Monday, June 10, 2019

Is Abortion Good or Evil?

Genesis 11:1-9 New Revised Standard Version (NRSV) 1: Now the whole earth had one language and the same words. 2: And as they migrated from the east, they came upon a plain in the land of Shinar and settled there. 3: And they said to one another, “Come, let us make bricks, and burn them thoroughly.” And they had brick for stone, and bitumen for mortar. 4: Then they said, “Come, let us build ourselves a city, and a tower with its top in the heavens, and let us make a name for ourselves; otherwise we shall be scattered abroad upon the face of the whole earth.” 5: The LORD came down to see the city and the tower, which mortals had built. 6: And the LORD said, “Look, they are one people, and they have all one language; and this is only the beginning of what they will do; nothing that they propose to do will now be impossible for them. 7: Come, let us go down, and confuse their language there, so that they will not understand one another’s speech.” 8: So the LORD scattered them abroad from there over the face of all the earth, and they left off building the city. 9: Therefore it was called Babel, because there the LORD confused the language of all the earth; and from there the LORD scattered them abroad over the face of all the earth.

There was a time in America when we were one people. There was a time when nothing we proposed to do seemed impossible. Our communal tower touched heaven and we certainly made a name for ourselves. Since then, a different type of Lord, similarly threatened by our success, has confused our language in a new and more insidious manner to the point where we no longer understand each other’s speech, and a frustrated populace gave up on trying, reverting to primate screeching and screaming instead. It is painful to watch, and it is agonizing to participate in the decaying remnants of our once glorious public discourse.

This is not about who says tomato and who says tomahto. The modern confusion occurs when I say tomato and you hear cucumber. There is no way for us to cook some spaghetti sauce for dinner with my tomato, or tzatziki with your cucumber. I don’t understand why I should chop some dill for the sauce when basil and oregano are the obvious choices, and you have no idea why I’m trying to boil a big pot of water instead of grabbing that Greek yogurt container from the fridge. Salt and garlic are the only things we can agree on, although in vastly different amounts, but nobody can survive on salted garlic. And so, we end up yelling at each other, and eventually we both go to bed angry, exhausted and hungry, each one of us convinced the other one is a hateful idiot and a traitorous saboteur of dinners. The Lord has prevailed.

Today, when I say Socialism, I see a democratic nation with a generous welfare system and thriving private economy, like Sweden or Denmark. You see Cuba or Venezuela, with millions starving in the streets while murderous, mustached dictators are wallowing in palatial riches. When I say Capitalism, I see hundreds of thousands of businesses innovating and competing to serve their customers while creating a land of plenty for all. You see racist, bigoted, exploitative tyranny of a few billionaire owned corporations, employing slave labor tactics to enrich themselves further while the rest of us starve to death. And that’s where the conversation ends, and the yelling commences. There can be no further discussion, no objective analysis, no learning and certainly no compromise. From both our perspectives, this is a fight between Good and Evil. You don’t discuss things, let alone compromise, with Evil.


Now let’s discuss abortion, which is perhaps the ultimate example of how fake language acts as a paralyzing venom in service of our predators. If you listen to the public debate now raging on social media and all other media, you would surmise that the battle lines are drawn between two distinct camps. The “pro-choice” camp stating that abortion is Good, without any caveats, and the “pro-life” camp which insists that terminating a pregnancy is Evil, again with no caveats. If you propose to restrict abortion in some cases, you are enslaving women. If you suggest allowing some abortions in special circumstances, you are a baby killer. Both pro-choice and pro-life terms were carefully selected to make polite debate impossible. You cannot be anti-choice or anti-life without being Evil. There is no terminology for anything in between. Oh sure, you can launch into a tirade, but nobody will listen to Evil.

Fake language creates fake realities. Few if any Americans are absolutist pro-life or pro-choice. There is a spectrum of opinions and feelings that was rendered all but inaudible once the screeching, screaming and yelling has begun. Recent polls (grossly tilted towards non-religious people) show that while most Americans label themselves pro-life or pro-choice, only 27% (at most, and likely a lot less) are firmly entrenched at the ends of the spectrum. The remaining vast majority is somehow rendered irrelevant in the current shouting match. If you want to stay relevant in this circus, we call public debate, or rather electioneering politics, you must recite the precise words of the gospel. And when opposing gospel reciters meet, this is what Babel sounds like:

Pro-death: Government has no business telling women what to do with their bodies. My body, my choice. Male members of the old white patriarchy have no say in this debate anyway, because they don’t have a uterus. Besides, the Supreme Court decided this already and we have a constitutional right to abortion.

Pro-coercion: The Supreme Court decision was wrong and must be overturned. Abortion is murder. Plain and simple. You don’t have a right to murder other persons, even if they were not born yet. Killing a baby in the eighth or ninth month of pregnancy, by tearing her to pieces in the womb, and finishing the job after birth if she survives, is infanticide. Is that okay with you?

Pro-death: Do you seriously want to prosecute and jail a twelve years old girl who was raped by her uncle and got pregnant? Do you want to force little girls to carry babies? Those late abortions don’t really happen, except in extreme cases to save the woman’s life. It’s a far-right myth. You’re watching too much Fox News.  So that’s a straw man, but sure go ahead, I’m sure you don’t care if women die and children are jailed. 

Pro-coercion: Oh yeah, you go ahead, lecture me about caring for children, while you massacre hundreds and thousands of babies every year. And if that wasn’t enough, now I’m supposed to finance your Commie holocaust. F*** off….

Pro-death: You’re the biggest hypocrite I’ve ever met, and a liar too. If you care so much for children, how come you refuse to fund public education and early childhood programs? How come you keep sending so many black boys to prison? You’re just a racist Trumpkin, in addition to clearly being a rabid misogynist, and I bet you love putting immigrant children in cages too. You can f*** off yourself… Idiot…

And on and on it goes. Note that both sides put forward reductio ad absurdum arguments, while responding solely with tangentially related ad hominem attacks on their interlocutor. Why is that? Well, maybe it’s because nobody in their right mind can defend imprisoning twelve-year-old rape victims, just like nobody in their right mind can defend terminating a perfectly good baby five minutes before it is due to be born. It is disheartening, but it is also a good sign that we haven’t gone completely mad just yet. Another thing to notice is that on both sides people are either not fully aware of simple facts or would much rather conduct this Babylonian conversation on a fact-free emotional level.

Did you know, for example, that when the Roe v. Wade decision was issued, plenty of progressive voices found it poorly reasoned and even counterproductive? None other than Justice Ruth Bader Ginsburg is on the record saying that “the Court ventured too far in the change it ordered and presented an incomplete justification for its action”. Now make no mistake, RBG is staunchly pro-choice, but the Court may have done more harm than good here, by impatiently stepping out of the judicial lane and into the legislative one, at a time when progress was slowly but surely being made in various States.

Did you know that in Roe the Court asserted that a woman’s right to an abortion is “fundamental”, but only for the first three months of a pregnancy and only in consultation with a physician? After that the State has its own rights to intervene with or outright deny this fundamental right, due to competing interests. Later, in Planned Parenthood v. Casey, the court discarded the medically outdated trimester framework and introduced a dynamic “viability” concept, bolstering the power of States to interfere with a woman’s fundamental right to an abortion, as long as no “undue burden” is imposed on the woman. Neither Roe nor Casey are giving women full rights to terminate a pregnancy whenever and however they see fit. Both Roe and Casey grant States the right to curtail reproductive autonomy of women, if they so choose.

In 1973 the Court decided Roe with a clear 7 to 2 majority. Ten years later, in Casey, the Court splintered into multiple plurality opinions with only one narrow 5 to 4 majority decision to uphold Roe with adjustments in favor of the States. I can’t even begin to guess how the lines will be drawn if an abortion case comes before the Court today. We share this country with one third of a billion other people. Societal consensus on important issues is rare, difficult, and takes decades if not centuries of patient and serious discourse to build. That’s why we have fifty States. We either relearn how to meaningfully communicate and compromise with each other or we will perish in most unnecessary and painful ways.

Wednesday, June 5, 2019

Health Care is a Risky Business

For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.

It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before.  The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.

At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.

Managing the Health Care Consumer

The most blatant attempt to throw people under the bus is the insanely brazen effort to remake medicine into a consumer industry. Patients, according to the narrative, are empowered when they spend their own money on health care. Increasing deductibles for health insurance, while also increasing premiums and limitting choice of service providers, is how we weaponize sick people in the war against rising health care prices. If enough diabetics choose to die rather than overpay for insulin, prices for the drug will surely go down eventually, because Southwest Airlines will come up with a disruptively innovative version of insulin that will not be as fancy, but it will be cheap enough to spur increased market participation and push Eli Lilly into bankruptcy. Any day now.

The return to pre-1965 days of consumerism in health care for the first $6,000 of medical expenditures was a good step forward, but the road to fully optimized profitability is long and full of terrors. Consumers are like goats. If left to their own devices, they will destroy your landscape in five short minutes. However, with proper guidance and supervision, they will clean and protect your property from the dangers of random wild fires. Managed Care insurance plans, coupled with high deductibles, ensure that consumers do not eat into your nice profits, while consuming enough garbage to keep your bottom line from going up in smoke.

From Volume to Value

Offloading risk to sick consumers is working relatively well by all accounts, but it is not working well enough, and it is not working for beneficiaries of public insurance where the consumer lever is rather short and limp. And so, we push the “provider” lever next. Once patients became consumers, their doctors, naturally, became providers. And just like empowered consumers, empowered providers should have some financial skin in this game. In the current system, you see, providers are just sitting there, placidly watching the register go cha-ching every ten, fifteen minutes like clockwork. If the consumer gets better, fine. If not, also fine. As long as there are no malpractice lawsuits, and the cash keeps flowing, providers are surely satisfied. How do policy makers and garden variety health care experts know this? Simple. It’s called projection.

Moving “from volume to value” does not mean moving from indiscriminate overconsumption to eclectic consumption of excellence. It means moving from lots of variably priced stuff to small amounts of cheap stuff. It means moving from assumed abundance to assumed scarcity. If you can find excellence at the Dollar Store, good for you. If you can’t, well, whatever. Saks Fifth Avenue is out of bounds. And your provider is supposed to enforce those boundaries, at his or her own risk. If you manage to sneak into Saks, your provider will be punished. If you stay where you belong, your provider will be rewarded. Simple. It’s called stewardship.

Global Budgets

This is not fair. Obviously. These very clever risk levers are based on wealth, and since we have massive wealth inequality, the levers are largely discriminatory. Wealthy providers couldn’t care less about adding or removing a dollar from each patient visit. Poorer providers can be driven out of business by a fifty cents difference in “reimbursement”.  Wealthy patients don’t have to become consumers at all. For patients who are not wealthy enough (or poor enough), even the Dollar Store is cost prohibitive. There is too much privilege at the top. The only fair solution is to shut down Saks Fifth Avenue completely. If everybody is forced into the Dollar Store, eventually the Dollar Store will get better. It will become as good as Saks, but at $1 prices, because the wealthy will demand it. Right. 

Shuttering the Saks Fifth Avenue of health care is hard. You can’t just show up at Bayonne Medical Center one morning with a wrecking ball and have at it. Fortunately, the Medicare For All aficionados have a solution: Global Budgets. Once the Federal government controls all health care dollars, they give Saks Fifth Avenue a fixed amount of money to service all their customers for the year. The amount of money is calculated based on Dollar Store costs, with a little markup perhaps, so we don’t appear overly vindictive. Within a few months, you won’t be able to tell the difference between a Saks store and a Dollar Store, except maybe the crumbling fa├žade from a bygone era. That’s how we rid ourselves of inequality and excess privilege, of course.

Remember when Paul Ryan and his evil acolytes proposed replacing the open-ended Medicaid financing model with block grants to States (i.e. fixed amount of Federal money to service all their Medicaid beneficiaries)? There is a one hundred percent overlap between the people who screamed about millions dying in the streets if Medicaid moves to block grants, and the people now climbing the Medicare For All barricades in support of global budgets. Rationing medical care for the poor, or “by ability to pay”, is immoral. Rationing medical care for everybody, regardless of ability to pay, is righteous. Simple. It’s called justice.

A Permanent Solution

It is not surprising that health insurance companies would look out for their bottom line at customers’ expense. After all, these are insurance companies, like home insurance or car insurance, which are notorious for continuously devising innovative ways to minimize current and future payouts. Perhaps it is also not too much of a shocker to see that government is at its best when working to eschew commitments made to its citizens. What should however give you pause is that both government and health insurers seem to have finally found a good way to coopt physicians into doing their bidding. Not all physicians, of course, but more than enough to make a permanent difference in the practice of medicine. Either due to misplaced fear or newfound conviction, your doctor’s prime directive now is to do no harm to the United States Treasury and the corporations for which it shills.