Oh, no. This is really a nightmare -- all those houses are going to be uninhabitable. What a lovely city -- I'm so sad I've only been once.
Not that it wouldn't be a tragedy anywhere, but New Orleans is so very unlike any other city in the United States. It really is heartbreaking.
I wonder if L. can swing a last minute transfer to UMich, or wherever was going to give her the free ride. Given the circumstances, it seems that they might stretch a point.
Minnesota, yeah, I'm sure they'd let her in.
Why is everyone is writing as if New Orleans is now off the map? Is it so bad that we won't rebuild or something? Is everything destroyed? I can't seem to find that information.
Well, I don't know what I'm talking about, so this is worry rather than knowledge, but the bits of New Orleans that everyone's attached to are old, fragile buildings. If the French Quarter, for example, is under 15 feet of water, I suspect that the buildings may simply not have survived in any usable form.
The Times article has the mayor saying that the city is 80% underwater (as much as 20 feet deep). Clearly, there's going to have to be massive rebuilding, and that's assuming that folks decide that it's worth rebuilding in the same vulnerable spot.
There's also that the city is situated in a basin, below sea level.
The French Quarter isn't as bad off as the rest of the city right now, being on somewhat higher ground. It's difficult to get much sense of just how massive the damage is, because martial law has been declared and all reporters ordered out.
SCMT, part of the allure of New Orleans was the old, crumbling nature of it, the sense of history being all around you. A great deal of that has undoubtedly been swept away and much that hasn't won't survive being submerged for weeks at a time.
it works for venice.
if that was in poor taste, may it be offset by the donation I'm about to make.
I've never been to N.O., but I can certainly see that such destruction is very sad. Because of the comments, I thought, perhaps, we were looking at a long-term refugee situation. So, again, very said, but less bad (I hope) than I feared.
I thought, perhaps, we were looking at a long-term refugee situation
I think we might be. A lot of the people who evacuated, or are in the Superdome, won't have homes to return to.
that's assuming that folks decide that it's worth rebuilding in the same vulnerable spot
Not to detract from the extent of this disaster, but being in a storm- or flood-prone area seems to very rarely dissuade people from returning. Florideans do it all the time. Given that New Orleans has actual history and culture worth saving, I'm confident the city's residents will display a similar bloody-mindedness.
Even if they rebuild, I fear the New Orleans I knew is gone. I'm afraid that the rebuilt New Orleans is going to be a corporate, Disneyfied interpretation of what was once there instead of a true rebuilding. Like if NYC got destroyed and they rebuilt the New York, NY casino from Vegas in its place. NOLA was already getting sanitized for tourists' protection and I'm afraid that the tourist and gaming industries will use this as an opportunity to accelerate the pace of that trend.
And for a lot of rebuilding, I just don't know if it's going to be economically practical. Sure, people return to flood zones, but I get the impression that this is going to be an insanely expensive rebuilding project. I suspect that lots of people simply won't be able to afford, even with insurance, to rebuild their homes.
But I shouldn't be opining, I know less than nothing about this.
I know less than nothing about this.
Maybe you'd like to guest post?
Ogged, given that this is all your and Wolcott's fault, should you really be mouthing off?
I won't be goaded into inappropriate comments.
Maybe you'd like to guest post?
Based on the record of your other co-bloggers, this is a transparent attempt to drive me from your blog. Nice try, but I'll keep my ignorant opinings in the comments section.
Is the reading group ever going to get restarted, BTW?
Yes, sorry, I should have posted about that. Given that I've actually been working and w-lfs-n is travelling, I figured there wasn't much point this week, since that's half of us. But yes, certainly going to start again.
Excellent. The next bit has me completely buffaloed, but it seems to clear up somewhat going forward.
Residents of Jefferson Parish are being let back in on Monday to collect their belongings--then they're being asked to leave for a month.
I was reading elsewhere that it will be very hard to drain the submerged parts of New Orleans because there's basically nowhere for the water to go. Things look very, very bad. I hope they can get the people out of the Superdome alright.
Wolcott has taken down the hurricane post, apparently.
New Orleans reveled in being old and run-down. Part of this was embracing the economic reality that it is, was, a poor city. Part of it was a real aesthetic value. That's not something that can be replaced.
As regards the refugee situation, people are not going to be allowed back in for a month, and power will take 2-3 months to restore. FEMA is preparing shelters for tens of thousands, but, I really have no idea how the financial situation will be settled. New Orleans, the people, and the surrounding areas need a lot of money. And Louiasana, now, too. New Orleans, just through casinos, raised $500,000 a day in taxes. That's a lot of money for this state.
I still don't have power, so sporadic commenting for the next day or so.
Baton Rouge. We were't hit that bad, just some power poles down in my neighborhood. The people I really feel bad for are people like my neighbor, who has a 2room + kitchen and bath appt, and now has 9 or so people living there, his relatives from New Orleans.
Well, in any case, take care, Michael. And drop in to let us know what's up, anytime.
Guys. Keep in mind that most construction in New Orleans (poor, middle-class, rich, what have you) requires a lot of maintenance in the best of conditions to be kept from disintegrating. Now keep in mind next that repairing the gaps in the levees through which water is pouring continuously is a major job that will be made all the more difficult by the current conditions. Add to that the fact that repairing the gaps is a precondition of draining the water already in the city. Add to that the fact that the water already in the city is already suffering from ghastly pollution (biological and chemical) and will only get worse in that respect. Add to that that the city administration of New Orleans is notorious for its incompetence and its police force notorious for its corruption. Add to that that municipal New Orleans has staggering levels of poverty, that much of its housing is owned by people who won't have any possible capital for repairs. Add to that the age and pleasant decrepitude of many of the city's most remarkable structures, which might be badly affected by even 2-3 feet of standing water, let alone 10 feet. Add looting.
So figure in these things: hundreds of thousands of people who cannot return to whatever is left for weeks, possibly months. Many or even most structures in the badly flooded areas needing complete demolition. Weeks, possibly months to remove water from the city boundaries. Structural damage from winds and lesser flooding to most city buildings. Unstoppable fires in structures above water, and possible oil or gas fires on water in some parts. Industrial infrastructure on the verge of the city badly damaged, possibly needing complete reconstruction.
This was the kind of thing that actually happened to human cities pretty often before the late 19th Century (major fires, earthquakes, storms), but it's been a long time since it's happened on this scale to a U.S. city. Yes, people rebuild. Sometimes. Sometimes they don't. Either way, it's a long, hard, horrible road ahead. Whatever New Orleans will be, it won't be what it was.
Damn, that really really sucks.
Maybe Galveston will become the new New Orleans, reversing the switch that happened when the big hurricane hit Galveston in 1900 and basically knocked it from being one of the region's most properous cities, the first in Texas I think with electricity and phone service, to consignment as a minor little seaside town. New Orleans took up the slack.
Crap. This is not a context where I wanted someone more informed to confirm my fears. (Um, but thanks, Tim! More information is always good.)
New Orleans is 80% under water. It's just awful.
Sorry; I didn't catch some of the earlier comments.
For those wondering, L. will be home Friday. The latest news I've heard is that Tulane isn't damaged too badly, but classes won't start until the 21st at the earliest. With the devastation in the rest of the city, who knows? Thanks for thinking of her.
Thanks for the update, L's Mom. Our best to her, and I'm glad she's coming home.
The longer I watch the news, the worse it gets. I suspect they are going to have to send the Army down there - what Army we still have in the country. I expect to see food riots in the next few days.
A million-plus people are homeless and have had their jobs destroyed along with their homes and possessions. We're going to have to build enormous refugee camps. I can't believe this is happening.
It really is unbelievable. The city is being wiped away. Now there's no drinkable tap water. And there are going to be nearly, what, a million refugees. And most of those people won't have jobs to go back to. All this compounded by the fact, as people said upthread, that the folks affected are mostly poor, and have nothing to fall back on. It's hard to imagine how this is going to play out over the coming months.
There's news coverage about looting right now, but who cares about looting? Seems like stopping looting should be pretty low on the list of priorities.
If we can afford 100 bil./yr in Iraq, we can afford it here. That works out to about 100K per person for a few years. I don't want to minimize how hard and awful it is and will be for many people from New Orleans, but I am fairly confident that they won't have to do it all alone. Right now I just want to minimize loss of life.
I do think they'll get some help, but given the number of people displaced, and jobs lost, I think this is going to play out over months and years, and not weeks. Where are these people going to go? Are we going to have massive refugee camps? At this point, we really don't know just how bad it's going to be, but this could be something that the whole country has to deal with for quite some time.
who cares about looting?
Um, me, I guess. Surely after a certain point the collapse of order would start to hinder rescue and emergency efforts, wouldn't it? No need to add unnecessary man-made problems to natural ones.
It also seems that visible anarchy would lower morale, spread panic, and so on. Civic spirit is especially important to hold onto when the city is collapsing around you. (And I say that as a New Yorker.)
It's not just that the looting isn't a big deal, considering the broader tragedy. It's that, given that the city is completely cut off from all but air travel right now, looting (at least for some things) is the right thing to do.
Fair enough. There might not be a clear line between people taking stuff and more general lawlessness, and insofar as that's true, then I suppose the cops should respond to looting. Still, at the moment, like Tim says, finding people and saving them seems more important.
42 to 40, of course.
looting (at least for some things) is the right thing to do
This is surely true in some cases, but not the, uh, most efficient means of distribution. I don't know what the state of emergency services is, so it's hard to say how necessary the looting is. (I'm watching CNN, which seems obsessed with law and order.)
Would it be too much to hope that this will make people think a bit more about poverty in this country?
There's news coverage about looting right now, but who cares about looting? Seems like stopping looting should be pretty low on the list of priorities.
You really think that the media is going to pass on a chance to show black people breaking the law?
Yeah, and the Saints are totally going to suck this year.
In all seriousness, Ogged, I was hoping that this would get people to think about the distribution of risk & "the ownership society."
Yeah, I was leaving off the overtly political or partisan stuff today, but there's a real issue here with who suffers when things like this happen. There's a reason we have things like a "safety net."
Heh-indeedy. Better if this could harm everyone a little bit than a smaller number to a greater degree, which is the sort of thing I usually think in connection with health problems. (You read the Gladwell article, right?)
Well, on the other hand, three things. First, a lot of the retail in the French Quarter is one of the few economic bright spots in a city that's heavily dependent on tourism, and some of those stores have unique merchandise (antiques, etc.) Second, some of the looting being reported in the area of downtown right near the French Quarter is not for bread and medicine, but appliances. I don't so much care about stopping someone doing that--let them go ahead, hell--but it doesn't exactly speak well to the looter's ability to think through the situation. Where's he gonna stash his new TV? Third, looting of the non-Jean Valjean needing-necessity kind isn't exactly known for increasing neighborly amity: there's already been one shooting reported between looters, and it's not exactly uncommon for looting of that kind to lead to fires, fights, and other kinds of disorder which really *could* turn into a bigger issue affecting search and rescue efforts.
Also, as one elderly black woman I saw on CNN observed, as she watched some of the looting, "They could be helping the people trapped, you know".
I agree it's low on the list of priorities at this point. But let's not start complimenting the dispossessed on their excellent critique of capitalist injustice, either.
I know I'm straining to be optimistic, but ...
I know someone who's been involved in some urban renewal projects in East St. Louis, which may be the most blighted place in the country. My sense, from discussions with him, is that really stricken places can be dramatically improved much more easily than non-stricken places. First, the baseline is a lot lower. But second, some of the problems aren't fixed for lack of a sufficient ante; things seem OK enough to let people live in way X, and so no one is willing to put up the start-up capital to make a dramatic improvement. I'm hoping that (a) New Orleans will be rebuilt, and (b) rebuilt in significantly improved fashion for its citizens.
I guess I'm really saying that this is terrible, but it's happened. Now all that we can do is try to ameliorate the situation. I'm hoping that the end result will somehow result in a substantially better city for people from New Orleans.
Yeah Tim, I think that's what ac is saying upthread, and "they could be helping" pretty much says it all.
You read the Gladwell article, right?
I'm a little scared to read Gladwell because he's so convincing, but I know, deep down, that I'm getting a very smooth (in all senses) account. Then I see this, from my hero, Mickey Kaus, which both makes me want to read and not read the Gladwell. But I'll read it, damn it. (And perhaps we shouldn't get off on a Kaus tangent.)
I feel like venting a bit; it's been a long day. I'm feeling pissed right now by our lack of resources. I've been watching news for a considerable part of the day, and it's just pitiful. Single helicopters airlifting people trapped on their roofs or in their attics, and police using their personal boats to find people. There's no major rescue equipment in play. And why not? Iraq. They've called Guardsmen in from California. Because all of ours are in Iraq. Soldiers from Cali won't know the area here, which I can't but think will make quite a difference in efficiency.
We didn't do anything to evacuate people from New Orleans. It was everyone for themselves, plus radio services advising the best routes. If the hurricane had been a little west, the people in New Orleans who are now suriviving/looting would have died.
It's just ridiculous that the levee system is broken like it is. It's not old; the weakness was known. And there's no firm plan yet for repairing it, last I heard (late this afternoon).
Thankfully, I don't know anyone/of anyone who was killed by the storm yet. It's been a little harrowing though, trying for hours to get in touch. We heard from my girlfriend's parents finally about noon today. And other friends and their relations as well.
I know several people who've lost their houses. I'm doing what I can to find an outlet for whatever emotion it is I'm feeling, a mix of sympathy and survivor's guilt. That means donations to shelters today, and volunteering tomorrow. But there's nothing really meaningful to be done.
Another thing I'm pissed about is that the shelter's were all set-up last minute, and they wouldn't take pets. A friend's mom rescued 18 dogs, but had to leave some to be drowned. There are plenty of reports of seeing dogs caught in power lines, being electrocuted to death. Some people stayed in their homes, refusing to abdicate their responsibility to their pets. A friend's dad wouldn't leave his 3 dogs, and hasn't been heard from yet. He was in a bad location, so there's a lot of worrying.
Upthread, Burke missed something. We're just at the beginning of the part of hurricane season which normally strikes Louisiana. It would be normal to have another hurricane or two.
And without New Orleans and tourism, I imagine this state's finances are going to take a heavy blow.
It's no wonder that Sen Landrieu and Governer Blanco were breaking down on camera today.
Jesus, Michael, hang in there. If the government hasn't mustered the resources to help people, I know that lots of regular folks are giving as much as they can, and the whole country is thinking of you guys. But what you're saying is just heartbreaking.
Since my school hadn't started yet but all of my summer commitments had ended, I spent a lot of the last two days watching CNN. Jim Cafferty does this asinine thing where he has people write in e-mails on the questions he asks, and one of them was whether or not the government should help out Katrina victims. A lot of people responded with the equivalent of, "No, the government shouldn't operate mandatory risk pooling schemes, if a natural disaster strikes someone who isn't me, screw'em." Cafferty was ambiguous about where he came down on this, but it was pretty sickening overall. Also, Jim Cafferty sucks.
There's no major rescue equipment in play. And why not? Iraq. They've called Guardsmen in from California. Because all of ours are in Iraq.
That's not all. It would also be nice to have that quarter-trillion dollars back right about now.
I know this is of little relevance with New Orleans under water and people in dure peril, but that Gladwell article is (almost) total crap.
CNN just flashed a graphic of available National Guard troops:
MS: has 60% of its Guard troops
LA: 65%
AL: 77%
FL: 74%
Total troops: 31,000
At least one man jumped off the superdome today. Right now, there are kids and adults trapped in roofs. I've heard that sharks were spotted downtown.
Apos, thanks for the link, but I'm even more frustrated now.
Michael, best wishes. I'll drink to you and everyone else in New Orleans. Donating also, but I hope you appreciate the drinking too.
You know, I just read the Gladwell, and I read the Kaus, and this Gladwell/Gopnik debate, and a terrible thought occurs to me: Malcolm Gladwell is the liberal David Brooks.
Appreciated, w/d. I'm having a couple drinks myself. I'm doing some terrific shutting off parts of my mind right now, but, worrying isn't going to do anything. Ethically, I'm not sure how to feel about that. I've been reading a lot of Peter Singer lately.
Gladwell's books, and many (most?) of his articles, are strictly non-partisan. What is the last thing Brooks wrote that was non-partisan?
That's fair, I was just reacting to his tendency toward glibness, or misleadingly simplified metaphors.
That debate ogged links made me want to poke myself in the eye with a stick. Gladwell's performance here makes his article on health care all the more inexplicable. Here are some sad facts:
1. Imposing costs back on the customer does constrain spending. That's why HMOs use a tiered formulary. If you want an expensive brand instead of an equivalent generic, you pay a higher co-pay. As you would expect, this reduces use of higher cost brands. (amazing to tell, at the same time that Gladwell represents health care spending as inelastic, he *simultaneously* argues that costs discourage the use of preventitive care. What the fuck?)
2. Oh, and on that topic of magic, cost reducing preventitive care. Gladwell is simply wrong that most preventitive care saves money in the long run. I wish it were so, but it's not. There are a few cases (asthma meds is a classic example) where this principle holds, but usually, more care means more total spend. The pap smear is one of the most cost efficient ways to save lives, but giving every woman a pap smear does not reduce overall health care costs.
I'm finding that I disagree with Gladwell both when he defends the current system, and when he attacks it. Any debate about health care in the U.S. has to start from the premise that the system is broken. Denying that is either foolish or callous. How to fix it is a much harder problem. There are (anecdotally, anyway), clear problems with the Canadian model, and I have no idea whether the cost of the French model is feasible here (I suspect not). I'm glad Gladwell has come around to hating the system, but "it's all about 'moral hazard'" doesn't help.
Yeah, its a broken system. (Although, oddly the symptoms of brokenness everyone cites aren't the ones that are compelling to me). I don't have a fix, but I suspect that fixes that stifle innovation or yet further distance providers and consumers from the cost of care can't be the answer. There's your insight right there!
Re: 64. ogged, I think you are right about Gladwell. On Gladwell's website he has a long discussion of his biases in which he states that if he were American he would vote Democrat, but that as a teenager he had a poster of Ronald Reagan on his wall.
Matthew Holt of the Health Care Blog had a great post up saying that if you cross Gladwell with Jill Quandagno (sounds so much like the word for a cush commission of the great and the good) you'd come out about right. Just ignore the comments by Ron Greiner who views all healthcare discussions as an opportunity to sell an HSA.
Of course, this should be in a new thread.
Michael,
I was pretty sickened when I heard that even though the city was being evacuated, they were sending the poor folks to the Super Dome. Vent as much as you need to.
Here's something to chew on.
The vulnerability of New Orleans has been something well known and well understood for three decades. The exact specific scenario that it is now facing is something was well known and well understood as a scenario, with all the particulars we're now seeing (city without potable water, inbound or outbound transportation, mostly under extremely contaminated water, levees broken, poor population without access to resources).
Specific place, specific likely conditions, specific likely technical problems. And when it came, what did we get?
1) An apparently improvised shelter plan to deal with people who couldn't or wouldn't evacuate inland.
2) No meaningful stockpile of supplies in a usable location.
3) No serious federal plan for aid and assistance.
4) Heavily improvised technical strategies for plugging broken levees.
5) Not much thinking about questions of public order.
and so on.
Kind of sounds like Iraq, doesn't it? No planning at all for the inevitable, forseeable future (occupation). Except this one doesn't just go on the Bush Administration's tally: it's a 30-year old sustained failure. Lots of study of the circumstances New Orleans would face, little concrete preparation for responding to those circumstances.
Doesn't exactly fill you with confidence that if there is a major terrorist attack on US soil, the government is going to be up to the challenge of coordinating a response.
On the other hand (re 72), different parts of the US have traditions of more effective city/state governance than New Orleans and Louisiana. I love the state I grew up in, but effective public policy is not one of its signature qualities.
The present situation does demonstrate that emergency preparedness is usually a low priority until the day it becomes terribly, terribly important. Even in places with good government.
I think Tim's first comment gets it exactly right: "Either way, it's a long, hard, horrible road ahead. Whatever New Orleans will be, it won't be what it was."
If I had to guess (and I don't have to but why comment in a blog if I'm not going to?), I would say there will be significant permanent migration, particularly from the poorer parts of town. Cousins in Chicago? An aunt in Houston? Some relatives in Memphis? They'll all be sending Greyhound tickets. If there's nothing to go back to, they won't be going back. Just like 1927 in the delta.
if a natural disaster strikes someone who isn't me, screw'em
This sentiment is all too common; when the tsunami hit, a man wrote the local paper complaining that the government shouldn't be sending money to a flooded island halfway around the world because when his street was flooded after a particularly heavy rainstorm, he didn't get any money from the government.
People underestimate how natural disasters are largely unavoidable.
Does anyone have the Red Cross phone number handy? I have had no luck getting through the website (hoping that's a good sign, that lots of people are giving money.)
Speaking with a friend today who has many family members in New Orleans, almost all of whom evacuated early. Most of their homes, from what they can see, are largely or wholly underwater. So the homes are going to be complete losses: basically at this point people have to recognize that almost every single-family house in the municipal limits of New Orleans is going to have to be demolished. They're going to have been in contaminated water up to their eaves or more for weeks by the time the city is dry: almost no structure can stand up to that and remain safely usable.
So at this point, some of her family members who can have already set in motion transfers of their jobs (those employed by employers with other branches besides New Orleans). Others are saying that they're still planning to go back, but I think in the next few days it's going to dawn on them what that means: no jobs, no home, and if you have no flood insurance, the best-case scenario is state and federal assistance for reconstruction, which I suspect will be a long time in coming. No stores or retail for a while. No tax revenues coming into the coffers of the municipal government, and a major hit to the financial resources of the state government.
The cold-blooded technocratic plan that might make sense at this point would be to drain the city, demolish almost everything besides the French Quarter and maybe Tulane, spend some months making new levees that could cope with a 30-foot storm surge, systematically modernize the pump system, raise the elevation of almost the entire city, and then rebuild it as a kind of theme-park heritage site, sort of like that Disney town in Florida or Las Vegas even, with twee French Quarter style architecture throughout the city. Keep all the people out in the meantime. Maybe even pay them off to go live somewhere else. Of course, here's what that means in real terms: megabillions of dollars, the loss of whatever authentic charm the city had before, the short-term death of Tulane as a functioning university, and vast anguish and discontent for hundreds of thousands, maybe millions, of people. So not probable or even desirable.
I'm not sure what the real-world scenario actually is,though. The demolition part is a reality no matter what the plan beyond that is.
This is so, so horrible.
I keep on going back and forth between having that hole-in-your-stomach feeling associated with ongoing tragedies and feeling tremendous pangs of guilt over the obvious fact that the reason this natural disaster is affecting me so deeply is because it's happening to FREAKIN' NEW ORLEANS, one of the two or three greatest cities in the world. I'm such a bad person. I gave money for Tsunami relief and all that, but it really didn't hit me emotionally at all.
I put about $500 into the NO economy in June on an overnight trip for an actuarial seminar. (I took another $250 back from the casino, but that's another story.) Say what you want about the tourist trade but it gave a lot of people a lot of jobs in an area that didn't really have anything else going for it. If NO is rebuilt as Disney-NO (Disnawlins?), especially if there is no way to restore the old buildings, I can't think of too many Louisianans who would be worse off.
My copy of A Confederacy of Dunces is free to anyone who has never been to New Orleans and now will never get to see what it was really like. My real email is linked (for once).
Mississippi and Alabama bore the worst of the hurricane, they say. True, they don't exist under the unique circumstances that make this so terrible for New Orleans, but the residents were also less prepared. The death toll is estimated at 200+ now.
This should be a new thread, but...
Imposing costs back on the customer does constrain spending.
Did Gladwell deny that? Didn't he argue that it constrains spending too much? And I don't see (but may have missed) a claim that healthcare spending is inelastic--more that demand is limited.
I grant the point that preventative spending may not save the healthcare system money. In fact, the example he goes on to cite immediately after that paragraph is the one of the guy who bandaged his broken hand. That doesn't seem to have cost the health system any money. But, you know, it would be welfare-increasing if we spent the money and the guy's hand got fixed. (Assuming a 'social insurance' as opposed to 'actuarial insurance' model--which is actually kind of relevant to post 58, e.g.)
Kaus complains that Gladwell doesn't explain that his criticisms apply to Democratic systems as well. OMG!!! He passed up a chance to bash Democrats when Bush is doing something far, far worse! Good ol' Kaus. (I think the real punchline in the article is the debunking of claims that we're overinsured, which goes to Bush's plans and not the Democrats'.)
And....
If people "go to the doctor grudgingly, because we're sick"--i.e. because we conclude we're sick--you'd think we could also conclude rationally when we're more sick and when we're less sick, when we really need of a doctor's visit (and never mind the copay) and when we have a cold we'll get over soon enough (so let's save the $20).
And if we could diagnose ourselves like that we wouldn't even have to go to the doctor! Here's a way of putting the point: There's already a cost associated with going to the doctor--it's timewasting and unpleasant (and you might pass out after having blood drawn, fall off the examining table onto your face, spend the whole morning in the ER, and have to show up at your ex-girlfriend's workplace all bloody and ask her to drive your car home). So few people going to go to the doctor unless they think they're sick--in fact, I won't head to the doctor unless I think I've got something more than a cold. It's not too hard to tell you're sick--it's harder to tell when you're so sick that it's worth going to the doctor and paying the copay too.
But why argue about it on first principles? Gladwell cited the RAND study that showed that high copays led to cutbacks on useful care. Kaus didn't have an argument that addressed it.
Ad hominems aside, and I'm not a big Gladwell fan, that's every point Kaus makes.
People from Canada tend not to be so scared of single payer health care. The US system costs more and is less effective than the canadian system. And, preventative medicine which improves overall utility even if it doesn't bring costs down.
It isn't stupid to wonder whether high co-payments are really a good idea, in fact, even if there are good theoretical reasons for them being a good idea.
Mm, on the health care debate, re: Canada. I'm drawing on limited personal experience here, but according to a former roommate and the boyfriend, both Canadians, most of the alarmist delays that get reported here (8 months for a replacement knee!) are not due directly to the spectre of socialised medicine, but to a doctor shortage in certain areas. Basically, a Canadian doctor can make more money in the U.S., so there's a brain drain problem. (And, while you're fine in the US if you can afford the MRI, if you can't, well, the MRI isn't even on the table, so I'm not sure how relevant the wait is.)
The system works as near as I can tell like a basic HMO. It's not free; there's a provincial tax that comes out of your pay check. If you can't pay it, you can't be denied healthcare unless you're a year overdue. Dental, vision, and prescriptions aren't covered, though drugs are heavily subsidized. That I think would be the big barrier to implementing a Canadian-style system here; we couldn't subsidize the drug companies enough. Canada gets away with it because there's a big country to the south with ten times the population where they can make their profit.
It's not too hard to tell you're sick--it's harder to tell when you're so sick that it's worth going to the doctor and paying the copay too.
If it's not a copay but the price of a doctor's visit, the answer is: you wait. I grew up without meaningful health insurance (a deductible that kicks in at $10,000 ain't that great); so, as a kid, if I had a high fever, a sore throat and was generally ill, we waited unless my parents thought it was strep. Why? Doc's visit was $75. Pills, if you're smart and ask for generic, maybe $20. You wait. You learn a lot of home remedies. You think you broke your arm? $375 to find out it was just a bad bruise.
Physicals? Don't happen. OB/GYN. Ha. Chronic meds? We were lucky. I can't imagine what would have happened if one of us had asthma.
Yes, people do make rational, incentive-influenced decisions based on how much they have to personally pay. I'm just not convinced that's a virtue.
Matt:
So, looking at a summary of the Rand study it's by no means clear that Gladwell summarizes it accurately. Here the first sentence of the section on Health outcomes:
We compared those persons given free care with all those given cost sharing because we could not find significant differences in health among people on the different cost sharing plans.
That, frankly, is a *stunning* result. 90% co-pay and 25% co-pay were not distinguishable on health outcomes. The only difference was between free care and all co-pay plans, and there only on vision correction, oral health, and blood pressure. I have yet to read the entire study, but if this is validation that co-pays do not reduce needless expenditure, I wonder what falsification would have looked like!
And on the cost-contraint point, Gladwell (amazingly) argues both that cost constrains spending too much in the preventitive cases *and* that health care is different than other commodities because moral hazard does not cause you to 'overconsume' free goods(his pepsi example). n drugs.
Likewise, while self-diagnosis is not perfect, it's not zero-reliability either. True, you will not catch your own melanoma. But there is lots (really lots!) of evidence that overconsumption of health care exists.
Joe O
Less effective as determined how? This is a very, very tough issue to address. The usual metrics used(more administrative costs, higher life expectancy) are highly suspect. What you want is direct comparison within disease indications. There have been some studies on this, which I cannot claim to be expert in. I do know, however, that if you ask Canadian rheumatologists, they think their patients would benefit from expensive bitoechnology drugs that are not reimbursed in Canada (but which are, routinely reimbursed in the US).
More effective by the usual metrics used. Health care related improvement in life expectancy versus cost is a good measure in my book.
Single payer systems go after the low hanging fruit. Health care systems that ignore 40% of the public can't do well on life expectancy based measures.
You can also just ask people. 93% of canadian are very or somewhat satisfied with their health care system. Only 51% of americans are very or somewhat satisfied with their health care system.
The US does some things better. We don't just burn the money. But the things we do better don't make up for the things we do worse.
This is so, so horrible.
Oh God. My heart goes out to—just everyone.
(I'm doing my best to read along. I miss you all. Stay well.)
SB! Good to know you're not underwater someplace.
you're not underwater someplace
This depends on how much he's a standpipe, and how much a bridgeplate.