Healthcare, You Can’t Unstir It

There are many people who like to keep their peas, carrots and tuna casserole carefully separate on their plate; I have always preferred stirring them all together – along with the ambrosia salad.

This seems often to be true of our approach to social, economic and political issues (see, I have just done it). But the lines of effect ultimately jumble together like spaghetti. First, to scoop things into neat little piles.

There are two basically different starting positions: 1) all people have a right to healthcare and 2) people should only have the healthcare (or anything else) that they can afford [1]. Add to these the absolute truism: no good or service can be had without compensation, immediate or eventual. Very quickly the mixing starts.

If we take the view that people should only have the healthcare that they can afford, the argument is greatly simplified. There is no need for much further consideration; a person acquires means by their effort in the economic system and can use that means to compensate those who have acquired medical and related expertise as their way of attain means. Those who have not acquired sufficient means do not get the services and goods of healthcare. We need no agencies, authorities, commissions, etc. to oversee such a design. Providers charge what the market will bear. The number and quality of providers is decided by the people’s ability to pay for service.

If in this design there are other opportunities to create new goods and services in support, these too should be allowed to fully express their creative potential, expanding and contracting in response to the ability to pay. There is no issue in this model with the need for compensation since it is immediate and required. What happens to those who do not have the means to acquire the healthcare goods and services is not a concern of the system, but only a concern for those who are without means. This is how it is for all other goods and services. If one does not have the means to get an Armani suit, then one doesn’t get one, rather perhaps making do with second-hand from Goodwill.

In this model the costs are known to be a personal responsibility; each person must prepare for eventualities by acquiring the means to meet the most likely needs. Those who, by either poor planning or misfortune, are short of the required amounts simply have to do without. The consequences are poor health, reduced vigor and death for such an underclass. Another way to describe the consequences is that people in poor health cannot contribute to the stability of the social order; in fact, the reduced vigor of the unhealthy produce a whole dynamic of effects, among them low productivity, illiteracy, dependency (on productive people), crime and social instability.

Remembering that all goods and services must be compensated, a large underclass creates by their very existence demands that must be compensated, both of their own and from those whose comfort and stability they challenge. And so whole armies of people would be required to supply goods and services to and in response to the unhealthy; they and those that they affect will demand it.

The major origin and consequence of this model is the “every man for himself” mind set; positive feedback quickly sets in and each increment of self-righteous distancing from ‘the other’ feeds the next increment. The adherents of this view will (happily?) pay, in taxes and their own security and other costs, twice as much for police forces, prisons, armies, courts, devices, etc. as would be saved by having a generally healthy population that feels respected and engaged in all the behaviors that support a functioning economy and a stable society; and all for the ‘peas in their own pile’ reason that they can’t stand the idea of “someone getting something for nothing,” especially if they think they are paying for it [2].

If all people have a right to healthcare, the issues swirl in the opposite direction. How are the providers to be compensated becomes the first concern. We know who gets care, just not how it is to be paid for.

This is such a different mind set that often people in the first group’s heads explode when they try to get close to these ideas (requiring medical attention). There are no ‘others’ in this view; we are all our brothers’ and sisters’ keepers; “What is done to the least of these is done to me;” that kind of thing. In fact, all living things are to be respected; harming or allowing harm to any other living thing (plant, animal or other) should only be done in necessity and never gratuitously. Every “brother and sister” is to be supported in the pursuit of a full life and no human is to be the direct or indirect slave of any other person or system. From here it is obvious that, since we are all in this ‘being alive on the earth business’ together, healthcare must be available to everyone.

The first principle of compensation for this model is that it not to be “privately” operated; for this point of view, ‘private’ is code for greed and selfishness (for the other view, ‘greed and selfishness’ is code for success). Therefore, healthcare must be a social good and managed in the commons, i.e., the compensation is made from a pool collected from the economic activities of each person and managed by representatives of the whole for the whole. The thinking is that the managers would be judged on their ability to deliver the most healthcare for the least amount; this would be the mandate from the whole community. Preventable illness and incapacity would be all but eliminated, the sick and injured would be respected in their need, a far smaller fraction of the population would be of reduced capacity in education, work and acts of social responsibility, and all for the ‘carrots in a pile’ cost of a national, publicly owned and funded single-payer health system.

But there are problems. How much is a provider to be compensated? Is it to be based on what the average (modal, median or arithmetic?) income recipient can pay? Should providers get rich delivering these services? How are inherent limits of time and opportunity to be apportioned? How are legitimate medical concerns to be distinguished from the frivolous? How are the amounts of available service to be balanced with amounts of need? Can the selfish and greedy use the system for their needs or can they be excluded?

None of these and many other concerns exist when a capitalist model is used: pricing mechanisms do several of these things more or less automatically. There is no social limit on wealth. Needed services and numbers of providers follow rates of demand as providers try to maximize their income. But this all functions by the pressures from the margins, euphemistic language for the lack of service, and in the case of healthcare, untreated sickness and injury. There are some of us who see this as acceptable and some of us who do not.

What about the costs of medical goods and services that by their very nature – huge numbers of man-hours, rare materials, energy intensive devices and procedures, significant preparation times, significant risk of unsuccessful outcomes – require very large compensations to get people to engage in them? What if people will not deliver the goods and services for the amounts made available?

Clearly goods and services must be compensated, and just as clearly a society that has no sense of community is a hollow shell, a failure and doomed to implosion. What can and must be the common values that underlie a huge polymorphous society like the USA and especially what are the common values that would support a workable healthcare system.

Those who focus on compensation solutions as wealth producing cannot be especially interested in the goal of universal care delivery (unless they can write the rules so that it is not really care delivery so much as it is compensation recovery). Those who focus on universal care delivery cannot be especially focused on goals of economic gain.

So which is it? Are people bunch of sheep to be fleeced by the few wolves and left to their own devices after the fleecing or are human beings valuable in and of themselves and to be made whole in specieshood as well as we can do? Is the goal of economic royalty more important than the health and life of fellow human beings? Do we honestly and in our best most giving spirit say that medical care is just too costly for the masses, that our economic system requires the striving after infinite wealth for it to function and that the attempt to stay healthy is a profit center that is just too good not to exploit?

The healthcare issue brings the divergence of these values into great clarity. But, ultimately it is in the messy mix of self-interest, concern for others, societal quality and equity, pain and suffering, life and death that each of us must make our stand. The vast majority of the Great Many – basically sane people whose self-interest looks first to what is good for family and friends rather than as a wealth engine – would help a person in distress and accept help in return. If we can’t make this a value for the society with a healthcare system that is universally delivered and fairly but not extravagantly compensated, then there is nothing that can be done for the other destructive forces challenging us.

We are in the thrall of the insanely wealthy; all our decision-making processes distorted by the social assumptions required to justify these excess accumulations. If I had to re-sort the wonderful mess on my plate into separate piles, the first one would be that excess wealth is a crime against life itself. Real healthcare must begin there.

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[1]What are the implications of people having only what they can afford? First, there are a number of unspoken concerns: afford in what currency of exchange? Is each and every person to be considered a completely independent unit? Are groups units so that a group might ‘afford’ a thing in one currency and distribute it to group members using a different currency or measure? The simplicity of the statement hides many issues.

What are the implications for social relations and the nature of social systems? Is it rational to expect all people to accept the same arbitrary system of accumulation and exchange? What are the consequences of people accepting systems of exchange that are destructive of both social and environmental order.

If the statement is changed to “all services must be compensated,” then the essential meaning is preserved, but focus is shifted from the accumulation of excess from which to compensate a service to the relationship between the receipt of the service and the returning to the service source of some meaningful value. What makes this significant is that accumulation without an intended object of exchange must be in some generalized form and emotionally is an action supported by some generalized need. Defining the compensation with an object turns the action into seeking the object rather than seeking the arbitrary ‘stuff’ of compensation.

And lastly there are intentionally hidden meanings – intentional in the actions of propagandists. ‘Affording’ becomes a code for social worthiness. There are trains of emotional connections to the idea of being able to afford a thing, with negative connotations to not being able to afford, especially, an important service. This also, partially, removes the social responsibility of others: the person doesn’t have the service, not because it is not available, but because they can’t afford it. Of course, if the cost is more that a person can accumulate, then the service is not available to them. If we are willing to go this far, then we have to look at the conditions that determine the ability to pay; and if the ability to pay is deduced by the actions of the larger society so that the ‘failure to afford’ is a fixed property of the society’s prescription for certain of its members, then the ‘can’t afford’ argument is a sham. That a few people escape this trap is no argument against both its existence and its domination of lives; a few people escape from prison too.

[2] I had a client once who disclosed to me that he literally could not sleep if he felt that someone had gotten the better of him in any economic matter, but slept like a baby when he had, by guile or lie, cheated someone else. It has become clearer to me over the years that this form of madness infects a significant number of people.

What We Must Do

The world’s events and processes, and their details, are compelling. It is detail that drives emotion, and emotion that drives our action: reason and logic can sometimes, hopefully, guide, but cannot sustain action. We need to know about events and to understand them; we need to act in response to them. This seems completely obvious. But, how are we to know? On what basis do we act? It is time to tell people what must be done – how life will be lived in one of our very likely futures.

There is a large and well informed collection of people who have concluded from the evidence gathered by biologists, chemists, earth scientists, atmospheric physicists and others that the biosphere of the earth is being changed in substantive ways, and very rapidly, by human action. Studies of population dynamics in species other than humans point to human population growth as an unprecedented aberration; adding to the mix that per capita consumption has increased by orders of magnitude, the total growth impact of humans is many millions of times more than the impact of pre-technology man. Combining these two lines of thinking, it is at the very least reasonable to consider the clear possibility that humans are, as ecologists and climate scientists have been saying for the past 50 years, blindly reducing biodiversity and rapidly changing both the energy balance and composition of land, air and ocean.

The major arguments against taking corrective measures to these universally recognized changes boil-down to, “We would have to live differently and we like it the way it is; thank you very much!” And, “The changes we would have to make are just too difficult.” The arguments denying the forces and processes of environmental impact are now made only by the poorly informed, fanatics and a few principled scientists who are still clinging to the few theoretical constructions that have not yet been disproved by unambiguous data (this last is as it should be) [1].

If the main body of scientists, philosophers, aware economists and politicians and the educated public are, in general, correct that human impact is changing the biosphere in ways detrimental to the earth’s present ecosystems and that as these changes impact the balance of stabilizing physical cycles and living things, so will humans be impacted by the loss of environmental free services. Economists are aware that very small changes in the amounts of energy and materials can have dramatic effects on confidence and expectation, that the consequent changes in availability and costs can collapse economies. There is a very good chance that the earth’s people, with the rest of the biosphere along for the ride, are heading toward a synergy of dramatic ecological and economic perturbation.

This is a possibility that we must not ignore. At the least we must, individually and collectively, consider what might be done to slow, stop and reverse the greatest damaging impacts that our species is fomenting. As a part of this consideration we, individually, should give thought to the likelihood that human beings, collectively, will not respond in even a palliative way, but will certainly respond in all the ways that history teaches us: with collective aid, empathy and compassion, all stirred together with hording, fear, xenophobia and war.

First a list of what would have to be done to really stop the damaging impacts. It makes sense to begin here; as when a person is sick or injured we look to see what help is needed rather than looking to our tool kit first to see what we might be most prepared to help with.

1) Lowered amounts of greenhouse gasses to levels that can be absorbed into the “planetary metabolism.”

2) Removal of emissions and other pollutants that cannot be “metabolized” in biophysical cycles.

3) Drastic reductions in release of sequestered heavy metals and naturally occurring system poisoning compounds by mining and other surface disturbing activities. This reduction would have to be to almost background rates.

4) Removal of most chemical species that are either foreign to, bio-mimics of or otherwise active on biological systems. This would include almost all pesticides, herbicides as well as many other common chemical compounds used as drugs, catalysts in plastic manufacture and others.

5) Stop the “industrial” changing of ecosystems with forest cutting, river damming and channeling, mountain top removal, many types and locations of roads. Add to the list various building, paving, waste sequestering, farming and other changes of established, adapted ecosystem uses of land and water spaces.

6) Reduce human per capita energy consumption to not much more than basic caloric intake from food.

7) Reduce human waste/pollution production to not much more than biological waste produced.

8) Reduce the total human ecological footprint to a level requiring no more than half an earth per year leaving fully half of the earth’s productivity for the other 10 to 100 million species that collectively create the stability of the biological part of the biosphere.

Before going into the extended consequences of some of these diagnosed requirements for the biosphere and constituent ecosystems to return to health, it needs to be clear: unless we do these things there is a very real chance that the biosphere with have a serious convulsive reaction from being so strongly put upon by damaging influences. If our conclusion is that we can’t or won’t correct them either in sufficient amounts or at all, then we will be saying that the price of our surviving and allowing the survival of the extant species and ecosystems is just too high. Now just how insane is that?

This a very challenging list. And it is no wonder that humans don’t want to admit its reality. But evidence is piling up at an exponential rate that these are the changes that confront us, assuming that we wish the earth, in something resembling its present assemblage, to sustain. Other questions have to be asked (and answered) before continuing: How much equity in hardship is expected or possible? Is allowing or manufacturing a great die-off of humans an option? Should humanity be attempting to maintain the largest possible population with low per capita consumption or a small controlled population with somewhat higher per capita consumption?

I am going to assume for this argument that there is humanity in humans; that reductions in consumption will be shared with some, though not perfect, equity; that population reduction will be accomplished more with education than with barbarity; that human adaptability and capacity will allow many, if not most, to make necessary changes once the way is demonstrated by a vanguard of people practiced in how to live successfully in the new conditions defined by the requirements for maintaining a healthy biosphere [2].

Begin with number 8. The only way for humanity to have an ecological footprint requiring ½ an earth’s productivity per year is for there to be quite a bit less than ½ of the present world population. Right now human beings alone are using about 1 ½ earth’s productivity per year and leaving nothing ‘on the books’ for the rest of life [3]. The evolution of ecosystems functions to make total life use one earth exactly. If humans use half an earth, then that should leave room for the rest of life to adjust and still supply adequate free services for a sustaining biosphere. The first step is to put the possibility and then the necessity in our heads to ponder.

There are a number of sources that discuss the difficulties of deciding the two primary variables determinative of population numbers: amount of per capita consumption (misleadingly called ‘life style’) and the percentage of total productivity that should be devoted to the human species. Depending on these and other variables, sustainable world population numbers have been suggested from .5 billion to 40 billion. I would select a sustainable population of about 1 billion living with an average per capita consumption rate of about 4 to 5 hectares productive capacity per year as a goal [4], but this a quite minor consideration for my purpose in this essay since we are presently a world of 6.8 billion with the richest millions of us using 20 to 100s, even 1000s. of hectares of capacity per capita while the poorest billions of us are using about 1 hectare of capacity per capita. It is a reasonable assumption that a human should have a minimum of about 2 hectares of productive capacity per year for health, safety and the possibility of fulfillment of basic human potential. The point is that over the next few decades many more people would have to die than are born. It is this fact and how it is accomplished that would dominate our experience.

The speed with which we must reduce population will be decided by how we treat the several other requirements for returning the biosphere to health. If the social expectation became the consumption associated with a 5 hectare ecological footprint and social sanctions were applied to those attempting to consume much over that amount and if real efforts were made toward the other 7 items above, it should be possible to reduce population without drastic measures. This would require the expectation of equity in consumption. Every other species of life on the earth functions on near equity of consumption; the consumption difference between the most successful and least successful living member of a species is seldom more than a few percentage points and almost never more than twice the average life sustaining amounts. This is a model we need to explore. (This essay will continue soon with part 2.)

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[1] I include in ‘fanatics’ the corporate/business and the political deniers who in their short-sighted greed for money and power ignore the evidence and champion the present patterns of consumption and growth.

[2] Other assumptions are just as reasonable, perhaps more so, but if we assume that humans will turn on each other without stint when the going gets tough, the aftermath of 7 to 9 billion slugging it out with everything from stones to atomic weapons would be the extinction event that our best efforts would be aimed to avoid. But such a conclusion to our evolution and adaptations is not certain.

[3] Of course, the rest of life is using the earth’s productivity for their own sustaining. Many organisms are reducing their already modest ecological footprint due to habitat loss and thousands are going extinct. This means that the total use of the earth’s productivity by all organisms is greater than 1 ½ earths by the amount being used by all non-human organisms combined. The difficulty in determining this amount is that all other organisms other than humans are in an integrated relationship with their ecosystems in which they compensate their every taking of productivity services in ways that support overall productivity. If this were not so, life would have long ago disappeared from the earth.

[4] In a classic irony we are reducing the earth’s productive capacity every day that we don’t actively begin to compensate for what we take from and the changes we make in the biospheric space. It may be that .5 billion or less will be the sustainable number by the time we act.

Don’t Do That… Again

Ross Douthat’s NYTimes Op Ed piece (2/15/10) attempts to give the impression of thoughtful balance, albeit from a Republican perspective. I have no idea if Douthat actually believes what he is saying, but have the sense that his “even handed” treatment of the limited understanding of the Democrats is mostly pretense. However, the essential error of the piece has little to do with the partisan bickering that passes for commentary.

There is no Free (sic) Market process either in place or possible… what we have currently in place is the ‘natural’ product of what has been called “free market” over the last half century. This is so obvious and simple: as groups of people come to accumulate wealth (and power) they use that wealth to strengthen their protection of it and in the process need more. In this positive feedback design even charity is a form of wealth protection just like a high wall or a locked vault.

People who enter this process of action and belief create ever more complex, opaque and effective designs to gather more wealth – this must include a public relations component to convince the Great Many that such accumulations are natural, essential and ultimately beneficial to all. Most end up believing their own propaganda and respond to rejection of their sophistries with the outrage of a zealot. This is especially problematic because of all the machinery that exists to respond with more wealth extraction, aggressive PR, power concentration and in-group identification.

The propaganda creates an ethic that wealth is good – at least natural – with the consequence that those who rise up to speak for and organize the cacophony of the Great Many are compromised by the wealth and power system that is in place – they become part of the PR arm of the elite; and if they can not be compromised, they can be frightened, marginalized as “nuts” or killed.

This is the reality that resides behind Douthat’s “Oh so reasonable and bipartisan” consideration of healthcare legislation. The question is not how can two (or more) rational and equally reasonable positions be compromised into a plan that will bring medical care to people in the most efficient and economical way; we have that answer from 30 other developed nations. But rather the question is: how can the current structures for accumulating wealth from medical services be left in place, or improved upon, while giving the impression that more services are being delivered to at least the more politically active in the society?

The argument between the Democrats and Republicans is over whether the wealth accumulators should have to give up a bit of the growth of their advantage or whether they should get a greater advantage in this moment of opportunity. This is called, in the linguistic Madness of our time, Socialism vs. Free Market.

Such arguments have to be replaced with a real ethical argument and it must be loud enough that it can be heard in the pauses of the media-dominated elite noise machine. Excessive wealth is not good, just like greed is not good. Wealth is not a condition, but a process that unprotects the tiny bits of wealth that actually productive people accumulate for their personal safety, unprotects with force, guile and law. The inherent form of such a relationship is enmity, thus the many war based metaphors of business.

Our present economic and political system unprotects the many tiny accumulations of those who actually add value to the objects and services of exchange and protects the accumulations of the moneychangers who position themselves at strategic points in the movement of wealth. This is a natural process in an unregulated world, natural like the build up of driftwood and silt in the bend of a river: the first random point to deposit a snag begins to reshape and build a stream bank that collects more and more until the force of a flood overpowers the design, resets the ‘established order’ and process begins again.

So long as we choose to live on the river bank or so long as we choose or must live in a complex economy we must regulate both for our safety. Wealth that exceeds about 10 times the average minimum levels for personal safety should be socially unacceptable, the pitchforked mobs on the march with torches in hand. That the medical industry grazes on the health needs and fears of the Great Many, and siphons off nearly 30 % of the Great Many’s medical payments into the paper work of insurance companies whose monetary incentive (forget human concern) is to deny medical care, that the 100 million dollar buildings housing these thieves are not being torn down with the bare hands of the outraged is remarkable.

No, Douthat’s argument is not some evenhanded, enlightened invitation to compromise with actual healthcare as the goal. It is a call to submission to wealth and power.

There is no going on from where we are now. There is only the flailing hopefulness of the hopeless. We see this in the insane recalcitrance of our political actors, in the unbelievably twisted arrogance of the economic elite and the madly mindless obsequiousness of the Great Many. Those with some purchase on reality are so marginalized and insignificant: they are like shrews in the forest – tiny, impossible to find in action, though occasionally a bone is found in the waste of a predatory bird or a discarded beetle skeleton with the marks of sharp little teeth. That is about how much evidence we see of real ethical and knowledge-based activism.

It is there, of course, just like the shrews, a ubiquitous presence of concern, distrust and potential activism, but its every move is countered by a predatory economic elite totally dedicated to the preservation of their entitlement. We have seen this before; when the Great Many finally have had enough they will, like dogs driven mad by mistreatment, attack indiscriminately, even (especially) each other. This is the bloody reality that boils beneath the maddeningly dishonest Op Ed machine and political playacting.