My half-sister, Kim, is a seasoned health care professional who has lived her entire life in the same red state. When she and I converse, we try to avoid talking about things which we've previously crashed through and cut ourselves on. Current US Health care policy is one of those topics.
More than a decade ago we discovered that it needed to be put in our 'agree to disagree' warehouse. Two years ago we took it out, added a few bits on Obamacare, confirmed we both still disagreed with the majority of the other's opinions, and put it back.
This week, she decided to bring it out again. Some people get a rush out of whacking a hornet nest with a stick (metaphorically) and I think there was more than a little bit of that guiding her decision to dredge this up from the depths.
She was discussing her job (which she can detail quite successfully, for hours, without touching on national policy) but ended up making a broad blanket statement demeaning everyone in the US without health insurance. She knows neither I nor my fiancee have any, so I took her criticism as an opening gambit. In order to test her resolve and determine if she actually wanted to re-open this topic, I said, "There are millions,
tens of millions, of US citizens who can't afford the luxury of health insurance."
"I know."
"Then how can you make a statement like that? Do you know how naïve you sound? What you just said was, effectively, 'all poor people are idiots'."
"That's not what I said."
"You said, 'all those uninsured fools'. Who were you talking about?"
"There are tons of people with moderate incomes who could afford to pay for health insurance but, instead, they don't. They live in expensive houses, own several cars, boats, campers, and go on fancy vacations, but don't have health insurance for themselves or their kids. When they get sick or injured they go to the emergency room."
"I assume the hospital sends them a bill if they don't have insurance."
"Sure. But even a minor operation could cost fifty-thousand dollars. They don't have that. They end up going bankrupt. Not paying."
"And those type of people will get a bill from the IRS if they pull that shit after 2014. The IRS will seize their tax returns and even garnish wages. Another good thing about Obamacare." At this point I could have said: 'But we've previously agreed to disagree about this so... how are your horses?' And changed the subject. But the hornet nest had been whacked and I wanted to buzz around so I added, "Which is just one more justification for socialized medicine."
"No it's not. Socialized medicine will ruin health care as we know it. I'm on the inside and I see all the machinations of the insurance industry, the pharmaceutical companies, the hospitals, the doctors, the patients, and the government Medicare-Medicaid programs. Medicare is completely broken. Socialized medicine would be the same as Medicare for everyone. Broken."
"As someone who has benefited almost my whole adult life from socialized medicine, I can tell you—from a patient perspective—it's better than the current insurance company's for-profit system."
"You've said that before, but the US military medical system isn't socialized medicine."
"You don't think so? Why not?"
"With true socialized medicine, like they have in many European countries and Canada, you don't have the freedom to choose your treatment. No options. They make the decisions for you. They follow an algorithm. One size fits all. The military is just another sub-group of the American system..."
"You tend to speak in broad generalities in instances such as this. I need specifics. Describe how a patient's treatment would differ, today, in a US hospital and a Canadian hospital."
At this point my sister began a lengthy diatribe of a hypothetical elderly woman with multiple certainly-fatal symptoms. She then explained how US doctor's would use extensive tests and many high-tech machines to come up with their diagnosis before explaining all the various surgical and prescription options available to the old cancerous crone. According to her, the Canadian doctors would weigh the availability of limited resources against an actuary table and decide what, if any, treatment the old crone would receive. At which point I said, "Death panels! You think they have death panels!"
"That's not what I said. You're putting words in my mouth."
"No no. I get it. And I agree."
"You agree with what? Death panels?"
"Yup. I think it's an unfortunate and misleading label for something that already exists, but hey...semantics. And putting aside the label, I don't think every last drop of life needs to be squeezed out of every lemon. I'm afraid I don't pray to the sanctity of life like some do. We live. We die. Some early. Some later. I don't agree that every last treatment should be made available to the soon-to-be-departed. Your hypothetical old woman with late-stage cancer should go home with some great pain medication and update her will."
"I guess I don't completely disagree. But you said death panels already exist?"
"When only one donor organ is available and two or more people desperately need that organ, who makes the list and who decides that the healthy thirteen year old gets to be higher on it than the sixty year old alcoholic?"
"I see where you're going with this, but it's not the same thing."
"No, not the same, but similar. And we're veering too far from the point, which was that I said the US military health care system is socialized medicine and you said it wasn't. Your example of doctors deciding treatments based on resources is EXACTLY what is done in the military. Military doctors, military administrators, and military pharmacists all get paid a salary; none have any incentive to perform tests, surgeries, or prescribe drugs to turn more profit. And the very first thing everyone in that military socialized medical system does for every patient—from triage nurse to neurosurgeon—is weed out the malingerers. Then they treat the real sick and injured people. Not many options are provided. Directives are given; focused on fixing the sick and injured and getting them back to work."
"But when it's your loved one, you want absolutely every possible treatment. No matter the cost."
"Nope, that's not me. I think one must weigh the cost of treatment in
not only dollars, but in probability of survival and in the quantity and—most importantly—quality of life after treatment. How many quality years would your hypothetical cancerous lady have, if she survived the full million-dollar treatment of surgery, chemo, et cetera?"
"There's no way to measure that."
"Sure there is. Probability. Statistics. Medical history."
"Not with any accuracy. Define
quality years."
"The quality baseline for any given person is equal to their mental and physical activity level before they were sick, with allowances made for the normal aging process."
"So you're saying if the probability that our lady with cancer will only have two or three years she should not be afforded a million dollars worth of treatment?"
"Two or three years! If she can have two years of quality life every effort should be made...hold nothing back. But. I suspect that isn't realistic. I think after months and months of treatments she'll never get back to her same old self. That she won't even have one more month of quality life. That even if she's lucky enough to be cancer-free for a few years, the therapy will cause her to be mentally and physically handicapped and dependent on caregivers for every remaining day.
"In America, we have that option. You don't think we should have that option?"
"No. If that woman happens to be lucky enough to have a million dollars she can choose to spend it on a bed-ridden, increasingly depressed and ever-weakening body that can't wipe it's own ass.
"America's for-profit system encourages expensive tests and treatments which result in increased profits for all concerned. The insurance companies pass the gouging of the hospitals and doctors on to the policy holders.
"Remove the ability to profit and all unnecessary tests and treatments stop. In socialized medicine, which is what military medicine is, every doctor earns his or her salary. With no chance of making more money for prescribing more drugs or ordering more tests, their focus shifts to repairing or curing the patient. That's it.
"And, in a social-medicine environment, what treatments are offered that woman with late-stage cancer would be determined by weighing the availability of doctors, surgeons, and medicine against the patients expected future quality of life. And—all other things equal—the thirteen year old cancer patient receives priority over an alcoholic sixty year old."
"Ahh, I see...full circle. But you know as well as I do that entrenched government employees just sit around and do nothing all day. Now you want every hospital to be staffed with them?"
"You and your stereotypes. Are you saying your mail doesn't get delivered? Your fires don't get put out? Your crimes don't get solved? Your wars don't get fought? I'm not saying everyone drawing a government paycheck is a workhorse, but in my military experience shiftless lazy fucks got kicked out. I see the same percentage of lazy punching-a-clock civilians and most of them get fired."
"I know that if you remove the profit incentive from the medical profession that innovation will freeze in place. Nobody will strive to create the next high tech gadget, the next super drug, or cure the next disease, nothing will move forward and, eventually, advances which have already been made will fall into disuse."
"Your opinion of mankind is much more dreary and pessimistic than I thought. You depict a dystopian medical environment where nobody will do anything to help anyone unless they can make money off the procedure. But you must know, even when you say it, that it isn't true. Billions of people live on this planet in countries with socialized medicine. They are treated their whole long lives by salaried doctors. Every military doctor I dealt with worked hard to help their patients."
"And now you're going to tell me there are pharmaceutical companies, somewhere, that produce drugs to help people and aren't just interested in making as much money as possible?"
"OK. I'll give you that one. But on the count of socialized medicine in the military?"
"Agree to disagree."
And back in the warehouse it went.
An amalgam of (as well as on) perfection—this philosophical compendium of prose, poetry, recipes for thinking, viewing, and living (as well as eating) captured my intellect and gorged it for about six-hundred pages (which would, obviously, be more-wonderful if it encompassed the entire 678 page book). The fact that the author lost me in a few places doesn't shine a shadow on the enormity of how De La Pava cleverly informs the reader through this fiction. Fiction? This is the truest creative non-fiction I've ever read! 
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