Doctors vs. Accountants©: Part II

Last week, I wrote that current attempts to expunge for-profit influences from American medicine are doomed because that simply involves reshuffling the medical bureaucracy. I came in for some mild criticism, suggesting I missed the point. “If we funneled a lot of the money that we put into welfare for corporations into helping people get the medical treatment they need,” a good friend wrote, “we could reduce a LOT of the bureaucratic harmful determinations.”

I understand the appeal of this argument, but I don’t believe it’s true. Yes, I’d love to see some of America’s massive federal subsidies to, say, hydrocarbon mining and tech giants, redirected to serving ordinary citizens’ interests. Certainly we need to stop using public funds to protect the wealthy while ordinary people lack access to common-pool resources. But I’m not sure that’s what’s really happening in medicine. It’s something more subtle and insidious.

All economies are structurally organized around some resource that forms a bottleneck. Something that’s scarce and desirable forms the foundation of every economy. Whether it’s gold, or land, or human labor, every economy needs something that exists in finite amounts; the medium we use to value and exchange that resource, we call “money.” The key to unlocking and reforming an economy lies in identifying that bottleneck resource.

What, in medicine, is the bottleneck? Two or three years ago, I might’ve said “human labor.” Because medicine is highly specialized, and requires years of technical training to begin a career, doctors and nurses will always be a finite supply. And while for-profit hospitals can outbid for the services of experienced, highly-skilled professionals, access to quality, affordable medical care for numpties like me will always founder on money.

But recent news makes me question this assumption. To give just one example that’s gained recent news-cycle traction, we’re also facing a potential shortage of Earth’s helium supply. When I say “helium,” you possibly think of party balloons and silly voices. But much highly specialized technology, including, say, MRI machines, relies upon helium, which is so scarce on Earth that we risk running out in about 35 years.

Therefore we must make valuable decisions about allocating our finite helium, and other nonrenewable resources. Simply turning free markets loose sounds desirable to strict libertarians: if doctors need helium more than party planners, let them outbid. But forcing doctors to compete in resource auctions will increase already-staggering prices, ensuring that ordinary people can afford medical care even less than we do now. Some authority needs to intervene.

One cannot overvalue the importance of scarcity. Those of us old enough to remember the Clinton Administration’s attempts to reform health care, derisively dubbed “Hillarycare,” will recall conservative anger at the attempt to nationalize one-seventh of the American economy. But by the time Obamacare rolled around, that number had risen to one-sixth. The cost of medical care is growing faster than the overall economy, apparently.

Somebody has to make life-or-death decisions about allocating limited resources. Conservatives want private corporations to make those decisions, while progressives trust the altruism of the state. In both cases, some poorly-paid underling with looming deadlines will have to make decisions, about which they might be under-informed or even ignorant, based on one-size-fits-all metrics handed down from authority. That’s the living definition of bureaucracy.

Not only is medical technology limited and expensive, so is skilled labor. So is physical space for providing patient treatment. So is decision-making to determine who receives treatment: a Dutch study found doctors widely agree that older patients are under-treated compared to younger patients, while the American Medical Association prizes “duration of benefit,” which privileges the young. So, despite our best efforts, we’re still asking bureaucrats to make important decisions.

Though I recognize the limits of a layperson’s thought experiments, I cannot separate bureaucracy from medical treatment in a capitalist structure. Hospitals were invented by Christian monks during the Crusades, and hospital treatment was initially a form of religious devotion. Perhaps we could separate money from medicine if we recaptured this sense of spirituality, but how? Money changes people’s values, and the change usually can’t be reversed.

Please don’t misunderstand: I dislike the status quo greatly, and believe it abuses poor and minority people in its lopsided distributions. But, unless we remove all resource bottlenecks, which cannot happen if we want high-tech treatments available, I can imagine no remedy that isn’t just another reorganization of the bureaucracy. Whether you prefer state or corporate bureaucrats more, they’re still bureaucrats. And we’re still running out of helium.

Boris Johnson, Donald Trump, and the Road We're On

Well, Boris Johnson has popped his head from the freezer and apparently seen his shadow, guaranteeing Britain another five years of bullshit. Faced with a tanking economy, scathing international ridicule, and no support from his party, the British public nevertheless gave him the electoral mandate which, until now, he has lacked. As a longtime Anglophile, I care about this sort of thing. But I suggest other Americans should care, too.

Because American and British politics have a history of moving in tandem. Margaret Thatcher’s election preceded Ronald Reagan’s, and their two hand-picked successors, John Major and George H.W. Bush, collapsed almost simultaneously. Bill Clinton coined the term “special relationship” to describe his liaison with Tony Blair, a relationship that continued with George W., cementing American perceptions that the two major parties are more similar than different.

Most important, the Brexit vote came just months before Donald Trump won the Presidency on a technicality. Neither Trump nor Britain’s Conservative Party won a straight majority (which is pretty common in both countries), but both nations have a first-past-the-post election system that means a weak candidate can strategically half-ass their way into an overwhelming legislative majority, which Johnson’s Conservatives did yesterday.

(For Americans, and others unfamiliar with the British system, the Prime Minister isn’t exactly like the President. Queen Elizabeth remains Britain’s nominal head of state, though no monarch has publicly contradicted Parliament since Queen Victoria. The PM is an elected Member of Parliament, who gets further elevated by Parliament itself. This means the PM is usually the head of the majority party, and therefore rarely faces meaningful opposition from the legislature.)

So, follow me here. Britain looked at a government with unpopular policies, a history of racism, and demonstrations of both criminal intent and widespread procedural incompetence, and said: sure, we’ll have some more of that. This should worry Americans already concerned with the Trump administration’s visible lawlessness. The English-speaking world is apparently ensnared in some multinational cultural moment where anything goes, as long as aging White people permit it.

I don’t say “aging White people” flippantly. In Britain and the U.S., the longstanding demographics are changing quickly, as former majorities are increasingly displaced by immigrants. Bruce Cannon Gibney writes that, at present, White Baby Boomers outnumber all minority voting blocs together in America, but their youngest members currently qualify for AARP discounts at most restaurants and grocery stores. And when they die, Whites will slip into the plurality.

Immigration from Latin America, in the U.S., and from the former Empire, in Britain, have changed both countries’ voting and cultural profile. Not that the heritage has disappeared; William Shakespeare and Edgar Allen Poe won’t lose their status in the near future. But we cannot trust that the “normal” aggregate citizen will, in coming years, look like me. I think that’s great. Others consider that an assault on everything they treasure.

Many voters respond by aggressively rejecting the outside world. Donald Trump ran on a platform of undisguised racism, economic policies that kick the weak, and promising to quit international alliances that have secured America’s political and moral leadership since World War II. And he won. So Boris Johnson ran that same platform on steroids. Britain’s economy has been dwindling since the Brexit vote, and British voters apparently don’t mind.

America’s economy is apparently more fraught than Britain’s; our current growth rate mostly depends on who you ask. Trump’s greatest accomplishment is, apparently, to not submarine the boom economy he inherited from the previous administration. But his racism, his profiteering from office, and his undisguised disdain for democracy remain on public display. I truly fear, if something doesn’t change soon, we’ll see the electorate next year shrug and continue unperturbed.

I don’t say this flippantly. Just yesterday, the same day the British electorate returned Boris Johnson to power despite his historically unpopular policies, former Arkansas governor Mike Huckabee announced his intent to shepherd Donald Trump to a third term, in defiance of the U.S. Constitution. This President’s apostles have taken their hero, who is, remember, an admitted sexual harasser and probable rapist, and elevated him to the status of secular Messiah.

I'll be on @seanhannity 2nite @FoxNews at 9pm ET and will explain how @realDonaldTrump will be eligible for a 3rd term due to the illegal attempts by Comey, Dems, and media , et al attempting to oust him as @POTUS so that's why I was named to head up the 2024 re-election.

— Gov. Mike Huckabee (@GovMikeHuckabee) December 12, 2019

Throughout my lifetime, the pattern has been clear: America and Britain aren’t the same, but they move on substantially parallel tracks. And the current track calls for the electorate to return a leader whose policies are massively unpopular, but who is personally somehow well-liked, to power, despite demonstrated incompetence in office. We who believe America has a moral mission in this world should take this as open permission to panic.

Doctors vs. Accountants©: the Role-Playing Game

Listening to a @NPR story of a woman who was diagnosed with cancer. insurance denied the medication that would save her life. Her doctor wrote a “compassion letter” to the drug maker asking for mercy.

I’m in my car screaming!

Why in 2019 are we begging to live? #Medicare4All

— Abshir Omar (@AbshirMSP) December 5, 2019

I just encountered another of those audience-grabbing stories about insurance companies failing to provide medical coverage. The bean counters apparently denied somebody’s necessary life-saving medical care. I understand the outrage this story causes, because we all imagine ourselves, with years ahead of us, suddenly facing mortality because an actuary somewhere said “no.” Putting ourselves in those shoes, the prospect seems horrific.

Is it, though? Princeton economic historian Jerry Z. Muller writes that, while medical metrics are frequently overused in ways that undermine doctors’ autonomy, that isn’t always bad. It certainly can be, when insurance executives who don’t understand medicine overrule a doctor’s opinions based on shoddy math. But throughout medical history, Muller says, hospitals have hosted tension between doctors who want to take heroic life-saving actions, and accountants who tally the costs.

Generations of TV medical dramas have convinced laypeople that medicine consists of earnest, energetic professionals making split-second decisions while lives hang in the balance. This might make sense in Emergency Room conditions, where people come in broken and bleeding, staving off burst appendixes and suppurating aneurysms. But most medical care is slow, deliberative, and costly. Asking whether continued costly treatment will have meaningful outcomes isn’t always unreasonable.

The model we’ve all seen in stories like House M.D. looks exciting, dangerous, and fun. Somebody enters the hospital with a twitching thigh muscle, and the glamorous doctors, who have only one case, piece together clues proving how an aortic dissection threw a clot to the brain, resulting in testicular obstructions: medicine as logic puzzle. I might’ve paid better attention in middle-grade biology had I thought I’d get jobs like that.

But an NPR human-interest story broadcast at the peak of that show’s popularity traced the costs of just one episode, landing on a $300,000 price tag—and that’s a conservative number, because I added up their annotated costs and got something far higher. And that’s nearly ten years ago; advancing technology and added administrative bureaucracy probably mean it’s far higher now. Even under the best circumstances, medicine is expensive.

The early-seasons core cast of House M.D.

Let me interrupt myself here and note: I don’t mean accountants should be more active in scaling back costs and denying medical care. A good friend recently received a medical diagnosis that mercifully ties all her disparate symptoms together. She should’ve received this diagnosis twenty years ago, but overworked, underfunded doctors made hasty short-term determinations, almost certainly rushed along by bean-counters. A little more time and money could’ve saved years.

So yes, I acknowledge that there’s no simple, arithmetic formula to strike a balance between the accountants and the doctors, whose desires often conflict. And the arena of that conflict is a patient’s body. The outcome, as seen in the tweet quoted above, can be tragic for individuals—but downright mandatory for the medical economy overall. Anybody hoping to solve this problem concisely should also wish for a pony, because it’ll do as much good.

Because, let’s be honest, when people complain about private insurance’s interference in medical decisions, their solution is often to nationalize medical care, to a greater or lesser degree. As America’s political Left wants to institute Medicare For All, Britain’s political Right is actively considering privatizing the NHS, which American progressives often brandish as a model of more efficient medical template. Which they want because the NHS isn’t much better.

British medical journalist Dennis Campbell, writing in the Guardian, a newspaper with undisguised Leftist allegiance, notes that NHS bureaucrats regularly overrule doctors’ opinions. Campbell cites a panoply of reasons bureaucrats to this, but buried in this list, he names “resources”—a weasel word meaning “money.” So the NHS, like America’s private insurers, overrules doctors’ wishes to keep costs down and funnel money where it’ll do the most good.

If we expect a constant stream of on-demand, high-tech medical treatment, we’ll inevitably run into the impediment that all resources, including money, are finite. Somebody needs to make decisions about who gets costly, invasive treatment. That “somebody” will inescapably be a bureaucratic goat whose official functions, whether funded by the state or private capital, will conflict with life-saving desires. Somebody’s live will take priority over another.

The system is heartless to individuals. I’m sure that woman whose life-saving cancer treatment got denied is suffering greatly. But trading corporate bureaucrats for state bureaucrats won’t solve anything. Unless we abjure high-tech medicine, which will never happen, we’ll always have to make finite resources cover infinite needs. That’s what bureaucracy does. Sometimes, that means making painful decisions and letting human lives go.

See also: Doctors vs. Accountants©: Part II

OK Go Boomer Computer

Billie Eilish

Pop singer Billie Eilish’s recent admission that she doesn’t know who Van Halen is, has reignited the generational debate that apparently flares every two weeks anymore. Van Halen’s fan base of older Gen-Xers have to admit they’re officially as old as they once thought their parents were. Since Van Halen never much spoke to me, I wouldn’t much care about this faux controversy, if it didn’t come so soon after the now-obsolete “OK Boomer” joke.

When I was 16, I  desperately wanted to be a Baby Boomer. Looking around, I saw the cultural and political power Baby Boomers possessed, the authority they held over my choices, and the simple ubiquity of their presence. When you're a kid, you have two options when faced with authority: you rebel against it, with the moral incoherence for which teenagers are justly famous, or you emulate it. I chose column B.

While still in elementary school, I remember watching PBS documentaries about the cultural milieu in which Boomers grew up, from the images of wealth they witnessed on shows like Leave It To Beaver and Bewitched, to the socially acceptable rebellion they helped create at Woodstock. Based on the exposure I received in childhood, I believed Boomers won the Civil Rights conflict—although Malcolm X and Dr. King were both born in the 1920s.

We didn’t have that. As a member of Generation X, I struggled with communal identity. We didn’t even have a generational handle until about 1993, nearly thirty years after our generation began; we bounced among “Latchkey Kids,” “the Baby Bust,” “the MTV Generation,” and “Generation 13” before Douglas Coupland’s novel gave us a name. If television documentaries gave me a false impression of Boomer unity, media treatment convinced me that my generation barely even existed.

However, we did exist. We test-marketed the claims many Millennials now use to make bank, including the claim that wages were flat while work was up, meaning we faced the likelihood of a chronically impoverished future; the claim that cultural institutions treated us exclusively as consumers, and demonstrated little patience with us as makers; and the claim that the economy was saddling us with debts we’d never be able to repay. History has vindicated us.

So you understand my frustration when, several weeks ago, New York radio host Bob Lonsberry tweeted that “Boomer is the n-word of ageism.” After forty years of constant saturation with the idea that Boomers were cultural innovators, political liberators, and better musicians than every subsequent generation, somebody purporting to be a Boomer spokesperson claimed Boomers are oppressed equally to African Americans. This takes oppression chic to a new level.

Eddie and Alex Van Halen
(don't ask me which is which)

The “OK Boomer” tag, like every other fad in our media-drenched environment, had a remarkably short lifespan. In November, it pushed people born between 1945 and 1965 to heights of spittle-flinging rage; but it’s already getting used ironically by comedians and basic-cable news commentators. Just like “MeToo” and “Black Lives Matter,” overexposure defanged the monster in its cradle. Yet the reaction it generated speaks volumes about its intended audience.

I have one problem about the Billie Eilish controversy, though: approaching fifty years since the Beatles released their final album, their music still appears timeless and relevant. Van Halen doesn’t. Van Halen’s peak album, 1984, is larded with okay songs like “Jump,” and shitty pieces of self-indulgence like “Hot For Teacher.” As the movie Yesterday recently demonstrated, playing the Beatles moves many generations equally. Van Halen sounds very early-1980s.

People slightly older than me feigning distress that a 17-year-old doesn’t know Van Halen, is like demanding a 17-year-old when 1984 was released, 25 years ago, remember Frankie Laine and Perry Como. I sure didn’t when I was 17. In both cases, the Billie Eilish faux-controversy and the “OK Boomer” outrage, we see people old enough to be parents or grandparents demanding they be treated as permanently, eternally young.

Essentially, we have two generations publicly demanding to act like Peter Pan, and it’s embarrassing. Boomers and their first-generation offspring expect history to freeze, their childhoods to be treated as sacrosanct, and post-Millennials to treat them like peers. They want congratulations for the innovations they nurtured, and then, they want all innovation to stop.

And making a teenage pop singer the embodiment of this desire for nothing new to happen, is the height of irony.

When “OK Boomer” began, I thought we were seeing old people refusing to get old. But clearly my generation is refusing to get middle-aged, too. Here’s hoping we can all stop being narcissistic, and appreciate that the world keeps growing and blooming, even when we’re not in the center of it.

Why Is Making a Superman Film So Hard?

Henry Cavill in Man of Steel

DC’s continued struggles to create an economically viable cinematic enterprise have reached a new low. Writing in Forbes, pop-culture critic Dani Di Placido describes DC's struggles to find something for Superman to do. You’d think an alien living in America, believing in justice and honor, would have important resonance in today’s divided cultural landscape. Perhaps movie studios, notoriously jittery about public opinion, find this too pointed.

The rush of armchair critics on FaceTube and InstaTwit have readily condemned this timidity, for obvious reasons. I’m tempted to echo these positions, because that’s low-hanging fruit. Superman’s backstory would seem ripe for utilization in today’s America. His historic connection of “the American way” with “truth [and] justice” should address our trend toward conflating Americanism with untruth, subjectivity, and avarice. This shouldn’t be a hard sell.

Yet considering the economic landscape responsible for controlling this discussion lies hidden beneath the cultural issues. Superman, Batman, and the MCU don’t just objectively exist; they are properties controlled by media conglomerates, which make remarkable money off their holdings. The rentier economy allows DC and Marvel to get wealthy by owning and licensing their intellectual property, but that wealth makes them risk-averse.

DC Comics is owned by WarnerMedia, so naturally Warner makes DC movies. WarnerMedia is America’s second-largest media conglomerate, controlling about sixteen percent of America’s media revenue. That’s slightly under half the revenue controlled by America’s first-largest media conglomerate, Disney, which owns Marvel Comics and Star Wars. Following its Fox buyout, which reduced America’s major media conglomerates from six to five, Disney controls approximately one-third of America’s media revenue.

Superman on the cover of Action Comics #1

So the continued runaway success of the MCU, and DC’s inability to compete, isn’t about the competition between these two comics companies; it’s a proxy feud between America’s two largest media corporations. As I wrote recently, talking about Martin Scorsese’s condemnation of the MCU’s box-office domination, this is somewhat misguided. Yes, major-studio franchises control America’s box office. But only two franchises, Star Wars and Marvel, are currently very successful.

And both are owned by Disney.

I’m loathe to offer suggestions to major media conglomerates for controlling their more lucrative properties, since history suggests they’ll misuse that power to further limit the government. These corporations have a history of kissing tyrannical ass to ensure their continued revenue flow: Disney itself has become particularly risk-averse since it temporarily lost China’s import market following their 1997 dud Red Corner. Conglomerates suck just fine without my help.

Nevertheless, Superman has loomed large enough in American culture for so long, that abandoning his principles to corporate timidity resembles a form of surrender. So I’ll weigh in anyway. Let’s start by remembering what made children embrace comic-book superheroes over eighty years ago: they embodied American moral convictions. They believed in the same things we believed in, and then followed through.

The runaway success of Wonder Woman should instruct DC what audiences want. The titular protagonist, who believes moral right exists as an objective force, and sets out to kill war, in the midst of history’s most pointless war ever, demonstrates what traits audiences reward with money. We want moral confidence, and a will to act upon this confidence. We want characters who remind us to do what’s right.

Christopher Reeve in Superman

Following the immense, brooding darkness of Man of Steel, many critics, including me, condemned the movie’s bleak, ends-justify-the-means attitude. Charles Moss, writing in the Atlantic, pointed out that Superman’s origins were remarkably grim and violent. But I’d suggest that misses the point. Early Superman had lite-beer socialist leanings, and his willingness (in a White, urban way) to confront slumlords and corrupt bankers, reflected America’s unexpressed urge toward revolution.

Christopher Reeve’s Superman expressed the morals of another time. Flush with cash in the post-WWII years, before media conglomerates began hoovering everything upward, this Superman reflected an era whose proletarian values were less communist, more communitarian. Reeve’s Superman busted villains whose machinations interfered with everybody’s desire to live well together, rather than punishing criminals by forcing them to live under the conditions they created.

Superheroes today must express contemporary moral sentiments. What do Americans fear today? The political insurgencies of Donald Trump and Bernie Sanders bespeak distrust of political and economic establishments, including media monopolies, that serve themselves, rather than the people. Both Trump and Sanders campaigned against a fossilized social order stealing from the people. What if Superman, and the Justice League generally, fought the same fight?

This would require WarnerMedia to turn against its business model. But whose hand feeds them, ultimately? The shareholders? Or ours?