July 31, 2009
Op-Ed Columnist
Health Care Realities By PAUL KRUGMAN
At a recent town hall meeting, a man stood up and told Representative Bob Inglis to “keep your government hands off my Medicare.” The congressman, a Republican from South Carolina, tried to explain that Medicare is already a government program — but the voter, Mr. Inglis said, “wasn’t having any of it.”
It’s a funny story — but it illustrates the extent to which health reform must climb a wall of misinformation. It’s not just that many Americans don’t understand what President Obama is proposing; many people don’t understand the way American health care works right now. They don’t understand, in particular, that getting the government involved in health care wouldn’t be a radical step: the government is already deeply involved, even in private insurance.
And that government involvement is the only reason our system works at all.
The key thing you need to know about health care is that it depends crucially on insurance. You don’t know when or whether you’ll need treatment — but if you do, treatment can be extremely expensive, well beyond what most people can pay out of pocket. Triple coronary bypasses, not routine doctor’s visits, are where the real money is, so insurance is essential.
Yet private markets for health insurance, left to their own devices, work very badly: insurers deny as many claims as possible, and they also try to avoid covering people who are likely to need care. Horror stories are legion: the insurance company that refused to pay for urgently needed cancer surgery because of questions about the patient’s acne treatment; the healthy young woman denied coverage because she briefly saw a psychologist after breaking up with her boyfriend.
And in their efforts to avoid “medical losses,” the industry term for paying medical bills, insurers spend much of the money taken in through premiums not on medical treatment, but on “underwriting” — screening out people likely to make insurance claims. In the individual insurance market, where people buy insurance directly rather than getting it through their employers, so much money goes into underwriting and other expenses that only around 70 cents of each premium dollar actually goes to care.
Still, most Americans do have health insurance, and are reasonably satisfied with it. How is that possible, when insurance markets work so badly? The answer is government intervention.
Most obviously, the government directly provides insurance via Medicare and other programs. Before Medicare was established, more than 40 percent of elderly Americans lacked any kind of health insurance. Today, Medicare — which is, by the way, one of those “single payer” systems conservatives love to demonize — covers everyone 65 and older. And surveys show that Medicare recipients are much more satisfied with their coverage than Americans with private insurance.
Still, most Americans under 65 do have some form of private insurance. The vast majority, however, don’t buy it directly: they get it through their employers. There’s a big tax advantage to doing it that way, since employer contributions to health care aren’t considered taxable income. But to get that tax advantage employers have to follow a number of rules; roughly speaking, they can’t discriminate based on pre-existing medical conditions or restrict benefits to highly paid employees.
And it’s thanks to these rules that employment-based insurance more or less works, at least in the sense that horror stories are a lot less common than they are in the individual insurance market.
So here’s the bottom line: if you currently have decent health insurance, thank the government. It’s true that if you’re young and healthy, with nothing in your medical history that could possibly have raised red flags with corporate accountants, you might have been able to get insurance without government intervention. But time and chance happen to us all, and the only reason you have a reasonable prospect of still having insurance coverage when you need it is the large role the government already plays.
Which brings us to the current debate over reform.
Right-wing opponents of reform would have you believe that President Obama is a wild-eyed socialist, attacking the free market. But unregulated markets don’t work for health care — never have, never will. To the extent we have a working health care system at all right now it’s only because the government covers the elderly, while a combination of regulation and tax subsidies makes it possible for many, but not all, nonelderly Americans to get decent private coverage.
Now Mr. Obama basically proposes using additional regulation and subsidies to make decent insurance available to all of us. That’s not radical; it’s as American as, well, Medicare.
Friday, July 31, 2009
Thursday, July 30, 2009
America’s healthcare should no longer be tied to jobs By Matt Miller
America’s healthcare should no longer be tied to jobs By Matt Miller
Published: July 30 2009 22:32 | Last updated: July 30 2009 22:32
The bipartisan “gang of six” in the Senate wants to fine employers whose workers choose Medicaid, the US public healthcare system, rather than more costly insurance from their company. The House wants to impose an 8 per cent payroll tax on all but the tiniest companies that do not offer healthcare. These damaging proposals show that both political parties remain deeply confused about the roles of government and corporations in a modern economy. Their premise – that companies have a duty to provide health benefits – has such perverse consequences that it may doom reform efforts altogether.
America’s unique employer-based healthcare system may have made sense 50 years ago, when healthcare was cheap and business faced little global competition. But today’s circumstances are radically different. Soaring health costs strangle business and absorb cash that could otherwise go to wages. The link between healthcare and employment explains why millions of Americans have lost coverage during this recession. Budding entrepreneurs with ill spouses or children stay in jobs they loathe for fear of losing the insurance they need. Keeping employers at the core of the welfare state is bad for business, bad for the economy and bad for families.
With flaws like these you would think a prime goal of health reform would be to give everyone access to group health coverage outside the employer setting. But you would be wrong. Amazingly, this goal was taken off the table at the start. President Barack Obama and Democrats in Congress feared that moving beyond the employer-based system would leave them assailed as “socialists”. Business feared being slammed by unions for “shirking responsibilities”. Unions feared that if health benefits were no longer shaped through collective bargaining, their standing would fall further. Everyone in Washington feared too much “change”.
But ignoring the key structural flaw in US healthcare is precisely what has brought the question of how to finance expanded coverage to its current impasse. Having decided not to move beyond employer-based care, politicians now view the shift of Americans to any plan that requires public subsidy as a negative, because it adds to the cost of reform.
The most depressing examples of this thinking are the proposed rules to keep people in job-based care. Strict limits, for example, would govern who could use new insurance “exchanges” that would give access to competing plans, including a public insurance option. Those who already have coverage from an employer would be barred from seeking coverage there. But this is exactly the opposite of what sound policy should be doing. Worse, this lockdown obviously does not lower national health costs at all – it just keeps the amount on the public ledger below some threshold deemed politically acceptable.
The better solution would be a “grand bargain”, through which business shifts health costs off its payrolls and on to government, in exchange for business supporting the broader revenue needed for government to accommodate this shift. Contrary to conservative claims, it is perfectly possible to do so in market-friendly ways. As health systems in Switzerland and Holland show, the US could have universal coverage without taking the road of single-payer care.
Democratic Senator Ron Wyden has been the lonely voice arguing that America must move beyond job-based healthcare to boost business competitiveness while assuring family health security. Mr Wyden mustered a small bipartisan coalition around such a plan, but the weight of dead ideas in Washington has stifled the proposal.
In the long term there is reason for hope. As long as some form of insurance exchange is included in any final bill, some non-poor, non-elderly Americans will for the first time have a way to buy group coverage outside employment. This infrastructure can expand and become a safe way to move more people out of job-based coverage over time. Mr Wyden hopes to accelerate that process; he has proposed that workers be able to take the money employers spend on their benefits and use it to buy coverage at the exchanges if they prefer. If these innovations are launched in even modest form this year, America will be on a path to consigning employer-based coverage to the dustbin of history, where it now belongs.
The writer, a management consultant, is the author of The Tyranny of Dead Ideas
Published: July 30 2009 22:32 | Last updated: July 30 2009 22:32
The bipartisan “gang of six” in the Senate wants to fine employers whose workers choose Medicaid, the US public healthcare system, rather than more costly insurance from their company. The House wants to impose an 8 per cent payroll tax on all but the tiniest companies that do not offer healthcare. These damaging proposals show that both political parties remain deeply confused about the roles of government and corporations in a modern economy. Their premise – that companies have a duty to provide health benefits – has such perverse consequences that it may doom reform efforts altogether.
America’s unique employer-based healthcare system may have made sense 50 years ago, when healthcare was cheap and business faced little global competition. But today’s circumstances are radically different. Soaring health costs strangle business and absorb cash that could otherwise go to wages. The link between healthcare and employment explains why millions of Americans have lost coverage during this recession. Budding entrepreneurs with ill spouses or children stay in jobs they loathe for fear of losing the insurance they need. Keeping employers at the core of the welfare state is bad for business, bad for the economy and bad for families.
With flaws like these you would think a prime goal of health reform would be to give everyone access to group health coverage outside the employer setting. But you would be wrong. Amazingly, this goal was taken off the table at the start. President Barack Obama and Democrats in Congress feared that moving beyond the employer-based system would leave them assailed as “socialists”. Business feared being slammed by unions for “shirking responsibilities”. Unions feared that if health benefits were no longer shaped through collective bargaining, their standing would fall further. Everyone in Washington feared too much “change”.
But ignoring the key structural flaw in US healthcare is precisely what has brought the question of how to finance expanded coverage to its current impasse. Having decided not to move beyond employer-based care, politicians now view the shift of Americans to any plan that requires public subsidy as a negative, because it adds to the cost of reform.
The most depressing examples of this thinking are the proposed rules to keep people in job-based care. Strict limits, for example, would govern who could use new insurance “exchanges” that would give access to competing plans, including a public insurance option. Those who already have coverage from an employer would be barred from seeking coverage there. But this is exactly the opposite of what sound policy should be doing. Worse, this lockdown obviously does not lower national health costs at all – it just keeps the amount on the public ledger below some threshold deemed politically acceptable.
The better solution would be a “grand bargain”, through which business shifts health costs off its payrolls and on to government, in exchange for business supporting the broader revenue needed for government to accommodate this shift. Contrary to conservative claims, it is perfectly possible to do so in market-friendly ways. As health systems in Switzerland and Holland show, the US could have universal coverage without taking the road of single-payer care.
Democratic Senator Ron Wyden has been the lonely voice arguing that America must move beyond job-based healthcare to boost business competitiveness while assuring family health security. Mr Wyden mustered a small bipartisan coalition around such a plan, but the weight of dead ideas in Washington has stifled the proposal.
In the long term there is reason for hope. As long as some form of insurance exchange is included in any final bill, some non-poor, non-elderly Americans will for the first time have a way to buy group coverage outside employment. This infrastructure can expand and become a safe way to move more people out of job-based coverage over time. Mr Wyden hopes to accelerate that process; he has proposed that workers be able to take the money employers spend on their benefits and use it to buy coverage at the exchanges if they prefer. If these innovations are launched in even modest form this year, America will be on a path to consigning employer-based coverage to the dustbin of history, where it now belongs.
The writer, a management consultant, is the author of The Tyranny of Dead Ideas
Sunday, July 26, 2009
THE STONE GODS, by Jeanette Winterson
THE STONE GODS, by Jeanette Winterson (Mariner/Houghton Mifflin Harcourt, $13.95.) This scary, beautiful novel envisions a post-apocalyptic future — actually, several of them. Amid ecological disaster and impending war, scientists, space captains and Robo sapiens grapple with love and fate. "The Stone Gods" is "a Baedeker for Earth's future," Susann Cokal wrote in the Book Review.
Paperback Row - List - NYTimes.com (8 August 2009)
http://www.nytimes.com/2009/07/26/books/review/PaperRow-t.html?scp=1&sq=%22the%20stone%20gods%22&st=cse
http://snipurl.com/pfb45
Paperback Row - List - NYTimes.com (8 August 2009)
http://www.nytimes.com/2009/07/26/books/review/PaperRow-t.html?scp=1&sq=%22the%20stone%20gods%22&st=cse
http://snipurl.com/pfb45
Friday, July 24, 2009
Kill the Rhinos! By DAVID BROOKS
July 24, 2009
Op-Ed Columnist
Kill the Rhinos! By DAVID BROOKS
Forget the wonkery. Let's get primeval. Rising health care costs are a stampede of big ugly rhinos. They are trampling your crops, stomping on your children's play areas and spoiling your hunting grounds.
President Obama wasn't exaggerating when he said this cost onslaught is unsustainable. The rhinos have been roaming unchecked for a generation. We've thrown research projects, legislative and corporate reforms at them, all in an effort to tamp down health care inflation. But the rhinos keep coming. They are ubiquitous, powerful, protean and inexorable.
They feed on fuel sources deep in our system: expensive technological progress, the self-interest of the millions of people who make their living off the system, the public's desire to get the best care for nothing, the fee-for-service payment system and so on.
The rhinos are closing off your future. As the White House folks say, health care premiums have doubled over the last decade. The government is saddled with $36 trillion in unfunded liabilities.
So your only question should be: Where do you find a tool or weapon big enough to stop the rhino stampedes? You know the problem is big, and you figure the response had better be gigantic.
Then you look on Capitol Hill and you see a bunch of popguns. The politicians describe these big ugly problems, but when it comes time to talk about their remedies they tell you: Don't worry. Nothing's going to change. In other words, we're going to eliminate the biggest, hairiest, most entrenched problem in the country without fundamentally changing the system and without asking for sacrifice from anybody.
Good luck.
Then you talk to the health care experts promoting the bills and they are very honest: We don't know exactly how to slow health care inflation. But we think we have some good ideas. We're going to put some innovations, information clearinghouses and pilot projects in this legislation, and over the next 10 years we will see what works to really bring down costs. We're going to go on a voyage of discovery to learn about rhino eradication.
And, indeed, some of the ideas do sound good: more information technology, comparative effectiveness research, conducting experiments to bundle hospital payments so they are based on outcomes. Some of the providers that do things right, like the Mayo Clinic, really are getting results.
But some of these ideas have been watered down in the legislation. And you're not a complete idiot. You know there is a big difference between finding islands of excellence and creating a national system based on them.
Besides, you've got a bunch of big, evil rhinos stomping around! You want more than some promising ideas to pinpoint waste, fraud and abuse. You want some big heavy hammers to clock those suckers in the head.
Now that the first wave of legislation is bogging down, you want to take the seeds of cost control and you want to do more. You want to eliminate or cap the tax exemption on employee health benefits. This is a big way to crush one of the core drivers of health care inflation. You're willing to give MedPAC-style technocrats a chance to take control of Medicare spending away from Congressional spendthrifts.
You want to loosen federal regulations so that states have more room to experiment — not tighten them, as the current legislation does, so that states have less. You want reforms throughout the system that will cut down on first-dollar reimbursement in exchange for catastrophic protection. You want to tie Medicare subsidies to income. You want to look at anything that will move us away from a fee-for-service model, the core perversion in the system.
You want to change incentives at both ends. The legislators who drew up the first bills want to change the provider's incentives. But big cost savings can also come if consumers have choices and incentives to hunt for cheaper coverage. The Wyden-Bennett bill gives people a chance to choose the best option, instead of imprisoning people in existing coverage, as the current legislation does. The Medicare Part D reform has produced impressive reductions by allowing consumers to pocket prescription drug savings. Other proposals would give people tax credits and allow them to go to any trusted community group — like AARP or a union or a religious group — that wanted to compete to offer coverage.
Not everything is compatible with everything else. But the point is that you have rhinos at the door! You'll try anything that works. You want a political class that no longer perpetuates the myth that people can get everything for nothing. You know that it was political pandering that got us into this mess in the first place.
Obama is right. Things will be bad if we don't tackle the problem this year. Things will be worse if we add to the costs without beating the rhinos.
Op-Ed Columnist - Kill the Rhinos! - NYTimes.com (2 August 2009)
http://www.nytimes.com/2009/07/24/opinion/24brooks.html?_r=1&sq=&st=cse&%2334;David%20Brooks=&scp=1&%2334;%20Rhinos=&pagewanted=print
http://snipurl.com/oj8be
Op-Ed Columnist
Kill the Rhinos! By DAVID BROOKS
Forget the wonkery. Let's get primeval. Rising health care costs are a stampede of big ugly rhinos. They are trampling your crops, stomping on your children's play areas and spoiling your hunting grounds.
President Obama wasn't exaggerating when he said this cost onslaught is unsustainable. The rhinos have been roaming unchecked for a generation. We've thrown research projects, legislative and corporate reforms at them, all in an effort to tamp down health care inflation. But the rhinos keep coming. They are ubiquitous, powerful, protean and inexorable.
They feed on fuel sources deep in our system: expensive technological progress, the self-interest of the millions of people who make their living off the system, the public's desire to get the best care for nothing, the fee-for-service payment system and so on.
The rhinos are closing off your future. As the White House folks say, health care premiums have doubled over the last decade. The government is saddled with $36 trillion in unfunded liabilities.
So your only question should be: Where do you find a tool or weapon big enough to stop the rhino stampedes? You know the problem is big, and you figure the response had better be gigantic.
Then you look on Capitol Hill and you see a bunch of popguns. The politicians describe these big ugly problems, but when it comes time to talk about their remedies they tell you: Don't worry. Nothing's going to change. In other words, we're going to eliminate the biggest, hairiest, most entrenched problem in the country without fundamentally changing the system and without asking for sacrifice from anybody.
Good luck.
Then you talk to the health care experts promoting the bills and they are very honest: We don't know exactly how to slow health care inflation. But we think we have some good ideas. We're going to put some innovations, information clearinghouses and pilot projects in this legislation, and over the next 10 years we will see what works to really bring down costs. We're going to go on a voyage of discovery to learn about rhino eradication.
And, indeed, some of the ideas do sound good: more information technology, comparative effectiveness research, conducting experiments to bundle hospital payments so they are based on outcomes. Some of the providers that do things right, like the Mayo Clinic, really are getting results.
But some of these ideas have been watered down in the legislation. And you're not a complete idiot. You know there is a big difference between finding islands of excellence and creating a national system based on them.
Besides, you've got a bunch of big, evil rhinos stomping around! You want more than some promising ideas to pinpoint waste, fraud and abuse. You want some big heavy hammers to clock those suckers in the head.
Now that the first wave of legislation is bogging down, you want to take the seeds of cost control and you want to do more. You want to eliminate or cap the tax exemption on employee health benefits. This is a big way to crush one of the core drivers of health care inflation. You're willing to give MedPAC-style technocrats a chance to take control of Medicare spending away from Congressional spendthrifts.
You want to loosen federal regulations so that states have more room to experiment — not tighten them, as the current legislation does, so that states have less. You want reforms throughout the system that will cut down on first-dollar reimbursement in exchange for catastrophic protection. You want to tie Medicare subsidies to income. You want to look at anything that will move us away from a fee-for-service model, the core perversion in the system.
You want to change incentives at both ends. The legislators who drew up the first bills want to change the provider's incentives. But big cost savings can also come if consumers have choices and incentives to hunt for cheaper coverage. The Wyden-Bennett bill gives people a chance to choose the best option, instead of imprisoning people in existing coverage, as the current legislation does. The Medicare Part D reform has produced impressive reductions by allowing consumers to pocket prescription drug savings. Other proposals would give people tax credits and allow them to go to any trusted community group — like AARP or a union or a religious group — that wanted to compete to offer coverage.
Not everything is compatible with everything else. But the point is that you have rhinos at the door! You'll try anything that works. You want a political class that no longer perpetuates the myth that people can get everything for nothing. You know that it was political pandering that got us into this mess in the first place.
Obama is right. Things will be bad if we don't tackle the problem this year. Things will be worse if we add to the costs without beating the rhinos.
Op-Ed Columnist - Kill the Rhinos! - NYTimes.com (2 August 2009)
http://www.nytimes.com/2009/07/24/opinion/24brooks.html?_r=1&sq=&st=cse&%2334;David%20Brooks=&scp=1&%2334;%20Rhinos=&pagewanted=print
http://snipurl.com/oj8be
Wednesday, July 22, 2009
101 Simple Salads for the Season By MARK BITTMAN
July 22, 2009
The Minimalist
101 Simple Salads for the Season By MARK BITTMAN
SUMMER may not be the best time to cook, but it’s certainly among the best times to eat. Toss watermelon and peaches with some ingredients you have lying around already, and you can produce a salad that’s delicious, unusual, fast and perfectly seasonal.
That’s the idea behind the 101 ideas found in this section. In theory, each salad takes 20 minutes or less. Honestly, some may take you a little longer. But most minimize work at the stove and capitalize on the season, when tomatoes, eggplant, herbs, fruit, greens and more are plentiful and excellent.
This last point is important. Not everything needs to be farmers’ market quality, but it’s not too much to expect ripe fruit, fragrant herbs and juicy greens.
Salt, to taste, is a given in all of these recipes. Pepper, too (if I want you to use a lot of pepper, I say so).
Herein, then, are enough salad ideas to tide you over until the weather cools down.
MOSTLY VEGAN SALADS
1. Cube watermelon and combine with tomato chunks, basil and basic vinaigrette. You can substitute peach for the watermelon or the tomato (but not both, O.K.?). You can also add bacon or feta, but there goes the vegan-ness.
2. Mix wedges of tomatoes and peaches, add slivers of red onion, a few red-pepper flakes and cilantro. Dress with olive oil and lime or lemon juice. Astonishing.
3. A nice cucumber salad: Slice cucumbers thin (if they’re fat and old, peel and seed them first), toss with red onions and salt, then let sit for 20 to 60 minutes. Rinse, dry, dress with cider vinegar mixed with Dijon mustard; no oil necessary.
4. Shave raw asparagus stalks with a vegetable peeler. Discard the tough first pass of the peeler — i.e., the peel — but do use the tips, whole. Dress with lemon vinaigrette and coarse salt. (Chopped hard-boiled eggs optional but good.)
5. Grate or very thinly slice Jerusalem artichokes; mix with pitted and chopped oil-cured olives, olive oil, lemon juice and a sprinkling of coarsely ground cumin. Unusual and wonderful.
6. Sichuan slaw: Toss bean sprouts, shredded carrots and celery, minced fresh chili, soy sauce, sesame oil and a bit of sugar. Top with chopped peanuts and chopped basil, mint and/or cilantro. (The full trio is best.)
7. Grate carrots, toast some sunflower seeds, and toss with blueberries, olive oil, lemon juice and plenty of black pepper. Sweet, sour, crunchy, soft.
8. Chop or slice radishes (or jicama, or the ever-surprising kohlrabi) and combine with chopped or sliced unripe (i.e., still crunchy) mango, lime juice and mint or cilantro.
9. Chop or slice jicama (or radishes or kohlrabi) and mango and mix with coconut milk, lime juice, curry powder and cilantro or mint.
10. Cook whole grape tomatoes in olive oil over high heat until they brown lightly, sprinkling with curry powder. Cool a bit, then toss with chopped arugula, loads of chopped mint and lime juice.
11. Chop and steam baby or grown-up bok choy until crisp-tender, then shock it in ice water. Drain, then toss with halved cherry tomatoes, capers, olive oil and lemon juice.
12. Combine sliced fennel and prune plums; serve with vinaigrette spiked with minced ginger. Nice pairing.
13. A red salad: Combine tomato wedges with halved strawberries, basil leaves, shaved Parmesan and balsamic vinegar.
14. A classic Moroccan thing: Thinly slice carrots, or grate or shred them (the food processor makes quick work of this). Toss with toasted cumin seeds, olive oil, lemon juice and cilantro. Raisins are good in here, too. There is no better use of raw carrots.
15. Cut cherry or grape tomatoes in half; toss with soy sauce, a bit of dark sesame oil and basil or cilantro. I love this — the tomato juice-soy thing is incredible.
16. Slice fennel and crisp apple about the same thickness (your choice). Combine, then dress with mustardy vinaigrette and chopped parsley. Come fall, this will be even better.
17. With thanks to Szechuan Gourmet restaurant: Finely chop celery and mix with a roughly equal amount of pressed or smoked tofu, chopped. Dress with peanut oil warmed with chili flakes and Sichuan peppercorns, then mixed with soy sauce.
18. Roughly chop cooked or canned chickpeas (you can pulse them, carefully, in a food processor) and toss with olive oil, lemon juice, lots of chopped fresh parsley and mint, and a few chopped tomatoes. Call this chickpea tabbouleh.
19. Mix cooked cannellini or other white beans, chopped cherry or grape tomatoes and arugula or baby spinach. Lightly toast sliced garlic in olive oil with rosemary and red pepper flakes; cool slightly, add lemon zest or juice or both, then pour over beans.
20. Shred Napa cabbage and radishes. The dressing is roasted peanuts, lime juice, peanut or other oil, cilantro and fresh or dried chili, all whizzed in a blender. Deliciousness belies ease.
21. Dice cucumbers (if they’re fat and old, peel and seed them first) and toss with cubes of avocado, a little mirin (or honey, but then it’s not vegan), rice vinegar and soy sauce. (You could mix in a little lump crab meat, really not vegan, even rice, and call it a California roll salad.)
22. Thinly slice button mushrooms; toss with finely chopped carrots and celery and mix with mung bean sprouts. Finish with peanut or olive oil, sherry vinegar, a little soy sauce and minced ginger. (This is a super vinaigrette, by the way.)
23. Thinly slice some cucumbers (if they’re fat and old, peel and seed them first), red onions, radishes and fresh chili pepper. Soak for a few minutes in equal amounts vinegar and water, with some salt and sugar. When they taste lightly pickled, drain and serve, alone or over rice.
24. Blanch spinach, then drain and shock in ice water. Squeeze it dry, chop it and toss it with toasted pine nuts, raisins, olive oil and a tiny bit of balsamic vinegar. Capers are good, too. Quite elegant, actually.
25. Combine chopped bell peppers, tomatoes, red onion, chilies and cilantro, then toss with corn tortilla strips, toasted in a 350-degree oven until crisp (or yes, use packaged chips; why not?). Dust with chili powder and lots of lime juice.
26. Combine mushroom caps and thinly sliced red onions with olive oil; broil gently until tender and browned. Toss with a lot of chopped fresh parsley or basil (or both) and a simple vinaigrette. Some chopped escarole, arugula or watercress is good, too.
27. Cook whole, unpeeled eggplant in a dry, hot skillet or on a grill, turning occasionally, until completely collapsed and soft. Chop and toss with toasted pita, toasted pine nuts, cooked white beans and halved cherry tomatoes. Dress with olive oil, lemon juice and lots of black pepper. Or a (non-vegan) yogurt dressing is good, especially one laced with tahini.
28. Toss mâche or another soft green with toasted slivered almonds and roughly chopped fresh figs. Thin some almond butter with water and sherry vinegar to taste and use as a dressing. Some will like this with fresh goat cheese.
29. Pit and halve cherries (or halve and pit cherries), then cook gently with olive oil and a little balsamic vinegar until they break down. Toss with chopped radicchio, endive, escarole or a combination, some toasted hazelnuts and more oil and vinegar, if necessary.
30. Fast, grown-up potato salad: Boil bite-size red potatoes. While still warm, dress them with olive oil, lemon juice, whole grain mustard, capers and parsley. Chopped shallots, bell peppers, etc., all welcome, too.
31. Roast beets whole (or buy them precooked), then slice or cube and toss with a little chopped garlic (or a lot of roasted garlic), toasted walnuts, orange juice and olive oil.
32. Same deal with the beets, but toss with cooked corn, arugula, olive oil, sherry vinegar and chopped shallots.
33. The real five-bean: Chickpeas, cannellini or other white beans, kidney or other red beans, steamed string beans and steamed yellow wax beans. Toss with vinaigrette, chopped scallions or red onion, and parsley.
34. Grill quartered romaine hearts, radicchio and/or endive. Drizzle with olive oil and sherry vinegar, and add dill and chopped shallots. Teeny-tiny croutons are great on this.
35. Combine cooked or canned black beans with shredded cabbage and this vinaigrette: olive oil, fresh orange juice, not much sherry vinegar, ground cumin.
36. Mix cooked or canned chickpeas with toasted coconut, shredded carrots, chopped celery, curry powder, olive oil, lime juice and cilantro.
VEGETARIAN SALADS
37. Cube smoked tofu, then brush it with a mixture of honey and orange juice; broil until browned. Toss with chopped cucumbers, radishes and peas or pea shoots; drizzle with soy sauce and lime juice.
38. Cube watermelon; combine with roughly chopped mint, crumbled feta, sliced red onion and chopped Kalamata olives. Dress lightly with olive oil and lemon juice. Despite saltiness of feta and olives, this may need salt.
39. Yucatecan street food as salad: Roast fresh corn kernels in a pan with a little oil; toss with cayenne or minced chilis, lime juice and a little queso fresco. Cherry tomatoes are optional.
40. Slice cucumber and top with capers, olive oil, lots of pepper and little dollops of fresh ricotta. Note: cucumbers, ricotta and oil must all be really good.
41. Halve avocados and scoop out some but not all of their flesh. Roughly chop and toss with black beans, queso fresco, cilantro, chopped tomatillos and lime juice. Serve in the meaty avocado shells.
42. Trim crusts if necessary from day-or-two-old bread (or even three-day-old bread), cube and marinate in black olive tapenade thinned with more olive oil. Add chopped capers and toss with tomatoes, basil and mozzarella. (Anchovies optional.)
43. Grate raw beets (use the food processor to avoid ruining everything within spattering distance) and toss with watercress or arugula. Top with sherry vinaigrette and a little goat cheese. Especially obvious, perhaps, but also especially popular.
44. Make a crisp grilled cheese sandwich, with good bread and not too much good cheese. Let it cool, then cut into croutons. Put them on anything, but especially tomato and basil salad. This you will do forever.
45. Halve or quarter cooked artichoke hearts (the best are fresh and grilled, but you can use canned or frozen) and combine with cherry tomatoes, bits of feta or Parmesan or both, olive oil and lemon juice.
46. Sauté mushrooms and shallots in olive oil. Add a lot of spinach, chopped unless the leaves are small. When it wilts, stir in parsley and crumbled blue cheese. Feels like a steakhouse side-dish salad.
47. Thinly slice raw button mushrooms; combine with sliced or shaved Parmesan, parsley and a vinaigrette of olive oil, sherry vinegar and shallots.
48. Toss roughly chopped dandelion greens (or arugula or watercress) with chopped preserved lemon, chickpeas, crumbled feta and olive oil. (Before you start cursing me out, here’s a quick way to make preserved lemons: chop whole lemons and put in a bowl with the juice of another lemon or two, sprinkle with a fair amount of salt and let sit for an hour or so.)
49. Toss greens with walnuts, blue cheese and raspberries; drizzle with a simple vinaigrette. Sell for $14 a serving.
50. It’s puttanesca-ish: Egg salad with pitted black olives, chopped tomatoes, capers, anchovies (optional), a tiny bit of garlic and some red onion; mayonnaise as needed.
51. Arrange sliced ripe tomatoes and hard-boiled eggs on a platter; scatter a handful of chopped pitted green olives on top. Drizzle with a dressing made with olive oil, sherry vinegar and a teaspoon of pimentón.
52. Chop hard-boiled eggs and mix with just enough mayonnaise to bind; spoon into endive leaves. Top each with a small canned sardine and drizzle with a vinaigrette of olive oil, lemon juice and mustard.
53. Peel beets and grate them in a food processor. Mix equal parts plain yogurt and tahini, and toss with the beets along with lemon juice and za’atar (a mixture of toasted sesame seeds, dried green herbs and ground sumac; you can make it yourself using dried thyme).
54. Slice roasted red peppers (if you must use canned, try to find piquillos) and fresh mozzarella. Toss with cooked white beans, olive oil, red wine vinegar, a chopped shallot and fresh rosemary or parsley.
SALADS WITH SEAFOOD
55. Mix watercress with chopped smoked salmon, avocado, red onion and capers. Make a vinaigrette with olive oil, sherry vinegar and mustard powder.
56. Salade niçoise, sort of: On or around a bed of greens, make mounds of olives, cooked new potatoes and green beans (warm or at room temperature), good tomatoes, capers, fennel slivers, hard-cooked eggs and good quality Italian canned tuna. None of these is crucial; you get the idea. Serve with vinaigrette or aioli.
57. Toss cubes of day-or-more-old good bread with soy sauce, chopped sautéed shrimp, chopped radishes and cilantro. Like a weird shrimp toast panzanella.
58. Sear tuna until rare (for that matter, you could leave it raw) and cut it into small cubes. Toss with shredded jicama or radish and shredded Napa cabbage; season with mirin, soy sauce and cilantro. Avocado and/or wasabi paste are great with this, too.
59. Sear tuna, or use good canned tuna. Chop it up and mix with chopped olives, capers, tomatoes, parsley and olive oil.
60. Ditto on the tuna. Mix with chopped apples, halved seedless grapes, chopped red onion, olive oil, a bit of cumin and black pepper.
61. Mix canned salmon (sockeye, or use cooked fresh) with capers, chopped celery, yogurt or mayonnaise, and lemon juice. Serve on greens or in endive leaves.
62. Dust shrimp with chili powder. Sauté in butter or oil (or a combination) with fresh corn kernels and flavorful cooking greens (bok choy is good, as is watercress). Add halved cherry tomatoes and lime juice at the last minute.
63. Sunday brunch salad: Mix diced cucumbers, chopped tomato, minced red onion and capers with bits of smoked salmon. Dress with lemon juice (you won’t need much oil, if any). Take a step further by adding croutons of cubed toasted bagels.
64. Alternative Sunday brunch: Shred or chop cucumbers (if they’re fat and old, peel and seed them first), then toss with flaked smoked trout or whitefish, capers, dill, lemon juice and olive oil.
65. In a hot pan, flash-cook cut-up squid in a little olive oil for no more than two minutes. Toss with cooked or canned chickpeas, chopped bell peppers, lemon juice, a little more oil and parsley.
66. In a hot pan, sear sea scallops for a minute or two on each side, depending on size. Slice or chop, then toss with thinly sliced fennel and lemon or orange vinaigrette and some chopped fennel fronds.
67. Bread salad for anchovy lovers: Chop together many anchovies, a few capers, lemon juice and olive oil (or anchovy oil). Toss with cubes of toasted bread and chopped tomatoes or halved cherry or grape tomatoes.
68. Mix crab meat with pan-roasted corn, chopped avocado, halved cherry or grape tomatoes, olive oil, lemon juice and perhaps a bit of cilantro and crumbled ancho chili.
69. Stir-fry small or chopped shrimp in olive or peanut oil with lots of ginger; while still warm, combine with tomato wedges, chopped romaine, cilantro, scallions and lots of lime juice. Good in pita.
SALADS WITH MEAT
70. Shred brussels sprouts in the food processor, preferably with the slicing disk. Toss with vinaigrette and crumbled bacon.
71. Combine sliced green tomatoes and sliced fresh mozzarella; top with roughly chopped basil, olive oil, black pepper and crumbled bacon.
72. Sort-of carpaccio salad: Broil or grill skirt or sirloin steak very rare and slice very thin. Arrange on a plate with tomato wedges, lettuce and lemon juice.
73. Hawaiitalian: Combine pineapple chunks with bits of any cured pork product — cooked guanciale is ideal, or any ham — and a not-too-subtle chili vinaigrette.
74. Julienne red, yellow and orange bell peppers; mix with thinly sliced red onion, olive oil and cooked crumbled sausage or chopped salami.
75. The Little Italy salad: Chop or julienne salami and prosciutto, then toss with cubed mozzarella, chopped tomato, pepperoncini, oil and wine vinegar.
76. Slice fresh figs — many, if you live where they grow — and top with crumbled bacon, balsamic vinegar (the best you have) and crumbled blue cheese.
77. Combine shredded cabbage or lettuce with bits of good turkey, Swiss cheese and rye croutons. Top with good old Russian dressing, call it a turkey sandwich salad and don’t knock it until you try it.
78. What happens when your Chicago hot dog falls apart: Toss together tomato wedges, chopped pickles, hot peppers, shredded lettuce and a few slices of broiled or grilled hot dog. Dress with a vinaigrette made with mustard (should be yellow for authenticity, but ...) and celery salt. (You could throw in freshly made croutons; inauthentic, but better than a hot dog bun.)
79. Sear a steak and move it to a cutting board (don’t wash the pan); wait a minute or two, then slice. Cut kale (preferably black, also known as Tuscan, or dino kale) into thin ribbons and toss in the pan over high heat for a minute. Turn off the heat, add chopped black olives, olive oil and sherry vinegar. Serve kale with steak on top.
80. Sort-of-Cobb salad: Choose any combination of hard-cooked eggs, chopped prosciutto, cooked chicken, crumbled Gorgonzola, chopped tomatoes, chickpeas or white beans, sliced red onion, olives. Make vinaigrette with capers and anchovies.
81. Soak sliced prune plums or figs in balsamic vinegar for a few minutes, then add olive oil, chopped celery and red onion, shreds of roasted or grilled chicken, chopped fresh marjoram or oregano and chopped almonds. Serve on top of or toss with greens. So good.
82. Cut pancetta into matchsticks and crisp in a skillet with some oil, then caramelize onions in the fat. Toss both with chopped bitter greens — radicchio, escarole or endive, for example — toasted pine nuts and halved cherry or grape tomatoes.
83. Toss thinly sliced Vidalia or other sweet onions with olive oil and red wine vinegar. Sear a skirt steak and let sit a minute; slice it thin. Toss salad greens with the onions, roasted red peppers, and steak; add a little more oil and vinegar if necessary.
SALADS WITH NOODLES
84. Spring rolls, unrolled: One at a time, soften a few sheets of rice paper in warm water. Drain, pat dry, cut into strips and toss with chopped cucumber, grated carrots, chopped cilantro, bean sprouts, chili flakes and chopped roasted peanuts. Dress with toasted sesame oil, fish sauce or soy sauce, and rice vinegar or lime juice. A few shrimp are a nice addition.
85. Mix lots of arugula with somewhat less cold whole wheat penne, lemon zest, olive oil and Parmesan. The idea is an arugula salad with pasta, not a pasta salad with arugula.
86. Toss chilled cooked soba noodles with diced cucumber (if they’re fat and old, peel and seed them first), a small amount of hijiki reconstituted with water, toasted sesame seeds and a vinaigrette laced with soy sauce and miso.
87. Cold not-sesame noodles: Combine about a half-cup peanut butter with a tablespoon soy sauce and enough coconut milk to make the mixture creamy (about a half cup), along with garlic and chili flakes in a blender or food processor. Toss sauce with cooked and cooled noodles, a load of mint, Thai basil, and/or cilantro, and lime juice. Shredded cucumber and carrots optional.
88. Toss cooked pasta with roasted red peppers, toasted walnuts, fresh goat cheese, basil and olive oil. Corny, but still good.
89. Soak or cook rice noodles, drain and rinse; toss with cubed unripe mango, chopped peanuts, shredded carrot and minced scallion. Make a dressing of rice vinegar, fish sauce, lime juice, chili and a bit of sugar.
90. Sort of classic pasta salad: Pasta, artichoke hearts, sliced prosciutto or salami, chopped plum tomato. Dress with olive oil and a bit of balsamic vinegar, perhaps with some mustard.
GRAIN SALADS
91. Cereal for grown-ups: Start with puffed brown rice; toss with chopped tomatoes, scallions, a minced chili, cooked or canned chickpeas and toasted unsweetened coconut. Dress with coconut milk and lime juice.
92. Simmer a cup of bulgur and some roughly chopped cauliflower florets until tender, 10 to 15 minutes. Toss with chopped tarragon, roughly chopped hazelnuts, minced garlic, Dijon mustard, olive oil and lemon juice.
93. Mix leftover rice with lemon or lime juice, soy sauce and a combination of sesame and peanut oils. Microwave if necessary to soften the rice, then serve at room temperature, tossed with sprouts, shredded radishes, chopped scallions, bits of cooked meat or fish if you like and more soy sauce.
94. Cook and cool quinoa. Toss with olive oil, loads of lemon juice, tons of parsley, some chopped tomatoes and, if you like, toasted pine nuts. Call it quinoa tabbouleh.
95. Mix cooked couscous or quinoa with orange zest and juice, olive oil, maybe honey, sliced oranges, raisins or dried cranberries, chopped red onion and chopped almonds. Serve over greens, or not.
96. Cook short-grain white rice in watered-down coconut milk (be careful that it doesn’t burn) and a few cardamom pods. While warm, toss with peas (they can be raw if they’re fresh and tender), chopped cashews or pistachios, a pinch of chili flakes and chopped raw spinach.
97. Toss cooked, cooled farro, wheat berries, barley or other chewy grain with chopped-up grapes. Add olive oil, lemon juice and thinly sliced romaine lettuce; toss again, with ricotta salata or feta if you want.
98. Toss cooked bulgur with cooked chickpeas, quartered cherry or grape tomatoes, a little cumin, lots of chopped parsley, and lemon juice.
99. Toss cooked quinoa with fresh sliced apricots, cherries, pecans, and enough lemon and black pepper to make the whole thing savory.
100. Mash a canned chipotle with some of its adobo and stir with olive oil and lime juice. Toss with drained canned hominy, fresh corn cut from the cob (or drained pinto beans), cilantro and green onions.
Basic Vinaigrette
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1/2 cup extra virgin olive oil
3 tablespoons or more good wine vinegar
Salt and freshly ground black pepper
1 large shallot, cut into chunks (optional).
1. Combine all ingredients except shallot in a blender and turn on machine; a creamy emulsion will form within 30 seconds. Taste and add vinegar a teaspoon or two at a time until balance tastes right to you.
2. Add shallot, if using, and turn machine on and off a few times until shallot is minced within dressing. Taste, adjust seasoning and serve. (This will keep, refrigerated, for a few days.)
Yield: About 3/4 cup.
July 22, 2009
Recipe
Real Ranch Dressing
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1 cup mayonnaise
1 cup buttermilk
1/4 cup buttermilk powder
Salt and freshly ground black pepper
1/4 cup chopped fresh chives or parsley leaves (optional).
1. Put mayonnaise, buttermilk and buttermilk powder in a medium jar with a tight-fitting lid. Sprinkle with a little salt and lots of freshly ground black pepper. Add chives or parsley if you like, put lid on, and shake jar vigorously for 30 seconds or so.
2. Taste and adjust seasoning. Use immediately or refrigerate for a few days. It will keep longer if you do not add the fresh herbs.
Yield: 2 cups.
July 22, 2009
Recipe
Yogurt-Feta Dressing
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
4 ounces feta cheese
1/2 cup plain yogurt, preferably whole-milk
1/2 cup olive oil, or less
1/2 cup chopped fresh mint
Zest and juice of 1 lemon
Salt
Freshly ground black pepper.
In a blender or food processor, combine feta, yogurt, 1/4 cup olive oil, mint, lemon zest and juice; sprinkle with salt and pepper. Blend or process until smooth, adding more oil if you need it to reach a smooth consistency. You can also mash mixture by hand, with a fork.
Yield: About 1 1/2 cups.
July 22, 2009
Recipe
Miso-Ginger Dressing
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1/4 cup peanut oil or neutral oil, like grapeseed or corn
1/4 cup rice vinegar
3 tablespoons mild or sweet miso, like yellow or white
1 tablespoon dark sesame oil
2 medium carrots, roughly chopped
1 inchlong piece fresh ginger, cut into coins
Salt and freshly ground black pepper.
Put all ingredients except salt and pepper into a food processor and pulse a few times to mince carrots. Then let machine run for a minute or so, until mixture is chunky-smooth. (If you want it smoother, use a blender.) Taste and add salt and pepper to taste.
Yield: About 1 1/4 cups.
July 22, 2009
Recipe
Avocado-Basil Dressing
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1 avocado
1/2 cup fresh basil leaves
1 clove garlic
Juice of one or more limes
1/4 cup olive oil
Salt and freshly ground pepper.
Put all ingredients in a mini food processor or blender and purée until smooth; add a few drops of water if you like a thinner dressing.
Yield: About 1 cup.
July 22, 2009
Recipe
Creamy Vinaigrette
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1/3 cup extra virgin olive oil
3 tablespoons or more good white wine vinegar
3 tablespoons sour cream, yogurt or mayonnaise
1 teaspoon Dijon mustard
1 small shallot cut into chunks
Salt and freshly ground black pepper.
1. Combine all ingredients except shallot in a blender and turn on machine; a creamy emulsion will form within 30 seconds. Taste and add vinegar a teaspoon or two at a time until balance tastes right to you.
2. Add shallot and turn machine on and off a few times until shallot is minced within dressing. Taste, adjust the seasoning and serve.
Yield: About 2/3 cup.
July 22, 2009
Recipe
Ginger Vinaigrette
By MARK BITTMAN
Adapted from “Jean-Georges: Cooking at Home with a Four-Star Chef,” by Jean-Georges Vongerichten and Mark Bittman (Broadway Books, 1998)
Time: 10 minutes
1 cup extra virgin olive oil
1 2-inch piece of ginger, peeled and roughly chopped
1 tablespoon sherry vinegar
2 tablespoons fresh lime juice
Salt and freshly ground pepper.
Combine all ingredients in a blender, using plenty of black pepper. Add 1 tablespoon warm water and blend until dressing is emulsified. Best if left to rest for a day before using, to enhance flavors.
Yield: 1 1/4 cups.
July 22, 2009
Recipe
Mayonnaise
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1 egg yolk
2 teaspoons Dijon mustard
1 cup neutral oil, like grapeseed or corn, or extra virgin olive oil
Salt and freshly ground black pepper
1 tablespoon lemon juice or sherry or white wine vinegar.
1. Put yolk and mustard in a medium bowl. Beat together with a wire whisk. Begin to add oil as you beat, a little at a time, adding more as each bit is incorporated. You will notice when a thick emulsion forms, then you can add oil a little faster. Depending on how fast you beat, the whole process will take about 5 minutes.
2. Add salt and pepper, then stir in lemon juice or vinegar. Taste and adjust seasoning if necessary.
Yield: 1 cup.
101. Cook a pot of short-grain rice. While it’s still hot, toss with raw grated zucchini, fermented black beans, sriracha, sesame oil, sake and a touch of rice vinegar. Add bits of leftover roast chicken or pork if you have it, and pass soy sauce at the table.
The Minimalist
101 Simple Salads for the Season By MARK BITTMAN
SUMMER may not be the best time to cook, but it’s certainly among the best times to eat. Toss watermelon and peaches with some ingredients you have lying around already, and you can produce a salad that’s delicious, unusual, fast and perfectly seasonal.
That’s the idea behind the 101 ideas found in this section. In theory, each salad takes 20 minutes or less. Honestly, some may take you a little longer. But most minimize work at the stove and capitalize on the season, when tomatoes, eggplant, herbs, fruit, greens and more are plentiful and excellent.
This last point is important. Not everything needs to be farmers’ market quality, but it’s not too much to expect ripe fruit, fragrant herbs and juicy greens.
Salt, to taste, is a given in all of these recipes. Pepper, too (if I want you to use a lot of pepper, I say so).
Herein, then, are enough salad ideas to tide you over until the weather cools down.
MOSTLY VEGAN SALADS
1. Cube watermelon and combine with tomato chunks, basil and basic vinaigrette. You can substitute peach for the watermelon or the tomato (but not both, O.K.?). You can also add bacon or feta, but there goes the vegan-ness.
2. Mix wedges of tomatoes and peaches, add slivers of red onion, a few red-pepper flakes and cilantro. Dress with olive oil and lime or lemon juice. Astonishing.
3. A nice cucumber salad: Slice cucumbers thin (if they’re fat and old, peel and seed them first), toss with red onions and salt, then let sit for 20 to 60 minutes. Rinse, dry, dress with cider vinegar mixed with Dijon mustard; no oil necessary.
4. Shave raw asparagus stalks with a vegetable peeler. Discard the tough first pass of the peeler — i.e., the peel — but do use the tips, whole. Dress with lemon vinaigrette and coarse salt. (Chopped hard-boiled eggs optional but good.)
5. Grate or very thinly slice Jerusalem artichokes; mix with pitted and chopped oil-cured olives, olive oil, lemon juice and a sprinkling of coarsely ground cumin. Unusual and wonderful.
6. Sichuan slaw: Toss bean sprouts, shredded carrots and celery, minced fresh chili, soy sauce, sesame oil and a bit of sugar. Top with chopped peanuts and chopped basil, mint and/or cilantro. (The full trio is best.)
7. Grate carrots, toast some sunflower seeds, and toss with blueberries, olive oil, lemon juice and plenty of black pepper. Sweet, sour, crunchy, soft.
8. Chop or slice radishes (or jicama, or the ever-surprising kohlrabi) and combine with chopped or sliced unripe (i.e., still crunchy) mango, lime juice and mint or cilantro.
9. Chop or slice jicama (or radishes or kohlrabi) and mango and mix with coconut milk, lime juice, curry powder and cilantro or mint.
10. Cook whole grape tomatoes in olive oil over high heat until they brown lightly, sprinkling with curry powder. Cool a bit, then toss with chopped arugula, loads of chopped mint and lime juice.
11. Chop and steam baby or grown-up bok choy until crisp-tender, then shock it in ice water. Drain, then toss with halved cherry tomatoes, capers, olive oil and lemon juice.
12. Combine sliced fennel and prune plums; serve with vinaigrette spiked with minced ginger. Nice pairing.
13. A red salad: Combine tomato wedges with halved strawberries, basil leaves, shaved Parmesan and balsamic vinegar.
14. A classic Moroccan thing: Thinly slice carrots, or grate or shred them (the food processor makes quick work of this). Toss with toasted cumin seeds, olive oil, lemon juice and cilantro. Raisins are good in here, too. There is no better use of raw carrots.
15. Cut cherry or grape tomatoes in half; toss with soy sauce, a bit of dark sesame oil and basil or cilantro. I love this — the tomato juice-soy thing is incredible.
16. Slice fennel and crisp apple about the same thickness (your choice). Combine, then dress with mustardy vinaigrette and chopped parsley. Come fall, this will be even better.
17. With thanks to Szechuan Gourmet restaurant: Finely chop celery and mix with a roughly equal amount of pressed or smoked tofu, chopped. Dress with peanut oil warmed with chili flakes and Sichuan peppercorns, then mixed with soy sauce.
18. Roughly chop cooked or canned chickpeas (you can pulse them, carefully, in a food processor) and toss with olive oil, lemon juice, lots of chopped fresh parsley and mint, and a few chopped tomatoes. Call this chickpea tabbouleh.
19. Mix cooked cannellini or other white beans, chopped cherry or grape tomatoes and arugula or baby spinach. Lightly toast sliced garlic in olive oil with rosemary and red pepper flakes; cool slightly, add lemon zest or juice or both, then pour over beans.
20. Shred Napa cabbage and radishes. The dressing is roasted peanuts, lime juice, peanut or other oil, cilantro and fresh or dried chili, all whizzed in a blender. Deliciousness belies ease.
21. Dice cucumbers (if they’re fat and old, peel and seed them first) and toss with cubes of avocado, a little mirin (or honey, but then it’s not vegan), rice vinegar and soy sauce. (You could mix in a little lump crab meat, really not vegan, even rice, and call it a California roll salad.)
22. Thinly slice button mushrooms; toss with finely chopped carrots and celery and mix with mung bean sprouts. Finish with peanut or olive oil, sherry vinegar, a little soy sauce and minced ginger. (This is a super vinaigrette, by the way.)
23. Thinly slice some cucumbers (if they’re fat and old, peel and seed them first), red onions, radishes and fresh chili pepper. Soak for a few minutes in equal amounts vinegar and water, with some salt and sugar. When they taste lightly pickled, drain and serve, alone or over rice.
24. Blanch spinach, then drain and shock in ice water. Squeeze it dry, chop it and toss it with toasted pine nuts, raisins, olive oil and a tiny bit of balsamic vinegar. Capers are good, too. Quite elegant, actually.
25. Combine chopped bell peppers, tomatoes, red onion, chilies and cilantro, then toss with corn tortilla strips, toasted in a 350-degree oven until crisp (or yes, use packaged chips; why not?). Dust with chili powder and lots of lime juice.
26. Combine mushroom caps and thinly sliced red onions with olive oil; broil gently until tender and browned. Toss with a lot of chopped fresh parsley or basil (or both) and a simple vinaigrette. Some chopped escarole, arugula or watercress is good, too.
27. Cook whole, unpeeled eggplant in a dry, hot skillet or on a grill, turning occasionally, until completely collapsed and soft. Chop and toss with toasted pita, toasted pine nuts, cooked white beans and halved cherry tomatoes. Dress with olive oil, lemon juice and lots of black pepper. Or a (non-vegan) yogurt dressing is good, especially one laced with tahini.
28. Toss mâche or another soft green with toasted slivered almonds and roughly chopped fresh figs. Thin some almond butter with water and sherry vinegar to taste and use as a dressing. Some will like this with fresh goat cheese.
29. Pit and halve cherries (or halve and pit cherries), then cook gently with olive oil and a little balsamic vinegar until they break down. Toss with chopped radicchio, endive, escarole or a combination, some toasted hazelnuts and more oil and vinegar, if necessary.
30. Fast, grown-up potato salad: Boil bite-size red potatoes. While still warm, dress them with olive oil, lemon juice, whole grain mustard, capers and parsley. Chopped shallots, bell peppers, etc., all welcome, too.
31. Roast beets whole (or buy them precooked), then slice or cube and toss with a little chopped garlic (or a lot of roasted garlic), toasted walnuts, orange juice and olive oil.
32. Same deal with the beets, but toss with cooked corn, arugula, olive oil, sherry vinegar and chopped shallots.
33. The real five-bean: Chickpeas, cannellini or other white beans, kidney or other red beans, steamed string beans and steamed yellow wax beans. Toss with vinaigrette, chopped scallions or red onion, and parsley.
34. Grill quartered romaine hearts, radicchio and/or endive. Drizzle with olive oil and sherry vinegar, and add dill and chopped shallots. Teeny-tiny croutons are great on this.
35. Combine cooked or canned black beans with shredded cabbage and this vinaigrette: olive oil, fresh orange juice, not much sherry vinegar, ground cumin.
36. Mix cooked or canned chickpeas with toasted coconut, shredded carrots, chopped celery, curry powder, olive oil, lime juice and cilantro.
VEGETARIAN SALADS
37. Cube smoked tofu, then brush it with a mixture of honey and orange juice; broil until browned. Toss with chopped cucumbers, radishes and peas or pea shoots; drizzle with soy sauce and lime juice.
38. Cube watermelon; combine with roughly chopped mint, crumbled feta, sliced red onion and chopped Kalamata olives. Dress lightly with olive oil and lemon juice. Despite saltiness of feta and olives, this may need salt.
39. Yucatecan street food as salad: Roast fresh corn kernels in a pan with a little oil; toss with cayenne or minced chilis, lime juice and a little queso fresco. Cherry tomatoes are optional.
40. Slice cucumber and top with capers, olive oil, lots of pepper and little dollops of fresh ricotta. Note: cucumbers, ricotta and oil must all be really good.
41. Halve avocados and scoop out some but not all of their flesh. Roughly chop and toss with black beans, queso fresco, cilantro, chopped tomatillos and lime juice. Serve in the meaty avocado shells.
42. Trim crusts if necessary from day-or-two-old bread (or even three-day-old bread), cube and marinate in black olive tapenade thinned with more olive oil. Add chopped capers and toss with tomatoes, basil and mozzarella. (Anchovies optional.)
43. Grate raw beets (use the food processor to avoid ruining everything within spattering distance) and toss with watercress or arugula. Top with sherry vinaigrette and a little goat cheese. Especially obvious, perhaps, but also especially popular.
44. Make a crisp grilled cheese sandwich, with good bread and not too much good cheese. Let it cool, then cut into croutons. Put them on anything, but especially tomato and basil salad. This you will do forever.
45. Halve or quarter cooked artichoke hearts (the best are fresh and grilled, but you can use canned or frozen) and combine with cherry tomatoes, bits of feta or Parmesan or both, olive oil and lemon juice.
46. Sauté mushrooms and shallots in olive oil. Add a lot of spinach, chopped unless the leaves are small. When it wilts, stir in parsley and crumbled blue cheese. Feels like a steakhouse side-dish salad.
47. Thinly slice raw button mushrooms; combine with sliced or shaved Parmesan, parsley and a vinaigrette of olive oil, sherry vinegar and shallots.
48. Toss roughly chopped dandelion greens (or arugula or watercress) with chopped preserved lemon, chickpeas, crumbled feta and olive oil. (Before you start cursing me out, here’s a quick way to make preserved lemons: chop whole lemons and put in a bowl with the juice of another lemon or two, sprinkle with a fair amount of salt and let sit for an hour or so.)
49. Toss greens with walnuts, blue cheese and raspberries; drizzle with a simple vinaigrette. Sell for $14 a serving.
50. It’s puttanesca-ish: Egg salad with pitted black olives, chopped tomatoes, capers, anchovies (optional), a tiny bit of garlic and some red onion; mayonnaise as needed.
51. Arrange sliced ripe tomatoes and hard-boiled eggs on a platter; scatter a handful of chopped pitted green olives on top. Drizzle with a dressing made with olive oil, sherry vinegar and a teaspoon of pimentón.
52. Chop hard-boiled eggs and mix with just enough mayonnaise to bind; spoon into endive leaves. Top each with a small canned sardine and drizzle with a vinaigrette of olive oil, lemon juice and mustard.
53. Peel beets and grate them in a food processor. Mix equal parts plain yogurt and tahini, and toss with the beets along with lemon juice and za’atar (a mixture of toasted sesame seeds, dried green herbs and ground sumac; you can make it yourself using dried thyme).
54. Slice roasted red peppers (if you must use canned, try to find piquillos) and fresh mozzarella. Toss with cooked white beans, olive oil, red wine vinegar, a chopped shallot and fresh rosemary or parsley.
SALADS WITH SEAFOOD
55. Mix watercress with chopped smoked salmon, avocado, red onion and capers. Make a vinaigrette with olive oil, sherry vinegar and mustard powder.
56. Salade niçoise, sort of: On or around a bed of greens, make mounds of olives, cooked new potatoes and green beans (warm or at room temperature), good tomatoes, capers, fennel slivers, hard-cooked eggs and good quality Italian canned tuna. None of these is crucial; you get the idea. Serve with vinaigrette or aioli.
57. Toss cubes of day-or-more-old good bread with soy sauce, chopped sautéed shrimp, chopped radishes and cilantro. Like a weird shrimp toast panzanella.
58. Sear tuna until rare (for that matter, you could leave it raw) and cut it into small cubes. Toss with shredded jicama or radish and shredded Napa cabbage; season with mirin, soy sauce and cilantro. Avocado and/or wasabi paste are great with this, too.
59. Sear tuna, or use good canned tuna. Chop it up and mix with chopped olives, capers, tomatoes, parsley and olive oil.
60. Ditto on the tuna. Mix with chopped apples, halved seedless grapes, chopped red onion, olive oil, a bit of cumin and black pepper.
61. Mix canned salmon (sockeye, or use cooked fresh) with capers, chopped celery, yogurt or mayonnaise, and lemon juice. Serve on greens or in endive leaves.
62. Dust shrimp with chili powder. Sauté in butter or oil (or a combination) with fresh corn kernels and flavorful cooking greens (bok choy is good, as is watercress). Add halved cherry tomatoes and lime juice at the last minute.
63. Sunday brunch salad: Mix diced cucumbers, chopped tomato, minced red onion and capers with bits of smoked salmon. Dress with lemon juice (you won’t need much oil, if any). Take a step further by adding croutons of cubed toasted bagels.
64. Alternative Sunday brunch: Shred or chop cucumbers (if they’re fat and old, peel and seed them first), then toss with flaked smoked trout or whitefish, capers, dill, lemon juice and olive oil.
65. In a hot pan, flash-cook cut-up squid in a little olive oil for no more than two minutes. Toss with cooked or canned chickpeas, chopped bell peppers, lemon juice, a little more oil and parsley.
66. In a hot pan, sear sea scallops for a minute or two on each side, depending on size. Slice or chop, then toss with thinly sliced fennel and lemon or orange vinaigrette and some chopped fennel fronds.
67. Bread salad for anchovy lovers: Chop together many anchovies, a few capers, lemon juice and olive oil (or anchovy oil). Toss with cubes of toasted bread and chopped tomatoes or halved cherry or grape tomatoes.
68. Mix crab meat with pan-roasted corn, chopped avocado, halved cherry or grape tomatoes, olive oil, lemon juice and perhaps a bit of cilantro and crumbled ancho chili.
69. Stir-fry small or chopped shrimp in olive or peanut oil with lots of ginger; while still warm, combine with tomato wedges, chopped romaine, cilantro, scallions and lots of lime juice. Good in pita.
SALADS WITH MEAT
70. Shred brussels sprouts in the food processor, preferably with the slicing disk. Toss with vinaigrette and crumbled bacon.
71. Combine sliced green tomatoes and sliced fresh mozzarella; top with roughly chopped basil, olive oil, black pepper and crumbled bacon.
72. Sort-of carpaccio salad: Broil or grill skirt or sirloin steak very rare and slice very thin. Arrange on a plate with tomato wedges, lettuce and lemon juice.
73. Hawaiitalian: Combine pineapple chunks with bits of any cured pork product — cooked guanciale is ideal, or any ham — and a not-too-subtle chili vinaigrette.
74. Julienne red, yellow and orange bell peppers; mix with thinly sliced red onion, olive oil and cooked crumbled sausage or chopped salami.
75. The Little Italy salad: Chop or julienne salami and prosciutto, then toss with cubed mozzarella, chopped tomato, pepperoncini, oil and wine vinegar.
76. Slice fresh figs — many, if you live where they grow — and top with crumbled bacon, balsamic vinegar (the best you have) and crumbled blue cheese.
77. Combine shredded cabbage or lettuce with bits of good turkey, Swiss cheese and rye croutons. Top with good old Russian dressing, call it a turkey sandwich salad and don’t knock it until you try it.
78. What happens when your Chicago hot dog falls apart: Toss together tomato wedges, chopped pickles, hot peppers, shredded lettuce and a few slices of broiled or grilled hot dog. Dress with a vinaigrette made with mustard (should be yellow for authenticity, but ...) and celery salt. (You could throw in freshly made croutons; inauthentic, but better than a hot dog bun.)
79. Sear a steak and move it to a cutting board (don’t wash the pan); wait a minute or two, then slice. Cut kale (preferably black, also known as Tuscan, or dino kale) into thin ribbons and toss in the pan over high heat for a minute. Turn off the heat, add chopped black olives, olive oil and sherry vinegar. Serve kale with steak on top.
80. Sort-of-Cobb salad: Choose any combination of hard-cooked eggs, chopped prosciutto, cooked chicken, crumbled Gorgonzola, chopped tomatoes, chickpeas or white beans, sliced red onion, olives. Make vinaigrette with capers and anchovies.
81. Soak sliced prune plums or figs in balsamic vinegar for a few minutes, then add olive oil, chopped celery and red onion, shreds of roasted or grilled chicken, chopped fresh marjoram or oregano and chopped almonds. Serve on top of or toss with greens. So good.
82. Cut pancetta into matchsticks and crisp in a skillet with some oil, then caramelize onions in the fat. Toss both with chopped bitter greens — radicchio, escarole or endive, for example — toasted pine nuts and halved cherry or grape tomatoes.
83. Toss thinly sliced Vidalia or other sweet onions with olive oil and red wine vinegar. Sear a skirt steak and let sit a minute; slice it thin. Toss salad greens with the onions, roasted red peppers, and steak; add a little more oil and vinegar if necessary.
SALADS WITH NOODLES
84. Spring rolls, unrolled: One at a time, soften a few sheets of rice paper in warm water. Drain, pat dry, cut into strips and toss with chopped cucumber, grated carrots, chopped cilantro, bean sprouts, chili flakes and chopped roasted peanuts. Dress with toasted sesame oil, fish sauce or soy sauce, and rice vinegar or lime juice. A few shrimp are a nice addition.
85. Mix lots of arugula with somewhat less cold whole wheat penne, lemon zest, olive oil and Parmesan. The idea is an arugula salad with pasta, not a pasta salad with arugula.
86. Toss chilled cooked soba noodles with diced cucumber (if they’re fat and old, peel and seed them first), a small amount of hijiki reconstituted with water, toasted sesame seeds and a vinaigrette laced with soy sauce and miso.
87. Cold not-sesame noodles: Combine about a half-cup peanut butter with a tablespoon soy sauce and enough coconut milk to make the mixture creamy (about a half cup), along with garlic and chili flakes in a blender or food processor. Toss sauce with cooked and cooled noodles, a load of mint, Thai basil, and/or cilantro, and lime juice. Shredded cucumber and carrots optional.
88. Toss cooked pasta with roasted red peppers, toasted walnuts, fresh goat cheese, basil and olive oil. Corny, but still good.
89. Soak or cook rice noodles, drain and rinse; toss with cubed unripe mango, chopped peanuts, shredded carrot and minced scallion. Make a dressing of rice vinegar, fish sauce, lime juice, chili and a bit of sugar.
90. Sort of classic pasta salad: Pasta, artichoke hearts, sliced prosciutto or salami, chopped plum tomato. Dress with olive oil and a bit of balsamic vinegar, perhaps with some mustard.
GRAIN SALADS
91. Cereal for grown-ups: Start with puffed brown rice; toss with chopped tomatoes, scallions, a minced chili, cooked or canned chickpeas and toasted unsweetened coconut. Dress with coconut milk and lime juice.
92. Simmer a cup of bulgur and some roughly chopped cauliflower florets until tender, 10 to 15 minutes. Toss with chopped tarragon, roughly chopped hazelnuts, minced garlic, Dijon mustard, olive oil and lemon juice.
93. Mix leftover rice with lemon or lime juice, soy sauce and a combination of sesame and peanut oils. Microwave if necessary to soften the rice, then serve at room temperature, tossed with sprouts, shredded radishes, chopped scallions, bits of cooked meat or fish if you like and more soy sauce.
94. Cook and cool quinoa. Toss with olive oil, loads of lemon juice, tons of parsley, some chopped tomatoes and, if you like, toasted pine nuts. Call it quinoa tabbouleh.
95. Mix cooked couscous or quinoa with orange zest and juice, olive oil, maybe honey, sliced oranges, raisins or dried cranberries, chopped red onion and chopped almonds. Serve over greens, or not.
96. Cook short-grain white rice in watered-down coconut milk (be careful that it doesn’t burn) and a few cardamom pods. While warm, toss with peas (they can be raw if they’re fresh and tender), chopped cashews or pistachios, a pinch of chili flakes and chopped raw spinach.
97. Toss cooked, cooled farro, wheat berries, barley or other chewy grain with chopped-up grapes. Add olive oil, lemon juice and thinly sliced romaine lettuce; toss again, with ricotta salata or feta if you want.
98. Toss cooked bulgur with cooked chickpeas, quartered cherry or grape tomatoes, a little cumin, lots of chopped parsley, and lemon juice.
99. Toss cooked quinoa with fresh sliced apricots, cherries, pecans, and enough lemon and black pepper to make the whole thing savory.
100. Mash a canned chipotle with some of its adobo and stir with olive oil and lime juice. Toss with drained canned hominy, fresh corn cut from the cob (or drained pinto beans), cilantro and green onions.
Basic Vinaigrette
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1/2 cup extra virgin olive oil
3 tablespoons or more good wine vinegar
Salt and freshly ground black pepper
1 large shallot, cut into chunks (optional).
1. Combine all ingredients except shallot in a blender and turn on machine; a creamy emulsion will form within 30 seconds. Taste and add vinegar a teaspoon or two at a time until balance tastes right to you.
2. Add shallot, if using, and turn machine on and off a few times until shallot is minced within dressing. Taste, adjust seasoning and serve. (This will keep, refrigerated, for a few days.)
Yield: About 3/4 cup.
July 22, 2009
Recipe
Real Ranch Dressing
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1 cup mayonnaise
1 cup buttermilk
1/4 cup buttermilk powder
Salt and freshly ground black pepper
1/4 cup chopped fresh chives or parsley leaves (optional).
1. Put mayonnaise, buttermilk and buttermilk powder in a medium jar with a tight-fitting lid. Sprinkle with a little salt and lots of freshly ground black pepper. Add chives or parsley if you like, put lid on, and shake jar vigorously for 30 seconds or so.
2. Taste and adjust seasoning. Use immediately or refrigerate for a few days. It will keep longer if you do not add the fresh herbs.
Yield: 2 cups.
July 22, 2009
Recipe
Yogurt-Feta Dressing
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
4 ounces feta cheese
1/2 cup plain yogurt, preferably whole-milk
1/2 cup olive oil, or less
1/2 cup chopped fresh mint
Zest and juice of 1 lemon
Salt
Freshly ground black pepper.
In a blender or food processor, combine feta, yogurt, 1/4 cup olive oil, mint, lemon zest and juice; sprinkle with salt and pepper. Blend or process until smooth, adding more oil if you need it to reach a smooth consistency. You can also mash mixture by hand, with a fork.
Yield: About 1 1/2 cups.
July 22, 2009
Recipe
Miso-Ginger Dressing
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1/4 cup peanut oil or neutral oil, like grapeseed or corn
1/4 cup rice vinegar
3 tablespoons mild or sweet miso, like yellow or white
1 tablespoon dark sesame oil
2 medium carrots, roughly chopped
1 inchlong piece fresh ginger, cut into coins
Salt and freshly ground black pepper.
Put all ingredients except salt and pepper into a food processor and pulse a few times to mince carrots. Then let machine run for a minute or so, until mixture is chunky-smooth. (If you want it smoother, use a blender.) Taste and add salt and pepper to taste.
Yield: About 1 1/4 cups.
July 22, 2009
Recipe
Avocado-Basil Dressing
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1 avocado
1/2 cup fresh basil leaves
1 clove garlic
Juice of one or more limes
1/4 cup olive oil
Salt and freshly ground pepper.
Put all ingredients in a mini food processor or blender and purée until smooth; add a few drops of water if you like a thinner dressing.
Yield: About 1 cup.
July 22, 2009
Recipe
Creamy Vinaigrette
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1/3 cup extra virgin olive oil
3 tablespoons or more good white wine vinegar
3 tablespoons sour cream, yogurt or mayonnaise
1 teaspoon Dijon mustard
1 small shallot cut into chunks
Salt and freshly ground black pepper.
1. Combine all ingredients except shallot in a blender and turn on machine; a creamy emulsion will form within 30 seconds. Taste and add vinegar a teaspoon or two at a time until balance tastes right to you.
2. Add shallot and turn machine on and off a few times until shallot is minced within dressing. Taste, adjust the seasoning and serve.
Yield: About 2/3 cup.
July 22, 2009
Recipe
Ginger Vinaigrette
By MARK BITTMAN
Adapted from “Jean-Georges: Cooking at Home with a Four-Star Chef,” by Jean-Georges Vongerichten and Mark Bittman (Broadway Books, 1998)
Time: 10 minutes
1 cup extra virgin olive oil
1 2-inch piece of ginger, peeled and roughly chopped
1 tablespoon sherry vinegar
2 tablespoons fresh lime juice
Salt and freshly ground pepper.
Combine all ingredients in a blender, using plenty of black pepper. Add 1 tablespoon warm water and blend until dressing is emulsified. Best if left to rest for a day before using, to enhance flavors.
Yield: 1 1/4 cups.
July 22, 2009
Recipe
Mayonnaise
By MARK BITTMAN
Adapted from “How to Cook Everything,” by Mark Bittman (Wiley, 2008)
Time: 5 minutes
1 egg yolk
2 teaspoons Dijon mustard
1 cup neutral oil, like grapeseed or corn, or extra virgin olive oil
Salt and freshly ground black pepper
1 tablespoon lemon juice or sherry or white wine vinegar.
1. Put yolk and mustard in a medium bowl. Beat together with a wire whisk. Begin to add oil as you beat, a little at a time, adding more as each bit is incorporated. You will notice when a thick emulsion forms, then you can add oil a little faster. Depending on how fast you beat, the whole process will take about 5 minutes.
2. Add salt and pepper, then stir in lemon juice or vinegar. Taste and adjust seasoning if necessary.
Yield: 1 cup.
101. Cook a pot of short-grain rice. While it’s still hot, toss with raw grated zucchini, fermented black beans, sriracha, sesame oil, sake and a touch of rice vinegar. Add bits of leftover roast chicken or pork if you have it, and pass soy sauce at the table.
Challenge to Health Bill: Selling Reform By DAVID LEONHARDT
July 22, 2009
Economic Scene
Challenge to Health Bill: Selling Reform By DAVID LEONHARDT
WASHINGTON — What’s in it for me?
On the subject of health care reform, most Americans probably don’t have a good answer to the question. And that, obviously, is a problem for the White House and for Democratic leaders in Congress.
Current bills would expand the number of insured — but 90 percent of voters already have insurance. Congressional leaders say the bills would cut costs. But experts are dubious. Instead, they point out that covering the uninsured would cost billions.
So the typical person watching from afar is left to wonder: What will this project mean for me, besides possibly higher taxes?
Barack Obama was able to rise from the Illinois State Senate to the presidency in large measure because of his ability to explain complex issues and then to make a persuasive argument. He now has a challenge worthy of his skills.
Our health care system is engineered, deliberately or not, to resist change. The people who pay for it — you and I — often don’t realize that they’re paying for it. Money comes out of our paychecks, in withheld taxes and insurance premiums, before we ever see it. It then flows to doctors, hospitals and drug makers without our realizing that it was our money to begin with.
The doctors, hospitals and drug makers use the money to treat us, and we of course do see those treatments. If anything, we want more of them. They are supposed to make us healthy, and they appear to be free. What’s not to like?
The immediate task facing Mr. Obama — in his news conference on Wednesday night and beyond — is to explain that the health care system doesn’t really work the way it seems to. He won’t be able to put it in such blunt terms. But he will need to explain how a typical household, one that has insurance and thinks it always will, is being harmed.
The United States now devotes one-sixth of its economy to medicine. Divvy that up, and health care will cost the typical household roughly $15,000 this year, including the often-invisible contributions by employers. That is almost twice as much as two decades ago (adjusting for inflation). It’s about $6,500 more than in other rich countries, on average.
We may not be aware of this stealth $6,500 health care tax, but if you take a moment to think, it makes sense. Over the last 20 years, health costs have soared, and incomes have grown painfully slowly. The two trends are directly connected: employers had to spend more money on benefits, leaving less for raises.
In exchange for the $6,500 tax, we receive many things. We get cutting-edge research and heroic surgeries. But we also get fabulous amounts of waste — bureaucratic and medical.
One thing we don’t get is better health than other rich countries, whether it’s Canada, France, Japan or many others. In some categories, like emergency room care, this country seems to do better. In others, like chronic-disease care, it seems to do worse. “The fact that we spend all this money and don’t have better outcomes than other countries is a sign of how poorly we’re doing,” says Dr. Alan Garber of Stanford University. “We should be doing way better.”
So far, no one has grabbed the mantle as the defender of the typical household — the opponent of spending that creates profits for drug companies and hospitals at no benefit to people’s health and at significant cost to their finances.
Republicans have actually come out against doing research into which procedures improve health. Blue Dog Democrats oppose wasteful spending but until recently have not been specific. Liberals rely on the wishful idea — yet to be supported by evidence — that more preventive care will reduce spending. The American Medical Association, not surprisingly, endorses this notion of doing more care in the name of less care.
Mr. Obama says many of the right things. Yet the White House has not yet shown that it’s willing to fight the necessary fights. Remember: the $6,500 tax benefits someone. And that someone has a lobbyist. The lobbyist even has an argument about how he is acting in your interest.
These lobbyists, who include big names like Dick Armey and Richard Gephardt, have succeeded in persuading Congress to write bills with a rather clever feature. They include some of the ideas that would cut costs — but defang them.
One proposal would pay doctors based on the quality of care, rather than quantity, but it’s a pilot project. Doctors who already provide good care may well opt in; doctors providing wasteful but lucrative care surely will not. The bills would also finance research on which treatments are effective. But Medicare officials would not be prevented from continuing to spend taxpayer money on ineffective treatments.
In reaction, some people who should be natural supporters of reform have become critics. The Mayo Clinic — one of Mr. Obama’s favorite models of care — says the legislation fails to “help create higher-quality, more affordable health care.”
On Thursday, Mr. Obama will visit another example he likes to cite, the Cleveland Clinic. Its successes capture what real reform would look like. Like Mayo, the Cleveland Clinic pays its doctors a salary, rather than piecemeal, and delivers excellent results for relatively little money.
“I came here 30-some years ago,” Delos Cosgrove, a heart surgeon who is the clinic’s chief executive, told me. “And I have never received any additional pay for anything I did. It never made a difference if I did five heart operations or four — I got paid the same amount of money. So I had no incentive to do any extra tests or anything.”
This is the crux of the issue, economists say: the current fee-for-service system needs to be remade. The administration has made some progress, by proposing a powerful new Medicare overseer who could force the program to pay for good results and stop paying for bad ones.
But even a strong Medicare plan won’t be enough. Reform will need to attack the piecemeal system in numerous ways. Among the most promising, which Mr. Obama has resisted, is a limit on tax subsidies for the costliest health insurance plans. This limit would give households and employers a reason to become smarter shoppers.
Above all, reform can’t revolve around politely asking the rest of the medical system to become more like the Cleveland Clinic.
In recent weeks, polls have shown that a solid majority of Americans support the stated goals of health reform. Most want the uninsured to be covered and want the option of a government-run insurance plan. Yet the polls also show that people are worried about the package emerging from Congress.
Maybe they have a point.
Economic Scene
Challenge to Health Bill: Selling Reform By DAVID LEONHARDT
WASHINGTON — What’s in it for me?
On the subject of health care reform, most Americans probably don’t have a good answer to the question. And that, obviously, is a problem for the White House and for Democratic leaders in Congress.
Current bills would expand the number of insured — but 90 percent of voters already have insurance. Congressional leaders say the bills would cut costs. But experts are dubious. Instead, they point out that covering the uninsured would cost billions.
So the typical person watching from afar is left to wonder: What will this project mean for me, besides possibly higher taxes?
Barack Obama was able to rise from the Illinois State Senate to the presidency in large measure because of his ability to explain complex issues and then to make a persuasive argument. He now has a challenge worthy of his skills.
Our health care system is engineered, deliberately or not, to resist change. The people who pay for it — you and I — often don’t realize that they’re paying for it. Money comes out of our paychecks, in withheld taxes and insurance premiums, before we ever see it. It then flows to doctors, hospitals and drug makers without our realizing that it was our money to begin with.
The doctors, hospitals and drug makers use the money to treat us, and we of course do see those treatments. If anything, we want more of them. They are supposed to make us healthy, and they appear to be free. What’s not to like?
The immediate task facing Mr. Obama — in his news conference on Wednesday night and beyond — is to explain that the health care system doesn’t really work the way it seems to. He won’t be able to put it in such blunt terms. But he will need to explain how a typical household, one that has insurance and thinks it always will, is being harmed.
The United States now devotes one-sixth of its economy to medicine. Divvy that up, and health care will cost the typical household roughly $15,000 this year, including the often-invisible contributions by employers. That is almost twice as much as two decades ago (adjusting for inflation). It’s about $6,500 more than in other rich countries, on average.
We may not be aware of this stealth $6,500 health care tax, but if you take a moment to think, it makes sense. Over the last 20 years, health costs have soared, and incomes have grown painfully slowly. The two trends are directly connected: employers had to spend more money on benefits, leaving less for raises.
In exchange for the $6,500 tax, we receive many things. We get cutting-edge research and heroic surgeries. But we also get fabulous amounts of waste — bureaucratic and medical.
One thing we don’t get is better health than other rich countries, whether it’s Canada, France, Japan or many others. In some categories, like emergency room care, this country seems to do better. In others, like chronic-disease care, it seems to do worse. “The fact that we spend all this money and don’t have better outcomes than other countries is a sign of how poorly we’re doing,” says Dr. Alan Garber of Stanford University. “We should be doing way better.”
So far, no one has grabbed the mantle as the defender of the typical household — the opponent of spending that creates profits for drug companies and hospitals at no benefit to people’s health and at significant cost to their finances.
Republicans have actually come out against doing research into which procedures improve health. Blue Dog Democrats oppose wasteful spending but until recently have not been specific. Liberals rely on the wishful idea — yet to be supported by evidence — that more preventive care will reduce spending. The American Medical Association, not surprisingly, endorses this notion of doing more care in the name of less care.
Mr. Obama says many of the right things. Yet the White House has not yet shown that it’s willing to fight the necessary fights. Remember: the $6,500 tax benefits someone. And that someone has a lobbyist. The lobbyist even has an argument about how he is acting in your interest.
These lobbyists, who include big names like Dick Armey and Richard Gephardt, have succeeded in persuading Congress to write bills with a rather clever feature. They include some of the ideas that would cut costs — but defang them.
One proposal would pay doctors based on the quality of care, rather than quantity, but it’s a pilot project. Doctors who already provide good care may well opt in; doctors providing wasteful but lucrative care surely will not. The bills would also finance research on which treatments are effective. But Medicare officials would not be prevented from continuing to spend taxpayer money on ineffective treatments.
In reaction, some people who should be natural supporters of reform have become critics. The Mayo Clinic — one of Mr. Obama’s favorite models of care — says the legislation fails to “help create higher-quality, more affordable health care.”
On Thursday, Mr. Obama will visit another example he likes to cite, the Cleveland Clinic. Its successes capture what real reform would look like. Like Mayo, the Cleveland Clinic pays its doctors a salary, rather than piecemeal, and delivers excellent results for relatively little money.
“I came here 30-some years ago,” Delos Cosgrove, a heart surgeon who is the clinic’s chief executive, told me. “And I have never received any additional pay for anything I did. It never made a difference if I did five heart operations or four — I got paid the same amount of money. So I had no incentive to do any extra tests or anything.”
This is the crux of the issue, economists say: the current fee-for-service system needs to be remade. The administration has made some progress, by proposing a powerful new Medicare overseer who could force the program to pay for good results and stop paying for bad ones.
But even a strong Medicare plan won’t be enough. Reform will need to attack the piecemeal system in numerous ways. Among the most promising, which Mr. Obama has resisted, is a limit on tax subsidies for the costliest health insurance plans. This limit would give households and employers a reason to become smarter shoppers.
Above all, reform can’t revolve around politely asking the rest of the medical system to become more like the Cleveland Clinic.
In recent weeks, polls have shown that a solid majority of Americans support the stated goals of health reform. Most want the uninsured to be covered and want the option of a government-run insurance plan. Yet the polls also show that people are worried about the package emerging from Congress.
Maybe they have a point.
Tuesday, July 21, 2009
9/11 Case Could Bring Broad Shift on Civil Suits By ADAM LIPTAK
July 21, 2009
Sidebar
9/11 Case Could Bring Broad Shift on Civil Suits By ADAM LIPTAK
WASHINGTON
The most consequential decision of the Supreme Court’s last term got only a little attention when it landed in May. And what attention it got was for the wrong reason.
But the lower courts have certainly understood the significance of the decision, Ashcroft v. Iqbal, which makes it much easier for judges to dismiss civil lawsuits right after they are filed. They have cited it more than 500 times in just the last two months.
“Iqbal is the most significant Supreme Court decision in a decade for day-to-day litigation in the federal courts,” said Thomas C. Goldstein, an appellate lawyer with Akin Gump Strauss Hauer & Feld in Washington.
On its face, the Iqbal decision concerned the aftermath of the Sept. 11 attacks. The court ruled that a Muslim man swept up on immigration charges could not sue two Bush administration officials for what he said was the terrible abuse he suffered in detention.
But something much deeper and broader was going on in the decision, something that may unsettle how civil litigation is conducted in the United States. Justice Ruth Bader Ginsburg, who dissented from the decision, told a group of federal judges last month that the ruling was both important and dangerous. “In my view,” Justice Ginsburg said, “the court’s majority messed up the federal rules” governing civil litigation.
For more than half a century, it has been clear that all a plaintiff had to do to start a lawsuit was to file what the rules call “a short and plain statement of the claim” in a document called a complaint. Having filed such a bare-bones complaint, plaintiffs were entitled to force defendants to open their files and submit to questioning under oath.
This approach, particularly when coupled with the American requirement that each side pay its own lawyers no matter who wins, gave plaintiffs settlement leverage. Just by filing a lawsuit, a plaintiff could subject a defendant to great cost and inconvenience in the pre-trial fact-finding process called discovery.
Mark Herrmann, a corporate defense lawyer with Jones Day in Chicago, said the Iqbal decision will allow for the dismissal of cases that would otherwise have subjected defendants to millions of dollars in discovery costs. On the other hand, information about wrongdoing is often secret. Plaintiffs claiming they were the victims of employment discrimination, a defective product, an antitrust conspiracy or a policy of harsh treatment in detention may not know exactly who harmed them and how before filing suit. But plaintiffs can learn valuable information during discovery.
The Iqbal decision now requires plaintiffs to come forward with concrete facts at the outset, and it instructs lower court judges to dismiss lawsuits that strike them as implausible.
“Determining whether a complaint states a plausible claim for relief,” Justice Anthony M. Kennedy wrote for the five-justice majority, “requires the reviewing court to draw on its judicial experience and common sense.”
Note those words: Plausible. Common sense.
The old world was mechanical. A lawsuit that mouthed the required words was off and running. As the Supreme Court said in 1957 in Conley v. Gibson, a lawsuit should be allowed to go forward “unless it appears beyond doubt that the plaintiff can prove no set of facts in support of his claim which would entitle him to relief.” Things started to change two years ago, when the Supreme Court found a complaint in an antitrust suit implausible.
In the new world, after Iqbal, a lawsuit has to satisfy a skeptical judicial gatekeeper.
“It obviously licenses highly subjective judgments,” said Stephen B. Burbank, an authority on civil procedure at the University of Pennsylvania Law School. “This is a blank check for federal judges to get rid of cases they disfavor.”
Courts applying Iqbal have been busy. A federal judge in Connecticut dismissed a disability discrimination suit this month, saying that Iqbal required her to treat the plaintiff’s assertions as implausible. A few days later, the federal appeals court in New York dismissed a breach of contract and securities fraud suit after concluding that its account of the defendants’ asserted wrongdoing was too speculative.
The judge hearing the claims of the falsely accused Duke lacrosse players has asked for briefing on whether their lawsuit against Durham, N.C., can pass muster under Iqbal. But the judge considering a case against John C. Yoo, the former Bush administration lawyer, said it could move forward despite Iqbal because the suit contained specific allegations about Mr. Yoo’s conduct in justifying the use of harsh interrogation methods.
In the Iqbal case itself, Javaid Iqbal, a Pakistani Muslim who was working as a cable television installer on Long Island, said he was subjected to intrusive searches and vicious beatings after being arrested on identity fraud charges two months after the Sept. 11 attacks.
Justice Kennedy said Mr. Iqbal’s suit against two officials had not cleared the plausibility bar. All Mr. Iqbal’s complaint plausibly suggested, Justice Kennedy wrote, “is that the nation’s top law enforcement officers, in the aftermath of a devastating terrorist attack, sought to keep suspected terrorists in the most secure conditions available.”
Justice David H. Souter, said the majority had adopted a crabbed view of plausibility and had in the process upended the civil litigation system.
In his dissent in Iqbal, Justice Souter wrote that judges should accept the accusations in a complaint as true “no matter how skeptical the court may be.”
“The sole exception to this rule,” Justice Souter continued, “lies with allegations that are sufficiently fantastic to defy reality as we know it: claims about little green men, or the plaintiff’s recent trip to Pluto, or experiences in time travel.”
But that is no longer the law. Under the Iqbal decision, federal judges will now decide at the very start of a litigation whether the plaintiff’s accusations ring true, and they will close the courthouse door if they do not.
Sidebar
9/11 Case Could Bring Broad Shift on Civil Suits By ADAM LIPTAK
WASHINGTON
The most consequential decision of the Supreme Court’s last term got only a little attention when it landed in May. And what attention it got was for the wrong reason.
But the lower courts have certainly understood the significance of the decision, Ashcroft v. Iqbal, which makes it much easier for judges to dismiss civil lawsuits right after they are filed. They have cited it more than 500 times in just the last two months.
“Iqbal is the most significant Supreme Court decision in a decade for day-to-day litigation in the federal courts,” said Thomas C. Goldstein, an appellate lawyer with Akin Gump Strauss Hauer & Feld in Washington.
On its face, the Iqbal decision concerned the aftermath of the Sept. 11 attacks. The court ruled that a Muslim man swept up on immigration charges could not sue two Bush administration officials for what he said was the terrible abuse he suffered in detention.
But something much deeper and broader was going on in the decision, something that may unsettle how civil litigation is conducted in the United States. Justice Ruth Bader Ginsburg, who dissented from the decision, told a group of federal judges last month that the ruling was both important and dangerous. “In my view,” Justice Ginsburg said, “the court’s majority messed up the federal rules” governing civil litigation.
For more than half a century, it has been clear that all a plaintiff had to do to start a lawsuit was to file what the rules call “a short and plain statement of the claim” in a document called a complaint. Having filed such a bare-bones complaint, plaintiffs were entitled to force defendants to open their files and submit to questioning under oath.
This approach, particularly when coupled with the American requirement that each side pay its own lawyers no matter who wins, gave plaintiffs settlement leverage. Just by filing a lawsuit, a plaintiff could subject a defendant to great cost and inconvenience in the pre-trial fact-finding process called discovery.
Mark Herrmann, a corporate defense lawyer with Jones Day in Chicago, said the Iqbal decision will allow for the dismissal of cases that would otherwise have subjected defendants to millions of dollars in discovery costs. On the other hand, information about wrongdoing is often secret. Plaintiffs claiming they were the victims of employment discrimination, a defective product, an antitrust conspiracy or a policy of harsh treatment in detention may not know exactly who harmed them and how before filing suit. But plaintiffs can learn valuable information during discovery.
The Iqbal decision now requires plaintiffs to come forward with concrete facts at the outset, and it instructs lower court judges to dismiss lawsuits that strike them as implausible.
“Determining whether a complaint states a plausible claim for relief,” Justice Anthony M. Kennedy wrote for the five-justice majority, “requires the reviewing court to draw on its judicial experience and common sense.”
Note those words: Plausible. Common sense.
The old world was mechanical. A lawsuit that mouthed the required words was off and running. As the Supreme Court said in 1957 in Conley v. Gibson, a lawsuit should be allowed to go forward “unless it appears beyond doubt that the plaintiff can prove no set of facts in support of his claim which would entitle him to relief.” Things started to change two years ago, when the Supreme Court found a complaint in an antitrust suit implausible.
In the new world, after Iqbal, a lawsuit has to satisfy a skeptical judicial gatekeeper.
“It obviously licenses highly subjective judgments,” said Stephen B. Burbank, an authority on civil procedure at the University of Pennsylvania Law School. “This is a blank check for federal judges to get rid of cases they disfavor.”
Courts applying Iqbal have been busy. A federal judge in Connecticut dismissed a disability discrimination suit this month, saying that Iqbal required her to treat the plaintiff’s assertions as implausible. A few days later, the federal appeals court in New York dismissed a breach of contract and securities fraud suit after concluding that its account of the defendants’ asserted wrongdoing was too speculative.
The judge hearing the claims of the falsely accused Duke lacrosse players has asked for briefing on whether their lawsuit against Durham, N.C., can pass muster under Iqbal. But the judge considering a case against John C. Yoo, the former Bush administration lawyer, said it could move forward despite Iqbal because the suit contained specific allegations about Mr. Yoo’s conduct in justifying the use of harsh interrogation methods.
In the Iqbal case itself, Javaid Iqbal, a Pakistani Muslim who was working as a cable television installer on Long Island, said he was subjected to intrusive searches and vicious beatings after being arrested on identity fraud charges two months after the Sept. 11 attacks.
Justice Kennedy said Mr. Iqbal’s suit against two officials had not cleared the plausibility bar. All Mr. Iqbal’s complaint plausibly suggested, Justice Kennedy wrote, “is that the nation’s top law enforcement officers, in the aftermath of a devastating terrorist attack, sought to keep suspected terrorists in the most secure conditions available.”
Justice David H. Souter, said the majority had adopted a crabbed view of plausibility and had in the process upended the civil litigation system.
In his dissent in Iqbal, Justice Souter wrote that judges should accept the accusations in a complaint as true “no matter how skeptical the court may be.”
“The sole exception to this rule,” Justice Souter continued, “lies with allegations that are sufficiently fantastic to defy reality as we know it: claims about little green men, or the plaintiff’s recent trip to Pluto, or experiences in time travel.”
But that is no longer the law. Under the Iqbal decision, federal judges will now decide at the very start of a litigation whether the plaintiff’s accusations ring true, and they will close the courthouse door if they do not.
Monday, July 20, 2009
Lost in the Cloud By JONATHAN ZITTRAIN
July 20, 2009
Op-Ed Contributor
Lost in the Cloud By JONATHAN ZITTRAIN
Cambridge, Mass.
EARLIER this month Google announced a new operating system called Chrome. It’s meant to transform personal computers and handheld devices into single-purpose windows to the Web. This is part of a larger trend: Chrome moves us further away from running code and storing our information on our own PCs toward doing everything online — also known as in “the cloud” — using whatever device is at hand.
Many people consider this development to be as sensible and inevitable as the move from answering machines to voicemail. With your stuff in the cloud, it’s not a catastrophe to lose your laptop, any more than losing your glasses would permanently destroy your vision. In addition, as more and more of our information is gathered from and shared with others — through Facebook, MySpace or Twitter — having it all online can make a lot of sense.
The cloud, however, comes with real dangers.
Some are in plain view. If you entrust your data to others, they can let you down or outright betray you. For example, if your favorite music is rented or authorized from an online subscription service rather than freely in your custody as a compact disc or an MP3 file on your hard drive, you can lose your music if you fall behind on your payments — or if the vendor goes bankrupt or loses interest in the service. Last week Amazon apparently conveyed a publisher’s change-of-heart to owners of its Kindle e-book reader: some purchasers of Orwell’s “1984” found it removed from their devices, with nothing to show for their purchase other than a refund. (Orwell would be amused.)
Worse, data stored online has less privacy protection both in practice and under the law. A hacker recently guessed the password to the personal e-mail account of a Twitter employee, and was thus able to extract the employee’s Google password. That in turn compromised a trove of Twitter’s corporate documents stored too conveniently in the cloud. Before, the bad guys usually needed to get their hands on people’s computers to see their secrets; in today’s cloud all you need is a password.
Thanks in part to the Patriot Act, the federal government has been able to demand some details of your online activities from service providers — and not to tell you about it. There have been thousands of such requests lodged since the law was passed, and the F.B.I.’s own audits have shown that there can be plenty of overreach — perhaps wholly inadvertent — in requests like these.
The cloud can be even more dangerous abroad, as it makes it much easier for authoritarian regimes to spy on their citizens. The Chinese government has used the Chinese version of Skype instant messaging software to monitor text conversations and block undesirable words and phrases. It and other authoritarian regimes routinely monitor all Internet traffic — which, except for e-commerce and banking transactions, is rarely encrypted against prying eyes.
With a little effort and political will, we could solve these problems. Companies could be required under fair practices law to allow your data to be released back to you with just a click so that you can erase your digital footprints or simply take your business (and data) elsewhere. They could also be held to the promises they make about content sold through the cloud: If they sell you an e-book, they can’t take it back or make it less functional later. To increase security, companies that keep their data in the cloud could adopt safer Internet communications and password practices, including the use of biometrics like fingerprints to validate identity.
And some governments can be persuaded — or perhaps required by their independent judiciaries — to treat data entrusted to the cloud with the same level of privacy protection as data held personally. The Supreme Court declared in 1961 that a police search of a rented house for a whiskey still was a violation of the Fourth Amendment privacy rights of the tenant, even though the landlord had given permission for the search. Information stored in the cloud deserves similar safeguards.
But the most difficult challenge — both to grasp and to solve — of the cloud is its effect on our freedom to innovate. The crucial legacy of the personal computer is that anyone can write code for it and give or sell that code to you — and the vendors of the PC and its operating system have no more to say about it than your phone company does about which answering machine you decide to buy. Microsoft might want you to run Word and Internet Explorer, but those had better be good products or you’ll switch with a few mouse clicks to OpenOffice orFirefox.
Promoting competition is only the tip of the iceberg — there are also the thousands of applications so novel that they don’t yet compete with anything. These tend to be produced by tinkerers and hackers. Instant messaging, peer-to-peer file sharing and the Web itself all exist thanks to people out in left field, often writing for fun rather than money, who are able to tempt the rest of us to try out what they’ve done.
This freedom is at risk in the cloud, where the vendor of a platform has much more control over whether and how to let others write new software. Facebook allows outsiders to add functionality to the site but reserves the right to change that policy at any time, to charge a fee for applications, or to de-emphasize or eliminate apps that court controversy or that they simply don’t like. The iPhone’s outside apps act much more as if they’re in the cloud than on your phone: Apple can decide who gets to write code for your phone and which of those offerings will be allowed to run. The company has used this power in ways that Bill Gates never dreamed of when he was the king of Windows: Apple is reported to have censored e-book apps that contain controversial content, eliminated games with political overtones, and blocked uses for the phone that compete with the company’s products.
The market is churning through these issues. Amazon is offering a generic cloud-computing infrastructure so anyone can set up new software on a new Web site without gatekeeping by the likes of Facebook. Google’s Android platform is being used in a new generation of mobile phones with fewer restrictions on outside code. But the dynamics here are complicated. When we vest our activities and identities in one place in the cloud, it takes a lot of dissatisfaction for us to move. And many software developers who once would have been writing whatever they wanted for PCs are simply developing less adventurous, less subversive, less game-changing code under the watchful eyes of Facebook and Apple.
If the market settles into a handful of gated cloud communities whose proprietors control the availability of new code, the time may come to ensure that their platforms do not discriminate. Such a demand could take many forms, from an outright regulatory requirement to a more subtle set of incentives — tax breaks or liability relief — that nudge companies to maintain the kind of openness that earlier allowed them a level playing field on which they could lure users from competing, mighty incumbents.
We’ve only just begun to measure this problem, even as we fly directly into the cloud. That’s not a reason to turn around. But we must make sure the cloud does not hinder the creation of revolutionary software that, like the Web itself, can seem esoteric at first but utterly necessary later.
Jonathan Zittrain, a law professor at Harvard, is the author of “The Future of the Internet — And How to Stop It.”
Op-Ed Contributor
Lost in the Cloud By JONATHAN ZITTRAIN
Cambridge, Mass.
EARLIER this month Google announced a new operating system called Chrome. It’s meant to transform personal computers and handheld devices into single-purpose windows to the Web. This is part of a larger trend: Chrome moves us further away from running code and storing our information on our own PCs toward doing everything online — also known as in “the cloud” — using whatever device is at hand.
Many people consider this development to be as sensible and inevitable as the move from answering machines to voicemail. With your stuff in the cloud, it’s not a catastrophe to lose your laptop, any more than losing your glasses would permanently destroy your vision. In addition, as more and more of our information is gathered from and shared with others — through Facebook, MySpace or Twitter — having it all online can make a lot of sense.
The cloud, however, comes with real dangers.
Some are in plain view. If you entrust your data to others, they can let you down or outright betray you. For example, if your favorite music is rented or authorized from an online subscription service rather than freely in your custody as a compact disc or an MP3 file on your hard drive, you can lose your music if you fall behind on your payments — or if the vendor goes bankrupt or loses interest in the service. Last week Amazon apparently conveyed a publisher’s change-of-heart to owners of its Kindle e-book reader: some purchasers of Orwell’s “1984” found it removed from their devices, with nothing to show for their purchase other than a refund. (Orwell would be amused.)
Worse, data stored online has less privacy protection both in practice and under the law. A hacker recently guessed the password to the personal e-mail account of a Twitter employee, and was thus able to extract the employee’s Google password. That in turn compromised a trove of Twitter’s corporate documents stored too conveniently in the cloud. Before, the bad guys usually needed to get their hands on people’s computers to see their secrets; in today’s cloud all you need is a password.
Thanks in part to the Patriot Act, the federal government has been able to demand some details of your online activities from service providers — and not to tell you about it. There have been thousands of such requests lodged since the law was passed, and the F.B.I.’s own audits have shown that there can be plenty of overreach — perhaps wholly inadvertent — in requests like these.
The cloud can be even more dangerous abroad, as it makes it much easier for authoritarian regimes to spy on their citizens. The Chinese government has used the Chinese version of Skype instant messaging software to monitor text conversations and block undesirable words and phrases. It and other authoritarian regimes routinely monitor all Internet traffic — which, except for e-commerce and banking transactions, is rarely encrypted against prying eyes.
With a little effort and political will, we could solve these problems. Companies could be required under fair practices law to allow your data to be released back to you with just a click so that you can erase your digital footprints or simply take your business (and data) elsewhere. They could also be held to the promises they make about content sold through the cloud: If they sell you an e-book, they can’t take it back or make it less functional later. To increase security, companies that keep their data in the cloud could adopt safer Internet communications and password practices, including the use of biometrics like fingerprints to validate identity.
And some governments can be persuaded — or perhaps required by their independent judiciaries — to treat data entrusted to the cloud with the same level of privacy protection as data held personally. The Supreme Court declared in 1961 that a police search of a rented house for a whiskey still was a violation of the Fourth Amendment privacy rights of the tenant, even though the landlord had given permission for the search. Information stored in the cloud deserves similar safeguards.
But the most difficult challenge — both to grasp and to solve — of the cloud is its effect on our freedom to innovate. The crucial legacy of the personal computer is that anyone can write code for it and give or sell that code to you — and the vendors of the PC and its operating system have no more to say about it than your phone company does about which answering machine you decide to buy. Microsoft might want you to run Word and Internet Explorer, but those had better be good products or you’ll switch with a few mouse clicks to OpenOffice orFirefox.
Promoting competition is only the tip of the iceberg — there are also the thousands of applications so novel that they don’t yet compete with anything. These tend to be produced by tinkerers and hackers. Instant messaging, peer-to-peer file sharing and the Web itself all exist thanks to people out in left field, often writing for fun rather than money, who are able to tempt the rest of us to try out what they’ve done.
This freedom is at risk in the cloud, where the vendor of a platform has much more control over whether and how to let others write new software. Facebook allows outsiders to add functionality to the site but reserves the right to change that policy at any time, to charge a fee for applications, or to de-emphasize or eliminate apps that court controversy or that they simply don’t like. The iPhone’s outside apps act much more as if they’re in the cloud than on your phone: Apple can decide who gets to write code for your phone and which of those offerings will be allowed to run. The company has used this power in ways that Bill Gates never dreamed of when he was the king of Windows: Apple is reported to have censored e-book apps that contain controversial content, eliminated games with political overtones, and blocked uses for the phone that compete with the company’s products.
The market is churning through these issues. Amazon is offering a generic cloud-computing infrastructure so anyone can set up new software on a new Web site without gatekeeping by the likes of Facebook. Google’s Android platform is being used in a new generation of mobile phones with fewer restrictions on outside code. But the dynamics here are complicated. When we vest our activities and identities in one place in the cloud, it takes a lot of dissatisfaction for us to move. And many software developers who once would have been writing whatever they wanted for PCs are simply developing less adventurous, less subversive, less game-changing code under the watchful eyes of Facebook and Apple.
If the market settles into a handful of gated cloud communities whose proprietors control the availability of new code, the time may come to ensure that their platforms do not discriminate. Such a demand could take many forms, from an outright regulatory requirement to a more subtle set of incentives — tax breaks or liability relief — that nudge companies to maintain the kind of openness that earlier allowed them a level playing field on which they could lure users from competing, mighty incumbents.
We’ve only just begun to measure this problem, even as we fly directly into the cloud. That’s not a reason to turn around. But we must make sure the cloud does not hinder the creation of revolutionary software that, like the Web itself, can seem esoteric at first but utterly necessary later.
Jonathan Zittrain, a law professor at Harvard, is the author of “The Future of the Internet — And How to Stop It.”
Health Reform Can Pay for Itself The task isn't as difficult as you may have heard. By Timothy Noah
prescriptions
Health Reform Can Pay for Itself The task isn't as difficult as you may have heard. By Timothy Noah
Posted Monday, July 20, 2009, at 5:43 PM ET
Alarmism is setting in about the health reform bill. "Alliances In Health Debate Splinter," says the Washington Post. "House healthcare plan to add to deficit: analysts," says Reuters, echoing earlier stor ies about Congressional Budget Office Director Douglas Elmendorf's congressional testimony last week that health reform would be a budget-buster. President Obama's approval ratings are slipping, and public approval of his handling of the health care issue has for the first time dropped below 50 percent. Slate warns readers on its home page, "We're About To Make a Huge Mistake on Health Care." Or maybe health reform is already dead because the Senate finance committee is dithering and six moderate senators are urging the Democratic leadership to slow things! down further. Bill Kristol, who helped strangle Hillarycare in its crib, smells blood.
Never mind that the health reform bill last week cleared three congressional committees (two more to go!) and that the House bill, which is more liberal than the bill approved by Sen. Ted Kennedy's health, education, labor and pensions committee, was endorsed unexpectedly last week by the American Medical Association. While it would certainly be more convenient for health reform to cle ar Congress before the August recess, a failure to do so, which is looking increasingly likely, will hardly be the devastating setback that's widely supposed. The New Republic's Jonathan Cohn worries that the recess will provide "four long weeks in which special interests can bang away at legislation, running ads and ginning up grassroots opposition." But it will also provide four long weeks in which supporters of health care reform, whose numbers and union backing are not inconsiderable, can bang away at legislators who aren't supporting health reform.
It would also provide four long weeks for Congress to figure out how to pay for the bill. The high cost of health care reform has emerged as the principal political argument against it. But this is an eminently solva! ble problem—and one that Congress has already solved to a much greater extent than many realize.
The Senate bill, as passed last week by the health committee, would cost about $600 billion over 10 years, according to the Congressional Budget Office's most recent calculation. The health committee proposed no offsetting taxes. But that's because the health committee can't propose any taxes: Taxation lies outside its jurisdiction. The Senate finance committee is giving serious consideration to offsetting health reform's cost by taxing employer-provided health benefits, which currently are not taxed. The exclusion costs the Treasury $250 billion per year. Unions hate the idea of limiting the exclusion, and during the 2008 campaign Obama attacked Sen. John McCain's proposal to eliminate it. But more recently, Obama has signaled that he might support scaling it back.
The health insurance exclusion is regressive, since people making more money tend to receive the most generous health benefits. On the other hand, eliminating the exclusion entirely would increase the tax liability of people earning less than $50,000, as a percentage of income, much more than it would people earni! ng more than $200,000, assuming both groups received health insurance through their employers. A reasonable compromise, therefore, would be to maintain the exclusion for people earning below a certain amount (say, $50,000) and reduce it for people earning more. In the March 17 New Republic ("Tax My Health Benefits, Please"), Cohn noted that a tax scheme along these lines, proposed by Jonathan Gruber of the Massachusetts Institute of Technology, would raise "more than $700 billion over ten years." If included in health reform, such a plan would net the feds a $100 billion surplus during the next decade. As a side benefit, it would exert some pressure on health insurers to lower premiums.
The House bill, as passed last week by the ways and means and! education and labor committees, would cost about $1 trillion, according to the Congressional Budget Office's most recent calculation. But this doesn't take into account the bill's sliding surtax on incomes above $350,000, which (according to the joint committee on taxation) would raise an offsetting $544 billion during the same period. (As liberal think tank Citizens for Tax Justice points out, $544 billion is a lot less than what this crowd got during the last 10 years from George W. Bush's tax cuts.) Other taxes in the bill and projected savings in Medicare and Medicaid further reduce the House bill's cost to $239 billion over 10 years. Congressional Quarterly gasps that this is "larger than the [deficit] run by the government for all of fiscal 2007."
But it comes to about $24 billion annually, a manageable amount that could be eliminated by adding in a much more modest scale-back of the health insurance exclusion than the one envisioned by Gruber. Further savings could be achieved if Congress were to adopt the Obama administration's proposal to create a Fed-like Medicare Advisory Council that could set rates for Medicare providers while being somewhat shielded from congressional meddling.
I won't even bother to suggest paying for health reform with a progressive Medicare payroll tax rather than the flat 1.45 percent tax on individuals that we have now. This would be the most sensible way to pay for health reform. Citizens for Tax Justice has a very modest proposal here; note that the top rate woul d be all of 2.5 percent. But Congress would never approve it. That's a shame, because it would raise $500 billion over 10 years.
"Let's pass [health care] reform by the end of this year," President Obama said today. His language would seem to signal that he's reconciled to waiting for a decent, fiscally responsible bill. It's possible he won't get it. But achieving it isn't all that hard, and it just may be that Congress gives him one.
Timothy Noah is a senior writer at Slate.
Health Reform Can Pay for Itself The task isn't as difficult as you may have heard. By Timothy Noah
Posted Monday, July 20, 2009, at 5:43 PM ET
Alarmism is setting in about the health reform bill. "Alliances In Health Debate Splinter," says the Washington Post. "House healthcare plan to add to deficit: analysts," says Reuters, echoing earlier stor ies about Congressional Budget Office Director Douglas Elmendorf's congressional testimony last week that health reform would be a budget-buster. President Obama's approval ratings are slipping, and public approval of his handling of the health care issue has for the first time dropped below 50 percent. Slate warns readers on its home page, "We're About To Make a Huge Mistake on Health Care." Or maybe health reform is already dead because the Senate finance committee is dithering and six moderate senators are urging the Democratic leadership to slow things! down further. Bill Kristol, who helped strangle Hillarycare in its crib, smells blood.
Never mind that the health reform bill last week cleared three congressional committees (two more to go!) and that the House bill, which is more liberal than the bill approved by Sen. Ted Kennedy's health, education, labor and pensions committee, was endorsed unexpectedly last week by the American Medical Association. While it would certainly be more convenient for health reform to cle ar Congress before the August recess, a failure to do so, which is looking increasingly likely, will hardly be the devastating setback that's widely supposed. The New Republic's Jonathan Cohn worries that the recess will provide "four long weeks in which special interests can bang away at legislation, running ads and ginning up grassroots opposition." But it will also provide four long weeks in which supporters of health care reform, whose numbers and union backing are not inconsiderable, can bang away at legislators who aren't supporting health reform.
It would also provide four long weeks for Congress to figure out how to pay for the bill. The high cost of health care reform has emerged as the principal political argument against it. But this is an eminently solva! ble problem—and one that Congress has already solved to a much greater extent than many realize.
The Senate bill, as passed last week by the health committee, would cost about $600 billion over 10 years, according to the Congressional Budget Office's most recent calculation. The health committee proposed no offsetting taxes. But that's because the health committee can't propose any taxes: Taxation lies outside its jurisdiction. The Senate finance committee is giving serious consideration to offsetting health reform's cost by taxing employer-provided health benefits, which currently are not taxed. The exclusion costs the Treasury $250 billion per year. Unions hate the idea of limiting the exclusion, and during the 2008 campaign Obama attacked Sen. John McCain's proposal to eliminate it. But more recently, Obama has signaled that he might support scaling it back.
The health insurance exclusion is regressive, since people making more money tend to receive the most generous health benefits. On the other hand, eliminating the exclusion entirely would increase the tax liability of people earning less than $50,000, as a percentage of income, much more than it would people earni! ng more than $200,000, assuming both groups received health insurance through their employers. A reasonable compromise, therefore, would be to maintain the exclusion for people earning below a certain amount (say, $50,000) and reduce it for people earning more. In the March 17 New Republic ("Tax My Health Benefits, Please"), Cohn noted that a tax scheme along these lines, proposed by Jonathan Gruber of the Massachusetts Institute of Technology, would raise "more than $700 billion over ten years." If included in health reform, such a plan would net the feds a $100 billion surplus during the next decade. As a side benefit, it would exert some pressure on health insurers to lower premiums.
The House bill, as passed last week by the ways and means and! education and labor committees, would cost about $1 trillion, according to the Congressional Budget Office's most recent calculation. But this doesn't take into account the bill's sliding surtax on incomes above $350,000, which (according to the joint committee on taxation) would raise an offsetting $544 billion during the same period. (As liberal think tank Citizens for Tax Justice points out, $544 billion is a lot less than what this crowd got during the last 10 years from George W. Bush's tax cuts.) Other taxes in the bill and projected savings in Medicare and Medicaid further reduce the House bill's cost to $239 billion over 10 years. Congressional Quarterly gasps that this is "larger than the [deficit] run by the government for all of fiscal 2007."
But it comes to about $24 billion annually, a manageable amount that could be eliminated by adding in a much more modest scale-back of the health insurance exclusion than the one envisioned by Gruber. Further savings could be achieved if Congress were to adopt the Obama administration's proposal to create a Fed-like Medicare Advisory Council that could set rates for Medicare providers while being somewhat shielded from congressional meddling.
I won't even bother to suggest paying for health reform with a progressive Medicare payroll tax rather than the flat 1.45 percent tax on individuals that we have now. This would be the most sensible way to pay for health reform. Citizens for Tax Justice has a very modest proposal here; note that the top rate woul d be all of 2.5 percent. But Congress would never approve it. That's a shame, because it would raise $500 billion over 10 years.
"Let's pass [health care] reform by the end of this year," President Obama said today. His language would seem to signal that he's reconciled to waiting for a decent, fiscally responsible bill. It's possible he won't get it. But achieving it isn't all that hard, and it just may be that Congress gives him one.
Timothy Noah is a senior writer at Slate.
Sunday, July 19, 2009
Friendly Skies? Not for Pet Owners By MICHELLE HIGGINS and Pets Onboard: Growls and Purrs By MICHELLE HIGGINS
July 19, 2009
Practical Traveler
Friendly Skies? Not for Pet Owners By MICHELLE HIGGINS
IT'S getting more expensive to take Fifi on vacation. Airlines may be raising the price of in-flight food and checked luggage, but pet owners say the fees for flying with their furry friends are getting out of control.
A number of airlines — including Alaska, American, JetBlue, US Airways and Virgin America — raised their pet fees by about $20 or more in the last year or so, and now charge $100 each way to take a pet on a flight. Continental, Midwest and United now charge $125 to bring a pet onboard, up from $100 previously.
Expect to pay even more to check in larger pets as luggage. Those fees now range from $300 round trip on American to $500 on United. It goes even higher for international flights.
These days, with airfares so low, a pet's fee can be more than a human's ticket.
James Garahan, an international tax lawyer from San Francisco, paid $299 for a round-trip flight from San Francisco to New York in December on United. But to take his 13-pound pug, Sophie, with him, United wanted an extra $350. (United has since lowered the cost to $125 each way, from $175, but that is still higher than the $100 it charged last spring.)
Mr. Garahan views the fee as "discriminatory against pet owners." Sophie, he points out, rides under the seat in front of him — "space I have already paid for."
But for airlines, it's another way to eke out more revenue. American, for example, raised its pet charges in May 2008 — the same time it began charging for things like a second checked bag. "The bottom line is that our fares and our fees together must cover our operating costs if we are to remain viable for the long term," said Andrea Huguely, an American spokeswoman.
Pet owners say they simply have no choice but to pay whatever the airlines charge.
"People that want to travel with pets are pretty much at their mercy," said Jerry Hatfield, a spokesman for Pet Travel Inc., which offers an online guide at www.pettravel.com. "If it's $100, that's what it is. There are no other options. Amtrak isn't accepting any pets."
Actually, there is a new option: Pet Airways (www.petairways.com), a pet-only airline based in Delray Beach, Fla., is beginning service this month. It plans to fly to smaller regional airports near New York City (Republic on Long Island), Washington (Baltimore/Washington International), Chicago (Midway), Denver (Rocky Mountain Metro) and Los Angeles (Hawthorne Municipal).
Aimed at pet owners frustrated with the high cost and poor service associated with most airlines, Pet Airways promises to fly animals in a climate-controlled cabin outfitted with individual crates instead of seats, and staffed with a flight attendant who will check on animals every 15 minutes. The company uses Beech 1900C turbo-props, some versions of which are 19-seat commuter planes.
Tickets for the flights, operated once a week by Suburban Air Freight based in Omaha, Neb., start at $149 each way. There is already a waiting list for the first month, according to Alysa Binder, a founder of the company.
"Size doesn't matter, snout noses don't matter," Ms. Binder said. "It's all about the pets."
Commercial airlines typically will not accept snub-nosed dogs like pugs or cats like Persians as cargo as they tend to be sensitive to heat. Also, many airlines will not accept pets as checked baggage or cargo when the ground temperature exceeds 85 degrees or is below 20 degrees.
Frontier Airlines has barred pets from cabins. "It's a customer service issue," said Steve Snyder, an airline spokesman, noting that customers can still transport pets on Frontier as luggage for $100 or $200 each way depending on size. "There are a lot of folks that may have allergies to pets, or may have a fear of dogs or cats or may not want to be bothered by somebody else's pets."
But some airlines are trying to be more pet friendly. Delta, which had some of the highest fees, lowered its rates this month to $100 each way, from $150, for carry-on pets on domestic flights, and to $175 from $275 for pets checked as luggage.
JetBlue, which transports more than 80,000 pets a year, created a frequent flier program for pets, JetPaws, which allows customers to earn double miles when bringing along their furry friends. Continental and Midwest have similar programs.
Perhaps sensing a competitive niche, Southwest last month began charging $75 to take small dogs and cats onboard, undercutting most other airlines. And on July 1, Air Canada began charging 50 Canadian dollars (about $42 at 1.19 Canadian dollars to the U.S. dollar) each way for pets.
Other tips to keep to mind:
• Airlines limit the number of pets on each flight, so book early if you plan to bring your pet.
• To avoid delays and reduce the stress on your pet, book a nonstop flight whenever possible.
• If checking your pet as luggage, avoid booking a mid-day flight in summer, when the cargo hold can be dangerously warm.
• "I recommend feeding them about four hours before the flight, if possible," said Melissa Halliburton, founder of BringFido.com, a travel site for dog owners. "They can and should continue to drink water right up to the time of travel, though."
• After purchasing an appropriate pet carrier, write your pet's name on it, including identification tags with your home address and phone number as well as the address and phone number of your destination, Ms. Halliburton suggests. If two or more pets are traveling together in cargo, put a sign on their crates indicating that they be placed near one another during the flight.
But if your pet is an anxious flier, consider leaving it home. Sitters can be found online at Petsit.com and Petsitters.org.
Mr. Garahan, the tax lawyer, ended up hiring a pet sitter for $25 a day for his pug. But next time, Mr. Garahan may have to spring for Sophie's flight since his wife, Pam Dickson, often travels to New York City for business.
"When I show up in New York, she's happy to see me," Mr. Garahan said of his wife. "But if I'm bringing Sophie, she's really happy to see me."
Practical Traveler - Flying With Pets Can Be Costly - NYTimes.com (2 August 2009)
http://travel.nytimes.com/2009/07/19/travel/19pracpets.html?fta=y&pagewanted=print
http://snipurl.com/oj9wg
FEEDBACK / COMMENTS FROM READERS
August 2, 2009
Practical Traveler
Pets Onboard: Growls and Purrs By MICHELLE HIGGINS
MEOW! Do people feel strongly about pets on planes.
In response to the July 19 Practical Traveler column, “Friendly Skies? Not For Pet Owners,” more than 100 readers weighed in on the subject. Many of the comments expressed outrage at the high fees airlines charge to transport pets, especially on international flights. A number of readers also described nightmarish travel experiences involving pets that arrived severely dehydrated or even near death after flying as checked luggage.
But a surprising majority of comments debated whether pets should be allowed on planes in the first place — a discussion worth summarizing here.
Allergy sufferers cited pet dander as a major health issue. “I have no desire to drug myself up with antihistamines and/or sneeze/wheeze endlessly because of another passenger’s selfish decision to bring their pet on the flight,” said a reader who identified herself as Eve from Portland. “It seems inconsistent for airlines to phase out peanuts as snacks but nonetheless allow animals in the cabin, when their mere presence causes severe discomfort for others.”
Allergy sufferers have little recourse if they find themselves seated near a pet. It’s possible to switch seats with another passenger to avoid sneezing through the entire flight, but that isn’t an ideal solution. “When I complained about a cat under my aisle seat in the front of the plane — I was moved to a rear, middle seat,” wrote Catherine from California. “Meds kept me alive but I was sick for a week from the resulting sinus infection.”
Pet owners, on the other hand, pointed out that they have few alternatives when it comes to transporting their animals, whether for a long vacation or a cross-country move. And banning pets because of allergy sufferers, they argue, is a slippery slope. “If airlines are going to start insisting on pet-free flights because of a few hothouse flowers complaining about the possibility of being annoyed by allergies,” a reader identified as HK from New York City asked, “can they also start banning people with colds?” HK continued, “Oh — and I guess they should ban people who wear too much perfume so that I don’t have to suffer a headache throughout the flight, people with sketchy hygiene and people who want to bring pungent foods onboard.”
But passengers had other reasons for wanting to ban pets from planes. Millie Smith, from Boulder, Colo., described how a small dog on a red-eye flight “barked incessantly for about 45 minutes on takeoff and a half hour on landing.”
So what’s wrong with putting pets in cargo? Even a former airline employee said he would not trust an airline with safely transporting his pets as checked luggage. “Knowing what I do about conditions on the ramp and in the baggage compartment, I would never transport my dog by air, no matter what the season,” said Scott from Morgantown, W.Va., “He would be terrified by the noise, the confusion, the isolation and the physical sensations of flight. It would be pure selfishness on my part to subject him to that just so I could take him along on a trip.” And Kay from Eugene, Ore., described how her daughter had to rush her kitten to the veterinarian when it arrived “at the point of death” from dehydration after a flight from Georgia to Arizona.
Some readers offered suggestions on how to get airlines to pay closer attention to pets. Jim Hutchins of Ogden, Utah, who keeps an online diary about his dog, Roxy, including her travels, recommended writing a friendly note on the carrier when checking a pet as luggage. This may help remind baggage handlers that your pet has a name and isn’t just another piece of cargo. Freezing a bowl of water can help reduce spills and keep the pet hydrated during a flight, he also noted. And booking a window seat may allow you to see your pet as it’s loaded into the aircraft.
Still, some owners go to extraordinary lengths to avoid the stress flying can cause to pets. Shirley Lin, from Arizona, wrote about driving to New York from the Southwest for four days and staying in pet-friendly hotels instead of checking her pets as luggage for a move in 2006. “As much as I would love to vaca (sometimes) with my dogs, it’s more stressful on them, and they’re perfectly happy at home with their favorite sitter,” she wrote.
But sometimes driving is just not an option, as when moving overseas. In those cases, airlines have been known to charge very high fees. One reader, who went by the screen name Krauset, griped about paying $1,700 to move the family dog, Jack, one way from Phoenix, Ariz., to England, on British Airways. “This was not much less than the total cost of our family’s four round-trip tickets,” Krauset wrote. “Shame on you British Airways. The least you could have done was put Champagne in Jack’s water bowl. Stop the price gouging!”
To avoid such charges, one reader, Ami from Washington, suggested smuggling a pet onboard: “I fly with my 20 lb. mutt often on US Airways, Jet Blue, Delta, Continental, etc. He is transported in a rolling bag that I carry on like a suitcase. I sneak him around as much as possible to avoid paying the pet charge. About 80% of the time he does not get spotted by ticketing agents or flight attendants. I only pay the fee when they catch me and make me pay it.”
Still others had more of an issue with pet owners than the pets themselves. “In our family we all have severe cat and dog allergies,” wrote a reader identified as rnzucker from Portland, Ore. “We were quite surprised one time when my daughter was sitting next to a woman who had a dog, who had no sympathy for my daughter and refused to move seats.
“My daughter ended up sitting totally separate from the family as a result,” rnzucker continued. “Pets in the cabin on planes (or on trains) can be a major health issue for many of us, even in carriers, and should not be ignored. Not everyone wants to be next to your pet.”
Will pet lovers and pet haters ever get along? One reader identified as markjay1 from New York City suggested fining dog owners if their pets misbehave onboard: “Every bark, yelp, growl or whine costs the owner $25, no limit. That’s for each one. A growl that ends with a bark is considered two infractions. Every ‘accident’ costs the owner $200. Every passenger whose allergies are set off by the dog is immediately paid $100 by the dog owner. If the dog gets out of its carrier the fine is $250. If the owner lets the dog out of its carrier the fine is $1,000. I think these rules are fair. If your dog is well controlled I have no problem with it, and you, on the plane.”
Practical Traveler
Friendly Skies? Not for Pet Owners By MICHELLE HIGGINS
IT'S getting more expensive to take Fifi on vacation. Airlines may be raising the price of in-flight food and checked luggage, but pet owners say the fees for flying with their furry friends are getting out of control.
A number of airlines — including Alaska, American, JetBlue, US Airways and Virgin America — raised their pet fees by about $20 or more in the last year or so, and now charge $100 each way to take a pet on a flight. Continental, Midwest and United now charge $125 to bring a pet onboard, up from $100 previously.
Expect to pay even more to check in larger pets as luggage. Those fees now range from $300 round trip on American to $500 on United. It goes even higher for international flights.
These days, with airfares so low, a pet's fee can be more than a human's ticket.
James Garahan, an international tax lawyer from San Francisco, paid $299 for a round-trip flight from San Francisco to New York in December on United. But to take his 13-pound pug, Sophie, with him, United wanted an extra $350. (United has since lowered the cost to $125 each way, from $175, but that is still higher than the $100 it charged last spring.)
Mr. Garahan views the fee as "discriminatory against pet owners." Sophie, he points out, rides under the seat in front of him — "space I have already paid for."
But for airlines, it's another way to eke out more revenue. American, for example, raised its pet charges in May 2008 — the same time it began charging for things like a second checked bag. "The bottom line is that our fares and our fees together must cover our operating costs if we are to remain viable for the long term," said Andrea Huguely, an American spokeswoman.
Pet owners say they simply have no choice but to pay whatever the airlines charge.
"People that want to travel with pets are pretty much at their mercy," said Jerry Hatfield, a spokesman for Pet Travel Inc., which offers an online guide at www.pettravel.com. "If it's $100, that's what it is. There are no other options. Amtrak isn't accepting any pets."
Actually, there is a new option: Pet Airways (www.petairways.com), a pet-only airline based in Delray Beach, Fla., is beginning service this month. It plans to fly to smaller regional airports near New York City (Republic on Long Island), Washington (Baltimore/Washington International), Chicago (Midway), Denver (Rocky Mountain Metro) and Los Angeles (Hawthorne Municipal).
Aimed at pet owners frustrated with the high cost and poor service associated with most airlines, Pet Airways promises to fly animals in a climate-controlled cabin outfitted with individual crates instead of seats, and staffed with a flight attendant who will check on animals every 15 minutes. The company uses Beech 1900C turbo-props, some versions of which are 19-seat commuter planes.
Tickets for the flights, operated once a week by Suburban Air Freight based in Omaha, Neb., start at $149 each way. There is already a waiting list for the first month, according to Alysa Binder, a founder of the company.
"Size doesn't matter, snout noses don't matter," Ms. Binder said. "It's all about the pets."
Commercial airlines typically will not accept snub-nosed dogs like pugs or cats like Persians as cargo as they tend to be sensitive to heat. Also, many airlines will not accept pets as checked baggage or cargo when the ground temperature exceeds 85 degrees or is below 20 degrees.
Frontier Airlines has barred pets from cabins. "It's a customer service issue," said Steve Snyder, an airline spokesman, noting that customers can still transport pets on Frontier as luggage for $100 or $200 each way depending on size. "There are a lot of folks that may have allergies to pets, or may have a fear of dogs or cats or may not want to be bothered by somebody else's pets."
But some airlines are trying to be more pet friendly. Delta, which had some of the highest fees, lowered its rates this month to $100 each way, from $150, for carry-on pets on domestic flights, and to $175 from $275 for pets checked as luggage.
JetBlue, which transports more than 80,000 pets a year, created a frequent flier program for pets, JetPaws, which allows customers to earn double miles when bringing along their furry friends. Continental and Midwest have similar programs.
Perhaps sensing a competitive niche, Southwest last month began charging $75 to take small dogs and cats onboard, undercutting most other airlines. And on July 1, Air Canada began charging 50 Canadian dollars (about $42 at 1.19 Canadian dollars to the U.S. dollar) each way for pets.
Other tips to keep to mind:
• Airlines limit the number of pets on each flight, so book early if you plan to bring your pet.
• To avoid delays and reduce the stress on your pet, book a nonstop flight whenever possible.
• If checking your pet as luggage, avoid booking a mid-day flight in summer, when the cargo hold can be dangerously warm.
• "I recommend feeding them about four hours before the flight, if possible," said Melissa Halliburton, founder of BringFido.com, a travel site for dog owners. "They can and should continue to drink water right up to the time of travel, though."
• After purchasing an appropriate pet carrier, write your pet's name on it, including identification tags with your home address and phone number as well as the address and phone number of your destination, Ms. Halliburton suggests. If two or more pets are traveling together in cargo, put a sign on their crates indicating that they be placed near one another during the flight.
But if your pet is an anxious flier, consider leaving it home. Sitters can be found online at Petsit.com and Petsitters.org.
Mr. Garahan, the tax lawyer, ended up hiring a pet sitter for $25 a day for his pug. But next time, Mr. Garahan may have to spring for Sophie's flight since his wife, Pam Dickson, often travels to New York City for business.
"When I show up in New York, she's happy to see me," Mr. Garahan said of his wife. "But if I'm bringing Sophie, she's really happy to see me."
Practical Traveler - Flying With Pets Can Be Costly - NYTimes.com (2 August 2009)
http://travel.nytimes.com/2009/07/19/travel/19pracpets.html?fta=y&pagewanted=print
http://snipurl.com/oj9wg
FEEDBACK / COMMENTS FROM READERS
August 2, 2009
Practical Traveler
Pets Onboard: Growls and Purrs By MICHELLE HIGGINS
MEOW! Do people feel strongly about pets on planes.
In response to the July 19 Practical Traveler column, “Friendly Skies? Not For Pet Owners,” more than 100 readers weighed in on the subject. Many of the comments expressed outrage at the high fees airlines charge to transport pets, especially on international flights. A number of readers also described nightmarish travel experiences involving pets that arrived severely dehydrated or even near death after flying as checked luggage.
But a surprising majority of comments debated whether pets should be allowed on planes in the first place — a discussion worth summarizing here.
Allergy sufferers cited pet dander as a major health issue. “I have no desire to drug myself up with antihistamines and/or sneeze/wheeze endlessly because of another passenger’s selfish decision to bring their pet on the flight,” said a reader who identified herself as Eve from Portland. “It seems inconsistent for airlines to phase out peanuts as snacks but nonetheless allow animals in the cabin, when their mere presence causes severe discomfort for others.”
Allergy sufferers have little recourse if they find themselves seated near a pet. It’s possible to switch seats with another passenger to avoid sneezing through the entire flight, but that isn’t an ideal solution. “When I complained about a cat under my aisle seat in the front of the plane — I was moved to a rear, middle seat,” wrote Catherine from California. “Meds kept me alive but I was sick for a week from the resulting sinus infection.”
Pet owners, on the other hand, pointed out that they have few alternatives when it comes to transporting their animals, whether for a long vacation or a cross-country move. And banning pets because of allergy sufferers, they argue, is a slippery slope. “If airlines are going to start insisting on pet-free flights because of a few hothouse flowers complaining about the possibility of being annoyed by allergies,” a reader identified as HK from New York City asked, “can they also start banning people with colds?” HK continued, “Oh — and I guess they should ban people who wear too much perfume so that I don’t have to suffer a headache throughout the flight, people with sketchy hygiene and people who want to bring pungent foods onboard.”
But passengers had other reasons for wanting to ban pets from planes. Millie Smith, from Boulder, Colo., described how a small dog on a red-eye flight “barked incessantly for about 45 minutes on takeoff and a half hour on landing.”
So what’s wrong with putting pets in cargo? Even a former airline employee said he would not trust an airline with safely transporting his pets as checked luggage. “Knowing what I do about conditions on the ramp and in the baggage compartment, I would never transport my dog by air, no matter what the season,” said Scott from Morgantown, W.Va., “He would be terrified by the noise, the confusion, the isolation and the physical sensations of flight. It would be pure selfishness on my part to subject him to that just so I could take him along on a trip.” And Kay from Eugene, Ore., described how her daughter had to rush her kitten to the veterinarian when it arrived “at the point of death” from dehydration after a flight from Georgia to Arizona.
Some readers offered suggestions on how to get airlines to pay closer attention to pets. Jim Hutchins of Ogden, Utah, who keeps an online diary about his dog, Roxy, including her travels, recommended writing a friendly note on the carrier when checking a pet as luggage. This may help remind baggage handlers that your pet has a name and isn’t just another piece of cargo. Freezing a bowl of water can help reduce spills and keep the pet hydrated during a flight, he also noted. And booking a window seat may allow you to see your pet as it’s loaded into the aircraft.
Still, some owners go to extraordinary lengths to avoid the stress flying can cause to pets. Shirley Lin, from Arizona, wrote about driving to New York from the Southwest for four days and staying in pet-friendly hotels instead of checking her pets as luggage for a move in 2006. “As much as I would love to vaca (sometimes) with my dogs, it’s more stressful on them, and they’re perfectly happy at home with their favorite sitter,” she wrote.
But sometimes driving is just not an option, as when moving overseas. In those cases, airlines have been known to charge very high fees. One reader, who went by the screen name Krauset, griped about paying $1,700 to move the family dog, Jack, one way from Phoenix, Ariz., to England, on British Airways. “This was not much less than the total cost of our family’s four round-trip tickets,” Krauset wrote. “Shame on you British Airways. The least you could have done was put Champagne in Jack’s water bowl. Stop the price gouging!”
To avoid such charges, one reader, Ami from Washington, suggested smuggling a pet onboard: “I fly with my 20 lb. mutt often on US Airways, Jet Blue, Delta, Continental, etc. He is transported in a rolling bag that I carry on like a suitcase. I sneak him around as much as possible to avoid paying the pet charge. About 80% of the time he does not get spotted by ticketing agents or flight attendants. I only pay the fee when they catch me and make me pay it.”
Still others had more of an issue with pet owners than the pets themselves. “In our family we all have severe cat and dog allergies,” wrote a reader identified as rnzucker from Portland, Ore. “We were quite surprised one time when my daughter was sitting next to a woman who had a dog, who had no sympathy for my daughter and refused to move seats.
“My daughter ended up sitting totally separate from the family as a result,” rnzucker continued. “Pets in the cabin on planes (or on trains) can be a major health issue for many of us, even in carriers, and should not be ignored. Not everyone wants to be next to your pet.”
Will pet lovers and pet haters ever get along? One reader identified as markjay1 from New York City suggested fining dog owners if their pets misbehave onboard: “Every bark, yelp, growl or whine costs the owner $25, no limit. That’s for each one. A growl that ends with a bark is considered two infractions. Every ‘accident’ costs the owner $200. Every passenger whose allergies are set off by the dog is immediately paid $100 by the dog owner. If the dog gets out of its carrier the fine is $250. If the owner lets the dog out of its carrier the fine is $1,000. I think these rules are fair. If your dog is well controlled I have no problem with it, and you, on the plane.”
Standards Might Rise on Monitors for Diabetics By GARDINER HARRIS
July 19, 2009
Standards Might Rise on Monitors for Diabetics By GARDINER HARRIS
Federal officials may soon require improvements for the glucose monitors used by more than 11 million diabetics in the United States.
The rise in the use of home glucose monitors, even by hospitals, is pushing the action by the Food and Drug Administration, which for decades has followed international standards that allow the devices to be wrong by as much as 20 percent. Such a wide error rate can leave patients vulnerable to severe problems, including seizures, unconsciousness and coma.
In June, the agency pressed the international group that sets the standards to tighten them. If the group refuses to act, the agency “may instead recognize other (higher) performance standards” on its own, according to a June letter from Dr. Margaret A. Hamburg, the agency commissioner.
A change in the international standards is the easiest and best option, officials said. The International Organization for Standardization, which sets the standards, can act quickly and broadly. But the F.D.A. can change the rules itself through a more time-consuming and cumbersome process.
Officials said they would keep pushing until monitor accuracy improves, a promise that diabetes doctors cheered. In a May letter, the American Association of Clinical Endocrinologists formally asked that the agency act on the issue.
“Because of the highly variable quality of the meters and the glucose testing strips in widespread use, the safety of our patients who depend upon those meters is threatened,” the letter said.
Khatereh Calleja, a spokeswoman for the Advanced Medical Technology Association, which represents monitor manufacturers, responded, “We think the present standard is working.”
Diabetes has been diagnosed in 18 million people in the United States, and another 6 million are estimated to have the disease without knowing it. It is the seventh leading cause of death and costs the United States an estimated $174 billion a year, with the federal Medicare program spending $1 billion on diabetes test strips alone.
Of particular concern to federal officials is the increasing use of home glucose monitors in hospitals. A landmark 2001 study published in The New England Journal of Medicine found that using insulin to maintain low blood sugar levels in critically ill patients, even those without diabetes, reduced hospital deaths by 34 percent — a result so astonishing that hospitals around the world soon adopted the practice.
But instead of buying the highly accurate and expensive glucose monitors used in the study, many hospitals bought cheaper home models never approved for hospital use. More recent studies have shown that critically ill hospital patients whose glucose levels were kept low suffered more problems — the opposite result from 2001.
The difference, F.D.A. officials said, may have resulted because many patients in the second study were checked with home monitors.
“We think this technology is not up to par for some of the protocols we see out there” like hospital treatment of critically ill patients, said Dr. Alberto Gutierrez, deputy director of the agency’s in vitro diagnostics office. “We feel passionately that this is an important issue.”
Besides having a wide error rate, many home monitors give the wrong result if patients are taking certain drugs like Tylenol or even vitamin C. The Accu-Chek monitors made by Roche can be confounded by drugs commonly used in dialysis. Julie A. Vincent, a Roche spokeswoman, said, “Every blood glucose monitor on the market has some limitation or interferences.”
The F.D.A. issued warnings about the drug-related problems, but doctors complain that they have a hard time keeping straight which drugs conflict with which monitors.
“In the hospital setting, you really don’t know how many deaths are due to things that may be related to meter accuracy,” said Dr. Richard Hellman, a former president of the endocrinology group. “I don’t know how common it is, but I don’t think it’s rare.”
A study by government researchers found that when comparing tests from five different popular monitors, results varied by as much as 32 percent. For a class science project recently, Morgan DiSanto-Ranney, 16, of Bishop O’Connell High School in Arlington, Va., bought seven different glucose monitors and had her father, a diabetic, use all of them.
“What I found was that almost all of the meters were off from one another by 60 to 75 points,” Morgan said in an interview. Two of the meters — Ascensia Breeze and Ascensia Breeze II, both made by Bayer — differed by an average of 62 points, she said.
Staci Gouveia, a Bayer spokeswoman, said her company’s monitors meet federal requirements. “If the F.D.A. standards change, Bayer will work with the F.D.A. to meet their requirements and assure the accuracy and effectiveness of our meter,” Ms. Gouveia said.
Morgan’s mother is Emilia DiSanto, a staff investigator for Senator Charles E. Grassley, Republican of Iowa. Briefed on Morgan’s test and other studies, Mr. Grassley sent a letter to the F.D.A. in June asking officials to review the problem.
As a result of her project, Morgan’s father lost faith in glucose monitors. “He doesn’t use them as much anymore,” she said.
That reaction is exactly what federal officials are hoping to avoid by quietly pressing manufacturers to improve accuracy. Multiple studies make clear that diabetics who routinely use monitors are healthier and suffer fewer serious complications than those who do not.
Manufacturers have long complained that any requirement to improve accuracy would lead them to raise prices, which would discourage use.
“If we decrease the use of meters, you will have some fairly dire consequences to health,” Dr. Gutierrez said, but requiring stricter accuracy standards “seems a reasonable and safe practice to do.”
Every year, the F.D.A. receives reports of several deaths and thousands of injuries related to glucose monitor failures, but the reports represent only a fraction of the actual toll. Insulin-dependent diabetics slip into unconsciousness once a year on average, and 40 percent suffer seizures or coma in their lifetimes because of low blood sugar levels, according to the American Diabetes Association, which has long advocated stricter accuracy standards for monitors.
“Insulin is a dangerous drug, and if someone makes the wrong decision about its use because of a bad test, they could die,” said Dr. David Sacks, an associate professor of pathology at Harvard Medical School.
Standards Might Rise on Monitors for Diabetics By GARDINER HARRIS
Federal officials may soon require improvements for the glucose monitors used by more than 11 million diabetics in the United States.
The rise in the use of home glucose monitors, even by hospitals, is pushing the action by the Food and Drug Administration, which for decades has followed international standards that allow the devices to be wrong by as much as 20 percent. Such a wide error rate can leave patients vulnerable to severe problems, including seizures, unconsciousness and coma.
In June, the agency pressed the international group that sets the standards to tighten them. If the group refuses to act, the agency “may instead recognize other (higher) performance standards” on its own, according to a June letter from Dr. Margaret A. Hamburg, the agency commissioner.
A change in the international standards is the easiest and best option, officials said. The International Organization for Standardization, which sets the standards, can act quickly and broadly. But the F.D.A. can change the rules itself through a more time-consuming and cumbersome process.
Officials said they would keep pushing until monitor accuracy improves, a promise that diabetes doctors cheered. In a May letter, the American Association of Clinical Endocrinologists formally asked that the agency act on the issue.
“Because of the highly variable quality of the meters and the glucose testing strips in widespread use, the safety of our patients who depend upon those meters is threatened,” the letter said.
Khatereh Calleja, a spokeswoman for the Advanced Medical Technology Association, which represents monitor manufacturers, responded, “We think the present standard is working.”
Diabetes has been diagnosed in 18 million people in the United States, and another 6 million are estimated to have the disease without knowing it. It is the seventh leading cause of death and costs the United States an estimated $174 billion a year, with the federal Medicare program spending $1 billion on diabetes test strips alone.
Of particular concern to federal officials is the increasing use of home glucose monitors in hospitals. A landmark 2001 study published in The New England Journal of Medicine found that using insulin to maintain low blood sugar levels in critically ill patients, even those without diabetes, reduced hospital deaths by 34 percent — a result so astonishing that hospitals around the world soon adopted the practice.
But instead of buying the highly accurate and expensive glucose monitors used in the study, many hospitals bought cheaper home models never approved for hospital use. More recent studies have shown that critically ill hospital patients whose glucose levels were kept low suffered more problems — the opposite result from 2001.
The difference, F.D.A. officials said, may have resulted because many patients in the second study were checked with home monitors.
“We think this technology is not up to par for some of the protocols we see out there” like hospital treatment of critically ill patients, said Dr. Alberto Gutierrez, deputy director of the agency’s in vitro diagnostics office. “We feel passionately that this is an important issue.”
Besides having a wide error rate, many home monitors give the wrong result if patients are taking certain drugs like Tylenol or even vitamin C. The Accu-Chek monitors made by Roche can be confounded by drugs commonly used in dialysis. Julie A. Vincent, a Roche spokeswoman, said, “Every blood glucose monitor on the market has some limitation or interferences.”
The F.D.A. issued warnings about the drug-related problems, but doctors complain that they have a hard time keeping straight which drugs conflict with which monitors.
“In the hospital setting, you really don’t know how many deaths are due to things that may be related to meter accuracy,” said Dr. Richard Hellman, a former president of the endocrinology group. “I don’t know how common it is, but I don’t think it’s rare.”
A study by government researchers found that when comparing tests from five different popular monitors, results varied by as much as 32 percent. For a class science project recently, Morgan DiSanto-Ranney, 16, of Bishop O’Connell High School in Arlington, Va., bought seven different glucose monitors and had her father, a diabetic, use all of them.
“What I found was that almost all of the meters were off from one another by 60 to 75 points,” Morgan said in an interview. Two of the meters — Ascensia Breeze and Ascensia Breeze II, both made by Bayer — differed by an average of 62 points, she said.
Staci Gouveia, a Bayer spokeswoman, said her company’s monitors meet federal requirements. “If the F.D.A. standards change, Bayer will work with the F.D.A. to meet their requirements and assure the accuracy and effectiveness of our meter,” Ms. Gouveia said.
Morgan’s mother is Emilia DiSanto, a staff investigator for Senator Charles E. Grassley, Republican of Iowa. Briefed on Morgan’s test and other studies, Mr. Grassley sent a letter to the F.D.A. in June asking officials to review the problem.
As a result of her project, Morgan’s father lost faith in glucose monitors. “He doesn’t use them as much anymore,” she said.
That reaction is exactly what federal officials are hoping to avoid by quietly pressing manufacturers to improve accuracy. Multiple studies make clear that diabetics who routinely use monitors are healthier and suffer fewer serious complications than those who do not.
Manufacturers have long complained that any requirement to improve accuracy would lead them to raise prices, which would discourage use.
“If we decrease the use of meters, you will have some fairly dire consequences to health,” Dr. Gutierrez said, but requiring stricter accuracy standards “seems a reasonable and safe practice to do.”
Every year, the F.D.A. receives reports of several deaths and thousands of injuries related to glucose monitor failures, but the reports represent only a fraction of the actual toll. Insulin-dependent diabetics slip into unconsciousness once a year on average, and 40 percent suffer seizures or coma in their lifetimes because of low blood sugar levels, according to the American Diabetes Association, which has long advocated stricter accuracy standards for monitors.
“Insulin is a dangerous drug, and if someone makes the wrong decision about its use because of a bad test, they could die,” said Dr. David Sacks, an associate professor of pathology at Harvard Medical School.
Why We Must Ration Health Care By PETER SINGER
July 19, 2009
Why We Must Ration Health Care By PETER SINGER
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn't going to be good. But suppose it's not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone's life? If there is any point at which you say, "No, an extra six months isn't worth that much," then you think that health care should be rationed.
In the current U.S. debate over health care reform, "rationing" has become a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons' attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline "Obama Will Ration Your Health Care," Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, "Americans will not put up with such limits, nor will our elected representatives." And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, "There is no rationing of health care at all" in the proposed reform.
Remember the joke about the man who asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. "So," he says, "would you have sex with me for $50?" Indignantly, she exclaims, "What kind of a woman do you think I am?" He replies: "We've already established that. Now we're just haggling about the price." The man's response implies that if a woman will sell herself at any price, she is a prostitute. The way we regard rationing in health care seems to rest on a similar assumption, that it's immoral to apply monetary considerations to saving lives — but is that stance tenable?
Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.
The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages. In May, Medicare's trustees warned that the program's biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation. According to the Congressional Budget Office, it is on track to double by 2035.
President Obama has said plainly that America's health care system is broken. It is, he has said, by far the most significant driver of America's long-term debt and deficits. It is hard to see how the nation as a whole can remain competitive if in 26 years we are spending nearly a third of what we earn on health care, while other industrialized nations are spending far less but achieving health outcomes as good as, or better than, ours.
Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won't be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?
Last year Britain's National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more than that, and research suggested it offered only about six months extra life. But the British media leapt on the theme of penny-pinching bureaucrats sentencing sick people to death. The issue was then picked up by the U.S. news media and by those lobbying against health care reform in the United States. An article in The New York Times last December featured Bruce Hardy, a kidney-cancer patient whose wife, Joy, said, "It's hard to know that there is something out there that could help but they're saying you can't have it because of cost." Then she asked the classic question: "What price is life?"
Last November, Bloomberg News focused on Jack Rosser, who was 57 at the time and whose doctor had told him that with Sutent he might live long enough to see his 1-year-old daughter, Emma, enter primary school. Rosser's wife, Jenny, is quoted as saying: "It's immoral. They are sentencing him to die." In the conservative monthly The American Spectator, David Catron, a health care consultant, describes Rosser as "one of NICE's many victims" and writes that NICE "regularly hands down death sentences to gravely ill patients." Linking the British system with Democratic proposals for reforming health care in the United States, Catron asked whether we really deserve a health care system in which "soulless bureaucrats arbitrarily put a dollar value on our lives." (In March, NICE issued a final ruling on Sutent. Because of how few patients need the drug and because of special end-of-life considerations, it recommended that the drug be provided by the National Health Service to patients with advanced kidney cancer.)
There's no doubt that it's tough — politically, emotionally and ethically — to make a decision that means that someone will die sooner than they would have if the decision had gone the other way. But if the stories of Bruce Hardy and Jack Rosser lead us to think badly of the British system of rationing health care, we should remind ourselves that the U.S. system also results in people going without life-saving treatment — it just does so less visibly. Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That's rationing too, by ability to pay.
Dr. Art Kellermann, associate dean for public policy at Emory School of Medicine in Atlanta, recently wrote of a woman who came into his emergency room in critical condition because a blood vessel had burst in her brain. She was uninsured and had chosen to buy food for her children instead of spending money on her blood-pressure medicine. In the emergency room, she received excellent high-tech medical care, but by the time she got there, it was too late to save her.
A New York Times report on the high costs of some drugs illustrates the problem. Chuck Stauffer, an Oregon farmer, found that his prescription-drug insurance left him to pay $5,500 for his first 42 days of Temodar, a drug used to treat brain tumors, and $1,700 a month after that. For Medicare patients drug costs can be even higher, because Medicare can require a copayment of 25 percent of the cost of the drug. For Gleevec, a drug that is effective against some forms of leukemia and some gastrointestinal tumors, that one-quarter of the cost can run to $40,000 a year.
In Britain, everyone has health insurance. In the U.S., some 45 million do not, and nor are they entitled to any health care at all, unless they can get themselves to an emergency room. Hospitals are prohibited from turning away anyone who will be endangered by being refused treatment. But even in emergency rooms, people without health insurance may receive less health care than those with insurance. Joseph Doyle, a professor of economics at the Sloan School of Management at M.I.T., studied the records of people in Wisconsin who were injured in severe automobile accidents and had no choice but to go to the hospital. He estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance. This difference held up even when those without health insurance were compared with those without automobile insurance, and with those on Medicaid — groups with whom they share some characteristics that might affect treatment. The lack of insurance seems to be what caused the greater number of deaths.
When the media feature someone like Bruce Hardy or Jack Rosser, we readily relate to individuals who are harmed by a government agency's decision to limit the cost of health care. But we tend not to hear about — and thus don't identify with — the particular individuals who die in emergency rooms because they have no health insurance. This "identifiable victim" effect, well documented by psychologists, creates a dangerous bias in our thinking. Doyle's figures suggest that if those Wisconsin accident victims without health insurance had received equivalent care to those with it, the additional health care would have cost about $220,000 for each life saved. Those who died were on average around 30 years old and could have been expected to live for at least another 40 years; this means that had they survived their accidents, the cost per extra year of life would have been no more than $5,500 — a small fraction of the $49,000 that NICE recommends the British National Health Service should be ready to pay to give a patient an extra year of life. If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.
Estimates of the number of U.S. deaths caused annually by the absence of universal health insurance go as high as 20,000. One study concluded that in the age group 55 to 64 alone, more than 13,000 extra deaths a year may be attributed to the lack of insurance coverage. But the estimates vary because Americans without health insurance are more likely, for example, to smoke than Americans with health insurance, and sorting out the role that the lack of insurance plays is difficult. Richard Kronick, a professor at the School of Medicine at the University of California, San Diego, cautiously concludes from his own study that there is little evidence to suggest that extending health insurance to all Americans would have a large effect on the number of deaths in the United States. That doesn't mean that it wouldn't; we simply don't know if it would.
In any case, it isn't only uninsured Americans who can't afford treatment. President Obama has spoken about his mother, who died from ovarian cancer in 1995. The president said that in the last weeks of her life, his mother "was spending too much time worrying about whether her health insurance would cover her bills" — an experience, the president went on to say, that his mother shared with millions of other Americans. It is also an experience more common in the United States than in other developed countries. A recent Commonwealth Fund study led by Cathy Schoen and Robin Osborn surveyed adults with chronic illness in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom and the United States. Far more Americans reported forgoing health care because of cost. More than half (54 percent) reported not filling a prescription, not visiting a doctor when sick or not getting recommended care. In comparison, in the United Kingdom the figure was 13 percent, and in the Netherlands, only 7 percent. Even among Americans with insurance, 43 percent reported that cost was a problem that had limited the treatment they received. According to a 2007 study led by David Himmelstein, more than 60 percent of all bankruptcies are related to illness, with many of these specifically caused by medical bills, even among those who have health insurance. In Canada the incidence of bankruptcy related to illness is much lower.
When a Washington Post journalist asked Daniel Zemel, a Washington rabbi, what he thought about federal agencies putting a dollar value on human life, the rabbi cited a Jewish teaching explaining that if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally. Perhaps that is how those who resist health care rationing think. But we already put a dollar value on human life. If the Department of Transportation, for example, followed rabbinical teachings it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same. Last year the Consumer Product Safety Commission considered a proposal to make mattresses less likely to catch fire. Information from the industry suggested that the new standard would cost $343 million to implement, but the Consumer Product Safety Commission calculated that it would save 270 lives a year — and since it valued a human life at around $5 million, that made the new standard a good value. If we are going to have consumer-safety regulation at all, we need some idea of how much safety is worth buying. Like health care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a human life is not worth the expense. Twenty years ago, the National Research Council, an arm of the National Academy of Sciences, examined a proposal for installing seat belts in all school buses. It estimated that doing so would save, on average, one life per year, at a cost of $40 million. After that, support for the proposal faded away. So why is it that those who accept that we put a price on life when it comes to consumer safety refuse to accept it when it comes to health care?
Of course, it's one thing to accept that there's a limit to how much we should spend to save a human life, and another to set that limit. The dollar value that bureaucrats place on a generic human life is intended to reflect social values, as revealed in our behavior. It is the answer to the question "How much are you willing to pay to save your life?" — except that, of course, if you asked that question of people who were facing death, they would be prepared to pay almost anything to save their lives. So instead, economists note how much people are prepared to pay to reduce the risk that they will die. How much will people pay for air bags in a car, for instance? Once you know how much they will pay for a specified reduction in risk, you multiply the amount that people are willing to pay by how much the risk has been reduced, and then you know, or so the theory goes, what value people place on their lives. Suppose that there is a 1 in 100,000 chance that an air bag in my car will save my life, and that I would pay $50 — but no more than that — for an air bag. Then it looks as if I value my life at $50 x 100,000, or $5 million.
The theory sounds good, but in practice it has problems. We are not good at taking account of differences between very small risks, so if we are asked how much we would pay to reduce a risk of dying from 1 in 1,000,000 to 1 in 10,000,000, we may give the same answer as we would if asked how much we would pay to reduce the risk from 1 in 500,000 to 1 in 10,000,000. Hence multiplying what we would pay to reduce the risk of death by the reduction in risk lends an apparent mathematical precision to the outcome of the calculation — the supposed value of a human life — that our intuitive responses to the questions cannot support. Nevertheless this approach to setting a value on a human life is at least closer to what we really believe — and to what we should believe — than dramatic pronouncements about the infinite value of every human life, or the suggestion that we cannot distinguish between the value of a single human life and the value of a million human lives, or even of the rest of the world. Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical.
Governments implicitly place a dollar value on a human life when they decide how much is to be spent on health care programs and how much on other public goods that are not directed toward saving lives. The task of health care bureaucrats is then to get the best value for the resources they have been allocated. It is the familiar comparative exercise of getting the most bang for your buck. Sometimes that can be relatively easy to decide. If two drugs offer the same benefits and have similar risks of side effects, but one is much more expensive than the other, only the cheaper one should be provided by the public health care program. That the benefits and the risks of side effects are similar is a scientific matter for experts to decide after calling for submissions and examining them. That is the bread-and-butter work of units like NICE. But the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question but an ethical one.
As a first take, we might say that the good achieved by health care is the number of lives saved. But that is too crude. The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved. If a teenager can be expected to live another 70 years, saving her life counts as a gain of 70 life-years, whereas if a person of 85 can be expected to live another 5 years, then saving the 85-year-old will count as a gain of only 5 life-years. That suggests that saving one teenager is equivalent to saving 14 85-year-olds. These are, of course, generic teenagers and generic 85-year-olds. It's easy to say, "What if the teenager is a violent criminal and the 85-year-old is still working productively?" But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.
Health care does more than save lives: it also reduces pain and suffering. How can we compare saving a person's life with, say, making it possible for someone who was confined to bed to return to an active life? We can elicit people's values on that too. One common method is to describe medical conditions to people — let's say being a quadriplegic — and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life. (These are hypothetical figures, chosen to keep the math simple, and not based on any actual surveys.) If that judgment represents a rough average across the population, we might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.
This is the basis of the quality-adjusted life-year, or QALY, a unit designed to enable us to compare the benefits achieved by different forms of health care. The QALY has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money. If a reformed U.S. health care system explicitly accepted rationing, as I have argued it should, QALYs could play a similar role in the U.S.
Some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value. The problem, however, does not lie with the concept of the quality-adjusted life-year, but with the judgment that, if faced with 10 years as a quadriplegic, one would prefer a shorter lifespan without a disability. Disability advocates might argue that such judgments, made by people without disabilities, merely reflect the ignorance and prejudice of people without disabilities when they think about people with disabilities. We should, they will very reasonably say, ask quadriplegics themselves to evaluate life with quadriplegia. If we do that, and we find that quadriplegics would not give up even one year of life as a quadriplegic in order to have their disability cured, then the QALY method does not justify giving preference to procedures that extend the lives of people without disabilities over procedures that extend the lives of people with disabilities.
This method of preserving our belief that everyone has an equal right to life is, however, a double-edged sword. If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. That implication, no doubt, would have been vigorously rejected by someone like Christopher Reeve, who, after being paralyzed in an accident, campaigned for more research into ways of overcoming spinal-cord injuries. Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition.
The QALY tells us to do what brings about the greatest health benefit, irrespective of where that benefit falls. Usually, for a given quantity of resources, we will do more good if we help those who are worst off, because they have the greatest unmet needs. But occasionally some conditions will be both very severe and very expensive to treat. A QALY approach may then lead us to give priority to helping others who are not so badly off and whose conditions are less expensive to treat. I don't find it unfair to give the same weight to the interests of those who are well off as we give to those who are much worse off, but if there is a social consensus that we should give priority to those who are worse off, we can modify the QALY approach so that it gives greater weight to benefits that accrue to those who are, on the QALY scale, worse off than others.
The QALY approach does not even try to measure the benefits that health care brings in addition to the improvement in health itself. Emotionally, we feel that the fact that Jack Rosser is the father of a young child makes a difference to the importance of extending his life, but his parental status is irrelevant to a QALY assessment of the health care gains that Sutent would bring him. Whether decisions about allocating health care resources should take such personal circumstances into account isn't easy to decide. Not to do so makes the standard inflexible, but taking personal factors into account increases the scope for subjective — and prejudiced — judgments.
The QALY is not a perfect measure of the good obtained by health care, but its defenders can support it in the same way that Winston Churchill defended democracy as a form of government: it is the worst method of allocating health care, except for all the others. If it isn't possible to provide everyone with all beneficial treatments, what better way do we have of deciding what treatments people should get than by comparing the QALYs gained with the expense of the treatments?
Will Americans allow their government, either directly or through an independent agency like NICE, to decide which treatments are sufficiently cost-effective to be provided at public expense and which are not? They might, under two conditions: first, that the option of private health insurance remains available, and second, that they are able to see, in their own pocket, the full cost of not rationing health care.
Rationing public health care limits free choice if private health insurance is prohibited. But many countries combine free national health insurance with optional private insurance. Australia, where I've spent most of my life and raised a family, is one. The U.S. could do something similar. This would mean extending Medicare to the entire population, irrespective of age, but without Medicare's current policy that allows doctors wide latitude in prescribing treatments for eligible patients. Instead, Medicare for All, as we might call it, should refuse to pay where the cost per QALY is extremely high. (On the other hand, Medicare for All would not require more than a token copayment for drugs that are cost-effective.) The extension of Medicare could be financed by a small income-tax levy, for those who pay income tax — in Australia the levy is 1.5 percent of taxable income. (There's an extra 1 percent surcharge for those with high incomes and no private insurance. Those who earn too little to pay income tax would be carried at no cost to themselves.) Those who want to be sure of receiving every treatment that their own privately chosen physicians recommend, regardless of cost, would be free to opt out of Medicare for All as long as they can demonstrate that they have sufficient private health insurance to avoid becoming a burden on the community if they fall ill. Alternatively, they might remain in Medicare for All but take out supplementary insurance for health care that Medicare for All does not cover. Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them.
One final comment. It is common for opponents of health care rationing to point to Canada and Britain as examples of where we might end up if we get "socialized medicine." On a blog on Fox News earlier this year, the conservative writer John Lott wrote, "Americans should ask Canadians and Brits — people who have long suffered from rationing — how happy they are with central government decisions on eliminating 'unnecessary' health care." There is no particular reason that the United States should copy the British or Canadian forms of universal coverage, rather than one of the different arrangements that have developed in other industrialized nations, some of which may be better. But as it happens, last year the Gallup organization did ask Canadians and Brits, and people in many different countries, if they have confidence in "health care or medical systems" in their country. In Canada, 73 percent answered this question affirmatively. Coincidentally, an identical percentage of Britons gave the same answer. In the United States, despite spending much more, per person, on health care, the figure was only 56 percent.
Peter Singer is professor of bioethics at Princeton University. He is also laureate professor at the University of Melbourne, in Australia. His most recent book is "The Life You Can Save: Acting Now to End World Poverty."
This article has been revised to reflect the following correction:
Correction: July 18, 2009
An article in The Times Magazine this weekend about the argument for rationing health care in the United States misstates the number of years it would take under the current system for the country to spend nearly a third of what it earns on health care. It is 26 years from now, or 2035, not 15 years.
Why We Must Ration Health Care - NYTimes.com (18 July 2009)
http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?_r=1&em=&pagewanted=print
http://snipurl.com/nh5eh
Why We Must Ration Health Care By PETER SINGER
You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?
If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn't going to be good. But suppose it's not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone's life? If there is any point at which you say, "No, an extra six months isn't worth that much," then you think that health care should be rationed.
In the current U.S. debate over health care reform, "rationing" has become a dirty word. Meeting last month with five governors, President Obama urged them to avoid using the term, apparently for fear of evoking the hostile response that sank the Clintons' attempt to achieve reform. In a Wall Street Journal op-ed published at the end of last year with the headline "Obama Will Ration Your Health Care," Sally Pipes, C.E.O. of the conservative Pacific Research Institute, described how in Britain the national health service does not pay for drugs that are regarded as not offering good value for money, and added, "Americans will not put up with such limits, nor will our elected representatives." And the Democratic chair of the Senate Finance Committee, Senator Max Baucus, told CNSNews in April, "There is no rationing of health care at all" in the proposed reform.
Remember the joke about the man who asks a woman if she would have sex with him for a million dollars? She reflects for a few moments and then answers that she would. "So," he says, "would you have sex with me for $50?" Indignantly, she exclaims, "What kind of a woman do you think I am?" He replies: "We've already established that. Now we're just haggling about the price." The man's response implies that if a woman will sell herself at any price, she is a prostitute. The way we regard rationing in health care seems to rest on a similar assumption, that it's immoral to apply monetary considerations to saving lives — but is that stance tenable?
Health care is a scarce resource, and all scarce resources are rationed in one way or another. In the United States, most health care is privately financed, and so most rationing is by price: you get what you, or your employer, can afford to insure you for. But our current system of employer-financed health insurance exists only because the federal government encouraged it by making the premiums tax deductible. That is, in effect, a more than $200 billion government subsidy for health care. In the public sector, primarily Medicare, Medicaid and hospital emergency rooms, health care is rationed by long waits, high patient copayment requirements, low payments to doctors that discourage some from serving public patients and limits on payments to hospitals.
The case for explicit health care rationing in the United States starts with the difficulty of thinking of any other way in which we can continue to provide adequate health care to people on Medicaid and Medicare, let alone extend coverage to those who do not now have it. Health-insurance premiums have more than doubled in a decade, rising four times faster than wages. In May, Medicare's trustees warned that the program's biggest fund is heading for insolvency in just eight years. Health care now absorbs about one dollar in every six the nation spends, a figure that far exceeds the share spent by any other nation. According to the Congressional Budget Office, it is on track to double by 2035.
President Obama has said plainly that America's health care system is broken. It is, he has said, by far the most significant driver of America's long-term debt and deficits. It is hard to see how the nation as a whole can remain competitive if in 26 years we are spending nearly a third of what we earn on health care, while other industrialized nations are spending far less but achieving health outcomes as good as, or better than, ours.
Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won't be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?
Last year Britain's National Institute for Health and Clinical Excellence gave a preliminary recommendation that the National Health Service should not offer Sutent for advanced kidney cancer. The institute, generally known as NICE, is a government-financed but independently run organization set up to provide national guidance on promoting good health and treating illness. The decision on Sutent did not, at first glance, appear difficult. NICE had set a general limit of £30,000, or about $49,000, on the cost of extending life for a year. Sutent, when used for advanced kidney cancer, cost more than that, and research suggested it offered only about six months extra life. But the British media leapt on the theme of penny-pinching bureaucrats sentencing sick people to death. The issue was then picked up by the U.S. news media and by those lobbying against health care reform in the United States. An article in The New York Times last December featured Bruce Hardy, a kidney-cancer patient whose wife, Joy, said, "It's hard to know that there is something out there that could help but they're saying you can't have it because of cost." Then she asked the classic question: "What price is life?"
Last November, Bloomberg News focused on Jack Rosser, who was 57 at the time and whose doctor had told him that with Sutent he might live long enough to see his 1-year-old daughter, Emma, enter primary school. Rosser's wife, Jenny, is quoted as saying: "It's immoral. They are sentencing him to die." In the conservative monthly The American Spectator, David Catron, a health care consultant, describes Rosser as "one of NICE's many victims" and writes that NICE "regularly hands down death sentences to gravely ill patients." Linking the British system with Democratic proposals for reforming health care in the United States, Catron asked whether we really deserve a health care system in which "soulless bureaucrats arbitrarily put a dollar value on our lives." (In March, NICE issued a final ruling on Sutent. Because of how few patients need the drug and because of special end-of-life considerations, it recommended that the drug be provided by the National Health Service to patients with advanced kidney cancer.)
There's no doubt that it's tough — politically, emotionally and ethically — to make a decision that means that someone will die sooner than they would have if the decision had gone the other way. But if the stories of Bruce Hardy and Jack Rosser lead us to think badly of the British system of rationing health care, we should remind ourselves that the U.S. system also results in people going without life-saving treatment — it just does so less visibly. Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits set by NICE. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That's rationing too, by ability to pay.
Dr. Art Kellermann, associate dean for public policy at Emory School of Medicine in Atlanta, recently wrote of a woman who came into his emergency room in critical condition because a blood vessel had burst in her brain. She was uninsured and had chosen to buy food for her children instead of spending money on her blood-pressure medicine. In the emergency room, she received excellent high-tech medical care, but by the time she got there, it was too late to save her.
A New York Times report on the high costs of some drugs illustrates the problem. Chuck Stauffer, an Oregon farmer, found that his prescription-drug insurance left him to pay $5,500 for his first 42 days of Temodar, a drug used to treat brain tumors, and $1,700 a month after that. For Medicare patients drug costs can be even higher, because Medicare can require a copayment of 25 percent of the cost of the drug. For Gleevec, a drug that is effective against some forms of leukemia and some gastrointestinal tumors, that one-quarter of the cost can run to $40,000 a year.
In Britain, everyone has health insurance. In the U.S., some 45 million do not, and nor are they entitled to any health care at all, unless they can get themselves to an emergency room. Hospitals are prohibited from turning away anyone who will be endangered by being refused treatment. But even in emergency rooms, people without health insurance may receive less health care than those with insurance. Joseph Doyle, a professor of economics at the Sloan School of Management at M.I.T., studied the records of people in Wisconsin who were injured in severe automobile accidents and had no choice but to go to the hospital. He estimated that those who had no health insurance received 20 percent less care and had a death rate 37 percent higher than those with health insurance. This difference held up even when those without health insurance were compared with those without automobile insurance, and with those on Medicaid — groups with whom they share some characteristics that might affect treatment. The lack of insurance seems to be what caused the greater number of deaths.
When the media feature someone like Bruce Hardy or Jack Rosser, we readily relate to individuals who are harmed by a government agency's decision to limit the cost of health care. But we tend not to hear about — and thus don't identify with — the particular individuals who die in emergency rooms because they have no health insurance. This "identifiable victim" effect, well documented by psychologists, creates a dangerous bias in our thinking. Doyle's figures suggest that if those Wisconsin accident victims without health insurance had received equivalent care to those with it, the additional health care would have cost about $220,000 for each life saved. Those who died were on average around 30 years old and could have been expected to live for at least another 40 years; this means that had they survived their accidents, the cost per extra year of life would have been no more than $5,500 — a small fraction of the $49,000 that NICE recommends the British National Health Service should be ready to pay to give a patient an extra year of life. If the U.S. system spent less on expensive treatments for those who, with or without the drugs, have at most a few months to live, it would be better able to save the lives of more people who, if they get the treatment they need, might live for several decades.
Estimates of the number of U.S. deaths caused annually by the absence of universal health insurance go as high as 20,000. One study concluded that in the age group 55 to 64 alone, more than 13,000 extra deaths a year may be attributed to the lack of insurance coverage. But the estimates vary because Americans without health insurance are more likely, for example, to smoke than Americans with health insurance, and sorting out the role that the lack of insurance plays is difficult. Richard Kronick, a professor at the School of Medicine at the University of California, San Diego, cautiously concludes from his own study that there is little evidence to suggest that extending health insurance to all Americans would have a large effect on the number of deaths in the United States. That doesn't mean that it wouldn't; we simply don't know if it would.
In any case, it isn't only uninsured Americans who can't afford treatment. President Obama has spoken about his mother, who died from ovarian cancer in 1995. The president said that in the last weeks of her life, his mother "was spending too much time worrying about whether her health insurance would cover her bills" — an experience, the president went on to say, that his mother shared with millions of other Americans. It is also an experience more common in the United States than in other developed countries. A recent Commonwealth Fund study led by Cathy Schoen and Robin Osborn surveyed adults with chronic illness in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom and the United States. Far more Americans reported forgoing health care because of cost. More than half (54 percent) reported not filling a prescription, not visiting a doctor when sick or not getting recommended care. In comparison, in the United Kingdom the figure was 13 percent, and in the Netherlands, only 7 percent. Even among Americans with insurance, 43 percent reported that cost was a problem that had limited the treatment they received. According to a 2007 study led by David Himmelstein, more than 60 percent of all bankruptcies are related to illness, with many of these specifically caused by medical bills, even among those who have health insurance. In Canada the incidence of bankruptcy related to illness is much lower.
When a Washington Post journalist asked Daniel Zemel, a Washington rabbi, what he thought about federal agencies putting a dollar value on human life, the rabbi cited a Jewish teaching explaining that if you put one human life on one side of a scale, and you put the rest of the world on the other side, the scale is balanced equally. Perhaps that is how those who resist health care rationing think. But we already put a dollar value on human life. If the Department of Transportation, for example, followed rabbinical teachings it would exhaust its entire budget on road safety. Fortunately the department sets a limit on how much it is willing to pay to save one human life. In 2008 that limit was $5.8 million. Other government agencies do the same. Last year the Consumer Product Safety Commission considered a proposal to make mattresses less likely to catch fire. Information from the industry suggested that the new standard would cost $343 million to implement, but the Consumer Product Safety Commission calculated that it would save 270 lives a year — and since it valued a human life at around $5 million, that made the new standard a good value. If we are going to have consumer-safety regulation at all, we need some idea of how much safety is worth buying. Like health care bureaucrats, consumer-safety bureaucrats sometimes decide that saving a human life is not worth the expense. Twenty years ago, the National Research Council, an arm of the National Academy of Sciences, examined a proposal for installing seat belts in all school buses. It estimated that doing so would save, on average, one life per year, at a cost of $40 million. After that, support for the proposal faded away. So why is it that those who accept that we put a price on life when it comes to consumer safety refuse to accept it when it comes to health care?
Of course, it's one thing to accept that there's a limit to how much we should spend to save a human life, and another to set that limit. The dollar value that bureaucrats place on a generic human life is intended to reflect social values, as revealed in our behavior. It is the answer to the question "How much are you willing to pay to save your life?" — except that, of course, if you asked that question of people who were facing death, they would be prepared to pay almost anything to save their lives. So instead, economists note how much people are prepared to pay to reduce the risk that they will die. How much will people pay for air bags in a car, for instance? Once you know how much they will pay for a specified reduction in risk, you multiply the amount that people are willing to pay by how much the risk has been reduced, and then you know, or so the theory goes, what value people place on their lives. Suppose that there is a 1 in 100,000 chance that an air bag in my car will save my life, and that I would pay $50 — but no more than that — for an air bag. Then it looks as if I value my life at $50 x 100,000, or $5 million.
The theory sounds good, but in practice it has problems. We are not good at taking account of differences between very small risks, so if we are asked how much we would pay to reduce a risk of dying from 1 in 1,000,000 to 1 in 10,000,000, we may give the same answer as we would if asked how much we would pay to reduce the risk from 1 in 500,000 to 1 in 10,000,000. Hence multiplying what we would pay to reduce the risk of death by the reduction in risk lends an apparent mathematical precision to the outcome of the calculation — the supposed value of a human life — that our intuitive responses to the questions cannot support. Nevertheless this approach to setting a value on a human life is at least closer to what we really believe — and to what we should believe — than dramatic pronouncements about the infinite value of every human life, or the suggestion that we cannot distinguish between the value of a single human life and the value of a million human lives, or even of the rest of the world. Though such feel-good claims may have some symbolic value in particular circumstances, to take them seriously and apply them — for instance, by leaving it to chance whether we save one life or a billion — would be deeply unethical.
Governments implicitly place a dollar value on a human life when they decide how much is to be spent on health care programs and how much on other public goods that are not directed toward saving lives. The task of health care bureaucrats is then to get the best value for the resources they have been allocated. It is the familiar comparative exercise of getting the most bang for your buck. Sometimes that can be relatively easy to decide. If two drugs offer the same benefits and have similar risks of side effects, but one is much more expensive than the other, only the cheaper one should be provided by the public health care program. That the benefits and the risks of side effects are similar is a scientific matter for experts to decide after calling for submissions and examining them. That is the bread-and-butter work of units like NICE. But the benefits may vary in ways that defy straightforward comparison. We need a common unit for measuring the goods achieved by health care. Since we are talking about comparing different goods, the choice of unit is not merely a scientific or economic question but an ethical one.
As a first take, we might say that the good achieved by health care is the number of lives saved. But that is too crude. The death of a teenager is a greater tragedy than the death of an 85-year-old, and this should be reflected in our priorities. We can accommodate that difference by calculating the number of life-years saved, rather than simply the number of lives saved. If a teenager can be expected to live another 70 years, saving her life counts as a gain of 70 life-years, whereas if a person of 85 can be expected to live another 5 years, then saving the 85-year-old will count as a gain of only 5 life-years. That suggests that saving one teenager is equivalent to saving 14 85-year-olds. These are, of course, generic teenagers and generic 85-year-olds. It's easy to say, "What if the teenager is a violent criminal and the 85-year-old is still working productively?" But just as emergency rooms should leave criminal justice to the courts and treat assailants and victims alike, so decisions about the allocation of health care resources should be kept separate from judgments about the moral character or social value of individuals.
Health care does more than save lives: it also reduces pain and suffering. How can we compare saving a person's life with, say, making it possible for someone who was confined to bed to return to an active life? We can elicit people's values on that too. One common method is to describe medical conditions to people — let's say being a quadriplegic — and tell them that they can choose between 10 years in that condition or some smaller number of years without it. If most would prefer, say, 10 years as a quadriplegic to 4 years of nondisabled life, but would choose 6 years of nondisabled life over 10 with quadriplegia, but have difficulty deciding between 5 years of nondisabled life or 10 years with quadriplegia, then they are, in effect, assessing life with quadriplegia as half as good as nondisabled life. (These are hypothetical figures, chosen to keep the math simple, and not based on any actual surveys.) If that judgment represents a rough average across the population, we might conclude that restoring to nondisabled life two people who would otherwise be quadriplegics is equivalent in value to saving the life of one person, provided the life expectancies of all involved are similar.
This is the basis of the quality-adjusted life-year, or QALY, a unit designed to enable us to compare the benefits achieved by different forms of health care. The QALY has been used by economists working in health care for more than 30 years to compare the cost-effectiveness of a wide variety of medical procedures and, in some countries, as part of the process of deciding which medical treatments will be paid for with public money. If a reformed U.S. health care system explicitly accepted rationing, as I have argued it should, QALYs could play a similar role in the U.S.
Some will object that this discriminates against people with disabilities. If we return to the hypothetical assumption that a year with quadriplegia is valued at only half as much as a year without it, then a treatment that extends the lives of people without disabilities will be seen as providing twice the value of one that extends, for a similar period, the lives of quadriplegics. That clashes with the idea that all human lives are of equal value. The problem, however, does not lie with the concept of the quality-adjusted life-year, but with the judgment that, if faced with 10 years as a quadriplegic, one would prefer a shorter lifespan without a disability. Disability advocates might argue that such judgments, made by people without disabilities, merely reflect the ignorance and prejudice of people without disabilities when they think about people with disabilities. We should, they will very reasonably say, ask quadriplegics themselves to evaluate life with quadriplegia. If we do that, and we find that quadriplegics would not give up even one year of life as a quadriplegic in order to have their disability cured, then the QALY method does not justify giving preference to procedures that extend the lives of people without disabilities over procedures that extend the lives of people with disabilities.
This method of preserving our belief that everyone has an equal right to life is, however, a double-edged sword. If life with quadriplegia is as good as life without it, there is no health benefit to be gained by curing it. That implication, no doubt, would have been vigorously rejected by someone like Christopher Reeve, who, after being paralyzed in an accident, campaigned for more research into ways of overcoming spinal-cord injuries. Disability advocates, it seems, are forced to choose between insisting that extending their lives is just as important as extending the lives of people without disabilities, and seeking public support for research into a cure for their condition.
The QALY tells us to do what brings about the greatest health benefit, irrespective of where that benefit falls. Usually, for a given quantity of resources, we will do more good if we help those who are worst off, because they have the greatest unmet needs. But occasionally some conditions will be both very severe and very expensive to treat. A QALY approach may then lead us to give priority to helping others who are not so badly off and whose conditions are less expensive to treat. I don't find it unfair to give the same weight to the interests of those who are well off as we give to those who are much worse off, but if there is a social consensus that we should give priority to those who are worse off, we can modify the QALY approach so that it gives greater weight to benefits that accrue to those who are, on the QALY scale, worse off than others.
The QALY approach does not even try to measure the benefits that health care brings in addition to the improvement in health itself. Emotionally, we feel that the fact that Jack Rosser is the father of a young child makes a difference to the importance of extending his life, but his parental status is irrelevant to a QALY assessment of the health care gains that Sutent would bring him. Whether decisions about allocating health care resources should take such personal circumstances into account isn't easy to decide. Not to do so makes the standard inflexible, but taking personal factors into account increases the scope for subjective — and prejudiced — judgments.
The QALY is not a perfect measure of the good obtained by health care, but its defenders can support it in the same way that Winston Churchill defended democracy as a form of government: it is the worst method of allocating health care, except for all the others. If it isn't possible to provide everyone with all beneficial treatments, what better way do we have of deciding what treatments people should get than by comparing the QALYs gained with the expense of the treatments?
Will Americans allow their government, either directly or through an independent agency like NICE, to decide which treatments are sufficiently cost-effective to be provided at public expense and which are not? They might, under two conditions: first, that the option of private health insurance remains available, and second, that they are able to see, in their own pocket, the full cost of not rationing health care.
Rationing public health care limits free choice if private health insurance is prohibited. But many countries combine free national health insurance with optional private insurance. Australia, where I've spent most of my life and raised a family, is one. The U.S. could do something similar. This would mean extending Medicare to the entire population, irrespective of age, but without Medicare's current policy that allows doctors wide latitude in prescribing treatments for eligible patients. Instead, Medicare for All, as we might call it, should refuse to pay where the cost per QALY is extremely high. (On the other hand, Medicare for All would not require more than a token copayment for drugs that are cost-effective.) The extension of Medicare could be financed by a small income-tax levy, for those who pay income tax — in Australia the levy is 1.5 percent of taxable income. (There's an extra 1 percent surcharge for those with high incomes and no private insurance. Those who earn too little to pay income tax would be carried at no cost to themselves.) Those who want to be sure of receiving every treatment that their own privately chosen physicians recommend, regardless of cost, would be free to opt out of Medicare for All as long as they can demonstrate that they have sufficient private health insurance to avoid becoming a burden on the community if they fall ill. Alternatively, they might remain in Medicare for All but take out supplementary insurance for health care that Medicare for All does not cover. Every American will have a right to a good standard of health care, but no one will have a right to unrationed health care. Those who opt for unrationed health care will know exactly how much it costs them.
One final comment. It is common for opponents of health care rationing to point to Canada and Britain as examples of where we might end up if we get "socialized medicine." On a blog on Fox News earlier this year, the conservative writer John Lott wrote, "Americans should ask Canadians and Brits — people who have long suffered from rationing — how happy they are with central government decisions on eliminating 'unnecessary' health care." There is no particular reason that the United States should copy the British or Canadian forms of universal coverage, rather than one of the different arrangements that have developed in other industrialized nations, some of which may be better. But as it happens, last year the Gallup organization did ask Canadians and Brits, and people in many different countries, if they have confidence in "health care or medical systems" in their country. In Canada, 73 percent answered this question affirmatively. Coincidentally, an identical percentage of Britons gave the same answer. In the United States, despite spending much more, per person, on health care, the figure was only 56 percent.
Peter Singer is professor of bioethics at Princeton University. He is also laureate professor at the University of Melbourne, in Australia. His most recent book is "The Life You Can Save: Acting Now to End World Poverty."
This article has been revised to reflect the following correction:
Correction: July 18, 2009
An article in The Times Magazine this weekend about the argument for rationing health care in the United States misstates the number of years it would take under the current system for the country to spend nearly a third of what it earns on health care. It is 26 years from now, or 2035, not 15 years.
Why We Must Ration Health Care - NYTimes.com (18 July 2009)
http://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html?_r=1&em=&pagewanted=print
http://snipurl.com/nh5eh
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