Letter 2 America for May 10, 2013

Dear America,

I saw Bill Gates on stage with President emeritus Clinton on Tuesday night.  It was the tape of an interview given to a reporter from MSNBC--which has a relationship with Microsoft that explains how Bill Gates got on the same stage as The President--and the star of the show was definitely Bill Clinton.  I sometimes forget what he brought to his office when he served in it, but whenever he speaks, I am reminded.  He is a liar personally, but as far as his political beliefs are concerned, they are all well reasoned, supported by logic and fact, and at least ostensibly sincere.  I doubt that he has stopped seducing women given the hard life that he wears on his face, but his politics are impeccably progressive with a Keynesian economic slant admixed with just a hint of capitalistic, free enterprise, Darwinian reservation.  Bill Gates, on the other hand, is another thing entirely.  His preference for self-reliance even in the cases of those whose self-reliance can never yield the modicum of creature comfort that should be universal is like a scar on the picture of Dorian Grey...except that it is on his face where it seems to me he thinks it is hidden.  Gates is a man who thinks that he is better than everyone else, and while his foundation makes an enormous show of helping the impoverished with problems like the malaria that is rampant in some of the third world, he also lives in a mansion and appears not to even think about the poor as his driver wends the limo up the driveway.  Mind you, that is a metaphorical observation as I have no idea whether Gates uses a limo, but the image seems apposite given the tone and substance of what he said.  As he opined that the market should be allowed in some way to control the outrageous cost of healthcare, Bill Clinton observed that we pay nearly 18% of our gross domestic product to health care providers and the next most expensive developed nation pays less than 12%.  He then made oblique reference to the fact that those other nations have universal health care institutions except for the one paying 12%, which uses a system like Obamacare.  In that country, the Netherlands, everyone has to buy insurance, but there are accusations of rationing medical care because there is such diversity among insurance plans depending on what people can afford.  Gates' rambling and essentially prattling advocacy of the free market was not even tangentially supported by fact, much less was it tangential to reality.  We have a free market, and it runs amok with impunity.  Listening to the two of them was like hearing a condensed version of the political dialectic occurring in this country today.  There was the captain of industry, who wears his greed on his sleeve like a badge of honor, implying that if he can do it anyone can and thus should be required to without government assistance, and there was the world class progressive politician who knows that if everyone could to it...well, everyone would.

Both men have probably read Dickens, but they have drawn politically diametrically opposed conclusions from his work...Gates identifying with the upper class and Clinton with Oliver Twist.  Gates is a pull yourself up by your bootstraps kind of guy, never considering that one who cannot afford shoes doesn't have bootstraps while Clinton sees need and feels that in those cases where there are no bootstraps, they should be provided.  With regard to medical care in particular, the evidence continues to mount that Gates' economic model for society is at best a fantasy and at worst an attempt to reify greed in the form of filthy lucre while Clinton's model is not just realistically compassionately founded, it is a matter of necessity because free enterprise is anything but free if you are not running it.  The federal government's Centers for Medicare and Medicaid Services released data on Wednesday on the subject of hospital charges.  The data demonstrate that those charges are completely deracinated from any reality based considerations and--this is my conclusion rather than anyone else's, but I believe it would be an impossible challenge to refute it--are rather motivated by sheer avarice and acquisitiveness.  There were cases in the study in which charges for the same procedure were ten or even twenty times as high on one side of a city as they were on the other.  In addition, private insurers and Medicare pay only scheduled prices for treatments of various kinds ranging from minimally invasive gall bladder removal to joint replacement, but those without insurance are required to pay the full rate, often hundreds of thousands of dollars: a debt burden that would be life changing for most of us, but catastrophic for those below the mainstream of our economy.

So the data primarily demonstrate two things.  First, someone is getting very rich charging almost a quarter of a million dollars to replace a knee joint in a geriatric patient when the cost of doing so could not possibly even approach that figure.  Second, the burden of that rapacity is being born disproportionately by the working poor and the newly anointed members of the middle class who are just starting to realize their ambitions.  It is Bill Gates versus Bill Clinton, and I know which Bill I prefer.  The data were summarized in the New York Times, but they came from a government survey derived from information provided by hospitals themselves, so the possibility that the data are skewed to make some political point is remote if it exists at all, and it may be just the tip of the iceberg.  If you have ever had major surgery in a hospital, you will most likely recall that you received one bill from the hospital and another, separate bill from your surgeon, and both of them were likely astronomical.  I respect the demands of the medical profession, and I would even acknowledge that ninety percent or more of doctors take those demands seriously and are up to meeting them, the other ten percent being the focus of a discussion on medical malpractice tort reform that we should also be having.  But even so, the idea that a surgeon can make $6,000 an hour challenges my concept of fair compensation.  When I had my three shoulder surgeries over the course of ten years, I had them at the orthopedists' "surgery center" where the procedure was performed on an outpatient basis.  My surgeon's car was self-evident each time, and they went from Porsche Carrera to Audi A8 to Mercedes 500 series AMG.  If you know anything about such things, you know that none of those comes cheep, and at least one goes for about what most people pay for a starter house.  It turns out that the surgeon collects such vehicles and is a scratch golfer, which means he plays a good bit of golf when he isn't in the operating room from noon on most days, and I suppose that would have been justified if he were that talented and capable, but I discovered something on the occasion of the third operation that is suggestive of the contrary.  

I had to sign an authorization for his physician's assistant to perform any part of the procedure, and I refused at first.  But she came into the pre-operation room where I was being prepared for anesthesia and asked me to sign it, which I did after asking her to confirm that the surgeon would be in the operating room at all times.  After she left the anesthesiologist said to me, "you want her to be in that room," and he declined to explain why, but the context of the remark and what I could glean in my aftercare suggested quite strongly that she did the bulk of the work on my shoulder, which frankly was not quite the success that I had hoped it would be.  Of course, my insurance paid what the doctor charged for his own services, not the reduced rate that could be expected to compensate for someone who had never been to medical school, and I paid a price as well as there was no indication that some of the problems noted on my MRI were even considered, much less treated.  My point is one I have often made.  Like most people, I don't mind someone getting rich because he makes an extraordinary contribution to society or to human progress.  But wealth that is not earned by dint of such contributions--what I call artificial wealth--is the vigorish that a privileged few take for themselves just because they can.  As it turns out, that problem pervades medicine just as it does finance,  pharmaceuticals and most every other economic endeavor in our capitalist system.  That is why American capitalism is in jeopardy.  That is also why we need a single payer health care system, toward the end of which the Affordable Care Act is just a beginning, and the evidence to prove it is in.

Your friend,

Mike