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Saturday, September 20, 2008

Lions in Loins


Dr. Lester CN Simon

So much. So much has happened over the past few days. It was as if we came face to face with who we really are and realized that we would and should never be the same again. The power outages were bad enough but the disinformation, and the disrespect for friends, foes and especially for holders of high office, drove many of us away from the media, electronic and print. We confined ourselves to the gloom of our lonely rooms and the darkness of our empty selves from which we quietly emerged with a solitary want: to know what is intrinsic to our way of life that forces us to become such rude and unruly cannibals.

Turning off and away and tuning in to BBC, I heard Mugabe suggesting that democracy might not be the best system for Zimbabwe. Say what you want about Mugabe (and there is much to be said against him), he is aware that the Mandela solution for South Africa was not really a solution but rather just the start of a journey with bigger and more dangerous battles ahead. Indeed, it can be argued that Mandela’s road to victory was relatively easy in light of the long march forward. To his eternal credit, Mandela realized this and walked away knowing that the next steps must be walked and championed by others. Mbeki is aware of his own limitations and that he is just one of the many links in the chain of leaders to come. He knows that Mugabe has his faults but he is also painfully aware of the limitations of both the path travelled by Mandela and by Mugabe.

It occurred to me that democracy, as currently attempted, might not be the best system for us either. It is not that we are intrinsically unable to govern ourselves along democratic lines. It is that our practicing of democracy has three requirements, which are reduced to one: Either we allow and engage the same long passage of time and turmoil that others endured in order to arrive at a workable, pragmatic constitution, or we learn very fast at warp speed, or we fashion democracy in light of the fact that we do not have the long passage of time to wait and that all of us cannot learn at warp speed and practice what we learn. Reformation is the way forward.

If we agree that “No man is an island”, can we agree on how many people it takes to run a country along democratic lines, as inherited from England? I do not think seventy or eighty thousand people qualify. Size and history matter. The link between business and government can lead to disastrous consequences in a small society because of the monopoly of big influence with little or no counterbalance. It means that a limit to political campaign finance contribution is of crucial and fundamental import in our small developing state. Reformation is the way forward.

There has been much talk about patriotism with reference to our national anthem, asking us to gird our loins and join the battle. We are prepared to join the battle only if the battle involves committing ourselves to really building a true nation, brave and free. In this regard, we have to take a long and hard look at how we govern ourselves. We must amend our constitution such that no one person can be prime minister for more than two consecutive terms. Any modern political party that cannot put up two different leaders or prime ministers for two consecutive terms is not concerned about succession planning and is not worthy of membership. Limitation on the terms of the prime minister would allow political parties to breathe and breed and help to abort the long term stranglehold big businesses have on some politicians. Reformation is the way forward.

We are verging on a state of inertia where people become disillusioned about the way we govern ourselves. The UPP is a single stepping stone away from darkness into light. We cannot go back to the blind past and we must not go along blindly with the UPP, as presently constituted, simply to avoid the past. We have to let politicians within and without the government know that when the anthem refers to all enduring to defend the liberty of Antigua and Barbuda, we must define firstly what is that liberty. The recent darkness has forced our imperfections into light and dictated that we gird our lions first, before we gird our loins, lest we chant the charge of the light brigade.

Thursday, September 11, 2008

Health Insurance


Dr. Lester CN Simon

I wish to suggest to you that by departing from its annual health expo to a road show, the MBS in exposing us to a paradigm shift not just in the way it functions but also in the way patients and health officials come to grips with healthcare delivery.

My premise is based on my understanding of the term, “moral hazard”. I came across this term in an article, The Moral-Hazard Myth, in 2005 in The New Yorker Magazine, by one of my favourite writers, Malcolm Gladwell, author of The Tipping Point. In fact, this address owes a great deal to the article by Malcolm Gladwell, a very insightful writer and thinker. Moral hazard is a term used by economists to describe the notion that insurance can change the behaviour of the person insured.

Moral hazard refers to the paradoxical and hazardous effect insurance can have by inducing risky and wasteful behaviour. It is not peculiar to insurance at all. You are insured and driving a car with all the appropriate insurance so you may drive faster and rougher. You are using a condom so (with all the appropriate “insurance”), so, to repeat the phrase, you may drive faster and rougher.

The “moral” part of the term, moral hazard, is derived from the fact that mathematicians studying decision-making in the 1700s used "moral" to mean "subjective". But we may simply understand moral hazard, as noted, to be the increase or new risk and wastefulness associated with the insured. It is felt that moral hazard arises because an individual does not bear the full consequences or costs of his actions, and therefore has a tendency to act less carefully than he otherwise would, leaving another party (like the MBS) to bear responsibility for the consequences of his actions.

According to Gladwell, it is the fear of moral hazard, the potential increase in risk and resulting wastefulness from insurance, that prevents the expansion of health insurance in USA. Hence some 45 million people (and counting) in USA are without healthcare coverage. One way to diminish moral hazard is co-payment in which the client pays a part of the cost, or deductibles. The insurance company assumes that through co-payment or deductibles, the patient will use the healthcare system more responsibly and hence moral hazard is reduced.

The crucial point Gladwell posits is that the problem with moral hazard is that healthcare is not like other types of insurance; nor is it like other waste-prone products. If the government were to give us free water or electricity, or both, the moral hazard argument is that we become irresponsible and wasteful since we do not have to pay. However, barring a very few pretenders or hypochondriacs, most people do not eagerly run to the doctor just to look at the doctor’s face. People seek health care because they are sick, or at least because they feel unwell. I am painfully aware that some clients do go to doctors to buy sick leave that they are not entitled to but that is another topic for another road show. I know some of my colleagues will come at me for saying this but I can defend my position.

Gladwell gets to the meat of the matter in The Moral-Hazard Myth by regarding the fundamental function of insurance. One model is to equalize the financial risk between the healthy ones in the country on one hand and the sick ones on the other hand. He refers to this as a sort of social insurance. We pay because we know that when we are sick and cannot pay, someone else will subsidize our healthcare delivery, as we subsidized others when we were well and paying. This is the form of health insurance practiced in large part in Canada, Germany, Japan and most industrialized nations with universal healthcare. This is not so in USA. The other model is the actuarial way in which we pay according to our actual individual situation and history, like care insurance, for example.

By putting the MBS on a road show, it begs the question: Where is the MBS going? Do we go forward by putting more of the cost of healthcare on the individual consumer by way of private insurance? In so doing we will reduce the redistributive element of the social insurance model. If the future of health insurance will be more along the lines of socialized (MBS-Style) as apposed to, or to a greater extent than, privatized health insurance, we are making fundamental assumption according to Gladwell. We are assuming that the more equally and widely the burdens of healthcare are shared, the better off the population as a whole is likely to be. In my opinion, this noble assumption can only hold in practice if we also assume and make real that the other burdens of the good life and not just the burden of healthcare are shared as well in word and in deed.

This is why I referred to a paradigm shift that the MBS road show is exposing us to. In fact, the MBS is exposing itself and all of us and asking us to consider not just the social insurance sharing of healthcare versus confined, private health insurance. It is forcing MBS and all of us to regard also the conjoint social aspects of education, crime and violence, immigration, general taxation, public health, etc. Indeed the MBS road show will drive us to the tipping point to regard all aspects of the way we live. Sadly, it took another killing for some of us to realise that it is not just tourism that is everybody’s business.

And so, with this exposure to the reality of sharing the wider aspects and burdens of living together, and not just healthcare, I am proud to be part of this noble effort as we join with the MBS to not only, “Get on the Road for Better Health”, but to get on the road for a less unequal and a more just and modern Antiguan and Barbuda.

Wednesday, September 3, 2008

The Commissioner


Dr. Lester CN Simon

Having written when the four Canadian police officers arrived, I feel compelled to have my say on the departure of Mr. Nelson. To all those who have been hurling blame at the government, I urge them to put on their thinking caps and consider what motive this government would have at this time to fire Mr. Nelson.

Some of the callers and critics who were calling for earlier and more detailed disclosure from the government, might not have had the misfortune of having to fire someone and might not be aware of the proper procedure, including official, written notification. Moreover, if the aggrieved party goes public, the right to know and hear from the government must be balanced by attention to official procedure and the responsibility to safeguard not only national security but the reputation of the aggrieved party as well.

Many of us pretend that we do not understand that the desire to reform an organization, even with, and especially with, the best of intentions, can lead to problems that compound the very problem that existed in the first place. We know many workers in government and in private service who are very friendly and who appear to get on well with the public and who seem to get the job done. And yet some of these admirable workers might be using processes and procedures that are counterproductive to the overall running of the organization. Indeed, these hardworking workers may be blind to the effects of their methods on the other workers because they are genuinely trying very hard to solve wrenchingly, complex problems.

Without having any information on the problems and internal struggles that led to Mr. Nelson’s departure, I can only regard Mr. Nelson’s own remarks and those of the prime minister on Observer Radio. In reference to crime fighting, Mr. Nelson said a few weeks ago that a particular crime-stop initiative was either being assisted by or pursued with the help of a civilian, who happens to be in the tourist industry. The extent of the involvement of this or any other civilian was not stated. Is this the way police business is carried out, even if it is done in concert with conscientious civilians, and especially when reform is the order of the day?

Mr. Nelson also freely and publicly gave out his phone number to at least two persons who called into a radio program on Observer Radio. They had called because of difficulties they had with police procedures. Interestingly this was on the day before the melee started over his departure. One caller was concerned about the delay in obtaining personal firearms legitimately. Now, nothing is wrong with the police commissioner disclosing his telephone number in public; in fact it is a welcome act, if only because we may have to call him as a last resort. And therein lies the problem. Mr. Nelson should have directed the caller to the appropriated police section or police officer first, especially at this time when reform is the order of the day.

As trivial as these examples might seem, I wonder how many more serious departure from protocol, in trying to sort out the beleaguered force, contributed to his departure. I know of one relatively minor situation in which his eagerness and honest desire to do good and assist others fell a touch short, forgivingly, of the 37 years of high ethical standards he speaks. He is human. And by the bye, we are familiar with high ethical standards too.

I am left to think that it was probably neither the difference in cultures that was at fault, nor the attempt to import a foreign solution. Mr. Nelson might have become too colloquial in his earnest desire to reform the force and was probably going down one of the very same roads many of the previous commissioners had traveled. It is all so very sad. Things can only get better as we learn and move on.