Adam Smith meets the rich young ruler

For more than sixty years American presidents have tried to reform our health-care system, to no avail. In the same time period, all other developed nations have set up systems that insure all their citizens, that spend less per capita than we do, and that have better outcomes in almost all categories. Why are American still lagging behind?

Ethicist Daniel Callahan diagnoses our problem in the most recent issue of Commonweal magazine and comes to this conclusion: we suffer from “the absence in this country of a solid common-good tradition.”

In his thoughtful article "America' Blind Spot: Health Care & the Common Good," Callahan points out that the absence of a common-good tradition is not ideologically based—it is felt at all points on the political spectrum. “In their opposition to liberal reform efforts,” Callahan writes, “conservatives invoke freedom, choice, and competition as their leading values. Liberals—and the Obama administration in particular—have no agreed-upon set of countervailing values.”

Instead of the common good, says Callahan, liberals have appealed to rights, obligations, and justice—fine concepts, but without much curb appeal. Conservatives invoke radical individualism, even though one of their heroes, Adam Smith,

believed that markets could not flourish without a strong underlying moral culture. Smith believed that such a culture is animated by empathy and fellow-feeling, by our ability to understand our common bond as human beings and to recognize the needs of others.

And all of us argue about the bottom line.

Sunday’s Gospel reading was about a man who asked Jesus what he needed to do to inherit eternal life. Jesus told him to sell his possessions and give them to the poor. “At that statement his face fell, and he went away sad, for he had many possessions” (Mark 10:22).

I confess: I don’t want the poor to take any more of my possessions. I pay taxes. I give to charities. In the wake of the recession, our income has taken a serious hit, and a tax increase would hurt. I would much rather offer the poor someone else’s possessions. Why not help them, as many European countries do, by restricting doctors’ income and insurers’ profits?

Strangely, my cardiologist’s office doesn’t want to lose any of its possessions either. A recent mailing urges patients to oppose health-care reform and Medicare changes, warning that their lives may be endangered if cardiologists are prevented from making big bucks from overusing expensive diagnostic equipment (this is not, of course, how they phrase it).

Oddly enough, insurance companies would like to hang on to their possessions too (though almost everybody in America thinks that Aetna’s CEO probably doesn’t need every cent of the more than $24 million he made in 2008). No wonder they are doing their best to scare us into keeping the present system.

Without a shared belief in the common good, who among us will go first? Or will we do nothing, hang on to our possessions, and go away sad, leaving health care unreformed and the poor uncared for?

Here is how Callahan concludes his fine analysis:

Suffering, disease, and death are our common lot. They ought to be dealt with as our common problem. It is a shame that the kind of empathy and mutual support that Adam Smith understood to be a requirement of morality have not, in our culture, been extended to health care—extended to one another in the recognition that we all have bodies that go awry and fail. Instead we are offered a consumer model, a national Walmart of medical choice where we are all sharp-eyed purchasers getting the best possible deal for ourselves. A construal of the common good as the freedom of consumers to get what they want, indifferent to the fate of others, is a cheap substitute for the real thing.

Callahan expertly diagnoses our problem, but he does not offer a solution. National revival comes to mind, but America already has a much higher percentage of church-going Christians than the countries that take care of all their poor and suffering. Maybe we won’t really care about the common good until more of us Americans experience poverty and suffering first hand.

Review: Travel as a Political Act

Rick Steves was a teenager when he first traveled overseas. Visiting a park in Norway with his parents, he had an epiphany:

Right there, my 14-year-old egocentric worldview took a huge hit. I thought, "Wow, those parents love their kids as much as my parents love me. This planet is home to billions of equally lovable children of God." I've carried that understanding with me in my travels ever since.

Now famous for his travelogues on public television, his guided tours of Europe, and his guidebook collections including the constantly updated Europe Through the Back Door, Steves is somewhat less well known for his devout Lutheran faith and his devotion to liberalizing America's drug laws. All of these interests coalesce in his new book, Travel as a Political Act.

Steves's message is simple: Go to other countries. Listen to the people who live there. Learn other ways of seeing and doing that you might not have considered before. Some of these ways are better than the ones we're used to. Some could help us make our country a better place.

America is a great and innovative nation that the world understandably looks to for leadership [he writes]. But other nations have some pretty good ideas, too. By learning from our travels and bringing these ideas home, we can make our nation even stronger. As a nation of immigrants whose very origin is based on the power of diversity ("out of many, one"), this should come naturally to us ... and be celebrated.

The book consists of eight essays drawing on his travels not only in Western Europe but also in the Balkans, Turkey, North Africa, Central America, and Iran (click here to watch his hour-long presentation on "the most fascinating and surprising land I've ever visited"). One thread unites the chapters: Steves's plea to us Americans to open our minds, ears, and hearts to people of other cultures and to learn to see things from their perspective. "Growing up in the U.S.," he writes, "I was told over and over how smart, generous, and free we were. Travel has taught me that the vast majority of humanity is raised with a different view of America."

I'm not a world traveler like Rick Steves but, beginning right after my sixteenth birthday, I've gone to school in France and worked in the U.K. and visited most of the Western European countries as well as Turkey, Syria, Lebanon, Israel, Taiwan, and Thailand. I've never, ever been treated rudely because I'm an American, but I've been startled to catch glimpses of what some non-Americans think of the American way of life.

I've watched anti-American banners parading down the street at a Swiss May Day parade, seen British TV political adverts warning that the opposition party might instigate a health-care policy as dreadful as America's, listened to an entire sermon in an English country church lambasting American evangelical religion, and heard German conservative evangelical politicians express disbelief and fury at the actions of George W. Bush. To me, Rick Steves's observations about how people of other nations view us ring true.

Rather than dominating other nations, Steves believes, we should listen to them and learn from them. A self-avowed capitalist (he runs a business, after all), he nevertheless sees value in some of Europe's social programs and is horrified by what U.S. businesses have done to Central America. An unapologetic Christian, he is comfortable with secular Islamic--not Islamist--governments. Appalled by Iranian totalitarianism, he still finds common ground with people he meets and even explains why the omnipresent "Death to America" posters may not be quite as menacing as they seem. And he thinks Europe's ways of curbing drug use are much, much smarter than America's.

As the title indicates, Travel as a Political Act has a strong political slant, but it is also full of human interest stories and quirky factoids about other cultures (did you know that on October 24, less than three weeks from today, the average American will have worked as many hours as the average Western European works in an entire year?). Color photos on nearly every page add to the book's appeal. Steves hopes to appeal to people of all political persuasions, though I suspect he is preaching largely to the left-leaning, well-traveled choir.

One reviewer at amazon.com wrote Steves off as just another liberal from the Northwest who is clueless about how the rest of America thinks (she doesn't say if she has traveled outside the U.S.). It seems to me that Steves knows a lot about how Americans think--and he is terrified, because too many of our views are not based on reality or understanding. Only to the extent that we know how others think--those "billions of equally lovable children of God"--will we Americans be able to add to the world's peace, prosperity, and freedom.

Review: Good in and out of bed

A few months ago when I reviewed Sarah Dunn's Secrets to Happiness, my daughter Heidi told me I'd also enjoy Jennifer Weiner's books. I usually take Heidi's advice on just about everything, but for some reason I didn't rush right out to get Weiner's first chick-lit best-seller, Good in Bed. Something about the title made me think maybe I'd need my mother's permission to read it.

(Before reading another word, note that the author's name is pronounced WYE-ner, rhymes with finer. Forget the wisecrack you were about to make.)

A couple of weeks ago, though, I went to the library in pursuit of comic novels to take along on a week's vacation. With no particular authors or titles in mind, I wandered through the new-book shelves and the paperback racks, and the more books I looked at, the worse I felt. Some of the books were similar to the New Yorker short story genre Weiner once described in an interview as "stories [that] seem to end with someone staring off at the white walls of a white room, and you think that something's happened but you're not quite sure what." Most had actual topics, but I didn't really want to delve into depression and dysfunction and people hurting people, at least not while relaxing in a cabin by the lake.

Suddenly Good in Bed sounded quite promising. Alas, it was already checked out, so I settled for its sequel, Certain Girls. I loved it.

The underlying conflict is between a 42-year-old mother, Cannie, and her 13-year-old daughter, Joy. Joy would like to be popular with the mean girls but does not want to alienate her nerdy friends. She wants a themed bat mitzvah party and a designer dress. Above all, she wants to distance herself from her mother, about whom she hates everything--especially after reading her mother's semi-autobiographical novel, including the X-rated parts.

Weiner dexterously alternates between Joy's viewpoint and Cannie's, seasoning the mother-daughter tension with great dollops of laugh-out-loud humor. For the first four-fifths of the book I'm thinking this is exactly the comic novel I've been looking for--and then something bad happens. Just like in life.

No spoilers in this review. I'll just say that Weiner can't help being funny and hopeful, and this book is not a downer. I liked it even better than the prequel, Good in Bed, which I read as as soon as it came back to the library.

Good in Bed lays the foundation for everything that happens in Certain Girls, and sensible people will read it first. The story takes place some 14 years earlier, when Cannie is in her late twenties and heartbroken, having just broken up with a man who is obviously (to all her friends and family) not a good bet for a long-term relationship. With all the humor of the sequel plus an improbable but delightful fairy godmother (in the form of a young, hard-drinking, big-spending movie star), this book also takes a sudden turn toward tragedy right near the end. It has to, I think, or Cannie would get permanently stuck, psychologically speaking.

Why are Weiner's books--bestsellers all--so popular? Well, she's incredibly funny. She's also intelligent--graduated summa cum laude from Princeton, for example. She connects well with readers on a personal level (if you want to be a fan, check out her blog). She tells a good story; she can be tender but is never saccharine; and her characters--despite distress and disaster--muddle through, hopefully and hilariously.

Oh, and one other thing: Cannie is a woman of size. Size 16, to be precise, and 5'10" tall--kind of like Weiner herself. Cannie's weight is not the focus of the stories, but her concern about it, and the way it makes her feel, keeps cropping up. In the "conversation" at the back of Good In Bed Weiner says, "I'd never read a book that really expressed the reality of what it's like to live in a larger-than-average body.... I wanted to encompass the unhappiness of living in a plus-size body, but also show that it's not pure, unadulterated, 200-proof misery. I wanted to show the whole scope of things--professional success, rewarding friendships, a loving, if vexing, family, a weird little dog, great meals, great adventures, and love, and self-acceptance at the end."

You don't have to look just like Cannie to have an idea of how she feels. I'm not heavy, but I'm uncommonly tall and a bit ungainly (I love Julia Child), and I have seen my reflection in a restroom mirror as I washed my hands next to 5'4" sylphlike friends, feeling like a giraffe among the gazelles. What woman has not had a similar experience, whatever her age or height or weight or disability or hair shortcomings? And what is it with us and our bodies? Why is it so hard to accept variety in the way we're packaged?

"My ideal reader," Weiner says, "is any woman who's ever felt like she needed to get undressed in the dark, any woman who's ever felt miserable about the size of her hips or the shape of her face or the texture of her hair... which is to say, lamentably, every single woman in America, and probably beyond, judging from the reception Good in Bed has gotten abroad."

Cannie, at age 28 and also at age 42, is a big woman who is doing just fine.

Review: The Unlikely Disciple

Kevin Roose was a 19-year-old Brown University student when he decided to try a unique variation on the traditional semester abroad: he would go undercover at Liberty University in Lynchburg, VA, Jerry Falwell's "Bible Boot Camp." Raised more or less Quaker by politically liberal parents, he took evangelical* lessons from a friend before signing up for classes: Contemporary Issues , History of Life (i.e., young-earth creationism), Evangelism 101, and survey courses in Old Testament, New Testament, and Christian theology.

He suffered instant culture shock, of course. He was amazed at his teachers' and fellow students' nearly obsessive concern with homosexuality. His parents and especially his lesbian aunts were terrified that he would go over to the dark side. And he feared his spontaneous reactions ("Holy shit!") would give him away--though he learned to admire Liberty students' creative alternatives ("son of a friggin' biscuit!").

I was in the mood for a comic novel when I absent-mindedly picked up Roose's tell-all book, The Unlikely Disciple: A Sinner's Semester at America's Holiest University. Within minutes I was laughing out loud and reading his stories to Mr Neff (who was trying to read something else at the time). Maybe you have to have had a somewhat fundamentalist upbringing to fully appreciate the humor, though readers with no first-hand experience of right-wing Christianity should still enjoy this anthropological tour of a university that issues reprimands (for hugging! watching an R-rated movie! wearing torn jeans!) as frequently as Dolores Umbridge, Hogwarts' high inquisitor, issued educational decrees.

One reason the book is a good read is that Roose does not have an agenda beyond understanding an alien culture. Appalled by the anti-intellectualism and homophobia at Liberty, he is nevertheless interested in his Bible and theology classes, intrigued by chaste dating, and attracted by the atmosphere of prayer, both public and private. He examines not only the school's way of life but also his own shifting opinions. For example, he writes:

I'm still not totally settled on prayer. Part of me still thinks it's a waste of time, and another part of me wonders whether I could be increasing my levels of compassion some other way--watching Nancy Grace every day, maybe, or reading news stories about famine in third-world countries. It's probably a bad sign if the only way I can tone down my narcissism is by forcing myself to believe that God is monitoring my thoughts. But for now, it doesn't seem to be hurting anyone, so I guess I'll keep at it. When I think of the benefits I'm reaping, a little cognitive dissonance seems like a small price to pay.

Another good feature about the book is that Roose has done his homework. His website lists popular books he read to help him act evangelical, and the background information he weaves seamlessly into his stories shows that he must have read plenty of more serious works besides.

I appreciate Roose's stance as a conciliator, not an ideologue. Without giving up his pre-Liberty convictions, Kevin learns that even Jerry Falwell had a good side, and that people of widely divergent religious and political views can still be friends. "This particular religious conflict," he writes, "isn't built around a hundred-foot brick wall. If anything, it's built around a flimsy piece of cardboard, held in place on both sides by paranoia and lack of exposure."

As a politically liberal Catholic living among evangelicals in Wheaton, IL, I've run into ignorance-based paranoia. I've also run into it from the other side, when I was a theological conservative from DuPage County taking classes at Loyola University in Chicago. Most of us think we know what the other guys are like, even if we don't know them very well. Cheers to Kevin Roose for first-hand (and first-rate) reporting and for making us laugh heartily, with malice toward none.
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*Evangelicalism is a big tent. As Roose well knows--but too many journalists do not--evangelicalism is not synonymous with the religious right. Jerry Falwell called himself evangelical. So does Jim Wallis, author of God's Politics: Why the Right Gets It Wrong and the Left Doesn't Get It.

September delights

We just spent a week in Michigan, not far from where our favorite produce grows. We're home again, and this morning I made my regular Saturday-morning trek to Wheaton's outdoor market. Today's haul is made up entirely of what Michael Pollan calls "the sort of food our great grandmothers would recognize as food."

This is what I brought home for $30: broccoli, red-leaf lettuce, eggplant, zucchini, roma tomatoes, a sweet onion, two bell peppers (red and yellow), a handful of red, yellow, and orange tiny sweet peppers, green beans, brussels sprouts, 4 ears of corn, blueberries, and raspberries from my favorite farmer from Berrien County (neighbors: check out the stand at the southeast corner of the market). And for another $5.25, a loaf of whole grain nutty bread from Great Harvest Bread Company.

In his recent book In Defense of Food, Pollan lays down three rules for healthy eating: "Eat food. Not too much. Mostly plants." This is easy to do if you live near southwestern Michigan or central Washington or other places where fruit and vegetables grow in profusion. It is somewhere between difficult and impossible to do if your food source has to be Target or Wal-Mart. As I noted in another post, Pollan believes that a reformed health-insurance system will lead to better food for everybody, since universal coverage will give insurers a huge incentive to keep people healthy.

I pray that he's right. But words like reform and rules and even health do not even begin to describe the food I brought home this morning. Think Abundance. Bounty. Plenty. Richness. Pleasure. Joy. Celebration. Gratitude.

Big food: the elephant in the living room

In his September 9 New York Times article, "Big Food vs. Big Insurance," Michael Pollan makes some interesting observations about why American health care is so expensive, and how reformed insurance companies may help to lower health-care costs. (If you haven't yet read Pollan's The Omnivore's Dilemma or In Defense of Food, this is the day to look for them at your library or bookstore.)

1. American obesity has a lot to do with American health-care costs. "The fact that the United States spends twice as much per person as most European countries on health care can be substantially explained, as a study released last month says, by our being fatter," Pollan writes. "One recent study estimated that 30 percent of the increase in health care spending over the past 20 years could be attributed to the soaring rate of obesity, a condition that now accounts for nearly a tenth of all spending on health care."

2. But "reforming the food system is politically even more difficult than reforming the health care system," Pollan notes. We Americans may hate the health insurance companies that deny us coverage, but we love our burgers and fries--and we heavily subsidize farmers who produce our now-omnipresent corn syrup. (If you wonder why we are so in love with food that is so bad for us, read David A. Kessler's The End of Overeating, or at least my review of it here.) "There’s lots of money to be made selling fast food and then treating the diseases that fast food causes," Pollan cynically observes.

3. A reformed health-insurance industry will almost surely put pressure on the powerful food lobby. When health insurers are required to accept everybody and keep everybody, they "will begin buying seats on those agriculture committees and demanding that the next bill be written with the interests of the public health more firmly in mind," Pollan believes. He writes:

When health insurers can no longer evade much of the cost of treating the collateral damage of the American diet, the movement to reform the food system — everything from farm policy to food marketing and school lunches — will acquire a powerful and wealthy ally, something it hasn’t really ever had before.

Wait a minute--why should Congress debate what I eat? Isn't my diet an individual choice?

Yes it is, but choice implies a set of options, and most of our options today--heavily subsidized by the U.S. government--involve too many sugars and fats, too few whole grains and fresh fruits and vegetables. What if Congress stopped propping up King Corn? Or what if it directed subsidies away from the foods that may make us sick and toward the foods that could keep us healthy? What if the most nutritious foods were also the cheapest?

Meanwhile, of course, it's a good idea to keep one's weight in the healthy range, even if doing so requires more time, more money, and more attention than we'd rather spend. One third of us do this already. If Pollan is right about insurance reforms, help for the other two thirds may be on the way.

Health care is a moral issue

A couple of weeks ago I previewed T.R. Reid's The Healing of America. I'm happy to see that today it is #18 on Amazon's sales ranking, #11 on Publishers Weekly's hardcover nonfiction best-seller list, and #6 on the New York Times hardcover nonfiction best-seller list. With Congress deadlocked on health-care reform and President Obama scheduled to speak to the nation about health care tomorrow night, this is a book everyone should read. Immediately.

I'm going to be reviewing it for Christian Century, and once I've written and they've posted the review, I'll link to it here. (October 15: CC is hot off the press. Click here.) The mills of God and publishing grind slowly, however, so meanwhile let me emphasize three of Reid's important points:

1. “The primary issue for any health care system is a moral one." If we believe no one should die for want of access to health care, we can find a way to provide care for all. If we believe health care is a commodity like TVs and automobiles, we can continue to exclude those who can't pay. “All the developed countries I looked at provide health coverage for every resident, old or young, rich or poor. This is the underlying moral principle of the health care system in every rich country—every one, that is, except the United States.”

2. It is possible to improve health care and save money at the same time. Hey, those other rich nations that provide health care to everybody spend about half as much per capita as the United States spends, and their citizens also live longer and enjoy better health. If we are willing to study the ways other developed nations handle health care, we're smart enough to devise an approach that suits our needs.

And by the way, we don't need to fear "socialized medicine," whatever that may be. As Reid points out, "the term was popularized by a public relations firm working for the American Medical Association in 1947 to disparage President Truman’s proposal for a national health care system. It was a label, at the dawn of the cold war, meant to suggest that anybody advocating universal access to health care must be a communist.” In fact, successful health-care systems in other countries have widely varying approaches, ranging from public funding and public health-care provision (Britain) to private insurance and private providers (Germany, Japan, France, Belgium, Switzerland, Japan). In fact, some European systems are considerably more private than ours.

Nor do we need to fear loss of choice: almost all developed nations allow more choice of provider than our insurance companies currently permit, and some also have more insurance companies to choose among.

3. The biggest source of waste in American health care comes from our approach to insurance: “20 cents of every dollar people pay in premiums for health insurance doesn’t buy any health care.” Insurance per se isn't the problem. Many developed countries, like the United States, rely on competing private insurance companies to pay health-care bills. There is just one major difference between their systems and ours: most of our private insurance is for-profit, and all of their insurance that pays for basic health care is not-for profit.

Reid does not discuss the army of lobbyists currently working feverishly to sway public opinion and persuade Congress to veto any significant reform, nor does he mention the enormous contributions made by health-care lobbyists over the last five years to key Senators and members of Congress. His book was completed before Wendell Potter, former head of corporate communications at CIGNA, blew the whistle on common unfair industry practices, so he doesn't mention Potter either. Likewise, he is silent about possibly excessive executive compensation at health insurance companies.

Reid is not concerned with abuse and corruption in the health-care industry so much as with flaws in the system itself. Even operating at its best and most honest, a for-profit insurance system cannot provide health care for everybody as cheaply as a not-for-profit private company or a public system. This is counter-intuitive to free-market advocates, but Reid backs up his assertions with figures: contrast 20% administrative costs in America with 6% in Canada, 5% in France and Britain, less than 2% in Taiwan.

1. again (this is Reid's most important point): “The primary issue for any health care system is a moral one." If we have the will to care for all our people, we will find a way. I was thinking about that Sunday while listening to the day's readings from the Revised Common Lectionary:

The rich and the poor have this in common:

the LORD is the maker of them all.

Whoever sows injustice will reap calamity,

and the rod of anger will fail.

Those who are generous are blessed,

for they share their bread with the poor.

Do not rob the poor because they are poor,

or crush the afflicted at the gate;

for the LORD pleads their cause

and despoils of life those who despoil them.

--from Proverbs 22

Listen, my beloved brothers and sisters. Has not God chosen the poor in the world to be rich in faith and to be heirs of the kingdom that he has promised to those who love him? But you have dishonored the poor. Is it not the rich who oppress you? Is it not they who drag you into court? Is it not they who blaspheme the excellent name that was invoked over you? ... If a brother or sister is naked and lacks daily food, and one of you says to them, "Go in peace; keep warm and eat your fill," and yet you do not supply their bodily needs, what is the good of that?

--from James 2