Health Care in the World of Tomorrow

I wrote a diary last week,Why Health Care Reform is tearing our country apart , that attempted to explore why this issue has elicited such powerful emotions among so many people, in some ways even more than the dissension over our wars.

After the diary had run its course I was still thinking about it, still convinced that I was on to something even though it wasn't picked up by too many people.  And then I came across this segment of a White House Bioethics Report, that could have been the summary of that diary.  

Attitudes toward Death and Mortality: An individual committed to the scientific struggle against aging and decline may be the least prepared for death, and the least willing to acknowledge its inevitability. Therefore, given that these technologies would not in fact achieve immortality, but only lengthen life, they would in effect make death even less bearable, and make their beneficiaries even more terrified of it and, in a sense, obsessed with it.

Fear of death is ubiquitous, as is aversion to suffering in ourselves and those we love. Other species may mourn their dead relatives, wolves and elephants come to mind, but none anticipate their own fates. All societies from time immemorial have had ways to deal with this knowledge, from modern religion, shamanism to Utopian visions that transcend our mortal existence. All of these also happen to entail a degree of acceptance, so that death is reinterpreted into something meaningful, transcendent, and as such, acceptable.

Only in recent times has this been changed, so that death and debility is seen as preventable, or at least able to be postponed until the distant future. We no longer believe in magic. We don't believe that a trip to the shrine of Lourds will allow the paralyzed to walk, the blind to see or cancer riven to be cured. Yet, we have not given up on faith, but rather changed its focus. Whatever our religious perspective, we have added a new tenet, that a modern health system can save us.

But unlike worshiping at a church, or being part of an idealistic movement, this new faith is intertwined with the global high tech free market economy. The payoff for primary research in basic science comes when it all comes together to cure or enhance the lives of individuals. And this is now happening at an accelerating pace.

The mechanisms to extend life, to end suffering and to make life fuller, have grown faster than our nations wealth. This is because discoveries in biology, chemistry and physics are reaching a point where they can be brought to bear on human disease. We may blame the high cost of maintaining health on greed, waste and inefficiencies, and certainly they exist; but cost increase is primarily because of the success of research that now provides cures for what had been death sentences.

Most people my age, nearing 70, have some loss of short term memory. With each forgotten name there is the chilling fear that this could be the beginning of something dire; the dreaded Alzheimer's, a subset of what is now seen as "Senile Dementia"

Drug companies would make fortunes if they produced a medicine that actually forestalls memory loss, but that's not actually a requirement. One that even gives the hope of this, the merest glimmer of temporary improvement, has value. It will be snapped up, with the public demanding it, at great profit to the provider. Aricept, the minimally useless drug for Alzheimer's is a good example.

The belief in medical miracles morphs into an expectation of them, and finally a demand that is so powerful that no panel, either of a health insurer or a government is able to say, "No, we won't pay for it because it doesn't work." So not only does every private insurer in America pay for this drug, but so does Medicare, and even the British National Health System provides it, as that government was not about to deny, what is actually only a hope.

It has become our secular common faith that with enough "health care" we can live better, longer fuller lives. It is this broad belief that makes every product or treatment associated with this demanded by the public, even when the evidence of effectiveness is lacking. This irrational faith causes ever growing demand with no consideration of cost, until the bill actually arrives.

There are serious scholars who say in the lifetime of those now being born, death itself can be defeated. Sounds absurd? If someone had said in 1940 that this new born child would live to see hearts, livers and kidneys routinely transplanted, to see infertile parents able to have their gametes joined outside of the body, with the embryos implanted to begin a full pregnancy. And that a fetus could be examined by ultrasound, his DNA (his what?) could be evaluated and the health of the child predicted, they would have been considered nuts.

The routine miracles of every day medicine that have occurred in my lifetime makes dismissing any prediction of future possibilities not an especially good bet. How inadequate does the term "health care" become when we are approaching a time when this is the institution that will determine who shall live in good health for an unimaginable period and who shall be deprived of this long stretch of vitality.

If every other industrialized country has achieved universal health care then why not us? That's really my point; they have already done it. Whatever the faults of their systems, the defects have become part of their civic culture. We are attempting to reconcile two opposing central central philosophies, that of egalitarianism and that of free enterprise. It's a problem our society deals with every day, but never in such stark terms as this.

The present United States Health Care System is a Byzantine agglomeration of Public (Medicare, Medicaid, VA, Chips, Research Funding) and Private (Insurers, Hospitals, Doctors, Drug Companies) with varying Federal or State Jurisdictions. Every state has elaborate rules on every aspect of health insurance, from what must be provided to how the rules are to be enforced. It's fair to say that no individual can possible understand the complexity of this system. The inequities that exist are acceptable to most because they are mostly unknown and unrealized.

Because of this complexity, we focus on our own interests in either preserving what we have, or demanding that we have more of the benefits to come. Without a specific proposal to evaluate, we are forced into two camps. The first is those who not only trust Obama, but have confidence in his capability to make this work, that an imperfect law will be the first step to their goals. The others are the mirror image, not only distrusting him, but despising him for threatening something that is precious for us all, and assuming a vague bill will be a slippery slope to their worst nightmares.

While many criticize President Obama for his handling of this endeavor, and I am one of them, it is useful to understand just why this is such an enormously difficult task. So let me rephrase the opening quote from the White House group:

Modern medical advances make death and debility seem no longer inevitable, and as such, even less bearable. As we learn of both the reality and the myths of such advances, those who fear being denied them become terrified, and at times, enraged. The stakes are high, and getting higher as the previously mysterious causes of death and disease start to be understood, with the growing real prospect of intervention.

One of the verities of humanity, that we are born, mature, have a period of healthy adulthood, and then decline and die, is for the first time in our species' existence being altered. We have no model for dealing with this change. The current health care reform debate, while unspoken, is made infinitely more difficult by this new reality.

It could be that the inability to find consensus on this legislation is much more than any failure of the sponsor, but the profoundness of the changes in Medical Science, that we as a people have not even begun to deal with.

Geico Insurance stonewalls legitimate claims

Geico Auto Insurance spends a fortune on entertaining ads seen by millions designed to humanize the company, to show them as "good guys." But based on my experience, they practice a standard prescribed set of dilatory unethical practices designed to exclude even the most legitimate claims.

After a month of absurd excuses for not paying my claim against their insured client who rear ended me, when I saw their ad showing a similar collision with their assertion of prompt payment, it was just a bit too much to take. They assume that saturation marketing is a better business model than actually being a responsible company. So, I put my own words to their advertisement (along with a bit of the one that followed.) It's an amateur job, with my dog's bark providing the sound effects for the crash, but the parody reflects my experience.



The actual events are more serious. The following facts are not contested by Geico. I was rear ended by one of their clients during slow traffic on I-5 north of San Diego. The woman got out of her Ford ranger, (which being protected by steel bars was undamaged) apologized, saying "my insurance company will pay for it," and she gave me a copy of her insurance card, writing down her phone and license number.

Only then, she offhandedly said she had been hit by a car behind her. So I went to see the damage to her car, which I snapped this photo of with my cell phone.



There is a small rim of something white around the hitch, but we will never know what it is, since although she was too busy to respond to Geico's request for a statement for over a week, she did have time to wash off the white stuff that she thought was paint, the only evidence of a collision that by California law had to have been forceful enough to have pushed her car into mine.

Only later did I find out that she reported to Geico that her car was overheating, and she was trying to get to the shoulder of the highway, explaining how she could have gotten too close to the rear of my car, and even caused the other car to bump her's.

Geico was happy to accept my prompt candid report of events when it suits them, yet ignore my words that refute their fantasy scenario that it was the purported hit and run driver who bears full responsibility. The problem for Geico's position is there was absolutely no damage to the rear of her car (including the hitch and attachment to the frame), she never called the police as he took off, and then she washed off the "evidence" of what she called a few chips of paint on her trucks hitch.

Here's a car similar to the one that hit me, describing the consequences of Geico's position.



Geico is proposing the theory that the rear hitch took the full force of the purported hit-and-run car to the frame of the car that hit me. If this actually happened this car would have hurtled forward rapidly. With no damaged bumpers, (designed to crumple to protect occupants) absorbing the hit, Geico's client would have recieved, at the least, a serious shock. If not enough to cause injury, at least enough to shake someone up. But there was no such effects, her calm state reflected in the perfectly legible license number she wrote on her insurance slip, as she was apologizing for hitting me.

(California law requires 100% certainty that her car was "pushed" into car ahead for release from liability, which is implied by the uncontested facts as described by this summary of California law for legal buffs: (reference )  For those who are really into California Insurance law, here is a history of the relationship with insurers and third parties (that's me) who make a claim against their insured.

Nevertheless, this excuse was good enough for Geico, as they are telling me no payment for my damaged car. Actually, what they are saying is you have to go through the legal mill, knowing your claim ($2250) is too small to get a contingency lawyer, so maybe you will just go away.

Geico is not only harming me by not paying this claim, they are harming their own client, who was apologetic, and fully expected my damages to be paid out by her insurance. If they simply paid this claim, while she may have have a small temporary increase in her rate, there would be no other repercussions. If I go to court, either small claims or superior, she will be served with a subpoena that she would have to respond to, and a judgment against her would be reflected in a downgrade of her credit record along with the insurance rate increase. So not only do I have to deal with this for the next month, year or more, but so does their client, whom they care about as little as they do about me.

And I did avail myself of the complaint services of the California Department of Insurance, which refused to buck Geico's fantasy theory...."just too complicated for them to evaluate." they said.

We live in a cynical age, where the phrase "No good deed goes unpunished" actually has validity. While I have an ingrained propensity to honesty, to thinking about our civil society that is based on good faith in dealing with others, from this experience, I can see that Geico doesn't share this value.

In a country where some forty thousand people die in car accidents every year, auto insurers actions have an effect on driver's behavior, and the carnage on our highways. My accident was not serious. But, had I been driving a small car with children in the back seat, this collision could easily have caused permanent injury to them given the "Urban Assault Vehicle" configuration of their clients car. Note the indentation from the steel bar at chest level on back of damaged Saab, my car.



Geico will get away with paying nothing in this incident. Doing so, they are subverting the punitive function of liability that influences driver behavior. They are also encouraging those who have minor claims such as mine to exaggerate them, to fabricate physical injury, as the only way their case will provide a large enough contingency payday to get legal representation. So, being forced into deceit to obtain a fair payment causes insurance rates to go up for everyone.

The damage to my car was minor. But the damage of thousands of such little injustices by powerful insurers has an effect. The next accident that depends on accurate eye witnesses to determine responsibility will be a little more likely to be tainted by self interest rather than follow the imperative to truthfulness.

I used to enjoy the little Aussie Gecko, and the abused Caveman, and assumed that the company that ran the ads shared the sensibilities of their characters. Those hundreds of millions of dollars spent on such public relations are effective.

Just hope you never need them to pay a claim.

Defending Bill O'Reilly---in Harpers Magazine, yet

Principles transcend personalities.

For those, the too few, who extend this to principles overriding even partisan identity, there are often strange outcomes. Even Justice Antonin Scalia, someone who has never been accused of being a liberal, cast the deciding vote in the decision that politically unpopular acts, even those deemed reprehensible by the vast majority were protected under our constitution. As such, even desecration the symbol of our country, burning an American Flag, is protected by the United States.


I ascribe to the same theory of seeking the larger principles over partisan warfare. So I wrote wrote a diary on a left wing blog, explaining that even Rush Limbaugh has a right to run political satire, even though the readership of the blog find such satire reprehensible.

I expressed the same sentiments, about O'Reilly's comment on the air that liberal commentators should be put in jail with the words, "you hear that FBI, put them in chains." My defense of O'Reilly is pretty rare in this Dailykos.com left oriented blog. Yet, it got a mixed review, even compliments in the midst of the criticism as indicated in a poll on the essay.

I sent a similar message to Harpers Magazine, the oldest liberal publication in the country, referring to an article that claimed that Bill O'Reilly was fostering the myth that liberals are stabbing the nation in the back.

There aren't many letters to the editor printed in Harpers, but the editors of the magazine felt that the accusation against O'Reilly was unfair, so they printed this letter in September of last year (quoted in part).

The author of the article implies that Bill O'Reilly meant his words literally when he urged that liberal commentators be put “in chains”

A fair reading of Bill O'Reilly's statement would show that he also never meant his words literally. His statement was pure satire, an acknowledgment that freedom of speech is so sacrosanct that even those with whom he disagrees have an absolute right to express themselves.

We are at a moment in this nation's history when the most crucial issues of the day are often addressed in words that have become shibboleths of an immutable perspective. This makes misconstruing of O'Reilly's comment meaningful. The implication is that this avatar of the right advocates the use of police power to destroy his political opposition.

As informative as the article is, it fails to transcend partisanship, and it increases, however slightly, the gulf between the two sides of our divided country.

The one advantage of trying to adhere to larger principle is that it gives more validity when it is your political opponent who has violated them. It puts every excess in a broader context rather than being relegated to the gross distortion of partisan rhetoric that tries to show only the depredations of the other side.

It's worth the incurring occasional anger of "your team" to take take this position.

End of Life Discussion is no "Death Panel"

How sad is is that the Democrats who first explained how what was being tarred as a "death panel" was only a provision to allow payment for doctors who have a discussion with their patients on end of life options.

And after defending it as appropriate, something that people could understand and even conservatives approve of, what do they do? They announce that they have removed it from the current Senate drafts of the Health Care Bill.

Forget about the ethics or principles involved, this is just blindingly stupid politics. If it was a positive change when included in the house bill, it is still so and should have been defended.

I worry about the fate of the two party system. Just how often will Democrats have the benefit of the opposing party starting a war that they said was based on the enemy having weapons that could destroy us, that would cost nothing since their oil would pay for it and be over in a few months with minimum casualties; with every last word turning out to be not only wrong, but based on intentional falsification.

And if that isn't enough, how often will we have a economic collapse that threatened to be a full scale world wide depression, mostly caused by the laze faire excesses of the opposition. And this collapse reaching its nadir on the very quarter of the election.

If the style of the Democratic party is to fold whenever there is any exaggerated attack, even one that had no substance, it asks the question of what exactly does this party stand for.

And I want there to be death panels, not those of the fantasies of Sara Palin and her ilk, but groups with the clout to prevent those who have decided on a peaceful death to make this happen. My Aunt, whom I just got off the phone with is the perfect example. At 106, she has lived long enough. It's not I who is says this, it is she.

I couldn't have this conversation with her now, because the two years that have passed has caused a major decline of her mental faculties. But a few years ago, I did have exactly the kind of conversation that the provision for paid end of life discussions with physicians would have provided.




Now it would be too late to ask her about end of life care, as her vocabulary has been reduced to only a few words, which becomes fewer with every conversation I have with her across the continent. She is still cheerful, but I can't be sure, since her nature is always to be concerned with others, and she knows that her being happy makes me happy.

What I fear, and what is probable, is that if she survives much longer with the current trajectory of mental decline, shortly she will lose the ability to talk at all. I will no longer be able to visit with her on the phone, so she still feels she has a family. And I don't want her long life to be capped with a period of despair, of being isolated and aware of all that she has lost.

I also fear that when she has the next medical crisis, perhaps a slight infection that weakens her, that she will be given antibiotics reflexively, allowing her body to continue on as she falls further into a frightening dark place filled with strangers whom she can't talk with. Eventually, my becoming one of them.

So in this entire multi part legislative process of Health Care Reform the single most useful improvement at a trivial cost, increasing the ability of someone to discuss how they want to die when they still have the ability to do so, is removed because the Democratic leadership refuses to defend it.

If the Democrats won't fight for my Aunt Lena, then who are they fighting for?