George Lakoff makes a good point here —

Health means life. If you get a major illness or injury and cannot get it treated adequately, you could die. And tens of thousands do.

Health means freedom. If you have a serious illness or injury and cannot get it treated, your freedom will be limited in many ways. Your physical freedom: you may no longer have the freedom to move around. Your economic freedom: you may not be able to work or your medical bills may impoverish you. Your emotional freedom: you will not be free to live a happy life.

Too many of us have, to one extent or another, bought into the libertarian fallacy that only government interferes with “freedom.” Probably nothing (next to being dead) reduces personal freedom more than an impaired brain or body. After that comes poverty, which reduces your choices and dictates you spend your time doing whatever you have to do to survive.

The most egregious example of non-freedom in American history, the institution of slavery, was not conducted by government. It was protected by government, but only because slave-owning citizens demanded that their “property rights” be protected.

A couple of days ago David Herszenhorn of the New York Times asked two people — Joseph R. Antos of the American Enterprise Institute and Jacob S. Hacker of Yale University who (I think) first suggested the public option — the simple question, why does health care cost so much? Although their answers differed, as Herszenhorn said they both boil down to “normal market forces mostly break down in the American health care system.”

There is a mega-question about whether “market forces” could ever create a sane health care system. There is no place on the planet where 21st century health care is being delivered by a “market driven” system, so any answer we come up with is entirely theoretical, but I say no. However, I’m going to put that question aside for now.

Something else struck me about the two answers that Herszenhorn didn’t discuss. It seems to me that Antos’s response was bristling with attitude about “entitlement” — a word he used twice — whereas Hacker was more dispassionate. Although I agree with some of what Antos said, the implication that patients are somehow being greedy or “demanding” by seeking the best health care they can get is, to me, disturbing.

And then conservatives are always the first ones who start screaming about “rationing” when anyone discusses the best allocation of our finite health care resources. Go figure.

Then Herszenhorn says,

One reason, as mentioned previously, is that people like to live and be healthy. There seems to be no upward limit on the amount of money that most people would spend toward that goal (as evident in the number of medical-related bankruptcies in America). And that, of course, puts the purveyors of health care at a distinct advantage over the consumers of health care.

I’m sorry I don’t remember where I read this — will the author please stand up? — but somewhere I read that health is different from other things we insure because there is no limit to the monetary value of life. If you insure your car, the most the insurer will ever have to pay is the replacement value of your car (overlooking the medical liability aspect of car insurance, which really is a health care problem). Same thing with your house, or other possessions.

But what is the “replacement value” of a life? People facing death generally will pay any price to keep living a little longer. Same thing with chronic pain or physical impairment. And, in a culture that is supposed to value individuality, there shouldn’t be anything wrong with that. Of course people want all the expensive, cutting-edge gizmos anyone ever invented to extend their lives and the lives of people they love.

The idea that one should live or die based on whether you’ve got the money to pay for health care should have no place in an egalitarian society. If thinking that way is “socialism,” then call me a socialist.

But this also, seems to me, points to the ultimate reality that the private insurance model is an inadequate, and even irrational, way to provide for a nation’s health care.

It also points to the ultimate reality that of course “market forces” will break down when you’re talking about something that is beyond ordinary monetary value. Because there is no limit to the value of a life or the quality of a life, “market forces” always will break down trying to provide for life and health. How could market forces not break down, unless everyone agrees on the monetary value of what is being marketed?

I probably find this more interesting than most of you, but I wanted to call attention to this article in the New York Times by Judith Warner on antidepressants. This week a study on Paxil and imipramine said the antidepressants worked no better than a placebo on people with mild or moderate depression. Lots of studies have said this. However,

Antidepressants do work for very severely depressed people, as well as for those whose mild depression is chronic. However, the researchers found, the pills don’t work for people who aren’t really depressed — people with short-term, minor depression whose problems tend to get better on their own.

There is a regular cult of people trying to get antidepressants banned because they believe them to be dangerous and fake and just a scam for the pharmaceutical industry to make money. And one of the arguments I hear is about all the studies that allegedly have shown they don’t work any better than placebos.

Warner goes on to document that, in America, people with clinical depression are more likely to be undertreated than overtreated.

This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or finding care that is ineffective.

James Oliphant writes in the Chicago Tribune that the mandate is being opposed by many progressives as well as most conservatives. The article does a good job of presenting both sides of this argument. Here’s part of the pro-mandate argument:

The justification for the mandate seems simple: It reflects the basic concept underlying all insurance. A large number of people pay relatively modest premiums, creating a pool of money big enough to take care of those who need help. Having people of all ages participate is especially important with health care, analysts note, because the medical problems that result in big claims are found disproportionately in middle-aged and older Americans.

If younger, healthier people go without insurance, premiums for the others would be driven higher.

The objection is that, especially without the public option, people are going to be forced to purchase increasingly unaffordable insurance and thereby enrich the insurance industry.

To which the pro-mandate side might respond that insurance is becoming increasingly unaffordable as it is, and those who go without insurance not only put themselves at terrible health and financial risk, they are also driving up the cost for everyone else, because health care bills that are paid get jacked up to pay for people who can’t pay.

As it is, there is some incentive for young and healthy people to get insured, because once they have a pre-existing condition they may not be able to purchase insurance. However, under the current bill, beginning in 2014 insurance companies will no longer be allowed to refuse to take a customer because of his pre-existing conditions. This would make it a lot easier to just put off getting health insurance until one begins to need health care beyond an annual flu shot.

But that would be a disaster for the people who are paying for insurance, because if younger, healthier people are not paying into the risk pool, there are more claims against fewer dollars. And the cost of insurance goes up.

There is a real concern that people are going to be required to buy policies they cannot afford. However,

Under the Senate bill, all a person would have to do is pay $750 per year or 2 percent of household income, whichever is greater, in order to avoid the mandate. The House penalty is slightly higher. (This difference will be worked out in negotiations this month.) …

… Linda Blumberg of the Urban Institute says much of the public’s resistance stems from still-sketchy details about how the new insurance exchanges that would likely be established for those without job-related coverage would operate. People who earn just over 100 percent above the federal poverty line would become eligible for Medicaid — and those up to 400 percent would qualify for federal subsidies.

I would like to see Medicaid expanded even more, and I would like to see more subsidies, and that may be something we should work on. But killing the mandate is un-progressive, IMO. And yes, with single payer this wouldn’t be an issue. And if I had the money I’d move to a penthouse on Park Avenue.

See also Nate Silver.

To get an idea why health care costs are insane, check out this article from the Sarasota, Florida, Herald Tribune. A boy banged his head on a bookcase during a pillow fight. The scalp laceration wouldn’t stop bleeding, so his mother took him to a hospital emergency room. A doctor took a quick look at the boy’s scalp and closed the superficial wound with one small staple.

“The doctor came in for all of five seconds, said he needed a staple, and then told us to go to a pediatrician to take it out,” Tobio said. “We saw the doctor for three minutes total.”

The bill: $1,654.

The boy’s mother wanted to know how one staple cost $1,654, so a reporter, Anna Scott, contacted the hospital to find out. It turns out the staple itself, the staple gun used to apply it, a bandage, and a topical anesthetic cost $274. The gun holds 35 staples, but it can be used only once even if only one staple is used. Then it is thrown away to avoid spreading infection. Whatever happened to sutures?

Note this part:

The staple is helping pay for about $60 million the hospital loses every year from people who are uninsured or cannot pay for treatment, said the hospital’s chief financial officer, David Sullivan.

When the hospital staff says the staple costs $274, they are accounting for the fact that they only receive, on average, 30 cents for every dollar they charge. That includes deals brokered with private insurance companies, too, deals current health care bills do not propose regulating directly.

I keep harping on this, but it’s obvious to me that — within the confines of the current health care reform bills — getting costs hauled back into Reality Land requires getting as many people insured as possible. I fully appreciate that paying for insurance can be a real hardship. I’ve been there. But what’s happening is that people who aren’t insured are running up bills that are being paid by people who are insured, which is one reason why insurance costs so much. Getting more people insured — especially more younger and healthier people — should help. That’s why I support mandates.

The doctor’s charge to do the stapling was $951: $480 for the visit and $471 to repair what the bill calls “a superficial wound.” … Because hospital doctors are usually private contractors, the hospital does not control what they charge.

Now, I suspect the doctor has to jack up his charge for the same reason the hospital does — he doesn’t always get paid for what he does. But I’ve read in several articles that hospitals that pay physicians a fixed salary do a lot better job of keeping cost down, at no loss of quality. However, I suspect that’s the sort of thing we probably can’t do much about until we get closer to a single payer system.

After a few seconds of medical care, the boy’s mother spent about an hour filling out forms. A recent PriceWaterhouse study found that $210 billion is wasted each year on medical paperwork, mostly having to do with insurance. I believe there’s a provision for uniform insurance forms in the House and Senate bills.

In the case at hand, apparently when the boy smacked his head his pediatrician’s office was closed, so the mother took him to an emergency room. That’s what uninsured people do, of course, which is the most gawd-awful cost-inefficient way to provide health care possible, because emergency rooms have horrifically high overhead. A system of neighborhood walk-in clinics for non-critical medical problems would provide care at a lot lower cost.

For his vote on the Senate bill, Sen. Bernie Sanders got an increase of $10 billion in funding for nonprofit community clinics to provide basic health care and pharmacy services, billing on a sliding scale. For this, lots of progressives blew up in outrage and threatened to campaign against him in the future.

And that’s the story of the $1,654 staple.