Non-optimal selection

23 May 2009

Saturday


Bill Moyers

I usually find it nauseating to watch Bill Moyers Journal on PBS, but last night it was about single-payer public health care and was pretty entertaining (though perhaps not entertaining at the level intended).

Moyers and his guests were absolutely right that congress has been and is artfully avoiding the topic. By and large, they won’t even talk about it, and those who control the agenda and the speakers control the debate. It is also absolutely true that this is a dishonest and underhanded way to go about the whole thing.

The honest thing to do would be simply to openly acknowledge that the US is not going to put the health insurance industry out of business in one fell swoop — nor in several such swoops. The health insurance industry is enormous. It employs thousands of people and deals in billions of dollars. It is the quintessential example of something that is too big to be allowed to fail, a fortiori, too big to kill.

But when do politicians ever do things the open and honest way? They don’t. That’s not the way that politicians operate. You don’t get elected in a democracy by being open and honest. You get elected by telling people what they want to hear, and you get re-elected by making people believe that you tried to keep campaign promises even if you have nothing to show for your efforts.

Probably it would be a good thing to put the health insurance industry out of business. The initial hit to the economy in the short term would be significant, but the long term benefits would outweigh this initial hit. But just as politicians don’t do things the open and honest way, democracies don’t do the prudent thing in the present in order to realize a long term benefit in the future.

Marx is often quoted as saying, “Men make their own history, but they do not make it just as they please; they do not make it under circumstances chosen by themselves, but under circumstances directly encountered, given and transmitted from the past.” (This is from the opening of The Eighteenth Brumaire of Louis Napoleon.) Here we have a classic case of history made under circumstances transmitted from the past.

Almost everyone in the Western world types on a “QWERTY” keyboard, as I am typing now. The QWERTY keyboard is engineered for inefficiency, so that early typewriters would not be overwhelmed by the speed of the typist. Fast forward to an age in which this no longer matters, and we still use the QWERTY keyboard. Sometimes social circumstances select for non-optimality.

This is what is happening with US health care today. The system is irrational and frequently counter-productive, but it has its claws into us and we would be hard-pressed to get rid of it, even if we knew that getting rid of it is the right thing to do. One knows that one ought to learn to type on a better keyboard, but one continues to use a QWERTY keyboard, not least because it is built into every commercially available computer today. No one profits from this; there are no vested interests. Keyboard manufacturers could make as much money producing optimally efficient keyboards, but they don’t produce them in mass quantities because there is no mass market. A market could be created for this technology, but no one is sufficiently motivated to do so.

With health care, there is a motivation to improve things, but there are vested interests (unlike the case with the QWERTY keyboard), and that would make any change all the more difficult. The health care industry knows that it faces an existential threat, and it will fight for its existence as tenaciously as any entity faced with the possibility of extinction. We can expect evolution to occur, and this will entail the extinction of old forms of health care delivery as well as the emergence of new species of health care delivery, but, as with “nature red in tooth and claw” (from Tennyson’s In Memoriam), culture is no less red in tooth and claw, and is perhaps more savage than nature.

If we possessed what I have elsewhere in this forum called “intelligent institutions” such transitions would be facilitated, but this is not yet the case, and may never be the case.

In Memorian: "    Are God and Nature then at strife,     That Nature lends such evil dreams?     So careful of the type she seems,     So careless of the single life;      That I, considering everywhere     Her secret meaning in her deeds,     And finding that of fifty seeds     She often brings but one to bear"
In Memoriam:
Are God and Nature then at strife,
That Nature lends such evil dreams?
So careful of the type she seems,
So careless of the single life;
That I, considering everywhere
Her secret meaning in her deeds,
And finding that of fifty seeds
She often brings but one to bear

. . . . .

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