"Society is produced by our wants, and government by our wickedness; the former promotes our happiness positively by uniting our affections, the latter negatively by restraining our vices." These are the words of Thomas Paine and are fundamental to the functional nature of government in American society. The purpose of government is to discern the natures of wickedness in all its forms and to create barriers to prevent the destruction of society from these indecent pursuits. The precise manner of governance is left up to the people but I feel that this quotation implies that it is best if at these times the governed take on the role of a child who is discovered with a hand in the cookie jar, and the government to take the role of an angered but loving parent. There are those who feel that the role of government is to be a spoiling influence and to provide for our wants. This is a modern invention of politicians who pander to the masses for votes. It is in some respects incompatible with a functional society. Governments tend toward assembling and gathering powers beyond those needed once appointed as a full provisionary force. It is therefore best that the government of a state be a force of influence; to promote the general welfare of its citizens, rather than provide for it directly. A society allowed to flourish under this promotion will always be more effective than any governing body at reaction and provision.
There is the contention of nationalizing or socializing the health care system so as to reduce the burdensome costs of health care. What must be examined and debated is whether this is in any way effective at actually producing a reduction of cost or if it is merely a manner of disguising the cost and, in the spirit of the medical tradition, not a treatment of the root of the disease itself. If it in no way reduces our costs but merely disperses them across our tax structure then of what use is this system. If it is ineffectual, then can we conceive instead of a manner that does reduce the overall costs of our health care system? Is it possible to conceive of a system which is less pervasive than an overall nationalized system and targets directly the root causes of our ever bloating health care bills? I believe that it is.
In order to decide what system would be effective, it is first necessary to ascertain the root causes of increasing health costs. The present costs are largely amassed not through the routine of a yearly checkup or other similarly mundane medical issues. In fact nearly all medical expenses are from complications or afflictions that ultimately end people's lives. Terminal illnesses and mortal injuries call for complex and expensive drug treatments or invasive surgical procedures that to attempt to repair or temporarily relieve the body's ailments. These are also situations that necessarily require at least moderately lengthy stays under medical care and supervision of some sort in addition to the actual treatments themselves, an additional expensive episode. The fact that these treatments are expensive is unlikely to be changed in the near future. It would be foolish if it were otherwise, to expect the medical field to reverse the causes of death cheaply. Therefore what must be examined is whether the demand for them can be reduced. Is it possible that our behaviors or environments are a contributor to the necessity of treating cancers and other terminal ailments? The answer for that is on the side of any cigarette pack purchased by any American smoker.
More moderate afflictions such as mental disorders or milder physical ailments, such as diabetes, which require continuous drug or other medical therapies to treat account for another significant portion of medical expense. Again, the cost of these drugs is unlikely to be immediately reduced without pressure. Here there is a positive solution which is readily apparent to any rational person but is not significant toward the possibility of nationalized care. It is obvious that there are alternatives to American pharmaceuticals available in other industrialized nations such as Canada or England. These alternatives could be introduced as they are very likely to have undergone similar rigorous tests to insure the safety of the drug as would occur here under the protection of American laws. Free market forces from competing drug companies would eventually force the lowering of prices for their products. Having the government pick up the tab for its citizens does nothing to make the drugs themselves less costly. We would instead have to be taxed additionally to assure that the drugs are indeed covered and paid for. Doing that merely conceals the high cost of our prescriptions from us and does not encourage them to become any more effective at treatments either.
Indeed this brings us our first and main detraction from nationalized care. The tax structure of countries which have such programs is significantly higher than here in America. The current American pays on average somewhere in the vicinity of 25 to 35 percent, with the highest and richest individuals perhaps paying a lot more; I'm not getting into that here. In Europe and Canada the average person pays at least 50 percent of their income to the government; in Scandinavia the rate has been as high as 70 percent. While there are other programs inherent to a more socialized system which account for some great expense themselves, the greatest portion of these government budgets emerges from health care costs. This is secondary to the more acute problem herein however. The principle that should be applied is does it reduce health care cost or merely hide it. As the tax is evenly applied regardless of health, if a person is in fact healthy they are subsidizing the less healthy persons. This is regardless of whether the infirm are so afflicted from advanced age, genetic flaws, or poor personal lifestyle choices. Thus without taking any other factors into account, there is no incentive for an individual to choose to remain healthy and in so doing not need to go to the doctor in the first place. If there is need only to go for a physical or some specific but regular checkup, there is very little cost relative to the overall bill. Even if there is only the need for a few tests to assuage the fear of a patient who has a slightly bizarre but by no means life-threatening condition, this is in fact a minor expense in the greater scheme. It is obviously impossible to remove all medical problems from age, injury or genetics entirely. Therefore it becomes necessary to reduce the costs amassed from unhealthy lifestyles.
What this suggests is that part of the reason for our bloated costs emerges from simple economics. People have greater need of medical attention today. Whether this is from general paranoia brought on from irresponsible media coverage and vague pharmaceutical commercials, or is in fact suggestive of a massive population of ailing people is another question, or all of these is another question but is for now irrelevant. If the demand for something is increasing, in order for cost to remain stable, the supply must correspondingly increase. This is of course the simple economics version that lacks government or cartel style price-fixing. The basic concept here is that in order to reduce our costs it is necessary first to reduce our demand for health care. The supply is relatively fixed as the arts of medicine and the application of healing is a mastery that few can attain properly. It would be entirely unseemly for our state medical licensing boards to allow the village idiots to poke around in an open chest cavity vainly trying to clean out clogged arteries and other similarly complex procedures. It is easier and safer to reduce demand than to open the faucet in this manner. Demand is down when our population is relatively healthy. Thus it is necessary to discern ways this happy circumstance can be creatively brought about by government influence. Simply paying for our indulgences by means of a blind tax does not in any manner reduce the cost. Someone will have to pay the doctor, and if it wasn't the patient directly, then it was the taxable public footing the bill.
Attached to this problem is that many people simply aren't paying the bill. Sometimes, in fact often, they are not capable of doing so, through lack of finances or lack of proper insurance coverage. I am not suggesting either of these is inherently wrong, merely that the poor or ignorant masses seeking medical coverage are not capable of paying for it once received. This was a topic of significant debate during the passage of the recent bankruptcy bill; people were amassing huge medical bills that they simply could not pay. Hospitals are businesses just as any other. But the employees who work are bound to a sacred oath to treat and cure the sick and injured. As such, doctors will treat and bind our wounds, but will expect some form of fiscal compensation for the expertise at doing so. This is entirely reasonable; doctors and nurses spend many years acquiring accreditation and training for what they do. This is a dedication to be rewarded. But what is unfortunate is that if people are unable to pay, and subsequently forfeit the debts via bankruptcy, someone else has to pick up the tab. A hospital isn't going to close ideally. Remember it's a business; it's going to raise prices on the people who do pay.
We have seen then the root causes of increasing price. It then appears the combat we must enter into is not merely to defray this spiraling expense account by socially paying for the bill, but instead to seek to ultimately reverse the spiral. The root causes of our unhealthy society are a hydra of sorts. There are in effect several lifestyle choices which weigh heavily upon a wave of subsequent ailments afflicting not only the body but also the mind. It is also no coincidence that precisely those people least educated in making healthy choices and concurrently least capable of making them in error are the people who undertake more dangerous paths toward long and healthy lives.
The Medicaid system reported that participants, who are generally required to be poor, were 50% more likely to be smokers (MMWR Report). And smoking appears to have the not only the largest direct fiscal effect on health costs but also the most visible warnings as to this effect. They are right on the side of the package:
"SURGEON GENERAL'S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy.
• SURGEON GENERAL'S WARNING: Quitting Smoking Now Greatly Reduces Serious Risks to Your Health.
• SURGEON GENERAL'S WARNING: Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth, and Low Birth Weight.
• SURGEON GENERAL'S WARNING: Cigarette Smoke Contains Carbon Monoxide."
That looks pretty concise with just the first line. Smoking causes lung cancer, heart disease and emphysema. All of these are effectively terminal ailments, which we know to account for the largest portion of health care costs. The second line suggests that a smoker should quit, and to do so right now if possible. The third suggests that a certain vulnerable group, namely pregnant women and the associated fetuses, are at risk of still more ailments. Premature births and fetal injuries resulting in defects are accountable for all manner of chronic ailments which require long-term or even a lifetime of care. The fourth line is the most vague in its suggestion. Anyone who sits in a garage with a running car long enough can tell that carbon monoxide isn't all that fun to inhale, even if they do not know what it is. The Nazis experimented with carbon monoxide as a gas exterminator for the Jews of Europe. It was quite effective, judging by the millions who died in the Holocaust. The implicit suggestion herein is that the smoke itself is a silent killer of those around the smoker. In other words, people who don't smoke shouldn't be near the smoker by choice for a long time. Putting this into raw numbers; treating smoking illnesses, days lost from work and premature deaths caused by it, smoking accounts for at least one half of the federal deficit by itself, at least $200 billion, perhaps as much as $300 billion. One of every five deaths in this country can be attributed to smoking and it is said that smoking reduces a person's life expectancy by 14 years. Lung cancer will do that; it's around 80 to 90% fatal. Few diseases achieve this level of an effective death sentence, even in the cancerous realm. And yet smoking seems to be connected to some of the most dangerous. Pancreatic or esophageal cancers are actually somehow almost completely fatal, but fortunately less commonly contracted. Smokers will contract these types more often than other people. Additionally smoking directly suppresses the immune functions of the body, making it susceptible to infections of all types, not just respiratory ones, and therefore more frequent visits to the doctor. This must be the first target and it must be hit much harder than is being done currently.
But before we proceed to the method we find that there are other major causes of our detrimental health. We have ascertained that continuous mental disorders accounts for a significant portion of the budget. There is a root cause, either directly or indirect, for a good percent of mental defections. It's alcohol abuse. Heavy drinking has all manner of mental disorders associated with the repeated brain damage done by it. Even if it does not directly afflict the drunk, then it is the often abusive or violent natures of an alcoholic's relationships which will transfer disorders to others. Psychological disorders can emerge years later which require extensive treatment from the varieties of mental, physical, and even sexual abuse which are expounded by inebriated parents upon children or each other. The abuse can begin during pregnancy as alcohol contributes heavily to birth defects and miscarriages. Alcohol's distant cousins, narcotic drugs, are not innocent of such things either. But as they are generally illegal already, it is unlikely that any further government measures will be able to alleviate the costs caused by their abuse. Both combined are guilty of over half of all fatal traffic accidents, with alcohol alone making up almost 40% itself. Traffic accidents account for an estimated 50 billion dollars a year in the American economy merely for the treatment of immediate injuries, insurance claims, and auto repairs. This is to say nothing of the treatment of permanent injuries and loss of work due to disabilities or even temporary rehabilitation. The stereotypical alcoholic is the street wino. While this is merely blind characterization, the assertion is clear. Alcoholics, and other drug addicts for that matter, are statistically more likely to emerge from impoverished social conditions to begin with. Being unable through lack of means and education to personally combat this threat, it must be dealt with publicly. Even dealing only with the effects on traffic, such addiction is a significant problem. Taking in the whole pile of effects and the pervasive nature of alcohol as a cultural phenomenon, it must be changed.
There is finally another emerging threat to public health. It is not bird flu. It is obesity. The propensity of Americans toward a sedentary lifestyle which consists of a great buffet of snacks to consume is an overly simple explanation. What is important is that our growing national waistline will soon rival and even surpass these two champions of ill health. Billions of dollars are lost yearly in the quest for magical diets and machines to allow us to do as little as possible and still lose weight. I say lost because almost nobody actually uses these exercise machines and any diet generally does not "work" without some exercise in the first place. Almost $120 billion more is lost by the associated treatment of diabetes, heart disease, arthritis and other maladies commonly plaguing overweight people. Again, as before, the group most likely to be overweight is below the poverty line and the tab is picked up elsewhere. Healthy foods paradoxically are more costly than junk food. This must be changed. Poor families are more likely to be trying to work long hours to pay bills and must prepare lower quality meals, from a health perspective, or pick up fast food on the way home due to lack of time and energy. Trying to get out for a run or jog, the most basic form of vigorous exercise, is usually inadvisable in a poor neighborhood. The risk of injury from poorly maintained sidewalks and assault by random strangers is too high. As a result of these difficulties the poor are plagued with higher rates of human inflation.
America is no stranger to this growing girth, but only recently has public policy attempted to address it at all. The rate of growth is still climbing and we are already at 30% of the adult population. Combating this expanse must be done, and quickly. The immediate fatality of being overweight is not as apparent. But the fact that someone can live being so significantly distended is not a testimony to progress. It is rather an indictment for change. It is time to reduce our tolerance and sensitivity to this problem. Simply poking fun at the fat kid, as was done on the playground, does nothing productive either. But dancing around it politically does not make living with these plagues any cheaper for the rest of us or even for those afflicted.
There is hope. But it lies not in simply subsidizing the lavish and excessive lifestyle each of these evils commands. Governments have long known that if something is to be encouraged, it can be subsidized. If it is to be discouraged, it is taxed or in someway punished. This then is the role I propose for government in this great crusade. The government is not a hospital. It is not composed of doctors. Therefore it should not attempt to act as one. What it can do is to promote the general health of its citizens. This is done for the greater good of society. It is entirely just that the people who are more physically fit by virtue of a healthy lifestyle be rewarded by being freed from their bonds to those who have not this wonderful state. It is also entirely just that people who commit themselves to an excess that leads directly to adverse health conditions should be made to pay some compensation for this choice. It is necessary that it be an active choice to be healthy. No one is going to compel anyone to get up in the morning and immediately start doing pushups and run four miles. Neither shall it be compulsory to eat properly or to avoid smoking. But somewhere in the middle there is at least a satisfactory human being with a decent chance at a healthy, and hopefully happier, life.
Death is inevitable, but if we are to reduce the cost of living with it then we must make death as basic as possible. Natural deaths from advanced age or freak accidents are generally swift and tragic. The months of agony and suffering endured by a cancer patient are not. The principle I wish to apply here is simple. The basic idea of training is to set up a reward structure and a fear or punishment structure. Thus participants of unwanted excesses will be punished; while the desirous reverse healthy construct will be rewarded. The reason for this structure is simple as well. It appears clear that the people most likely to be unhealthy are precisely the same group that is unable to afford to be so poorly conditioned. Namely this is the poor, but also the elderly and the young, who are apt to be poor anyway. By protecting the poor from the self-afflicted wounds of excess, and leaving self-destruction to the less numerous rich, we would be better equipped to properly fund the remaining, and hopefully reduced, needs of health care. It remains to show how this could be done.
The punishment phase is most interesting to me, in part because in some places it has already begun. In many states, there are excise taxes on items like cigarettes. The purpose is to discourage the use and to collect monies for the indulgences of the citizens. In most states this was all that was done. However, Oregon passed a law recently which did something slightly different than the mere punishment of excess. In the war against smoking, a 15% tax was proposed. Any amount up to and over 10% has been shown to have immediate gains in converts of people who now chose to try to quit smoking out of ficsal frustration. So that was part one of the Oregon law; achieve a population who wants to quit. Part two is the "good" part. A significant portion of the money collected went to subsidize prevention and support programs to both limit future smokers through fear, and to promote quitting by making it an attractive and cheaper option. The idea was to make the quitters more permanent and to make doing so an attractive option.
Here in this law was the nature of prevention of excess. Many excesses come from people who do not care in the first place. This is true regardless of the economics involved. Rich or poor however, the disease is going to cost the same. Since the rich account for a small percentage of the population and can, if need be, pay for medical care, then the laws must unfortunately target the people who cannot pay and who are more numerous. What is necessary is twofold; one, get people to care about what they are doing by making effective and tangible change in fiscal cost. And two, educating them that either what they are doing is in someway unhealthy, or at least that there is a different and somehow better way to live healthy.
The adage goes that an ounce of prevention is worth a pound of cure. Therefore here is what I would propose: A significant national excise tax, something almost prohibitively high, on smoking and tobacco products, perhaps as high as 100% or even higher, probably gradually reaching that height over a decade. The money raised would go toward the immediate treatment of disease associated with these cancer devices and toward fanatical subsidizing for anti-smoking campaigns. Namely these would go to those associated with quitting, but also those which dissuade future smokers. There would be even more exposure to anti-smoking advertisements and greater inducements for the treatment of the addictions associated with it. The idea is to hit people squarely in the wallet while simultaneously offering the open doorway out of the danger zone. Under this premise the choice must be so obvious that there is little consideration for the alternatives. Smoking and illegal drugs offer little to no positive health benefits that cannot be achieved in some other fashion while at the same time offering death and serious illness to regular users. Continuing to tolerate and bear this cost is not tenable. It must be stopped or at least minimized, right now, in our lifetimes.
For drinking and for junk food, I would offer similar, although not nearly as severe, taxes. Moderate drinking has even been found to have some potential health benefits which, curiously enough, are almost opposite the negatives of heavy drinking. Whether these benefits would outweigh family histories of alcoholism or personal preference should be a personal decision, perhaps aided by consultation with a physician. Again the tax must go toward preventative programs and treatments of the associated ailments. There must be associated informative and communicative campaigns on the part of doctors themselves with the common patients who exhibit signs of substance abuse, including alcoholics, in order to find the people who crawl deeper into hiding. Alcohol or drug abuse and eating disorders which contribute to obesity are often strongly associated with severe bouts of depression as well. Dealing directly with this problem by offering more extensive psychiatric counseling cheaply to those who seek to change this unhappy circumstance must be done in concert with other means. Here again the advice and counsel of a family doctor would be useful in pointing people in this direction. Where a family doctor isn't available, generally in the poorest neighborhoods, free clinics must be placed with at least the basic services and information to attempt to promote the health of the denizens surrounding this new beacon of vitality.
The idea must be to discourage those who cannot control themselves and encourage them to seek levels of moderation. People who can contain themselves to a couple of beers now and then are not in our interest to punish if that's all they are doing. People who chug through a 12 pack in a couple of nights regularly are. People who frequent bars with the intent of achieving drunkenness are the issue. People who have a party now and then are probably not at issue. This is not Prohibition. The idea is to make it prohibitive, not prohibited. Alcohol would be treated more as a luxury for special occasions for example. Its consumption should not be taken for granted. The effect should be that some will seek help by realizing the economic damages of a habitual use. People who consequently moderate their levels of consumption will be left relatively unaffected. The net effect of reducing alcohol abuse would also have accompanying reductions in all manner of social issues not directly related to health costs; violent incidents, traffic accidents, spousal and child abuse, and mental disorders all have close ties to drunken buffoons. The reward here is less apparent. Responsible alcohol use is still legal. Anyone who can get drunk responsibly can still do so. I would be contented with that.
The same is true of food. A few chocolates are likely not going to kill someone; at least if that person isn't seriously allergic to the dark master of the American sweet tooth: the cocoa bean. But these sweets should be likewise viewed as a luxury type item. Perhaps I would waver and allow a "duty free" period surrounding traditional candied holidays like Halloween or Easter. But I can find little healthy benefit for candies and cookies other than that people, especially children, like to eat them. A similar tax should be applied to certain fast food offerings and greasy potato chips as well. No law I can conceive is going to force Americans start running around and working out. However using the "sweet" tax to subsidize things like dieticians or trainers for people interested and committed to healthier lifestyles might help with our sedentary lives. Some enlightened businesses have begun building gyms or supplying workout equipment at places of employment. The purpose is to provide free access to exercise for employees, while reducing the cost of health insurance for the employer. This sort of behavior should be rewarded and funded to make it more wide-spread. I would also propose that the tax would be used to provide subsidies to local produce farmers. Not to agricultural conglomerates as is typical now, but instead the little guys who are in competition and find themselves growing things like tobacco to make a living. The idea here would be to encourage people with substantial enough plots of land to grow some of their own produce from time to time and then to decrease the direct cost of a diet richer in fruits and vegetables. Studies show that as much as half the adult population does not consume the recommended daily 4 to 5 servings of fruits and vegetables. Following this recommendation coincidently happens to promote a healthy immune system, among other things. Eating junk food by contrast seems to promote poor dental health, diabetes, and clogging of the arteries.
As to rewards, a significant rebate and special rates should be required of a health insurance company each year to people with relatively clean bills of health. This would have the effect of greatly aiding the healthy poor as the funds returned are inherently more valuable to someone who has fewer fiscal resources. It provides an excuse and tangible reward for positive lifestyle choices, besides merely having a healthy body. I ask why not simply create a division between the groups of healthy and unhealthy where they truly and plainly exist and make the distinction a real and tangible one in the wallet.
I can conceive of no greater circle than to create a system which attempts to destroy the capacity of self-annihilation and replaces it with a better self-defence system on the individual level. This is a long-term solution we are looking for. We are not interested in robbing the piggy bank to pay for things right now. A nationalized system, even in the form of a prescriptive drug coverage plan, offers no incentive toward doctor and pharmacological competition which could naturally lower prices. It also, by itself, provides no motivation toward personal maintenance of healthy lifestyles. I do not see penultimate health care as a necessity of human life. Certainly some measures are expected in emergencies and traumatic circumstances. But it is ultimately our own personal choices in life that can lead us to have additional emergencies or to desire additional medical care. If a warning is not heeded then it is a choice to do so and a lack of desire to overcome this weakness. The sympathy of others must be stunted by the fact that a reckless lifestyle choice was made. The additional problem is that healthy people are not encouraged sufficiently by a system where the subsidizing flows from the desired to the undesirable. Nationalized health care is not the answer to naturally reducing health cost. What it does is convert the money from one source to another. If someone is physically fit and happens to be rich then it could be the intent to use this wealth to help others attain a similar constitution. But it should not be a requisite of social participation. On the other hand if people wish to make choices, then it seems fair and appropriate that we should not burden their minds with obtuse options. In fact since it is statistically likely that the "wrong" decision will be made often, it is necessary that we should ask the government to step forth and to help institutionalize the right one. Nationalized care is guilty of not achieving any of these positive enlightened aims on its own standing. A system very much like the proposal here would be needed anyway to achieve any appreciable effect on national health. Why not simply target the offenders among us, reduce them in number and effect, and make them take ownership of an often self-afflicted problem, in so doing resolve the root causes of our health epidemics.
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