"a fish, a barrel, and a smoking gun"
for 5 June 2000. Updated every WEEKDAY.
Cancer Schmancer:
As long as you've got your health



Just as Grape-Nuts have nothing to do with tasty purple fruits, just as comedy clubs have nothing to do with laughter, so do such quirky verbalisms as "health care" and "health insurance" confuse us as to the nature of the Thing Under Discussion. In partial confirmation of the Sapir-Whorf hypothesis, such little tricks of language condition the way Americans perceive the world, hypnotizing us. Even supersmart policy eggheads can lose perspective when confronted with such linguistic shuffles.

In the pages of The New Republic (a hip alterna-zine whose contributions to America's longest-running and most boring national policy conversation can hardly be overstated) Gregg Easterbrook recently waxed perplexed over the phenomenon of Americans' impatience and anger with managed-care HMOs. "It's one thing for the public to loathe an industry whose performance is declining," the wonderboy wonders, "but the health care business is losing stature at a time when its performance is improving. By almost all measures, U.S. public health gets better every year. Americans are living longer than ever before, and heart disease, stroke, hypertension, AIDS, and most forms of cancer are steadily declining."

Easterbrook is making a category error here. Perhaps its consequences are not as dire as wandering into the Laff Factory and expecting a good time, but it's an unfortunate one nevertheless. A similar confusion bedeviled some of the less pragmatic partisans in the recently departed (and sadly missed) media cirque d'Elián, who bolstered their pro-Juan Miguel arguments by noting that officials in Cuba are really dedicated to health care.

They sure are. "Official statistics" in Cuba claim a populace of mighty-thewed warriors with Methuselan longevity, Derridan reading skills, and baby-fresh complexions. Outside observers in the '90s have found drugs, disinfectants, medical equipment, and drinkable running water in short to no supply. Party newspapers praise health care developments while doctors, spoken to candidly, can only point to low-fat diets and plenty of exercise (because no meat or motor vehicles are available) as health pluses for Castro's Heroes. But actual results don't matter to Cuba's American fans, especially because they'd never dream of going there for health care, and if by chance they had to it would be in one of the better equipped hospitals that saw a steady flow of American currency. What makes Cuba a paradise to the sort who care about health care is not results, but the dedication (total, to be sure) to health care qua health care. (A similar combination of officially superlative health care with near complete misery can be found in Canada, where the diaspora of comedy talent is only one clue to the dark realities concealed beneath the shining maple leaf.)



But the point such health-care partisans miss — ignoring for a moment the one atop their heads — is that health care only matters for people who aren't healthy. Not only does it not have any direct link to health — look again at Easterbrook's list of things that doctors don't prevent, but only try (often ineffectually) to cope with once they strike — but logically the relationship is the opposite of what is carelessly assumed. The more health care you consume, most likely the less healthy you are.

There are many reasons 40whatevertheysaytoday million Americans don't have health insurance. Surely not being able to afford it is one. But let us not forget the simple — and often perfectly rational — decision that it's a really bad gamble for the typical person between the ages of 20-40, both because insurers always try their damnedest not to pay off anyway and because you are more likely than not never going to need any medical care that you couldn't afford to pay for out of pocket — especially if that pocket is filled with the money that didn't go to pay for health insurance.

Of course, not everyone can afford to pay for sudden health emergencies that may arise without insurance. America already has a grandly traditional decentralized way of shifting costs, a dilemma Hillary Clinton thought we needed to build paperwork towers to the Moon in order to resolve: Poor people get health care in emergency rooms, give fake addresses, and then never pay their bills. Then the lost costs are passed on in inflated rates to the insured and wealthy. This sort of grassroots free-market Yankee ingenuity can never be matched by those fathead bureaucrats in D.C.!

Our blindness toward the dubious link between health and health care is of course the result of the mind-bending wizardry of the medical profession. The Learned Elders of the AMA are forever scheming in their mountain strongholds for a wider and stronger grip on the medicines we can consume, the machinery we can run our brains through. Now, through the agency of swingin' jazzman Jack Kevorkian (who should be canonized as an AMA saint) they are even trying to medicalize and professionalize — of all amateur pleasures — suicide. The prestige and incomes of doctors remain huge (though the incomes shrank slightly over the past decade) while the wonders of medical care — as opposed to the wonders of sanitation and nutrition — are grossly overrated by everyone; in fact, whether the day has come when medical care saves more lives than it either destroys or does no good for is still an open question. Not since Demi Moore has any force in our culture managed to get paid so highly for delivering so little.



"Good" health care, health insurance — neither add appreciably to American health. Nor is that health harmed by that public menace of the early '90s, health care cost inflation. Expenditures on health care didn't rise quite as much as the feisty and concerned citizens on Designing Women feared they would over the '90s — they now make up 13.5 percent of a growing GNP instead of the 13.7 percent they did in Clinton Health Care Plan Year Zero. But, hey, what if that percentage did keep growing? Like all things that can't go on forever, the rising trend would eventually have stopped. But in the meantime, as our real needs as mammals on earth (food, shelter, non-Windows web browsers) are increasingly met for less and less effort (except for people living in San Francisco or near Au Bon Pain outlets) well, the money has to go somewhere, and why not to the sometimes bitter entertainment of medical care? As conversation with any number of over-60s reveals, there's a sizable pure-consumption element to health care expense — an enormous quantity of which is spent on the last weeks of life in a hospital, adding little to either personal health or well-being.



The only rhetorical way to sell the absurdity of health care's relation to health is through public policy sleight-of-hand. We all know for ourselves that any extended dealings with the health care system are a sign that something's gone very wrong and that we are more or less on a toboggan ride to either disaster or some heinously unpleasant pit stop in disaster's direction.

But the conflation of health care with health is part of a more general infantilization, a notion that life outcomes have more to do with what others are there to do for you than what you do yourself. Obsessions with "prenatal care" obviate the simple need to eat well and avoid poisons while pregnant; obsessions with "health insurance" obviate the need to save money for the occasional emergency. The traditional trinity of Healthy, Wealthy and Wise becomes the responsibility of the health-care system, game shows and the educational system instead of one's own decisions. In reality health has far more to do with lifestyle choice and clean water than with health-care; and doctors' stature and income far more to do with restrictive licensing than expertise. The mentality of the health-care policy fanatic could be considered diseased; the physician, under the auspices of the AMA and the HMO, has healed himself.

courtesy of Eugen von Bohm-Bawerk
picturesTerry Colon

Eugen von Bohm-Bawerk