I called attention to Blinder’s presentation of the long-term budget problem as almost completely a problem of the rising price of healthcare. I pointed out that you could take any country with a life expectancy greater than ours – including the other high-income countries – and put their per capita healthcare costs into our budget, and the long-term budget deficit would turn into a surplus.

My question was simple: are Americans so inherently different from other nationalities that we can’t have similar healthcare costs? And if not, then why are we talking about long-term budget problems – instead of how to fix our healthcare system?

Damn good question. Their replies were what you would expect:

None of the panelists offered a serious answer to this question. Auerbach, the moderator, said that other countries have rising healthcare costs, too. And some of the others said or implied that healthcare costs were rising at an unsustainable pace worldwide.

But this is nonsense. The United States pays about twice as much per person for healthcare as other high-income countries – and still leaves 50 million people uninsured. This is a result of a dysfunctional healthcare system that has had healthcare prices rising much faster than those of other high-income countries for decades.

As Mark explains, what they were really saying is that we have to stomp grandma instead of reining in insurance companies and big Pharma.

What the budget hawks are basically telling us is that we must assume that insurance and pharmaceutical companies will have a veto over the provisions of healthcare reform for decades to come. And that, therefore, we must find other ways to make up for these excessive costs, including cutting social security and other government spending, and pushing us into higher rates of poverty and inequality than we already have.

Yay for economists!

Though crop subsidies certainly helped to make corn (and its boon companion, soy) the mainstay of our food system, eliminating those subsidies might not by itself be enough to topple king corn. Decades of crop breeding, advances in farm machinery and the building of a rural infrastructure all devoted to these crops means a Midwestern farmer can produce a bumper crop of corn with just a couple months of work while at the same time holding down another job. Growing anything else would mean a lot more time and work in the fields, and at this point that farmer probably depends on the other source of income.

As for subsidizing vegetables, that, too, is trickier than it seems. Subsidies tend to result in surpluses, which in the case of grain is fine: you can store surplus corn or soy in a silo for years. Try doing that with broccoli. In the case of “specialty crops” — the U.S.D.A.’s term for crops you can actually eat — we would be better off subsidizing demand rather than supply: giving vouchers to the poor to buy fresh produce, say, or incentives to retailers to lower prices in the produce section.

So then what do we do if we want to make organic, locally grown fruits & vegetables affordable?

This is the $64,000 question. There are certainly steps the government can take to make healthful food somewhat less expensive: underwrite farmers’ transition to organic and other kinds of sustainable agriculture; support the renaissance in local meat production by making it easier to build and run small slaughterhouses; use crop subsidies to reward farmers for diversifying their fields and growing real food rather than “commodity crops” like corn and soy; enforce federal antitrust laws to break up the big meatpackers and seed companies.

But these measures will never make high-quality food as cheap as industrial food, some of which will only get more expensive if we take the steps needed to civilize feedlots, clean up water and protect farmworkers from exploitation. Faux populists in the food industry battle such measures on the grounds they want to keep food prices low for the poor. But the institution of slavery kept crop prices low, too — at a cost we ultimately decided was too great for a democratic society to pay. (Come to think of it, slavery still exists in parts of the food system, according to reports out of Florida.) Cheap food has become a pillar of our low-wage economy, one reason Americans have managed to stay afloat as their wages have declined since the 1970s. In the end, if we want healthful and conscientiously produced food for everyone, we’re simply going to have to pay people enough so that they can afford to buy it.

I don’t know enough about the economics of food to know if he’s right. But even if he is, I think we could do better than “we’re simply going to have to pay people enough.” I bet a smart Agro economist could figure out a way to subsidize vegetables that didn’t result in massive surpluses. And there’s an awful lot we could do on the demand side on a large scale if we wanted to.

For example, when I used to work in downtown DC, due to government subsidies my employer automatically added $50 a month to my Metro card, which basically made going to & from work by mass transit free. What if we are to create something similar for organic, locally grown fruits & vegetables? We already have Health Savings Accounts that subsidize you by not taxing money you put into the account. Why not Food Health Savings Accounts where the government would put in a certain amount every month into your account? If it’s set up like a debit card, the way my HSA is, it shouldn’t be rocket science to make it work well for consumers, grocery stores, and farmers (assuming we also tackled the “food desert” problem in poor neighborhoods).

But Michael Pollan is right about one thing: figuring out how to Stack the Odds in favor of healthier diets will definitely take some work.

Ask a Briton to describe “American-style” healthcare, and you’ll hear a catalog of horrors that include grossly expensive and unnecessary medical procedures and a privatized system that favors the rich. For a people accustomed to free healthcare for all, regardless of income, the fact that millions of their cousins across the Atlantic have no insurance and can’t afford decent treatment is a farce as well as a tragedy.

But critics here warn that a similarly bleak future may await Britain if a government plan to put more power in the hands of doctors and introduce more competition into the NHS succeeds — privatization by stealth, they say.

So frightening is the Yankee example that any British politician who values his job has to explicitly disavow it as a possible outcome. Twice.

“We will not be selling off the NHS, we will not be moving towards an insurance scheme, we will not introduce an American-style private system,” Prime Minister David Cameron emphatically told a group of healthcare workers in a nationally televised address last week.

In case they didn’t hear it the first time, Cameron repeated the dreaded “A”-word in a list of five guarantees he offered the British people at the end of his speech.

More juicy quotes from the article:

[Conservative PM Cameron:] “If you’re worried that we’re going to sell off the NHS or create some American-style private system, we will not do that,” he said. “In this country we have the most wonderful, precious institution and also precious idea that whenever you’re ill … you can walk into a hospital or a surgery and get treated for free, no questions asked, no cash asked. It is the idea at the heart of the NHS, and it will stay. I will never put that at risk.”…

Governments of all stripes have taken office pledging to reform the system, to streamline it and make it more efficient, but none has fully succeeded, knowing that they tinker with the NHS at their peril. The current Conservative Party-led coalition, which has embarked on the most radical public spending cuts in a generation, has promised not to take a penny from the health service.

To each other, Britons love to complain about the NHS, retailing gruesome tales of substandard care, of long waiting lists for simple operations like hip replacements, of snotty surgeons and naughty nurses. But when Americans began citing the NHS as the epitome of socialized medicine gone wrong, people here bristled.

Given the rhetoric of how much physicians hate reform, you would think doctors were very happy before reform passed. You’d be wrong. With the exception of Austria and Germany, fewer doctors were satisfied with practicing medicine [in the US] than any other surveyed country.

His most entertaining takedown:

When people want to demonize single payer systems, they always wind up going after rationing, and more often than you’d think with hip replacements…

It’s not true. They don’t deny hip replacements to the elderly. But there’s more.

Do you know who gets most of the hip replacements in the United States? The elderly.

Do you know who pays for care for the elderly in the United States? Medicare.

Do you know what Medicare is? A single-payer system.

Definitely worth checking out.

When doctors are deciding which drug to prescribe a patient, the idea behind evidence-based medicine is that they inform their thinking by consulting scientific literature. To a great extent, this means relying on medical journals.

The trouble is that pharmaceutical companies, who stand to win or lose large amounts of money depending on the content of journal articles, have taken a firm grip on what gets written about their drugs. That grip was strong way back in 2004, when The Lancet’s chief editor Richard Horton lamented that “journals have devolved into information laundering operations for the pharmaceutical industry.” It may be even tighter now.

Drug companies exert this hold on knowledge through publication planning agencies, an obscure subsection of the pharmaceutical industry that has ballooned in size in recent years, and is now a key lever in the commercial machinery that gets drugs sold.

The planning companies are paid to implement high-impact publication strategies for specific drugs. They target the most influential academics to act as authors, draft the articles, and ensure that these include clearly-defined branding messages and appear in the most prestigious journals.

Big Pharma has been using the strategy for a while, and they’re getting increasingly brazen. Take the case of Merck, one of the biggest pharmaceutical companies in the world:

In a flow-chart drawn up by Eric Crown, publications manager at Merck (the company that sold the controversial painkiller Vioxx), the determination of authorship appears as the fourth stage of the article preparation procedure. That is, only after company employees have presented clinical study data, discussed the findings, finalised “tactical plans” and identified where the article should be published.

Perhaps surprisingly to the casual observer, under guidelines tightened up in recent years by the International Committee of Journal Editors (ICMJE), Crown’s approach, typical among pharmaceutical companies, does not constitute ghostwriting….

“We’ve never done ghostwriting, per se, as I’d define it”, says John Romankiewicz, president of Scientific Therapeutics Information, the New Jersey firm that helped Merck promote Vioxx with a series of positive articles in medical journals. “We may have written a paper, but the people we work with have to have some input and approve it.”

So the next time some college kid gets caught plagiarizing, maybe instead of kicking them out of college they ought to get him an internship in Big Pharma.

Only 12% of U.S. hospitals had adopted electronic health records (EHR) as of last year, a modest increase over an adoption rate of 9% in 2008, according to researchers at the Harvard School of Public Health.

And of the 12% that have gone electronic, plenty are still struggling:

* A study by University College London found that many EHR projects fail, and “the larger the project, the more likely it is to fail.” Researchers say the systems can improve auditing and billing but may make primary clinical care less efficient.

* Experts from the Institute of Medicine who visited healthcare facilities last year found that “care providers had to flip among many screens and often among many systems to access data; in some cases, care providers found it easier to manage patient information printed or written on paper.”

One big reason why healthcare IT is still going so slowly: the joys of a market economy.

Often, the cost savings from the use of technology don’t go to the owner of the technology but to another player in the healthcare system, like the insurers.…A CIO at a for-profit company would have a hard time getting approval for an IT investment that saves money for the industry but not for the company.

“The incentives [in healthcare] are not aligned at all. In fact, there are perverse incentives there,” Stettheimer points out. “That’s very simplified, but it’s a problem we need to overcome.”

In the words of lobbyist Lauren Maddox, “The policy process is an extension of the market battlefield.”

The answer is not necessarily found in broader or stricter “ethics rules” barring specific gifts to politicians. Such rules may have little effect and will not, on their own, restore public trust. Instead, we need to consider how to prevent high-stakes market competition from intruding on political decision-making, to create what might be considered “safe zones” where the market has no influence.

I don’t have a problem with the changes Reich wants to make — public financing, slowing down the revolving door between public service jobs and corporate jobs, etc. But wishing for “safe zones” makes about as much sense as wishing for unicorns (or safe zones patrolled by unicorns).

Take the last healthcare fight. Reich writes:

Doctors squabbled over whether primary-care physicians would get a Medicaid payment boost or a somewhat smaller boost would go to all doctors. Insurers that specialize in higher — cost plans mainly going to unionized companies squared off against those specializing in plans that cater to lower-wage workers on whether taxes should be raised on high-cost plans and at what level the tax would kick in. Middle — sized companies fought against small employers over the size of businesses that will be exempt from the requirement of insuring their employees. And on and on.

Many of these battles continue but have moved into the regulatory process, where different companies, sectors, and industries are seeking rules that advantage them and disadvantage their competitors.

As opposed to when? The only reason we had any chance of a real debate this time is that the Godzilla of the medical world, the AMA, had its monopoly of power broken by the insurance companies a few decades ago. Case in point: from the New York Times in 1965.

The American Medical Association said today that it was placing an advertisement in 100 newspapers to make its position clear on its opposition to health care reform. The advertisement calls health care reform ‘the beginning of socialized medicine.’

What was the AMA trying to nuke? Medicare.

Healthcare is a particularly good case because even if, for example, somehow you magically created a public debate “safe zone,” Big Pharma would still have plenty of indirect influence over it. Remember this charming story from the New York Times last year?

A growing body of evidence suggests that doctors at some of the nation’s top medical schools have been attaching their names and lending their reputations to scientific papers that were drafted by ghostwriters working for drug companies — articles that were carefully calibrated to help the manufacturers sell more products.

I’m not arguing we couldn’t rein in some of the insanity. But it’s ridiculous to that we can treat market power like it’s a stain on public discourse.

In fact, I think this denial makes the problem worse. By pretending that power isn’t an inextricable part of the economy, we undermine building support for the real solution — insuring everyone has a real say by creating Checks and Balances .

1. Strives for full democratic participation.

2. Builds capacity for a truly sustainable infrastructure and green economy.

3. Creates and share “green” wealth.

The rest of the report shows how groups around the country are fighting for this vision.

Take Harlan County, Kentucky. You probably know about the environmental devastation caused by strip top mining. At the same time, most folks in Harlan County are in a no-win situation.

There are few employment alternatives to coal-related jobs, even as coal employment in Kentucky is a third of what it was 30 years ago, largely due to the increased mechanization of the industry. Large absentee landlords and local land-owners are unaccountable to new forms of economic development. The local elite maintain tight control over politics, commerce, and public life in this region.

But folks are fighting back, in part through a statewide organization called Kentuckians for the Commonwealth (KFTC).

In Benham, a coalition made up of KFTC and the Mountain Association for Community Economic Development (MACED) is exploring a range of “green,” renewable energy sources. In addition to wind power, potential exists for micro-hydro power, utilizing the creeks that run through the towns, and small-scale solar energy. The coalition’s efforts are informed by two reports from the Massachusetts Institute of Technology: one on models for developing locally owned wind power and a second on viable strategies for local renewable energy and energy efficiency improvements. As the mines “write people off,” with job elimination that trigger growing desperation and anxiety, Harlan County KFTC leader, Carl Shoupe, a retired, disabled third generation miner, realizes that this moment is a “critical time” to take action.

In San Diego, the Environmental Health Coalition is also fighting to create a just, green economy for all. Last year, it

successfully blocked the expansion of a fossil fuel power plant in Chula Vista, California, where over 80% of residents are people of color and 16% of all residents fall below the poverty line. This proposed plant expansion would have more than doubled the size of the existing plant…. It would have been sited 1,300 feet from a local elementary school and only 350 feet from the nearest home in that community.

In fighting against the plant expansion, which blatantly violated the town’s general plan that EHC spent two years working to pass, EHC didn’t just argue against the plant. They won in part because they proposed an alternative vision of the future.

They drafted a detailed energy plan that described the rationale and benefits for alternatives such as solar arrays on rooftops and parking lots, repair of transmission lines, and improvement of residential energy efficiency. EHC also provided expert testimony and analysis showing that these options were not only feasible and cost effective, but could provide three to four times the energy that the proposed plant would provide.

Similarly, in New York City, WE ACT has been fighting for years to take on pollution in their neighborhood.

Five out of six public transit bus depots on Manhattan are located in the brown and black, low-income communities of Northern Manhattan. For the most part, these bus depots are situated close to apartments, schools, playgrounds, and senior centers. Inundated by toxic diesel pollution, residents suffer some of the highest rates of childhood asthma hospitalizations in the nation, and disproportionately high levels of other respiratory illnesses and heart disease. Northern Manhattan’s cancer and child-asthma rates exceed area, state, and national averages….

Years of advocacy by WE ACT for Environmental Justice (WE ACT)2 and other partners have certainly helped lessen the toxic burden of these transit depots. Their coalition work has resulted, for example, in the conversions of 400 diesel buses into compressed natural gas buses, and another 900 into hybrid electric buses. But WE ACT’s environmental justice efforts go well beyond these near term mitigations.

For example, after many years of community pressure, NYC’s MTA decided they would rebuild a Lower Manhattan bus depot that handles 120 buses a day. WE ACT trained folks in the community “in the principles of green building and the science of sustainability,” and now they are working with the MTA to create a truly green depot, including features such as “a green roof, air pollution controls, energy efficiency, and gray water reclamation.”

The report also highlights how some groups who began by fighting for economic justice have broadened their vision to for a just, sustainable economy. In Miami, in 2001 “the Miami Workers Center (MWC) sought to prevent the demolition of low-income housing developments in Liberty City,” eventually forcing developers to build units that were affordable for everyone who lived in the development. As part of their experience in that fight, now one of their main goals is “to deepen community involvement in the redevelopment and green design process.”

In early 2008, MWC collaborated with US Green Builders to host a community design competition, called a charette, of the Scott-Carver site. These charettes have served as a popular education piece for residents, and MWC members and have helped the wider community understand the connection between environmental and racial justice….

Poinciana Industrial Park, a mostly vacant industrial site that for three decades was supposed to have brought economic development and opportunities to the black community. MWC is helping policy makers and developers understand the value of turning that Park into a “green enterprise zone” that will host small to medium scale green businesses. In its attempt to reframe conventional “green” discourse, MWC uses the term “Community Driven Green Industry” to describe the public, non-profit, and private sector ventures that create environmentally friendly products and services that also generate long-term living-wage jobs at all skill levels. As Benford explained, MWC “really need[s] to drive consciousness of what kind of development we need to be focused on,” given Miami’s track record of pursuing “shallow” development versus wealth-generating development.

And in LA, home of the highway car chase, last year the Labor/Community Strategy Center helped create Transit Riders for Public Transportation, a network of 11 groups across the country fighting to “bring environmental justice and civil rights priorities to the upcoming federal surface ransportation act—whose budget is estimated to be at least $500 billion.” Eric Mann, the Labor/Community Strategy Center’s Director, argues that

a strong investment in public transportation can create real green jobs (defined as jobs that reduce fuel emissions, and provide sustainable, long term employment with promotions potential for minority populations).

The Labor/Community Strategy Center estimates, for instance, that 7,000 green jobs could be created for every 1,000 buses built. For every 100 buses, they estimate that 300 drivers could be hired to enable buses to run round the clock. Jobs in clerical work, cleaning and maintenance, bus mechanics, and bus construction would also be created…

“a mass transit system that prioritizes the needs of the most transit-dependent communities can serve the needs of all. The process of getting people out of their cars can begin now, not after manufacturing 200 million electric cars or after constructing a multi-billion or trillion dollar new rail project, or after transitioning to a clean electricity grid 20 years from now.”

You can read more about these organization’s struggles and their vision of a better future for all in the Environmental Justice and the Green Economy report. If you or your organization wants to endorse their Vision Statement, check out http://ejstimulus.wordpress.com/selected-list-of-endorsers/

But then I thought about the nasty pothole I try to avoid while getting on the freeway ramp to work (unfortunately, public transit to my latest job is dismal). Almost every freakin’ day it gets on my nerves. So do the drivers who, in an effort to spare their axles, make incredibly stupid, last-minute maneuvers. If I had the chance to rid myself of that jarring irritation at the start of every day, I’d vote that sucker off the asphalt island in a second.

And knowing that I and my neighbors had the power to make that call? I’m ashamed to admit, it would mean more to me than getting to vote for my city council rep. Except when my Councilperson does something really awful, I don’t pay that much attention. I know, bad, bad me. But I’ve only got so many minutes and brain cells to spend every day, and DC’s city government feels like the weather — there’s not much you can do about it but complain. It feels too far away, too removed from my daily life. And the amount of work it would take to have a real impact feels overwhelming.

But voting on that pothole? It feels real — a victory in the daily battle against life’s small irritations.

Similarly, I’m sure my city council rep has voted to create a community garden or two in our district. But if I were the one doing the voting — and therefore meeting my neighbors who were pitching it — I’d feel a real sense of ownership. If my neighbors’ and my votes gave the green light to that community garden, I’d check it out once in a while to see the results of our small exercise of power. Even if I never put seeds into the earth, I could look at it and say, I did that.

In turn, that small exercise the power might change the way I think about DC’s government. The $1.3 million budget I’d vote for is a drop in the city’s bucket. But if I had a real say over it, I might start paying more attention to where the rest of my city tax dollars were going. And now that my neighbors and I had taken smaller actions together, taking action together on a slightly bigger stage might not feel so overwhelming.

What does this have to do with healthcare reform? Polls have consistently shown that one of the biggest long-term obstacles to reform is that most folks don’t trust the federal government. They may vote for their senator and for Obama or McCain, but they don’t believe they’ll have a real say or that their needs will get met. We can probably get out of this mess by delivering more victories like the half-asked-but-way-better-than-status-quo healthcare bill. But taking small steps that hand back direct power, even if it’s just over potholes, could also make a real difference.

For example, one of the most important players in the fight for high quality health care for all that doesn’t bankrupt us is Medicare. Medicare solicits lots of “community input” through public hearings, etc. Right now, Big Pharma and other big players still win hands down because the rest of us are checked out. But if more folks had a real say over their community’s potholes, progresses might convince them it’s worth fighting to give everybody a real say over their community’s medical procedures. Even in small doses, hope can do amazing things to the body politic.

Maybe potholes and speed comps aren’t so mundane after all.