Efficiency in the health care market: A short treatise on a perplexing paradox (by Skylanda)

On any given day, you can hear talking heads on a dozen sides of the health care reform debate arguing about which version of health care delivery is the most efficient. Many lay claim to this holy grail of financing, they cannot all be right, so who is doing the truth-telling and who is doing the lying?

“Efficiency”, like many jargon-able phrases, has different meanings to different people who use the word. In classical 101-level economics, efficiency is a market phenomenon that happens when you allow an unfettered entry of buyers and sellers to a common exchange. Demand and supply sort themselves out to some sort of equilibrium, and a movement of goods occurs at a point where the maximum possible number of buyers and sellers are happy with the outcome – a mechanism essentially mediated by price. This is a dynamic process, with price rising as a good becomes more popular and sellers can demand more compensation (concert tickets on the day of a sold-out show, plywood and flashlights on the day a hurricane rolls through town), and price dropping as surpluses flood the market or goods lose the cache to drive high price (disco shoes circa 1980, manual labor in the era of mechanization). Though this kind of efficiency by no means makes everyone happy, it is one way to reach maximal contentment with minimal interference and to drive supply in accordance with demand. (This model harbors a wealth of flaws when applied to health care, but set those aside for a moment.)

“Efficiency” in the health care world has taken on a life of its own, and in looking at the cross-purpose uses of this word, we can start to understand why so many sides of the debate lay claim to this distinction – and while none of them are exactly lying, how we can use a better understanding to pick which of these sorts of “efficiencies” actually align with reasonable health care systems.

On one hand, one could reasonably use the term “efficiency” to describe how much of a system’s health care dollars go into actually health care, versus how much goes into overhead, upkeep, and general bureaucratic usage. To give you a sense of the norms, Britain’s National Health Service runs a usual overhead rate of about 5%. Medicare – America’s near-universal program for insuring retirees, run by the much-maligned US government – comes in at a spectacularly low 3% overhead rate. In both of these notably “socialist” programs, 95% or more of the cash flow runs straight to actual health care.

Private for-profit insurers in the United States routine run an 80-20 split: 80% to actual health costs, 20% to overhead and other costs. By any measure, for-profit US insurers are an entire digit less “efficient” than the universal insurers in any other developed country. Shocking, no?

Well, maybe not. Because it depends on your actual goal when you define the term “efficiency.” In the very succinct words of TR Reid in his eminently entertaining jaunt through comparative health care economics, The Healing of America:

“It’s revealing that, in the lingo of the US health insurance industry, the money paid to doctors, hospitals, and pharmacies for treatment of insured patients is referred to as “medical loss.” That is, when health insurance actually pays for somebody’s health care, the industry considers it a loss. (Health insurance executives explain that “loss ratio” is a technical term borrowed from the fire and casualty insurance business.) Insurance executives, securities analysts, and the business media carefully watch each company’s medical loss ratio to make sure that the actual medical payments don’t eat too deeply into administrative costs and profits. If a health insurance company consistently spent much more than 80 percent of its money on actual health care, its stock would plummet and its CEO would be axed.”

If your goal is health care, 3% overhead is a remarkable feat of efficiency. If you goal is profit – as it is for the bulk of American coverage providers – efficiency is measured not in low overhead, but in low outlay toward “losses” – losses that, for Medicare or the NHS, add up to a whomping 95-97% of their budget. This view of efficiency (maximizing profit, minimizing unnecessary losses) would ring true for a car manufacturer, a legal services office, a retail clothing outlet – why would it be any different for a commercial insurer? Read from this angle, the American private health insurer is a star of efficiency, wringing a spectacular profit out of an industry in a manner achieved in no other developed-world nation. And incidentally, along the way, creating the most expensive health care system with some of the most notably mediocre outcomes in the developed world.

By looking through these opposing lenses, we can start to see how both the universal-coverage proponents and the free-marketeers both claim the mantle of efficiency. The question then simply becomes which kind of efficiency we want: the kind in which the cash flow through the health coverage system is maximized for health, or the kind in which the monetary investment in the health insurance industry is maximized for profit? This is a question of both desired outcomes and moral fiber of a nation. It is a question that is currently being answered for us in a variety of ways, but which behooves us to step up to the plate and take a brave stab at answer for ourselves.

Now let me put a third spin on the definition of “efficiency” – or in this case, inefficiency. Outside of the hallowed halls of academic economics and the somewhat shadier halls of the for-profit health insurance business, there are the busy and chaotic halls of your local hospital and clinic. On ground zero of the coverage debate – where physician meets patient – a different version of inefficiency arises, one that has little interest in actuarial tables and national policy and theoretic curves of supply versus demand. This is a nebulous, harder-to-define inefficiency, along the lines of how a famous person once described pornography: “I know it when I see it.” It goes like this:

On an average day, I see a certain number of patients, treat their complaints, send them on their way. And then I take a deep breath and dive into the hours of paperwork generated every day by the intentional hoops, denials, and obfuscations created by a system fractured into competing for-profit insurers. These hours are spent completing prior authorizations, appealing denials, cooking up secondary codes when insurers don’t want to cover diabetic blood tests under the code for “diabetes.” Hunting down lists of approved drugs only to receive a fax back declaring the medication chosen was actually not on the approved list, then filing a prior authorization, and then receiving a fax back declaring that oops, it actually was on the list to begin with. Memorizing arcane grids of which labs work with which insurance agencies, and remembering to choose the purple tube or the green tube before performing basic tests (and calling patients back for repeat testing if by chance I pick the wrong one, or they change insurance carriers in the interim). Fielding calls from panicked patients that a test that should have been covered was not. Fielding calls from angry patients that three weeks into a request, we still have no answer on a prior authorization. Fielding mystified looks from patients who legitimately ask, “Will this be covered by my insurance?” when the answer from me is that I have no way of answering – not only because I cannot memorize some thousands of constantly-changing benefits packages, but because if I hazard a guess, I know I will be held to it. This sort of inefficiency may not be well-theorized by the economists and financiers, but it perhaps the one that most affects your satisfaction with your health care. It is driven – both intentionally and not – by the multiplicity of insurers and the drive to deny services and maintain that 80% maximum outlay toward “medical loss,” as the insurers call it (or “health care” as the rest of us call it).

This is the soul-grinding inefficiency that makes so many primary care doctors want to flee the business altogether. It is also a rankly understated part of the reason why health care is so expensive in the US: not only are private insurers routinely skimming 20% of the health care dollars that pass through their hands, almost no model I have ever seen accounts for direct patient care time lost to the demands that insurers place on doctors. I could see several more patients per day at the same salary were it not for the trail of paperwork each leaves behind - sometimes several-fold the actual face time spent with a patient. This is time that increases insurance company profits at the expense of decreases physician income per hour - essentially, unreimbursed time providers spend working on behalf of the profit interests of insurance companies. And with delays, uncovered costs, and a thousand other annoyances small and large, this contributes mightily to the soul-grinding inefficiency that makes so many patients so dissatisfied with their primary care experience.

Single-payer (or at least more tightly regulated) systems remove a large part of this latter inefficiency by offering more uniform benefits packages that physicians might reasonably be expected to master, by forcing ancillary services like labs and imaging centers to utilize less fractured logistic practices, and ultimately by making the goal of health care to take care of people rather than to deny services. And therein allowing physicians to do what they do best – practicing medicine – instead of do what we usually do worst: push paper.

Cross-posted from my recently relocated and re-launched blog, America, Love it or Heal It. Of note, much of the background information for this discussion is derived from TR Reid’s most impressive The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care – which tackles the usual dry topic of comparative health economics in a most enjoyable format. This should be required reading for any non-expert interested in the problem of health care reform, and I highly recommend it for anyone interested in understanding the different formats of single payer/universal coverage around the world and at home.

Honoring Wangari Maathai (by Jan Cottingham)

Wangari Maathai died last Sunday, and I've been coaxing a good friend of mine, Jan Cottingham, to write a little about her experiences. -- Suzie

Wangari Maathai was the same person talking to a poor Kenyan farmer as she was with the chairman of the Norwegian Nobel Committee or the chairman of the largest chain of newspapers in Japan. I saw her in those situations, but I'm sure her manner extended to heads of state. She treated everyone with dignity and kindness.

She was also the rare person, not to say public figure, who was the same in private as in public.

She was brave, smart, kind, honest -- whatever adjectives that denote goodness she was. She was also nobody's fool. We tend to equate goodness with naivete. Wangari Maathai was not naive. She was a good judge of human nature, and clever and cunning and outspoken when she needed to be, though, to my knowledge, never cruel.

Wangari Maathai was the finest person I've ever met.

I write "met," rather than knew, because it would be presumptuous of me to say I knew her well. I interviewed her in July 2005 for a profile for a magazine I edited. The magazine was published by a U.S.-based international nonprofit. When I left the nonprofit, I worked for "Prof," as Wangari's daughter called her, for four months or so as a freelancer, helping handle communications for Wangari and her nonprofit, the Greenbelt Movement.

She was "Prof" because she'd been a university professor. I didn't feel comfortable calling a Nobel Peace Prize laureate by her first name, and Prof was a good alternative. For she was, at heart, a teacher. She taught people how to plant trees for food and profit as well as for the environmental benefits they provided.

Prof also taught that we must be kind to the earth, we must love her. And she taught democracy and human rights, particularly women's rights. A scientist by training, she saw the whole of things.

She was the first environmentalist to win the Nobel Peace Prize and the first African woman to win it. Prof was a lot of firsts, including the first East African woman to earn a doctoral degree.

She overcame many obstacles to achieve her firsts. She came from humble circumstances, if not poverty. She was an African girl born in mid-century Kenya, and girls just didn't go to school. But her brother urged her parents to educate Wangari because she was so obviously bright and curious. Prof always mentioned that brother, her advocate, with love because he had fought for her.

Her memoir, "Unbowed," is great reading for those who want to know more about her.

And I think everyone should know more about her because her life story is one long lesson in how to live right, how to make the most of whatever gifts you might have and how to use those to lift up others.

Prof wasn't a plaster saint. She demonstrated a sharp sense of humor, and because she was a keen judge of character, she could be wickedly funny and tart about people. She expected people to pull their weight. She had no use for laziness.

I must mention this: I swear by all that's holy that she exuded some kind of golden light and gentle warmth. I have never seen anything else like it, nor do I expect to.

Two last things: 1. Wangari Maathai, daughter of Kenya, had a great soul and showed me what greatness humans were capable of and 2. I loved her.

Today's Dose of Misogyny: The Conservative Take On Elizabeth Warren's Message.

Remember Elizabeth Warren? She is running for Senate in Massachusetts, and in one of her earliest meetings with voters she said the following:

“There is nobody in this country who got rich on his own. Nobody,” Warren said. “You built a factory out there? Good for you. But I want to be clear: You moved your goods to market on the roads the rest of us paid for. You hired workers the rest of us paid to educate. You built a factory, and it turned into something terrific or a great idea: God bless. Keep a big hunk of it. But part of the underlying social contract is you take a hunk of that and pay forward for the next kid who comes along.”

The viral video:





That bothered some conservatives, including Rush Limbaugh. A lot. Glenn Reynolds linked to one response to Warren with obvious approval:

BEST ELIZABETH WARREN PARODY/RESPONSE YET: This was posted by Ashtad Bin Sayyif, but I’m not sure if he’s the original author or just reposting. Anyway, it goes to the core problem. Are you the state’s property, or not?

Here's the bit about being the state's property or not. Click on it to make it bigger if needed:

The way we are to understand this joke is that taxes are like rape or forced prostitution. Or so I was told. So let's take that interpretation seriously.

Are taxes like rape or forced prostitution? Don't you get anything back for your taxes? Like roads, national defense, law enforcement, fire protection?

Aren't we supposed to pay when we buy something?

But sure, taxes do have that obligatory nature. You have to pay them even if you would prefer a world without roads or street lights (or foreign wars paid by you) if the majority decision in your community is to have those services provided by the government.

The obligatory nature is because of that free rider problem: Once the roads and the street lights are there it's really really hard to keep those who did not pay for them from using them. That, in turn, gives people an incentive not to pay if such payments are voluntary, given that they can use the services for free!

But because the same logic would apply to everyone, voluntary taxes would mean that fewer roads would be built and most of them would be dark. So it goes.

None of that has anything to do with my first reaction to the parody piece. To see that reaction, juxtapose these sentences from Warren's original message and the parody piece:

Warren:

There is nobody in this country who got rich on his own. Nobody. You built a factory out there? Good for you. But I want to be clear: You moved your goods to market on the roads the rest of us paid for.

The parody:

There is no woman in this country who got hot on her own. You have a really nice ass and a great boob job? Good for you. But I want to be clear: You got to the gym on the roads the rest of us paid for.

Warren's choice of the pronoun "his" makes this comparison even easier to see as indicating that an inherent aspect of men is their financial property, and that an inherent aspect of women is their sexuality.

Sexuality is compared to a factory. It is something women work to create by having boob jobs and a nice ass which they presumably could peddle for money.

If men are expected to part with their very own money, women should part with their very own sexual capital! Women are in the business of sex, just as factory owners are in some industrial business.

And no, that is not my final reading of the two pieces. The view of women as being sexual entrepreneurs who should be free to do with their sexuality as they wish is not contrasted to men as somehow embodying their financial capital but to all tax payers, including female ones. Nevertheless, my reading goes very well with what I have learned from the mindset of some conservative men who truly think that it's all about money when judging men as individuals and all about sex when judging women as individuals.

The parody is full of misogyny, in any case. It continues by suggesting that American women can keep foreign boobs and asses out of this country by using government-funded services. That helps with the markets for sex and suggests that just by being female all women are sex entrepreneurs. This piece of the parody smells a lot like the misogynist sites which are all about the need to get obedient traditional wives from abroad because American wives no longer obey or cook or clean or spread their legs on demand.

So there it is: The treatment of sexuality (but only for women) as sex capital and the treatment of all women as sex workers. Even if that interpretation was the correct one, it would only result in the argument that sex workers, too, should pay their taxes, just like everyone else.

But the parody does not take that approach. A better parable for what it does is to suggest that anyone who gets life-saving treatment on, say, Medicare, should then be required to donate a spare kidney as a payment for that treatment. Or a spare eye or something.

That example shows more clearly what is wrong with the original parody when applied to financial payments such as taxes. Money is not embodied in us. Requiring that people pay for the collective services is not the same as slavery or rape or forced prostitution.

And whoever wrote that parody is a misogynist.

The golden lining: The more this parody spreads, the worse conservatives will look.
----------
Link to all this by Thers on Eschaton.

Shameless Self-Promotion

I forgot to link to this book review in the Summer issue of Ms Magazine. I was limited by the number of words allowed which made it difficult to state clearly enough that I'm not necessarily opposed to single-sex education as such, just to the reasons the new promoters of single-sex education offer.

Here's an interesting interview of the authors: Rivers and Barnett.

From the Wall Street Protests: The Police As Thugs?

Yes, the protests that the media has tried so hard to ignore. Several YouTube videos suggest that the police is over-reacting. Here is one example:





But this is the one I had planned to write about when I saw it, even before I found references to it in the media:





Here is what the powers-that-be say about the incident:

Raymond W. Kelly, commissioner of the New York Police Department, said Wednesday that its Internal Affairs Bureau would look at the decision by the officer, Deputy Inspector Anthony Bologna, to use pepper spray, even as Mr. Kelly criticized the protesters for “tumultuous conduct.”
At the same time, the office of the Manhattan district attorney, Cyrus R. Vance Jr., has opened an investigation into the episode, which was captured on video and disseminated on the Internet, according to a person briefed on the matter who spoke on the condition of anonymity because the inquiry is continuing.
Inspector Bologna was identified on Wednesday in another video spraying others in the Occupy Wall Street demonstration with pepper spray. Recordings of the episodes show Inspector Bologna striding through a chaotic street scene along East 12th Street, where officers arrested some protesters and corralled others behind orange mesh netting.
Deputy Inspector Roy T. Richter, the head of the Captains Endowment Association, the union that represents the upper echelons of city officers, said Inspector Bologna, who formerly led the 1st Precinct and now works in counterterrorism, would “cooperate with whatever investigative body the police commissioner designates to perform this review.”
Inspector Richter continued: “Deputy Inspector Bologna’s actions that day were motivated by his concern for the safety of officers under his command and the safety of the public. The limited use of pepper spray effectively restored order without any escalation of force or serious injury to either demonstrator or police officer.”
Mr. Kelly said he did not know what precipitated the action, but seemed to offer a justification for it. He said the group was disorderly and “intent on blocking traffic” as it marched on University Place, returning to the financial district, where protesters have camped for more than a week.
While the department’s Patrol Guide says pepper spray should be used primarily to arrest a suspect who is resisting, or for protection, it does allow for its use in “disorder control” by officers with special training.

Others suggest that Inspector Bologna is not a sharp-shooter with the spray, that he aimed it at some other protesters and got the young women in the corral by accident.

I report, you decide...

How Is Health Insurance Like High-End Fashions For Women? On The Costs of Health Insurance.

Answer: It is getting ever more expensive and skimpier and skimpier.

You probably read about what has happened in the last year:

Premiums for employer-sponsored health insurance continued to escalate this year even as the share of workers getting less generous coverage reached a new high, according to survey data released Tuesday.
In 2011, for the first time, half of workers at small firms with individual policies faced annual deductibles of $1,000 or more. In 2006, that figure was 16 percent. At large firms, the share has grown from 6 percent to 22 percent over the same five years.
At the same time, the survey by the Kaiser Family Foundation found that premiums for family plans rose 9 percent in 2011, after several years of slower annual growth. A similar recent survey by the consulting firm Mercer found that yearly premium increases have been hovering around the 6 percent mark and will grow by slightly less in 2012.
Both sources point to the same fundamental long-term shift: Faced with continually climbing premiums, a record share of employers have moved to plans that require workers to pay more out of pocket.
“Without any real national discussion or debate, there’s a quiet revolution going on in what we call health insurance in this country,” said Drew Altman, president of the Kaiser foundation, which conducted the annual survey of employers in conjunction with the Health Research & Educational Trust. “Health insurance is becoming less and less comprehensive. . . . And we expect that trend to continue.”
Employers seem to be turning to cost-shifting as an alternative to dropping coverage outright. During the first half of the decade, the share of companies offering health insurance shrank from 68 percent to 60 percent, and the figure for very small firms dropped from 58 percent to 48 percent. But since about 2005 that decline has leveled off.
Premiums paid directly by workers have galloped ahead of wage increases and inflation — rising 131 percent between 2001 and 2011 for family plans. Employer costs for those plans have gone up 113 percent over the same period, as some have asked their workers to take on a higher proportion of premium costs.
Still, employers are primarily coping with rising health-care expenses by moving their workers into plans with higher out-of-pocket costs such as deductibles, co-pays and co-insurance.

You, the worker, pay more and get less.

Some of these changes can be explained by health insurers trying to get the most out of the current system before the planned changes set in. But the rises mentioned in the quote (a 131% increase in premiums over a ten-year period!) are not unique to the recent past. Health care has not become more expensive simply because everything is getting more expensive; it has been the engine that pulls up the general cost of living. And that is a very important point.

I could write a book, all about why the costs of health care rise so rapidly in the United States. It's easy to say a few basic things about those reasons, much harder to discuss the whole mess in a few sentences.

This is because we can look at the problem from many different angles: Where, when, who and why. Just to begin with, mind you. The overall problem is like a large number of necklaces, all intertwined and knotted. When you try to pull one out, the others may get more knotted. You have to tease them apart, slowly and with care.

But to begin with, let's set certain Rapid-Repsonse-Reactions about health care costs to rest here:

No, it not just the greediness of health insurers which makes the costs rise so rapidly, as many on the left believe.

Neither is it the fault of the government messing with the markets and not allowing them to compete so that prices could come down, as many on the right believe.

And no, it's not just Americans getting so much sicker ("those lazy, fat and greedy buggers who refuse to take care of themselves" argument). Whatever role these explanations might play, none of them is sufficient to explain more than a small part of the rising health care costs.

Where?

One way to look at the health care cost debacle is to ask which parts of the system are most expensive, and this gives us the following list:

First, hospitals, then physician visits, then durable medical equipment. If hospitals and nursing homes are treated together as institutional care, almost half of each dollar spent on health care goes to institutional care.

Looking at that list suggests that the control of health care costs requires that we do something about the cost of institutional care and about the cost of physician visits. Drugs are also expensive, of course, but note that they are not among the top three contenders, and neither have the costs of drugs risen terribly fast in the recent past.

Note, also, that we should not "press one end of the balloon" in trying to control the high-cost products and services. If you press the balloon at one end, gently, it will just inflate at the other end. Likewise, controlling costs in hospitals could simply transfer them to nursing homes or out-patient care without always causing an overall cost reduction. To give an opposite example, it might be a good policy to spend much more on some drugs if that reduces hospitalization. It's the overall savings to the whole system which matter.

When?

The most expensive patients come from two overlapping groups: Those in the last year of their lives and the elderly.

Health care costs are rising both because we live longer and because we can do more to prolong life. But some of those end-of-life technologies are very, very expensive.

The costs of nursing home care rise partly because many more of us live to a very old age, rather than succumbing to a heart attack at sixty-five. In a paradoxical way, leading a very healthy life may not reduce the overall costs to the system, if it means several years of need for medical assistance at the end of one's life.

Who?

This question is my way of asking whether costs rise so rapidly because of something the providers do or because of something the consumers do, or both. I'm ignoring the dance between the two and the rest of the participants, just to keep things very simple.

Let's start with the consumer side.

Most of us are consumers of health care services. What is it about the way we buy them that might push costs up more than in, say, the case of computers or cell phones?

The first thing which comes to mind has to do with the amount we would be prepared to pay for something like life-saving care. Few needing such care will spend time and energy comparing prices and looking for alternative providers, and when it comes to life-or-death, many of us would be willing to pay almost anything for that care.

In other words, the markets for certain kinds of health services have a very low price elasticity, meaning that consumers are not going to exhibit great price sensitivity and are not going to hunt for the cheapest provider (assuming that they are conscious and able to do so).

Add to this the second aspect of the consumer side: The majority of the health care buyers still have insurance. The very existence of insurance makes us less price sensitive: If we are not going to pay the whole bill, we are going to accept higher-cost alternatives more easily.

Those who believe that it is the consumer-side of the market which drives health care cost increases use these two arguments: low price elasticity of demand and widespread insurance, to explain why market competition doesn't seem to result in price competition.

What about the provider side?

Here's where the dance between the consumers and providers matters. Given the nature of the consumer side of the health care markets, what are the best alternatives for the providers? Insured consumers are not going to be terribly price-sensitive, so competing in prices makes less sense than competing in quality.* But increasing quality drives up prices because it drives up costs.

That is, of course, overly simplistic, because a closer look at the supply side of the health care markets reveals an enormous variation of institutional forms, a mix of for-profit and not-for-profit firms and all sorts of different combinations of the two (for instance, for-profit physician firms may use not-for-profit hospitals for their patients).

It is difficult to know whether not-for-profit firms (such as many hospitals) actually try to maximize something resembling profits, and if they therefore try to keep costs down.

These firms are also subject to many government regulations, most having to do with safeguarding the quality of care the patients receive. But some of those regulations can also be used to limit entry to the industry, and that increases the market power of the firms. Firms with market power set their prices higher than firms in a competitive market. And hospitals in some areas are natural monopolies, in the sense that they have no real local competition. The entry of students into the occupations of physicians and dentists is highly regulated and the professions are highly unionized. In short, there are very few parts of the health care industry which look anything like competitive markets.

Those who favor the supply-side explanation point out the market (and labor) power in the industry as a major reason for rising health care costs**. Put in very simple terms, the consumers' expenditures are ultimately the incomes of those who work or invest in the industry. Any successful cost containment will therefore hurt the incomes of some in the current industry.

Why?

That is the sixty-thousand-dollar question. Because of the arbitrariness of the expositional device I have picked, the why-question has already been given many answers. But two which are most important, in my not-so-humble opinion are these:

1. What can be done in medicine has changed drastically in the last one hundred years. These changes have included cost-saving inventions such as penicillin and various vaccines. But in the most recent years medical inventions and innovations have largely been of the kind which increase the costs of care.

Take one simple example: Arthritis in the hip joints. Before hip replacements, most that could be done for the sufferers consisted of cheap pain relief prescriptions.

The hi-tech, institution-centered aspect of medicine is now taken for granted. But it is a very expensive aspect of today's medicine and one of the main reasons why health care costs are rapidly rising.

Inventions and innovations in medicine are not independent of the incentives the system offers. The incentives for quality-increasing innovations are strong in the American system, the incentives for cost-saving innovations are weak. Thus, what researchers focus on is much more likely to increase the quality of care even if that means higher costs.

I also suspect that the traditional paths of research are now yielding rapidly diminishing returns. By that I mean that we are getting ever more expensive inventions which may only bring marginal improvements in the quality of care: An extra month for a terminally ill patient, some marginal improvements in the control of a chronic disease.

The "technological change" is certainly an important part of the answer to the high health care costs puzzle. But it does not suffice to explain why the US costs are rising more rapidly than costs in other countries. For that we need to add:

2. The patchwork approach to health care provision with exactly the wrong type of market solutions.

It is useful to read about the accidental births of many aspects of the American health care system, because it lets us understand why we now have such an illogical patchwork system. Many of those patches were introduced because of tears in the initial fabric. But once the patches were there, they were taken as part of the original fabric, not to be interfered with. Instead, we keep on adding more and more patches:

Keep employment based health insurance (which leaves out those too ill to work, many of those in low-paid jobs and those working for small firms), pick up some of those who are not covered with Medicaid (which depends on the charity of the states and does not cover all low-income people) and institute Medicare for those over sixty-five only. Observe what happens under such a system when costs keep on rising and count the number of the uninsured or under-insured. Estimate the unpaid care that laws require to be offered, observe the continuing drop in the number of the still-insured and weep.

Then fix the system! Except that the fix requires all the old patches to be left in place. All it does is reinforce some of the seams and put down a few new patches. We will still have an increasingly for-profit health insurance industry with incentives to limit care as much as possible, we will still have providers with market power.

Any attempt to define insurance packages in a newly created market will not get around the information problems consumers have:

If all I know is that I'm buying apples and the price per pound, how can I make an informed decision? The apples will be delivered at some point in the future. What if I find I didn't get a pound for every pound I paid for? What if the apples are rotten?

Or in terms of health care, what if my claims are denied?

And health insurers will price their products, if allowed, in such a manner as to attract the young and the healthy and to discourage the old and the sick.

Add to that all the exemptions that seem to be in the works and what you have is a New And Improved Patchwork Health Care Quilt. It will continue to get more and more expensive to maintain.








-----
*On the other hand, some intermediaries on the consumer side, such as large firms buying insurance coverage for their workers, do have price sensitivity and the time and energy to look for better deals. Whether they do so in a way which replicates what well-informed final consumers would do is unclear. I think they might not choose to bargain for prices but accept the skimpier coverage as the easier road to go.
**Micro-level explanations also discuss the incentives that providers are given to either limit costs or not to limit costs, based on how they are reimbursed. The problem with reimbursement systems which encourage cost-containment has to do with the possibility that costs could be contained by cutting necessary care. In general, the problem of informational asymmetry in health care is a huge giant lurking behind this post and the ultimate reason for many of the otherwise-problematic aspects of the system. Providers are so strictly regulated to protect consumers, but that strict regulation does increase costs through its impact on market concentration.

Good News From Saudi Arabia

King Abdullah has overturned the ten-lash sentence a court earlier gave a woman for driving.

The cases of two other women, caught driving while female, are still in the court system, however.

Idle Thoughts on Orgasms and Reproduction

When I was writing those two posts below on female orgasms and their possible evolutionary roots I was thinking what poor things female orgasms are, fickle, hard to achieve, quite unnecessary. Well, I wasn't thinking that way, except that the topic is mostly presented in those terms. As I pointed out there, many women can have multiple orgasms in a row. How that goes with the theory that female orgasms are just a by-product of male orgasms I don't know.

Never mind. We get what is served us. That's why I thought it might be fun to offer some science-fictiony alternatives to the way we humans have reproductive sex. For instance, what would happen if women came into heat once a year, say? How would the world be different?

Would women in heat have long lines of hesitant men walking behind them, stopping whenever she stops, continuing when she does? That's what I saw dogs do when I was a child. The dogs were quite respectful of the bitch in heat, but they were there, just in case she would choose *him*.

It's a fun thought, isn't it? Or would human females under those conditions mate with everyone as often as they could, as chimpanzees appear to do, based on more recent research? How would parenting be arranged in such a world?

Stepping even further into imagination, suppose that we were like the marsupials. Children would be born when they are only few millimeters long, would crawl into that nice pouch and would then complete their growth inside it. I like that idea of giving birth, myself, but I'm not sure how the pouches would work with clothing.

Or we could be egg-layers, hiding the eggs in some nifty place. Would the men sit on the eggs or not to hatch them? Would we write posts about the need to share that task? Property rights to egg-laying sites would probably be a big thing in that world.

A long time ago I imagined a world where men don't produce sperm but pollen. Contraception means using umbrellas or parasols to prevent it from touching the female reproductive organs.

There. I told you these were idle thoughts. And I haven't even gotten to the world where women lay a group of eggs and just walk away.

Was It Good For You, Too, Baby? Or What's The Point of The Female Orgasm. Part 2.

The first post on this topic can be found here.

In this second part I will look at the way a particular study is discussed in Jennifer Abbassi's good write-up:

The schism between the two camps deepened this month with the publication of a new study of twins and siblings in Animal Behavior that seems to rule out the by-product theory of female orgasm. Researchers Brendan Zietsch at the University of Queensland in Australia and Pekka Santtila at Abo Akedemi University in Finland asked 10,000 Finnish female and male twins and siblings to report on their “orgasmability” (their word, not mine). They looked for similarities in orgasm function between female and male twins. If the by-product theory of female orgasm is true, they say, this similarity should exist. Due to the inherent differences in orgasm between women and men, females were asked to report how often they had orgasms during sex and how difficult they were to achieve, while males were asked how long it took them to reach orgasm during the act and how often they felt they ejaculated too quickly or too slowly.

Zietsch and Santtila found strong orgasmability correlations among same-sex identical twins, and weaker yet still significant similarities between same-sex non-identical twins and siblings. However, they found zero correlation in orgasm function between opposite-sex twins. “We show that while male and female orgasmic function are influenced by genes, there is no cross-sex correlation in orgasmic function -- women’s orgasmability doesn’t correlate with their brother’s orgasmability,” explains Zietsch. “As such, there is no path by which selection on male orgasm can be transferred to female orgasm, in which case the by-product theory cannot work.”

Mmm. Did you get it? The answers had some similarities between same-sex siblings and same-sex identical twins and stronger similarities between identical twins. The answers of brothers and sisters or the answers of non-identical different-sex twins did not show such similarity, on average. All this is a roundabout (and common) way of trying to infer that something is an inherited trait, in the absence of direct evidence.

The critical response to the study is fairly obvious:

Lloyd and other proponents of the by-product theory agree that weak selection pressure could be acting on female orgasm, but not enough to maintain it over the eons of human evolution. Rather, if female orgasm bestows any reproductive benefits onto the human race, it would be by happy accident. Unsurprisingly, Lloyd has a lot of bones to pick with the recent study. Comparing different orgasm traits in women and men is a textbook case of apples and oranges, she says.
Kim Wallen, a behavioral neuroendocrinologist at Emory University and frequent collaborator with Lloyd, explains it thus: “Imagine that I wanted to compare height in men and women. In women I used a measurement from the top of the head to the bottom of the foot. In men I used how rapidly they could stand up. Would I be surprised that each measure was correlated in identical twins within sexes, but uncorrelated in mixed-sex twins? Such a result would be what was predicted and completely unsurprising. Zietsch and Santtila have done the equivalent of this experiment using orgasm instead of height.”

It's like comparing oranges and apples, right.

Except that ANY comparison of female and male orgasms might be exactly that, if we adopt a basic theory other than the by-product one. After all, researchers argue that the female orgasm serves functions such as strengthening pair-bonding or finding a high-quality mate, whereas the male orgasm is there just to spread seed. If the two types of orgasm have such different tasks, couldn't we argue that they are inherently different creatures and can never be compared in such simplistic ways?

Then there is this self-criticism by one of the study authors:

Zietsch says he doesn’t have a favorite theory on the evolutionary function of female orgasm, but if forced to guess he’d say that it provides women extra reward for engaging in sex, thus increasing frequency of intercourse and, in turn, fertility. (There’s no proof of this yet, though, as Lloyd points out.) Zietsch continues: “I’ve shown in another paper, though, that there is only a very weak association between women’s orgasm rate and their libido, so the selection pressure on female orgasm is probably weak -- this might explain why many women rarely or never have orgasms during sex.”

My first post talks about the proof that would be required to show a correlation between orgasms and fertility or other outcomes and how difficult finding such a proof would be. But more generally, I'd like to know how studies measure libido.

It seems to me that the concept of libido, even if initially a biological one, has so many cultural over-pinnings that it's pretty much impossible to measure it in some simple quantitative way that lends itself to interpersonal comparisons. But I may just be ignorant.

Then we come to something quite fascinating:

Wallen also points out that previous research has shown that traits under strong selective pressure show little variability, while those under weak pressure tend to show more variability. With human orgasm this bears out in that men report almost always achieving orgasm during sex, while the ability to orgasm during intercourse varies widely among women. (Penis and vagina size – both necessary for reproduction -- show little variability, suggesting they are under strong selective pressure, Lloyd says, while clitoral length is highly variable.) Wallen asserts that Zietsch and Santtila, “chose to compare apples to oranges because the evidence is so strong that men’s and women’s orgasms are under different degrees of selective pressure, the very point they were trying to disprove.” Yikes.

Very interesting. Of course I immediately want to know if the female ability to orgasm is correlated with clitoral length or not. If it is not, the information about the clitoral lengths are of no consequence here. If it is, then I would expect to see lots of studies about that correlation.

The "selective pressure" concept is also interesting. Are we to interpret it here in purely a-cultural and a-historic terms? When, exactly was the selective pressure applied and by what phenomena?

My extreme lay-goddess interpretation of this is that men who couldn't orgasm failed to reproduce much but women who couldn't orgasm did reproduce. This assumes that the male orgasm is necessary for ejaculation. It also assumes that at some point in time there were men who could not orgasm at all.

But what are the reasons for the selective pressure differences? To what extent might they be cultural, caused by the ancient practice of women not having much say over getting married or having sex, say? Or are we expected to abstract away from culture altogether?

This sentence:

...the evidence is so strong that men’s and women’s orgasms are under different degrees of selective pressure...

suggests that the selective pressure differences still operate. That, in turn, brings culture into the conversation.

Suppose*, just for the sake of a thought experiment, that female orgasms really are a happy accident, a by-product of male orgasms in humans. Could it not then be the case that those women who have a biologically lower orgasmic capability will now choose to have less sexual intercourse with men? If it is not much fun, why bother, unless you wish to have children? Many more women today are able to refuse intercourse if they wish than has been the case in the past.

You can see where I am going with this experiment. Any current differences in selective pressures by gender might diminish, if orgasmic** women have more intercourse, on average, than women who do not have orgasms, assuming that "more intercourse" leads to more children.

Yeah, it's a silly thought experiment. But somehow I get a similar flavor from this whole field. We know so very little and speculate so very much. And most everything that is speculated will then be debated in those public rancorous debates.
-------
*I do not have a favorite among the theories discussed in these two posts.
**"Orgasmic" is here defined in the same way as it seems to be defined in the studies Abbassi describes. It is a narrow definition, having to do with a woman orgasming during penis-in-vagina sex. And no, I have no idea if the position must be a missionary one.

Was It Good For You, Too, Baby? Or What's The Point of The Female Orgasm. Part 1.

I know nothing about the evolutionary research into the purpose of female orgasms, nothing. I haven't read the studies or the books and I have not participated in the debate, either.

This is a fun position to be! Because I am going to write on the topic. Many, many writers do exactly that every day, after all. (Nasty, nasty Echidne), and I thought you might like to join me on this virgin voyage into the wonderful world of Female Orgasms: Why Have Them?

You are going to be neophytes with me or the wise advisers, depending on your own knowledge. But in either case you are going to hear the questions I have after reading a very good write-up (by Jennifer Abbassi) of a recent study and the field in general, this one.

So let's put our tourist hats on and grab our guidebooks.

The write-up begins:

There may be few questions of human sexuality more rancorous than those about the female orgasm. Scientists agree that women probably started having orgasms as a by-product of men having them, similar to how men have nipples because women have them. As Elisabeth Lloyd, a philosopher of science and theoretical biologist at Indiana University put it in her 2005 book The Case of the Female Orgasm: Bias in the Science of Evolution: “Females get the erectile and nervous tissue necessary for orgasm in virtue of the strong, ongoing selective pressure on males for the sperm delivery system of male orgasm and ejaculation.” But why we ladies still have orgasms is hotly debated.

Take that very first sentence:

There may be few questions of human sexuality more rancorous than those about the female orgasm.

Why the rancor? We should NOT travel any deeper into the wilderness without thinking about this. Does Abbassi refer to rancor between researchers? Or rancor within the wider society? And why is something presumably scientific treated with such quarreling?

The obvious reason is, well, obvious: If women's orgasmic capacity is weak for evolutionary reasons, perhaps even disappearing (!), then nobody much needs to be bothered about women who have problems orgasming. They just don't have the capacity, and no army of dildos can change that! What a relief. We can go back to talking about sex as sex-for-men, at least as far as orgasms are concerned.

All this reminds me of that old misogynist joke:
Q: "Why do some women have great difficulty orgasming while having intercourse?"
A: "Who cares."

That's a bit exaggerated but not much. No wonder the topic is rancorous: It has strong gender-political consequences without having many obvious (say, health) benefits for anyone.

Then take that second sentence in the above quote:

Scientists agree that women probably started having orgasms as a by-product of men having them, similar to how men have nipples because women have them.

This idea is also an obvious one, and the nipples-example explains it quite well. Except that it does not explain why the same by-product argument wouldn't work with all mammals, say. As far as I know, female orgasms are not that common among animals, though it seems that other primates have them, too. Are male orgasms common among mammals? Nipples on male dogs and cats are. Do female dogs and cats have orgasms? How do we know when an animal is having an orgasm if it cannot communicate with us?

OK. So far we have the theory that the female orgasm is a by-product of the male orgasm, but perhaps not a by-product in general among mammals?

According to this view, men need to orgasm to ejaculate, and women get orgasms as random presents:

Male orgasms exist, it’s widely believed, to encourage men to spread their seed. On face value, it would be easy to say that women orgasm for the same reason: to encourage them to have sex and make babies. But in practice, compared to male orgasm, female orgasm is very difficult to achieve. There's a lot of variation even within individual women, and 10 percent of women never have them at all. And, unlike male orgasm, female orgasm isn’t a prerequisite for pregnancy.

Is it really true that male animals cannot ejaculate without orgasms (orgasms as a feeling of intense pleasure, not as contractions, say)? I have no idea.

And what is it that we assume the alternative state to be in these orgasm debates? For instance, is it a total absence of all pleasure from intercourse, or just an absence of that moment (or many moments) when your toe nails fly to the ceiling and so on? Suppose that intercourse was very pleasurable for men but that they would not have that peak. Would they then stop wanting to spread their seed?

I'm pretty sure that the researchers distinguish between orgasms and sexual pleasure. Do they do this for males as well as females?

Then the bit where the different nature of female orgasm is first defined:

But in practice, compared to male orgasm, female orgasm is very difficult to achieve. There's a lot of variation even within individual women, and 10 percent of women never have them at all. And, unlike male orgasm, female orgasm isn’t a prerequisite for pregnancy.

As I mentioned above, I'm not yet certain if a male orgasm (as a feeling) is necessary for pregnancy to follow.

But sure, female orgasms do differ from male orgasms in various ways. One way not mentioned in the above paragraph is that at least some women can orgasm multiple times in a row. I'm not sure why the multi-orgasmic aspect is omitted here or whether it is usually omitted in these discussions.

Let's move to the other camp of thought. We have met the by-product school. Now we are going to meet Our Own Orgasm School:

So why do women have orgasms at all? There are two firmly opposed camps on this question. The first group proposes that it has an adaptive function in one of three categories: pair bonding, mate selection and enhanced fertility. I’ll break these down. The pair-bonding theory suggests that female orgasm bonds partners, ensuring two parents for the offspring, while mate selection offers that women use orgasm as a sort of litmus test for “quality” partners. The enhanced fertility theory, meanwhile, proposes that uterine contractions during female orgasm help to “suck up” sperm into the uterus.

The by-product camp, on the other hand, claims that female orgasms are to this day an incidental by-product of male orgasm, not an evolutionary adaption. “There’s no documented connection between women who have orgasm at all, or faster, having more or better offspring,” Lloyd says.

Very interesting stuff. Could it ever be the case that male orgasms might also be explained in a more nuanced way like this, too? After all, they might contribute to pair-bonding or finding "quality" partners, too. And of course there's the idea (which I introduce with some trepidation) that women might have orgasms because it increases their likelihood of having voluntary sex.

That there is no documented evidence of women-with-orgasms having more or better offspring wouldn't be that much proof of anything.

Just imagine trying to do a study like that! You'd have to wait until the women in question are pretty old to make sure that they have completed their child births and to have time to measure the "quality" of the offspring, but not wait so long that the women are dead, because then you can't ask them anything.

You'd have to find women who are going to talk to you quite openly about orgasms and such, who have had the goal of having either many children or "high-quality" children and who have not used contraception. Then you have to make sure that the society those women live in allows them complete choice over their fertility decisions, to isolate the orgasm-variable as the decisive one.

I doubt that it could be done.

This completes my first post on the fascinating topic. I'm sure I have asked many stupid questions here. More stupid questions about a new study in the field in the second part.

Today's Action Alert

You may have read the good news that Saudi women will be allowed to vote in 2015. This is great.

However, Saudi women are still not allowed to drive. If they try, they may be sentenced to ten lashes:

It just got even worse. Shayma Jastaniah was found guilty of driving and sentenced to ten lashes as punishment. Shayma, who has an international driver’s license, says she was driving a family member to the hospital.

Shayma’s situation - alone at home with a family member who needs medical attention - is far from uncommon. Another Saudi woman, Najalaa al-Harriri, is set to face trial in a month for driving, not out of defiance, but in order to take care of her children and run basic errands. Unable to drive, women are forced to hire drivers - which can be expensive and dangerous - or rely on waiting for male relatives to find the time to drive them around. The ban is not only a daily inconvenience but it has also exposed many women to financial, social and psychological exploitation by their male relatives and drivers.

You can sign a petition which demands that the charges against these two women be dropped here.

Big Mama Thornton

Singing Little Red Rooster. Via Sidhra.

The Republican Students' Bake Sale. As American As Apple Pie?

Here's a fun idea for a cookie sale:

UC Berkeley student senators voted Sunday to condemn discriminatory behavior on campus - even if done in satire - in response to a Republican student group's plans for an "Increase Diversity Bake Sale," with pastries labeled according to race and gender.
The 19-0 vote, with one absence, came during a special meeting of the Associated Students of the University of California, as the debate over affirmative action reignited in Berkeley.

...

The bake sale - which the Berkeley College Republicans still plan to hold Tuesday - is an effort to denounce a bill now on Gov. Jerry Brown's desk that would allow the University of California and California State University to consider race, ethnicity and gender in student admissions.

...


The Republicans' posting describes five price levels for their bake sale, with pastries described as "White/Caucasian" going for $2, "Asian/American American" for $1.50, "Latino/Hispanic" for $1, "Black/African American" for 75 cents, and "Native American" for a quarter. A 25-cent discount is offered for women.
"If you don't come, you're a racist," the post declares.

Hmmm. Here are my most obvious thoughts on all this:

First, explicit consideration of gender in admissions would probably benefit men, not women, if such considerations are applied to general admissions. This is because women are currently the majority in the university system. That suggests the 25-cent discount should be given to men.

Second, the White/Caucasian category actually benefits under the current admission policies. If the policies were based on nothing but test scores and grades, the California higher education system would take in more Asian-Americans and less from all other ethnic groups, including whites. I grant that most people don't know that whites benefit under the current admission rules. Nevertheless, the price for Asian-Americans should be higher than the price for whites.

Third, what about all the other groups who get "preferential" treatment in admissions? What about athletes, with their scholarships? What about children of the alumni? What about the so-called development cases, the children of very rich parents? How much would they pay for their pastries at this bake sale? A few in these groups get free lifetime pastries.

Finally, and most importantly, comparing higher education admissions to buying pastries fails on several levels.

The most obvious one is that in terms of that bake sale some buyers only have 25 cents, some only have a dollar, and so on. If all the pastries are priced at 2 dollars, then only those who have 2 dollars can buy them. This could be handled through considerations of family income in admissions.

But acquiring a college education is not like eating a pastry. We can all do the latter. Universities test people to see if they can do the former. It's more like selecting people to BAKE the pastries and THEN eat them, and what is used as the signals of the students' abilities ARE affected by their past training.

That, in turn, is affected by their family background, the quality of their schools and their family income. Ethnicity and race, when used in combination with income measures, can capture some of those past training differences. Ignoring them completely will make the system give precedence to those who had most help earlier on, even if their future potential is limited.

One might also argue that having a diverse student body has wider societal benefits. It's a bit like trying to avoid a world where bakeries have nothing but apple pie on their shelves.
-----
I have not read the new bill so I cannot comment on the changes it proposes. This post is about the bake sale, not about the bill itself.

Fraying Decency And False Equivalency

I read Anand Giridharas' piece about the fraying national decency of the United States with rising excitement. Finally, here's someone preaching the Echidne gospel, the hidden one, which is only delivered to my high priestesses and priests! How the real problem with us humans is that inability to keep remembering that, yes, the "other" is also a human being, first and foremost, before being counted as a member of any deplorable sub-group.

He links to an important article which lifts the curtain and shows us what might be behind the convenience of getting our Amazon purchases delivered overnight. And then he writes:

The prevailing American story line right now is seething anger at politicians: that they’re corrupt, or heartless, or socialist, or dumb. But the Amazon story, and many other recent developments, suggest that the problem is significantly deeper.
Far beyond official Washington, we would seem to be witnessing a fraying of the bonds of empathy, decency, common purpose. It is becoming a country in which people more than disagree. They fail to see each other. They think in types about others, and assume the worst of types not their own.

It takes some effort these days to remember that the United States is still one nation.

Yesss, I hiss, and give myself high-fives. And then I read on and collapse.

Because Giridharas goes on to construct false equivalencies of the type so very common in the media these days: Well, perhaps he is a serial killer, but you slapped your neighbor once over a border dispute. You both have lost your decency!

Check it out yourself:

It doesn’t feel like one nation when a company like Amazon, with such resources to its name, treats vulnerable people so badly just because it can. Or when members of a presidential debate audience cheer for a hypothetical 30-year-old man to die because he lacks health insurance. Or when schoolteachers in Chicago cling to their union perks and resist an effort to lengthen the hours of instruction for children that the system is failing. Or when an activist publicly labels the U.S. military, recently made safe for open homosexuals, a “San Francisco military.” Or when most of the television pundits go on with prefabricated scripts to eviscerate their rivals, instead of doing us the honor of actually thinking.
The more I travel, the more I observe that Americans are becoming foreigners to each other. People in Texas speak of people in New York the way certain Sunnis speak of Shiites, and vice versa in New York. Many liberals I know take for granted that anyone conservative is either racist or under-informed. People who run companies like Amazon operate as though it never occurred to them that it could have been them crawling through the aisles. And the people who run labor unions possess little empathy for how difficult and risky and remarkable it is to build something like Amazon.

Can you spot the false equivalencies? I have bolded the presumed losses of decency by those left of the political aisle. The rest of the paragraph describes right-wing losses of decency or something shared by all.

Any attempt to pair them shows the stupidity of trying to find equivalency:

Amazon seems to have been treating some of its warehouse workers like easily replaceable machines, to be used harder and harder until they break and are then tossed on the rubbish heap.

What shall we pair this with? School teachers refusing to have smaller pay, smaller pensions and longer days in order to stop children from suffering? Note that those school teachers are not the owners of the school system, reaping some profit from it but simply workers and not high-earning workers, either.

Or should this be paired with the failure of unions to marvel over the risks and efforts it must take to create a firm like Amazon? Should trade union officers perhaps condone what Amazon is doing with its warehouse workers? Especially when the Amazon workers are not unionized?

Any pairing I attempt results in such false equivalencies.

The only bolded bit that stays has to do with the assertion that many liberals take it for granted that conservatives are either racists or uninformed. It is not paired with anything similar. Perhaps it is intended to balance the Republican audiences applauding when death of others was mentioned? Or the anti-gay remark about the military?

But those are not the proper missing part. That would be something like "Many conservatives I know take it for granted that anyone liberal is either a baby-killer or a parasite sucking on the teats of the government." To omit this suggests to me that Giridharas was trying, hard, to balance the scales of indecency in this country.

But that turns the piece into another he-said-she-said story, and we have plenty of those already.

Fun With Statistics: Barack Obama Versus George W. Bush as Presidents.

Here's an interesting headline from a recent poll:

Majority Rates Obama ‘Same’ as or ‘Worse’ Than George W. Bush

To be fair, the headline is taken from the writeup of the poll by Gallup:

Majority Rates Obama Same or Worse Compared With Bush

The headlines are true, of course. But the reverse headlines would also be true! The data all these are based on are as follows:

When compared to George W. Bush, 43% of the respondents regard Obama as better, 22% about the same and 34% worse. The tricky bit is how to view those three figures. The headline makers chose to add together the last two figures, thus getting the result that the majority rates Obama no better than George W. Bush.

But if we add together the first two figures we get a clear majority (and a bigger one at 65% vs. 56%) which rates Obama better than or same as George W. Bush!

Miraculous, isn't it, how these headlines are picked? (This doesn't excuse Obama's inability to do better than this in a poll. Against Georgie Porgie, of all people!)







A Guest Post by Anna: A Literary Canon of Women Writers, Part Ten: The Eighteenth Century

Echidne's note: Earlier parts of this series can be found here: Part 1, Part 2, Part 3, Part 4 ,Part 5, Part 6, Part 7,Part 8, and Part 9.)


Eliza Haywood (1693 – 25 February 1756) was an English writer, actor, and publisher. Haywood wrote and published over seventy works during her lifetime including fiction, drama, translations, poetry, conduct literature and periodicals. She is a significant figure of the 18th century as one of the important founders of the novel in English.

Haywood’s writing career began in 1719 with the first two installments of Love in Excess, a novel, and ended in the year she died with conduct books "The Wife and The Husband", and the biweekly periodical "The Young Lady". She wrote in several genres and many of her works were published anonymously. There is much of Haywood’s writing career that still remains unknown.

Haywood’s first novel, "Love in Excess or The Fatal Enquiry" (1719–1720) touches on themes of education and marriage. Termed a bodice-ripper by some, this novel is also notable for its treatment of the fallen woman. D’Elmonte, the novel's male protagonist, reassures one woman that she should not condemn herself: “There are times, madam”, he says “in which the wisest have not power over their own actions.” The fallen woman is given an unusually positive portrait.

"Fantomina; or Love in a Maze" (1724) is a short story about a woman who assumes the roles of a prostitute, a maid, a widow, and a Lady in order to repeatedly seduce a man named Beauplaisir. Schofield points out that, “Not only does she satisfy her own sexual inclinations, she smugly believes that “while he thinks to fool me, [he] is himself the only beguiled Person.” This novel asserts that women have some access to power in the social sphere, one of the recurring themes in Haywood’s work.

"The History of Miss Betsy Thoughtless" (1751) is a sophisticated, multi-plot novel that has been deemed the first novel of female development in English. Betsy leaves her emotionally and financially abusive husband Munden and experiences independence for a time before she decides to marry again. "Betsy Thoughtless" represents an important change in the 18th century novel. It portrays a mistaken but intelligent and strong-willed woman who gives way to society’s pressures toward marriage. According to Backsheider, "Betsy Thoughtless" is a novel of marriage, rather than the more popular novel of courtship and thus foreshadows the type of domestic novel that would culminate in the 19th century such as Charlotte Brontë’s "Jane Eyre". Instead of concerning itself with attracting a partner well, "Betsy Thoughtless" is concerned with marrying well, and its heroine learns that giving way to the role of women in marriage can be fulfilling.

These works are widely available in English, and many of Haywood’s early works are available in “Fantomina and Other Works (Broadview Literary Texts)” by Eliza Haywood, Alexander Pettit, Margaret Case Croskery and Anna C. Patchias.

Françoise de Graffigny, née d'Issembourg Du Buisson d'Happoncourt (11 February 1695 - 12 December 1758) was a French novelist, playwright and salon hostess. Initially famous as the author of "Lettres d'une Péruvienne", a feminist novel published in 1747, she became the world's best-known living woman writer after the success of her sentimental comedy, "Cénie", in 1750. But her reputation as a dramatist suffered when her second play at the Comédie-Française, "La Fille d'Aristide", was a flop in 1758, and even her novel fell out of favor after 1830.

From then until the last third of the twentieth century, she was almost forgotten, but thanks to new scholarship and the interest in women writers generated by the feminist movement, Françoise de Graffigny is now regarded as one of the major French writers of the eighteenth century. "Lettres d'une Péruvienne" is available in English as “Letters from a Peruvian Woman (Texts & Translations)” by Francoise De Graffigny, translated by David Kornacker.

Fukuda Chiyo-ni (also known as Kaga no Chiyo) (1703-1775) was a Japanese poet of the Edo period, widely regarded as one of the greatest female haiku poets. She worked in a time when haiku was largely a male domain, unlike today.

Born in Matto, Kaga Province (now Hakusan, Ishikawa Prefecture) as a daughter of a picture framer, Chiyo-ni began writing haiku poetry aged 7. By the age of 17, she had become very popular all over Japan for her poetry. Her poems mostly deal with nature. Chiyo-ni's teachers were two students of Bashō, and she stayed true to his style, although she did develop on her own as an independent figure. At the age of fifty-two Chiyo-ni became a nun, shaved her head, and changed her name to Soen (Simple Garden). She is perhaps best known for this haiku:

morning glory!
the well bucket-entangled,
I ask for water
(trans. Donegan and Ishibashi)

Shokouji temple in Hakusan contains a display of her personal effects. Some of her poems can be found in “Chiyo-ni: Woman Haiku Master”, translated by Patricia Donegan and Yoshie Ishibashi.

Hannah Cowley (14 March 1743 – 11 March 1809) was an English dramatist and poet. Although Cowley’s plays and poetry did not enjoy wide popularity after the nineteenth century, critic Melinda Finberg rates Cowley as “one of the foremost playwrights of the late eighteenth century” whose “skill in writing fluid, sparkling dialogue and creating sprightly, memorable comic characters compares favourably with her better-known contemporaries, Goldsmith and Sheridan.”

Cowley’s plays were produced frequently during her lifetime. The major themes of her plays, including her first, "The Runaway" (1776), and her major hit which is being revived, "The Belle's Stratagem" (1780) revolve around marriage and how women strive to overcome the injustices imposed by family life and social custom. Her works are available in English as “The Works Of Mrs. Cowley, Dramas And Poems,” by Hannah Cowley.

Anna Laetitia Barbauld (1743 – 9 March 1825) was a prominent English poet, essayist, literary critic, editor, and children's author. Barbauld had a successful writing career at a time when female professional writers were rare. She was a noted teacher at the Palgrave Academy and an innovative children's writer; her primers provided a model for teaching for more than a century. Her essays demonstrated that it was possible for a woman to be publicly engaged in politics, and other women authors emulated her. Even more important, her poetry was foundational to the development of Romanticism in England. Barbauld was also a literary critic, and her anthology of 18th-century British novels helped establish the canon as known today.

Barbauld's literary career ended abruptly in 1812 with the publication of her poem "Eighteen Hundred and Eleven", which criticized Britain's participation in the Napoleonic Wars. Vicious reviews shocked Barbauld and she published nothing else during her lifetime.. Her reputation was further damaged when many of the Romantic poets she had inspired in the heyday of the French Revolution turned against her in their later, more conservative, years. Barbauld was remembered only as a pedantic children's writer during the 19th century, and largely forgotten during the 20th century, but the rise of feminist literary criticism in the 1980s renewed interest in her works and restored her place in literary history.

Her complete poems are available in English as “The Poems of Anna Letitia Barbauld,” by Anna Letitia Barbauld, William McCarthy, and Elizabeth Kraft. Also relevant is “Anna Letitia Barbauld: Selected Poetry and Prose (Broadview Literary Texts),” by Anna Letitia Barbauld, William McCarthy, and Elizabeth Kraft.

Charlotte Turner Smith (4 May 1749 – 28 October 1806) was an English Romantic poet and novelist. She initiated a revival of the English sonnet, helped establish the conventions of Gothic fiction, and wrote political novels of sensibility.

Smith was born into a wealthy family and received a typical education for a woman during the late 18th century. However, her father's reckless spending forced her to marry early. In a marriage that she later described as prostitution, she was given by her father to the violent and profligate Benjamin Smith. Their marriage was deeply unhappy, although they had twelve children together. Charlotte joined Benjamin in debtor's prison, where she wrote her first book of poetry, "Elegiac Sonnets". Its success allowed her to help pay for Benjamin's release. Benjamin's father attempted to leave money to Charlotte and her children upon his death, but legal technicalities prevented her from ever acquiring it. Charlotte Smith eventually left Benjamin and began writing to support their children.

Smith's struggle to provide for her children and her frustrated attempts to gain legal protection as a woman provided themes for her poetry and novels; she included portraits of herself and her family in her novels as well as details about her life in her prefaces. She published ten novels, three books of poetry, four children's books, and other assorted works over the course of her career. She always saw herself as a poet first and foremost, however, as poetry was considered the most exalted form of literature at the time. Smith's poetry and prose was praised by contemporaries such as Romantic poets William Wordsworth and Samuel Taylor Coleridge as well as novelist Walter Scott.

But after 1798, Smith's popularity waned and by 1803 she was destitute and ill—she could barely hold a pen. She had to sell her books to pay off her debts. In 1806, Smith died. Largely forgotten by the middle of the 19th century, her works have now been republished and she is recognized as an important Romantic writer. Her work, including "Elegaic Sonnets", is widely available in English.

Frances Burney (13 June 1752 – 6 January 1840), also known as Fanny Burney and, after her marriage, as Madame d’Arblay, was an English novelist, diarist and playwright. Her best known work, "Evelina", portrays the English upper middle class from the perspective of a seventeen-year-old woman who has reached marriageable age. A comic and witty novel, the work is ultimately a satire of the kind of oppressive masculine values that shaped a young woman’s life in the eighteenth century, as well as of other forms of social hypocrisy. Encyclopedia Britannica describes "Evelina" as a "landmark in the development of the novel of manners.” It is available in English as “Evelina (Oxford World's Classics)”, by Frances Burney, Edward A. Bloom, and Vivien Jones.

Phillis Wheatley (1753 – December 5, 1784) was the first published African American poet and the first African-American woman whose writings were published.

Born in Gambia, Senegal, she was made a slave at age seven. She was the slave of the Wheatley family of Boston, though they did teach her to read and write English, and helped encourage her poetry. In 1768, Wheatley wrote "To the King's Most Excellent Majesty" in which she praised George III for repealing the Stamp Act. However, as the American Revolution gained strength, Wheatley's writing turned to themes from the point of view of the colonists. In 1770 Wheatley wrote a poetic tribute to George Whitefield that received widespread acclaim. Wheatley's poetry overwhelmingly revolves around Christian themes, with many poems dedicated to famous personalities. Over one-third consist of elegies, the remainder being on religious, classical, and abstract themes.

Many white Americans of the time found it hard to believe that an African woman could write poetry, and Wheatley had to defend her literary ability in court in 1772. She was examined by a group of Boston luminaries, including John Erving, Reverend Charles Chauncey, John Hancock, Thomas Hutchinson, the governor of Massachusetts, and his lieutenant governor Andrew Oliver. They concluded she had written the poems ascribed to her and signed an attestation which was published in the preface to her book "Poems on Various Subjects, Religious and Moral", which was published in Aldgate, London in 1773. The book was published in London because publishers in Boston had refused to publish the text.

The publication of Wheatley's "Poems on Various Subjects, Religious and Moral" brought her fame, with figures such as George Washington praising her work. Voltaire stated in a letter to a friend that Wheatley had proved that black people could write poetry. John Paul Jones asked a fellow officer to deliver some of his personal writings to "Phillis the African favorite of the Nine [muses] and Apollo." Wheatley also visited England for five weeks accompanying her master's son and was praised in a poem by fellow African-American poet Jupiter Hammon.

Wheatley was emancipated by her owners after both her poetic success and the death of her master, and she soon married. However, when her husband was imprisoned for debt in 1784, Wheatley fell into poverty and died of illness. Her collected work, including her letters as well as her poetry, is available in English in “Phillis Wheatley, Complete Writings”, by Phillis Wheatley.

Joanna Baillie (11 September 1762 – 23 February 1851) was a Scottish poet and dramatist. Baillie was very well known during her lifetime and intended her plays for the stage, not to be simply read aloud, unusual for a woman in those days. Her tragedies had an influence on Edgar Allan Poe, and many of her contemporaries placed her above all women poets except Sappho. She hosted a literary society in her cottage at Hampstead.

Baillie took seriously the power her eminence gave her, and authors down on their luck, women writers, and working-class poets like the shoemaker poet, John Struthers, applied to her for assistance. She wrote letters, drew on all her contacts, and used her knowledge of the literary world either to advise or to further a less well-connected writer. In 1823, she edited and published by subscription a collection of poems by many of the leading writers of the day, in support of a widowed old school friend with a family of daughters to support.

Some of her works are available for free at Project Gutenberg: http://www.gutenberg.org/browse/authors/b#a5598 A book “The Dramatic and Poetical Works of Joanna Baillie, complete in one volume” is also available.

Ann Radcliffe (9 July 1764 – 7 February 1823) was an English author, and considered a pioneer of the gothic novel (although The Castle of Otranto, by Horace Walpole, is generally regarded as the first gothic novel).

Her style is romantic in its vivid descriptions of landscapes, and long travel scenes, yet the Gothic element is obvious through her use of the supernatural. It was her technique of explained Gothicism, the final non-supernatural explanation of supposed ghosts etc, that helped the Gothic novel achieve respectability in the 1790s. Throughout her work traditional morals are asserted, yet women’s rights are advocated for, and reason prevails. Her works also had an influence on Jane Austen, the Marquis de Sade, and Sir Walter Scott. Paul Féval, père used her as his protagonist in the novel La Ville Vampire.

Her works are widely available in English; for example, there is “The Mysteries of Udolpho (Oxford World's Classics),” by Ann Radcliffe, Bonamy Dobrée, and Terry Castle.

Anne Louise Germaine de Staël-Holstein (22 April 1766 – 14 July 1817), commonly known as Madame de Staël, was a French-speaking Swiss author living in Paris and abroad. She influenced literary tastes in Europe at the turn of the 19th century. Her novels were bestsellers and her literary criticism was highly influential, and when she was allowed to live in Paris she greatly encouraged any political dissident from King Louis's regime.

Auguste Comte included Madame Stael in his Calendar of Great Men [sic] and in a book with the same name, Comte's disciple Frederic Harrison wrote about Stael and her works, "In 'Delphine' a woman, for the first time since the Revolution, reopened the romance of the heart which was in vogue in the century preceding.” Her works are widely available in English.

Susanna Centlivre (born Susanna Freeman, also known professionally as Susanna Carroll) was an English poet, actress and one of the premier dramatists of the 18th century. During her long career at Theatre Royal, Drury Lane she became known as the Second Woman of the English Stage after Aphra Behn.

Her plays were so celebrated that many famous actors and actresses of the 18th and 19th centuries won their fame through their performances of her characters; perhaps the best known example is David Garrick who chose to end his acting career as Don Felix from "The Wonder", a role that had previously brought him critical acclaim.

She was lampooned as having a supposedly mannish appearance (among other faults), most famously by Alexander Pope in several pieces, but regardless of her peers’ opinions, her plays would be staged for over 150 years after her death.

Overall, Centlivre was a powerful influence on society as a female intellect and her foundation created another early stepping stone for female writers to continue to push the limits of traditional role as her works allowed for the progress of femininity by establishing the first public thoughts of equality between sexes. Her works are widely available in English.