Last week my company issued a press release quoting me. Itself not necessarily worth reporting on this blog, but some web sites have published it substituting various words. I’m guessing they do this as link bait for SEO, so they show up differently from the sites that simply republish releases verbatim.

But there’s some humor in the “after” compared to the “before”. Like it’s almost a human speaking, but not quite.

Excerpt from the release as issued (full release on BusinessWire here):

“A health care transparency tool is only effective if employees use and gain value from it,” said Ethan Prater, vice president of products, Castlight Health. “Castlight goes beyond great technology and data to help customers like Regis create well-designed programs that engage users and drive cost-conscious health care decisions that benefit employees and employers alike.”

With the same excerpt “substituted” (on a random site here):

“A illness care clarity apparatus is usually efficient if employees use and earn worth from it,” mentioned Ethan Prater, clamp boss of products, Castlight Health. “Castlight goes over great technology and data to help customers similar to Regis emanate well-designed programs that rivet users and expostulate cost-conscious illness care decisions that benefit employees and employers alike.”

There’s an album title in here somewhere. Clamp boss, indeed.

• Full release also on Castlight Health’s site here

Old consensus: we need Freddie and Fannie in order to make housing “affordable.”
New consensus: we need them in order to “prevent further house price declines,” in other words, to make housing less affordable.

A crazy world we Americans live in.

• A Consensus to Question by Arnold Kling
• Arnold Kling, on a roll by Tyler Cowen
• The Best Line on Fannie and Freddie You’ll Read All Day by Joe Weisenthal
• Can We Please Be Honest About Fannie and Freddie? They Now Exist to Make Houses More Expensive by Henry Blodget [a lengthier piece on how/why this plays out]

When I was on the management team at a former company, we agonized about employees’ health care. Not just how (or whether) to absorb the astonishing annual increases in their health insurance premiums, but what we could do to help them get better care, not to mention even to let them actually take home the money we were willing to pay on their behalf (as opposed to having it vanish into those insurance premiums). Seems HSAs, if implemented properly (that is, the employer not trying to hold on to too much of the savings), are a good technique.

• “Hoosiers and Health Savings Accounts: An Indiana experiment that is reducing costs for the state and its employees” by Mitch Daniels, Governor of Indiana (Republican). Opinion piece in The Wall Street Journal, March 1, 2010.

A non-ideological, results-driven report on how even public sector employees are choosing Health Savings Accounts when HSAs are offered. Be sure to read the reader comments – quite a useful discussion going on there. I like Daniels’ summary paragraph, too.

The Indiana experience confirms what common sense already tells us: A system built on “cost-plus” reimbursement (i.e., the more a physician does, the more he or she gets paid) coupled with “free” to the purchaser consumption, is a machine perfectly designed to overconsume and overspend. It will never be controlled by top-down balloon-squeezing by insurance companies or the government. There will be no meaningful cost control until we are all cost controllers in our own right.

• “Health Savings Accounts are the Answer” on the blog Civil Society Trust (no author credited).

I’ve no idea what this blog is – this is the first I’ve run across it. Has the sort of scary vibe of a libertarian polemic, but this article, at least, is almost entirely reasonable. Emphasizes how the structure of the HSA can reduce the distortions in the US health care market. Makes good sense to me. And I like how the author links HSAs to health insurance portability.

True portability.   As stated earlier, typically health insurance for an employee and perhaps their family disappears with the loss of the job.   It is common to hear of people staying with jobs they don’t like, “just to have the health insurance”.   What does the employer gain from that?   What do the employer’s customers gain from that?   Note that the savings account of the HSA is owned by the employee, not the company.   So over time, this pool of money can grow and provide financing for medical expenditures regardless of employment. Furthermore, since the accompanying catastrophic policy would be dramatically cheaper than a “traditional” plan, it would be inherently more affordable during an period of unemployment.

As I mentioned in an earlier post touting David Goldhill’s cover story in The Atlantic (September 2009), I think the structure of health care financing in the US is the primary cause of both rising health care costs and poor health care outcomes. Would be nice to see HSAs in wider use, see if they help address the problems.

Earlier this month (February 2010) he gave the following excellent presentation at a Meetup in NYC. I don’t know his co-author Anna DeYoung, but let’s give her some credit, too.

Really good stuff here for web product managers and interaction designers. Some nice real-world adaptions of the techniques described in Steve Krug’s Don’t Make Me Think, the first book anyone concerned with web usability should pick up.

It seems obvious to me that “written” (committed to paper) and “oral” (spoken) are just two more distinct forms of “verbal” (using words). Yet in the workplace I frequently hear the more general “verbal” confusingly used as a synonym for the more precise “oral.”

Statements like, “We have a verbal [agreement],” are seemingly meant to indicate that a potential client or employee agreed to something on the telephone, and that the only step remaining is to sign a paper contract.

But aren’t all business agreements verbal (made in words)? Isn’t the only meaningful difference whether they’re spoken (oral) or on paper (written)? It seems needlessly imprecise (and therefore unclear and inefficient) to confuse verbal with oral!

Rather than consult the Trusty Tubes of the Interweb for their participants’ thoughts on this question, I went to the English style and usage guides my own bookshelf.

Turns out that while my angst over this confusing usage is widely shared, different pundits suggest handling it in different ways. Here’s a summary of what I found.

I started with what’s usually the best – Fowler’s Guide to English Usage. This excerpt is from the third and most recent edition by R.W. Burchfield. Unfortunately he’s uncharacteristically verbose and wishy-washy. But he does point out that this “misuse” of verbal to mean oral is quite longstanding.

verbal. This common adj. has several established senses including:

1 Of the nature of a verb (verbal noun).

2 Concerned with or involving words only rather than things or realities (Opposition between these two modes of speaking is rather verbal than real–B. Jowett, 1875).

3 Consisting or composed of words (the verbal wit and high-flown extravaganza of thought and phrase which Euphues had made fashionable–J.R. Green, 1874).

4 Expressed or conveyed by speech instead of writing: oral (The archbishop believed that a verbal agreement was all which would be demanded of him–J. A. Froude, 1877).

All four senses have a long history of recorded use (1, 3, 16c.- ; 2, 17c,- ; 4, late 16c.-), but since the late 19c. some usage commentators have drawn attention to the possibly ambiguity of sense 4, and have expressed a preference for oral in such contexts. Perhaps the best policy for the present is to restrict verbal in sense 4 to a few fixed phrases (e.g. verbal agreement, contract, evidence); but use oral in most other circumstances when a formal distinction is contextually called for between a spoken and a written statement. It is worth noting that the oral tradition believed to have preceded the writing down of ancient poetry (Greek, Old English, etc.) is always so called, never the verbal tradition, verbal composition, etc.

Burchfield, R.W. ed. The New Fowler’s Modern English Usage. 3rd ed. Oxford, England: Oxford University Press, 1996. 820-821. Print.

My two news-oriented style guides (from the Associated Press and U.S. News & World Report) are nicely brief and to the point:

oral, verbal, written Use oral to refer to spoken words: He gave an oral promise.

Use written to refer to words committed to paper: We had a written agreement.

Use verbal to compare words with some other form of communication: His tears revealed the sentiments that his poor verbal skills could not express.

Goldstein, Norm, ed. The Associated Press Stylebook and Briefing on Media Law. Fully Revised and Updated with a New Internet Guide and Glossary. Cambridge, MA: Perseus Publishing, 2000. 183. Print.

oral/verbal. Oral refers to what is spoken; verbal refers to what is conveyed in words, either written or spoken.

Grover, Robert O., ed. U.S. News & World Report Stylebook: A Usage Guide for Writers and Editors. 9th ed. Washington, DC: U.S. News & World Report LP, 2001. 166. Print.

However, if we have to acknowledge that using “verbal” to mean “oral” is indeed long-established practice, may we at least approach it the way that Theodore Bernstein so elegantly suggests in The Careful Writer?

ORAL VS. VERBAL Although it is true that verbal means in the form of words, and has even taken over the specialized meaning of in the form of spoken words, it cannot be denied that much would be gained in the cause of precision if writers would use oral when they mean spoken words and written when they mean words committed to paper. Verbal might well be confined to those situations in which it is desired to distinguish communication by words from other forms of communication like gestures, smoke signals, and the light that shines from lovers’ eyes. To speak of a verbal agreement may leave some doubt whether the agreement was made in conversation or signed in a lawyer’s office. Confronted with a choice between a word that can mean two things and another that can mean only one, are we not making better use of the tools of language if we select the precise word?

Bernstein, Theodore M. The Careful Writer: A Modern Guide to English Usage. New York, NY: Atheneum, 1980. 319. Print.

Yes. What he said. Bergen and Cornelia Evans, scions of the $64,000 Question game show in the ’50s, seem to agree in their Dictionary of Contemporary American Usage:

oral and verbal are not synonymous, though verbal is misused for oral quite often, perhaps by persons encouraged to take as precedent the very special case of verbal agreement, which means oral agreement, agreement in speech only. Actually oral means uttered by the mouth, spoken (He teaches oral interpretation of literature), as opposed to what is conveyed in writing. Though verbal is used for oral in verbal agreement, it normally applies to the words, spoken or written, in which thought or feeling is conveyed. When we refer to a verbal account of an event, we mean an account conveyed in words instead of one conveyed by gestures, pictures, or other means. Thus verbal is the more inclusive term, emphasizing words themselves as distinguished from ideas, emotions, actions, images.

Evans, Bergen, and Cornelia Evans. A Dictionary of Contemporary American Usage. New York, NY: Random House, Inc., 1957. 341. Print.

Bryan Garner gets a touch more prescriptive in his similarly-titled Dictionary of Modern American Usage:

verbal = (1) of, relating to, or expressed in words, whether written or oral; or (2) of, relating to, or expressed through the spoken word; oral. Many regard sense 2 as a SLIPSHOD EXTENSION. In fact, given the primary sense, the movie producer Samuel Goldwyn wasn’t really very ironic when he remarked, “A verbal contract isn’t worth the paper it’s printed on.” After all, a written contract is verbal. The phrase requires oral.

The error is especially acute when verbal is opposed to written — e.g.: “Take care with words, verbal [read oral] and written.” Sydney Omarr, “Horoscope,” Wash. Post, 22 June 1997, at F2. Take care indeed!

Garner, Bryan A. A Dictionary of Modern American Usage. New York, NY: Oxford University Press, 1998. 676. Print.

As do Wilson Follett and Jacques Barzun in the also similarly-titled Modern American Usage:

verbal means relating to words without specifying whether the words are spoken or written. Consequently, the common phrase verbal agreement to mean one that is not written down is a misnomer. The proper term is oral agreement–oral meaning by [word of] mouth. To capture and preserve the distinction, this or oral exam and verbal aptitude test.

Follett, Wilson and Jacques Barzun. Modern American Usage: a Guide. New York: Hill & Wang, 1966. 341. Print.

Bill Bryson, the most recent commenter, errs on the permissive side in Bryson’s Dictionary of Troublesome Words:

oral, verbal. “The 1960 understanding  … was a verbal understanding that was never written down” (New York Times). Because oral can apply only to the spoken word, it would have been a better choice here. Verbal, which can describe both spoken and written words, is more usefully employed to distinguish between words and gestures or between words and substance. In the example above, however, neither word is necessary. It would be enough to say, “The 1960 understanding was never written down.”

Bryson, Bill. Bryson’s Dictionary of Troublesome Words. New York: Broadway Books, 2002. 153. Print.

While the surprisingly lame Oxford Companion to the English Language avoids the issue almost entirely:

VERBAL [15c: from Latin verbalis to do with words]. (1) Relating to words or consisting of words, often in contrast to something else: verbal ability; a verbal protest, as opposed to a protest in writing; a verbal distinction, as opposed to a distinction in reality. [...]

McArthur, Tom, ed. The Oxford Companion to the English Language. New York, NY: Oxford University Press, 1992. 1085. Print.

What does that muddle even mean? Sigh.

But I saved the best for last: the “real” Fowler’s English Usage, the 1965 second edition by Ernest Gowers (buy this book right now if you don’t own it – only Strunk & White is essential in the same way). While his isn’t quite the answer I expected when going to the shelf, given the historical precedent for using “verbal” to mean “oral,” Gowers suggests a reasonable approach in the warmest possible way:

verbal. The object of the provision was to apply it to all contracts, whether in writing or verbal. / The British Embassy have made both written and verbal protests to the Soviet Foreign Office. The primary meaning of verbal is consisting of words. Written contracts and protests consist of words no less than spoken ones, and we have for more than 300 years another adjective–oral–with which to distinguish the spoken word from the written. To give verbal that narrower sense was therefore both quite unnecessary and also a possible cause of ambiguity unless it is expressly contrasted with the written word, as in the above examples. But its use with this meaning is very common; the OED recognizes it without any deprecatory comment, and gives examples from the 16th c. The COD however calls it “loose”, and the supersession of oral is not yet so complete that those whose care for the niceties of language leads them to prefer it need fear a charge of pedantry.

Fowler, H.W. A Dictionary of Modern English Usage. Ed. Sir Ernest Gowers. 2nd ed. New York, NY: Oxford UP, 1965. 674. Print.

Just like Scotch whisky takes two forms, blended and malt, verbal expression takes two forms, written and oral. So skip your “verbal” contracts – be clear and efficient with “oral.” Nothing pedantic about it!

And my friends (yes, both of you!) know that I’m generally apolitical, at least in the sense of organized party affiliation. Certainly I have little to add to the vast flood of words spilled about US federal government policy, including the ongoing debate about health care financing.

But my friendly acquaintances are probably tired of my forwarding around David Goldhill’s much-discussed article in the September 2009 issue of The Atlantic, “How American Health Care Killed My Father.” So I thought I might just point it out here on my blog, give it a tiny bit more of SEO juice, and put my own annotations in a place where they’re easier for me to cut and paste into the next forwarded e-mail.

Goldhill makes a collection of points that don’t always hang together, yet are wonderfully provocative – reasonable, though often quite contrary to received wisdom. You should read his article directly, but I’ll call out a few of his best observations here:

• Health care costs are rising without any coherent notice, scheme, or cap – both as percentage of GDP and federal government budget.

  “By what mechanism does society determine that an extra, say, $100 billion for health care will make us healthier than even $10 billion for cleaner air or water, or $25 billion for better nutrition, or $5 billion for parks, or $10 billion for recreation, or $50 billion in additional vacation time—or all of those alternatives combined?
  

  The answer is, no mechanism at all. Health care simply keeps gobbling up national resources, seemingly without regard to other societal needs; it’s treated as an island that doesn’t touch or affect the rest of the economy.”
  

  Goldhill argues that the method and structure of health care finance obscures any meaningful signal by which we could even trade off health care costs for other societal benefits, either as individuals or as a society.
  

• Granting health insurance a special status – codified in tax law and other forms of government subsidy – has distorted the national economy by creating artificial excess of supply at inflated prices, similar to what has happened to housing.
• Health insurance isn’t the same as health care – it’s just a (highly unusual, and probably detrimental) mechanism to finance health care.

  “We can’t imagine paying for gas with our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance. Most pregnancies are planned, and deliveries are predictable many months in advance, yet they’re financed the same way we finance fixing a car after a wreck—through an insurance claim.”
  

  This is Goldhill’s central and strongest point. As long as the policy discussion is about how to provide comprehensive health insurance, then there’s little likelihood of creating a system with lower costs or better outcomes. And I’ve often wondered the same thing – what is it about health care that makes us think it needs a different or special financing mechanism from all other services?

• Price opacity drives prices up – and in the current health care financing scheme, it’s in the interests of medical institutions to keep prices (and outcomes) opaque.

  “For almost all our health-care needs, the current system allows us as consumers to ask providers, “What’s my share?” instead of “How much does this cost?”—a question we ask before buying any other good or service. And the subtle difference between those two questions is costing us all a fortune.
  

  Without transparency on prices—and the related data on measurable outcomes—efforts to give the consumer more control over health care have failed, and always will.”
  

• No one seems to have investigated the conventional wisdom that emergency room care is the most expensive form of health care.

  Goldhill’s two-paragraph attempt to discover hospitals’ true emergency room revenues and costs is not that useful, but the question stands – is emergency room care really that expensive compared to other treatments, and if so, why?

Goldhill makes some predictable (but no less worthy for that) points about the inability of a central authority to control costs (governments can control prices), pointing out that  health care programs in single-payer countries including Canada, France, and the UK face skyrocketing costs despite price controls.

He uses the example of LASIK surgery to show how a health-related procedure generally not subject to insurance financing responds to market forces, with providers competing on the basis of price and quality, just like in other areas of the economy.

Given the relative patchwork of issues Goldhill points out, he doesn’t propose a particularly unified solution. But that’s okay – he has a few ideas, most of which boil down to changing the method of health care financing. Rather than assuming comprehensive insurance as the standard, he argues convincingly that over time insurance should cover catastrophic and some chronic conditions, while the rest are paid for from individual income and savings managed through Health Savings Accounts (HSAs).

Most other benefits and fixes flow from that single mechanism, including an interesting extrapolation to the utopian point at which we pay for outcomes. Specifically, he hypothesizes that currently-separate links in the health care delivery chain will come together to serve the consumer (similar to an idea explored in Atul Gawande’s June 1, 2009 New Yorker piece called “The Cost Conundrum“).

In any case, Goldhill’s article reveals no obvious political ax to grind. He says he’s a Democrat, though it’s likely that some folks would claim his distrust of a centrally-set price policy would put him on the right. I just see a heartfelt exploration of what structural changes might really improve the general lot of American society, and I bet that if you engage his ideas thoughtfully, you’ll find the same.

• “How American Health Care Killed My Father” (David Goldhill; The Atlantic, September 2009)
• “The Cost Conundrum” (Atul Gawande; The New Yorker, June 1, 2009)
• “10 Thoughts on the Health Care Situation” (The Chris Motes Blog, September 19, 2009)