According to the Congressional Budget Office, 24 million people could lose their health care coverage over the next ten years (14 million of them in 2018) if the GOP’s current strategy to “repeal and replace” Obamacare results in a bill that gets through Congress and which President Trump signs. The prospective bill may be dead in the water, at least as of this writing. The GOP has caught pushback from both sides: at town hall meetings from those who have acclimated to Obamacare and don’t want it changed, versus conservatives who claim the GOP plan is too similar to Obamacare and hasn’t been changed enough.
This is what happens when an entitlement mentality dominates entire sectors of a society, and a critical mass of citizens expects government to take care of them.
In a series of articles done almost three years ago (first installment here), I reviewed a past investigation into the trajectories major civilizations tend to follow, from their inception based on a set of ideals, their rapid growth, and their maturing into developed governance units with a single language, legal and administrative structure, trade routes, respect for genuine learning, and a solid work ethic. Then something goes wrong. Wealth and comfort become ends in themselves. Generations rise who reap the benefits of wealth and comfort without any sense of the work that went into them. Their intellectuals embrace a relativism that rejects their founding ideals as having no special standing. This relativism encourages the resentment felt against those who built the civilization by those who did not.
The civilization falls into successively more destructive waves of decadence. It furthers policies whereby some can live at the expense of others, and since it’s all legal, if you are one of those others, you cooperate or eventually the government sends men with guns pointed at your head. Corruption sets in, financial as well as political. Wealth is generated increasingly by speculation and borrowing against the future, not productive work. An entertainment/celebrity culture rises, marked by hedonism, ostentatious displays of wealth, and a fascination with endless varieties of sexual debauchery. Substance abuse becomes a problem. So do two social phenomena once on their way to being conquered: economic inequality and poverty (a bogus “equality” of all lifestyles having been fostered as a surrogate for the real thing, which must be earned and cannot result from government freebies.)
The society, once relying successfully on rules for successful immigration and expecting immigrants to assimilate (most did), opens its borders to unassimilable outsiders who flood its cities with a dozen different languages. Its legal system increasingly supports the outsiders over its own. To the political class, the outsiders are potential votes. To the corporate class, they’re cheap labor. Many of these outsiders mean no harm, and have been caught in bad situations. Some, however, are actively hostile and begin to tear at the society’s fabric. The problem is that there is no reliable way of determining in advance who is who. One terrorist with a rifle or a truck bomb can destroy a lot of lives!
As those who remember the “old ways” gradually die off and are not replaced, the civilization itself begins to die. It dies further when small handfuls of dissident writers and intellectuals warn of danger from these various forces and are demonized as racists, xenophobes, homophobes, nationalists, supremacists, tinfoil-hat wearers, or deplorables. It dies the rest of the way if enough of its remaining productive citizens simply pack up their affairs and flee to less repressive jurisdictions on other continents.
Does this sound at all familiar? I could be speaking of almost anywhere in the Anglo-European West right now, with variations from country to country, where a sense of entitlement is the mindset of the day, whether it is an entitlement to cross open borders or to have one’s health care paid for at someone else’s expense.
In areas like public health, attempts to satisfy this sense of entitlement require centralization and bureaucracy. Eventually, as all professionals are pulled into the Weberian iron cage, the efforts become unsustainable. Prices go up. Quality drops. We are at that point with health care in America, as I’ve argued previously: the national conversation is not about human health but how health care is to be paid for. This preoccupation is not crazy, moreover, because prices have indeed escalated uncontrollably, and one lengthy hospital stay can bankrupt a person.
The idea that promoting better health education and better health practices would lower the price by reducing the supposed need for centralized bureaucracy occurs only to a few of us, out here in the conceptual equivalent of flyover country, as it were. Those locked into the entitlement mentality with all four claws see calls just for eliminating Obamacare as morally equivalent to allowing people to die. Just the other day, on the mainstream Bloomberg site: “America has already decided, as a society, that people should not to die in the street for lack of health care.” We decided, collectively. “We” don’t make these things up.
A friend of mine wrote an account of what has gone wrong with health insurance in America that nails the problems so clearly that I was tempted just to copy and paste. Unfortunately his account is a bit long, so I must summarize. He argues as follows:
One buys insurance of any sort to protect oneself from events that have a low probability of happening to any of us, but if they do happen, the results are potentially catastrophic. Thus we try to protect ourselves against criminal break-ins, fires, floods, earthquakes, and so on. The idea is to “insure” millions of people against losses that are probably not going to happen to most of them, but with a risk that is sufficient that they are willing to pay the right premium for protection against it, just in case it does happen.
My friend identified three factors at work here. (1) The probability of the undesirable event happening to any one person must be low. (2) If it did happen, its effects on that person would be disastrous. (3) Millions of people must be willing to pay into a single pool of resources made available to minimize the effects for those few for whom it does happen. I would add a fourth: (4) the organization managing this pool of resources and administrating claims must be able to make a profit. These are businesses, after all, not charities.
In a nutshell, this is how insurance works. Something very bad happens perhaps one time in a million, but its costs are so high that millions of people are willing to pay to be protected financially should it happen to them.
Now for the $50,000 question. Do health and sickness really fall into this insurable category?
First, illnesses, even serious ones, are much more common than the other catastrophic events we listed. And the older you get, the greater the probability of serious and possibly debilitating illness. Eventually it happens to the majority of us.
Second, over the past century we’ve seen a major shift from acute to chronic conditions. Acute conditions were either cured or the patient died. Chronic conditions, on the other hand, are not cured but managed. Their management is often quite profitable to doctors, hospitals, and Big Pharma. In a sense, managing millions of people’s chronic conditions is what enables us to say we no longer have a health care system but a sick care system.
Third, as a population ages, these conditions grow in number — eventually those with chronic conditions threaten to outnumber the healthy! And their conditions get increasingly expensive to manage!
Because of these factors, universal health insurance for a population of over 325 million people (not counting those living in the U.S. illegally) was always a Utopian dream! An insurable risk, by its nature, has to be something that rarely happens, not something that eventually happens to the majority of the population! Attempting to insure expanding groups of elderly people whose chronic conditions are only going to get worse is a recipe for a financial black hole!
That is to say, the math doesn’t work. The only way to make it work is to force young people who don’t need as much insurance to pay the costs of those who do — the individual mandate in Obamacare. This accords with the entitlement mentality: some are entitled to live at the expense of others. Force the young to pay into that resource pool, even though they receive few or no benefits.
This is not true insurance, it is wealth redistribution. It is moving money from the pockets and bank accounts of the young and relatively healthy to pay for the health care costs of the elderly. Welfare for the old, that is, paid for by the young. All Obamacare did was point the metaphorical de jure gun at their heads. Buy health insurance or pay a penalty to the IRS for noncompliance.
The fact that the penalty was sometimes less than one’s premiums, taken on a yearly basis, which were skyrocketing under Obamacare, was a sign of the latter’s fundamental dysfunction.
This is not a system that can be amended, reformed, repaired, or “repealed and replaced.” It should be scrapped, lock, stock and barrel. It is time to recognize that in the long run, it does not work. It cannot be made to work.
If Paul Ryan and Donald Trump try to make “GOP-care” work without the individual mandate, however, the resulting system will soon run out of money and indeed, people who thought they could depend on it will be left high and dry.
The idea should be to get free of dependency.
Replace “GOP-care” with health education for primary prevention, which includes, and requires, freedom and responsibility — personal, familial, and local.
This sort of thing needs to be incorporated into every school system in the land: public, private, or homeschool curriculum. Education for primary prevention should include information on proper nutrition, the importance of exercise, stress reduction, and the avoidance of unnecessarily risky behaviors.
The biggest thing presently in the way: the entitlement mentality.
Few people are old enough to remember when anything resembling freedom was the norm: that is, when your treatment was between you and your doctor or other specialist; Medicare was not involved; insurance companies were not involved; your doctor was not under pressure to sell you Big Pharma’s latest expensive drugs.
Thus the resistance currently facing the attempt to replace Obamacare which was, after all, designed to make money for Big Pharma and Big Insurance.
This belief that health care is an entitlement, not the result of systems of preventive actions persons take as individuals or as family members, is one product of our present Age of Decadence.
In the past, an Age of Decadence has directly preceded a civilization’s implosion, usually resulting in a lower standard of living. If that happens in the U.S., its masses will realize — too late! — that entitlements were an illusion.
This is not to say that those unable to care for themselves should not be cared for. But when people are not forced against their will to pay the medical costs of strangers, they are more likely to be generous; and when their families and their communities are autonomous, their capacity to care for the totally infirm is likely to be greater. Incidentally, the number of people requiring tertiary care due to long-term chronic conditions will drop dramatically when everybody or at least the vast majority of citizens are practicing primary prevention as a way of life. This incidentally includes minimizing the distance between food’s origin (farms) and one’s dinner table. Believe it or not, there was a time when today’s most serious life-ending illnesses — cancers and heart disease — and most common chronic conditions such as diabetes and, for the elderly, dementias such as Alzheimer’s disease — were almost unheard of. The problem is the garbage in our food: high fructose corn syrup and other sweeteners, additives such as flavor enhancers, preservatives, and environmental contaminants.
The point is, functional universal health insurance is and will remain a Utopian dream. We will not force the numbers to add up any more than we can force water to run uphill.
Sadly, you cannot explain this to people mentally locked into the entitlement mindset. I know; I’ve tried. What I’ve realized is that there is a great danger that increasing chronic illnesses coupled with an inability to pay for treatment will be one factor in Western civilization’s downfall. One can only hope the GOP-controlled Congress figures this out. If not, it will be up to us as individuals and families to use the knowledge we have, take care of our health and that of our families outside whatever dysfunctional systems prevail, and minimize our contact with them.