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Deconstructing Stupid

Here’s a newsflash; I’m not opposed to making cuts to medicare. I believe that we can cut medicare spending significantly, while improving services for medicare recipients. One of the really good aspects of the health reform bill was how cuts to medicare were made. I wholeheartedly agreed with cutting funding to medicare advantage.

If you’re not familiar with medicare advantage, let me give you the broad strokes. It was an experiment that Bill Clinton tried, where he outsourced medicare to private insurance companies. The idea was the old republican mantra that private companies can “do it” more efficiently than government can. I believe it was an experiment worth trying. But fifteen years into it, the results were in; not only did it cost 14% more than traditional medicare, but it didn’t deliver better results. It was a nice try, but it failed. Defunding it and getting our 14% back made all the sense in the world.

I believe that there are similar cuts that can be made. I’ll get to those later.

Paul Ryan put this out yesterday:


Apparently, he’s decided that instead of back peddling out of his disastrous plan to fuck seniors, he’s going to double down. I’m not sure if he’s going for an Oscar a la Al Gore, but I wouldn’t waste my time lobbying the nominating committee if I were him.

Bear with me while I go through this point for point, because it’s not all bullshit.

The first point that he makes is that Americans spend fifty times more on healthcare today, than we did in 1960. Yes Paul, that’s because we have a system run by private corporations. He fails to mention that we pay more than double (per capita) for health insurance than other countries with nationalized health care systems do.

Next he talks about how medicare spending will nearly double in the next ten years. The actual increase amount is 86%, but I can see how “double” has a more dramatic effect. Those figures are true. What he didn’t say is that in relation to GDP, this represents a growth difference from 3.6% of GDP now, to 4.1% of GDP in 2020. Yes, the amount of spending is going to explode, but a little bit of relative perspective goes a long way. By the way, I love it how everyone acts like no one saw the number of baby boomers coming. What the fuck? You couldn’t count all of the births from sixty-five years ago, and predict how many medicare recipients there would be today? If we’d been making incremental adjustments all along, there wouldn’t be a “crisis” now. Shut the fuck up with your crisis nonsense, especially if you’ve been in the house for over twenty years.

The next point he makes is actually a good one. We have a system that pays for procedures, rather than results. It’s referred to as “fee for service”. This system doesn’t encourage curing a patient. It incentivizes doctors to rob the system by running tests in perpetuity so that they can get paid for each test. We should absolutely change the system so that it pays for results. This is the type of cost savings measure I can get behind. But I have to say that his line about, …” A patient is very disconnected from the cost” made me vomit in my mouth a little. Do you really think that if a patient knew what each procedure cost, they would know enough to pass on an MRI that may or may not be necessary? How the fuck are they supposed to know if it’s necessary? People go to school for nine years to learn if the MRI is necessary. The implication is that the patient is glutting themselves on health care as if it’s a luxury item, because they don’t know how much it costs. Asshat.

Then he makes the tired, lame ass comment that medicare costs are going up because there’s no competition. Hey asshole, go back to the numbers at the beginning of your presentation and see how much “competition” had helped out with health care costs in the past sixty years. Also, review the cost difference between medicare and medicare advantage. You might be able to make this point if private insurance costs were growing at a significantly lower rate than medicare costs are. They’re not. They’re growing at a much faster rate, even with a much younger population in the private system. The only reason why medicare is in “crisis” is because of exploding enrollment numbers, not exploding profit margins. And by the way, in which universe are private insurance companies clamoring to grab that “hip replacement” segment of the US demographic? Let me reiterate, asshat.

Then he goes into how his plan is going to “save” medicare. This is the most comical statement of them all. Here’s how you know that he’s not saving medicare: right now when grandma goes to the doctor, that doctor gets paid with a check from medicare. Under Ryan’s plan, there will be no more checks from medicare. The doctor will ostensibly be paid with a check from the private insurance company that is chomping at the bit to get grandma’s business. Good god, there are so many things wrong with that last sentence. But the bottom line is that there will be no medicare. His plan will give seniors vouchers for $15,000 per year to go buy their own insurance. There will be medicare in the sense that those deductions will still come out of your paychecks for your entire working lives. But at the end of it, that money will ultimately get paid out to private companies. Do I even need to break down how fucking stupid that is?

Fortunately, Americans seem to viscerally understand that Paul Ryan’s plan blows. But the downside is that everyone is caught up in black or white thinking. The choice is either leave it alone or kill it. Neither of those will work. We need to take a critical look at the system and make smart cuts that improve the system and ensure its longevity. Unfortunately, I don’t think that we’re going to make it that far into the national conversation. My prediction is that we’re going to be plagues with “medicare crisis” talk for the next couple of decades.

That should be fun.


1 thought on “Deconstructing Stupid

  1. When the Mafia runs a protection racket and demands your money or your life, everyone recognizes it for what it is — extortion.

    When Wall Street and the insurance companies collude with our politicians to do the same thing, it is called ‘insurance’, ‘free enterprise’ – or the Affordable Care Act / Commonwealth Health Insurance Connector [Massachusetts], and they charge much, much more when all they are doing, really, is changing the name for it.

    Even with massive public subsidies, the so-called healthcare industry’s so-called ‘products’ are inherently unprofitable without support mechanisms to justify the overcharge those who can pay and to under-serve those who cannot. Given these facts anyone who can add and subtract, multiply and divide can understand this. But more importantly, medicine, surgery and nursing (which involve the application of science to the studied practice of an art) cannot, in truth, effect the production of a commodity, i.e., an abstraction designated ‘healthcare’. Treated as if the practice of medicine, surgery and nursing were a genuine commodity, they become something else. ‘Healthcare’ it turns out is not ‘care’ at all, but in reality insurance, with co-pays and deductibles which are merely further financial barriers (i.e. ‘shake-downs’) that function as gatekeepers to real care. ‘Healthcare’ is a ‘financial product’, a purely commercial transaction, essentially auto insurance for our bodies.

    Insurance provider executives graduate from business schools and speak of ‘plans’ and ‘products’, not patients, who are thus transformed into ‘customers’. Rather than ‘plans’, it would be more honest to speak of ‘schemes’, and in most instances, ‘scams’, since they are all driven by the principle of Let’s Not and SAY We Did – if they really want to stay in business and turn a profit. What does it mean to talk of ‘healthcare’ if patients are ‘customers’? It means a great deal. It means, for instance, that practitioners are never fully focused on the patient and the task of healing for which they have trained, but instead focus upon billing procedures and accounting, which have really nothing to do with the patient and his or her symptoms. Let’s repeat that, NOTHING: yet billing is where 30% or more of each healthcare dollar goes. Accounting is a respectable profession, but it requires a very different skill set from medicine, surgery or nursing, and as a result even more money that belongs at the bedside is wasted on public relations, lobbying and ‘advertising’ (the latter being a shakedown by the mass media), in order to distract the public from the real focus in healthcare — and indeed real purpose of ‘healthcare’: i.e. billing.

    Satisfaction surveys have been designed as a substitute for absent elements of care, i.e. compassion, 1) because nobody really ‘cares’ in a commercial context since insurance companies cannot bill for such a ‘service’ (and insurance and financial service companies provide nothing for free); and 2) because the existence of satisfaction surveys tacitly acknowledges that it is still highly important that patients think someone does care, whether anyone actually does, or not: one cannot tell by completing a survey. Moreover, slobbering all over someone’s ass because he or she is paying to have this done it is not the same thing as caring: and in any case, doing so is a function of a very different profession, a fact ignored by the survey process. Yet the need for some element resembling compassion persists, and this is why there are so many costly surveys in the modern healthcare delivery experience.

    Belief that someone cares is important because only compassion can connect a patient to his or her symptoms and a response, if any, to treatment. Surveys may perhaps assess ‘customer satisfaction’, but cannot fairly assess the competence of a practitioner – if they could, we would not need any practitioners in the first place. They would have been quickly replaced by much cheaper ‘customer service representatives’ – most likely ‘practicing’ by phone. At most this would only require a little coaching in English as a second language for overseas telemarketers.

    A market based healthcare system is neither ethical, nor rational, nor efficient. But it is a grand and glorious hoax to pretend that it is all three, and the insurance industry and pharmaceutical industry spend vast sums on advertising and public relations — and, especially – political lobbying to sustain and promote this hoax so that the premiums keep coming. (It pays off — we now have a system whereby a private financial interest has been essentially licensed to tax us in the guise of premiums.) A market based system is, moreover, intrinsically inimical to the goals of medicine, surgery and nursing, which cannot be forced to effect the production of ‘healthcare’ commodities without untoward, severely pernicious, and ultimately Procrustean, consequences.

    The least egregious of these is that ‘customers’ visiting the doctor become a species of livestock ‘consulting’ a veterinarian on behalf of the billing entity, an experience absent any notion or sense of a professional bond – at either end of what is, ultimately, now merely a financial ‘transaction’.

    Professionals and administrative and clerical staff alike, captive to a profit driven, market based delivery model that enforces such bizarre shifts in professional roles and priorities are likely to be, in large measure, resentful – and bored — and thus highly unlikely to cultivate or sustain the kind of compassion required to perform the subtle tasks and observation attendant upon true and artful healing. Staff will come to do so with little or nothing resembling insight, tact or finesse. Nonetheless, indifference and inattention are as lethal as incompetence when dealing with patients, whether one ‘labels’ them ‘customers’ or not.

    If they were really customers, it would not matter – there would be little or no possibility, for instance, that they can, and will, drop dead – much less because you have killed them.

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