It's amazing how sometimes you can find something interesting to ponder in the most unlikely places. Take the New York Times Magazine, for example, an often infuriating waste of ink, paper and time. The NYTMag has become the national homosexual highbrow magazine over the past dozen or so years. I am not against homosexuals, but sometimes I do get a little sick of hearing about how wonderful, and how oppressed, they are--and how so altogether wonderful single-female or in any event male-less parenting can be (when all the actual social science data we have says otherwise). I don't care what people do in private with their genitalia as long as they don't insist on telling me about it, and that goes for heterosexuals as well as homosexuals and transsexuals and metrosexuals and any other kind of -sexuals you can think of but I can't.
I also get a little sick of the term homophobic, as if not assenting to and cherishing the "gay" lifestyle means you're somehow afraid of it. I'm not afraid of vomit, but that doesn't mean I'm particularly interested in someone else's manifestation of it. Well, I suppose that if this sort of thing is what the Magazine's readers really want, then the editors are right to give it to them. And how should I know? I haven't done a survey.
I like the Magazine for the puzzles, especially the acrostic, which they run every other week. They amount to brain exercise, which I need. I don't like the crosswords as much because to do them efficiently requires a lot of pop culture knowledge, to include television and Hollywood movie watching, two activities I do not do a whole lot of--which is not a boast, just a fact.
Anyway, every once in a while the Magazine will have a great piece--I can think of four or five over the past year--not a high average, perhaps, but not entirely useless. Yet today what struck me were three items on the Letters page....of all places. One was a letter by an economics professor from NYU, someone named Edward Wolff. He was commenting on last week's cover piece by David Leonhardt about education. He main point was that, pace Leonhardt, there is no statistical evidence that mean improvements in education pay any economic dividend.
My reaction to this is that Wolff simply must somehow be wrong--either the statistics are misaligned with what they are supposed to measure, he is not standing far enough back to see the causal chain, or something. This just seems too counterintuitive at first blush to possibly be true. And yet, he may well be entirely right. It may be that human capital as applied to economic growth is highly skewed, that a few thousand scientific geniuses, enlightened tinkerers and entrepreneurs account for nearly all the productivity growth at base in out society, and that what 99% of everyone else knows doesn't count for a whole helluva lot. That's not something you want to say too loud in an egalitarian-minded culture (never mind the reality of things). But it might actually be true. It would be nice to know; damned if I'm prepared to trust one economist's opinion.
Even more interesting was a little note from a medical doctor in Vermont, Rebecca Jones. She points out that for all the medical technology we have, it can't and doesn't trump such basics as diet, exercise, sleep and emotional well-being in our overall health. She's so obviously right that I see no need to defend her further--and I will only return to this point briefly below, since #5 on my presidential platform is about health care. Amazing how three sentences from someone with experience and common sense can make hundreds of thousands of pages of technical writing about the health care crisis seem so pointless.
Best of all, however, was mention, by someone named Rosaleen Mazur from Rhode Island, of a book called Agenda for a New Economy by someone named David Korten, who I admit I never heard of until this morning. Maybe it's a bad book--who knows? But it sounds like it bears a thesis I have carried in my head and heart for 40 years--that we ought to be developing an economy based around local communities, even as an international economy goes ahead based around Wall Street and international trade. That means supporting one-of-a-kind local businesses, locally owned, that use local labor and care about the local environment.
This approach reminds me of the Prosperity Index that the Legatum Institute has devised, which insists that quality of life issues need to be counted is as much as stuff than can be measured with numbers. To have ever not realized that is the price we pay for our public schools having ignored philosophy and ridiculed religion all these past forty or so years, of course, but that's another story. I have to find Mr. Korten's book, and then, perhaps, Mr. Korten, and invite him into The American Interest.
We'll see--he sounds like the subsidiary-loving type, the crunchy con-type perhaps (though he may not realize it), the anarchist-as-opposed-to-statist kind of person I have always been myself. I distrust all concentrations of power, whether private or public. I insist on metis and subsidiarity as the most effective and morally sound way to solve problems, whenever possible. I insist that there is an ecology of liberty--that people who do not develop in their everyday lives the habits of self-sufficiency cannot make up the ingredients of a genuinely free society. Ah, but more of this later. Now to health care.
I know that this is a very complex problem, one with many, many, many moving parts. I do not expect, and no one else should expect, that a short blog post can encompass it all. But I will try.
No. 5: Don’t even try to create a national health care system.
The main reason health care costs are skyrocketing is fairly easy to understand, but almost no one who has not thought systematically about this seems actually to understand it. Here it is in a nutshell: Science and technology are rapidly expanding the range of diagnostic and treatment options, but without—as in other areas of our economy—also enabling us to substitute capital for labor to make medical functions more cost-efficient. In medicine, no matter what sorts of diagnostic and care options there are, we still need highly skilled doctors and nurses and lab techs. Machines or robots can’t substitute for people in medicine like they do in building cars or making steel or growing food. Trained human capital is very expensive, and this double-whammy—new options opened by bioscience and the need for skilled people—is what makes health care costs keep rising.
Of course, that’s not the only reason. There are at least seven others I can count; let's just list them.
One is demography. We are an aging population (not as much so as some others, like Japan, China and the EU, but aging all the same), and older people suck up more medical care dollars than younger people. This is structural; there's nothing we can do about it, but it is only temporary, because eventually the population pyramid will change its shape.
Two is that about half of all medical spending in the United States is spent by the Federal government, and the Federal government spends inefficiently because it is too large. Its transactional costs are huge, and it has a knack for making them even hugher—the insane HIPPA “privacy” legislation being a key case in point.
Three is that private insurance companies also have huge inefficiencies and transactional costs. And they are not entirely honest about how they go about their business. They cherry-pick and they exclude.
Four is the near total disorganization of the capital-technical stock in medicine. Some regions have too many machines and labs and some too few. Some regions, like Rochester, New York where the Mayo clinic is, are something like 17 percent more efficient than the norm. We don't need a national health insurance infrastructure to model and scale up health care systems within the United States that have proven efficient. If we do that--learn from our successes--we can mitigate the effects of our supply-push system, defined, simply, as "we have a machine, we use it whether it makes sense or not." We have an obsession with the technology, and we ignore common sense, as Dr. Jones says: diet, exercise, sleep, emotional well-being (eg., stress). We are terrible at preventative care in this country. There are all sorts of cultural reasons why this is, including how doctors get trained these days, but we do not have time to linger on this.
Also, note that doctors use the machines in part to protect themselves from malpractice suits--lawyers and their damned overlawyering--that's the fifth factor. But the cost of malpractice, while significant, lamentable and avoidable with good policy, is actually not as huge as is often assumed. Probably more expensive over all are, six, the lobbies for the pharmaceutical industry, a very powerful special interest that gets Congress to vote it all sorts of expensive favors. Not only are we overlawyered and over-machined, we are also outrageously over-medicated.
And seven, one other major reason for the problem is something no one wants to talk about: religion. Yes, you heard me right.
In an age of older, more innocent religious belief, mortality was accepted as a natural facet of living. Aging was seen as not only inevitable but noble; we respected our elders, and venerated them. Now most Americans run from aging and mortality like scared children. No wonder, then, that people today seize upon the possibilities of rejuvinative medicine in a way most of our forbears never would have. Upwards of 40 percent of all medical expenses in the United States is reportedly spent on very elderly, ill people in the last eighteen months of their lives! And a lot of that spending is on operations and treatments of dubious real value to anyone, except those who sell painkillers and medical machines. (Increasingly, too, disproportionate amounts of money are spend on those at the very beginning of their lives, including many damaged infants who will never be able to lead normal, productive or independent lives, but that's another matter.)
This spending we do on the aged and permanently infirm is absolutely crazy. I am not advocating euthanasia, so don't get prematurely excited. Of course I respect the non-instrumental, intrinsic sanctity of all human life; I am a religious Jew, after all--I have no choice. But that does not mean we should use machines and scarce medical resources to keep such people alive at the expense of others, which is, in effect, what we are actually doing. Unless people write binding living wills, children and other relatives are extremely loath to “pull the plug”, and medical professionals are afraid of being sued if they do. But how dumb do we have to be not to realize that if insurance pools have to take into account that 40 percent of all costs that are spent on people who we know will never get well, and whose lives have generally lost purpose or any sense of enjoyment, premiums are going to be very expensive?
Now, policy can be important. If there is way to use policy to encourage people to eat right, get exercise, get good sleep and enjoy emotional well being, that would solve most of our health care crisis overnight. You bring core costs down, and suddenly insurance premiums become far more affordable--like duh, right? And this really is is the beginning of wisdom here: It is plain stupid to worry about insurance coverage without thinking of ways to reduce the overall cost structure of health care, but to do that you have to understand where the escalatory pressures actually come from. They come from the culture--the political culture and the culture more generally.
It follows that, by definition, there is no single technical or bureaucratic fix for our circumstances. Can you think of policies possible in our Congress that would make people eat right, exercise, sleep well, and--the most wildly improbable of all--see to their emotional well-being?! I can think of one: Stop letting fast-food crap "restaurants" advertise their destructive so-called "food" on television, and here we come back, yet again, to one of the the roots of evil on our country, television and TV advertising, with its mean-world syndrome that increases our national stress quotient and its relentless pollution of our national capacity to distinguish "need" from "want", thus infantalizing our entire culture--because, yes, knowing "need" from "want" is what has traditionally distinguished an adult from a child.
As I say, better governance would help, certainly, if it were practically available (which it isn't)—but no, it won’t really fix the problem anyway. As with problems of equal access to decent education, health care issues amount to a series of what are essentially moral issues. Who deserves what care, or enhancement? What should a minimum level of care be, regardless of a person’s ability to pay, and who gets to determine that minimum? If the patient can’t pay, who should—and who gets to determine that? When does, or should, the concept of triage kick in for the care of the elderly and terminally ill?
Obviously, these are controversial and fraught questions. We will probably never likely agree on them at a national level, anymore than we’ll agree on abortion and gay marriage. If we try to create a national health care system, we will be forced to answer such questions for all of America’s religious and regional communities at the same time. That is just asking for trouble.
Of course, if we do this we will also inevitably saddle ourselves with a highly bureaucratized, inflexible and expensive management apparatus, as well (again, not that the market-driven model we have now is a paragon of efficiency!). That's why ideas of creating a Federal Health Board will probably end up doing, unless they are very carefully designed with strict principles of exclusion in mind. Everyone who is honest about the problem knows that. Such an apparatus will help drive talented young people away from careers in medicine—already a worrisome trend. Thus, in order to deal with what some construe as a problem of fairness, we will make the problem of costs much worse, and the vast majority of Americans will be worse off for it. With dollars for health care relatively scarce, the last thing we should want to do is add gratuitous transactional costs to our medical system.
Given the nature of the problem—which, again, is as much moral and cultural as technical or administrative—it is also one best handled at the state level. The State of Massachusetts under Governor Mitt Romney managed to hammer out a way to do universal health care. Other states have taken note, and if it works in Massachusetts variations can work elsewhere. But circumstances differ from state to state, and sustainable solutions have to fit local conditions. To think there is a one-size-fits-all solution on a national level is delusional. It represents the “will to a system” of social engineering that every sensible philosopher and observer has warned against. The solution to intrinsically difficult problems like health care costs is not made easier when its scope is made larger. This is so obvious that, under ordinary circumstances, it should not need to be explicitly pointed out. But evidently we are not living in ordinary circumstances.
There is another reason we need now to recognize and deal with the moral and political aspects of our health care problem: It’s going to get worse. There is already a troubling blurring trend between what is medically necessary and what is merely desirable. For example, drugs originally developed for legitimate therapeutic reasons, like Viagra, are now used for essentially recreational and enhancement purposes. It is also becoming harder to distinguish some minor surgeries and physical therapies justified for physiological reasons from cosmetic surgeries. But the real looming problem before us concerns the impact of genetic engineering: hence my next idea.
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