The Best-Laid Schemes O’ Mice an’ Men Gang Aft Agley (And Other Things)

(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.

17 thoughts on “The Best-Laid Schemes O’ Mice an’ Men Gang Aft Agley (And Other Things)

  1. Panda,
    Doesn’t it feel weird to be just starting Lent when everyone else is celebrating Easter this weekend? (I am assuming Greek Orthodox is on the same calendar as Antiochican Orthodox).


  2. Panda, just ran across this article in the Boston Globe about a looming catastrophe created by the Massachusetts healthcare reform (an influx of free-riders and a corresponding reduction of reimbursement rates). You won’t be alarmed, of course, having seen this kind of thing coming from day one…but I wish more people would pay attention.

    (I am actually for some sort of federally guaranteed major medical policy which may be given outright to the very poor and offered for sale to anybody who wants it.  The problem is that for it to work, it would have to be mandatory and making it so would be almost impossible to enforce unless we had a get-tough attitude, turning away those without insurance.  Unfortunately as long as we have EMTALA and it is implemented to avoid litigation we will never be able to get people who can but refuse to pay to pay a dime for medical care.  That’s one of the problem, as I understand it, in Massachusetts, namely the difficulty in forcing people to pay even cut-rate premiums. -PB)

  3. What happened in Mass is they had way more people sign up for the government subsidized care (FREE=MORE), and way less people sign up for the unsubsizded care (MORE=LESS)

    In essence, you have self rationing at it’s finest. People chosing NOT to sign up for mandated health care because the fine is less than the cost.

    Yet, when it’s free, the gates to health care salvation get over run.

    Now, guess what happens when you have a state of subsidized health care.

    they will be forever consume the FREE=MORE mentality.

    And you still have those without insurance adding cost to the system.

    IF you want EVERY body covered, you will have to have heavy duty ration. Either you are denied expensive therapies and cares.

    Or you have to pay your fair share.

    But you can’t have FREE care and unrationed care at the same time.

  4. HorusCat:


    Doesn’t it feel weird to be celebrating Pascha when 1/4 of the world’s Christians are just starting the Great Fast?

  5. Chris C.,
    You misunderstood my post. I am Orthodox and was smiling to myself at the revelation (to me) that PandaBear is, too. Obviously, you are as well. I don’t know where you live, but in the midwest, Orthodox Christians are relatively few and far between. I eat lunch with different groups of people almost every day, and I will be explaining for some time to come how it is that I am fasting after “everyone” else’s Easter (and why that doesn’t just mean fish on Friday!).

    I apologize if you thought I was making fun of PandaBear.


  6. Chris C.,
    That’s weird. I submitted a comment, but I don’t know where it went. The same place my socks go in the dryer, I guess.

    I am Orthodox, also. Perhaps you live on the coast, or in one of the areas of the midwest where being Orthodox is common, but I live in an area of the midwest where being Orthodox is cause for a number of curious questions. The one I will be fielding for some time to come is how it is I am fasting after Easter–and doesn’t that just mean eating fish on Friday, anyway??


  7. Ah, so I did mistake. And then both your comments showed up.

    It doesn’t feel weird if you get yourself into the mindset that everyone else is doin it wrong.

    I live in the SF Bay Area, where nothing anyone does can be remarked on as particularly weird. I’m a subdeacon, and on my way home from church I’ve received compliments on my “nice coat” (i.e. cassock) that were genuinely well-meaning, where I’m sure in other parts of the country I’d just get hostile stares. Not that I don’t get those too once in a while, but it’s far from the norm.

  8. There in SF, people are probably jealous. Our church does a festival every summer with Middle Eastern food, music, dances, etc., and I have found that a surprising number of people are familiar with St. George’s because of that. They are truly interested in what it means to be Orthodox, even while having almost no frame of reference for it. I have to confess that while I have no trouble giving up meat and fish for Lent, I really struggle with the dairy. Coffee with cream in the morning…I guess I can live with CoffeeMate for a few weeks!

    (They’re not really interested in Orthodoxy.  They’re interested in our quaint ethnic customs, our exotic-looking icons, and our Baklava, nothing more.   It’s just one more equal opportunity religion to them, as in, “Gee, Honey, maybe we can work some Greek Orthodox elements into our Shinto marriage on the beach in Jamaica.  But breathe to them that their is no Salvation except through Christ, that to be Orthodox is to accept the Resurrection of the Lord (else, if I can paraphrase Paul, what’s the point of Christianity?), and that to be an Orthodox Christian (or any Christian) is to view Christ not as yer’ personal friend but as your master and they will get all snarky and open-minded on you.  My point is that they have no interest at all in what it means to be Orthodox except that they can add it to their cafeteria plan of spirituality even though to be an Orthodox Christian excludes believing in any other religion.  So sorry.  We don’t really discuss religion on my blog (but you started it) and you and anybody can believe whatever you want but that’s the way it is.  When I was the Parish Council Vice-President of my Church I wanted to do away with the “Greek Festival” mentality. -PB)

  9. Well, you are of course, right. Is there anything less p.c. than asserting that being a good person isn’t enough to get you right with God? And even worse, that it means being Christian in a particular way? I won’t break the rules of your blog, because it ISN’T a religion blog, I was just excited to meet a fellow-traveler. There is a great group of Orthodox folks over on Free Republic.


  10. “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.”

    Why don’t you doctors start the exodus?

    (Believe me, it’s happening.  Like I said, many physicians, especially in some of the more esoteric specialties, don’t take any Medicaid or Medicare.   I think that eventually, we’re going to have a lot more “retainer” or “concierge” practices as physicians who can (I can’t, in my specialty) opt out of the insurance market.  The risk is that patients are conditioned to pay next to nothing for medical care so they might not pay the physician what he thinks he’s worth.  On the other hand the overhead in a “retainer” practice is substantially less so one might need a smaller panel of patients to make the same amount of money as one does with a Medicaid panel.  The government will try to get around this by outlawing private practice, invoking the usual language of entitlement and class envy.  On a related note, one of the reasons I do not want the government to pay for medical education (as some advocate) because then they can legitimately dictate terms as we will have sold our soul to the Devil. -PB)

  11. Hallelujah!

    After my experience with the “indigent” patients (e.g. those that don’t qualify for medicaid, but get free coverage as we are a teaching hospital as they “don’t have enough money to buy insurance”, but seem to have little problems affording the accouterments of life like iPods, booze and cigarettes) seeking pain meds on our ambulatory medicine service yesterday, I hope that there will still be private practice by the time I finish residency.

    But, right now, I wouldn’t bet on it.

  12. Hey Panda,

    Really enjoy reading your blog. A couple of things: 1-would you mind if I link to your website on my blog and 2-what do you think about the Happy Hospitalist’s stint with MonaVie? Does it reek of health food consumerism to you?

  13. Panda Bear, has awarded you their weekly scrubby award for your The Best-Laid Schemes… blog on March 17, 2008. With this award (which began as basically just a form of recognition) includes a free set of red, yes red scrubs:)

    There are no strings, no catches and we will not try to sell you anything. Simply, its our way of recognizing good (in our opinion) and interesting medical blogging. If you would like to receive these free scrubs, please contact me through this email by March 25, 2008. If not, we will give them to someone on the weekly honorable mention list.

  14. LAG,

    About MonaVie:

    I recently met a guy, online, who started suggesting I get involved with them. He sent me some bullshit videos to watch, and then offered to buy me dinner so we could talk. (Sweet.)

    So I go to the establishment he wants me to meet him at, and something’s not right: I get the creeps, actually. Eventually he mentions it’s owned and operated by the Landmark Forum, an updated offshoot of Werner Ehrhard’s EST cult. O.K., so now I’m watching this guy, and backing far away from MonaVie.

    But he keeps calling. if I won’t do MonaVie, maybe I’ll get into another kind of business deal with him. I’m black – how about acting as middle-man on a big pot deal? (I shit you not.) He’s Jewish – how about telling a lie that I’m Jewish (with him coaching me) to get a huge Hebrew Free Loan? Come on: He did it with a Hispanic guy!

    I finally told the guy to disappear. He doesn’t. He wants to be “friends”. Why? So he can meet my friends. Take them out to dinner,….

  15. Not sure how I stumbled across your blog or why I followed the link to “the macho response,” either, but I did. You say “The Emcee is nothing if not reasonable,” which may be so. Hard to tell, though, because he’s barely intelligible.

    (You need to read his blog with an open mind and also with an appreciation that the Crack Emcee is an artist and therefore his opinions are going to be presented in a unique way that you may not be able to understand at first. Keep reading. I have an engineering degree, a medical degree, and an extensive liberal education and I assure you that The Macho Response is a work of rare eloquence. You are a little put off by his justifiable rage but that’s just you. Since neither the Crack Emcee or I are running a cult nor are we fascists, you are allowed and encouraged to have your own opinions and to disagree with everything and anything you choose with our full support and encouragement. In fact, one of the problems with modern life is how we are all being turned into a bunch of conformist pussies so knock yourself out but at least have the decency to recognize a truly unique point of view. -PB)

  16. What are the chances that this huge debate about socialized medicine is only a single facet of a much larger problem?

    It’s the slow fading away of the American middle-class. What good are all the cutting edge advances in medicine of the past 20 years to the rest of us if the majority of Americans never made enough money to afford them in the first place?

    Can’t you see? Free trade and globalization means American jobs are moving overseas, while technology (automation, the internet) replaces human workers in everything from manufacturing to retail. The main people who benefit are of course the ones who own all the capital. Nearly everyone is hurting except the wealthiest 0.1% who only get more spectacularly wealthy by the day.

    Socialized medicine you say? It’s the American way of life that’s disappearing. Healthcare will need to be socialized, all so that the wealthiest 0.1% don’t need to worry about angry mobs rioting in the streets. Angry, b/c they are denied what from birth we were all taught we deserved – a decent standard of living.

    Point your finger at the masses all you want. Accuse them of being lazy. Lament the rise of big government. But IMO, there are larger forces at work here.

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