U.S. Healthcare: Money for Nothing?

I was intrigued by an article by a New York-based City Planner in the latest issue of Planning magazine (no link — subscribers only). He was on a bicycle trip to Cuba when his friend dropped dead of a heart attack. “The experience, while traumatic, would take me into places difficult for a foreigner to reach.” Although Cuba has a reputation for excellent medical care he found “a country that was shockingly primitive. The medical attention my friend received was rudimentary, in a facilities that were skeletal.” He was “shocked at the worn, run down hospital corridors and the appearance of staff simply standing around, doing nothing.” He had to move his friend’s body into the hospital himself. “Parts of the hospital were dirty. To cite one vivid example: Directly across from the examining room where doctors tried to revive my friend was an overflowing toilet with a broken sink; there was no place for visitors to wash their hands.”

And yet, according to the article, “Cuba’s life expectancy matches the U.S., according to United Nations statistics.” Hmmm.

There are two possibilities here. One is that Cuba’s statistics are fraudulent. Although as I noted when U.S. life expectancy was found to be falling for certain sub-groups of the population, vital statistics – like murder for crime statistics – are the social measures that are most difficult to fudge, easiest to count, and least likely to be wrong.

The second possibility is that the U.S. healthcare is, for the most part, a waste.

How could Cuba’s life expectancy match the U.S.? Well, there is what they have. “While the hospital facilities I saw there were worn, public health specialists I interviewed in the U.S. said Cuba excels at primary care, including things like clean water, vaccinations, and neonatal care” the article reported.

And what they don’t have. According to the article “by American standards the traffic here was light. But it was amazingly diverse, mixing horse drawn vehicles with cars, as well as bicyclists and people on foot.”

Bicyclists and people on foot! Without the affluence required to buy and fuel machines to do the work for them, Cubans have to use their bodies to get around. And probably to do other things as well. Americans do not.

That reminds me of a passage in a book “Reinventing Collapse,” a humorous analogy between the collapse of the Soviet Union and the possible collapse of the U.S. economy, and how to survive it. The author underestimates the adaptability of capitalism, and its ability to shift from collapse to mere diminished circumstances, such as those most Americans are experiencing. But he does have some interesting things to say.

“Economic progress creates a ratcheting effect, by which what are at first comforts and conveniences gradually become necessities” according to the author. “True necessities are those few items found at the base of Maslow’s necessity hierarchy: oxygen, water and food in that order. The order is determined by seeing how long someone can stay alive when deprived of any of these few: a few minutes for oxygen; a few days for water; a few weeks for food. These are followed by non-necessities such as shelter, companionship, opportunities for sexual release and meaningful activities, such as exercise, play or work.”

“Turning the comfort/necessity dichotomy around,” the author of Reinventing Collapse wrote, “beyond the first three (air, food, water), the only true necessity for survival is discomfort. Deprived of discomfort, our bodies turn into a tender, marshmellowy mess.” The kind of discomfort one gets from exercise, which gets the muscles sore but makes them and the bones stronger, or heat and cold, which the body can acclimate to.

Another thing Cubans don’t have, according to the Planning magazine article, is meat, particularly red meat. The lack of beef is something Cubans are more likely to complain about than the lack of democracy. “Cubans are fond of beef dishes like ropa vieja, but it is difficult to obtain because most of it goes to tourists in restaurants that Cubans can’t afford. To the extent that they have meat at all, Cuban’s eat pork and chicken.”

That is their situation. Life is hard there, and there are many things they are forced to do without, but at least Cubans are not a “marshmellowy mess.” But what about our situation?

Under the pre-Obamacare set of arrangements, no American has the right to basic, preventive, primary care. Most received it under one program or another, through private but publicly-subsidized insurance contracts, or otherwise, but this is not guaranteed, and does not always occur. So the basic, dirt -cheap health care that is needed to get most people through most of their lives in good health is considered by our society to be optional, or at least optional for other people. And there are those who are apparently willing to throw the federal government into bankruptcy, and set off a downward financial spiral, to keep things that way.

Upon reaching age 65, on the other hand, Americans gain a right to force other Americans (or future Americans) to pay for them to receive nearly unlimited health care at a nearly unlimited cost, even if vast sums must be spent in order to achieve a few short years of constant pain, disability or dependence. Multiple courses of chemotherapy are made available until the patient can’t stand them anymore, even as the chance of a cure goes down. So are multiple surgeries for the cardiovascular system. And artificial knees, hips and other appendages. None of which are available to those of working age who cannot afford them.

Given this difference in priorities, it is likely that the similar average life expectancy of the U.S and Cuba masks a significant difference in the distribution of health by age. With Cubans far more likely to make it to age 65, in part because they are not a “marshmellowy mess,” and in part because they have a right to excellent primary care. And the Americans who make it to age 65 living far longer once they get there.

Not that anyone under age 55 or under today can expect to receive the same benefits upon reaching age 65 that prior generations have had. Because prior generations have been unwilling to pay for what they insisted on having., and voted for those who promised to tax them less and given the more. When one political party, the Republicans, had control of the White House and Congress it pushed through a huge increase in Medicare spending for today’s seniors, and put it on the credit card while cutting taxes. That same party later objected to any restraint on soaring Medicare spending for today’s seniors.

But with the federal debt soaring, as what were private debts are shifted to the public sector to prevent an economic collapse, that same political party demands drastic cutbacks in the health care today’s middle aged and young people will be entitled to when they get old. Because, even though they are poorer on average, they have “time to adjust.” The adjustment? If the age of Medicare eligibility is increased for those now age 55 and younger, as Paul Ryan and the Republicans have proposed, more Americans will die of curable conditions before they become eligible. In fact I personally know of two people who had a multiple bypass operation right at age 65, after becoming eligible for Medicare.

What is the point of view of the Democrats on the cost of Medicare? They want to pretend there is no problem for another decade, until the entire 1960s generation is already in the program, borrowing as much money as possible to put off the day of reckoning. And then slash benefits for those coming after not because they want to or planned it that way (they will say), but due to “circumstances beyond our control.” That whole passionate clash over ideology in Washington? Theater, about shifting the blame of screwed younger generations for what Generation Greed has done.

What if the U.S. was to take the opposite approach? Imagine that the federal government were to simply pay for all the inexpensive primary and preventive care that the National Institute of Health recommended, so that everyone would receive that level of basic care regardless of ability to pay? Instead of having a thousand funding streams, with some of those who were paying taxes for others to have unlimited corrective care falling through the cracks and entitled to nothing?

Take flu shots for example. If your insurance won’t pay for it, you have to pay to get one. But when people get flu shots they not only protect themselves from the flu, but through “herd immunity” they protect others. In fact, public health measures were not something the rich generously provided to the poor 100 years ago. They were something the rich IMPOSED on the poor, if necessary, to protect themselves from disease, and ensure a productive workforce. So why isn’t it the case that the federal government gives away vaccines for free, and charges people to NOT be vaccinated?

And at the other end of life, what if instead of increasing the age of eligibility for Medicare (after grandfathering in Generation Greed), the government were instead to limit the amount of time one would be eligible for Medicare to 20 years, allowing people to enter the program when they chose at any point after age 45? And include today’s seniors in the limit.

Once eligibility ran out, people would be entitled to preventive care, palliative care and perhaps hospice care, but not to unlimited drugs, surgeries, and radiology. If you got cancer, heart disease or suffered a stroke at that point, it would be your time to go – at home, not in an expensive hospital. Those who got Medicare at 65 would be ineligible at 85, starting now. Those who started at 45 would only be eligible to receive Medicare (and Medicaid) to age 65. Etc.

I’ll bet that under that system the differences in U.S. life expectancy among rich and poor would be much narrower. Life expectancy might go up, because a higher share of people reaching age 65 of 70 would more than offset people who no longer have a year or two added after age 80. And spending might be somewhat lower. But we would have to admit that all of us will have to die sometime, even the most selfish and entitled Americans, even Generation Greed. So why is it that everyone seems willing to condemn younger generations to a more and more diminished future and even a shorter and shorter life, but no one would ever suggest something like this?

In the meantime, let’s get back to that “marshmellowy mess” issue. More and more research is in the press extolling the benefits of exercise, but no one is going to prescribe it unless someone with power makes money off it. And prescribing it doesn’t mean that anyone is going to do it. In fact my health insurance company (or, more fairly, the health insurance company chosen by my employer) is prepared to subsidize membership in a health club, for those who have time to go to health clubs. But they won’t provide any subsidy for the fact that I ride a bicycle nine miles each way to work three or four times a week.

Why not? Because, I’m told, they have the health club take attendance to make sure that people show up, as a requirement to receive the subsidy. Which makes me wonder – how does Citibike track how many miles people are riding? Could whatever device they are using be put on individual bicycles as well, so people could qualify for similar health insurance subsidies?

That might be a good plan. Because riding a bicycle fits perfectly with the situation younger generations find themselves in, here in the United States. They can’t afford one automobile per adult, which is what Generation Greed insisted on. They won’t be getting as much health care. They’ll have to work and pay taxes for those who came before and those who have more power, while doing for themselves what those who came before had lesser people do for them.

In fact, their situation is similar to that of Cubans after the Soviet Union could no longer prop them up with cheap oil. Americans can no longer prop up their lifestyle with more debt, and will be forced to pay back the debts run up by others. On that Republicans and Democrats agree. But at least, perhaps, they can use their own bodies to get around on their own power, and thus not become a “marshellowly mess.” Although with the risk that others might “exercise their rights as Americans” and run them over in their motor vehicles, as encouraged by the New York Post.

Stay in shape as long as you can, so you can keep working and paying for Generation Greed. And after that, all you’ll get is medical marijuana followed by legal assisted suicide. And that’s if the Democrats are in. The Republicans won’t even give you that. If younger generations are those who can be legitimately disadvantaged to benefit Generation Greed because they have “time to adjust,” at least older generations can stop lying to them so they can start making adjustments.