Medical Care: How about a Real Debate?

Some form of restraint in our choice of medical procedures is going to be necessary. The debate we should be having is over whether restraint in our use of medical services should be initiated by government officials or left to consumers. The Democrats want to avoid that debate. Instead, they make it sound as if they can make excess health-care spending disappear by magic. But even if we were to stipulate for the sake of argument that all of the supposed savings from preventive care, electronic medical records, and eliminating the waste and greed supposedly inflicted by insurance companies and doctors will actually materialize, the excessive use of medical procedures would still be the main problem with our health-care system...Both government rationing and consumer cost-sharing seem unpleasant. The debate between the two approaches would not be one-sided. But until Democrats are willing to stand up toe-to-toe and have that debate, we will not see any move toward cost-effective health-care reform....The Non-Debate over Non-Reform, Arnold Kling, National Review, 6/24/2009

With ABC's White House infomercial tonight, their news division's most craven programming choice in a long time, it' s useful to look at what serious critics of socialized medicine are saying.

Arnold Kling used to write for Tech Central Station, a remarkable site founded by James Glass. Glass departed for other pastures. Tech Central Station is struggling. And, Arnold Kling is appearing on National Review. What he has to offer in this article is the proverbial elephant in the living room.

Yes, it's all about demand. We want to be cured of all that ails us. That's fine. That's what medicine aims at. Unfortunately, we also want to be cured of all that upsets us – being overweight; aging; body parts too big or too small. A lot of private insurance covers that and it is fabulously expensive. We also, however, want to challenge mortality. And, that is not the job of medicine. What does that mean?

Challenging mortality does not mean living forever. It means putting it off until the maximum possible number of years, months, weeks, and yes, even hours, have passed. In practical, accounting terms, it means that we'll spend almost ninety percent of health care money on the last year or two of our lives.

William F. Buckley, Jr.'s son Christopher, with whom he had many and profound disagreements, is a gifted satirist. A few years back he wrote a book called Boomsday. In it, a young radical's cause was not socialized medicine, but a dramatic reform of how entitlements are given to the old and paid for by the young. In the course of working with a public relations firm, she convinces a Senator to introduce legislation with a truly startling objective: those 65 and older, if they agree to commit suicide, will be able to pass on their estates without taxes. The bill is introduced, not with the hopes that it will actually pass, but to start a serious national discussion about the pending disaster in Social Security and Medicare. Naturally, this being a Chris Buckley story, the bill becomes the principal issue in a Presidential campaign. In the course of increasingly frantic efforts in Congress to pass some form of the bill, lobbyists pour down on Capitol Hill. By the time the bill approaches actual passage, with the sitting President an eager supporter, the age of Boomer suicide has been moved upwards to 85, making the bill not so much contemptuous of human life and Western values as utterly meaningless. That's politics. By its very nature, it can't address this issue. Why?

None of us wants to die. In a post-religious society – like it or not, that describes an emerging majority – the here and now is all there is. Nobody wants to give the bright now up for a black, insensate eternity; nobody wants to take it away from anyone else. And, so we routinely expect insurance and Medicare to pick up the million dollar cost of extending an old woman's life for six months. And we do this a million times. Not in France.

The writer is not advocating here, only discussing, something you are unlikely to hear on the ABC infomercial tonight.

In France, they have a remarkably successful single payer system, with a high quality of care delivered at costs somewhat less than in the United States. Doctors are not government employees. However, no procedure can be done for a fee greater than that set by the single insurance company (the French government). Efficiency and greater income come about by doctors performing more procedures at a fixed cost, not by charging more money based on their reputation or on their public relations. Sounds great, so why not here?

The French system depends to a remarkable degree on a form of cost control that Americans won't even discuss. Here's how it works.

If you need coronary bypass surgery (or major cancer therapy) or any of a number of other major operations or treatments, and you're over 65, you can't get them in France. The working assumption, as cold as dry ice, is that if you're retired and no longer producing goods and services, you have to depend on luck, genetics, and medical tourism, mostly to the United States, if you want to get past a major illness. Do they enforce it?

With a cruelty that is horrifying – remember 2005? In that year of Muslim youth setting fire to thousands of cars across France, the summer was an especially hot one. At its height, in July 2005, reports began to trickle out about a ghastly tragedy. Tens of thousands of aged French citizens in nursing homes were dying of effects from the heat. Why? The state-owned nursing homes did not have air conditioning. By the end of the heat wave, between fifty and one hundred thousand old folks in France had died. During this time, despite appeals from the press, the children of these old people, many of whom had fought in the Resistance, did not leave their vacation spas on the Mediterranean, neither to rescue their parents and grandparents nor to even claim the bodies of the dead. As an indication of a society that has decided that if you're old, you're useless and expendable, these abandoned old people, left to die, were a sickening paradigm. But far more die in France lacking procedures we consider routine for the old in the United States.

In the United States, the almost vertical growth rate of Medicare and Medicaid expenses, which will bankrupt the next generation or three, and have already bankrupted New York State and California, are a clear indication that we don't accept the French notion of what it means to be old and retired. There's nothing wrong with that moral assessment. After all, it still means something to us that the person we'd be abandoning with such a radical accounting practice would be our own mothers, fathers, and grandparents and, ultimately, ourselves as we reach that age. We don't accept that because it is fundamentally, and brutally, callous. However, the discussion is not complete, because we can't afford to continue this way.

Why wasn't this such a common problem in the past? It's very simple. In the past, as people aged, most were prepared by the practices and beliefs of faith, and by common sense and ordinary observation, to acknowledge that as one aged, nature's way and God's way of telling us it was time for the next generation was for us to become feeble, grow sick, and die. We were going to a better place, according to our faith. Even if we didn't believe, we knew that that unvarying process would break us down, and that our best hopes lay in the generation coming up. In both terms of faith, and those of materialism, that was a profoundly healthy understanding of aging, illness and death. After all, even with today's remarkable technologies, in chemistry, prosthetics, machines, and surgery, the end will come. The old folks were right after all. But we don't believe that. We act as if the expenditure of yet another hundred thousand, or another million, will put off that day.

That's the way people who refuse both faith and evidence act. But there's a difference between hope and hallucination. Ask any drug user. If Grandma is 89 and suffering from the dozens of systemic breakdowns that happen to anyone that age, a million dollars that might have kept a dozen children from an early death, or from stunted, abbreviated lives might provide Grandma with sixty days of semi-conscious life. But, we won't decide.

That's why the choice falls on two forms of rationing: price; and government edict. With the latter, everyone has to stand in line and money doesn't matter. As in France, the government can issue a decree that certain, expensive procedures or medications won't be given to certain classes of people. With the former, the major effect is that the inheritance of one generation is given to only one segment of the economy. Both are inherently material means of rationing. Both avoid the most serious ethical choices. Both are a product of our hallucinations about immortality, or at least outliving everybody else.

Is it better to preserve a dozen young lives, or to give a few extra months to the old?

Is it best to preserve individual choices on what is worth doing and what is not, or to let government set every standard?

Are we so foolish as to assume we can attain a practical immortality, or are we willing to accept a judgment of both nature and God that we have only a limited time before we must let the next generation come into its time and place?

If Americans won't make those choices, insurance companies and the United States government will make them for us.

Luther