(With apologies to Robert Burns. -PB)

Less is Better

I imagine that some day Graham, the author of the superlative medical blog Over!My!Med!Body, who is just now emerging Siddhartha-like from the palace of his father to see the world-as-it-really-is rather than how he wants it to be, is going slam his imported microbrew down on the bar of his favorite San Francisco bistro and announce to his friends that the problem with medical care is “All them goddamn free-loaders mooching off the system,” after which he will stagger to the registrar of voters, change his registration to “Libertarian,” and have his designated driver scrape the Obama bumper sticker off his Prius. He’s certainly headed in that direction, especially on perusing one of his latest articles on futile care where he correctly identifies the disassociation between cost and effectiveness of much of what we inflict on patients in their twilight years. He’s also slowly gaining awareness that many of our patients, far from being poor-but-noble victims of the brutal society in which we live are, in fact, shameless opportunists who will take and take all of the government freebies social justice that they can get their hands on.

In other words, he is slowly, oh so slowly, seeing the obvious: That the problem is one of demand and cost, not some nebulous failure of social justice or systematic oppression. Sure, we can blame insurance executives with their multi-million dollar severance packages and greedy physicians opening specialty centers and concierge practices but the fundamental problem is that everybody wants all the medical care they can eat but nobody wants to pay for it themselves. Hey, it’s a right after all. We don’t have to pay for our freedom of speech and since burning an American flag only costs a few bucks, why should we pay a dime for medical care?

I mention this because it’s an excellent series of articles, by themselves justification for including him on my blogroll, full of bang-on insights to some of the problems of American medical care, many of which I agree with wholeheartedly. You all know my views on futile care for example but Graham and I also share a disdain for Direct To Consumer drug advertising, a practice which I think is ridiculous on so many levels that I hardly know where to begin. Now, as a rapacious, right-wing, pro-industry capitalist who will kill a million caribou without a qualm to drill for Alaskan crude, like Nixon going to China, I probably have a little more…I don’t know…maybe we’ll call it “authenticity” than Graham when it comes to attacking a cherished part of our capitalistic system but Graham still knows of what he speaks.

My only qualm with Graham is the general impression one gets that every solution to every problem is going to involve a whole lot more government involvement. In other words, to decrease the amount of fraud and abuse in whatever socialized or quasi-socialized (or we-swear-it-isn’t-socialized) system the TPGA-axis eventually forces on us Graham would likely turn to the gubbmint’ to implement some byzantine regulatory solution in whose labyrinth will vanish whatever efficiency, flexibility, and innovation is left in our system. It cannot be otherwise. Governments do not give money to anyone willingly, despite the promises of politicians, and money is scarce and getting scarcer. The fundamental problem, in fact, and almost the exclusive preoccupation of every Western Democracy is how to buy off their citizens, to whom were promised lavish social welfare benefits, with treasuries that are becoming rapidly depleted. Covertly or not, medical care and other freebies need to be rationed and governments, to avoid admitting that they’ll be putting down yer’ granny, disguise rationing behind impenetrable bureaucratic obstacles. In Greece, for example, my ancestral homeland and the poster-child for Socialism Gone Wild, while everybody gets free medical care, unless you can fork over a bribe or belong to one of the 149-or-so trade associations with good insurance plans (kind of like co-ops, many of which have failed to the extent that they are all going to be nationalized shortly into about a dozen broad associations), your wait-time for a major operation that even our winos can get in less than a day can be months or years.

That maybe what we need to do is decrease the amount of government involvement in medical care is never seriously considered by anybody, at least not anybody who has a decent chance of doing anything about it. The conventional wisdom upon which every major politician from both parties operates is that government has to do something, the exact something although it may vary is still usually just a question of how much more, not whether it needs to be done at all. For my part, while I think that both Graham and I agree that few can really afford a major hospitalization or the high cost of getting old and multiply comorbid, I have never understood the lust of the wonketariat to provide comprehensive medical insurance for free to everybody whether they need it or not. Surely we will always have some unavoidable costs in our system that the tax-payers will have to suck up. There are many people in our country who are not only poor but completely helpless, conditioned by years of mammary government to be incapable of solving a single problem in their lives without guidance and support from a bureaucrat. The elderly at the other end of the spectrum, many of whom have not contributed nearly as much into Medicare, both from payroll deductions and premiums, as they will eventually use need to be supported as do those who are struck, from out of the blue, by a debilitating illness that leaves them incapable of productive work. To let people die because they can’t afford life-saving treatment, while not exactly a mortal sin against the capitalist ethos, would nonetheless be demoralizing to our nation and only the most Borg-like of Ayn Rand followers would think otherwise. But why compound the problem, why run up the tab on obligations that we cannot possibly meet, by giving away medical care to those who can pay for it themselves? In other words, why bankrupt the nation to ensure that nobody ever has to decide between cable television and taking their kid to the pediatrician?

Which is kind of the choice many of our citizens make, the mantra of the middle class in particular being “Thousands for Personal Watercraft but not a Dime For My Doctor.” Primary care on an individual basis is not that expensive and we are not a nation of paupers. In a country where even the poor can drop a couple of hundred a month for luxuries, things like ringtones for their cell phones and designer clothes, why Graham or anyone agonizes over the best way to make sure that nobody has to pay a dime for medical care if they don’t want to is inexplicable. They’re just not giving people enough credit, displaying the suffocating paternalism that is the hallmark of those with a religious faith in the power of government to solve problems and whose fear is that most of the sturdy and not-so-sturdy yokels, if allowed to make their own decisions about medical care with their own money, will let their children suffer and their own health deteriorate before they’ll spend a dime of their beer money.

Can’t have that of course. People making rational decisions about how they’ll spend their own money. Pandemonium would ensue! The Apocalypse! Panic in the streets! Human Sacrifice! Dogs and cats living together! But, if primary care is relatively cheap and getting cheaper with the advent of four-dollar generics at the shopping Mecca of your choice, where is written that people need expensive comprehensive medical insurance or that the taxpayers, through the sausage-nozzle of government, have to pay for it? If you give a crap about your health, by definition you will pay a hundred bucks every now and then to see your doctor and twenty bucks a month for the (hopefully) minimum amount of medications she deems necessary to control your potentially dangerous medical conditions. If you don’t give a crap you won’t pay which is a personal problem, nothing more. People don’t want to pay because they have been conditioned, first by fifty years of comprehensive medical insurance as a de facto condition of employment and lately by the munificent hand of government that lets them present to the Emergency Department with a complaint of “My ass is sweating” without being arrested for embezzlement of public funds, to expect medical care to flow as effortlessly and cheaply as water from a tap. There is, you understand, a certain transparency to public utilities. Water comes out of the faucet and is carried away to Candyland by the toilet and people don’t really think about it. These things just exist which is how many in the public would like to view medical care, an endeavor which requires several orders of magnitude more money and effort than providing water.

For both mice and men, the best-laid plans often go astray. Unintended consequences flourish, particularly when government which is largely staffed by people who are not qualified for any other job but public service gets involved and tries to control behavior with complicated schemes. We have a nation of unmarried teenage mothers and ruinously expensive government health care grown to a hundred times its most pessimistic projected cost to remind us that socialism is a moth-eaten, half-starved, unpredictable tiger that once let out of the cage is almost impossible to put back in. It’s an economic theory entirely built on the mistaken idea that people will cheerfully and willingly work long and hard to support people they have never met and who don’t do anything for them in return. It is, finally, a philosophy which is turning the West into a nothing more than a crappy nursing home, full of people without the foggiest notion how to be productive and look after themselves, and paid for by money borrowed from the Sheiks of Araby and the Mandarins of China who will eventually decide that paying for the cradle-to-grave benefits of a French poet or the inhabitants of a trailer park in the vast, empty wastes of Massachusetts is not such a good investment. Unfortunately, Western socialism is financed with borrowed money and is therefore unsustainable, especially as economic growth cannot keep up with the growth of entitlements.

It would be a simpler, cheaper, and, as our country is terrifically overdoctored and overmedicated, probably not even detrimental to the aggregate health of our nation if the government withdrew from as much of the medical industry as possible and instead, if they can’t resist the temptation to tinker, enacted policies that encouraged people to pay for as much of their own medical care as possible. Nobody, for example, except the very poorest (to be determined by Graham’s compassion Gestapo) should have a dime of their primary care paid for by the the government on any level. If you need to go the doctor for a cold or to check your blood pressure, you need to pony up. If the government has to be involved, and as most of us agree that a major illness or two will wipe out most people, it can guarantee the solvency of high deductible, major medical policies that citizens would be expected to buy for themselves and their families. Maybe even make it mandatory, call it a tax, and be done with it. We can always take it out of the Earned Income Tax credit for the majority of Americans who, in fact, pay no income tax whatsoever.

On the carrot side, we can encourage health savings accounts from which primary care and other medical expenses can be payed without involving the complicated dance of the bureaucracy, the idea being to encourage the health care market to be a little more transparent and rational. If you’re spending your own money, maybe you don’t want all of those marginally useful treatments and studies.

Of course, medical care is still going to be horrifically expensive. Things cost what they cost and it is impossible that the elderly and their lobbying groups will accept the kind of rationing that is needed to really control spending. Maybe when I get to be seventy I’ll also want my share of heart caths and joint replacements so all of us have a terrific self-interest in supporting our current high-tech and highly expensive medical system. But if a few simple reforms (simple conceptually but almost impossible politically, I mean) to include tort reform could shave twenty or thirty percent off of our current two trillion dollar per year spending spree, that would be enough to keep things solvent.

Other Blogs You Should Read

The best blog on my blogroll, the Macho Response, is not even a medical blog but rather the observations and reflections of a guy living deep in one of the many strongholds of the lunatic fringe and who is slapping them around as they deserve and to the best of his abilities. I’m sure we don’t agree on everything. The Crack Emcee, as he styles himself, is an artist, a musician, and an atheist while I am tone deaf, art-insensate, and a devout Orthodox Christian…but I ain’t a fascist and there is plenty of room in my mind at least for some reasoned differences of opinion. The Emcee is nothing if not reasonable which is not to say that he doesn’t, in a commendable macho fashion, disembowel the usual sensitivity fascists, self-help gurus, and the obnoxious cult-like behavior that is the norm among many of our elites. Sometimes even reasonable men must run up the Jolly Roger, spit on their hands, and commence to cutting throats (If I can paraphrase H.L. Mencken).

You also need to read, regularly, the Happy Hospitalist. I used to think I could write a good article or two but now I must cower in shame in the long shadow of a guy who can really break things down to their most basic level and demonstrate not only what’s wrong with them but what would be required to fix them. My non-medical readers need to go over there because most people who are not involved in medicine have no idea of the obstacles put in the path of a typical private practice physician by the same people who wonder why there aren’t enough doctors to go around.

I have to plug Kevin, MD of course because he is the Don Vito Corleone of the medical blogosphere and he promised to send some of his capos over to break my kneecaps if I didn’t.

Do It for the Children

I’m still looking for more advertisers. I like writing my blog and I hope you folks enjoy reading it but it can be something of chore, not to mention that my wife wonders why I spend so much time doing it instead of surfing for internet porn like normal husbands. At least if I make some money it won’t seem so weird.

Advertising inquiries can be directed to [email protected]. I am getting about 30,000 unique visits a month (according to Sitemeter) so while I am not in the Kevin, MD league maybe we can talk.