HEALTH CARE

I knocked on the trailer door. An elderly man opened the door, and I introduced myself to him as his caseworker. In 1960 I was a social worker assigned to Old Age Security in Tulare County, and I needed to carry out an annual review on his case and perhaps his wife’s case if they came due near enough to each other. In the course of discussion, I asked after their health. He replied he had been having angina attacks. He said he couldn’t afford to go to the doctor, buy medicine, and also buy food. They chose to buy food. Social Security was just starting to kick in, and there was no Medicare. I remember at the time thinking the man should get as good a care for his heart as a wealthy man. Maybe the rich guy could get a swanky room and food, but the actual medical care should not depend on how much money he had.

Segue 55 years into the future. Medicare and Medicaid have kicked in, but we still debate vociferously the cost and availability of health care. I want to try to analyze this issue to see whether we can find a more objective set of ideas.

1 – SOMEONE MUST PAY FOR HEALTH CARE OR HEALTH CARE WILL NOT EXIST.

            Actually, all the ruckus about the ACA, aka Obamacare, is only about insurance: who pays who and how. The fuss has never actually dealt with the cost. We repeatedly talk about reducing the cost of health care, but we really mean reducing the cost of insurance. Let’s look first at the cost of health care itself, then insurance.

In 1985 I went as pastor to Hodge Baptist Church. In the congregation, there was a recently retired physician.  While visiting his wife in the hospital I asked him whether he was completely retired or carrying a smaller case load. He replied that he couldn’t afford to work part time. To do so, he would have to pay for all the overhead: office, utilities, receptionist, and nurse. As I remember he had estimated it would take $40,000 a year to break even, and he didn’t want to work that much.  That was in 1985 dollars.

Most of my pastorates have been in smaller towns with rural hospitals that struggle to stay afloat. People prefer local hospitals for “normal” illnesses such as when flu or pneumonia puts you in bed with an IV. But even in a 50 bed hospital, you can see how many people must be paid and how many services offered. There’s at least one RN on every shift on every unit (I know, they sometimes cheat), and LPN’s or aides to give patient care. There will be a lab with at least one technician a shift, plus an x-ray. Then most places have an ER, which is one raison-d-etre for local citizens to demand a local hospital. Lots of lives get saved during heart attacks and kids legs and arms splinted. Then there’s housekeeping, including maids and floor moppers and waxers, and a maintenance guy or two. And you have to keep up to date reasonably well with lab and x-ray equipment. Then you have to pay utilities and insurance. On top of all that come the administrator and clerks, perhaps more office personnel.

How do we pay for all that?

Well, the patient does. The patients do. That’s why there’s a basic room fee. At the end of the day, we have to collect enough money from all the patients to pay the salaries of everyone plus all the other bills. If all these people and equipment total, say, $350,000 a month, then we have to average that much in patient fees. Some county hospitals may receive help from tax funds or various grants, but someone somehow pays for it, or the hospital shuts down.

There is no free lunch.

There is no free health care.

No public figure I know has discussed in the media how to reduce health care costs, only how to make insurance affordable. That means we expect the insurance companies to pay for our medical care. OK, but where do they get the money? We’ll talk more about that in a minute, but right now let’s dive back in before the insurance comes in.

How do we reduce the actual cost? The actual amount charged each patient?

I’ve noticed only one thing in the last 55 years, and you may not like it. Actually, I’ve only noticed in the last 15 years since I became eligible for Medicare. I observe that every bill I get has several columns.

First comes the charge for the service. Example $150 office visit

Next a column headed “Medicare allows” Ex - $100

Medicare will pay 80%                                                80

Patient may be charged                                              20

Note in the above example, that the government set the prices. Now I am sure this triggers a game between the med providers and the government – and other – insurance. If they will cut my $150 fee to $100, what will I get if I charge $175? And this goes on all the way up and down the line. Private insurance does the same thing, by the way. Plus, they will add some to the cost for their profit, unless they are a mutual insurance company. (That’s the theory anyway.)

Can you see any other way to reduce the actual cost of medical care apart from government regulation? I know the whole idea of regulation is anathema to the business world, because it limits profits. In many areas I would agree, but medical care to me is an exception. I still don’t think a homeless guy having a heart attack on the street should get less quality care than a millionaire who lives in a penthouse.

And yet – if we have regulation, it must be intelligent regulation. I hear all the time people having to postpone surgery while their doctors hassle the insurance companies to get the surgery approved. I envision some high school graduate at a computer feeding in the data of the patient and the condition and the surgeon’s recommendation, then waiting for the computer to say yes or no. Few doctors will prescribe antibiotics for a sore throat over the phone without having the patient come in for an examination. And we make potentially life or death decisions a thousand miles away by computer? Saying the surgeon on site with years of training and experience doesn’t know?

We must have intelligent regulation.

LOUISIANA DETOUR – Adjust this discussion for your state. In Louisiana, we have what’s left of a state hospital system that has been radically cut the last ten years along with colleges, because of repeated budget crises. The theory is that the indigent can go to one of several state hospitals scattered in major cities for health care. These are generally attached to med schools or at least staffed by residents from med schools. Every general hospital in the state must have an Emergency Room, and each ER must treat any emergency who comes in. In actual practice they must treat anyone who comes in, emergency or not, for fear of lawsuit if they turn away a patient who subsequently dies or has a major complication bring him back. As a result, many poor use ER’s as their primary care because they can afford nothing else, or they don’t want to spend the money when they can get it free. As a result, private ER’s do enough treatment to make sure the patient is not critical, then ship them off to a state hospital. Still, the high volume in the ER makes it very difficult to make the hospital operate in the black.

But other issues affect costs as well. So let’s turn now to pharmaceuticals and equipment.

DRUG COSTS          

A guy bought a pharmaceutical company that owned a critical drug for cancer care. He raised the price from a barely affordable $100 or so to several thousand! In physics “every action has an equal and opposite reaction.” I’m not sure if it was equal, but there was definitely a major reaction, not to say explosion, from the entire country. Did he assume insurance would cover the outrageous price? Did he believe that being the only curative drug for that disease would force people to round up the money? I don’t know. The last I heard the price went down, but not as low as at first.

Personally, I take three meds that total $5-600 a month. Medicare reduces the cost to be affordable, except when it lands me in the coverage gap, aka “the donut hole.” Other drugs I take have generics that cost only $2-10 a rx. Drugs are patented when they first come out to protect them from other companies and generics, so the inventors can pay for the research and developments costs which can be quite high.

A patent lasts for 20 years, but may be issued at any point during the development process. Exclusivity comes after FDA approval and prevents others from marketing the drug for, usually, 3-7 years depending on the type of drug. A company can spend hundreds of thousands of dollars on research to discover new drugs, but after that discovery, must spend sometimes more to test the drug in three stages, each of which must be completed before moving on to the next phase. Only after the third round of trials are successful will the FDA approve the drug to go on the market.

It is reasonable for a company to use its exclusive marketing opportunity to recover the cost of all those scientists and lab work to bring the new drug to market. A problem arises, however. Even though these companies are publicly traded, they do not publish the cost of developing and testing the drugs. The funding of R&D is largely hidden as a trade secret. That means we have no way of determining when they have met the overhead on that particular rx and gone into profit. Nor can we say what amount of profit is reasonable. Certainly as an end user paying $300 for a script I might have a different idea than those who invest in that company, not to mention the major owners and managers.

The same principle applies to all medical equipment companies – AND THE DISTRIBUTERS AND PHARMACIES. A drug store has to pay for the meds, plus the salaries of one or more pharmacist, clerks, rent, utilities, and the like. The same is true of medical supply houses. You can see there are several levels that must first break even then make at least some kind of profit to stay in business. Each level from Pharmaceutical company to wholesaler to pharmacy must make a profit, or the owners would shut the business down.

What’s a reasonable profit?

How do you decide?

Who decides?

Market based economics would answer that we should allow supply and demand to work. That works fine in many industries where competition keeps prices down and responsive to market demand. But what about the guy who jacked up a price out of sight because he had exclusivity and NO competition.

Medicare Part D providers deal with the situation by dividing drugs into different categories. Generics they will mostly cover. Then there are “Preferred Drugs,” determined by the company to be reasonable, so they discount these quite well. At least to the donut hole. Then there are other drugs that the Med D people are reluctant to cover. If there is a generic drug that does the same thing as a newer one, they will pay for the generic, but not the newer one – or at least with a smaller discount on the new one.

What this practice says is the doctor cannot treat with the latest meds. If the patient wants the lowest prices, he or she will have to accept five-year-old quality medical care. The insurance position is understandable, and we’ll look at it in more detail in a bit, but getting the cheapest medicine comes at a cost of quality care.

A little over a year ago I had an attack of A-fib. Twelve years before that I had a heart attack and was taking meds to manage cardio-vascular disease. The doc shocked my heart back into rhythm and then changed me meds from a generic to two new meds to prevent the new risk of stroke. These are two of the high-priced ones that Med D doesn’t want to pay for.  (Yes, there are work-arounds, but this is already a complex discussion, so let’s not complicate it further.) There are cheaper meds they used before these two came out, but I can afford these, so should I take less than cutting edge treatment?

HEALTH INSURANCE

Now let’s look at how we pay for all this medical care and drug costs. The really old-fashioned way, going back 150 years or so, is the simplest. Cash. Or in the famed cases of country doctors with chicken, eggs, vegetables and the like. Does anyone do that anymore? If so very few. Enter insurance.

The concept of insurance depends on spreading the risk and the cost. Let’s assume a random collection of 100 people of varying ages. In most years, only a small percentage will go into a hospital. Maybe half will see a doctor and two thirds take some kind of meds. So if each of the 100 pays $1000, there will be a pool of $100,000 which will pay for, or at least help pay for the expenses of those who use medical care that year.

An insurance company will develop “actuarial tables” that take into consideration the population they serve and the cost of their medical care. Then they take that overall cost and divide that cost among all those they serve as premiums. My understanding is that in good years, where less people are treated and at less total cost, the company increases its profits, but does not drop the cost of the meds. That’s why people buy stocks. They want dividends coming back from profits, and buying the stock is what gives the drub company the money to create and manufacture drugs. If government restricts profits, stock sales will fall off. That means the pharms will have less money to develop drugs, so new drugs may not appear as quickly.

Obviously, those who seek “single payer” insurance are correct that this form of insurance will be the cheapest. Why? Because the pool of people covered include the whole nation. If every individual is paying into the pool, that includes millions of young adults who may go years without seeing a doctor, taking meds, or needing a hospital. Their premiums make up for the older folks who are always having stuff go wrong and running up bills steadily.

The problem with this form of care, as we find in Canada, England, most of Europe, is the cost. Proponents think it can be done by taxing the rich, but at least in the above countries the tax is much more widespread. A Canadian physical therapist where I work out has a “green card,” which he showed me. Talk about being disconcerted: it was white! Like a credit card. White! Nevertheless, I asked him what the taxes were like up there on average, and he replied around 35%. I googled European taxes and found they were indeed much higher than in the US.

This means that in single-payer societies, the patients still pay for their health care. It also means you close all the private insurance companies, throwing millions out of work and greatly restrict the profit of all other medical entities. American doctors are already complaining about the limits Medicare and Medicaid pay them. The Canadian system puts most doctors on a salary except for the few who hold out for the wealthy who can afford private care.

But with a total actuarial pool, you do have the lowest possible rate. In a profit based system, the insurance companies juggle the costs for their own particular pool. For example, they may refuse to cover pre-existing conditions. By ruling these people out, you are automatically omitting certain costs because of their on-going illness. So it’s not surprising that even many who don’t like the Affordable Care Act do approve of the provision requiring the insurance to cover pre-existing conditions. But as I write this at the end of 2016, much publicity has gone out that the costs of insurance, even under the ACA, is going up as much as 25% next year. Why? I’m sure one reason is that adding all those people to the pool who were destined to high medical cost from pre-existing conditions ran those companies into losses. Also, not nearly as many young and healthy adults signed up as were expected. Why is this a surprise? They’d much prefer to pay a comparatively small fine than the larger premium. But this healthy group is what gives the insurance providers the money to pay for the chronically ill bunch.

THE TAKEAWAYS

1 – Someone must pay for medical care. We mostly do that through insurance. The national argument has been on what kind of insurance set up is best for the most people.

2 – At this point, the only way I personally can see to reduce the actual cost of medical care is regulation. We’ve had that for a long time both with private insurance and Medicare.

3 – This raises the question of what is a fair profit in medicine. That carries with it the problem of who is to decide that?

4 – What can you do personally to keep your medical costs down? First, stay in front of your health. Get checkups and begin treatment, following your doc’s advice, as soon as a problem pops up. Plus you’ve heard over and over: exercise, keep your weight down, eat right.

I recognize this is incomplete and needs much more thought. I will add to it as I learn more and change my mind here and there. If it sounds technical and difficult, you are beginning to grasp the problem!

HEALTH CARE

I knocked on the trailer door. An elderly man opened the door, and I introduced myself to him as his caseworker. In 1960 I was a social worker assigned to Old Age Security in Tulare County, and I needed to carry out an annual review on his case and perhaps his wife’s case if they came due near enough to each other. In the course of discussion, I asked after their health. He replied he had been having angina attacks. He said he couldn’t afford to go to the doctor, buy medicine, and also buy food. They chose to buy food. Social Security was just starting to kick in, and there was no Medicare. I remember at the time thinking the man should get as good a care for his heart as a wealthy man. Maybe the rich guy could get a swanky room and food, but the actual medical care should not depend on how much money he had.

Segue 55 years into the future. Medicare and Medicaid have kicked in, but we still debate vociferously the cost and availability of health care. I want to try to analyze this issue to see whether we can find a more objective set of ideas.

1 – SOMEONE MUST PAY FOR HEALTH CARE OR HEALTH CARE WILL NOT EXIST.

            Actually, all the ruckus about the ACA, aka Obamacare, is only about insurance: who pays who and how. The fuss has never actually dealt with the cost. We repeatedly talk about reducing the cost of health care, but we really mean reducing the cost of insurance. Let’s look first at the cost of health care itself, then insurance.

In 1985 I went as pastor to Hodge Baptist Church. In the congregation, there was a recently retired physician.  While visiting his wife in the hospital I asked him whether he was completely retired or carrying a smaller case load. He replied that he couldn’t afford to work part time. To do so, he would have to pay for all the overhead: office, utilities, receptionist, and nurse. As I remember he had estimated it would take $40,000 a year to break even, and he didn’t want to work that much.  That was in 1985 dollars.

Most of my pastorates have been in smaller towns with rural hospitals that struggle to stay afloat. People prefer local hospitals for “normal” illnesses such as when flu or pneumonia puts you in bed with an IV. But even in a 50 bed hospital, you can see how many people must be paid and how many services offered. There’s at least one RN on every shift on every unit (I know, they sometimes cheat), and LPN’s or aides to give patient care. There will be a lab with at least one technician a shift, plus an x-ray. Then most places have an ER, which is one raison-d-etre for local citizens to demand a local hospital. Lots of lives get saved during heart attacks and kids legs and arms splinted. Then there’s housekeeping, including maids and floor moppers and waxers, and a maintenance guy or two. And you have to keep up to date reasonably well with lab and x-ray equipment. Then you have to pay utilities and insurance. On top of all that come the administrator and clerks, perhaps more office personnel.

How do we pay for all that?

Well, the patient does. The patients do. That’s why there’s a basic room fee. At the end of the day, we have to collect enough money from all the patients to pay the salaries of everyone plus all the other bills. If all these people and equipment total, say, $350,000 a month, then we have to average that much in patient fees. Some county hospitals may receive help from tax funds or various grants, but someone somehow pays for it, or the hospital shuts down.

There is no free lunch.

There is no free health care.

No public figure I know has discussed in the media how to reduce health care costs, only how to make insurance affordable. That means we expect the insurance companies to pay for our medical care. OK, but where do they get the money? We’ll talk more about that in a minute, but right now let’s dive back in before the insurance comes in.

How do we reduce the actual cost? The actual amount charged each patient?

I’ve noticed only one thing in the last 55 years, and you may not like it. Actually, I’ve only noticed in the last 15 years since I became eligible for Medicare. I observe that every bill I get has several columns.

First comes the charge for the service. Example $150 office visit

Next a column headed “Medicare allows” Ex - $100

Medicare will pay 80%                                                80

Patient may be charged                                              20

Note in the above example, that the government set the prices. Now I am sure this triggers a game between the med providers and the government – and other – insurance. If they will cut my $150 fee to $100, what will I get if I charge $175? And this goes on all the way up and down the line. Private insurance does the same thing, by the way. Plus, they will add some to the cost for their profit, unless they are a mutual insurance company. (That’s the theory anyway.)

Can you see any other way to reduce the actual cost of medical care apart from government regulation? I know the whole idea of regulation is anathema to the business world, because it limits profits. In many areas I would agree, but medical care to me is an exception. I still don’t think a homeless guy having a heart attack on the street should get less quality care than a millionaire who lives in a penthouse.

And yet – if we have regulation, it must be intelligent regulation. I hear all the time people having to postpone surgery while their doctors hassle the insurance companies to get the surgery approved. I envision some high school graduate at a computer feeding in the data of the patient and the condition and the surgeon’s recommendation, then waiting for the computer to say yes or no. Few doctors will prescribe antibiotics for a sore throat over the phone without having the patient come in for an examination. And we make potentially life or death decisions a thousand miles away by computer? Saying the surgeon on site with years of training and experience doesn’t know?

We must have intelligent regulation.

LOUISIANA DETOUR – Adjust this discussion for your state. In Louisiana, we have what’s left of a state hospital system that has been radically cut the last ten years along with colleges, because of repeated budget crises. The theory is that the indigent can go to one of several state hospitals scattered in major cities for health care. These are generally attached to med schools or at least staffed by residents from med schools. Every general hospital in the state must have an Emergency Room, and each ER must treat any emergency who comes in. In actual practice they must treat anyone who comes in, emergency or not, for fear of lawsuit if they turn away a patient who subsequently dies or has a major complication bring him back. As a result, many poor use ER’s as their primary care because they can afford nothing else, or they don’t want to spend the money when they can get it free. As a result, private ER’s do enough treatment to make sure the patient is not critical, then ship them off to a state hospital. Still, the high volume in the ER makes it very difficult to make the hospital operate in the black.

But other issues affect costs as well. So let’s turn now to pharmaceuticals and equipment.

DRUG COSTS          

A guy bought a pharmaceutical company that owned a critical drug for cancer care. He raised the price from a barely affordable $100 or so to several thousand! In physics “every action has an equal and opposite reaction.” I’m not sure if it was equal, but there was definitely a major reaction, not to say explosion, from the entire country. Did he assume insurance would cover the outrageous price? Did he believe that being the only curative drug for that disease would force people to round up the money? I don’t know. The last I heard the price went down, but not as low as at first.

Personally, I take three meds that total $5-600 a month. Medicare reduces the cost to be affordable, except when it lands me in the coverage gap, aka “the donut hole.” Other drugs I take have generics that cost only $2-10 a rx. Drugs are patented when they first come out to protect them from other companies and generics, so the inventors can pay for the research and developments costs which can be quite high.

A patent lasts for 20 years, but may be issued at any point during the development process. Exclusivity comes after FDA approval and prevents others from marketing the drug for, usually, 3-7 years depending on the type of drug. A company can spend hundreds of thousands of dollars on research to discover new drugs, but after that discovery, must spend sometimes more to test the drug in three stages, each of which must be completed before moving on to the next phase. Only after the third round of trials are successful will the FDA approve the drug to go on the market.

It is reasonable for a company to use its exclusive marketing opportunity to recover the cost of all those scientists and lab work to bring the new drug to market. A problem arises, however. Even though these companies are publicly traded, they do not publish the cost of developing and testing the drugs. The funding of R&D is largely hidden as a trade secret. That means we have no way of determining when they have met the overhead on that particular rx and gone into profit. Nor can we say what amount of profit is reasonable. Certainly as an end user paying $300 for a script I might have a different idea than those who invest in that company, not to mention the major owners and managers.

The same principle applies to all medical equipment companies – AND THE DISTRIBUTERS AND PHARMACIES. A drug store has to pay for the meds, plus the salaries of one or more pharmacist, clerks, rent, utilities, and the like. The same is true of medical supply houses. You can see there are several levels that must first break even then make at least some kind of profit to stay in business. Each level from Pharmaceutical company to wholesaler to pharmacy must make a profit, or the owners would shut the business down.

What’s a reasonable profit?

How do you decide?

Who decides?

Market based economics would answer that we should allow supply and demand to work. That works fine in many industries where competition keeps prices down and responsive to market demand. But what about the guy who jacked up a price out of sight because he had exclusivity and NO competition.

Medicare Part D providers deal with the situation by dividing drugs into different categories. Generics they will mostly cover. Then there are “Preferred Drugs,” determined by the company to be reasonable, so they discount these quite well. At least to the donut hole. Then there are other drugs that the Med D people are reluctant to cover. If there is a generic drug that does the same thing as a newer one, they will pay for the generic, but not the newer one – or at least with a smaller discount on the new one.

What this practice says is the doctor cannot treat with the latest meds. If the patient wants the lowest prices, he or she will have to accept five-year-old quality medical care. The insurance position is understandable, and we’ll look at it in more detail in a bit, but getting the cheapest medicine comes at a cost of quality care.

A little over a year ago I had an attack of A-fib. Twelve years before that I had a heart attack and was taking meds to manage cardio-vascular disease. The doc shocked my heart back into rhythm and then changed me meds from a generic to two new meds to prevent the new risk of stroke. These are two of the high-priced ones that Med D doesn’t want to pay for.  (Yes, there are work-arounds, but this is already a complex discussion, so let’s not complicate it further.) There are cheaper meds they used before these two came out, but I can afford these, so should I take less than cutting edge treatment?

HEALTH INSURANCE

Now let’s look at how we pay for all this medical care and drug costs. The really old-fashioned way, going back 150 years or so, is the simplest. Cash. Or in the famed cases of country doctors with chicken, eggs, vegetables and the like. Does anyone do that anymore? If so very few. Enter insurance.

The concept of insurance depends on spreading the risk and the cost. Let’s assume a random collection of 100 people of varying ages. In most years, only a small percentage will go into a hospital. Maybe half will see a doctor and two thirds take some kind of meds. So if each of the 100 pays $1000, there will be a pool of $100,000 which will pay for, or at least help pay for the expenses of those who use medical care that year.

An insurance company will develop “actuarial tables” that take into consideration the population they serve and the cost of their medical care. Then they take that overall cost and divide that cost among all those they serve as premiums. My understanding is that in good years, where less people are treated and at less total cost, the company increases its profits, but does not drop the cost of the meds. That’s why people buy stocks. They want dividends coming back from profits, and buying the stock is what gives the drub company the money to create and manufacture drugs. If government restricts profits, stock sales will fall off. That means the pharms will have less money to develop drugs, so new drugs may not appear as quickly.

Obviously, those who seek “single payer” insurance are correct that this form of insurance will be the cheapest. Why? Because the pool of people covered include the whole nation. If every individual is paying into the pool, that includes millions of young adults who may go years without seeing a doctor, taking meds, or needing a hospital. Their premiums make up for the older folks who are always having stuff go wrong and running up bills steadily.

The problem with this form of care, as we find in Canada, England, most of Europe, is the cost. Proponents think it can be done by taxing the rich, but at least in the above countries the tax is much more widespread. A Canadian physical therapist where I work out has a “green card,” which he showed me. Talk about being disconcerted: it was white! Like a credit card. White! Nevertheless, I asked him what the taxes were like up there on average, and he replied around 35%. I googled European taxes and found they were indeed much higher than in the US.

This means that in single-payer societies, the patients still pay for their health care. It also means you close all the private insurance companies, throwing millions out of work and greatly restrict the profit of all other medical entities. American doctors are already complaining about the limits Medicare and Medicaid pay them. The Canadian system puts most doctors on a salary except for the few who hold out for the wealthy who can afford private care.

But with a total actuarial pool, you do have the lowest possible rate. In a profit based system, the insurance companies juggle the costs for their own particular pool. For example, they may refuse to cover pre-existing conditions. By ruling these people out, you are automatically omitting certain costs because of their on-going illness. So it’s not surprising that even many who don’t like the Affordable Care Act do approve of the provision requiring the insurance to cover pre-existing conditions. But as I write this at the end of 2016, much publicity has gone out that the costs of insurance, even under the ACA, is going up as much as 25% next year. Why? I’m sure one reason is that adding all those people to the pool who were destined to high medical cost from pre-existing conditions ran those companies into losses. Also, not nearly as many young and healthy adults signed up as were expected. Why is this a surprise? They’d much prefer to pay a comparatively small fine than the larger premium. But this healthy group is what gives the insurance providers the money to pay for the chronically ill bunch.

THE TAKEAWAYS

1 – Someone must pay for medical care. We mostly do that through insurance. The national argument has been on what kind of insurance set up is best for the most people.

2 – At this point, the only way I personally can see to reduce the actual cost of medical care is regulation. We’ve had that for a long time both with private insurance and Medicare.

3 – This raises the question of what is a fair profit in medicine. That carries with it the problem of who is to decide that?

4 – What can you do personally to keep your medical costs down? First, stay in front of your health. Get checkups and begin treatment, following your doc’s advice, as soon as a problem pops up. Plus you’ve heard over and over: exercise, keep your weight down, eat right.

I recognize this is incomplete and needs much more thought. I will add to it as I learn more and change my mind here and there. If it sounds technical and difficult, you are beginning to grasp the problem!

PERRYGRAPHS

POLITICS:  A COMMON SENSE PARTY

(I abhor party platforms! Each issue should be examined carefully with recommendations from experts. At that point lawmakers should propose, debate, and decide each issue by itself, unless it connects vitally with a larger issue. In other words, a Democrat should be able to oppose abortion, and a Republican can on occasion vote to raise taxes. There should be no “whip” pressuring party members to fall in line, but each should vote their own conscience.)

1.     THE ROLE OF THE CONSTITUTION:

My training lies, among other places, in Biblical scholarship. The rule is first, discover what it meant; then discover what it means. How did the first readers and those who wrote intend their meanings? One example, Paul instructs women not to cut their hair. Was that meant as an eternal principal, as some Pentecostal groups interpret it, still refusing to cut ladies’ hair? In that culture, one mark of a prostitute was short hair, which was a form of advertising. So one possible modern application might be “don’t dress like a prostitute,” or just dress modestly. Most denominations had taken this approach in the first quarter of the 20^th century.

Turning to the US Constitution, it becomes vital to understand how and why the founders made the choices they did. The problems they dealt with are at least analogous when not identical to those we now face. They came from 13 colonies, very different colonies in geography, history, ethnicity, and activity. All were English colonies, but with saltings here and there of Dutch, French, Spanish, and a great many slaves. The constitution had to receive approval by a 2/3 vote of 13 legislatures to complete the unifying of one nation. Among other things that last fact resulted in the 10^th Amendment stating that those powers not granted to the federal government remained in the province of the state. Though that provision hasn’t been spoken about nearly so much as the first and second amendments, it may well be the most abused of all. Congressmen do bring it up when they are having difficulty defeating a bill, seemingly just to add one more argument against it. There are indeed many pieces of legislation that could easily be relegated to the states, and many more that could go either way.

An editorial in today’s paper (10/11/16) is a diatribe against one law professor who favors ignoring the Constitution as from a bunch of 18^th century white men. The latter part is true. In fact, those 18^th century white men were considering primarily other 18^th century white men who also owned property. Remember that neither blacks nor women were allowed to vote. Many forget that initially only white property owners could vote. The reasoning was that they were the only ones who primarily paid taxes, so why should others take their money? But note that 100 years later black men could vote, along with white men who did not own property. In the next 40-50 years women also gained the ballot.

But to insist that situation invalidates the document misses the mark. Note that those faults WERE corrected by a process those white men built into the Constitution itself. Less than 30 amendments over 233 years, under 20 if you drop the first 10 that are virtually part of the body itself, testifies to its relevance.

Look at some of the compromises they made. In passing, note they DID compromise, and it was not a dirty word. They built in checks and balances to require compromise for government to function. Where government has bogged down, it almost always come from refusal to work out a mutual agreement, each side adjusting until both find something they can live with. One fundamental compromise was the bicameral legislature. The smaller states were afraid the more populous states would control the legislation and leave them begging. So they created the House of Representatives and required all financial bills to begin there. That kept small states from overtaxing the larger ones to their benefit. They also created a Senate with equal representation – 2 Senators – from every state regardless of area or population. That prevents the big states from running roughshod over the smaller ones. The use of electors to cast the actual ballots for President came from poor travel and slow communication. Should they arrive without a majority, they were free to work out a deal to elect a President with general support. The latter could certainly be modified today with instant communication and easy travel. I’d like to see a national law, perhaps an amendment, requiring ALL states to send electors directly proportional to the vote. Today some states have a winner take all, so a close election there would send, say, 10 electors to vote, rather than 6 and 4 that reflect the vote.

So I think I have shown that I like staying as close as possible to the original constitution, but still adjusting to those things influenced by changes in technology, but not so much in changes of society. One thing I don’t know how to do is to make the Supreme and Appellate Courts apolitical. I would like to see Justices appointed with no commitment to preserving only the original meaning OR to modernizing any suspected Founders’ meaning. The tilt should be conservative, because after all it’s a constitution and supposed to be an infrastructure. But each case should be decided on its own merits, not because the Justice has an agenda.

PERRYGRAPHS

Riffing on Contemporary Ethics

This is turning out very different from where I intended it to go. I envisioned an academic column from my philosophy background discussing ethics – you know, hedonism, utilitarianism, authority, manipulation, even motives. Well some of that is in here, but the piece is much more rambling and personal than I expected. Some preaching sneaked in too. So here are my thoughts, still very much under development.

I have been noticing many new problems arising from changing times and new technology especially. Many of them are being discussed in the intelligent press, but I’m not sure how they interface with traditional ethics. These pieces will be an effort to begin that conversation.

Just this past month, the hacking of the Democratic National Committee came up along with the Clinton campaign organization. These two events remind us immediately of the recent scandal of Hillary’s unauthorized use of a private server as Secretary of State, thus not availing herself of the maximum safety strategies of the US. Look at all the questions these issues raise:

1 – When does hacking become a crime? In the early days of computer development, the geeks developing the technology considered everything fair game. If you could do it, then by all means strut your stuff. But 30 years ago, even 20, none of these events could happen. They were not likely to happen even ten years ago. I remember when Obama became president, he was frustrated that the Secret Service wanted him no longer to use the Blackberry he was accustomed to in order to text.

In the intervening time, everyone stores all sorts of documents on their computers and mobiles. There are even increasing numbers of “cloud” sites that enable one to use the same documents on desktops and mobiles, even sharing them with others.

A.   – There is little disagreement that hacking in order to steal material is wrong, whether social security numbers and other identifiers or documents. “Thou shalt not steal” is virtually axiomatic in every ethical code.

B.   – There is disputed grounds about whether documents, once hacked, should be released. The security clearances of several people did not keep them from releasing to the newspapers all sorts of political and secret documents. Many of those items gave the public a needed and fuller picture of international diplomacy. Much of the material was similar to stories collected in various histories and biographies. But those tales as presented are hearsay and can be discounted. Printing the actual documents however, is another kettle of fish. Yet while the overall result can be counted as salubrious, still these people did violate their oaths of office.

   Note the newspapers also are confronted with an ethical problem. When the New York Times received the stolen emails, they had long discussions prior to deciding to publish. The threat – almost certain – of outlaw websites like Anonymous publishing them seems to have tipped the balance. At least the Times did some selective editing before they published, presumably on the lookout for release of top secret material.

  A May edition of Vanity Fair published an interview with Edward Snowden who leaked so much material to Glenn Greenwald, who in turn furnished it to the NYTimes and a London paper. In the interview Snowden expresses a careful delineation between what should and should not be revealed. Putting people’s lives at risk by publishing their names is wrong. Julius Asange disagrees. Snowden believes in spying and secrecy, but disagrees on what should be secret. (Is this similar to the  discussion re the Clinton emails about what is confidential and top secret?) Wikileaks and Anonymous seems to have not qualms about revealing anything. Snowden says he appreciates the low level people at NSA, but distrusts the top brass. Which raises the question about a private or even a captain questioning a general’s orders. Theoretically a solder can refuse to commit a war crime, but in actual practice…?

*A Basic Issue: What do you do when you strongly object morally to the rules or commands you are expected to obey? Gandhi and King proposed and effectively used a passive resistance technique where to refused to obey and took the consequences. It turned out to be a powerful way to bring change, but only after pain and deaths.

These two are related to the “right to privacy,” which we first heard about in the court affirmation of abortion. I’m an aficionado of cop shows, both in books and tv. For several years now, almost every program or book at some point has authorities turning to security cameras for recorded evidence or to locate someone’s whereabouts.

   Even in small towns, businesses have security cameras, and even households have cameras to record people on the property. What are the ethics of this? It seems ok if I want to put a live camera aimed at my door, so I can see who’s knocking. (Although we’ve gotten by for thousands of years by simply calling out, “Who’s there?”

The trade-off in this area, as it’s developing in some others, is security versus personal control. What right does anyone have to know what store I went to, what I did there, and to whom I talked? Presumably the owner has the right to survey his property. After all, if he were standing there in person, he would see the same thing. But do other parties, like the police or government or hackers also have that right?

The ultimate fear goes back to a tyrannical government controlling its citizens and taking away their freedom. See the novels 1984 and Brave New World.

II. – What about Ad-tracking?

     Yesterday I looked up a book for someone on Amazon. Today on Facebook I saw an ad for that book and another by the same author. This is now normal, if a little spooky at first. FB defends the policy by saying we are going to put up ads anyway so wouldn’t you rather have ads that might interest you? But another way to put the question might be wouldn’t you rather have ads that are more likely to entice you to spend money? Hmmm.

     If you’re not, you should become familiar with computer “cookies.” A cookie is an electronic marker a website places in your computer browser that will identify you the next time you arrive on their site. These can be great. Thus I went on my library account this morning and it recognized me and printed out my card number for me. Likewise Facebook doesn’t require me to sign in, but connect immediately with the correct feed. (I do wish it would let me change the default to “Latest” instead of what their mysterious algorithm thinks is “most important.” On either feed, they are not likely to show a post from a friend who only posts a few times a year. I would argue those are the most important ones I want to see!

    

This is probably too much to read now, so I’ll post and come back later…