"We hate the government, except for the large part of it that helps us"

[Colin Woodard's map of 11 American nations]

I just got back from another nation.

According to Colin Woodard, author of American Nations (and this recent article summarizing that book's thesis), the United States comprises eleven distinct cultures. By upbringing and acculturation, I belong to two of them, The Left Coast and Yankeedom. Earlier this week, I got together with friends in The Far West. I am still scratching my head.

Some of these friends hate the federal government, especially its Democratic representatives, and particularly the Obama administration. My views about government, Democrats, and Obama are radically different from theirs, though I understand why some people fear government overreach, I accept that good Republicans exist, and I occasionally disagree with President Obama myself.

But here's what baffles me. Everyone in the group of Far West friends I saw this week is a huge fan of VA hospitals, even though the US Department of Veterans Affairs is the second-largest department of the US government, and even though, as T.R. Reid points out in The Healing of America, VA healthcare is one of the world's purest examples of "socialized medicine."

Everyone in the group is also a huge fan of Medicare, even though Medicare is a US government program that closely resembles Canada's National Health Insurance, often derided by Obamacare opponents.

When I suggested that it would be nice if everybody in America had access to healthcare as good as that provided by VA hospitals or Medicare, everyone nodded. I think they were agreeing with me, though perhaps they were just being polite.

The thing is, we wouldn't have VA hospitals or Medicare if we didn't have a strong federal government.

• The Veterans Health Administration, established during the Truman years as the Department of Medicine and Surgery, today "operates the nation’s largest integrated health care system."
• Medicare, signed into law by Lyndon B. Johnson with Harry S Truman by his side, accounts for 14% of today's national budget--and that's without including the government's healthcare programs for the poor. Add Medicaid and the Children's Health Insurance Program (CHIP) and you bring the total up to 21%.

Of the seven of us gathered around a table at El Adobe Cafe earlier this week, five get Medicare, one gets VA benefits, and one is a caregiver. My friends love these programs because they need them, and they know what their lives would be like without them. At the same time, some of them hate the federal government that makes the programs possible.

I don't get it, but I've learned that arguing gets me nowhere. Even if these people are biting the government's outstretched hand, I'm glad they're getting fed. And speaking of food, El Adobe Cafe serves some of the best Mexican food I've ever eaten. The Far West gets some things exactly right.

A Canadian who loves her health-care system

This morning a Canadian woman wrote such an interesting comment on an old post of mine, "Rationing is not a four-letter word," that I want to share it with you. I don't know the author, her full name (though she tells me her first name is LaVonne, so she's obviously a great person), or her contact information, so I can't give her full credit. But thanks, LaVonne-in-Canada: I learned a lot from you.

Here's what she wrote about how Canadian health care works for her. I've added a few comments in red, in case you want to compare the situation of LaVonne-in-Canada with that of LaVonne-in-the-United-States.

As a Canadian, I can't understand why a medicare plan such as we have is not feasible in the USA.

As a a retired person, I pay $65/mo. When I was working, it was less - employer paid a touch more than half. [As an American retired person, this year I paid $265.85/mo--that would be $104.90 for Medicare Part B (medical insurance), $44.10 for Medicare Part D (prescription insurance), and $116.85 for Medigap Plan G (to cover Medicare's very high co-pays). When my husband was employed, my insurance cost was half that amount because his employer paid about 3/4 of the total cost--but three months ago, the employee's cost for that policy at least doubled.]

Since 2008 I have had two major operations which didn't cost me anything except $35 per day for a private room in the hospital (my choice...a 4-bed ward would have been free). [In 2011, before going on Medicare, I had a major operation which cost me $2,111.35, which seemed like a real bargain since the hospital bill was originally $172,833.97. Insurance agreed to pay $116,748.28. Earlier this year--again, before going on Medicare--I had an outpatient procedure that cost me nothing, even though the hospital bill was originally $47,914.28. Insurance agreed to pay $15,763.77. It's a strange way of doing business.]

Moreover, no charge to Canadians for doctor's office visits. We don't have to delay need for care, might save worsening condition. [Because I bought a Medigap policy (Plan G), I first pay a $147 yearly deductible, after which I am not charged for doctor's office visits. Under our former Blue Cross Blue Shield plan, I was charged $20 to see my primary care provider and $40 to see a specialist.]

We have a population of less than 35 million. Our population can support a universal healthcare plan. The USA has more than 10 times the population of Canada. Surely 350 million people can support a universal health care plan successfully - many more people to pay into it, and as well, more healthy employed people than sick people by far to support the plan, I should think.

By the way, my $65/mo covers 60% of my dental care, too, however this is an option my former employee-plan (union job) allowed me to take. If I'd wanted to pay in more, I could have opted for 80% dental coverage, or 100%. Medicare without the dental would cost $57/mo.(rather than $65). [Alas, my $265.85 includes no dental coverage. And even though I pay for prescription insurance, I also pay out-of-pocket for prescriptions: in my case another $57/mo as long as I don't need anything next year that I'm not already taking.]

Do you think that if your legislators could corrall Big Pharma and Big Insurance Co., that maybe your country could get something even better going? The current Obama-care is not the whole way your President wanted to go (he wanted something more along the lines of the Canadian plan) but he was hog tied, he had to compromise.

We are not socialists in Canada. We have a capitalist system, too. However we don't fret at the thought of socially subsidized provision for people's health, and I think as a consequence we might have a healthier population. The Native Indian people in Canada have totally free healthcare - they don't have to pay any monthly premiums at all.

Now if you happen to think that the Affordable Care Act (aka Obamacare, in spite of what Jimmy Kimmel's interviewees believed) will give us a Canadian system, please, please, please read "Obamacare vs. Canada: Five key differences." The two systems are very, very different--and the differences help to explain why I pay hundreds of dollars more a month than LaVonne-across-the-border, and get significantly less.

And if you're itching to point out that Canadians have to wait longer than Americans for health care, or that Canadians stream over the border to American hospitals, or that Canadian seniors can't get hip replacements, please, please, please read "5 Myths About Canada's Health Care System" and learn what is really happening across our northern border. It's probably not what you think. It's certainly not what the U.S. anti-health-care lobby wants you to think.

These are short articles. You have time.

The truth is, as LaVonne-in-Canada noted, the Affordable Care Act is not exactly what President Obama wanted. He had to compromise, and as a result, Obamacare is not nearly as effective as Canadian health care--though it's somewhat better than what we had before. And Canadian health-care benefits aren't as amazingly good as, say, French or Swiss benefits (which still cost considerably less than ours, by the way), though if our aim is to keep costs as low as possible while still insuring everybody, we still  might choose to imitate Canada rather than some of the more generous countries.

But until the American people come to realize that our current mishmash of a system is costing them a lot more than a more centralized system could--and until our lawmakers find the courage "to grapple in a systematic fashion with the overall inefficiencies in health care delivery and financing, the administrative burden of multiple payers, providers and plans, and the cost pressures of defensive medicine," as the "Obamacare vs. Canada" article suggests--we will keep on paying more, getting less, and regularly shutting down the U.S. government and (who knows?) maybe crashing the entire world's economy.

Medicare Part D: Another year, another huge price increase

I signed up for Medicare last month. In addition to standard Medicare, I added Part D, the prescription drug benefit. My 2013  costs, if they had covered the entire year, would have come to $529 for insurance and $330 for prescription copays.

Today's mail brought the rates for 2014. The insurance premium has increased to $650, or by about 23%. Copays have also increased, to $616, or by nearly 87%. The total increase - assuming I won't need any additional medications - comes to 47%.

I was not happy when President Bush proposed and AARP supported Medicare Part D, the prescription drug benefit. The idea of insuring seniors' drugs was good. The resulting law, which specifically forbids the federal government from negotiating prices with pharmaceutical companies, was insane.

Well, "insane" is putting a good face on it. The financiers who supported the companies who bought the politicians who voted for the law were by no means insane. They were lining their own pockets, never mind the rest of us.

It's obvious, isn't it? If the government gives away money without limits and accountability, retail prices rise, insurance premiums rise, and consumers end up paying as much (or more) out-of-pocket than before the government stepped in.

Want proof? Take a look at this chart from the Kaiser Family Foundation. Notice that the U.S. government spends about as much of its GDP on healthcare as other developed countries (without, however, insuring everybody, as the other countries do). Notice that, unlike citizens of other countries, U.S. citizens spend a whopping amount in addition to what the government spends. The difference? Those other countries put strict limits on what pharmaceutical companies and other medical suppliers can charge.

Some Americans suggest that the government should just stop subsidizing things like health care and education. That doesn't make sense unless you think that only rich people should have access to schools and hospitals. But it makes more sense than subsidizing something without putting a ceiling on what the lucky recipients can charge for their goods and services.

I am going to look for a different Medicare Part D insurance company. I don't expect to find one that's much better, however, until our lawmakers learn to say Yes to middle-class and disadvantaged people and a loud, resounding No! to rich institutions and individuals who want to get even richer at our expense.

On becoming a senior citizen: morning-after thoughts

[A toast to a new era]

Yesterday I turned 65.
Twelve days ago my Medicare insurance (parts A, B, D, and supplemental) took effect. Any day now my RTA Reduced Fare Permit will arrive in the mail. On Friday my husband, who is also 65, will be officially retired from the job he held for 28 years.

It feels like adolescence all over again, but with less energy.
Like our three teen-aged grandchildren, we are making big decisions that will affect the rest of our lives. Should we stay in our familiar environment or move to a different part of the country? Our granddaughters have opted to move: Katie is beginning college nearly 2000 miles from home, Susan is considering colleges all over the country. We've been involved in a wide variety of work and extracurricular activities: is it time to refocus and choose the one(s) that interest us most? Our grandson Chris, about to start high school, is making similar choices.

It also feels like being two years old, but with less cuteness.
Our grandson Max, who is impossibly cute and universally adored, still has daily trials that seem a lot like ours. How do we deal with the frustration of knowing what we want to do but not being able to do it? Do we want to be independent ("Baby self!"), or do we want the security of nearby family ("Mommy come!")? The answer, of course, is both, and when we can't have both at once, we might fuss just a little.

Or is it more like a midlife crisis, but with fewer distractions?
Our middle-aged children's lives are in as much transition as ours. One daughter has recently gone back to work after a 16-year hiatus, and it won't be long before her nest is empty. The other daughter has, in only three years, become a tenured professor, gotten married, had a baby, and bought her first house. One son-in-law's company and the other son-in-law's industry are undergoing major changes. And they're all starting to think about how to help their aging parents make good decisions ("Move closer to us!" "Don't buy a house with stairs!").

Well, as C.S. Lewis wrote in an entirely different context,

It may be hard for an egg to turn into a bird: it would be a jolly sight harder for it to learn to fly while remaining an egg. We are like eggs at present. And you cannot go on indefinitely being just an ordinary, decent egg. We must be hatched or go bad.

--Mere Christianity

Note to self when, overwhelmed by change, I feel like I'm banging my head against a wall: maybe I'm just banging my beak against a permeable shell.

J. Alfred Prufrock contemplates retirement

There will be time, there will be time

To prepare a face to meet the faces that you meet;

There will be time to murder and create,
And time for all the works and days of hands
That lift and drop a question on your plate;
Time for you and time for me,

And time yet for a hundred indecisions,

And for a hundred visions and revisions,

Before the taking of a toast and tea.
 T.S. Eliot 

Wednesday is my husband's last day at the office.
We've been looking forward to this next phase of our lives for a long time. For some 25 years we've been sending a large percentage of our modest incomes to retirement accounts. We joke that our retirement plan is to live on so little that we won't miss it when it's gone.

For the last several months we've been crunching the numbers. When exactly should he retire? Would a reallocation of our retirement resources make them last longer? Which of our two highly professional, fee-based, but disagreeing financial advisers should we follow? When should we take Social Security? When can we start getting Medicare benefits? Which work-based health-insurance plan should we sign up for in order to stay covered until Medicare kicks in? Which of the many Medicare supplemental insurance plans is best? Which of the many insurance companies offering such plans is most likely to stay solvent and keep its rates low? Which Medicare Part D prescription drug plan will best suit our needs?

We've also been looking at lifestyle questions. Should we stay in the place that has been home for 25 years, or should we move to be closer to family? We know about living too far from our kids - 1100 miles from one daughter's family, 800 miles from the other's - but is it possible to live too close? If we move, how do we find good realtors, here and there? What do we need to do to get our place ready to sell? We already live in a townhouse - should we downsize even further? When thinking about a place to live, what factors are most important to us? Will we need a place without stairs?

And then there's the question everybody asks: What will you do in retirement?

"First," my husband says, "I'm going to clean the garage." I hope he's not joking.

Please hire me

[Working till she drops]

A couple of years ago my 40-something cardiologist earnestly told me that the Social Security/Medicare problem was a cinch to fix--all we had to do was increase the retirement age. Right, I thought - I'm in my 60s and facing open-heart surgery, but once I recover I can go pound the pavement. My cardiologist is not an economist, however, and he's a good doctor, so I held my peace.

Yesterday's New York Times ran an article by Economic Scene writer Eduardo Porter, who should know better. In "The Payoff in Delaying Retirement" Porter writes:

What if there were a way for the government to ease the strain that the aging place on the budget while actually increasing their income in retirement, at little or no cost to their benefits? A well-designed reform would even improve the nation’s rate of economic growth. The way to do it is simply to encourage older workers to spend a larger share of their increasing life spans in the work force.

 Sometimes solutions that look good on paper don't work so well in the real world.

First, most boomers are already planning to work until they drop, since they have saved practically nothing for retirement. I'm not sure they need any additional encouragement. What they need is reality therapy.

Second, over the last decade or so, a lot of companies have downsized. Their PR departments speak of this as right-sizing. What it means is that (a) fewer jobs are available; (b) older workers--the ones getting the bigger paychecks because of seniority--are in greatest peril of being laid off; and (c) the remaining jobs require much longer work days. Such policies, good as they may be for a business's bottom line, are not conducive toward extending one's working years.

Third, it's hard for laid-off older folks to get entry-level jobs. Not only are they overqualified (whatever that means), but the jobs just aren't there. Ask any recent grad.

Fourth, while some older people can work at full capacity well into their 70s and 80s, many cannot. However cheerfully chirpy AARP publications may be, 60 is not the new 40. Over 70% of Americans between ages 60 and 79 have some form of cardiovascular disease, for example, compared to fewer than 40% of people between ages 40 and 49 (see data here). For every person between ages 40 and 44 who is diagnosed with cancer, more than eight people between ages 65 and 69 are so diagnosed (see data here). And those who plan to die with their boots on should be aware that nearly 14% of people over 70 have Alzheimer's disease (see data here).

But let's neglect all those potential problems and stipulate that those of us who are capable of working really should be working, at least until--shall we say--age 70. OK, I'll offer myself as a test case. 

I am 64 years old. I have a solid work history with excellent recommendations, though I have not had a regular employer for some 13 years and my industry--book publishing--is in a hard place. With three master's degrees and a background in teaching as well as editing, writing, and management, I'm quite versatile. My health has been pretty good since my open-heart surgery a year and a half ago (I will require excellent medical insurance, however). I have an extended network of other aging publishing professionals.  

So keep me off Social Security and Medicare for another five years. Offer me a full-time job with a respectable salary and benefits.

Or isn't "encourag[ing] older workers to spend a larger share of their increasing life spans in the work force" quite as simple as Mr. Porter believes?

Advice for November 6: Choose your battle wisely

Vice-President Aaron Burr spoils his political career by
killing former treasury secretary Alexander Hamilton.

Yesterday during the Prayers of the People at St Barnabas, someone in the congregation spontaneously thanked God that the American election season is almost over. Everyone laughed.

One reason this election has brought out the worst in us is that we are fighting two battles at once. I fear that, no matter who wins the presidency, we will continue to fight these battles. We will probably still be fighting them in 2016.

We are fighting an economic battle between those who believe that the federal government should spend tax dollars on the military and little else, and those who believe that the federal government should also play a major role in assuring health care for all, supporting the indigent and elderly, rebuilding our infrastructure, and aiding disaster-stricken areas.

At the same time, we are fighting a moral battle between those who believe the federal government should allow individuals the freedom to decide whom to marry and whether to carry a child to term, and those who believe the federal government should outlaw abortion and recognize only heterosexual marriages.

The two major parties have divided up our concerns in unexpected ways. The Democratic ticket is communitarian in economics and libertarian in morals; the Republican ticket is just the reverse. This creates a problem for people who are consistently communitarian or libertarian.

A lot of students at Miami University of Ohio, as Bill Keller points out today in "The Republican Id," are consistently libertarian: they are enthusiastic about Republican economics but reject Republican morals. For them, economics trumps morals: the majority support Romney.

Most Catholic bishops, on the other hand, are consistently communitarian: they support Democratic economics but reject Democratic morals. For many bishops, morals trump economics (see David Gibson, "Catholic bishops make last-minute push for Romney"): they too support Romney.

The students are far smarter than the bishops.

If Romney and Ryan are elected, there's a good chance that federal programs such as Social Security, Medicare, and Medicaid will be gutted (click here for five good reasons to be worried, even if you're over 55), along with smaller programs such as highway construction, education, and food stamps. There's not much chance, however, that abortion or gay marriage will go away. Overturning Roe v. Wade would not outlaw abortion; it would return the question to the states. As long as a woman had enough money, she could simply travel to wherever abortion was available.

If you're a student at a highly rated university like Miami, you probably figure you'll be one of the elites that would be helped by Romney/Ryan economics. As one of those elites, you could find your way around Republican moral strictures. So yes, as long as you're not concerned about people who haven't done as well as you, it makes sense for you to vote for survival of the fittest. (In a decade or two you may discover you're less fit than you thought you were, but you can vote differently then.)

The Catholic bishops, on the other hand, are showing themselves to be as wise as doves and as harmless as serpents. Even if they get their way - in the name of religious liberty! - Americans will continue to use contraception. They will continue to marry or live with whomever they please. They will continue to get far too many abortions (though if abortion goes underground, a lot more women will die).

Catholic bishops have little effect on American morals (even among their own parishioners: click here to see statistics on abortion rates and here to see statistics on contraceptive use among Catholics), but if they tip the election to Romney/Ryan, they may have a major effect on American economics - an effect that goes against more than a century of Catholic social teaching. In the name of freedom and small government, more families will struggle to put food on the table, to send their children to college, to find adequate housing, to care for their aging parents. Americans will continue to die younger than people in countries with universal health care. Our highways and bridges will deteriorate, and environmental pollution will increase. We may tumble back into recession or even depression.

Here's my point. Our next president's policies will probably have a major effect on America's economic health and, very likely, the economic health of the world. His policies will probably have a minor effect, if any effect at all, on America's morals.

If you like Romney/Ryan's Darwinian proposals, if you think the financiers who are paying for their campaign will help the middle class, if you believe that trickle-down economics help the poor (or if you think the poor shouldn't be helped), if you think business can thrive in the absence of a strong infrastructure, if you think climate change is a hoax, and if you trust for-profit health insurance companies with your life, then by all means vote for Romney-Ryan.

Just don't think they're going to bring about moral renewal in America.

Saving Medicare the Republican way

It's a promise: "A Romney-Ryan administration will protect and strengthen Medicare, for my mom’s generation, for my generation, and for my kids and yours." That's what Paul Ryan told the Republican National Convention last night in his acceptance speech.

How do the Republicans plan to do this? The Republican Platform spells it out: "The first step is to move [Medicare and Medicaid] away from their current unsustainable defined-benefit entitlement model to a fiscally sound defined-contribution model."

Right--that has worked so well for pension plans.

Once upon a time we were told that the 401(k) defined-contribution plans would let us retire rich. We could choose our own investments! No intermediaries would take hefty cuts! The miracle of compounding interest would do the rest!

But then interest rates tumbled, and financial institutions took hefty cuts anyway, and our houses lost a third of their value, and most of us forgot that we really needed to be socking away the maximum allowable percentage of our salaries if we planned to continue eating in retirement.

You might want to check out David Callahan's article, "A Perfect Failure: Why the 401(k) Has Been a Flop." Or you might just want to consider your own 401(k). Will you have saved a million dollars by the time you retire? That's how much you'll need if you want to draw out a modest $40,000 a year, and if you want your savings to last as long as you do.

Now ask yourself: do you really want an individualized, free-market Medicare along with your individualized, free-market 401(k)?

Soon-to-retire Boomers will remember a sentence reportedly uttered by an American officer in Vietnam: "We had to destroy the village in order to save it." That's pretty much how Mr. Ryan plans to save Medicare.

I do hope Messrs Obama and Biden come up with a better idea.