There are several truths that must be acknowledged before any realistic discussion on health care reform in the US can even begin:

1) Health insurance and health care are two different things. You can have a health insurance policy potentially worth millions of dollars, but if health care providers won’t accept it, or if your out-of-pocket costs before coverage kicks in are prohibitively high, then in effect you have no insurance.

2) Buying insurance is a sucker’s bet if there is no substantial harm in going without it. The very notion of insurance is predicated on assessing and managing risks. The customer’s risk comes with laying out money for fixed premiums, and the insurer’s risk comes with promising to cover the customer’s medical expenses if and when they arise. For insurance to work, both sides must accept those risks; no matter how cleverly you try, you cannot legislate the dual risk dynamic out of the insurance industry. More to the point, you cannot push all the risk onto the insurer’s side by permitting customers to buy insurance only when they desperately need it. A guy whose house is burning down will be eager to purchase fire insurance—but no insurance company will sell it to him. You buy insurance because you think you’ll eventually need a payout, not because you need the payout now; you may end up forking over more than you ever get back, but that’s the risk you take when you pay your premiums. It’s a form of gambling, like poker. You ante up with your premiums. You ante up before the cards are dealt. You can’t look at your cards, and then decide whether you want to be in the game. No ante, no chance of a payout. That’s the penalty for not anteing up in poker. Likewise, there must be a penalty for not carrying health insurance. In a decent society, however, it can’t be a death penalty.

3) Health care is a commodity, which means, like all other commodities, it is subject to the law of supply and demand. Calling health care a “right,” whatever you think that means, does not exempt it from the law of supply and demand; nor does calling it a “right” alter the fact that in a broadly capitalist economy, people who can afford better stuff tend to get better stuff.

The critical question to ask is what we want a reformed health care system to do. What are we hoping to accomplish by reforming the current mishmash? Here, I think, are a few answers:

1) We want to bring down costs for many, if not most, individuals, and we want at least to rein in costs for the federal, state, and local governments who now subsidize, to a greater or lesser degree, health care expenses.

2) We want to make sure that people with pre-existing conditions are not locked out of the health insurance market altogether, yet we don’t want to create a moral hazard that allows people currently without insurance to wait until they’re sick to buy it. Again, there must be a penalty for not carrying insurance.

3) We want to simplify, insofar as possible, the purchase of insurance and the delivery of health care.

4) We do not want to ration care in such a way as to stifle medical research or thwart new and innovative treatments.

So how do we get started?

Step One: Cap malpractice awards nationwide. I can’t tell you exactly what the cap should be, but it should be as low as possible and pegged to the future earnings of victims. No punitive damages; no money for pain and suffering. If you want to increase the number of providers, you need to lower the overhead expenses for those entering the profession and continuing to practice.

Step Two: Increase the number of providers by lowering the credential requirements to provide primary care. You need a create a vast army of “primary care nurses” empowered to examine patients, recommend treatments, and prescribe medications—who do, in short, the same job primary care physicians now do—but who lack medical degrees. These nurses must be trained and certified above the current level of nurse practitioners but well below the level of licensed physicians. Their compensation will be significantly higher than the former but significantly lower than the latter. They will occupy a middle ground between the two.

Step Three: Establish two networks of primary care providers nationwide, one superior and one inferior. (If you cannot accept that one network will be superior, and one inferior—that two distinct and unequal levels of care are necessary and intentional—and that many people will wind up in the inferior network, you may as well stop reading now.) To underscore this point, and since this is my sketch, I’m going to call the superior tier the Shakespeare Network; the inferior, I’ll call the Shaw Network. Shakespeare will be populated by traditionally-credentialed primary care physicians; Shaw will be populated by primary care nurses. (Ideally, primary care nurses will work in clinics under the supervision of one or two certified physicians—though this will not always be possible in rural areas.) Specialists will not belong to either network.

Step Four: Reform employer-based insurance. If employers want to contribute to their workers’ health care insurance, let them do so. But give the employees a choice of whether to accept the company plan (whether it puts them in the Shakespeare or Shaw Networks), or to take the individual cost of the company plan as an annual bonus designated to buy their own insurance. If the employee can find a cheaper plan that suits his needs, let him pocket the difference…and if he wants a more expensive plan, let him add his own money to the pot. Among the many problems with the current system of employer-based insurance is that fact that employers offer group insurance plans that cover all employees the same way (so, for example, male employees must carry insurance that covers mammograms, and female employees must carry insurance that covers prostate exams).

Step Five: Let people shop anywhere for their policies, and let insurance companies tailor their offerings to narrow demographics. Why, for example, should I be forced to carry a policy that covers mental health care costs if I’m confident I’ll never incur those expenses? How much cheaper would a policy be that omits mental health coverage? Yet many states require that all insurance plans sold within their borders cover mental health care. Ditto acupuncture, erectile dysfunction pills, birth control, etc…if I know I’ll never incur these expenses, why should I be compelled to insure against them? Insurance companies should be free to offer pared down policies at lower premium costs—and to sell those policies to anyone anywhere.

Step Six: Let people further reduce the cost of their insurance by buying plans that restrict their primary care to the Shaw Network. Access to the Shakespeare Network, where primary care is provided by physicians rather than by nurses, should cost more. If you select the cheaper Shaw Network, but grow unhappy with your plan, you can opt into the Shakespeare Network by paying a substantial one-time adjustment penalty (based on your current age, life expectancy, overall health) and higher premiums from that point onward if and only if you are not already sick. If you are already sick—if you have a preexisting condition—you are locked into the Shaw Network. You cannot move up. So, too, if you choose not to carry health insurance for a year or more, you can pay a substantial one-time adjustment penalty and buy into the Shaw Network, but, again, you are locked in. You cannot move up to the Shakespeare Network under any circumstances.

Step Seven: Since specialists (including surgeons) belong to neither network, their services will be available to anyone insured by either network. But scheduling priority will be given to members of the Shakespeare Network…which makes sense, given that provider compensation is greater in the Shakespeare Network. Expect substantially longer waits for specialized services if you are a member of the Shaw Network. Also expect coverage for more expensive specialized services to be occasionally denied to members of the Shaw Network. You pay less, you get less. The medical industry will thus continue to innovate for members of the Shakespeare Network; benefits from the innovations will eventually trickle down to Shaw Network members, but wait times will no doubt be long, and the process of price-dropping will no doubt be slow.

Step Eight: Medicaid funds can only be used to access Shaw Network providers and services.

Step Nine: Medicare should be reconfigured as a lump sum annual payment sufficient to cover the cost of buying private insurance on the Shaw Network. The individual can then supplement that dollar amount to buy into the Shakespeare Network—provided that he has been a Shakespeare Network member for a minimum of (say) 20 years, or that he has no pre-existing conditions to prevent him moving from Shaw to Shakespeare and is willing to pay the cash penalty for such a move.

Review of Walter Laqueur's The Changing Face of Anti-Semitism

The Changing Face of Anti-Semitism, by Walter Laqueur
Oxford University Press, 228 pages, $22.00
Book Review by Mark Goldblatt / first published in the Claremont Review of Books, 2007

The Book of Esther in the Hebrew Bible recounts what is perhaps the world’s first attempted pogrom. The fanciful tale of the persecution and deliverance of the captive Jewish people during the reign of the Persian King Ahasuerus (often identified as Xerxes I, who reigned from 486-465 B.C.) tells the story of Haman, the king’s second-in-command, who plots to kill all the Jews under Persian rule. Haman feels slighted because the Jewish leader Mordecai won’t bow down to him and urges Ahasuerus to authorize genocide: “There is a certain people scattered and separated among the peoples in all the provinces of your kingdom; their laws are different from those of every other people, and they do not keep the king’s laws, so that it is not appropriate for the king to tolerate them. If it pleases the king, let a decree be issued for their destruction…” (Esther 3:8-9). Haman’s plot is eventually foiled by the king’s favorite wife, Esther, herself a Jew and Mordecai’s cousin. Haman is hung on the king’s orders, Mordecai is promoted in his place, and “for the Jews there was light and gladness, joy and honor.”

Rarely since then have things turned out so well for the Jews, as Walter Laqueur recounts in his new book, The Changing Face of Anti-Semitism. Laqueur, a historian and author of Fascism: Past, Present, and Future (1996) and The New Terrorism: Fanaticism and the Arms of Mass Destruction (1999) sets for himself the daunting task of chronicling the long history of anti-Semitism from biblical times to the present. That he mostly succeeds, in just over 200 pages, is a remarkable achievement.

According to Laqueur, the roots of anti-Semitism can be traced, at least in part, to the historical fact of the Diaspora—the scattering of Jewish people throughout the ancient world after the destruction of the state of Judea by the Romans in 73 A.D. Of course, many ethnic and religious groups have been dispersed by calamity and conquest—Laqueur cites the example of the Kurds—but they have tended to remain in roughly contiguous territories, awaiting an opportunity to coalesce again into an autonomous state; Jews, by contrast, actually did disperse, forming recognizable minority communities across the globe—each of which seemed to reinforce, to outsiders, the distinctive nature of Jewish society. Even though Jews often assimilated, they seemed to do so for strictly pragmatic reasons; in matters of the heart, or when push came to shove, they “stuck to their own, isolated themselves, and (so it appeared to outsiders) considered themselves somehow better than others because of being the chosen people and having a special connection with their god.”

If anti-Semitism in the first few centuries after the Diaspora was exceptionally far-flung, it was, as Laqueur notes, only “one of many national and ethnic antagonisms.” Hostility towards Judaism acquires its peculiar status with the ascendance of its rival sect, Christianity—which became, by decree of Theodosius, the official religion of the Roman Empire in 380. Jews, after all, had rejected Jesus and were believed by many Christians to be the main culprits in his death. “There is no doubt,” Laqueur writes, “that the advent of Christianity and…its subsequent interpretation present the turning point in the history of anti-Semitism and the Jews.” Whenever and wherever Christianity reigned during the Middle Ages, anti-Semitism was likely thrive. Even as thoughtful a figure as St. Augustine implores God to slay the Jews so that none would be left to oppose His word. Christian communities were rife with rumors of Jewish treachery; Jews, it was believed, butchered Christian children to bake into their Passover bread, poisoned local wells, and spread disease. Denunciations, persecutions, and forced expulsions became so frequent during this period that it comes as a surprise when Pope Clement VI issues a papal bull in 1348 insisting that the Black Death was not specifically the fault of the Jews but rather a divine punishment against all mankind for its sins.

Jews fared slightly better under Islam after its rise in the 7th century. Though relegated to second-class citizenship under Muslim rule, the Jews were nevertheless spared the relentless suspicion and concerted assaults they suffered in Christian Europe. According to the Koran, Muhammad himself had Jewish friends; Muslims regard Moses, as well as Jesus, as genuine prophets, and both Jews and Christians are ahl al-kitab—People of the Book. On the other hand, the Koran also specifically instructs Muslims to kill Jews and refers to them as “sons of apes and pigs.” A 9th-century hadith (commentary on the Koran) states that the “last hour” will not come until Muslims fight against Jews, until the trees and stones themselves cry out, “O Muslim, there is a Jew hiding behind me. Come and kill him.” The status of Jews under Muslim rule, in short, if slightly more secure than under Christian rule, remained tenuous.

The Protestant Reformation brought with it improved circumstances for the Jews of Europe. Luther, it is true, was rabidly anti-Semitic, and authored a 1543 pamphlet called “The Jews and Their Lies” in which he suggested that synagogues be burned, Jewish homes be destroyed, and the remaining Jews be put under one roof so that “they realize that they are not masters in our land as they boast but miserable captives.” On the contrary, Calvin’s attitude towards Judaism was more enlightened. He noted that the “seed of Abraham” was part of the body of Christ and that God’s divine calling of the Jews could not be rendered null and void, insisting that “our differences with them were purely theological.” Throughout the Reformation, where Calvinism took deepest root—most conspicuously in the Netherlands—Jews fared relatively well.

The idea of Judaism as a foreign entity, a kind of contagion within the body of humanity, rather than merely as a religious sect, began to emerge during the Enlightenment. Speaking of Jews, Voltaire wrote, “I would not be in the least surprised if these people would not some day become deadly to the human race.” Kant and Hegel also held low opinions of Jews, and such sentiments were to acquire the whiff of scientific respectability with the advent of race theory in the late 18th century. Racial categorization was, from the outset, more than just anthropological color coding; each race was assumed to possess innate behavioral characteristics. The Jews, by their very nature, were parasitic. It wasn’t merely their beliefs or traditions that were alien; alienation was their essence. They insinuated themselves into a society like a cancer and began to suck the life out of it.

The term “anti-Semitism” first came into common use in the second half of the 19th century, popularized by Wilhelm Marr, a German journalist, who meant it not as moral critique but as a policy recommendation. Marr argued that it was ignorant, and strategically foolish, to attack Jews as “Christ-killers” or for their alleged ritual murder of Christians. He believed that the real danger posed by Jews lay in their disproportionate influence in upper strata of German society and, related to that, the effects on the national culture of the “Jewish spirit”—a sense of cosmopolitanism (or, if you prefer, statelessness) that undermined traditional notions of German identity. Unless the people could defeat the Jewish spirit—that is, enact anti-Semitism—Marr concluded, they had no future: “Finis Germaniae.”

We are now within sight of the Holocaust. The Holocaust is the shadow that looms over Laqueur’s work; indeed, it is hard to read any narrative of the persecutions of Jews without a sense of dread, of the gathering momentum of collective animus and theoretical justifying which culminates in the hell of Nazi Germany. The singularity of the Holocaust derives not from its body count. What makes the Holocaust unique is the methodology, the step-by-step legal process enacted by the Nazis which identified Jews under their control, isolated them in ghettoes, deported them to concentration camps, and then systematically exterminated them. History is rife with shallow graves. But only in the Holocaust did the blundering ham-fisted brutality of the human species take up a scalpel. This is the first and final truth of the crematoriums. Laqueur’s account of the Third Reich’s campaign of liquidation, though brief, is undoubtedly the highlight of his book.

That said, the book is not without faults, the most glaring of which is a function of its length. This is mostly a mentioning book. It is short on both anecdote and analysis, which makes it a consistently dry read. Indeed, at times it has the feel of an extended encyclopedia article. But like a good encyclopedia article, by the end you sense you’ve gotten a thorough overview of the subject. For that, Laqueur is to be applauded.