Dealing with that annoying gorilla odor

Understanding what's going on in the American health care system today is impossible unless you appreciate the "code languages" that are being used. To a large extent it's all doublespeak - attempts to explain why the room smells like a gorilla (and to suggest elaborate schemes for getting rid of the odor) without actually mentioning the 900 pound ape swinging from the chandelier.

As demonstrated more completely in The Grand Unification Theory of Health Care, all the mighty forces within the health care system today are fully and vigorously engaged in the covert rationing of our health care.  Simultaneously, those same forces are taking every pain to convince us (as well as themselves) that, not only is there no rationing, indeed, there are no limits to what we ought to expect from our health care system.

The key for organizations that want to flourish within such a system of covert rationing is to identify leaders who can respond both to the irresistible need to ration health care, and to the equally irresistible need to rationalize the rationing behavior in terms acceptable to the rest of us.  Those individuals, men and women of vision, are presently the Most Valuable Players of health care. The enabling visions advanced by such individuals – visions that permit covert rationing activities to go forward openly, freely, and often profitably – can be categorized into two general schools of thought: the Clintonian school and the Gekkonian school.

By keeping in mind which school of thought the speaker represents, we can successfully interpret virtually every public pronouncement being made today on health care.

The Clintonian school of thought

The Clintonian school of thought is the one most commonly espoused by government officials, politicians, public health officials, and other health care policy makers, as well as most liberals. I have taken the liberty of naming this school of thought after the individuals who have, thus far, done the most to advance its basic premises.

Clintonians believe that the root cause for all the problems in our health care system lies in human weaknesses (specifically, you may recall, in too many greedy doctors using too much expensive technology).  The fix for these problems therefore rests in setting public policy and promulgating governmental regulations to hold that greed in check.  From a philosophical point of view Clintonians believe in Original Sin, in the essential evil in man – if you give a fellow too much freedom, he’ll probably do something bad.

The Clintonians’ point of view is amply supported by the uncontestable fact that that the traditional fee-for-service health care system institutionalized the natural human greed of physicians. Under that system, the more technology doctors used and the more procedures they ordered, the more money they made.  Indeed, it simply cannot be denied that this system fosters profligacy, waste and the overutilization of expensive resources. 

According to the Clintonian school, the greed inherent in our health care system is only underscored by the fact that millions of Americans have been shut out of the system altogether. Where is the cry of outrage from our “compassionate” physicians over the high number of uninsured?  The lack of quality in our present health care system is further underscored by the embarrassingly high infant mortality rate in the U.S., and our lagging life-expectancy rate compared with other developed countries.  Again, where is the professional outrage?  Clearly there is a fundamental problem with our health care system, a problem that stems from the misguided incentives and maladjusted motivations of health care practitioners and other profiteers. 

Politicians and public policymakers naturally gravitate toward the Clintonian school of thought, since its basic premise is that the problem with health care results from misguided incentives coupled with human greed. This premise obviously places the solution squarely in the hands of those same policymakers, who can do the job with new, stricter regulations and more enforcement muscle.

The Gekkonian School of thought

This school of thought is usually espoused by the insurance industry, health care executives, many physicians, and most proponents of a free-enterprise economy, including most conservatives. I have named it after Gordon Gekko, the character in the movie Wall Street, whose chief operating philosophy was that greed is good.

Its basic premise is that the open marketplace generally offers the best solution to society’s problems.  Philosophically speaking, Gekkonians believe in the essential goodness of man – give a fellow his freedom, and just watch the good things flow.

 Gekkonians assert that the health care crisis stems directly from the fact that, while doctors may be good at practicing medicine (or for that matter, maybe they’re not), they’re certainly no businessmen. And health care is simply a business, like any other economic enterprise. 

Leave it up to the doctors, and they’ll forever practice medicine the way they did in 1910 – as hundreds of thousands of independent guildsmen, each running their own shop, duplicating expensive services, multiplying inefficiencies, and shutting out the competition. No wonder the health care system is such an inefficient, wasteful mess. Instead, the health care industry should be treated as a market, just like any other market, and not as some sacred, protected economic sphere.

Let those who know how to run a business run the business of health care, and let the doctors practice medicine (under the guidance, of course, of the fiscally adept). Bring the efficiencies of the for-profit, free enterprise system to the health care industry, and the health care crisis will take care of itself.

Clintonians v. Gekkonians

At first glance, the Clintonians and the Gekkonians would seem to have little in common. The Clintonians believe that too much greed is the problem, so the health care crisis can only be solved by regulations to hold that greed in check.  The Gekkonians, on the other hand, propose to use market incentives (or, if you will, greed) to solve the health care crisis by reducing artificial constraints on the market (i.e., by reducing governmental regulations). 

A closer look, however, reveals that these two schools of thought actually have very much in common; certainly enough to explain why Clintonians and Gekkonians can often be seen forming alliances with one another in their efforts to reform the system.

First, both schools of thought are based firmly on the notion that the health care crisis is due solely to too much waste and fraud within the health care system.  While one school tends to blame the waste and fraud on greed and the other on incompetence, the basic problem according to both schools is the inefficient use of resources.  There are fatal limitations to the “waste and fraud” hypothesis. (See Section 2 of The Grand Unification Theory of Health Care.)  But still, it is always attractive to suppose that enough waste exists in the system to make rationing unnecessary.

As a direct result of the “waste and fraud” hypothesis, both schools of thought are able to assert that the underlying problem with health care is one of “system.”  For the Clintonians, the traditional health care system allows, and even encourages, greedy health care workers to rip off the public.  For the Gekkonians, the traditional, nearly medieval, guild-like health care system discourages competition and stifles efficiency.  Either way, the problem is in the system, so the solution is simply to fix the system (either through regulatory means, or market-based means). Since the problem is merely systematic, there is no reason to question our underlying premises, and thus no reason to question our American health care myth. (This myth, essentially, is that where health care is concerned, there are no limits.) Both schools of thought leave this myth entirely unchallenged and intact.

These two schools of thought have one more common feature that deserves prominent mention.  In each, the primary solution to the health care crisis requires limiting the capacity of doctors to behave as independent agents.  In one case this is to be done by regulatory means in order to stifle physician greed; in the other it is to be done by the marketplace in order to eliminate physician inefficiency.  But either way the primary goal, the number one priority, is to control physician behavior.  To the extent that controlling physicians’ behavior prevents them from being greedy or inefficient, that’s good. But to the extent that controlling their behavior prevents them from fulfilling their role as advocates for their patients, that’s very, very bad.

Thus does each school of thought provide a serviceable “cover” for activities that, if we weren't so anxious to believe that rationing is unnecessary, would quickly be seen for what they are – rationing activities.  Indeed, understanding these two schools of thought allows us to comprehend the secret language of covert rationing.  For covert rationing behavior is virtually always couched in terms of one school of thought or the other.

So far in the race to control our hearts and minds, neither school of thought has clearly predominated.  In 1993 and 1994, the “heyday” of the Clintons’ health care reform efforts, the Clintonians were clearly in the driver’s seat.  Then, when the Clinton plan went down to overwhelming defeat, the Gekkonians rapidly took the fore.  Now it would appear that the public is beginning to sour on health care run by the ostensible “free market,” and the Clintonians are making a strong comeback. It isn’t likely that either school of thought will be vanquished in the near future.

But such a “horse race” scenario is a gross oversimplification.  Many forms of covert rationing are supported by both schools of thought, and the “race” has been characterized more by collusion than collision.  In any case, for doctors and patients struggling in the trenches, it doesn’t much matter which school of thought represents the paradigm of the day.  And whichever one is providing the “cover” at any given point in time, covert rationing in any guise renders the pursuit of health care exceedingly difficult, frustrating and dangerous.

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