THOUGHTS ON HEALTH REFORM

AND THE "PROGRESSIVE" MOVEMENT

(reworked on 23 Oct and 22 and 27 Dec 2009) 

Recently, on a list I belong to, a good friend of mine, very intelligent, very well educated, replied to a third member.  It would be inappropriate to quote without identifying the writer and asking permission, and anyway I replied on-list (as did numerous others, as it  turned out).  But that point of view is widely held and deserves examining, so I'm addressing it here.  For simplicity's sake and respect for privacy, I'll call the writer Leslie, a gender neutral name for additional privacy. 

So, here's Leslie...

…Individuals used to accept responsibility for their own health, by taking care of themselves or selecting what health care they need and can afford.  Then we got the combination of health insurance plus the government (Medicare, Medicaid, and regulations as to what health insurance must cover), and most people abdicated their responsibility and let either the government or the insurance company take care of them.

 If we do not put the responsibility back on each individual, but instead go to a complete government system, as in Canada and most of Europe, we will have something that performs as poorly as theirs do.

Leslie began with some assumptions, stating them as truth.  Which some of it seems to be, and some of it doesn't; at any rate it's worth a closer look.  For one thing, Leslie has simplified it all to hell, ignoring the underlying system.

"What in hell does that mean, you BS-ing  socialist sonofabitch?" you might ask.   (Leslie wouldn't, but you might.)  Hang with me; I'm coming to that.

Part of what Leslie wrote, I go along with: the penultimate responsibility belongs to the individual living his or her life. (The penultimate, the next-to-basic.  Where the ultimate, the basic responsibility belongs I can hardly guess –– to "God" maybe? –– but penultimate will do for now.)

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The overall system is far more complex than Leslie stated.  To deny that is a widely used dodge that gets in the way of intelligent discussion or decision.  It's comparable to holding (as some true believers seem to do) that most of biology is redundant, that the only meaningful part is molecular biology, the most basic level.   But if that true believer has an accident that breaks his back — then ask him what's important.  He's not going to say the Krebs Cycle, essential though it is to life.  The biochemical Krebs Cycle is, in  brief:

Two carbon atoms arehttp://en.wikipedia.org/wiki/Oxidation oxidized to CO_2,  the energy from these reactions being transferred to other metabolic processes by GTP (or ATP),  and as electrons in NADH http://en.wikipedia.org/wiki/NADH and QH₂.  The NADH generated in the TCA cycle may later donate its electrons in oxidative phosphorylation http://en.wikipedia.org/wiki/Oxidative_phosphorylationto drive ATP synthesis; FADH₂ is covalently attached to succinate dehydrogenase,http://en.wikipedia.org/wiki/Succinate_dehydrogenase an enzyme functioning both in the TCA cycle and the mitochondrial electron transport chain in oxidative phosphorylation… (Wikipedia) and so on, just to give you a notion.

Don't ask me to explain it.  It's a piece of biochemical lore you kind of get used to, something that helps make sense of a lot of other things.  It does!  Honest to gosh!  And there's a whole physiological matrix that lays it out.  After 50 years I don't remember it beyond the most general features.  Enough to check it out with friend Wikipedia, via friend Google, who jointly helped me revisit it.  Shades of 1957, when I took the course!

In fact, all of molecular biochemistry is important, but higher levels of system integration — circulation of the blood for example — demand our attention from time to time, you bet. 

And what do I mean by "system integration?"  Look at it this way:  Circulation of the blood doesn't exist at the molecular level.  It doesn't!  It exists some levels of integration higher, and you'd better know those levels if you're trying to deal with them.  All of these and many many others play roles, all integrating, each with its own functions, importances, etc.

Beyond which, individual volition plays an important role in the overall system.

The "Higher" Levels of Integration

in Government and Culture

Now I'll jump from biology to social phenomena. Consider war for example: War involves and integrates the activities of many individual human beings, each with its own perceptions, intentions, experiences, values, beliefs, fears, loves, appetites, loyalties, hatreds, expectations.  And genomes.  And  memories…  Participating reluctantly or eagerly, skillfully or clumsily… Knowing their individual genomes is very far from enough to explain their behaviors, responses, skills… Then factor in the weather, the state of the roads, state of nutrition, condition of uniforms (especially boots); equipment, morale… Family, ethnicity, culture, religion… Statistics, as a tool in understanding, is a murky, muddy lens, but it can be useful.  And don't neglect informed intuition.

But be ready to be surprised.

One approach to analysis, practical but by no means reliable, is to divide a problem into smaller, defined pieces that you do  somewhat understand.  For example, those folks over there are Arab Sunni Muslims, and tend to react in certain ways in certain situations.  While those are Israelis, with their own responses, and those others are Christians of Protestant persuasions...

Anything you say about it will be approximate, inaccurate, and quite possibly somewhat misleading.  Although "full speed ahead and damn the torpedoes" may be necessary.

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Nowadays, government and social conflicts are big issues in the news, and the basic realities behind them are poorly understood.  The processes are diffuse, interwoven through too many levels of integration.  But basically it seems to me that for better or worse, we're trying to round the bend into an era in which we, collectively, are "our brothers' (and sisters') keepers" — within not yet defined limits.  And we don't yet know how to do that, or how far to take it. Especially without painful effects on other aspects of life.  It's always our first time in that particular situation. 

The "Higher" Levels of Integration

in Government and Culture

Now I'll jump from biology to social phenomena. Consider war for example: War involves and integrates the activities of many individual human beings, each with its own perceptions, intentions, experiences, values, beliefs, fears, loves, appetites, loyalties, hatreds, expectations.  Genomes.  Memories…  Participating reluctantly or eagerly, skillfully or clumsily… Knowing their individual genomes is far far from enough to explain their behaviors, responses, skills… Then factor in the weather, the state of the roads, state of nutrition, condition of  uniforms especially boots; equipment, morale… Family, ethnicity, culture, religion… And statistics, as a tool in understanding, is a murky, muddy mirror, though it can be useful, along with intuition with its various roots.

That's the nature of the universe and our world.

One approach to analysis, practical but by no means reliable, is to divide a problem into smaller, defined pieces that we do somewhat understand.  For example, those folks are arab sunni muslims, and tend to react in certain ways in certain situations, while those others are Israelis, and those are christians of protestant persuasions.

Government and social conflict are big issues today in the news and in life, and our knowledge of the basic realities behind them are poorly understood.  The processes are too diffuse, spread over too many levels of integration.  But basically it seems to me we're trying to round the bend into a era in which we are "our brothers' (and sisters') keeper" — within not yet defined limits.  And we don't know  how to do that.  Especially without painful effects on other aspects of life.  It's our first time, and we're groping our way into  it.  We have lots of opinions, assumptions and theories, but limited actual experience.  

And what do I mean by "system integration?"  Circulation of  the blood doesn't exist at the molecular lever.  It exists only at a number of levels of integration higher, and it's well to know somewhat of those levels, if you're trying to deal with them.

 The "Higher" Levels of Integration

in Government and Culture

Now I'll jump from biology to social phenomena.

Government and social conflict are big issues today in the news and in life, and our knowledge of the basic realities behind them are poorly understood.  The processes are too diffuse, spread over too many levels of integration.  But basically it seems to me we're trying to round the bend into a era in which we are "our brothers' (and sister's') keeper" — within not yet defined limits.  And we don't know  how to do that.  Especially without painful effects on other aspects of life.  It's our first time, and we're groping our way into  it.  We have lots of opinions, assumptions and theories, but limited actual experience.  

Societies have worked on top-down social reform in the past.  The Brits tried it in very different circumstances in the mid-1600s, and ended up with a regicidal, genocidal (to Irish Catholics) English religious dictatorship that lasted less than a generation.  It went dead in the water, and the Brits reinstalled the royal family.  But meanwhile, in Britain, kings were no longer what they had been, so overall even an utterly failed solution led to improvement.  A century later we had our own revolution, and soon after that the French had theirs, bloodier and more thorough, and the rebound was bloodier still. 

Later, in the early 1900s, the Russians had a really ham-handed revolution (arguably the only kind possible there at the time) that turned out to be a horror. 

 Lots of lessons there.  But the European experience was different than ours; their revolutions established despotisms.  Though eventually they outgrew them. 

 We Americans have never had a big-time dictator.  On our closest approach, we were lucky to  have Abe Lincoln at the helm.  In fact, except for African Americans and American Indians, Americans have not experienced the level of civil oppression European nations experienced along the route.

Our own Civil War was seriously bloody, but the lessons were somewhat different — more undefined and ongoing.  We're still learning them.  If I were to sum up those lessons to date, it would amount to increased emphasis on education: inculcating the life lessons learned over a century and a half, in schools, in homes and neighborhoods, and in government.  Learning sometimes the hard way.  Always too slowly, and always too fast! — for one faction or another.

I'm not telling you anything you don't already know, just reminding you.

The more successful European health systems (and the Canadian) already have government control, in one form or other, and are coping with the unintended side effects, learning and benefiting as they go.  Evolving.  (Can you tell me please why people imagine/insist we have to "get it right" the first time,  for crying out loud?  The best we know how maybe, or the best we can afford, or the best we can get those idiots across the aisle to allow — but get it right?  The first time? 

 Well, maybe — if "right" means simply a stride forward.  

A Case Study of Government in Health Care

"Our brothers' keeper."  The word our can be taken to mean our individually or our collectively.  Here I use it in the collective sense, as in government, or corporations, or co-ops for that matter.  In the individual sense it's been generally accepted for a long time, but it is not altogether new in the collective sense either.  Nor just in the military.  For example:  

 In August 1948, the 500-foot-long bulk carrier Ball Brothers tied up at a wheat dock at Duluth, Minnesota to take on cargo.  (Some other old-timer may say, "Hey, wait an ever-lovin' minute.  The Ball Brothers didn't haul grain.  She was a self-unloader in the limestone and coal trade.  Different breed of cat."  At some point, probably in the 1960s or 70s,  she was converted to a self-unloader.  Before that, her down-bound cargoes were iron ore and grain.)

 So on that sunny August morning in Duluth, thousands of tons of grain began pouring out of the giant grain elevators through what look like big steel culverts, plummeting into the ship's cargo holds, and sending up great clouds of dust and chaff.  I was on watch in the stoke hold, the boiler room, oblivious to what was going on above deck, when suddenly a thick dust cloud billowed out of our ventilator, filling the stoke hold and triggering my asthma big-time.  I finished the watch on my feet, gasping and coughing, but still able to heave coal and clean fires.  So, I thought, I just need to tough it out, and when the ship left, I remained aboard.

Hah!  It got worse, not  better.  That evening I couldn't stand watch, and didn't dare lie down, because when prone I couldn't breathe at all.  So I reclined propped up against my sea bag.  Coughing became almost continuous.  My belly muscles were sore as boils, and I was physically exhausted; unrelenting coughing is hard work.  Later that evening Captain Hansen visited the fireman's quarters to see how I was doing.  (It may quite possibly have been his first time ever in the firemens quarters.)  By that time I was really in a bad way, and when loaded it was a 40-hour trip across Lake Superior from west to east.  At the lock at Sault Ste Marie, Michigan, an ambulance was waiting for me, with oxygen and a hypodermic of adrenalin.  Captain Hansen, there to see me loaded into the ambulance, told me "boy I am glad you made it.  For a vhile dere ve didn't t'ink you vould." 

 I'd been too out of it to wonder.

I was five days in the merchant seaman's ward in the Chippewa County Hospital, recovering sufficiently to ride the Greyhound home.   It was three weeks before I could work again, six weeks before I could sleep lying down.

So what's the point of recounting this, 61 years later?  A long overdue poor poor thing party?   No, it's because in that "stalwart era" of "virtuous individual responsibility" (mark this, Leslie), I was not billed for any of it –– not for the ambulance, not for the hospital, not for the doctor — and I suspect the paperwork was minimal.  Certainly I never saw any; nor was I questioned other than medically.  Nor asked to sign anything.  And...there were no layers of overlapping insurance claims and decisions.  Because in 1871 — that's 1871, Leslie — Congress had authorized federally funded hospital wards — even whole hospitals! — for sick or injured merchant seamen. 

Yes, 1871, nearly 140 years ago. The system was established in response to (what else?) scandals during and after the American Civil War.  

 Now of course there is Medicare, for which I'm profoundly grateful, flawed though it is through being integrated with assorted insurance companies. 

 People will always do dumb stuff –– and people will also always be subject to getting blind-sided by life.  And most of us fear death and suffering.  Even having largely or entirely transited the 6th internal monad — call it the realization of terminal illness monad — I am no fan of suffering.  But at 83, and slowly declining with emphysema, the odds are good that five years from now, I'll have succumbed to pneumonia or the flu because of emphysema.  Meanwhile I keep percolating along at my keyboard with an oxygen feed in my nose, happier than a lot of good folks.

I agree that any decent handling of the health care situation will require getting people to behave more rationally with regard to their own health, and to our health collectively.  In other words to a rational view of — what else?— life (and death) in the real world.  But that's for a later write-up.  It's not likely to be a quick fix.  And at any rate, society in general is increasingly aware that there is a collective health care problem, and that everyone's life and well-being is at risk, either directly or at second hand.  So there will be legislation, probably soon.  And whatever it is, it will prove flawed.  And therefore be tinkered with, rethought and revised, over and over — if for no further reason than that an ever-changing world requires it. 

 As for Leslie's claim (and maybe yours) that "a complete government system," such as Canada's or Sweden's, performs more poorly than ours –– that is blatantly untrue.  (There!  I didn't say "bullshit!"  Oh I'm so good!)   ;-D   I've been widely acquainted with Canadians and Swedes, from being much involved in Canada/USA youth hockey activities (1970-1995, first with my son, then my grandsons),.  And with Canadian science fiction conventions from Winnipeg to Victoria.  And I have yet to hear a Canadian extol our "system" over theirs. And believe me, the subject came up often.  Usually it was they who brought it up; they considered ours barbaric, and were puzzled at our obstinate resistance to reform.  My familiarity with the Swedish system comes from long closeness with Swedes and Sweden, including hosting visitors, grad students and post-docs, considerable fraternal correspondence, and four weeks in Scandinavia.  The Swedes had the same opinion as the Canadians, the same puzzlement, though they tended to put it more diplomatically.  Canadians tend to be quite good at calling a duck a duck (quack quack quack!).

 And that's all for now.  In case you're interested, I've addressed other aspects of health care elsewhere on my site, with references, and this probably will not be my last visit to the subject.  

 

 

 

John Dalmas