Dear Mr. President: How to save millions on health care

Mr. President, Members of Congress, members of the press, and fellow bloggers---

There's a way to save millions of dollars on health care that nobody is talking about. It's a simple concept, and the start-up costs would not be enormous. It would be ideologically satisfactory to Democrats and Republicans. It would satisfy the President's call for "uniquely American" solutions, because it is based on free enterprise. Though it would not solve the current health-care crisis, it would help to contain costs while a solution is found.

Our current health-care system resembles free enterprise like a mugging resembles a trip to the mall. When we go to the doctor, the pharmacist, or the hospital, it's "your money or your life." We consumers usually have no idea how much any health-care service or product will cost until the bill arrives--we only know that we need help, and so we pay whatever is asked. Comparison shopping, an essential feature of budget management, is impossible.

So what if we figured out a way to make comparison shopping not only possible, but easy?

What if doctors' offices were required to post a list of their most common procedures, with prices for each? What if they also had to list all their prices on a central online data bank that consumers could access? What if pharmacists, laboratories, scan centers, hospitals, clinics--all providers of health care--had to do the same?

Imagine going online and checking to see how much your local family-practice physicians charge for a 15-minute office visit before making the appointment.

Imagine being given, along with your prescription, a computer print-out showing where your medication can be purchased, how much it costs from each pharmacy, and what other, cheaper options might be equally satisfactory.

Imagine being able to refuse your doctor's offer to use the CT scanner across the hall, which he owns, and instead driving three miles to a different CT scanner that costs half as much. Or confidently using the doctor's scanner, knowing that his prices beat out the competition's.

How hard would this be?

Posting the prices of usual procedures would take, what, an hour?

Listing all prices on the internet could take anywhere from ten minutes to a day, depending on how many services are offered.

Setting up an internet portal for providers and consumers would be the most expensive and time-consuming part. Google might be happy to help. Or Bill Gates.

Price-fixing could be a potential problem ("Let's all get together and charge the same outrageous amount ..."), though it is already illegal. Undoubtedly there will soon be caps on medical malpractice lawsuits. Perhaps underemployed ambulance chasers could move into antitrust law, which would certainly increase their popularity.

Some providers might object that they themselves don't know what their prices are, because so much depends on insurance company payments. Well then, imitate hotels and publish your maximum rack rate. Or imitate airlines and change your rates hourly (this would be time-consuming, and I really wish airlines didn't do it--but still, it's a lot easier to comparison-shop for a plane ticket than for a mammogram). Or keep your prices low and reasonable for everyone, and stop asking the uninsured to subsidize the insurance companies' discounts.

Any health-care system acceptable to Americans will contain some element of free trade. To the extent that we want the free market to play a role in our health care, let's insist that normal market forces operate. We live in an information society. Why not information for consumers on what our health care is going to cost?

Why I am a liberal

Liberal means favoring freedom.

In 17th and early 18th-century Europe, liberals brought down the Ancien Régime—a totalitarian alliance of church and state—and (with many false starts and not a little bloodshed) developed their current democratic systems of government. In America, liberals wrote (and fought for) the Declaration of Independence, the Constitution, and the Bill of Rights.

In England and America, especially, liberals favored free markets and strong businesses. Commerce, they believed, was a safer ruler than king or pope, because commerce was based on “enlightened self-interest.” Economic liberalism led to exploration, the industrial revolution, and an increased standard of living for Europeans and Americans.

However, 19th century captains of industry began rivaling 18th-century despots in their opulent lifestyle, and in turning a blind eye to the miserable living conditions of the workers who supported it. Liberals—that is, lovers of freedom—began arguing that freedom is possible only when everyone has access to education, decent housing, adequate food, reasonable working hours, and a safe working environment.

Today, some Americans think that liberals are anti-business and pro-government. Perhaps some who wear the liberal label are, but this is not true liberalism. I repeat: liberalism means favoring freedom. But this does not mean freedom without limits.

As a Christian, I believe in original sin: we all fall short of God’s ideal. I also believe in community: we are individually members of one another, and our enlightened interests must extend to others as well as ourselves. (That is why I am a liberal and not a libertarian.)

Alas, communities of sinful people are rarely better than the individuals who form them, and often—because of the increased power of the group—they are considerably worse. Think of the powerful medieval church, for example. Christ instituted the church for the good of humankind, but “power tends to corrupt, and absolute power corrupts absolutely.” Lord Acton, a devout Catholic, wrote that in a letter about the power of the pope.

If power corrupts the church, it also corrupts secular governments and multinational corporations. America’s founding fathers limited religious power by including the first amendment to the Constitution in the Bill of Rights. They limited the government’s power by dividing it into three branches: executive, legislative, and judicial. They did not limit the power of multinational corporations, because even though the Dutch East India Company had been founded in 1602, multinationals were not a huge concern in colonial and frontier America.

Paradoxically, excess power, wherever it occurs, needs to be limited in order to allow freedom to flourish. Another name for freedom without limitations is anarchy, and a frequent result of anarchy is totalitarianism. Untrammeled freedom can destroy liberty.

Given humanity’s power-hungry sinfulness, the best way of limiting one power is often by keeping it in balance with other powers. In the Western world today, our princes are not kings or presidents or bishops, but CEOs and financiers. Tomorrow our princes may come from some other sector, requiring different kinds of limits. The important thing for a liberal is not to be anti-business or anti-government or anti-church, but rather to be pro-liberty, and to seek to limit any power that is dangerous to basic human rights.

One thing is certain: as original sinners, we are powerfully attracted to the god Mammon. Whoever has the power also has the money, and whenever power goes out of control, it enriches itself at the expense of others. If you want to know who needs restraining at any given moment, follow the money.

Review: A Plague on Both Your Houses

Knowing of my fascination with medieval sleuths, a friend recommended the Chronicles of Matthew Bartholomew by Susanna Gregory.

I began with A Plague on Both Your Houses, listed all over the internet as #1 in the series that is now up to 15 books, even though the book jacket unaccountably calls it the third chronicle. I suspect this book was the third written though the first chronologically, just as The Magician's Nephew is the 6th chronicle of Narnia though the first chronologically. Which makes me wonder how you can have an unchronological chronicle, but perhaps I'm being too logical.

The story takes place in 1348, some two centuries after Brother Cadfael flourished in Shrewsbury and nearly a century before Dame Frevisse roamed Oxfordshire, but only 15 years before Owen Archer will unravel his first mystery in York. Cadfael and Frevisse are monastics; Archer is an retired soldier and apothecary who works closely with a monastery; and Matthew Bartholomew is a physician who lives with monks and friars in a Cambridge college.

Gregory, a police officer before earning a PhD at Cambridge, has skillfully created the richly detailed historical ambience that medieval mystery readers crave. She includes not only descriptions of 14th-century university life, but also gruesome portrayals of what bubonic plague did to the human body, how it destroyed entire villages, and what the young doctor did to try to alleviate his patients' suffering. You can almost smell the piles of rotting corpses waiting to be tipped into the communal pit.

Of course--since this is a mystery--there is moral putrefaction as well: plots, conspiracies, greed, betrayal, all connected to a series of bizarre murders. Unlike many of his confrères, Bartholomew is naïve and very, very good. Like his biblical namesake (aka Nathanael), he is a man "in whom is no guile" (John 1.47). His innocence gets him into all sorts of trouble.

Bartholomew's character is well drawn, and his companions are believable. Conversation, however, is often stilted and professorial ("'There have been other signs, too,' Michael continued after a moment. 'In France, a great pillar of fire was seen over the Palace of the Popes in Avignon. A ball of fire hung over Paris. In Italy, when the plague arrived, it came with a terrible earthquake that sent noxious fumes all over the surrounding country and killed all the crops. Many died from famine as well as the plague.'" To the author's credit, Bartholomew nearly falls asleep listening to Brother Michael drone on.)

Occasionally Gregory seems guilty of anachronism. Though she depicts the general ignorance and superstition underlying 14th-century medical practices, and though she acknowledges that Bartholomew is ahead of his time, his ideas about the causes and treatment of disease sometimes seem unbelievably advanced. The plague is not a punishment from God; leeches are harmful; there is no reason to waste time with horoscopes ... will we discover in a later installment that a time machine has flung Bartholomew back from the Renaissance into the Middle Ages?

This is a complex, tightly plotted book. Trying to get my bearings, I kept returning to page 7, where the eight Fellows of Michaelhouse are briefly described. Eventually I knew everybody well enough to read in a more linear fashion, but then the bodies started to pile up. Gregory helped me out by having Bartholomew stop every now and then to take stock, usually by asking himself a paragraph or two full of questions ("Was it Abigny? Had he come back from wherever he was hiding when he had heard that Bartholomew knew about the [spoiler deleted]? Could it have been Swynford, back from his plague-free haven? Was it Michael, who had reacted so oddly at Augustus's death? Was it William, who had prompted him to look at the bodies in the first place, or Alcote, skulking in his room?" Is it tedious to read so many questions?).

The author also helped by neatly tying off all the loose ends in the final chapter and epilogue, which seemed just a little like cheating--but then if she had followed the novelist's adage Show, don't tell, the book might have become too heavy to lift.

Whether this is the first or the third chronicle, it is an early book in a series that has a lot of devoted fans. A reader who thinks the Matthew Bartholomew books "are simply the best out on the market" (and he's read them all) wrote this in an Amazon customer review: "Admittedly it has taken Ms Gregory 4 novels to really get going and you can almost see the development in the writing skills as you read each one." That's how I felt about the Dame Frevisse novels, with which I eventually fell hopelessly in love. So perhaps, several books from now, I'll be in love with the Bartholomew chronicles too.

Bestsellers, 2008

I've been looking at Publishers Weekly's list of bestselling books 2008 (which they inexplicably title "Bestselling Books 2009," but publishers must think ahead), and I confess I have read very few of them.

The list includes books that were published in 2007 or 2008 and that sold (in the United States, in 2008) more than 100,000 copies each. Of these, 156 were fiction and 119 were nonfiction. I have read eight of the novels and one and a half of the nonfiction books (although I spent a long time at Barnes & Noble leafing through another nonfiction book on the list, How Not to Look Old.)

Fiction
PW's fiction list is predictably heavy on brand names: Grisham, Patterson, Cornwell, Baldacci. My own brand preferences run more to PD James and Alexander McCall Smith, both of whom also made the list. Here are the eight bestselling novels I read, with comments:

• The Story of Edgar Sawtelle. David Wroblewski. Ecco (9/08) 1,320,000 (Well, it’s about dogs and families, and it’s well written, but why did everyone like it so much?)
• The Guernsey Literary and Potato Peel Pie Society. Mary Ann Shaffer and Annie Barrows. Dial (368,288) (Yes! By far the best of the lot. A book for booklovers, and also a beach book.)
• Remember Me? Sophie Kinsella. Dial (336,870) (Forgettable fluff, but fun)
• One Fifth Avenue. Candace Bushnell. Voice/Hyperion (290,004) (Also FF but F)
• The Private Patient. P.D. James. Knopf (235,000) (Excellent. PD James is still wonderful at age 88.)
• People of the Book. Geraldine Brooks. Viking (212,498) (Good, but I liked Year of Wonders more.)
• The Miracle at Speedy Motors. Alexander McCall Smith. Pantheon (150,000) (Mma Ramotswe is my favorite serotonin enhancer.)
• Liberty. Garrison Keillor. Viking (101,000) (Ranges from annoying to infuriating, with occasional spots of comedy.)

Nonfiction
The nonfiction list was crowded with “how to fill your life, which currently sucks, with wealth, meaning, and beauty” books, which I have avoided ever since it occurred to me that if any of these books actually worked, no more would need to be published.

Since 2008 was an election year, political and issues books were also popular. I read half of

• Hot, Flat and Crowded. Thomas L. Friedman. Farrar, Straus & Giroux (9/08) 625,363

a book with an excellent premise that is easily understood in the first chapter or two, so that eventually the remaining chapters seemed superfluous.

I also read

• Things I've Been Silent About. Azar Nafisi. Random (100,305)

perhaps not as compelling as her earlier Reading Lolita in Tehran, but still a fine memoir that has increased my understanding of the frequent scary headlines from Iran.

Religion books
Interestingly--at least to me, since I've worked for some 30 years in religion publishing--21 of the 119 nonfiction bestsellers were religion books. Each of the 21 either was by an already well-known author or else profited from a recent sensational news story. I can't comment on their content, since I haven't read any of them. One of two looked worth reading (if you wrote one, no doubt I am referring to yours).

Of the fiction books, only one was published by a religious house: Dead Heat by Joel C. Rosenberg (Tyndale). Alas, it's a right-wing political thriller.

Marilynne Robinson's Home didn't make the bestseller list, though perhaps it will in 2010. Meanwhile, it is accumulating awards. Christianity Today chose it as the best religious novel of 2008, it won Britain's Orange Prize, it appeared on the New York Times "100 Notable Books of 2008" list, and it was a finalist for the 2008 National Book Award.

Which just goes to show . . . bestseller lists are interesting sociological and business phenomena, but they're not a great guide to good reading.

You knew that all along. Now you have the data.

Summer reading: nonfiction reviews

Over the last 15 months I've reviewed or commented on some 40 books on this blog. Here's the nonfiction list--with links to my reviews--of books about sex and marriage, worship and coffee, anxiety and happiness, food and animals ...

OK, so there isn't much of a theme, which must mean I'm a hedgehog and not a fox. If that metaphor is unfamiliar, check out the first review on the fiction list here.

Brown, The Body and Society
Butcher, A Little Daily Wisdom
Coontz, Marriage: A History
Galli, Beyond Smells and Bells
Gill, How Starbucks Saved My Life
Grandin, Animals Make Us Human
Hathaway, The Year of the Goat
Jones, The Tenth Muse: My Life in Food
Kolodiejchuk /Mother Teresa, Come Be My Light
Madigan & Levenson, Resurrection: The Power of God for Christians and Jews
McMahon, Happiness: A History
Paulsell, Honoring the Body
Pearson, A Brief History of Anxiety
Pollan, The Omnivore’s Dilemma
Squire, I Don’t: A Contrarian History of Marriage
Stark, The Rise of Christianity
Sweeney, Almost Catholic
Wright, Days of Deepening Friendship

3 more lists
2008 Books: The 10 Mosts
Books and films that break your heart
Fiction reviews through June 2009

Summer reading: fiction reviews

Over the last 15 months I've reviewed or commented on some 40 books on this blog. Here's the fiction list--with links to my reviews--of mysterious, grisly, heartbreaking, heartwarming, thought provoking, or silly books, most of which I enjoyed.

Clearly my reading is not thematic. It does, however, promote happiness, and if you'd like to read more on that topic, check out McMahon's book on the nonfiction list here.


Barbery, The Elegance of the Hedgehog
Cornwell, Blow Fly
Frazer, The Apostate’s Tale
Genova, Still Alice
Harvey, The Wilderness
Keillor, Liberty
McCall Smith, Tea Time for the Traditionally Built
Minot, Evening
Mohsin, The Reluctant Fundamentalist
Munro, The Complete Saki
Perrotta, The Abstinence Teacher
Robb, The Apothecary Rose
Robinson, Home
Sansom, Dark Fire
Sansom, Dissolution

3 more lists
2008 Books: The 10 Mosts
Books and films that break your heart
Nonfiction reviews through June 2009

Two elegant hedgehogs

As a former French teacher who lives with an elegant little terrier named Mrs Tiggy-Winkle, how could I not like Muriel Barbery's The Elegance of the Hedgehog?

A runaway best-seller in Europe--over a million copies sold in its native France since its 2006 publication, translation rights sold to 31 countries--the book is #14 on the most recent New York Times paperback trade fiction best seller list.

Last September when the U.S. edition was published, Caryn James characterized it as belonging "to a distinct subgenre: the accessible book that flatters readers with its intellectual veneer." I love being flattered, I am pining for France, I'm a sucker for best sellers, and there's the hedgehog thing. I put a hold on it at the public library.

In James's New York Times review, she offers this interesting insight into the book's title:

The sharp-eyed Paloma guesses that Renée has “the same simple refinement as the hedgehog,” quills on the outside but “fiercely solitary — and terribly elegant” within. Yet there is no mention of “The Hedgehog and the Fox,” Isaiah Berlin’s essay on Renée’s beloved Tolstoy, which may make this the sliest allusion of all. (What are the odds that a philosophy professor with a working knowledge of hedgehogs and Tolstoy would not have known it?) In Berlin’s famous definition of two kinds of thinkers — foxes gather multiple unrelated ideas, while hedgehogs subsume everything into a controlling vision — Renée, intellectually eclectic yet determined to cram her thoughts into a self-abnegating theory of life, resembles Berlin’s description of Tolstoy, who was “by nature a fox, but believed in being a hedgehog.”

Well, actually, Ms. James, the hedgehog idea wasn't Berlin's. The ancient Greek poet Archilocus said it succinctly 27 centuries ago: πόλλ' οἶδ' ἀλώπηξ, ἐχῖνος δ'ἓν μέγα; and Erasmus of Rotterdam ran with the idea some 21 centuries later: Multa novit vulpes, verum echinus unum magnum. You can read all about it here, if you happen to be a fox.

But enough intellectual veneer. Now that I've read The Elegance of the Hedgehog, I'll suggest another important literary reference buried within it--an allusion to Beatrix Potter's The Tale of Mrs Tiggy-Winkle. Consider Potter's story: Depressed little girl meets "a very stout short person" with bad hair. The prickly person works for many people of higher status than herself, including the sad child. A garment gets lost in the washing. Eventually the old woman serves the girl a cup of tea, and the two look "sideways at one another." An improbable friendship forms.

And then there's the whole thing about laundry and dry cleaning, about which I will say no more to avoid spoiling Barbery's plot.

OK, I've been playing with you. What I just did is exactly what Renée, the concierge/ hedgehog/ protagonist of Barbery's book, despises. "If you want to make a career" in academia, she muses,

take a marginal, exotic text ... that is relatively unexplored, abuse its literal meaning by ascribing to it an intention that the author himself had not been aware of (because, as we all know, the unknown in conceptual matters is far more powerful than any conscious design), distort that meaning to the point where it resembles an original thesis, ... devote a year of your life to this unworthy little game ... , and send a courier to your research director.

That kind of reflection permeates this strangely absorbing little book, which--after a great deal of philosophy and French spleen--ends up affirming art, music, friendship, beauty, goodness, and the wonder of daily life.

I'll say no more. For a really fine introduction to and review of The Elegance of the Hedgehog--far better than I could provide--read Michael Dirda in the Washington Post.