Reframing the issues of the health care "debate"

I am despondent on the whole health care reform thing.

I view it as a circus distracting people from the real issues, actually.

I was nearly driven bankrupt, twice, by the current system, and have a long list of detailed complaints about what is wrong with it at present. Coping with the current system, as it exists, with a pill for every malady, and pills to cure the side effects of those pills, and pills to cure the problems caused by the other pills... made me considerably more sick than I needed to be, for far longer than I needed to be, and coping with the stresses of the system didn't help either.

However, living where I do now, I don't have to pay into the US system any more, and I don't intend to go back. In fact, the risks involved in going back are so high - one traffic accident, and I would be on the brink of bankruptcy again - that it is a profound disincentive to even think about visiting the USA again.

So I really shouldn't care, anymore, but I got into a debate about it the other night and thought I'd type up my side of the argument.

I think that the legions of non-medically trained auditors and lawyers and lobbyists should not exist.

I also find the idea of one nationwide universal health bureaucracy for 300 million people abhorrent. I believe that the central government of the US should be as weak as possible and mostly concerned with national defense. If a given one of the 50 states wants Obama-like health care, great! Maybe people will want to live there more.

For example, both Massachusetts and Tennessee implemented Obama-like care a few years ago.

How's it working out? Is it a success? How are the demographics changing?

It is far easier to experiment with public policy at the state level than it is to do so at the Washington, DC, level, and far, far easier to rectify mistakes. Even then (witness the decline of California vs NJ, for example) it may take decades to reverse course.

Most importantly, most of the developed world is in a demographic trap. The old are getting older; there are not enough of the young. The haves - mostly the boomer generation, now - is trying to extract as much money as possible from the have nots - the successor generations - at every step of their slow decline into senility, so their Woodstock goes on and on while we have to clean up the messes they've left behind.

There are easy solutions to the demographic problem - lots and lots of immigration, easy citizenship, and incentives for child-rearing - that aren't on the table, and won't be until it is too late.

I wrote a story once, called "the good life", which was about a life insurance salesman that sold the "good life" to those young and healthy - cars, booze, parties, trips, etc - in exchange for a few organ donations when they hit 30... And naturally, being raised ignorant and away from valid work, they'd go into debt selling off more organs and limbs, partying further, after that, until they had nothing left but a brain attached to a few machines, and big payments to make on keeping those running too, and after that... nothing.

Their organs and limbs went to the old, who were living on cruise ships....

The old preyed on the young in this brutal dystopia until there were no more young left to support them, and revolution ignited between the oldsters fighting over the last "useful" young people, who by then were being bred in jars and kept in the matrix, dreaming, until they could be harvested for spare parts.

...

Jerry Pournelle writes:

"... the one fix we know will not happen is some modification of the malpractice laws and the tort system. That simply will not happen. There are several other sacred cows that will not be touched no matter what changes are made in the system. That's simple politics. So: given that some of the obvious fixes are impossible, and will not happen, is the system so broke that it needs a fundamental revision that will not make the obvious fixes like tort reform? ...

And I ask, again, the obvious: where did your obligation to pay for someone else's health care come from? Under what principle is this to be done? The pragmatic argument is that it will save money if everyone is put under a health care plan, and preventive medicine will save huge
amounts. I doubt that those who say this believe it; certainly few others do. We don't need health care reform to put a tax on sugar pop or even to end the sugar protections and subsidies; is that likely? Is there any evidence that preventive medicine applied to an entire population lowers health care costs? Depends, of course, on the preventions: cleaning up toxic wells and providing clean water certainly works. Does exhorting people to lose weight do it? If so, on which audience do the exhortations work?"

I have a long list of things that would help American health that are politically unacceptable - from banning sugar and corn subsidies (as per the above), to taxing fast food restaurants, and taxing or banning bad foods, full of carbohydrates and such (and subsidizing vegetables in return), to taxing tivos, tvs, and game consoles (and in turn subsidizing gyms, yoga retreats, and international travel)

Here's another one: Why on earth do businesses still work 9 to 5, with employees wilting under dim florescent lighting, when outside there's a sun already shining? Is it to sell more vitamin D cream, gym memberships, and anti-depressant medications?

None of these solutions are on the table. On my bad days I tend to think that modern society is oriented towards killing off those that cannot summon the will to turn off their tivos and take a walk once in a while.

Lastly I'm going to quote a few more choice words from Jerry Pournelle on the issue of the largest health care cost of all - treatment near the end of life:

"one reason health care costs so much is this business of the last two years of life. If we could eliminate those two years we would no longer be spending more than others. Or eliminate even one of them.

And that poses real moral dilemmas. We know how to save the money. Have the good grace to die. MIT economist Lester Thurow never put it that bluntly, but he's been talking about this for a least a dozen years, as for instance in the lecture I attended in Boston as part of a AAAS meeting about that long ago when he gave a very good presentation of the dilemma of health care planners, and as part of it talked about the Esquimaux culture's solution: "It's a good day to die." Of course I was considerably younger in those days.

The moral dilemma comes when you try to plan out who shall make these end of life care decisions? And who shall pay for them? If the dying person has the resources to pay for all that expensive treatment, should the state prevent that "waste", so the money can be inherited and subject to inheritance tax? And who shall have the right to speak for the dying person? Who can determine whether that person is mentally competent? But one assumes that the moral principle is clear, the property owner has the right to use that property to preserve every last
second of life. Note that even with that clear principle the details get sticky.

Now suppose Grandma doesn't have the resources? Or, if they are used to keep Grandma alive with tubes, all the family resources will be gone, and Grandpa will be on the dole? It's still their property, so that's just another complexity.

Now suppose they don't have the resources at all. Someone else must pay for both their end-of-life expenses. Who is obligated to make that payment? Is it an entitlement for all and an obligation on the public purse (and which public purse, local, state, or federal)? If it's an entitlement for all, then these costs are actually the property of the patient, and the individual decides whether to spend great sums on staying alive.

Of course there are details to worry about. Clearly we can find some cases in which we'd all agree that prolonging life at great expense just isn't worth the money it's costing us. I can also cite cases of 96 year old grandmothers coming out of quadruple by-pass heart surgery with a
couple of good years (possibly more) of life ahead. Now what?

These are the questions that need answering when we evaluate the cost/effectiveness of health care. I don't think they are actually being debated in Congress, because the political implications are so great.

More another time: but that's why health care costs so much. So very much of it is spent in the last two years of life. The cost reduction is obvious. What is the effect of that saving, and who decides?"

In anticipation of the flames, it's probably a good idea to put on my asbestos suit now... even though that causes cancer, in the long term.

Labels: healthcare, insurance, meme war, obama

  ¶ 3:30 PM