Politics

Obama's Glamour Problem

Former reason editor Virginia Postrel on the economics of health care and the intersection of glamour and politics.

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Virginia Postrel has a knack for changing the way people think about everyday phenomena. As editor of reason during the 1990s, Postrel predicted how Western enthusiasm for Marxism would, in the wake of communism's collapse, transfer seamlessly to a top-down, regulatory brand of environmentalism. When the World Wide Web triggered the excitable imaginations of censorious legislators, she calmly explained that thick strains in both major political tendencies cling to the precautionary principle at the expense of liberating progress.

In The Future and its Enemies (1998), Postrel tossed aside the traditional left-right paradigm and posited a new postā€“Cold War divide between "dynamists" and "stasists," in which the former championed choice and creativity and the latter clung to fear and control. In The Substance of Style (2003), she unpacked the economics of design and offered an appreciation of the Age of Aesthetics. And when she donated her own kidney to a woman on the organ waiting list in 2006, Postrel introduced tens of thousands of people to the once radical idea of organ markets in a way no academic treatise ever could. In each of these cases, those who encounter Postrel's work will never look at the subject the same way again.

In 2009 Postrel launched a new website called Deep Glamour to probe (as its motto says) the "intersection of imagination & desire." In a typically eclectic selection from March, the site discussed female body image, the universal hatred for Oscar speeches, the power of nonverbal rhetoric, and whether cuteness and glamour can co-exist. By changing the way we think about glamour, Postrel is helping us better understand, among other things, the allure and frustration of the current American president.

Now 50, Postrel has spent her post-reason career writing for The New York Times, The Atlantic Monthly, and her popular personal blog (vpostrel.com/weblog). reason.tv producer Ted Balaker caught up with Postrel last February in Los Angeles, where she returned in 2007 after living for several years in Dallas. You can watch an edited video of this interview at reason.tv.

reason: Tell us about DeepGlamour.net.

Virginia Postrel: DeepGlamour.net explores glamour in its many manifestations. We write essays; it's not a street fashion blog or something like that. My view of glamour is that it is not a style, it is not just about movie stars, and it is in fact a powerful form of visual rhetoric and persuasion, an imaginative process like humor that takes place between an audience and an object. It takes many different forms, depending on the audience and what they find glamorousā€”the cultural context.

reason: You've called glamour a beautiful illusion. A lot of people would say that describes President Obama. 

Postrel: Yes, President Obama is a very glamorous figure. Glamour is a particular form of illusion. It's an illusion that tells a truth about the audience's desires, and it requires mystery and distance. During the campaign people projected onto Barack Obama whatever they wanted in a president or even in a country. Lying is usually a bad thing, but they would project onto him that he was lying about his positions because he secretly agreed with them: "Anyone that smart has got to be a free trader at heart. He's just saying this to pander to those idiots. He can't really mean it."

You've seen, as he's taken office and tried to govern, this back and forth where he is consciously or unconsciously trying to maintain his glamourā€”which requires a kind of distance from the political process so that people can continue to see him as representing them, regardless of their contradictory viewsā€”while actually trying to be president, which means you have to decide what to do about Guantanamo. You have to decide what health care bill you're going to back. You have to decide all these things, and you're going to make somebody disillusioned. This morning I saw that the former editor of Harper's is about to write a book, The Mendacity of Hope, attacking Obama from the left. That's the power and the downside of glamour.

reason: I'm going to read you something you wrote in an April 2008 column: "Obama's glamour gives him a powerful political advantage, but it also poses special problems for the candidate and, if he succeeds, for the country." Can you explain what you meant and how it has played out?

Postrel: The flip side of glamour is horror. People say, "Oh, there's something he's hiding. It must be something terrible." They say "he's secretly a radical Muslim" or "he's secretly really born in Kenya." As opposed to saying he has policies that are bad for the country. So that is one type of disadvantage.

The other is the one that I just talked about, which is that there is always this capacity for disillusionment. People have projected so much of what they think, including things that are sort of impossible, onto a glamorous figure, that when any flaw shows up the glamour is dispelled and suddenly he becomes terrible.

reason: Is glamour bad for a president seeking re-election, after people have realized he couldn't possibly live up to all of our hopes?

Postrel: There were two glamorous presidents in my lifetime besides Obama. The first was JFK, and he dealt with this problem by getting killed. That was something I didn't want to mention in an article about Obama. There were lots of problems in the Kennedy administration and lots of secrets that were being hidden that came out later. But because he was assassinated, the glamour stayed. 

The other glamorous president of my lifetime, I would argue, was Ronald Reagan. And he managed to govern because he actually did stand for some specific ideas that brought a broad consensus of supporters together. He was still a figure of distance and mystery, to the extent that his authorized biographer, who followed him around for years, was unable to get at what the man was really like and wrote a semi-fictionalized biography with fake characters. But there was a core of identifiable beliefs that enabled him to govern and to maintain this sort of glamour, particularly to the Reagan coalition. Libertarians would say, "well, he's really more libertarian," and social conservatives would say, "well, he's really more socially conservative." But he did have specific beliefs that held those people together. They didn't hold together so well after him. 

reason: Is Sarah Palin glamorous?

Postrel: That's a really interesting question. I think Palin does have some of that frontierswoman, multicompetent sort of glamour to her, but I think she's not primarily a glamorous figure. She's too familiar. In fact, for people who like her, it's her familiarity, her ordinarinessā€”she's an extraordinary version of an ordinary personā€”that's appealing. And that's not glamorous; it's a different kind of appeal. It's like the appeal of Sandra Bullock vs. the appeal of Angelina Jolie or Grace Kelly. She's more the girl next door.

reason: About a year ago you wrote an article called "My Drug Problem" in The Atlantic. It was very controversial. Can you talk about the main point you made in the article and why readers responded so strongly to it?

Postrel: In 2007 I was diagnosed with a particularly aggressive form of breast cancer called HER2 positive, for which there is what can only be called a miracle drug called Herceptin. Given the particulars of my case, the existence of Herceptin cut my chances of dying from this disease from 50-50 down to maybe 5 percent. And I'm now apparently cancer free. Herceptin is an expensive drug. My treatment, which was the standard treatment, cost about $60,000. It's a one-time thing; it's not $60,000 a year for the rest of your life. 

Most developed countries cover Herceptin because it is so effective, but I discovered in the course of researching what I thought was going to be an article on something else that New Zealandā€”which is the exemplar of rational drug price controls, having one of these boards that really put the screws to the drug companiesā€”had not covered Herceptin for people like me who were early-stage cancer patients. I wrote about this dilemma: when you have these very expensive biotechnology cancer drugs, what happens when you have essentially a single-payer system and somebody has to decide bureaucratically whether they get covered or not.

It becomes a politicized process. In New Zealand, Herceptin is now covered because it became an election issue. Cancer patients and their sympathizers and their doctors made it a political issue. In the U.K. it was a political issue for about five seconds. The government just said, "Forget what the National Health Service said. We're not even going to let them evaluate it. We're going to pay for it." Because the truth is these things are political.

The idea that objective science can settle these issues is false. Objective science can tell you the chance this treatment is going to work in various types of patients. But is it worth $60,000? What if it were $70,000? What if it were $30,000? That sort of tradeoff is very difficult to make at a one-size-fits-all level. 

Our system, for all its screwiness, has some advantages. There is competition for coverage. There is political pressure, which is how you get various kinds of mandates, and there is legal pressure through lawsuits over what should be covered, over what your insurance contract means. So there's a general tendency to cover things. As a result, not only do people get their drugs, but this is the biggest market for new drugs in the world, and we subsidize the rest of the world in bringing promising drugs to market. 

That's what the piece was about. The system where everyone gets covered with the best kind of health care for free and tradeoffs are made in a perfectly rational and scientific way is a myth. When a drug promises to treat some dread disease, it becomes a very passionate issue. 

reason: You mentioned tradeoffs. What about the tradeoff between innovation and equity? Maybe the drug that worked so well for you wouldn't be as readily available in a universal system, but more people would be covered, so more lives would be saved.

Postrel: Well, poor people get breast cancer too. The problems of coverage, falling through the cracks of coverage, tend to be less severe with acute issues like cancer and more severe with chronic conditions and with diagnosis, catching things early. There are all sorts of ways, formal and informal, that people get covered for things like cancer, major events. Some of it is through things like Medicaid, but also the drug companies give drugs to, say, UCLA's oncology department, which they can then use to treat patients who don't have access.

People talk about coverage in a magical way. Going back to glamour, there is glamour to the idea of the universal coverage, I think. What does that mean? What should it cover? Are you concerned about equity in the sense of everybody should be the same, or are you concerned about a safety net? Those are two different things.

Our system is screwed up because it ties health insurance to employment. That's an artifact of wage and price controls during World War II. And anybody who looks at it wants to get rid of that tie, except the average guy who's afraid of losing his insurance, so that's an issue. I think both the people who want to go to a more competitive, market-oriented system and people who want to go to some universal, government-run system agree on this one thing: that the tie to employment is not good, because when you really need insurance, if you lose your job you're screwed.

I don't have the magic bullet. But except for people who are born with obvious birth defects, we all start out insurable. Insurance is about taking care of unexpected events; it's not about taking care of an H1N1 shot. It's not about taking care of routine maintenance. That we can take care of the way we take care of haircuts and auto repair: put it on your MasterCard. And if we're worried about a safety net, just give people money. 

So the question is what happens when you become uninsurable, or when we know that you have diabetes, or we know that you have a heart condition, or we know that I had breast cancer. My oncologist says that I have no more chance of getting breast cancer again than a similarly situated person who didn't have breast cancer, but I doubt that I'm going to convince an insurance company of that. So I'm a good example. This is the problem of pre-existing conditions. What do you do about that? There is a very good idea that Cato and others have worked on: health status insurance [which would allow you to insure against the risk that medical coverage will become unaffordable because of changes in your health].

reason: Talk about your personal experience with navigating the world of insurance after you got breast cancer.

Postrel: The most interesting thing had to do with getting a wig. The only reason my insurance covered a wig, I'm sure, is that the state of California requires it to. And the truth is, I could have bought my own damn wig. An expensive wig costs a few hundred dollars, and there are cheap ones. And I never even wore my wig except for three times, one of which was on reason.tv. I just wore scarves and hats. But because my insurance covered a wig, I went out and spent more moneyā€”I bought twoā€”than I would have if the insurance hadn't covered a wig. Then I spent months fighting with the insurance company to get them to put the right little code in there so they would pay the shop where I bought the wigs. It was a nightmare. When you're having cancer treatments, you just don't want to deal with insurance companies.

Most of the things that are screwy about the American system ā€”most of the things that drive people crazy, like dealing with insurance companiesā€”are also true of Medicare. Medicare has a million forms. Where do you think all these DRG [diagnosis-related group] numbers come from? They come from Medicare. It can be nightmarish.

The Obama administration early on was saying, "We can give you better care for less with better management." Well, I believe management can make a difference. It makes a difference in the private sector; it could make a difference in health care. Let's do a trial run with Medicare. Let's try it out there first and see how it works. I called Peter Orszag at the Office of Management and Budget, and he basically said, "We can't do that, because the AARP is only on board if we do the whole system." Well, OK. We can't take you very seriously with this "better care for less" if you can't apply it to the one system you already control.