Paying The Bills

                                                                                

Percentage of United States budget for Health Care:ⁱ

Other health care costs:

Total cost of your health care:

I'm not a sophisticated economist. No. Change that. I'm not an economist. But my mind wandered a little this morning and I started wondering about health care costs. The presidential election's over now, and with it the rhetoric that usually clouds such issues with the complicated overlays of emotion and politics that make any real understanding difficult at best.

So I have the luxury of considering [selected] numbers without having to factor in such distractions [from the numbers] as guilt, responsibility, and the purpose of society. It's even easier since I've decided not to look up the numbers right now. I'll do that presently – after I've given some thought to the nature of the problem. Only then, when we both have a little more information, can we try to quantify it. I may be surprised and find out that no problem exists, but in the meantime I can give some thought to the way we manage money in our current society.

So let me get to some basic considerations, and they're really considerations of human nature. Because I spent most of my life in medicine (no, not taking, it but working as a physician) I'm focusing on health care. I noticed early on – in fact I noticed as a college student before I became a doctor – that there was a paradox in the cost of scientific glassware. It was both unconscionably expensive, and it was free. It was “free” because someone else was paying for it – usually the government or a granting foundation – but the price was inordinately high because the vendors knew that the people ordering it weren't paying for it themselves. And very often they didn't even need it. I also learned that there was a basic rule that you always spend all of the money given you, or you may get less the following year.

That's the way money management works. An individual may be very careful with his own budget, but will freely disburse what he doesn't see as his own. And he'll spare no effort to increase his intake – as income for himself or as money he can give away or spend on others. There's always an organization or some sucker with deep pockets who can be convinced to pick up the slack.

But that philosophy is one that involves not only people: governmentsⁱⁱ have little hesitation about spending our money on programs that sound good, and we don't care – especially since we don't recognize that in the end we'll wind up paying the tab. More likely our grandchildren or their grandchildren will wind up with the bill. We're paying for the generosity of those who preceded us. We're paying for their guilt and magnanimity, and our descendants will pay for ours. Actually we're only making the interest payments, but sooner or later our creditors will demand that we – really it will be those who follow us – start paying off the principle. That principle is the National Debt, which now amounts to … (I'll look that up later, too). We keep kicking the can down the road, but sooner or later someone will get it and have to open it – and it's a real can of worms. Greece knows that.

The needy, however, are everywhere, not just in our country. And they suffer not only from poverty but from disease and oppression.ⁱⁱⁱ The basic idea, and it is a beautiful one, is that we are all responsible for each other. In the Western tradition, the Bible tells us to help the poor, the widow, and the orphan. “Love thy neighbor.” And I have no doubt that there are similar injunctions in all other cultures. But religious teachings often place limits on the amount that one can give away, and realpolitik governs the extent of involvement we're permitted in the affairs of other countries. We're not always wise to try to care for all of humanity, nor are we always free to do so. We know about the tribulations of those around the world, but we can't afford to deal with all of them. And, many believe, it's not our place to do so.

That, however, is neither here nor there. At least it's not the subject of today's discourse. More to the point is our consideration of the cost of caring for the health of our own citizens. That used to be a family obligation but not any longer. Now it is a duty that has devolved onto society in general, even if we may disagree on what standards we should use to judge it^iv and those who receive it, we all pay for it.^{v vi} We consider it self-evident that those who can better afford it than we should pay more to support the kind of care that all our citizens deserve.^vii

Oh. I finally got around to checking. Health care makes up about 23% of the national budget. Apart what you pay for your own care, $230 of every $1,000 you pay in income taxes goes in that basket.^viii As well as 23% of what you pay in a variety of other taxes you pay – like tariffs for imported items – and the costs incorporated into the prices of whatever you buy. The latter reflect producer's and manufacturer's costs that are simply passed on to the consumer. Congratulations. The bottom line is that you're probably paying not only for your own medical costs but for those of others as well. I trust you feel magnanimous.

By the way, our National debt now is over $16 and a quarter trillion and rising rapidly with each new program. But who cares? There isn't any real problem (for me). It's only money, and soon enough it will be someone else's burden.

Next episode: “Growing Down” – It's a tall order.

i      By the way, the use of health care costs is only an example The same issues and calculations can be considered for all parts of our budget. I won't look up any numbers for you though.

ii     Or, more accurately, our elected representatives who are looking for votes in the next election.

iii    Sickness doesn't stop at the water's edge. Nor does guilt.

iv    We wish to raise our standards, but as more and more individuals become eligible for subsidized care, as payments for that care diminish, as medicine becomes more assembly-line, standards are more likely to diminish.

v      That includes Christian Scientists and others who may oppose the programs in general or some who oppose particular parts for religious reasons (like those who consider abortion to be murder). The First Amendment guarantee of religious freedom does not extend to health care.

vi      The reimbursement for some services can be lowered artificially, but that doesn't actually change the costs of performing or providing those services. If it leads to a lowering of salaries it will drive the best practitioners into other fields, diminishing both the number of providers and their quality. It may be necessary to enlarge the bureaucracy to supervise these services even if that will raise costs. The more people involved in regulating and minimizing the costs, the higher they'll be. But it will provide jobs.

vii    “From each according to his ability to each according to his needs.” It was good enough for Robin Hood and it's good enough for us (even if it's not clear who decides on ability and needs). The redistribution of resources makes a lot of sense in a society that prizes equality. Those who view Marx's words ("Jeder nach seinen Fähigkeiten, jedem nach seinen Bedürfnissen!") as a call for socialism are simply mean-spirited. And those who fear that this kind of redistribution will lessen the initiative of the capable are fear-mongers. We'll all work hard and work long hours to support those who don't.

As for those who contend that actions of this sort are contrary to the ideas of the Founders, they should be aware that the Declaration of Independence and the Constitution are outdated, and we now have the Supreme Court to make the laws.

viii   As you must certainly realize that is the amount expended by the government only. It covers Medicare and costs that cannot be paid by the poor and the disabled. It does not cover your costs to private insurers (I pay for long-term insurance to protect my children), deductibles, and out-of-pocket expenses for medications and the like.

Better Things For Better Living

                                                                                  

Mark Rothko committed suicide.ⁱ So did Diane Arbus, Gorky, van Gogh, and Virginia Woolf. And George Sands was insane, along with Nietzsche, Nijinsky and, perhaps, Leo Tolstoi. Yet all were great artists. According to Plato, in Phaedrus, a “divine madness” is responsible for the productions of great artists.

Allen Ginsberg took hallucinogens. His “divine madness” was augmented by LSD. And other great artists have also taken drugs.ⁱⁱ Keith Haring, for example, and Cary Grant, Ronnie Gilbert and Aldous Huxley. If their art was thus improved, were they guilty of taking “performance-enhancement” medications? And if they took those medications, is their art in any way less valuable and enduring?

“Performance-enhancement” in sports is perceived as one of the great evils of our times. Most newsworthy nowadays is Lance Armstrong, who lost both medals and endorsements because of the scandal, but overall such behavior is best exemplified by Barry Bonds who, it is alleged, took steroids to build up his body and, with it, his home run production. He “cheated.”ⁱⁱⁱ For this he was condemned by Congress, team owners and other baseball officials. But, using an expression from another sport, perhaps we've jumped the gun. Perhaps our society is of two minds about such drugs and “cheating.”^iv

When preparing for the SAT's, numerous students take courses to improve their scores. Isn't that the academic equivalent of taking performance-enhancement drugs? Countless Hollywood stars undergo cosmetic surgery to help their careers. They, too, are enhancing their performance artificially. They, too, are “cheating.”

If a team prays together before a game, or a public figure smokes a cigarette to relax before an appearance, is that unjustified performance-enhancement?^v If, before a battle, an officer “psyches up” his forces, is he doing something wrong? If we have a drink or two at a cocktail party to help ourselves produce small talk and immunize us to that of others, have we broken some kind of social convention?

And when candidates prepare for a debate – when they practice their “spontaneous” responses to questions they expect, or to anticipated comments by their opponents – is that any different? But there I go again.

As a society, we're not sure. Milli Vanilli was drummed out of the entertainment industry for lip-syncing its own songs^vi while Deborah Kerr, Audrey Hepburn, Natalie Wood and Marilyn Monroe, among others, were praised for their wonderful performances even though Marni Nixon dubbed “their” musical numbers. And there is no question about Sid Caesar's comedic genius. We don't fault him for mouthing jokes by Mel Brooks, Woody Allen and others.

We live at a time when team owners offer huge salaries for stars who bring fans to the stadium. Records help to bring out the fans, and that's what's really important,^vii so whatever accomplishes that goal is justified. If steroids achieve it, owners will look the other way irrespective of long-term deleterious effects of the drugs. As long as it doesn't become public.

In the history of baseball for example, the ball itself was made more “bouncy” so as to go farther, designated hitters have been used to increase run production, and baseball stadiums have been designed to match the strengths of hitters, while players are chosen who will do well in a particular setting. That's the sport's way of improving performance, excitement, and attendance. Everybody does it.

Of course, “everybody does it” is not justification for doing wrong. But if, in fact, everybody does it, perhaps we should look again and reevaluate whether “it” really is wrong. Cosmetic surgery will not make a bad actress a good one, nor will steroids turn an average baseball player into a superstar.

Certainly those who perform exceptionally are exceptional, though artificial aids may enhance their glitter. When a superstar tries to improve his image to get more of the money that owners are throwing around, it is understandable. But we don't want our children to see our hypocrisy, so we castigate publicly what we simultaneously encourage. Perjury by anyone, including our heroes (in this case falsely denying the use of drugs – before Congress or the courts) is never permissible. We expect honesty of our superheroes, and justifiably so. But if one is faced with the possibility of losing his market value though, because society is looking for a scapegoat, falsification is understandable, even if inexcusable.

So is “performance-enhancement” acceptable? Maybe yes, maybe no. The answer isn't quite as obvious as we'd like to believe.

 

 

 

 

 

Next episode:  "Paying The Bills" -- Avoidable.

 

 

i      Look it up. The examples that follow, as well. I'm too tired to document all this.

ii     We can't sanction “immoral” behavior so we ignore it and focus on the results. At least most of the time. We sometimes reject the results of immorality and unethical behavior. It's high-minded, even if it's sometimes foolish. Indeed, it may be immoral to ignore the results of medical research performed unethically, when the use of those results would help people, although some consider that the “right” thing to do. But that's a subject for another time.

iii    Breaking the rules by sports figures is not permitted because it's so public. Gambling may be an important fund-raiser for casinos and governments but, as Pete Rose discovered, it's forbidden for athletes.

iv     Many of them, having “done” marijuana or other drugs in the past, sound silly criticizing the athletes, especially if the critics' children are aware of their past (or, perhaps, ongoing) behavior.

v      It's certainly bad for his health, but it may calm him down.

vi    Actually they were scorned because they were caught and their actions publicized, embarrassing everyone else.

vii   Money makes the world go 'round.

The First Step

                                                     

“My name is Sir Oracle, and I'm a retrophiliac.

“I've sort of known that for a long time, but I never gave it much thought. I never really considered its implications, or the effects it might have on others. But when I finally recognized the seriousness of the condition I “googled” it, and I think I now understand it better, and I understand myself better. But I also know that I'll always be a retrophiliac. I'll never be cured.

“And I'm glad.”

I know I'm not supposed to feel that way and I should certainly not say it in public, but that's the way it is. I don't want to be cured! That admission doesn't make for an auspicious start to the process, but the emphasis is on honesty and I have to be honest. So my first step at RAⁱ has to be seen as something less than a complete success.

A retrophiliac, by the way, is someone who's nostalgic; who has a preference for things as they were, rather than as they are. And that's the way I feel. Not for all things – but in some categories. Too many things are changing simply because they can. A lot of those changes are related to the increasingly rapid advancement of science. Many, however, are based on economics. Someone, or some company, has figured out a way to get money from the public and isn't shy about hawking a useless product, or a book about a useless technique, or something else, to a gullible audience. I remember a time when the latest car model wasn't very different from the last,ⁱⁱ and prices (and the stock market) didn't change wildly from day to day.ⁱⁱⁱ It was a time of stability. At least it seemed so to me.

Perhaps it seemed so because the primary responsibilities belonged to my parents. I had no concern about life's practicalities and little interest in the world around me. Except, of course, for baseball. But even there you knew that the players on your favorite team would be the same ones as last year. That's certainly not the case today.

Times have changed. Prices go in only one direction – up. Women's clothes seem to be fashioned as part of a competition for the bizarre, and the models are chosen for their appearance of boredom, or their similarity^iv to dazed drug addicts with eating disorders. Food styles emphasize exotically-flavored dishes in tiny portions.^v In addition, we live at a time when popular “music” isn't music. Rap with a backup of rhythm only, and loud^vi rock mock what we used to hear.

And things are moving too fast for me. Especially science.^vii There's a new discovery daily of what life is like^viii a few billion light-years away. But we'll never experience it, so we'll never really know. And most of us – people like me – won't care. The development of nanoscience, at the other end of the spectrum, may have more practical applications, but it is equally incomprehensible, as well as being hidden from our view. I do welcome many of the medical advances that have taken place in recent centuries, especially in therapies, but perhaps we have moved too fast in other aspects of biologic science. As much as I may admire the development of genetics, I'm not convinced that we'll gain from the cloning of human beings^ix or the ability to design our offspring.^x

There are several driving forces behind the rapid scientific advancement. The wish for fame is certainly one of them,^xi but an important factor is economic. Marginal improvements in unnecessary products are hailed as “game changers.” We wind up with frequent news conferences announcing a larger TV screen, or the latest model of cell phone, pod or pad or computer, indispensable even though we didn't realize we needed it. And the last one goes into a drawer or the attic.

I guess I'm an anterophobe.^xii It's not that I'm against progress, but I need the time to digest one “advancement” before I'm presented with its second, third, or fourth generation. I don't have a cell phone or other electronic device. I'm satisfied with what I have and with peace and quiet. In Greta Garbo's words, “I vant^xiii to be left alone.”^xiv We need to slow down.

Surely my views are not new. They've been the same for generations. I suspect that those who preceded us found the changes that occurred during their lifetimes too rapid. Our music didn't please them and they had trouble keeping up with all that was happening around them, whether in science, politics, or style. Our children and grandchildren will be appalled by the way we live. They won't be able to understand how we could go around without an iPad^® or its equivalent, and our great-grandchildren won't believe there was a time when such conditions existed – even though the particular devices are fossils. But that's the way it is. I can't understand how people lived before there was a reliable refrigerator.

So I'm a retrophiliac. But the more I think about it the happier I am. I'll leave the advances to the advanced, and wallow in my memories. I like nostalgia. Thinking about step one of my treatment has convinced me that I don't want to be “cured.” The world's wrong. I'm right, and I'm convinced that the best thing we can do is to stop the world.

Next episode: “Better Things For Better Living" – On the art of self-improvement .

i      Retrophiliacs Anonymous. Not the Royal Academy, Rifle Association, Rural Americans, Resident Advisors, or the Rabbinical Assembly.

ii      Actually that's as true now as before, but the advertising has become more aggressive, and minor differences are promoted as major improvements – advances that change the industry.

iii    Indeed. There were times when there was little change from century to century. But I'm not that far gone. And I have neither the interest nor ability to be a medieval farmer.

iv     Or, of course, they may be the real thing.

v      Both the flavors and the portion sizes are offensive. I would not be appeased by being served a large dish of something with, for example, cilantro. [Cilantro lovers and other fools should stop hissing.]

vi     It's always loud.

vii    I said it before, but it's worth repeating. Looking back at the previous mention of this idea gives me a feeling of nostalgia and comfort.

viii  More accurately “what things are like.” We have no idea at this time whether “life” exists elsewhere. We may suspect it but there is no adequate proof at this time.

ix     If it hasn't been done already.

x      Ditto.

xi     Sometimes leading to falsification of results. As the wise man once said, even a retraction adds to the length of your resumé. Fame, and employability, are sometimes more closely related to quantity than to quality.

xii    Don't waste your time “googling” it or looking it up on Yahoo! I made it up as the opposite of retrophilia, which does exist. It's not that I fear the future, but I think that our race to it is unwise. I don't think we look enough to the past and to incorporate its lessons before we go hurtling forward and making changes that are ill considered and which impoverish us.

xiii   No disrespect is intended by the use of her accented English. However she pronounced it, she had it right.

xiv    In “Grand Hotel.”

Time In

                                             

To everything there is a season, and a time to every purpose under heaven.ⁱ

Kohelet was philosophical in its delineation of the events of life, and our need to accept them as necessary and unchangeable features of our existence. Birth, death, killing, healing, planting and harvesting are aspects of our lives that will always be around, and we can only benefit from that knowledge.

Shakespeare spoke in poetic terms when he outlined the ages and stagesⁱⁱ of man in “As You Like It,”ⁱⁱⁱ but he, too, employed descriptive terms without any real attempt to address the causes of these stages, or any actions that people might take to take advantage of his time or what, in fact, the time meant.^iv

Perhaps more practical even if only a few could understand it, Einstein weighed in on the issue of time. In his discussion of relativity he told us that time isn't fixed but varies with the speed and location of the observers of phenomena. His work, though theoretical, has been demonstrated to be correct, however much others, in search of fame, try to disprove him.^v

Even a more pragmatically descriptive and physiologic cataloging of human life leaves us with more questions than answers. There's no denying that language learning, frontal lobe development, sexual development, physical strength, wisdom, and old age occur at different times relating to frontal lobe maturation, hormonal secretion, and telomere length among the clinical explanations, and learning, experience, and observation derived from living itself. But although this may help us understand the passage of time, and its implications, a little better, it doesn't touch on the “nitty-gritty” of our everyday lives.

As for that nitty-gritty, we don't pay much attention to time – except to be sure we don't miss some television programs. And until that show is on we'll while the time away.

Actually we spend most of our time with the whiling and with our wishes. Whether we're waiting for summer vacation, the weekend, the kids to go to sleep, or just the completion of some unpleasant task, better times are always ahead. Little attention is paid to the idea that each moment changes us and brings us closer to death. And as we while our time away and wish that some unpleasant time or task would be completed, we are really leaving the past behind and reaching for our end.

Thomas Wolfe pointed out that “You Can't Go Home Again”; that home looks different. Physical and human changes have occurred. The houses, stores, streets, and even the vacant areas – both building lots and open land – are nothing like what you remember. What you once might have overlooked as the day-to-day differences which go on everywhere and aren't worthy of note or mention, add up, and when, after a long absence, you revisit your past, it doesn't conform to what you thought you left.

People have aged, died, and moved. It's not the same. All you're left with is nostalgia, and, as Yogi Berra said, “Nostalgia ain't what it used to be.”^vi

Not only has the place you once called “home” changed, though, but so have you. Certainly your age has changed, but so have your views and your place in life. There have been changes in your family and your friends, as well as in your level of education and employment status. And time flows in only one direction. Whatever you may have read in science fiction stories, whatever you may have seen in the movies or on television, you can't return it or yourself to what you remember.

That's not always bad, though. I suspect the some of your past would now be disappointing or, in some instances, awkward. Progress and experience temper many earlier embarrassing situations. Sometimes the passage of the years has treated old hurts. As Dorothy Parker is reported to have quipped, “Time wounds all heels.”

In any event, such speculation is meaningless. There's no going back. Maybe that's sad; maybe it's depressing. But that's the way it is. Home is where you hang your hat. Now. “You only go around once.”^vii The past may live in your memory, but nowhere else. And the stages described by Kohelet^viii and Shakespeare, however archaically phrased, are all we have. Use the season and the time well.

Next episode: “The First Step” – Atoning for the past, or accepting it.

 

i      Kohelet (Ecclesiastes) 3:1

ii      Periods, not proscenia and their environs.

iii    Act II Scene VII. It's part of a famous speech that begins: “All the world's a stage ...” (Proscenium and its environs, not a period.)

iv    Perhaps a future essay will discuss “meaning” itself. For the moment just go with whatever interpretation seems to work here.

v     The phenomenon is comparable to what you see in western movies when someone wants to outdraw “the fastest gun in the west.” In this circumstance, however, professional death is often substituted for the physical kind.

vi     Yogi Berra is worth reading. His words seem comical, but the ideas they depict are often quite deep.

vii    At least in this world. If, however, you believe in reincarnation, ...

viii   “The Preacher” in Kohelet.