on Reihan Salam's book opposing open borders. By which I was also persuaded. But that was last year.

I am a tall stalk of grass, destined to bend in whichever direction blows the wind…

The Secret Place

[Amazon Link]

This is the 2014 entry in Tana French's series of novels about murder most foul, as investigated by the Dublin police murder squad. As always, a couple of the detectives here were supporting players in a previous French book.

It's about the reopening of a cold murder case, set mainly at a prestigious boarding school for girls. Which is (as is usually the case) right next to an equally prestigious one for boys. One night last year, one of the rich, good-looking boys got his head stove in with a hoe on the schoolgrounds.

What suddenly causes the case to come alive: someone's posted a pic of the vic in the school's "Secret Place", where the girls are encouraged to post things they wouldn't disclose out loud. And added the caption: "I know who killed him."

The cold-case detective, Stephen Moran, brings the picture to one of the original detectives, Antoinette Conway. Stephen's ambitious and sees this as a possible path to promotion. Conway is hard-as-nails and cynical, but agrees. And they're off to the school to see if they can shake anything loose. (And, eventually, they do.)

The narration alternates between first-person Steve chapters focusing on the newly opened investigation, and third-person chapters describing the events leading up to the murder. Suspicion boils down to two groups: four "Mean Girls", and their antagonists, four "Weird Girls". (Holly is one of the weirdos.) We're obviously supposed to root for the underdogs, but… nope, things aren't that simple.