Socialized Medicine: Utopia or Dystopia?

Rep. Utt (R-CA) said this about Medicare in 1965.

First, what is it?  That's right, do you know what socialized medicine is?

A better question, perhaps, is what people mean when they use the phrase.  The simplest definition is a system of health care for all paid for with public funds.  Providers (which means doctors, hospitals, and everyone else who renders health care to patients within the system) provide the care, and it is paid for with money that comes from taxes.  In its pure form, then, there is no health insurance, there are no bills, and there are no deductibles or copays.  You, as a human being in need of health care, consult me, a physician; I take care of you; no money changes hands; the government pays me, using public dollars (tax revenues) for what I do.

There is a lot more information on what people use, and have used, this term to mean, including complete control by the state (meaning the government) of the health care system.  Depending on how you view the government - is it competent, reliable, trustworthy? - the thought of a government-run health care system may hold more or less (maybe even zero) appeal for you.  But in its most basic sense, the essence of what I'm writing about here is public financing of health care, which can occur within but does not require a health care system that is operated by the government.  So, for example, the Medicare and Medicaid systems are financed with public dollars, and the Veterans Health Administration is operated by the government.  Right there you can see how a broad spectrum of opinion might be generated on the idea of the government doing things.  The VA has its admirers and critics - recently mostly critics, because of failings in looking after the health care needs of veterans, and Medicaid has more critics than there are crystals of salt in the ocean, it seems, while Medicare gets pretty high satisfaction ratings from seniors.

The USA is, in many ways, fundamentally opposed philosophically to the very idea of socialism, because it seems to require Big Government.  Most (but certainly not all) of our Founding Fathers were mistrustful of the idea of a powerful central government.  During the 19th Century there was vigorous public debate over whether the government should be involved in, and spend public dollars on, "internal improvements" such as roads and canals.  After the development of an Interstate Highway System in the 1950s it may seem odd to us that in the first half of the 19th Century many were opposed to giving this sort of power to the federal government, and foremost among the opponents, perhaps, was President Andrew Jackson.  Some of my readers may recall that Jackson was also the last president during whose administration the national debt was paid off, so support for or opposition to public spending has obvious potential implications.

Aside from basic mistrust of Big Government by some, there is concern about Big Waste by the feds.  After all, can we trust public financing of health care by the same government that paid $600 for a hammer?  (By the way, the $600 hammer is a myth.)  Well, Medicare is, by any measure, less wasteful than just about any private health insurance enterprise, in that it spends a higher proportion of every dollar on health care, with less going toward administration and zero going to profit.  The role, or lack thereof, of profit in the health care system and the way we finance it is an important part of the consideration of "socialized medicine."  That could be the subject of a very lengthy essay all by itself, but if you believe the profit motive is bad in this context, I submit that socialized medicine is the only way to eliminate it.

Physician satisfaction with Medicare is another matter altogether, and many doctors are opposed to socialized medicine largely because of their frustrations with Medicare.  Medicare, they believe, pays too little for their services and requires them to do a great deal of useless clerical work to collect what they do get.  Ironically, that should be part of the attraction - not the repulsion - of socialized medicine.  Medicare irritates me as much as it does any other doctor, mostly because I'm a pretty irritable fellow (also known as a crank).  But if we have a system in which all health care is financed with public dollars, the reasons for most of what Medicare does that annoys doctors could (and should) disappear.  In the system I envision, I could be paid for taking care of patients in a way that wouldn't require me to provide documentation of everything that was done or doing all sorts of clerical work (or paying others to do all that) to submit claims to an administrator.  I could go back to putting information about my caring for the patient in the medical record for its original purpose: communicating with other people who are also caring for that patient or who will in the future.

Now wait a minute, I can hear my physician readers saying.  The only way that could happen would be if I become a government employee.  That isn't necessarily so, but it does require a system in which money is allocated for the health care of the general public and is paid to the providers of that health care without being based explicitly on the exact services provided.  That doesn't require that doctors be government employees, although that is one approach. What it does require is a fundamentally different approach to financing health care from what we have now.

Doctors aren't necessarily the only ones leery of physicians being employed by the government.  Many of us like to quote, derisively, the imaginary expression, "I'm from the government and I'm here to help you," as if those two things couldn't possibly go together, and anyone who says such a thing should be viewed with a mixture of amusement and paranoia.

But we don't have a problem with firefighters being government employees.  Or the Coast Guard.  Or air traffic controllers.  Or any number of other people we trust with our lives.  So we certainly shouldn't assume that doctors who are government employees would be in any way inferior.  The patients in the VA system do not, as a rule, have a problem with the quality of the doctors but with the system that lacks the capacity to care for them.  As a nation we recognize that shortfall, and we are demanding it be remedied.  If we had a system for everyone that had inadequate capacity, how quickly do you think we would demand - and get - action to remedy that?

Many who deride socialized medicine look to the United Kingdom's National Health Service and say people wait weeks or months for elective surgery, and Americans won't tolerate that.  Three things you should know about that.  First, Americans with no health insurance don't wait weeks or months for elective surgery.  They wait forever.  And that is unacceptable in the wealthiest nation in the history of the world.

Second, the satisfaction of the Brits with the NHS is higher than our satisfaction with our non-system, regardless of any of the (exaggerated) claims about their waits for elective surgery.  Third, per capita spending on health care in the UK is half what it is in the US.  I am entirely unwilling to believe we couldn't create a system that covers everyone with what we're spending, with high quality and no long waits for anything.

[What we have now, instead, covers 85% of our population, many with woefully inadequate health insurance that has ridiculously high copays and deductibles, and leaves 15% (perhaps a bit less now with expansion of Medicaid under "Obamacare") with nothing.]

If you think we can't do that, I must ask you why.

There are two possible answers that come immediately to mind.  The first is that we are a lot dumber than the Brits, and although that is possible, I don't think so. The second is that we cannot do that without eliminating all of the waste associated with having a for-profit health insurance industry, in which many dollars intended to be spent on health care are, instead, spent on administration (twice what the government spends for Medicare administration), and profit, and seven-figure executive salaries.  If you guessed that the second possibility may really be a big part of the problem, go to the head of the class.

I must now ask you to consider a simple question.  If you work for a living and have employment-based health insurance, it's called a benefit of employment. That means you worked for it.  You earned it.  And every dollar that you earned that is spent on health insurance premiums is, in principle, a dollar that should be spent on health care.  Looked at the other way, every such dollar that is not spent on health care is a dollar wasted.  So, every dollar that a health insurance company diverts to profit, to eye-popping executive salaries, and to excessive administrative costs is a dollar wasted.  Looked at even less charitably, every such dollar spent on those other things is a dollar stolen from you.

The solution?  Eliminate the health insurance industry.  If we do that, we must have a new way to finance health care.  What would that be?  Re-read the first two paragraphs.  And now you know the answer to the question posed in the title of this essay.  Utopia or dystopia?  Neither.  It is, plainly and simply, what we must seriously consider if we hope to have a system for financing and providing health care that works for everyone, rather than the absurdly fragmented and wasteful non-system we have now.

Feel the Bern

Many of you who have been victims of Facebook's facilitation of my political proselytizing are now keenly aware of my support for the candidacy of Vermont Senator Bernie Sanders for president.

What follows are a few thoughts I shared with another FB poster, someone I don't know and have never met and likely never will.

To offer context, much of it is rooted in comparison with Hillary Rodham Clinton.

My correspondent thinks Hillary has a more refined understanding of foreign policy issues than anyone else in the race.

It is possible to have the most refined understanding and still be wrong.  I think my understanding of the Levant (an almost forgotten term resurrected by John Kerry) is more "refined" than that of most Americans, and I thought the invasion of Iraq might actually accomplish something useful.  I thought the long-term outcome could be a stable democracy in Iraq that would help the entire region move forward toward peace and security.

I was, I now believe, flat wrong.

I'm not sure we know what Hillary thought about it over the last dozen years, or even what she truly believes now.

Sanders, on the other hand, thought it was a mistake even when Iraq was still called Mesopotamia, and he has (wisely) seen no reason to change his mind.

I like a man who chooses positions on issues wisely.  Is he a foreign policy geek?  Perhaps not.  Can he be trusted to make sound foreign policy decisions, faced with an array of complex options?  I believe so.

Then I was reminded of the undeniable advantage of the experience of having served as secretary of state when a foreign policy crisis arises.  So here we are at the campaign commercial about the 3 AM phone call again, only then (2008) Hillary's experience didn't yet include service as a member of the cabinet.

There were plenty of people who thought the peanut farmer from Georgia would be clueless about foreign policy, and many people still blame him for some of the mess that developed in Iran with the overthrow of the Shah.  But that was only the first draft of history, and he is now getting credit for the lack of US involvement in war during those years, so perspective is an ever-changing thing.

My partner in this discourse then wondered "what this wonderfully principled man (Sanders) would be able to accomplish with a Congress full of loons."

I like a man who can be described as "wonderfully principled," I think he can get elected if people will step out of their echo chambers, or take their fingers out of their ears and stop saying "LA-LA-LA-LA" and just listen, and I think a Congress full of loons can be bent to the will of a president who gets the people behind him.

Were you listening when Sanders reminded us that the Walton (Walmart) family has more wealth than the "bottom" 140 million Americans?  What about when he talked about how it is unconscionable that the average American college graduate has to work many years to be free of the burden of educational debt? (So, don't go to college?  Not everyone is cut out to be a plumber or an electrician.)  Were you plugging your ears, because you have a job with health insurance as a benefit - although you have to pick up the lance and the shield to get them to pay for stuff - when Bernie called us out as the only First World nation without universal access to health care and a rational mechanism for funding it?

Perhaps inevitable is the skepticism about whether Sanders could accomplish much of anything as president, given the dominance of the Republican obstructionists in Congress.  Seriously, have you been paying attention to the monkey-wrench-in-the-works approach of the House Freedom Caucus, that group of 40-odd far-right congressmen prepared to shut down government to prevent continued funding for Planned Parenthood, settling instead for the resignation of John Boehner as speaker?

Well, the same question could be asked about any Democrat, although one might imagine Hillary learned something from Bill's experience in working with Newt Gingrich.  But this is not 1994.  It's far worse.  And my correspondent noted that the current occupant of the Oval Office campaigned on a theme of change and has been stymied more often than not.

That is a fair point.  But Obama disappointed me by putting his oratorical skills on the shelf after he won the election in '08 instead of using them to shape public opinion and get the people to turn the flames up high under the derrieres of Members of Congress.

No, instead he chose to try to work with a Congress that is controlled by the wealthy, the powerful, and the multinational corporations.

Obama knew when he took office that pursuing his agenda would take a revolution.  Sanders knows that, too.  Barack didn't follow through.  I'm convinced Bernie would.

Realizing that the perspective of the "opposing" argument must seem awfully gloomy, my debate partner then simply admitted inability to share my optimism. I was ready with a reply to that:

You can share my optimism.  I have plenty, and would be more than happy to spare some for you. You may have some difficulty sharing my vision, but when I look at Bernie, I see a man with integrity, high principle, and the courage of his convictions.  I see a man who is willing to be the TR of the third millennium, to launch peals of thunder from the bully pulpit and stir the masses to demand reform, to bring low the high and mighty who use their wealth and power for nothing but the accumulation of more wealth and power.

It is time to use the federal government for something important and worthwhile: to rebuild the middle class and to bring many of the poor up into that middle class.

Today's corporate robber barons don't even have the redeeming virtues of Rockefeller or Mellon or Carnegie, who realized they had an obligation to use a substantial chunk of their amassed wealth for philanthropy, building institutes and universities and endowing museums, even if it may have been partly to get their names all over them.

No, now it is all about wholly unrestrained greed, accumulating wealth for its own sake.  It is inviting revolution.  That revolution needs a leader.

HRC might be a good president.  She will never lead a revolution.

Bernie Sanders, that Brooklyn-born independent thinker from Vermont, is the man for the times. 

Is Law Enforcement Racist?

A teenager named Michael Brown was shot dead by a police officer in Missouri last summer.  He was black.  The officer was white.  The youth was unarmed. Conclusions were drawn that were likely inevitable in a country in which race relations have their roots in the enslavement of Africans, brought to the New World to perform hard, forced labor.

Was this really about skin color?

Rewind to the early 1970s.

I was a teenager in Philadelphia, a student at an academic high school then considered one of the best in the country.  One day after school I was waiting at the bus stop on the edge of the school's grounds.  Some time in the last day or so a car had struck the pole holding the bus stop sign, which was now bent over to an angle of about sixty degrees with the pavement.  I straddled the pole and leaned back against it, there reclining while awaiting the bus.

A police cruiser stopped, and the officer, disturbing my reverie, barked, "Get off that pole!"  I looked in his direction, perplexed and a bit annoyed.  "What?"

"Get off that pole!  That's destruction of public property!"

I said the '70s equivalent of "Dude?  Seriously?" - explaining that the pole had obviously been hit by a car, and it was ridiculous to think that I had the strength to bend this solid metal cylinder.

The officer was disinclined to engage in thoughtful discussion.  I had questioned his authority.  He ordered me into the cruiser and drove to a police station, where I was placed in a holding cell.  A few hours later my mother appeared to pick me up and take me home.

I was not arrested or charged, and I acquired no record of violating the law.  I did, however, learn a valuable lesson about what is, and what is not, a sensible way of responding to an order from a police officer.  Questioning authority is risky.

A young man in Missouri last summer was told by a police officer to get off the street and walk on the sidewalk instead.  His response, like mine, was to question authority.  I could have told him that was a bad idea.

The sequence of events that followed was tragic - and resulted in the young man's death.  A grand jury spent many hours hearing testimony and reviewing physical evidence and drew the conclusion that there was insufficient evidence to indict the officer.  I have not heard the testimony or reviewed the evidence myself, and so I cannot draw an independent conclusion.  News reports suggest to me, however, that the investigation was thorough, and our legal system must be trusted to reach conclusions that are fair, even if they do not satisfy everyone - indeed, even if they satisfy no one.

The reaction in Missouri to the shooting last summer included looting and rioting.  The reaction to the the grand jury's conclusions has been worse: more rioting, more looting, numerous cars and buildings set ablaze.  The property damage will likely total in the millions of dollars.  The damage to the collective psyche of the community cannot be tallied.

The population of Ferguson, Missouri is about two thirds black.  The police department, nearly all white, has only a small handful of black officers.  The fact that the officer was white and the young man questioning his authority was black was, as a matter of statistical probability, to be expected.  One can argue that a police force should mirror the community it serves.  But often it does not, and yet the police and the citizens must still engage each other in ways that are positive and constructive.

Michael Brown, according to the accounts available to the public, not only questioned authority but responded in a hostile, aggressive manner.  There was a scuffle.  Brown's conduct was described as threatening.  The officer said he feared for his physical safety.  Brown was a big fellow, with an intimidating physique.  His size, and his behavior, were such that the fact that he was unarmed did not figure into the officer's reactions.

Michael Brown has been variously described as a congenial and docile boy and as a thuggish delinquent.  We have all read the news accounts and have drawn at least some tentative conclusions of our own as to what he was really like.  But we did not know him, and we did not know officer Darrin Wilson.

It is easy to believe that what happened between Brown and Wilson was largely determined by the color of their skin, or by the tension between law enforcement and the community when the police department and the citizenry are demographically on opposite sides of a racial divide.

I do not doubt that race can be a factor in such incidents. But this particular incident started with a response by a teenager to a command from an officer of the law.  That response was not one of respectful obedience.  A response by a teenager to a police officer that is not one of respectful obedience is a bad idea.  I learned that the easy way, if spending a few hours in a holding cell and then having to explain oneself to a mother who was every bit as authoritarian as the police officer can be described as easy.

But compared to what happened in Ferguson, Missouri last summer, my lesson came cheap.  Michael Brown is dead.  And last night Ferguson was ablaze.  It may be partly about race - anyone who says race played no role is naive and will be branded a fool.  But it is also about teaching our children that the command, "Question authority" comes with a responsibility to do so prudently. It is not something to do in interactions with police officers to whom we have assigned the responsibility to exercise authority in maintaining order in our communities - and who must spend all day, every day, dealing with persons who question authority, often in belligerent ways, and sometimes in ways that put an officer's personal safety at risk.

We have much to do in this country to bridge the racial divide whose roots go back to the slave trade.  Thomas Jefferson, prescient in his foretelling of the Civil War, said the question of slavery awakened him with terror, "like a fire bell in the night."

A century and a half after the Civil War, that bell is still ringing, and the fires are still blazing, this time in Ferguson, Missouri.  We had better get to work.

The Star Spangled Banner

Lately I have seen some graphics posted in various social media about "The Star Spangled Banner," specifically about the notion that its place as our national anthem should be reconsidered.  On Facebook I have been repeatedly urged to "like" a graphic if I think we should keep it.

I can't say I ever gave much thought to whether it should or shouldn't be the national anthem.  I am a bit of a history buff, so I always found interesting the fact that the lyric was composed by a lawyer (Francis Scott Key) held prisoner aboard a British ship in Baltimore Harbor during the War of 1812, with "bombs bursting in air" and "rockets' red glare" over Fort McHenry.

As many of my readers know, but some likely have forgotten (or never learned), the lyric was much longer (four stanzas) than what we usually hear or sing (just the first).

This past weekend was the bicentennial of Key's composition of the lyric. While there were surely some festivities in Baltimore, if there was much attention paid to the fact that "The Star Spangled Banner" is now 200 years old in the rest of the country, I missed it.

Fort McHenry

Some years ago a junior reporter (from the New York Times, if memory serves) conducted a person-on-the-street survey, asking people questions about our national anthem.  The format was multiple choice, which means the answers had to be only at what educators call "recognition level" in the minds of respondents.  In other words, it's easier to pick Francis Scott Key's name from several possible choices than it is to remember it if the question is fill-in-the-blank.

Not surprisingly, most people could do that.  But the results were much worse when they were asked during what war it was written, the occupation of the man who wrote the lyric, or what harbor the ship was in while he was being held prisoner on it and was inspired to compose.  As I recall, the War of 1812 came in last, behind several other choices, and so did Baltimore Harbor, despite the fact that one of the other choices was Omaha, which is on the Missouri River (and has another river, the Platte, to its west) but doesn't actually have a harbor. Baltimore also trailed San Francisco, but if you picked the wrong war, you probably wouldn't know San Francisco wasn't a city in 1812 and that as a city its name was Yerba Buena until the Mexican War (1840s), as a result of which it became part of the United States.

The medal on the right reminds us this was not a one-year war.

The more I thought about it, the more I realized that our attachment to our national anthem might be based on nothing more than sentimentality.  Just as most people didn't seem to know it was composed during a battle in the War of 1812, I doubt many are aware it was officially adopted as our national anthem in 1931.  I shudder to think how many people never really give any thought to the meaning of the words.  The lyric is about how our flag flew over Fort McHenry during the battle and served as a symbol of this fledgling country's determination to endure and to survive what was, in essence, its second war for independence from Great Britain.

We do have a certain obsession with our flag.  As a child, not only did I have to sing the national anthem from time to time - which for a boy who (according to my sister) needed a basket to carry a tune often meant mouthing the words while others sang - but I recited the Pledge of Allegiance (to that star spangled banner) every morning in school.  I have no trouble understanding this.  Frankly, I think our national banner, spangled as it is with white stars on a blue field accompanied by 13 red and white stripes, is the best looking of all national flags.  I admit to a certain nationalistic bias, but that's what I think, just the same.

A Canadian friend
once called out
"God Bless America"
upon seeing a woman
dressed like this.

But the idea that we should replace it with another song as our anthem has been around for quite some time.  People have complained that it's too hard to sing, and even though we typically sing only the first of the four stanzas, many still have trouble remembering the words. Furthermore, in the last generation or two it has been fashionable to show a distinct lack of respect for our flag.  We all know about the controversy over the words "under God" in the Pledge, but as long as I can remember there have been people who didn't want to pledge allegiance to a flag at all.  Maybe "to the republic for which it stands," but not to the flag itself. People have insisted on making articles of clothing out of the flag, or at least wearing articles of clothing made to look like that, which is deeply frowned upon by traditionalists and is technically a violation of US law (the Flag Code), although the Supreme Court has told us violations of the Flag Code are protected by the First Amendment.  And of course the extreme version of disrespect, burning the flag, is also a form of expression protected by the First Amendment.

This kind of flag burning, a
flag retirement ceremony, is
appropriate for worn-out flags.

Yet, despite all this belittling of our flag, we continue to pledge allegiance to it and (at least try to) sing Francis Scott Key's ode to it in his lyric.  I'm convinced it's a matter of tradition.  Frankly, I even think at least a little bit of the opposition to statehood for Puerto Rico or the District of Columbia stems from the fact that people like the flag with fifty stars and don't want to see it changed.  (But, hey, if the Big Ten athletic conference can keep that name through the addition of teams - now up to fourteen! - we wouldn't really have to add more stars.)

Having thus decided that tradition and inertia account for our attachment to it, I looked about for reasons to change it - perhaps to "America the Beautiful," a popular homage to this great land that one could argue is about our nation and not about its flag, or war.  (The trouble with that song may be its repeated references to God, a drawback also to "God Bless America," sure to raise the ire of those who insist upon "freedom from religion."  Even "Hail, Columbia," which was often used as an anthem before the official adoption of "The Star Spangled Banner" in 1931, is a song about war with religious overtones and mention of God.)

Edward ("Ted") Widmer, an historian (Harvard Ph.D.), wrote an illuminating article on the subject for the online magazine Politico, in which, after the obligatory mention of the music being that of an old English drinking song rather than composed originally for our anthem, he gets to something of real substance: namely that Key was a slaveholder (and vigorously defended the "peculiar institution") and that the lyric (in the third stanza) makes reference to fugitive slaves who fought with the British in that war.

Widmer does a fine job of assembling the arguments in favor of change and seems to favor "America the Beautiful" as a replacement.  Although very much a traditionalist myself, I would not object to serious consideration of doing that.  I would, however, insist that the lyric be adopted in present form, with no mucking around to get rid of the phrase "God shed his grace on thee."  Given that we live in a time of tension between Christians and atheists, the former would surely agree with me on that, and the latter would strenuously object.  So I think "The Star Spangled Banner" is going to remain our national anthem.

One of my favorite "fun facts" about the War of 1812
is that the Battle of New Orleans, which made a
war hero and future president of Andrew Jackson,
was fought after the war was officially over.
No Twitter back then to give him the news.

A Marxist Minimum Wage?

This morning I read a comment on social media about the minimum wage - specifically about the notion that some fast food workers are asserting they should be paid $15/hour.  This is a fascinating subject in economics. Not just because economics is fascinating - which it is to me, but not to most people - but because it's one of those issues in economics about which virtually everyone has an opinion.

Those who support a higher minimum wage note that it is not a "living wage."  Certainly someone earning minimum wage with no benefits would be challenged to support himself at today's price levels, never mind any dependents.  But of course life is not that simple, because a person with that level of income may be eligible for public assistance in various forms, including Medicaid, housing subsidies, SNAP (food stamps), etc.

Those opposed suggest that minimum wage is not really supposed to be a living wage, not when it is paid to people in entry-level jobs often held by teenagers or part-time workers adding to a family's income.  Trying to figure out just how many people there are who are really struggling to support themselves as independent adults at minimum wage jobs is a bit of a challenge.  But it seems to be enough that we can agree we are not just talking about burger-flipping high school kids making money to pay for their social lives and give their parents a break.

Karl Marx is famous for (among other things) having popularized the expression, "From each according to his ability; to each according to his need."  In the conception of many, this means we should all contribute to society in the manner of which we are capable, and our economic reward should be based on our need for sustenance.  Thus if I have the innate ability to master the knowledge and skills required to practice medicine and my neighbor's natural attributes are suitable for driving a bus, those are the things we should do.  But my needs in life are inherently no greater than his, and so my income should not be (as it is in the United States) substantially higher.

How does such an economic model work with human nature?  I've never driven a bus, but I have driven a truck (delivering newspapers), and I can tell you it's much less mentally demanding work than practicing medicine, and there are some days when I'd gladly switch to doing that if it paid the same as being a doctor.  It wouldn't be intellectually challenging or rewarding, and in some ways it is physically more strenuous, but overall I'd have to say it was a much easier job.

In our economy, with market forces, one of the things motivating people to enter professions that require high levels of intellectual ability and many years of education and training is money.  Those professions are financially rewarding. Are there plumbers who earn as much as pediatricians?  Sure.  But, by and large, the jobs that require a lot of smarts bring bigger bucks.

We want the best and brightest of our nation's youth to enter professions like medicine.  (We can argue about some other high-paying professions.  For example, there seems to be general agreement that we need more engineers and not so many lawyers, so maybe we should look at incomes for those professions.)  If physicians are paid no better than manual laborers, how will we create a society in which young people with the innate ability to become doctors choose that path?

Thus, the first - and arguably most important - question is whether the minimum wage should be adjusted so that it is a living wage.  That seems a no-brainer, unless there is a downside.  Surely there is a downside.  Let's look at the worker at the fast food restaurant who earns minimum wage.  If that wage is raised - without any increase in revenues to support it - where will the money come from? Will the restaurant simply lower its profit margin?  Unlikely, unless there is sufficient competition to make raising prices unwise, and profit margins are currently ample, making a reduction acceptable.  But if all fast food restaurants are affected the same way by an increase in the statutory minimum wage, then most likely all will raise prices.  (For those of you who are aware of how things are different in other countries, I'm staying away from that because it makes the analysis even more complicated than it already is.  For those of you interested in the comparison, see this essay from Denmark.)

This concern can be generalized.  If the minimum wage were raised for all, would that not put upward pressure on prices, meaning there would be inflation, with the corresponding reduction in purchasing power, so those earning minimum wage wouldn't really be better off after all?  The short answer is no.  You see, most of us earn more than minimum wage, so if we raise that wage, the upward pressure on prices is limited because most people's wages are not going up.  So there might be a little inflation, with a very modest effect on purchasing power, so those earning minimum wage still benefit substantially, while the negative effect on everyone else is quite small.

What about the burger?  If you tell Burger King it has to pay its minimum wage workers 40% more (the effect of raising the minimum wage from $7.25 to $10.10), won't the price of a burger go up 40%?  Again, the short answer is no, because the wage paid to employees, especially only those earning minimum wage, is a relatively small contributor to the price of a burger.  Would the price of a burger go up?  Probably - but probably only a little.

What about the possibility that workers would be dismissed?  There may be some sectors in which that is a real possibility.  Burger King is not in one of them. BK employs the number of people it takes to do the work.  No more, no less. They cannot really schedule fewer workers because they're paying them more, because that would mean worse service and loss of business, unless their workers suddenly became more productive, which is unlikely.

I think this analysis makes it pretty clear that raising the minimum wage for many workers at that level will do far more good than it would have any significant downside.

And that brings me back to the consideration of economic incentives.  As is evident from this essay - and more so to my regular readers - I have a special interest in health care.  Suppose a new high school grad can get a job flipping burgers for $15/hour.  Alternatively, she could enroll in the local community college and get an associate degree to become a paramedic.  The second option costs money and takes 15-18 months of serious study.  In many places in the US, paramedics don't get paid more than $15/hour.  You can say that being a paramedic is much more emotionally rewarding than flipping burgers, but it takes education and training to get the job, and it's hard work.  (Also, there are many websites devoted to the frustrations of work in EMS and the abuse of these folks by their patients, so I'm concerned about how many of them would chuck it all for a job at Micky Dee's if the money were no different.)

Notwithstanding our philosophical attraction to egalitarian principles, there is a lot of class warfare in this country.  Some of it is between the rich and the poor, and there is much angst about the growing gap between them.  The US has unequal distribution of wealth to a degree substantially greater than other First World nations.  Corporate CEOs are paid hundreds of times what their line workers earn.  But I am most intrigued by the class warfare between those who are much closer to each other - between the poor and the lower middle class, for example. So, the person who earns $15/hour and works hard for that money may find it truly irksome that the fellow flipping burgers should assert a right to the same pay.

But the most serious macroeconomic problem we currently face, in my view, is not that the minimum wage is too low, but that employment is too low.  Forget the unemployment rate, which is a meaningless number if ever there was one.  Look instead at the labor force participation rate, which has been on a slow but steady decline over the past decade, and which shows that for every five people currently working, there are three others who should be but aren't.

What's the connection?  This dismal statistic powerfully influences my view of the minimum wage debate.  We can talk about whether the high school kid flipping burgers deserves $15/hour, or even $10/hour, and I won't argue with much enthusiasm for either wage.  But should the person actually trying to support himself on minimum wage be paid something that makes that feasible?  I look at this person and think, hey, this is somebody who's working, who has an oar in the water.  This is a person who is actually trying to hold up his end of the Marxist aphorism: from each according to his ability.  If we, as a society, cannot find a way to hold up the other end, and see to it that he gets paid enough to support himself, we had better step back and re-think our economy.

Hobby Lobby: Time for a Revolution

Well?  Should we make Hobby Lobby provide health insurance coverage that pays for birth control?

To begin with, I will remind readers that I wrote about the issue of coverage for birth control by private health insurance over two years ago, making the argument that the economic case for coverage for women who are not indigent is weak.  Women who are sufficiently needy that such coverage makes the difference between having and not having access to birth control are typically covered by Medicaid or eligible for low-cost services from Planned Parenthood.

So we are, as a practical matter, not talking about denying women access to products or services based on someone's religious beliefs.  What the Supreme Court said in Burwell v. Hobby Lobby is that, under certain circumstances, a company that is "closely held" (private ownership by a small number of people) cannot be required to pay for coverage for birth control the use of which violates their religious beliefs.

The 5-4 majority opinion in this case relies heavily on the Religious Freedom Restoration Act (RFRA), a 20-year-old federal law intended to preclude substantial burdens upon the free exercise of religion.  That law was enacted with a mere three dissenting votes in the Senate and not a single "nay" in the House, which is quite remarkable.  Surely the Congress had no idea that two decades later the law would be the basis for such a controversial Supreme Court opinion. We have a national legislative body of 535 people who have ceaselessly behaved as though they've never heard of the Law of Unintended Consequences.

The Supreme Court's decision has been lambasted by progressives in every forum imaginable.  This I understand, because many people who vigorously advocate in the realm of reproductive health care have very strong feelings about these issues.  And I am inclined to agree with them that the effects of this decision are undesirable.  But that doesn't mean the decision is incorrect. Examined from the standpoint of legal reasoning, the majority opinion seems to me to be entirely logical.  Difficult though it is to separate one's view of a judicial opinion's effect from the logic of its reasoning, when I force myself to engage in the exercise, that is my conclusion.

The logical short-term solution is obvious from the text of the RFRA itself.  A federal statute adopted subsequently can explicitly exclude application of the RFRA to its provisions.  Problem solved.  Can federal law mandating coverage of contraception now be enacted with such explicit language?  That is a political question.  And the people who have the power to answer that question are the ones going to the polls this November.

Quite willing to be an opportunist, I am now going to take advantage of the opening afforded by this decision to make the case I have advanced in many postings on social media but have not expounded in this blog.

I don't want Hobby Lobby to pay for birth control.  I don't want Hobby Lobby to pay for anything.  I don't want Hobby Lobby to provide health insurance coverage to its employees.  I don't want any employer in the US to provide health insurance coverage to its employees.

In the United States of America it is time for a Declaration of Independence from the absurdly fragmented non-system of financing health care that has plagued us for decades.  We have some people covered by employer-based health insurance.  We have some people covered by government programs. We have 15% of the population covered by nothing.  When we look at all of the people, no matter which group they fall into, it is arguable that the current arrangement serves no one well.  Ask doctors, nurses, and the people who run hospitals if they think the status quo is good for any of them or any of their patients.  Ask patients - even the ones on Medicare, which has the highest levels of satisfaction - whether everything is just fine and dandy.  The Medicare patients who've been socked with big bills, because the government would pay for observation (meaning outpatient) services instead of a hospital admission, will tell you they are none too pleased.

What's the problem here?  All of the payers are trying to get away with paying as little as possible for all services provided.  They'd like to pay nothing whenever they can get away with that, and leave doctors, patients, and hospitals holding the bag.

The solution?  A system that includes everyone: a National Health Service. Everyone is a stakeholder. All patients have the same status, because everyone is a "covered life" on equal footing.  There is no health insurance industry, because there is no health insurance.  People who work pay taxes.  These public funds are used to finance the health care system.  There is only one payer. Decisions about what to pay for and how much to pay are made by agencies of the government composed of stakeholders, heavily weighted toward experts: doctors, health policy wonks, health care consumer representatives.

Do you think when decisions are made that way we will have anyone deciding it makes any sense not to pay for birth control?  Of course not!  Because that is bad public policy and bad health policy, defying all logic and common sense. Whether it violates anyone's religious precepts won't even be part of the discussion.  I can hear some readers asking, "What about the Hyde amendment, prohibiting the use of federal funds to pay for abortions through the Medicaid program?"  That is yet another example of why we need to scrap the current crazy-quilt non-system and start over, taking these decisions out of the hands of politicians and giving them to governing boards with representation from all groups of stakeholders.  When everyone in the nation is a stakeholder, we won't have anyone making decisions that don't have broad support.  If it is decided that something will or won't be paid for, that decision will have to stand up to scrutiny from the entire body politic.

Now I will confess that I do not believe we will have a system like the National Health Service of the United Kingdom in my lifetime, because I have only a few decades left, and the political power of the health insurance industry is immense and will be brought fully to bear to prevent such a change.  But I am here to tell you that we will never solve all the myriad problems arising from the insanity in our health care financing until we make just this kind of radical change.

    

The Last Transition

The phone rang in the emergency department at two o'clock in the morning.  The unit clerk answered, spoke briefly, hung up, and turned to tell me a patient upstairs had died, and the nurse needed me to come and pronounce death.

It is an oddity of state law where I practice that, when a patient dies in the hospital, a physician must pronounce death.  A nurse can identify the absence of breathing and a heartbeat every bit as well as I can.  But nobody asks me about things like this when they periodically revise the Nurse Practice Act.

I am at a community hospital that is part of our health network.  My primary position the last three years has been at a big teaching hospital, where there are residents (doctors training in specialties) in the hospital around the clock, and so there is no shortage of physicans to attend to such matters.  Here, however, late at night there is only one doctor in the building - the emergency physician - and so all responsibilities requiring a doctor belong to one person.

Sometimes that means attending to emergencies involving inpatients: critically low blood pressure, respiratory distress, prolonged seizures.  Sometimes it means seeing patients at the very end of life.

As I walked into the patient's room, I was reminded of one of the very first times I did this.  A very recent medical school graduate in my first year of residency training, I was accompanied to that patient's room by an equally newly minted nurse.  I entered the room and gazed at the ceiling.  The new graduate nurse asked me what I was looking at, and I explained that when a person has just died, if you watch closely, you can see the spirit rise.  I was lucky she didn't smack me for that twisted sense of humor, instead briefly thinking I meant it and then saying, "Oh, you're teasing me."

Tonight I placed my stethoscope on the patient's chest and listened for a heartbeat as I watched for the rise and fall of the chest that would be present if she were breathing.  No heartbeat.  No breathing.  The nurse handed me the patient's chart, and I signed the "pronouncement of death" portion of the state form.

My note on the chart said, "Called to see patient who had ceased to breathe.  No heartbeat or respirations.  Death pronounced."  I signed my name.

I looked at the patient's face and thought about whether her expression was peaceful.  And I realized I knew nothing about her other than that she was now dead.  I could review the chart to see if I could figure out the cause.  When I read newspaper obituaries, they rarely say anything about the cause of death, unless it's a famous person.  And I often wonder.

But that wasn't what I really wanted to know.  I had a much longer list of questions.

What was she like as a child?  What were her hopes and dreams?  What about as a young woman?  Did she fall in love and get married?  Did she bear and raise children?  Was she a homemaker, a wife and mother?  Did she work outside the home, pursue a career?  Was she a homebody, or did she travel?  What were her aspirations for herself, her husband, her children?  Were they fulfilled?

Did she have grandchildren?  How many?  What was she like as a grandmother?  Did she try to make up for all the mistakes she had made as a mother through lack of experience?  Did she try to give the benefit of that parenting experience to her children and their partners raising that next generation?

If she had married and had children and grandchildren, what were their memories of her, and which ones were their most cherished?  Did she outlive her husband?  How badly, and for how long, had she missed him after his passing?  If he had survived her, how would her death affect him?

Had she had any regrets?  Had she come to terms with them?

Had she ever made a bucket list?  How many of the things on that list had she been able to cross off?  How many were left?  How many were only dreams, things she knew would never be crossed off but she thought still belonged there?

I will never know the answers to those questions, but I will ask them just the same, about every patient I care for who dies, and every one I see for the first time at the very end of life.  I will write on the chart, but nothing I write there is what matters.

Every one of us is a collection of answers to such a list of questions.  Each time I reflect on them, I think about what the answers will be at the end of my own life.  Sometimes I think I should not dwell on my own mortality.  But I believe keeping in mind that the journey is finite can sharpen our focus on making the most of it.  And I happen to be in a profession in which reminders that the journey is finite are all around me, all the time.