A Modest Health Care Proposal

Paul Scott Thomas Edge of the World

The US Supreme Court has taken up the issue of so-called ObamaCare: the controversial plan to extend private health insurance to all citizens, with a stiff tax penalty for those who refuse to purchase private health insurance. I know something about it, since I live in Massachusetts, a state that adopted so-called RomneyCare, after Mitt Romney, who was our governor at the time, and is now running for president. ObamaCare is modeled on RomneyCare.

The Supreme Court wasted a day discussing whether the tax penalty is a tax or a penalty, a distinction that\’s relevant only in the context of some arcane law concerning the litigation of unjust taxes, but lost on everyone, because the penalty shows up on one\’s tax bill. This point was discussed ad nauseam, so I will not discuss it or any of the other issues relating to ObamaCare that everyone banters about endlessly. Instead, I will say what no-one is saying: Obamacare (and Romneycare) invalidates the notion of health insurance.

First, let\’s make sure that we are all clear on the concept of insurance. Insurance is generally taken to mean a promise to pay out a settlement (or coverage) in case of a certain event (fire, flood, sickness), in exchange for a recurring cost (premium) and, usually, a deductible (or self-insurance). Insurers weigh the risk of the event against the amount of the settlement. Thus, if the policy is against your spontaneous combustion, with a risk estimated as 1 chance in a billion per year, and you want to insure yourself for $1 billion, then your premium is $1 per year, plus whatever the insurance company wants to charge you for writing the policy. If, however, you are currently engulfed in flames, then the risk goes up to 100% and the premium would theoretically be $1 billion, same as the settlement, but no insurance company would ever write such a policy because the risk is too high.

Now, health insurance is a strange proposition to start with, because everyone dies, and nobody dies healthy, so most people require medical treatment at some point. (A few people spontaneously combust, I suppose. They are still none too healthy during the few seconds before they die, but that\’s not long enough for them to avail themselves of medical attention. But that\’s a very rare case.) The point is, if all houses burned down at some point, there would be no fire insurance, and if all houses flooded at some point, there would be no flood insurance. But everyone dies, and yet there is health insurance. How is that?

ObamaCare introduces the provision that health insurers are not allowed to decline insurance coverage to individuals with pre-existing health conditions. That is equivalent to mandating fire insurance for houses engulfed in flames, or flood insurance for houses slowly sinking while floating downstream. In return, insurance companies are assured that they will be able to spread the risk over the entire population, which will be coerced to purchase their product by being threatened with a stiff tax penalty.

Some coercion is certainly required for people to accept such a faulty product. My family\’s health insurance bill comes to nearly $15,000 a year, with a $2,500 a year deductible. That is, we have to consume more than $2,500 a year in health care before the insurance pays anything. If I am employed, then the employer has to pay 80% of the premium; if I become unemployed through no fault of my own, then the state picks up the 80% for a few months; after that, I have the option of paying even more for an individual insurance plan, or paying somewhat less for the tax penalty but then risk being bankrupted by a medical emergency.

Recently, I called my insurer to ask how much a certain elective procedure might cost. You see, under this system, the doctor bills the insurer, the ensurer “adjusts” the amount, and then I pay the adjusted amount. I wanted to know the adjusted price beforehand, but I was told that they do not give out this information. The adjustments are generated by an inscrutable computer program, which determines the numbers on the spur of the moment based on a set of formulas. Now, normally I don\’t do business with companies that refuse to quote a price before I place the order. That\’s where the tax penalty is most helpful to them: it leaves me no choice but do business with, and get robbed by, this company.

As Vladimir Nabokov once pointed out, nothing breaks the human spirit more effectively than consistent bad treatment. To this end, forcing everyone to navigate an infuriating bureaucratic maze with their very health held at ransom is quite an effective strategy. Another is to force everyone to abide a blatant falsehood, such as calling health insurance “insurance” (now preferring, I notice, the more abstract word “coverage”) whereas it is definitely not insurance at all but a tax. Yet another is to force people to make false choices, such as between Romney, author of RomneyCare, and Obama, author of ObamaCare, which are very similar. At this point, the American spirit seems very well broken, along with the economy and the political system, and I do not advise you to squander your precious energies in trying to fix the latter two. I do, however, recommend that you mend your spirit, and stop thinking it necessary to abide a falsehood: health insurance is not insurance.

What is it then? “Insurance” that everybody is forced to buy as a legal precondition of citizenship? Where the risk pool includes the entire country? Where compliance is enforced by a federal agency, the Internal Revenue Service? (But where, if one does comply, the money goes to private entities, to pay other private entities.) What is that? Why, of course, it\’s a private tax collection service! Under ObamaCare, medical insurance companies become private tax collectors. Now, private tax collectors are not unprecedented in the annals of empire. The Roman senate bid tax collection contracts out to publicans, with mixed results: farmers often opted to abandon their land rather than farm it and have the grain confiscated to pay taxes. But ObamaCare takes private tax collection one step further: under it, the tax collectors not only collect the taxes, but also set the level of taxation as they see fit. That is, the medical “insurance” companies are allowed determine the “health tax.”

What makes this complex scheme of private tax collection so necessary? Its benefits include maximizing health industry profits, which can be recycled as electoral campaign contributions to elected officials who then protect the prerogatives of the health industry, keeping this private tax collection scheme running smoothly. But none of these benefits have much to do with keeping the population healthy. On the other hand, it creates a massive perverse incentive to maximize health care costs, while at the same time institutionalizing a private system of public robbery.

I therefore propose that the health tax be collected 

directly by the Internal Revenue Service.

Furthermore, in absence of any competent agency within the US that could be charged with administering a public health care system, I propose that health care be directly funded by the Internal Revenue Service as well, as part of an integrated strategy for maximizing tax revenue: the “Keep American Taxpayer Healthy” plan.

The unambiguous mandate of the IRS is to maximize tax revenues. This it will do by making sure that taxpayers are healthy, so that they can earn the maximum of income and pay the maximum of income tax. It will make it a priority to provide good health care to all children, who are IRS\’s “seed stock”—the taxpayers of the future. It will also make sure that the health needs of the working-age population are attended to, to make sure that they continue to work, earn, and pay taxes. It will also provide palliative care to the retirees, to keep up the morale, but certainly nothing as lavish as what is available to them now. Since their tax-paying potential is negligible, keeping them alive as long as possible is not a priority from a tax revenue maximization perspective.

Not being specialists in the medical field, but realizing that basic and preventive care have the highest health care ROI and specialist care the lowest, the IRS would probably want to dramatically simplify health care delivery. Huge hospitals and medical centers, with their teams of specialists, support staff, swarms of administrators, billing departments, medical labs, intensive care units and MRI machines, are too complex for the IRS to even audit, never mind administer effectively. It is far simpler to establish neighborhood clinics, and to provide them with a fixed fee per patient per year, to spend in line with the overall mandate.

Provisions would be made for some number of specialists, probably shared between clinics, but with the understanding that, from a tax revenue perspective, specialist care reaches diminishing returns rather quickly. For instance, a triple coronary bypass is hard to justify financially, because the patient\’s earning potential, even after a full recovery, usually does not cover the cost of the operation.

Also, the IRS might consider actually denying health care to rich people (those with net worth over $5 million) in order for the treasury to reap the windfall from estate taxes when they die. Such people (Mitt Romney is a good example) rarely pay their fair share of tax in any case, being able to hire accountants and lawyers, who exploit every possible loophole. And so, there shouldn\’t be any free heart transplants for Dick or free brain transplants for George.

Having the health care system administered by the Internal Revenue Service may seem rather inhumane to you. However, I hope I have succeeded in pointing out that doing so would still work better than ObamaCare. This health care system is so bad that improving it is not any sort of challenge at all: I submit to you that even the IRS would do a better job of it.

Trained for Success, Bred to be Eaten

[日本語訳]

I ended my last post with a provocative question:

Why is that reasonably rational individuals who are able to follow an argument and who are unable to refute it are at the same time incapable of making the transition from thought to action? What is stopping them? Humans are clearly smarter than yeast, what does that matter if they are incapable of acting any more intelligently?

As I promised, I will attempt to address this question in this one, helped by all the comments I have received. Ugo Bardi was quick to contribute this:

People just don\’t care about understanding what\’s going on and what\’s going to happen. If they are rich they care about how to make money on oil; if they are poor they care about miracle devices that will save us from the brink of the cliff. Then, as we start falling, interest in understanding what\’s going to happen will fade even more.

Ugo also cited Too Smart for Our Own Good by Craig Dilworth, summarizing it as follows:

The gist of Dilworth\’s book is that we are smart, individually, but that we aren\’t collectively. So, we are very good at solving individual problems, but that has the cost of creating larger collective problems which, then, we can\’t solve.

Dilworth\’s own summary of his book contains this:

We are destroying our natural environment at a constantly increasing pace, and in so doing undermining the preconditions of our own existence. Why is this so? This book reveals that our ecologically disruptive behaviour is in fact rooted in our very nature as a species. Drawing on evolution theory, biology, anthropology, archaeology, economics, environmental science and history, this book explains the ecological predicament of humankind by placing it in the context of the first scientific theory of our species\’ development, taking over where Darwin left off. The theory presented is applied in detail to the whole of our seven-million-year history.

This provides me with as good a jumping-off point as any, so let me begin.

Do you know of any humans that are living sustainably, in complete balance with the natural world? Chances are, you don\’t, unless you are an anthropologist, and even then only if you are lucky. Such humans are by now quite thin on the ground. Most of them have been either murdered or herded into “civilized” (i.e., unsustainable) society. Sustainable humans are a difficult subject to study, because our history is the history of unsustainable living, and ignores long, undocumented periods of time during which nothing notable took place in a multitude of sparsely populated locations.

But had these nondescript humans been left alone, the result would have been largely the same. You see, groups that live sustainably, in balance with the natural environment, do not experience exponential population growth. And so the populations which did not exhibit the fatal traits that give rise to Dilworth\’s “predicament of mankind,” even if left unmolested, would have quickly found their numbers dwarfed by the initially tiny part of humanity that increased its numbers exponentially by consuming nonrenewable resources while degrading the natural environment. As with a yeast sample, population size doesn\’t matter; all that matters is that you have a few viable specimens of the right strain, to start a culture.

A spike and crash in human populations is not unprecedented: out of a population of humans living in homeostatic equilibrium within their constant environmental footprint a small group emerges that, through some technological development—stone-tipped spears useful for big game hunting, or a plow design useful for breaking sod for agriculture, or toxic fracking fluid cocktails useful for getting at the dregs of fossil fuel resources—gains access to a new energy resource. Made delirious by their newly-gained powers, they throw all caution to the wind. Their population soon starts to double, crowding out everyone else. In the process, they hunt the big game to extinction, turn prairie to desert and deplete reserves of fossil fuels. Once further investment of energy in exploiting their favorite resource begins to produce diminishing returns, the population dies back, and a new homeostatic equilibrium reemerges, at a lower population level than before, because of the lowered carrying capacity of the now degraded environment. What makes the current experiment in unsustainable growth different is that it has engulfed the entire planet, depleting not just some but all natural resources in tandem.

The human populations that can live in equilibrium with their environment for thousands of years, and those that destroy it in a hurry, are not different species; they are not even different subspecies. Evolution has precious little to do with their differences: it is a matter of culture, not genetics. The time scale on which these events take place is far too short for long-lived organisms like humans to evolve any traits as specific adaptations to them. There are a few adaptations that develop this quickly: darkening or lightening of skin in response to sunlight, which takes less than 10000 years; resistance to diseases, through attrition of individuals who lacked genetic resistance to specific pathogens; changes in body form, lanky and hairless to shed heat in hot climates, portly and hairy to conserve it in cold ones. Beyond that, humans exhibit remarkably little genetic variation.

Although “culture” is an easy label to apply, and although cultural differences do abound, what distinguishes a population that insists on looking seven generations back and seven generations into the future when making decisions from one that is mainly concerned about the quarterly revenue and the year-on-year growth and their effect on stock price is their different thought processes (or lack thereof), which are, in turn, determined by their different priorities. You see, the man who lives and dies by the quarterly earnings report is already living right at the brink of extinction, eating through nonrenewable resources faster and faster, riding the exponential curve on the way up. As soon as that ride stops, he might as well promptly drop dead, but he will usually want to give cannibalism a try first. Thinking about the remote future is just not an effective short-term survival strategy for him. Asking him to invest in a sustainable development strategy based on some medium to long-term projections is like asking a man who is being chased by other men armed with knives and forks—and feels that he is in immediate danger of being eaten—to stop and help you with a crossword puzzle.

And herein lies the conundrum: to preserve all that\’s worth preserving—which, to me, is all the culture that is actually worth the name—art, literature, music, science, philosophy and fine craftsmanship—and to carry it over into a sustainable, low-energy, low-impact way of life, requires access to resources, and that, in turn, takes substantial quantities of money. But money is controlled by people who are always busy running away from their competitors lest they be eaten, and who cannot see how investing in a scheme which will never “pay off” could possibly be to their personal advantage or benefit (which is all the poor fools seem able to think about). How can we make it so that “the fool and his money are soon parted”? I have some ideas, and I will take up this question up in the next post or two.

C-Realm: Theater of the Mind

In this 300th C-Realm Podcast episode, KMO welcomes Dmitry Orlov back to the program to check in on the collapse narrative and to compare the actual unfolding of events with Dmitry’s perspective of five years ago.

\”…I did an episode a few months back with—Guy McPherson was on, and Kurt Cobb, and Henry Warwick. And Henry was saying that it\’s just really irresponsible to talk about collapse to audiences who don\’t understand the very specific meaning of the word you have in mind, because generally when people hear \”collapse,\” they think \’Mad Max Scenario\’, when in fact a collapse in the Joseph Tainter sense can be advantageous, you know, in fact it could be that we are due for some financial, political and commercial collapse, but social and cultural collapse are things you would want to avoid at all costs.\”

\”Well, yes, it\’s not all one thing. The criticism that I use this word, well, you know, let them propose a different word. I haven\’t exactly redefined what I\’m talking about, I\’m just adding detail. So I don\’t know if that\’s entirely valid.\”

No Physical Basis for Recovery

Cyril Lagel

[Update: This post used to be about non-renewable natural resource scarcity, but things didn\’t go as planned. Now it\’s mostly about turning the heads on a small boat into a steam room/sauna, and that\’s just fine. See the comments for details.]

[This is a guest post from Chris, who has been looking into nonrenewable resource depletion for some time now. His conclusion is that, even if oil weren\’t the immediate problem, we\’d still be \”running out of planet\” for many commodities without which an industrial civilization will collapse.]

The prevailing perception among the American public is that the hard times we are currently experiencing are temporary, that their leaders are implementing the proper mix of economic and political fixes, and that life will be back to normal soon. While this perception is entirely understandable given their historical experience, it is also entirely wrong. There will be no recovery this time.

[The ungrateful author didn\’t like my edits (his manuscript, as submitted, was a bit woolly) so I am taking down the text and leaving the graphics, which tell the story just fine even without the text. For more on this topic, read Richard Heinberg\’s Peak Everything.]

20th Century US Societal Well-being

20th Century US NNR Utilization

Peak US NNR Utilization

Peak US Societal Well-being