FunnyIndian.com: Indian Comedian / Desi Comedian Rajiv Satyal

Day 535/-197: Friday, March 1, 2008: The Doctor Is In (written 10/19/08)

October 20th, 2008

Here’s the transcript of the health care monologue I wrote for my talk show:

6th Century BC Ayurvedic medicine is first used. We were there.

4th Century BC Hippocrates wrote his Oath. We were there, too.

20th Century AD Hillary Clinton prescribes a cure for the ailing US medical system. We were so there.

21st Century AD Barack Obama and John McCain duke it out over universal heath care. We’re all over it.

Welcome to another edition of Desi States of America. I’m your host, Rajiv.

As you may now know, this program is dedicated to tackling a complex topic and simplifying it so you can digest it and maybe even regurgitate it to friends. Because that’s my specialty – I take the complex and simplify it and I take the simple and complicate it. Ask anyone who knows me. A plan to leave a full-time job and jump into comedy? Decision made. Do I want coffee or tea? Hmmmm… let me think about that.

As always, we’ll start with an overview and then the past, present, and future.

This week, we dive into that monolithic topic of Health Care. That is one of the hot button issues of this election and has been a problem for years. In fact, costs have become so bad that we don’t even report them as part of the national debt. The national debt is $9 trillion. But if you add in entitlement programs such as Medicare, Medicaid, and Social Security, it’s more like $60 trillion. $60 trillion! And we’re talking about $9 trillion. Talk about randomness in reporting. “I owe you $9. Well, I really owe you $60 but that other $51 is not important.” Wait. What?

So, pretty much everyone agrees that the current system is broken and so needs to be changed. That’s a start. You don’t have the classic liberal vs. conservative debate, w/ the former arguing change and the latter purporting the status quo.

So, what do both sides agree on? Both parties agree health care insurance shouldn’t be tied to your employer. I mean, that system sucks. if you lose your job, you lose your coverage. It’s bad enough that you no longer get free bagels and coffee. After that, tho, the sides, namely Barack Obama and John McCain, differ. How? We’ll get to that.

So, how did we get here? Historically, the gov’t didn’t provide health care b/c the role of gov’t was more to protect people from other people, not from disease. In the 1920s, advanced medicine took off and the health care industry was born. And in short, inequalities in health were directed to inequalities in wealth.

The problem was compounded after World War II. During WWII (the abbreviated form), the gov’t financed the war by printing money and by price & wage controls. Corporations began to offer medical care as a fringe benefit. When the IRS started making them report them as real wages, workers complained because they were now taxed on something that was free. And so Congress passed a law that ensured (not insured, tho I think they changed that recently) that health care remained tax-exempt. So, the conclusion is that we can blame WWII, just as we can for putting women in the workplace. We wouldn’t have so many problems if they would’ve just stayed home and breast-fed their kids now, would we?

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During Nixon’s administration, HMOs (Health Maintenance Organizations), were born. These large third-party insurance companies eventually became the middleman between the patient and the doctor.

And it’s not a good system. In every other industry, the more cases you ship, the more money you make. In insurance, companies try to cover as many people as possible and treat as few people as possible. They are actually rewarded for NOT providing a service.

Does this sound familiar? Well, if you saw Michael Moore’s movie, SICKO, then it should. The number you often hear bandied about is 47 million. That’s how many people are without health insurance in this country. Now, it’s a little disingenuous because it includes children who often don’t need health care insurance. Funny how people inflate or deflate numbers according to their needs. $9 trillion national debt, not $60 trillion. 47 million uninsured, not… who knows the number?

Well, SICKO didn’t focus on the uninsured. It focused on those of us who have coverage but not as much as we think. In other words, you might think you’d be covered for a procedure but you may be wrong. So, the subjects of the movie were largely people who were UNDER-insured.

Why do insurance companies run health care in America? Good question. Do they need to? Better question. The short answer is no. After all, “health care” and “health insurance” aren’t synonyms but they have become exactly that. Think about insurance in all other contexts. Insurance is generally used to guard against the home run – a prevent defense – a catastrophe that is unlikely but expensive if it does occur. That’s why people have insurance, isn’t it? Peace of mind. You want to be able to sleep at night knowing that if something horrible occurs, someone is going to take care of it. You couldn’t afford to repair your house if a fire destroys half of it in the middle of the night. Or in the day – guess that doesn’t matter. And you have auto insurance but you don’t use it to pay for oil changes. Routine stuff you take care of. It’s the accidents you need help with.

In a very long article that I read in preparation for this (despite falling ill – which I found ironic given this episode’s topic), the economist Milton Friedman gave an excellent overview of health care in this country. He cited three main trends that modern medicine has experienced:

- technological advances
- rising costs
- widespread dissatisfaction

Health care is the only industry in which the last 2 exist despite the first one. Think about it. In everything else, technology lowers costs and improves experiences. Consider computers. Moore’s Law tells us that computers double their speed every 18 months or so. You can now get a very decent laptop for $500. And consumers are happier than ever – maybe mostly with Macs but I’m not going to get into that one.

Costs are rising all over the world, but the US spends more per capita and more as a percentage of GDP than any other country – we’re at 14% and the next one, Germany, is at a distant 2nd with 11%.

Why do we pay more? That’s a tough one to answer, even for ol’ Miltie. But as he says, “Nobody spends somebody else’s money as wisely or frugally as he spends his own.” And that’s precisely what we do in this country. It’s not your money when you go to the doctor. Not really. I mean, you’re responsible for your co-pay but that’s the small number on a doctor’s bill or the statement you get from your insurance company, where it brags about what it spent on you as if you’re supposed to give it up now like a girl on a date.

The other thing is that we’re half-pregnant… like the girl after a date. A bad one, I guess. We haven’t as a country made a decision as to whether we want private or public health insurance. So we have this quasi-public/private system. And a mixed system is bad. We have high quality and accessibility (no long waiting lists) but it costs a lot more. Completely individual (fee for service) would have high quality and accessibility and hold down costs. Completely collective would reduce quality, have a mixed effect on accessibility (more people could go but w/ waiting lists), and costs would go up.

So, what Friedman proposes is this:

- Eliminate the tax exemption for medical expenses so people go out and buy their own insurance. This way, the costs of health care isn’t subsidized by your company. So, it’d be like food or anything else we buy. We’d demand better quality and lower cost just like with anything else.
- Eliminate Medicare and Medicaid so people aren’t dependent on the gov’t.
- Give everyone catastrophic insurance to guard against the home run – peace of mind.
- Remove restrictions and regulations on insurance so people can buy what they want.

This is actually pretty much what McCain proposes and it appears most economists actually think the GOP has a better plan than the Democrats. Go figure.

So, let’s figure. The only downsides of this plan are that the elimination of Medicare and Medicaid would leave people who are old and poor out. And so would the fact that people can now choose which plan they want. This is great for young and wealthy (and generally healthy) people – I’d just run out and buy what I need. But this means that the elderly and indigent are now paying more for their own, because right now if we all have similar options, I’m subsidizing their payments. So the McCain plan screws the old and the poor – what a big surprise. [Parody] “John McCain does not care about poor people…”

But it does use market forces to drive competition and does empower the individual. This is more likely to address the biggest problem we have with health care – spiraling costs. If everyone is now a direct consumer, prices should fall drastically.

McCain also proposes the use of savings accounts. We had that where I used to work and it was awesome. Just don’t tie them to the stock market the way Bush wanted to do with the ones that were going to replace Social Security. Not too smart.

The only thing I’d probably add is some kind of safety net – I wouldn’t eliminate Medicare and Medicaid. I’d do what Bill Clinton and the Republicans did w/ welfare reform. Help people get off of it but don’t just kick them out.

So, what does Obama propose? Well, in a classic dichotomy of modern politics, whereas McCain relies on personal responsibility and market forces, Obama thinks we should use government and regulations.

In short, Obama uses Pay or Play. Employers would either provide coverage or pay a tax for not providing it. Given the escalation of costs, employers would likely just pay the tax to get it all off their books. After all, you know what they say about General Motors – it has become a health care company that happens to make cars.

So, individuals would be on their own… as individuals tend to be. But the key difference here is that Obama wants everyone to be able to enroll in a program similar to Medicare or Medicaid or the one that Congresspeople have. People COULD go to private insurers but they wouldn’t because the Democrats are mandating that any rival must offer the same value, which will be hard given that the government plan covers a LOT of stuff. So, the private insurers would go out of business – no one is exactly upset about this.

And Medicare & Medicaid are surprisingly efficient – 2% administrative costs vs. upwards of 30% for private insurers. The government… efficient? Yes, it’s apparently possible.

The problem with this approach? Well, several. If you’re young and healthy, you’ll end up paying for a lot of stuff you don’t need, which is the fundamental appreciation of the Communist mantra, “From each according to his ability to each according to his need.” Furthermore, this doesn’t address the biggest issue of them all – rising costs. You STILL have someone else paying for you so where’s the incentive to hold prices down? And do you really want the guys who brought you the DMV running your health care plan? And finally, the US makes all the innovation happen… everything is discovered and invented here. If private enterprise is made to suffer in this country, the whole world will lose out on new drugs and machines.

Besides, it’s socialist. Ooooh. What Michael Moore showed us in SICKO was basically factually correct but it only showed the downsides of the American system and the upsides of others’.

I mean, George Bush, a Republican, tried to pass an easy drug prescription benefits bill. And that went over so well that out of the 21 million people who were eligible, you know how many signed up? 1. Well, one million. Not 1 person. That would be funny, tho – meet Bob. The one guy who signed up. Gets lots of attention. But still 1 million out of 21 million? If I threw a party and invited 21 people and only 1 showed, I’d be pretty pissed. But the problem is that no one could explain what the Bush plan does. It’d like giving directions to your house and they’re just so convoluted that no one comes.

That’s the one good thing about my HMO – the Blue Shield brochure is so easy to read. So at least you SEE how bad they’re screwing you. And maybe that’s the solution – I’d probably join the Club for Fascists if the booklet were colorful and pretty.

Better than my friends’ HMO. They had a baby girl and now the HMO is mailing letters to their residence in her name. “Dear Olivia…” Her Mom is considering writing back in crayon, “I can’t read yet.” [Graphic.]

So, what’s going to happen? Well, if McCain wins, he’ll probably try to push his ideas thru but may have a hard time given that the Democrats will still likely run Capitol Hill. If Obama wins, he will likely make some strides towards universal health care. So, I think what we have to ask ourselves is how good these plans are if only parts of them are implemented? That’s really the way to evaluate anything in this country. But that’s kind of hard. If you’re living in Chicago, would you rather take a trip to NY or LA? You could evaluate that decision. But what if you only make it halfway? So, now do you want a vacation in Wyoming or Pittsburgh? Harder call.

And being an ideologue isn’t helpful – someone who thinks things should just be a certain way philosophically. “I’m for less government and that’s that.” Well, that’s not helpful. We need practical solutions. After all, conservatives are against corporate welfare but it’s OK to bail out Freddie Mac and Fannie Mae to the tune of hundreds of billions. What does that phrase “to the tune of” mean, anyway? What does that sound like? Whatever millions of people being screwed at once sounds like, I guess. So, maybe it’s an orgy. I don’t know.

To some extent, tho, you do have to start with what you truly believe is fair. Because both plans have their merits – there’s nothing wrong with the personal responsibility of the Republican plan and there’s nothing wrong with the empathy of the Democratic plan.

So, do you believe that health care is a privilege or a right? To me, I’d have to say it’s a privilege. We shouldn’t let people die in the streets any more than we let them starve to death. And we don’t – doctors take an oath to treat the patient in front of them. And it’s illegal for a hospital to turn someone away even if he doesn’t have insurance. Just like starvation – no one starves to death in this country. There are soup kitchens and shelters. There IS a safety net. And besides, if you’re rich, you get better EVERYTHING. That’s just the way it works. You get better air, food, water, shelter, and clothing. Why wouldn’t you get better health care?

And why should I as a healthy person pay for an unhealthy person’s lifestyle? Granted, most of why I’m in the shape I’m in has to do with genes and luck. But I do eat right. And I do take care of myself. So why should I chip in for a morbidly obese wastoid? Perhaps that’s what we should do. Do it by weight. Come in and get weighed every year. And your premium varies as a function of that. Not sure what we’d do about diseases that make you gain weight or the invasion of privacy thing but I’m all for it.

Not sure how that’d work in India, where everyone is skinny, anyway. They run all their stuff at the local and state level, tho. And who can measure anything over there what with the population and all?

And maybe that’s the solution here, too. Fewer people. See, we’re the only developed nation without universal health care. That reflects the conservative values of this country, which has never made sense to me given that it was founded to be progressive. But anyway, we’re also the only developed nation that is so pro-gun, the only one considering a ban on abortion, the one that starts so many wars, and the one with the death penalty. Conservatives need to move on the abortion one, tho – less government interference but OK to tell us what to do with the biggest decision we could possibly make? See the other ones make sense – more guns, more wars, more deaths. That’s one way to lower costs – just get rid of all the people.

That’s it for us here at the Desi States of America. I’ve been your host, Rajiv. And I still am.

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