Health Care Summary

A rather thoughtful, complete, and sober assessment of the health care issue in the United States is presented on Patio Boat (link). If you would like to see this subject properly sorted, please follow the link. Here is a carrot in the form of that post’s initial sentence:

If you’re wondering who socialized medicine in the United States, it wasn’t Barack Obama. It was Ronald Reagan.

The Hidden Logic of Health Care

At my birth in 1936 in Hungary the country already had 30 years of experience with a nationalized health care system, founded in 1907. That program was called “National Workers' Sick-Benefit and Accident Fund”; it was replaced, in 1928, with the “National Social Insurance Institution.”  The country has had such a system ever since, more and more inclusive and entirely state run and funded.  By the way, the first insurance program that only covered part of the population, miners, went back all the way to 1496.

With this in my background, is it any wonder that I have a rather negative view of the health care debates in the United States. Every member of my own family had directly experienced the benefits of so-called “socialized” medicine from birth on forward. In addition, my Grandfather was a doctor; and his grandfather had been a very prominent doctor as well, responsible for all mental diseases in Hungary. Therefore we all had close contact and knowledge of the profession that delivered the services—always being paid civil services wages.

These memories arose today because Brigitte came across a brief book review, H. Gilbert Welch’s Less Medicine, More Health (Beacon Press, 2015). Welch argues that we have too much health care with many decidedly negative concomitants—and that it costs way too much. The brief article also suggested to me that we tend to overlook the fundamental logic of health care—and how that logic is violated when we let the Hidden Hand decide how medicine should be practices.

Another memory arose as well. Once long ago in Kansas City I gave a talk to a group of medical students. I’ve completely forgotten my subject, but afterwards I had a chance to socialize with a small group of students. I made an attempt to discover what had motivated these men (all men then) to follow their chosen profession. An amazing six of the seven people I talked with all pointed to the potentially high income medicine promised them. One man only half shamefacedly confessed that service to humanity had drawn him into doctoring. And yet another: While living in Minnesota, we got to know a skin doctor who’d moved to the United States from Canada and, well-established there, actively boasted that he’d crossed the border because the Canadian system had failed to give him the opportunity to turn his arduous learning into wealth. I’m actually understating what all he said…

The logic of health care therefore runs something like this. Medicine might attract too many people to practice it for the wrong reasons. For them a Free Market medicine provides all sorts of wrong incentives—to treat more, and more intensively—because every transaction increases income. In a socialized framework they can never get rich; therefore those drawn to medicine will be drawn by its inherent character, the opportunity to help people. Much as in Minnesota we changed skin doctors, so throughout our life here we’ve sought out doctors who have the genuine motivation and avoided the others.

With nationally controlled income for doctors, many of the problems cited by Dr. Welch would disappear on their own accord. We’d have much less unnecessary testing, fewer visits, lower administrating staffing, and much more affordable and probably more effective health care. We’ve seen it practiced like that in Hungary, Poland, Germany, and France. When you work as a provider of care in countries like that, you won’t need anyone to manage your wealth. You won’t have any. But you’ll live in comfort. And I’d like to tell all this to the Hidden Hand—if only I could see it.

Collective Wealth

Still reading Toynbee’s monumental work on history, it strikes me—as I see him assessing ancient cultures’ decline and occasionally touching on our own—that humanity has never experienced a situation like our current one (viewed some 80 years after Toynbee wrote his first five volumes). It is a situation in which extraordinary wealth touches a huge population—but it’s  not wealth as once understood, namely personal control of physical resources and money; it is wealth in the form of collective systems, structures, technologies, and organized knowledge.

Two examples may be Communications and Health Care. Communications anciently demanded personal wealth in that, to deliver a message, one had to send a courrier to distant places; no such media as telegraphy, telephony, radio, or television existed—and general circulation news papers were also absent. Health Care then was centered on the person of a doctor, midwife, or a surgeon—and what small bag he or she carried. The hospital, with its emergency room—accessible even to the poor—did not exist; nor did colossal testing technologies, clean-rooms, remote and robotic surgery, or the pharmaceutical industries.

Behind communications today are submarine cables and space satellites; behind the satellites stands an aerospace industry. Behind medicine are mountains of extraordinarily sophisticated institutions, technical developers very much cut of the same cloth as aerospace, computer technology, and world-wide supervisory organizations communicating, by means of the never-before-seen communications sector, to inhibit the spread of plagues; among them is our own Centers for Disease Control and Prevention.

These two sectors—and they are just two of many others that operate in the same way, for the collective—represent a form of wealth one cannot discover in ancient times except in the most rudimentary forms: state-built roads with their bridges and water control on a large scale for river management and for delivering water via aqueducts.

Can our collective wealth, which makes even the poor a little “wealthy,” be traced to a single discovery? Yes. It is the “discovery” of fossil fuels. I put that word in quotes because, of course, coal and oil were known before the age of fossil fuels dawned. They were also used, principally for making weapons-grade metals, usually employing human-made and therefore manufactured charcoal. The discovery, however, was triggered by a technological innovation, the steam engine. That device—the Luddites’ first nightmare—then led, step-by-step, to an extraordinarily massive geological raid of dormant energy hidden beneath the earth probably by cataclysmic global changes literally eons ago.

The quite foreseeable exhaustion of this incredible and non-replaceable deposit of wealth will have consequences we can logically project forward. The extent to which essentially “free” energy underlies virtually everything we do and touch—not least how we communicate and heal—is effectively invisible to the public—except its members visit filling stations. The sooner it becomes the daily conscious worry of the average citizen, the sooner can creative responses to future troubles begin. The most important job now is to slow our current energy consumption drastically—to give humanity more time to adapt to conditions where effective “wealth” will once more become personal and nothing much beyond—except roads, bridges, aqueducts, and (I hope) sewage systems that will still, collectively, support us all.

Tale of the Pedometer

In this world where self-promotion has become Job 1—and the practice has captured ordinary people, so that at times I experience a bullet spray of people I’ve never met who wish to “friend” me on Facebook—I have come to question bursting health-news tips. The latest is that to live forever (meaning to reach about 80), we must take 10,000 steps a day. Fair enough. So let’s just see what that might mean. A memory came as Brigitte was telling me about this. I had a pedometer somewhere. Memory is a wonderful thing. I wonder how many “deep” memories we ought to have “daily” to avoid Alzheimer’s disease? In any case my memory produced an image of the center drawer of my upstairs desk. Quite a few odd fellows live there. Sure enough, the pedometer was there.

It happens to be an OMRON HJ-112 pedometer. We got it ages ago. A trip to Rite Aid for a new battery ($4.99), and Brigitte began to count her steps. It turned out that ordinary life produces a ridiculously low number—though Brigitte is constantly in motion all day long. Around 1,000-2,000. Eager not to miss even a few, getting ready for her aquadynamics session at home, she strapped it to her bathing suit while fetching, you know, the shoes, the towels, bag, and all the rest. But memory can also be a chancy thing. By the time she got to the pool, she had forgotten that she was still wearing it. You can guess the rest.

Now these things cost around $37-plus. So here was this thing, discovered as she was drying off, full of water. You couldn’t even see the display for the many tiny bubbles. Later I tried to dry it out in the heat of a powerful work-bench lamp, but all that did was turn the display midnight-black. So it came to rest on my downstairs desk, a simple folding table. It lay there for some days. Then, to my astonishment one morning, as I sat down to write in my diary, I saw that OMRON had miraculously recovered. Everything worked again as if the little thing had never been baptized—including its newly acquired battery.

Some things work—even these days. But we kind of wonder who came up with those 10,000 steps a day? Let’s see. There are all kinds of fancy sports-shoe producers, sweatband makers, and, also, manufacturers of pedometers. But, frankly, OMRON, if you make them that good, you’re simply missing out on sales, despite the great assist you recently got from the medical community.

Under God

I pledge allegiance to my Flag and the Republic for which it stands, one nation indivisible, with liberty and justice for all. [Francis Bellamy’s original Pledge, adopted in 1892]

The Supreme Court’s current focus on the Affordable Care Act led to a discovery today. The issue in that act is a mandate requiring every person not already insured to buy health insurance. But does the government have the right, under the Interstate Commerce Act, to compel anyone to buy something? My dark musings on  this subject led me to mutter, “One nation, under Market, infinitely divided, with competition among all…”

So then, later, I looked up the history of the Pledge and discovered, with some surprise, that I was already a resident here when, in 1954, the two words in my title were added. 1954. Yes, indeed. By then the Pledge had undergone four changes. The first came in 1892 when the word to was added: “…to my flag and to the republic…” Note that flag and republic have lost their capital. In 1923, came another change: “…to the flag of the United States…” In 1924 (oops, we left something out) came the addition: “…of America…” In 1954, finally, that under God.

Pledge recital circa 1941

Amusingly, Francis Bellamy was a Baptist minister. Amusingly, the pledge was recited with a salute—and, ironically, with the arm extended forward, palm down. Later the palm was turned the other way (can’t be doing a “Heil” in the Land of the Free). Finally came the current salute of hand-over-heart, instituted by the U.S. Congress. This came as an amendment of the Flag Code, first passed June 22, 1942 and amended (oops, left something out) on December 22.

Endless contradictions. The U.S. Congress can “compel” hand gestures. Under a Constitution which prohibits establishment of religion, thus gives firm standing (with others) to atheism, we must say “under God” when Pledging Allegiance. But, some argue, Congress cannot compel anyone to buy health insurance. It might be time to revise the Pledge along the lines that I was muttering aloud.

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Picture from Wikipedia commons (link).

Market v. Community

The second anniversary of the health care act, which is today, started me some days ago looking at data. Today I dug out the global rankings of health care outcomes produced a while back (1997) by the World Health Organization. It’s rather a complicated index built around the achievement of five health goals. One among them is that the national system’s costs should be fairly distributed, thus the degree to which everyone  contributes should be as equal as possible. I had to dig a little to discover how WHO visualizes fairness. Here is the process WHO suggests.

Measure first the total amount of each household’s contributions to healthcare—in whatever form. Next, calculate the household’s income net of the portion spent on subsistence—thus presumably food, clothing, shelter, and perhaps necessary work-related transportation. Now take the money contributed to healthcare and divide it by the net income figure. You’ll get a percentage. WHO’s idea of fairness is that all households should have the same percent.

Before I comment, one or two bits more. The total contribution above includes out-of-pocket expenditures, insurance premiums and co-pays, and that portion of taxes, paid by the household, directly earmarked for health care or later allocated to health care by government. WHO’s idea of fairness also stipulates provisions in the system that protect households from catastrophic expenses.

An equal contribution using percent of income naturally translates into actual total household contributions which will be zero for those who barely earn their subsistence, small for  relatively low earners, and high, indeed very high, for the rich. If one household’s residual income after necessities is $10,000, another’s $100,000, and the percent of health care contribution is uniformly 15 percent, one pays $1,500 the other $15,000. The pool, however, is distributed back to the contributors based on need.

The agency obviously sees health care as a communal system—not as a market. WHO is trying to find an equitable way to pay for it. From every household according to its ability to pay, to every household according to its needs. This, of course is the community model. Every sort of entitlement is best handled this way.

In this country two models are always at war. One is based on nature, the other on nurture. Health care providers like to speak of demand, of consumption—because they must compete to provide services and are thus forced to masquerade as merchants. Those who love the market join them in seeing health care as just another commodity. They think that the market will soon sort it if we just put the scalpel in its hidden hand. Those who are left out—and the market always leaves somebody out—are grudgingly given a dole. It is for this reason that some people abhor all programs that counter the hit-and-miss outcomes of markets. They have the means and want to keep them. They echo one of my daughters’ famous words when, still a little girl and urged to share her toys she announced: “I want to share by myself.” And therefore we have the equivalent of a feeling that all entitlements are theft—even when we paid throughout our working lives to collect ours in old age.

Déjà Vu

CNN presented a show yesterday titled GPS Road Map for Saving Health Care. The GPS there stands for “Global Public Square.” It was a well-done comparison of heath care programs around the globe, including the United Kingdom, Taiwan, and Switzerland. But I kept having a powerful sense of déjà vu—if not the genuine kind. I really remembered seeing something quite like this. As one segment ended I went to tell Brigitte what the next country on the list would be. Sure enough. I had been right. And after the show ended I said to her: “I’ve seen something very much like this, very much. The same absolute content, same sequence—even some of the people interviewed are the same.”

It turns out I was right; I did the digging this morning. Back on April 15, 2008 PBS’ Frontline presented a program called Sick Around the World. That program had segments on health care as delivered in the United States, UK, Germany, Japan, Taiwan, and Switzerland.  President Obama signed our health care bill on March 23, 2010, thus two years later. CNN’s program, presented by Fareed Zakaria, was quite excellent, Zakaria’s summation correct and eloquent. Such shows, however, have zero influence on actual political behavior. The reason for that is another interesting subject.

Fifty Years: GDP and Healthcare

A picture worth a thousand words. A post on LaMarotte (here) today led me to play with graphical depictions. Here is one such image. It shows, in scale, Gross Domestic Product for 1960 and for 2009, with health care expenditures shown in red at the center of each. In 1960 health care amounted to 5.3 percent of the much smaller economy, in 2009 for 17.6 percent of the much greater. The population has grown 1.7-fold, the economy 27-fold, the health care expenditures 89-fold. And the target has gotten a lot more visible, hasn’t it?

La Forza della Fortuna

Since the dawn of modernity, which Jacques Barzun dates from 1500, we’ve substituted nature for fortune in an effort to deny soul to anything existent—not least to humanity. But I prefer to think of the force of nature, especially when we speak of the human sphere, in the Italian phrase—and if I wish to sound even more ominous, I use the Spanish: La Fuerza de la Fortuna. In parentheses I note that I’ve always found this denial alien, suggesting that I’ve never managed to emerge from the medieval—but never mind. The phrase was there this morning, its object the vote on the health care issue. The image in my mind, neither Italian nor Spanish, was that of Nancy Pelosi standing before a badly baked and sagging chocolate cake. Look at it. It leans dangerously to the right. Nancy holds a spatula in hand. A troubled look on her face, she takes a bit more chocolate from the bowl and smears it very carefully—lest the whole thing tumble into ruin—on the left side of the lean in an “historic” act of bakery.

Relating strange things on my mind on waking threatens to skew this blog too far into the subjective—but I promise. I’ll find some other way to introduce my future posts. This time around, I also remembered an angry phrase Brigitte spat out the other day as we were chatting over the news. “Too Big to Work,” she said—and then her grim expression changed, her face lit up, and we both laughed. Inspiration comes from above.

La forza della fortuna, at present, it seems to me—is perhaps a quite natural development. It comes about precisely because we’re so intent on sucking soul out of reality. In the process we relinquish the power to hold things together, weakening the centripetal force of community. The current bill is an attempt to make the center hold, but it’s so weak that the message, even of its passing, produces the opposite meaning. The bill, after all, enables states, at their initiative, to opt out of the provisions of the bill if passed and signed, and thirty-six states incline to do so.
Such structures of thought are in the air. The other day, at yet another of our discussions over news, Brigitte and I went into flights of futurism. What will the future look like if the center actually fails to hold? It was quite interesting. We contemplated a future America which had devolved into separate and independent political units. We contemplated the largest and most powerful state after the slow-motion breakup. It would be California, primus inter pares: it has people, good agricultural land, and access to the ocean. Water is the problem, and your prophets confidently predicted the Water Wars of 20XX. We guessed that the Great Lakes states would cohere into a federation (Minnesota, Illinois, and Michigan - Mother Mimi?); their union would be to guard fresh water and, perhaps, to engage in a brisk export of protein. How? Well, the invasion of the Asian carp suggests its exploitation as an export item. We imagined Missouri as the Capital of Wheat, its port on the Missouri, the wheat flowing from Kansas and Colorado toward the east—people of the east flowing into Kansas and Colorado drawn by land grants which, in modern language, might be called the recapitalization of the poor. The running out of oil might be the occasion to draw on labor, once again, and those horses from the Land of Wheat—the best in the land. And, yes, we went on. If the company is right, this makes for an interesting subject.

Ah, Fortuna. What Brigitte and I concluded—and our discussion ranged all over time and space—was that the Romans never noticed the end of the Roman empire. The barbarian invasions (Vandals, Goths, etc.) were paced in time far enough apart so that they seemed more like ordinary wars and times of trouble, and these things also passed. When, some day, Kansas imposes export duties on its precious wheat, it will produce a flurry of news. But the army will not march to instigate regime change in Topeka. There will be an artful euphemism to cover the will of the people of Kansas. And later, when you’ll need a visa to enter California, it will seem something quite natural to those who fill in the application.

When Compromise Compromises

Compromise is certainly one of the virtues of democratic politics, but, it seems to me, it only works when the problem to be decided is what E.F. Schumacher (1911-1977) called a convergent problem. Schumacher, an interesting figure, came to be known beyond narrower circles of economics with the publication of Small Is Beautiful, a contribution to thought about global development. He was a German-born economist who lived in Britain and worked on the post-war economic rebuilding of Germany, later on Britain’s National Coal Board, and later yet as a writer and advisor on international development. He also wrote a brief philosophical work called A Guide for the Perplexed which, in essence, reflects his encounter with the transcendental. He became a convert to Catholicism at age 60. In Guide he proposed that some problems are convergent and are therefore soluble by the collective contributions of people working together (the democratic situation, in my current context) and those that are divergent, thus problems that polarize groups and can never be resolved by those directly involved in the debate. Practical problems tend to be convergent: how to land humans on the moon. Value questions are often divergent because those on either side do not share a common understanding of the problem or the goal to be achieved.

The health care issue strikes me as a divergent problem but presented as if it were merely a matter of finding the right mix of solutions—as in the case of finding a less-polluting engine or a drug with fewer side effects.

The attempt to compromise the problem, meaning matching the demands of both sides by careful give and take, will not solve the problem. Too many contradictions are involved. Here are those that come to my mind.

If health care costs are a burden on industry and make it less than competitive against others based in countries where a national system picks up the cost, retaining a mixed system does not help our industry. If we provide subsidy for those who cannot get employer insurance, the availability of this option will give industry incentives to get out of subsidizing health insurance—unless the payroll tax on those who opt out is higher than the cost of insurance. If the latter is true, though, U.S. industry will still be hampered in foreign competition; it will continue to be tempted to ship jobs overseas.

One of the highest costs of our system is administrative, arising from the large community of insurance companies, each with its separate overhead. Continuous reliance on the private insurance model guarantees that costs won’t drop.

Another major source of costs is the slicing and dicing of health care into innumerable, separately-billed sub-activities. People of my age are all too aware that medical care consists of one visit to a doctor followed by three separate tests, leading to one or two specialists, each of whom in turn relies on additional tests. And so it goes. To change this system by so-called incentives will only work if the incentives are higher than the benefits now derived by the participants. And if the government tries to keep its own involvement modest, no reform will actually take place.

Another reason for the endless testing is to protect the doctor against malpractice suits. But the reluctance of the Obama administration to tackle tort reform—capping damage awards at low but reasonable levels—suggests that the incentives to continue over-testing will stay in place.

There are convinced elements on the hard right who sincerely believe that social Darwinism is an appropriate view of humanity. Those who hew to such beliefs don’t sincerely want a national health system. Their concept of community is open-ended. Those who cannot qualify must be left outside without much wringing of the hands. At the left is a hardcore of people who believe with equal sincerity that in this case the government must be the sole agent. They are joined by a few royalists like me. This view is rational enough because costs must be brought under control, and this cannot be achieved by the usual incoherence of confusing cost-sharing arrangements, special interest accommodations, and letting the almighty Market decide all of the details. This view is communitarian; all people are included. That, of course will make people think of socialized or European-style medicine which is routinely castigated despite its proved benefits. Never mind that Count Bismarck, who worked for a king, introduced such practices in the nineteenth century already, and Germans are still benefiting from it. But here the culture is excessively individualistic despite the obvious interlocking of all things technological; we seem unable to see the forest for the trees. I call this a classical stand-off. Values are clashing. Compromising this situation will only rearrange how the insurance industry gets its money.

We could, at least in theory, satisfy both sides. We need two health care systems, one for the great majority, funded by all; and the other for those who want luxurious care and are willing to pay its extra costs. The larger system would offer complete but somewhat rationed services to all comers; it would be government-run, financed, and managed but its services delivered by doctors and hospitals participating voluntarily. A completely private system could coexist with it, supported by insurance, as the current system is. All citizens, however, would be required to bear the costs of the main, the public health system. Those who have more can spend their money as they wish on extra or more rapid services and health care that goes beyond the strictly necessary.

Demography is the most basic determinant of social life; culture is the other. Our culture produces mind-sets antagonistic to a rationalized system enjoyed by most of the people in Europe, in Canada, and in many other advanced countries around the world. Are those systems perfect? Of course not. Do they reach all the people? They do indeed. Are they affordable? Yes, they are.

Right now the patterns of discourse are beginning to sound unpleasantly like the build-up to the collapse of the Clinton initiative a decade and a half ago. This troubles me. The message reaching us now is pointing in the wrong direction, the direction of a confused compromise. We really don’t need another convulsion of meaningless reorganization. I don’t want health care compromised by yet another compromise.

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A more statistical approach to this problem is presented here, on LaMarotte, with numbers enough to help visualize the problem in a quantitative way.

One Size is Fine

One-size-fits-all-big government takeover of health care. John McCain and others.

In what way, pray tell, does shoe-size really relate to health-care plans? Suppose we had a national health plan that provided medical services for actual ailments, preventive care, catastrophic care, psychiatric, dental, and optical care, hospitalization, sports as well as accidental injuries, pharmaceuticals, other medications, physical therapy, pregnancy, long-term care, acute and chronic conditions—in short for any and all matters that normally fit under the category of health care? I wave my hand. Here it is. Here is the program. It covers everybody in the same way: embryos to the oldest still alive, with or without preexisting conditions, whether acquired carelessly or innocently. Get it? Everything. Now what aspect of this program—provided something wonderful like that would be available—wouldn’t fit someone? That size should fit one and all. And if, by some innocent omission, I missed something in the above, the person who has it can go with my blessing to Mexico, Mali, Madras to get it taken care of there. I’ll chip in to help buy the ticket.

Controlling an irrational seizure, I write myself a personal note and underline it six times in heavy marker pen: Thou shalt Not watch congressional hearings on health care reform. It may be injurious to your health.