Real Health Care Issues

The recent "reform" was, like most politics, a distraction. That plan was more about paying for health care than about actually delivering it (see a later entry), and the right steadfastly ignores that it's almost identical to the plan Mitt Romney set up in Massachusetts. The delivery system is just as broken, though. Almost nobody talks about these problems, and the government won't touch them. The dangerous idea here is that "we have the best health care system in the world." In a handful of metrics we do better than other countries, but overall it's a bleak picture: we pay more and get less for our health care expenses. The insurance apologists seize on anecdotes from other countries and that handful of metrics, but they can't change the facts, and they certainly can't save any lives.

Problem the First: Basic economics. The principle of supply and demand is easy to understand: when supply goes up, prices go down; when demand goes up, prices go up. In other words, something that's easy to get is cheap, while something that's hard to get is expensive. The demand part of our health-care system is us--that is, people who get sick. That demand is only going to go up as the population gradually increases and even more as the boomers age. The supply part is medical personnel, such as doctors and nurses. Everything else is incidental: you can't staff a hospital, run a test, or prescribe a drug without personnel. The supply has actually gone down, because almost all medical students these days (an amazing 98%) become specialists, not general practitioners. Specialists earn much more money, which tells you where their priorities lie. So supply is going down while demand is going up: prices are inevitably going up.

Solution the First: Doctors have abandoned the role of general practitioner, so we need a different profession to fill that role. Nurse practitioners are the likely stopgap solution. In the long run we must have primary care providers who can diagnose and treat simple problems, prescribe medicine, and refer patients to providers with more specific skills. A major step toward fixing this problem (and several others) would be to blur the line between doctors and everyone else, that is, create grades of medical personnel based on function, not education. Allow people to learn as much as they can about medicine in whatever way they can, then let them take tests to certify themselves. If I can learn what a GP should know without the time, expense, wasted energy, and built-in prejudices of medical school, why shouldn't I be able to do a job that doctors themselves refuse to do? It wouldn't be a bad thing, either, to show doctors that they can be replaced; that might put a dent in their arrogance.

Problem the Second: Geriatrics. One-third to one-half of all medical spending in this country goes to keep people alive in their final month. Preserving life is a worthwhile goal when it makes sense, but postponing the inevitable for a few hours or days doesn't make sense. The patient goes through unnecessary indignity, discomfort, and pain. The family goes through false hope and often financial hardship. The only benefit goes to the doctors, hospitals, and drug companies, and that benefit is purely financial.

Solution the Second: Encourage living wills. This has nothing to do with "death panels"; nobody wants to kill your grandmother. Try to understand the distinction. It's one thing to euthanize people who are still healthy. It's another thing entirely to allow someone to pass away quietly, someone who would die anyway and has already made an informed decision to do so without any fuss. I'll repeat the critical part--someone who would die anyway. There is too much focus on the quantity of life and not enough on the quality of that life.

Problem the Third: Prevention. An ounce of prevention, in medical terms, is worth about ten ounces of cure. Less than a pound, but still a substantial savings. It may be dramatic for surgeons to save someone's life with a risky operation, but real life is not like TV. It's much less expensive to teach someone at risk for heart disease to eat properly than to do bypass surgery. There's no mystery here. Most chronic diseases can be prevented. For some reason, though, many of us listen to the politicians, who would rather pretend to solve splashy expensive problems than quietly prevent them from ever happening. The system is geared towards trauma care, towards rescuing people from imminent demise, towards the dramatic rather than the sensible.

Solution the Third: If you're at risk for, say, heart disease, get some exercise and change your diet. If you refuse to do so, you are committing slow-motion suicide. The medical establishment should recognize this fact by classifying you as a coronary DNR. If you ever have a heart attack, nobody will try to resuscitate you; nobody will perform bypass surgery on you; nobody will try to save you from your own bad behavior. On the other hand, if you have a genetic predisposition to heart disease, you should get treatment and medication to reduce the risk of a heart attack, and you should be treated properly if you do have a heart attack. Conversely, if you have no risk factors at all and still have a heart attack, you should get treatment. The operative principle here is to prevent what you can and treat what you must.

The bottom line: Somehow we have gotten the idea that medical resources are infinite. We can treat everyone for everything, we can look for cures to every known disease, we can save every accident victim and premature baby, all at the same time. Is it any wonder that prices are going through the roof?

Introduction

A word about the title. In one of his concert films, the late Richard Pryor talks about his cocaine addiction. Jim Brown, a football player, intervenes and asks, "What ya gonna do?" Pryor tries to justify his habit. Brown keeps repeating, "What ya gonna do?"

Well, Pryor didn't do anything. Shortly afterward, he set himself on fire (accidentally or on purpose, there's no way to be certain). He spent several painful months in a burn ward.

This blog will be, among other things, an occasional look at some of the addictive and potentially dangerous ideas in American politics. We've already been burned by some of them, and unless something changes, we'll get burned again and again.

My nominee for most addictive idea is that the wealthy somehow deserve a break from the rest of us. It begins with someone arguing for "trickle-down" economics (or whatever they're calling it this year), which is nothing more than a simple "bait and switch" con. Bait and switch works because it's simple and it plays on greed.

Here's the scam. Someone approaches you with a wallet or bag containing money and claims to have found it. He or she would be happy to split it with you if you'll just put up some money for "security." That's the bait part. If the two of you find the original owner, you get your security back; if not, you get your security and half the money. You can't lose.

You go to the bank and withdraw your security money. Your new friend puts it in the bag. After a while he hands you the bag and tells you he's going to look for the owner, or contact the police, or use the bathroom--anything to get away from you. That's right, this is the switch part, and you're "left holding the bag." During that brief time between your putting your money in the bag and his handing you the bag, he has switched bags on you. When you get nervous enough to look inside, you find only scrap paper.

What does that have to do with tax breaks? Remember that the government's money belongs to everybody, including you (that's oversimplifying, so we'll cover it later). The bait in this case is jobs. We hear that if we allow wealthy people and corporations to keep more wealth, they will invest it and stimulate the economy. In an ideal world, it might work. In the real world, it doesn't. Just in America, we've tried it about twenty times, and not once has it worked as advertised. That's the switch: they promise to use your money to help you, but they only help themselves. An individual who gets conned ought to know better, but as a country, we've fallen for it every time. One definition of insanity is repeating behavior and expecting a different outcome.

I have two main objections to cutting taxes for the wealthy. One, they've already gotten ample rewards from the economic system. There is absolutely no reason for them to get further rewards from the political system. On the contrary, as the ultimate beneficiaries of society, they have a vested interest in maintaining that society. Over the last three decades, they have made short-sighted decisions that have instead harmed society: sending jobs overseas, keeping wages flat, adding profit motives to the health-care system, discouraging union activity, repealing consumer protections, and starving government of funds for things like infrastructure, education, and research. All these strategies have weakened our country as a whole, simply to make the wealthy even wealthier. The government should have stopped every one of these schemes as a matter of national interest.

Two, the other part of the argument is that the wealthy somehow know best how to invest. Two words: Bernie Madoff. The wealthy are at least as gullible, if not more so, than anybody else. Where were the responsible investors who should have researched instruments like collateralized debt obligations, realized they were bogus, and told everyone not to buy them? Why did anyone ever buy a "junk bond"? How many people gave their money to Madoff simply because everyone else was doing it? And Madoff is by no means an isolated case.

The whole "invisible hand" idea of capitalism relies on diffusion, not concentration, of wealth. As in politics, the more people we have making decisions, the better those decisions turn out to be in the aggregate. Yes, some people lose money, but with more people handling smaller shares of wealth, the risk is spread out. We have seen this idea turned on its head, with more and more wealth flowing into fewer and fewer hands. For instance, in 1980, the top 1 percent of Americans owned 7 percent of the wealth. Today that same 1 percent owns 20 percent of the wealth. The capitalists are destroying capitalism.

The 1890s version of the trickle-down scam used the "horse and sparrow" analogy. You feed a horse oats, they pass through its digestive system, and sparrows eat the leftovers. Think how many sparrows you could feed with those oats if you bypassed the horse entirely. That's what happened in the 1940s, when the New Deal got a chance to work. Ordinary lower- and middle-class people were able to go to college, get good jobs, and spend money. The result was the longest and strongest economic expansion in human history. Apparently the capitalists considered that a bad thing, because they set about reversing everything the New Deal accomplished. Part of that reversal, of course, included tax cuts for the wealthy.

Here's another point nobody talks about: when exactly does this trickling down reach the rest of us? After three decades of helping the wealthy, shouldn't the economy be doing well? Instead we have the worst conditions since the Great Depression. But the wealthy are doing better than ever. They don't need a break. The rest of us do.