A week has gone by and I still haven’t paid my narrative respects to Bill Buckley yet. Were he not such a homophobe (yet so eerily flitty at the same time, with his aristocratic airs), I’d feel bad about that. He did, after all, pave the way for the Reagan revolution, and for that the US owes him a tremendous debt of gratitude.This week’s column would also be a perfect place to dance on the rapidly-excavating political grave of New York Governor Eliot Spitzer, a.k.a. “The Sheriff of Wall Street”, a.k.a. “Client Nine”. But I’d rather deftly abstract from the former AG’s hooker habit by again explaining the difference between liberals and conservatives thus:
“Having principles means that it’s possible to run afoul of them; exposing you to charges of hypocrisy. Having no principles guarantees that you’ll never be a hypocrite. But you’ll always be a scumbag.”
In Spitzer’s current fix, he IS actually open to charges of hypocrisy, having nailed (figuratively speaking) prostitution rings during his tenure as the New York Attorney General. But those amoral social critics who focus only on the hypocrisy aspect completely miss the fact that, juxtaposed with the actual OFFENSE (the misconduct), the hypocrisy angle pales in comparison.
No, this week’s column is one that’s been percolating since seeing an ad for Hillary’s universal health care proposal last month. She seems to be locked in a war with Barack Obama over who can promise more on the matter of health care. And not just AVAILABILITY of care, no; COVERAGE.
Yes, if you are eligible for state-paid health care and you don’t sign up, there will be penalties. Criminal charges. Fines. Wage garnishments.
(Aside: I can’t help but wonder what the Christian Scientists think of this debate. Yes, the whole “no doctors” part of the faith seems a little kooky to me too, but so what? Have we actually reached the point in America where self-determination [i.e. “liberty”] has been subverted by the daddy-knows-best socialism of the vapid knee-jerk do-gooder majority? Isn’t that called “oppression”?)
At the end of the twat’s ad, the narrator says, “If you believe health care is America’s moral obligation, join her on Tuesday.”
And of course, the requisite, “I’m Hillary Clinton, and I approve this message.”
Moral obligation, huh?
There aren’t sufficient expletives, either in number or brutality, to hurl at such twisted, backward thinking.
Nobody’s going to deny that health care is getting more expensive. And when prices spike, people whine; and when people whine in a democracy, blowhard politicians start squawking about fixing their problems for them. In truth, there are innumerable reasons for the increase in health care costs, almost none of which can be precisely targeted by legislation.
Tort abuse, yes. Shysters like John Edwards, who make their livelihoods by convincing 12 ignorant people at a time that the soul of a pitiably handicapped palsy baby is inside of him, asking them to award multi-million dollar damages to his/her onerously burdened parents.
(These millions, by the way, are punitives against a doctor who “failed” to recommend a caesarian section, despite the fact that there’s no scientific evidence that a caesarian section surgery would have lessened the odds of the child having cerebral palsy.)
That money comes from somewhere; a malpractice insurer, probably, which pushes up malpractice insurance rates, which pushes up health care costs.
And then, from tort abuse, springs the subsequent problem of “defensive medicine.” Doctors who are afraid of being sued for malpractice by Democratic presidential candidates are tempted to over-treat the maladies they confront, out of fear of a lawsuit. But health care is already expensive; too much health care is way too expensive.
There’s also the uninsured, of course. By virtue of living in the US – even today, without any federal universal healthcare mandate – you have access to health care on an emergency basis. If you go to an emergency room with an emergency condition, the hospital cannot turn you away. The hospital can send you a bill for $10,000 after your treatment, but in the vast majority of cases, it’s turnip blood. So those losses become built into the price of care for people who actually pay for it.
In addition, a particularly annoying angle to the problem of the uninsured is the VOLUNTARILY uninsured: people who can afford health insurance but choose not to purchase it, knowing that emergency care cannot be denied if needed. I actually mentioned this glaring irresponsibility to my socialist ex-boyfriend, who made a respectable wage as a contract employee, but chose a flashy car and thrice-weekly trips to O-Bar over health care.
He replied, “Well, if I had to go to the emergency room, I’d pay for it.”
“Really? You live check to check, but if you got in a car wreck and the bills totaled to $50,000, you’d have the cash to just fork over?”
(The Romney plan – coverage mandates, with subsidies for the insolvent – would have fixed his little pink wagon… but I digress.)
On top of the uninsured, though, there’s a counterintuitive problem: the insured themselves.
Insurance is a tricky business. Carrying insurance results in a disconnect between the policyholder’s consumption and his responsibility to pay for it. So the temptation is to consume more than he otherwise would.
“I could take the five minute consultation and the prescription, but ‘just to be on the safe side’ I’ll get an MRI. The bill’s getting sent to Aetna anyway.”
(The economic term for this psychological effect of pooling demands and costs is “reciprocal externality”, but I won’t bore you with why.)
Clearly, the reciprocal externality problem (like the defensive medicine problem) results in people receiving more than the “optimal” level of care. Demand is artificially multiplied, which pushes up prices.
“But wait, how can you ever say ‘no,’ to more health care? Aren’t people healthier when they receive more health care? What is this blasphemy about an ‘optimal level of care’? It’s HEALTH CARE! We should have as much as we need, whenever we need it!”
…And THAT sentiment, dear reader, is the real root problem with health care costs. Health care has become an entitlement. We want it, we think we deserve it, so to hell with the cost. And in the economic equation, when cost isn’t a factor, the quantity demanded is as much as people can stuff themselves with.
Health care, however, isn’t really an entitlement. That’s right, I said it: Health care is not a “human right.” And the proof is in the fact that it’s a moving target. If your “human rights” didn’t entitle you to a Polio vaccine or an AZT prescription before they were invented, how do those same rights entitle you to those things just because they now exist?
Do you really think you have an open-ended claim on society that it take care of you by its best possible efforts? You selfish fuck!
(And to you left-wing folk who consider yourselves benevolent for your big-hearted socialism: do you really think that you have the right to use the force of the state to check-jack American taxpayers for the purposes of your hegemonic brand of compulsory charity? You self-congratulatory douchebags!)
The entitlement mentality is a manifestation of the “necessity creep” phenomenon: Polite society frowns on telling people that they don’t actually “need” something that they claim they do. So we used to “need” food, clothing, and shelter. Now, we “need” vacations and hair color and True Religion Jeans.
But, level of necessity notwithstanding, just because you “need” something, does that mean it’s OWED to you?
And before you say, “Yes”, consider this: I’d bet a clear majority of voters in Los Angeles County would say that they “need” a car. And cars are expensive. Does that mean that the government should provide cars to them?
The head-scratcher about the entitlement mentality, though, is that it’s actually a product of our affluence. (So much for the myths of Scrooge and Mr. Potter.) My reference a few weeks back to the middle class of yesteryear being dirt poor compared to the middle class today holds true. As we get richer, we feel entitled to more and better. And health care, at the level we receive it in the US, is a luxury good, which means we want more of it as we get richer.
So, as our incomes increase, not only do we spend more on health care, we spend a greater fraction of those incomes on it. We consume more health care per capita in real terms than ever before.
…Is that actually a problem though?
Honestly, is it?
Certainly the other issues I listed above, and some others I neglected, ought to be addressed. Tort reform legislation, maybe, and new health care options, like the Definity plan I have, which are designed to encourage the procurement of necessary care, and to cover the beneficiary in the case of a catastrophe, but to discourage frivolous overspending.
But, look: if we achieve greater wealth than prior generations, and therefore desire to be healthier than prior generations… It seems to me that we should also expect to have to pay for it.
Plainly, the government can’t afford to be the sole payor for a moving-target expense whose cost is growing at, what, four times the rate of GDP? More?
It doesn’t take a genius to see that, despite the PLURry fantasy of free hospital stays and nobody ever being refused care, if the government takes over health care, it will end up being rationed.
It’ll be an insidious form of rationing, though. Sure, we’ll feel the squeeze when we walk into a DMV-reminiscent “take-a-number” office to get a checkup, but what we won’t see are the IMPROVEMENTS to the field of medicine that we’re foregoing by moving health care out of the private realm.
In realistic terms, it’s relatively cheap to take the existing body of medical knowledge and apply it to a group of beneficiary citizens. What’s expensive is to blaze new trails: building the FIRST C-T scan machine; producing the FIRST antiretroviral pill; performing the FIRST lung transplant. What incentive would the state have to invent new, cutting-edge treatments, if the only result is that the public will have a new claim on the government to pay for them to receive it??
The moving target stops moving.
In a “lite” sense, the rationing of care is already happening, as I learned in my brief stint in health care finance. The company for which I worked performs kidney dialysis, and under federal law, End-Stage Renal Disease qualifies the victim for Medicare (but only after a waiting period of about three years if he/she already has his own private insurance). As a result, something like 75% of the company’s patients were Medicare patients, and Medicare’s set reimbursement rate per treatment was about $200. Unfortunately, that reimbursement rate fell at or below our provider cost (depending on medication levels), which meant that we only broke even, or even LOST MONEY on 75% of our patients. Medicare can’t afford to pay any more though, so with government reimbursement rates not improving, the only way the company could keep the doors open was to SOAK people who carried actual private insurance.
The company actually maintained a VERY important team (of which I was an occasional part) in the corporate office dedicated to figuring out how to stay in business under this scheme. How long does an average patient stay on dialysis? For how much of that time does the patient carry private insurance? And what kind of insurance? We broke down payors by every conceivable variable, looking for ways to make our forecasts more accurate: by state, by metropolitan area, HMOs vs. EPOs vs. PPOs, and on and on.
The company was actually very healthy while I was there, after coming back from the brink of bankruptcy in 2000. But imagine what would happen if a new drug were invented that extended the dialyzed life expectancy from seven years to ten: We’d have to soak private insurers even worse.
And that’s the road to hell. Private insurers grow unprofitable and close down, and then private providers (being reimbursed only at unprofitable government rates) become unprofitable and close down, and the government takes over responsibility for care provision as well.
So now, instead of paying for our own health care (a moving-target luxury good), we demand it from the state, which – in its signature bureaucratic fashion – hemms and haws and rations care; and as an ancillary “fuck-you,” does a lousy, bureaucratic job providing it.
Take away competition, and consumers lose.
We would all love to believe that health care providers are a benevolent group of people; that they do what they do out of a selfless love for humanity, and that if only food and rent and HBO were free, they would practice their arts gratis. (Oh, and that the people who manufacture the syringes and design the CAT Scan machines and develop new medicines are all similarly munificent, too.)
But we would be disastrously wrong. Do you really think that we’d have the same quality of health care in the US if we relied on the “Patch Adams” free clinic model? What kind of absurd thinking does it take to expect doctors to go to school for a decade, and then slave away for a few more sleepless years of gruntwork as interns, if their only reward at the end were to be allowed to do the same tortuous work for the rest of their lives, except with nobody looking over their shoulders?
No, in a capitalist system, the way we encourage people to go about pursuits that benefit us (like medicine) is with money. Which means that health care will cost money to its consumers. “Translating lives into dollars” is an ugly business (who wants to be the prick who does the math on when we can expect dialysis patients to die?) but it’s the bridge that has to be made when lives are on the line in a capitalist system.
Capitalism itself is still a good system; and here’s why: It redirects natural human greed toward a generally positive result: prosperity. This is in stark contrast to socialism, which redirects apocryphal human benevolence toward an elusive positive result: equality.
Don’t get me wrong here; I’m an optimist and I believe that humanity is basically good. I have greater faith, though, in a system that cooperates with self-interest than in one that works against it. Because as big-hearted as humans might be when they’re full, generosity takes a back seat to eating when they’re hungry, and there will always be hungry people.
To quote Winston Churchill, “The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries.”
Ask yourself this; which system is better: A) one where everybody shares a small pie fairly equally, or B) one where everybody shares a large pie unequally, but 80% of the people have a bigger slice than the people who are sharing the smaller pie?
If you answered A, would your answer change if you knew that the other 20% hadn’t contributed anything to bake the pie, or had possibly even refused a slice when it was offered?
If you still answered A, would your answer change if you knew that the smaller pie also grew more slowly than the large one? (Think of the children!)
Just remember that the next time you hear Hillary or Barack (or John, GODDAMMIT) sing the praises of the single-payor model
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