All that money hasn’t done much to cure Alzheimer’s. On the other hand, says Pipes, between 1950 and 2000 the death rate for heart disease, America’s number one cause of mortality (not counting forgetting your wedding anniversary, which I blame on Alzheimer’s), was reduced by 59 percent. And America’s rate of infant mortality has gone from twenty-nine per one thousand live births in 1950 to fewer than seven.
Yes, yes, but other countries have done better while spending less, say health care reformers. There are almost thirty other countries where life expectancy is longer than it is in the United States.
Other countries are not the United States, Pipes points out. America’s homicide rate was 5.9 per 100,000 people in 2004. Canada’s was 1.95. Germany’s was.98. America had 14.25 traffic fatalities per 100,000 people in 2006. Canada had 9.25. And France had 7.4 because the French sit around in cafés all day and don’t go anywhere except in August when French traffic is too jammed to kill anyone in. Maybe life just seems longer in other countries.
Although you may live to a greater age overseas, don’t get cancer while you’re doing it. Pipes gives the following figures. The survival rate, five years after diagnosis of breast cancer, is 83.9 percent in the United States and 69.7 percent in Britain. Americans are 35 percent more likely to survive colon cancer than the British. And the prostate cancer survival rate is 91.9 percent in the United States, 73.7 percent in France, and 51.1 percent in the UK.
About a dozen countries have a live birth mortality rate lower than America’s. But don’t fly there to be born if you’re not feeling well. America has sophisticated neonatal facilities that help preemies survive. This doesn’t make America look better statistically. Those premature babies are still at high risk, and if they die they get counted as having died instead of being stillborn. The United States adheres to the World Health Organization’s definition of live birth, wherein the baby “breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.” In Switzerland, says Pipes, “an infant must be at least 30 centimeters long at birth to be counted as living.” In France, a live birth is not counted as such unless there is a “medical certificate stating that the child was born alive and”—here’s the catch—”viable.” In France and Belgium, “babies born at less than 26 weeks are automatically registered as dead.”
America’s health care spending may be excessive but one of the things we’ve bought with that excess is progress. The Cato Institute published a paper33 by Glen Whitman and Raymond Raad (an economist and a physician, respectively) about America’s role in making everybody—even foreigners—healthier. Among the figures cited were the number of Nobel Prizes for medicine and physiology (more rigorously vetted, I understand, than Nobel Prizes for peace). Between 1969 and 2008 Americans were awarded fifty-seven Nobels, seventeen more than were received by residents of the EU, Switzerland, Japan, Canada, and Australia combined. The U.S. National Institutes of Health has an annual budget of over $30 billion. Its counterparts in Europe receive a total of between $3 billion and $4 billion.
Whitman and Raad also drew up a list of the twenty-seven most important innovations in medical diagonostics and therapeutics since 1975, drawing on 2001 research published in Health Affairs and updated with a survey of 225 primary care doctors. American scientists and physicians had a significant role in twenty of the inventions or advancements of technique including nine of the top-rated ten. Scientists and physicians from the EU and Switzerland made important contributions to fourteen innovations and only five of the top ten, despite western Europe being as wealthy as the United States and having almost 200 million more people. (The Netherlands leads the way in treating bong injuries.)
Health care in America is expensive not only because we’re brilliant and hardworking, we’re also old and fat. Sally Pipes reminds us that two-thirds of Americans are overweight, one-third of us are obese, one out of eight of us is over sixty-five, and by 2030, when the baby boom is fully installed in Nike brand walkers (slogan: “Just Do It—In Depends”) the number will be one out of five.
An August 20, 2009, New York Times Web site article34 about dying hospital patients stated—with a hint of healthy, young outrage that I’m not sure the New York Times is entitled to—that “a third of Medicare spending goes to patients with chronic illness in their last two years of life.” Of course it does, that’s when they’re sick.
And, until we get sick, we’re packing on the pounds. According to the Centers for Disease Control, weight-related medical bills accounted for $147 billion in health care spending in 2008. One hundred forty-seven billion is about half of what Medicare costs per year. My suggestion for health care reform is that we skip lunch and quit picking on sick people.
This was not President Obama’s suggestion. President Obama suggested we find somebody to pick on that we hate even more than we hate sick people. With the clear-sighted political instincts for which the president is known, he suggested we pick on health insurance companies.
Everyone hates health insurance companies. Health insurance companies are always trying to get us to bet that something terrible will happen to us. And it’s not like they’re very good about paying up when they lose. “Your heart? Preexisting condition! Preexisting condition! You were born with a heart.”
The president’s idea was that the government get into the health insurance business to compete with private sector health insurance companies. The government would be just another competitor, like any other health insurance company. The only difference is that this competitor, being the government, has the legal monopoly on deadly force. This competitor has guns. What’s another competitor, just like any other competitor, except it has guns? Suddenly, over at Blue Cross, it was like being the last legit trash hauler in New Jersey.
To put it another way, private sector health insurance companies are on the ducking stool. And President Obama has a scummy pool of numbers to dip them in. Forty-six million Americans, including nearly 8 million children, have no health insurance—figures that appeared in 2008 on the official Barack Obama Web site.35 That’s 15 percent of the population. But, if you enjoy hating health insurance companies this is not a statistic you should look at too carefully the way Sally Pipes did in Top Ten Myths: “Myth Three: Forty-six Million Americans Can’t Get Health Care.” It seems that almost 10 million of the uninsured make more than $75,000 a year,36 and 18 million make more than $50,000. These people should be able to buy some kind of health insurance or pay for their own medical treatment unless something extra terrible happens to them. The more so since these 28 million Americans tend to be young—nineteen- to twenty-nine-year-olds are one of the largest and fastest-growing segments of the uninsured population.37 Another 10 million uninsured Americans turn out not to be Americans. That is, they aren’t U.S. citizens.38 Personally, I think when they get sick they should get as well as anyone else. But, technically, they’re uninsured Canadians or uninsured Brazilians or uninsured chainsmoking Czech grad school habitués overstaying their student visas or whatever. Furthermore as many as 14 million uninsured Americans aren’t uninsured. They qualify for the social insurance available under Medicare, Medicaid, and/or State Children’s Health Insurance Program (SCHIP), but they have not been enrolled.39 Among these are a full 70 percent of uninsured children.40
Let’s see, 10 million plus 18 million plus 10 million plus 14 million equals... Surely the official Barack Obama Web site could have produced even louder calls for hope and change if it had claimed “52 million Americans have no health insurance.”
And there are those among that 52 million who do need help with their medical bills, people who make a decent wage but have chronic or degenerative conditions, who need expensive prescription drugs, who have sick children. And there’s me. Only two years remain before I can drink (medicinally) from the Medicare tap, but what if, in the meantime, an unknown admirer were to send me a box of genuine Havana Montecristo no.
3s, putting me off my Nicorettes, and my health insurance company finds out?
There’s something unhealthy, anyway, about framing a medical debate in terms of insurance. If your house catches fire do you call Allstate or the fire department? We’ll figure out how to pay for the health care if we live. If we don’t, fuck it.
The purpose of insurance is not to cure all that ails us but simply to prevent the plot of The Merchant of Venice. Antonio’s covered by AIG and isn’t worried about being short on cash to lend to Bassanio for wooing Portia. Tony can do a derivative swap and rake in the ducats. Shylock stays home watching interest rate fluctuations on the Bloomberg Business Canal. His daughter Jessica never gets a chance to go meshugana over Lorenzo (a schmuck, I’m telling you) and run off and charge a fortune on dad’s Venetian Express card. And nobody’s forced to become a mackerel snapper in Act 5. (True, Shylock never delivers his “If you prick us, do we not bleed?” solilioquy, which put an end to anti-Semitism in Europe for the next four hundred years. But everything comes with a price.)
Making everyone get health insurance has been tried in the United States, in Massachusetts, under the aegis of Republican governor Mitt Romney. As of July 1, 2007, everybody in the state had to either enroll in a state or federal program, if eligible, or buy a private insurance policy with no limit on annual benefits and a yearly maximum deductible of $5,000 per individual and $10,000 per family.
Massachusetts provides subsidies for private insurance policies purchased by families with incomes up to 300 percent of the poverty level. All employers with ten or more employees must provide health insurance for their workers or be assessed $295 per year per worker. And an individual who fails to get health insurance is charged $912 a year by the state. Carrots are available, in a stir-fry of small sticks.
Michael Tanner, a senior fellow at the Cato Institute, wrote a report41 on what could be called the clinical test trial of universal insurance with Massachusetts as the clinic. Tanner concluded that it’s all worked pretty much as expected—if you expect government programs to work the way I expect them to. The insurance subsidies were intended to cost state taxpayers $725 million a year. They cost more, as things that cost taxpayers usually do. By mid-2008 Massachusetts was estimating that the health insurance subsidies would cost $869 million in 2009 and $880 million in 2010. Income from assessments and penalties was supposed to be $45 million in 2007 and $36 million in 2008. There was no income from assessments and penalties in 2007 and $7 million in 2008. At the time of Tanner’s report, the price of Massachusetts health care reform in 2009 was projected to be $225 million more than had been anticipated. State spending on all health care programs had risen by 42 percent since 2006. And health care reform was calculated to account for about a third of the $1.3 billion 2008 state deficit.
The percentage of people without health insurance in Massachusetts did decline by 74 percent from 2006 to 2009. But somehow 167,000 state residents were still left without health insurance. And this is a state with only six and a half million people, where those six and a half million have a greater per capita disposable income than the people of any other state except Connecticut, New Jersey, and Wyoming.42
Meanwhile guess what Michael Tanner said about health insurance premiums in Massachusetts? Or, if you prefer to get your information from a source less biased toward free enterprise than the Cato Institute, here is a headline and subhead from the August 22, 2009, Boston Globe: “Bay State Premiums Highest in Country: Rein in healthcare costs, Massachusetts urged.”
I couldn’t have gotten into a medical school. I couldn’t have gotten into a veterinary school for goldfish. (“Flush twice and call me in the morning.”) At the college where I went all they taught about health care was how to nurse a hangover. But I do know something about going to hospitals and about other people who go to hospitals and about the percentage of us people who go to hospitals needing medical treatment who get it, which, in America, would be 100.
If you’re sick or injured and you come to an emergency room, they have to take you in. It’s the law. That this doesn’t cost “health care providers” a fortune is not a law. Much of what happens in the American health care industry would—in any other business—be called shoplifting. Even in utopian Massachusetts, where the number of people without health insurance dropped by 74 percent, the number of people who received un-reimbursed care from the state’s hospitals dropped by only 36 percent.43
I also know something about politics. The Affordable Health Care for Americans Act, passed by the House of Representatives on November 7, 2009, was 1,990 pages long. You could stand on it to paint the ceiling. The entire U.S. Constitution can be printed on eight pages. That’s eight pages to run a whole country for 221 years versus four reams of government pig latin if you slam your thumb in a car door.
No congressman had read this bill (even assuming they all can read). And the busy president of the United States could hardly have had time to do so. Not that this matters. Health care reform is the Sports Illustrated Swimsuit Issue of politics. Beautiful, enticing, generously endowed legislation like this is not for reading. How it looks is what matters. From the neck up it can be as empty as you like.
There’s only one thing about a government proposal of this complexity that we can be sure of: it won’t work. No government proposal more complex than “This note is legal tender for all debts, public and private” ever works, and that one hasn’t been working lately.
Also, doesn’t anybody in Congress remember that Hillary Clinton has already been there with health care reform, seventeen years ago? A lot of people say that Hillary’s health care reform plan almost destroyed Bill Clinton’s first term. It certainly diminished Hillary’s influence in the White House. Bill had to seek help from a different woman to almost destroy his second term.
There’s a simpler way to make health care cheaper. Just make it worse. And politics can do that. Government-controlled health care will drive the best people out of the business. Who wants to spend all those years studying to be a doctor just to end up as a petty bureaucrat?
Someday we’ll be wheeled in for a heart bypass operation and the surgeon will be the same person who’s now behind the counter when we renew our registration at the Department of Motor Vehicles.
If we’re not careful we’ll get a health care system like they’ve got in Canada, a nation that’s going broke from health care spending, even though Canada is a sparsely populated country with a shortage of gunshot wounds, crack addicts, and huge tort judgments. Anyway, what are Americans supposed to learn from a health care system devoted to removing pucks from goalie bridgework and treating sinus infections caused by trying to pronounce French vowels?
What we’ll learn is to fix prices. Because that’s all that political health care reform is—price fixing. Price fixing works so well in Cuba and North Korea. And in New York City rent-controlled apartments. Everybody knows how easy it is to find an inexpensive apartment in a nice neighborhood in New York.
And, by the way, why is price-fixing a public service when the government does it and a great big crime when Wall Street CEOs get together on a golf course?
Personally, I do smoke44 and drink and my idea of exercise is getting up at 3 a.m. to go to the bathroom. I’m self-employed and I have to buy my own health insurance. I hardly need say that it comes with a high deductible and doesn’t exactly cover everything. In fact, when my wife became pregnant, thirteen years ago, I discovered that my health insurance did not cover “normal pregnancy.” In fairness, a pregnancy isn’t an illness or an injury, and there’s no such thing as it being an accident if you’re Catholic.
We went to the hospital. My wife endured labor pains and the even bigger pain of having me there, uselessly hysterical. She gave birth to a beautiful baby girl, Muffin.
Mother and daughter were going fine. They were ready to be discharged. I went to the hospital’s business administration office and said, “How much do I owe you?”
The woman a
t the desk stared at me, dumbfounded. She said, “Please complete all requisite insurance forms.”
I said, “There’s no insurance involved. Do you take credit cards, or would you like a check?”
She stared at me, dumbfounded.
I said, “Or, if you wait a moment, I can go to the bank and get cash.”
Finally she said, “I have to get my supervisor.”
The supervisor came out—and stared at me, dumbfounded. The supervisor had no idea how to handle this situation. From all appearances no one had ever before attempted to actually personally pay anybody for health care.
5
Climate Change
There’s not a goddamn thing you can do about it. Maybe climate change is a threat, and maybe climate change has been tarted up by climatologists trolling for research grant cash. It doesn’t matter. There are 1.3 billion people in China, and they all want a Buick. Actually, if you go more than a mile or two outside China’s big cities, the wants are more basic. People want a hot plate and a piece of methane-emitting cow to cook on it. They want a carbon-belching moped, and some CO2-disgorging heat in their houses in the winter. And air-conditioning wouldn’t be considered an imposition, if you’ve ever been to China in the summer.
Now, I want you to dress yourself in sturdy clothing and arm yourself however you like—a stiff shot of gin would be my recommendation—and I want you to go tell 1.3 billion Chinese they can never have a Buick.
Then, assuming the Sierra Club helicopter has rescued you in time, I want you to go tell a billion people in India the same thing.