Wednesday, September 25, 2013

Post No. 188a: A Country Has to Know Its Limitations

In one of our earliest posts back in 2008, we examined some of the issues which might potentially arise should the federal government become further involved in the healthcare of its citizens. Since then, The Patient Protection and Affordable Care Act was passed. Now that it is scheduled to take effect, it is back in the news for a variety of reasons. Although some of the original proposals in 2008 did not make their way into the legislation, we thought it worthwhile to revisit some of the points we made at that time.

© 2008 and 2013, the Institute for Applied Common Sense

On November 30, 2008, shortly after Sen. Obama’s election, we asked our readers whether any governmental entity should have the responsibility to provide healthcare for its citizens.

We invited our readers to provide their views on the subject, prior to our putting forth an argument as to why no government entity should have that responsibility, except perhaps in the case of veterans, or those injured during the course of service for the nation. (Since that time, we have also considered the inclusion of children below a certain age, since they have very little role in making decisions about their health until they are much closer to adulthood.)

It led to a very lively and stimulating exchange. Even a cursory examination of the comments in connection with Post No. 68d reveals the diversity and passion of opinion regarding this subject.

Is it really the government's responsibility to ensure the good health of, and the provision of health care facilities and treatment to, its citizens? Why do so many citizens feel that it is something which the government, at some level, should provide? Is there a reasonable expectation on the part of the taxpayers that health care is a "service" due them by virtue of their current level of tax contribution?

What responsibility should be placed on the citizens themselves to make the "best efforts" to maintain their health, and utilize the very latest in scientific knowledge about health risks, particularly nutrition, and the detrimental consequences associated with certain behaviors? Should citizens be required to show that they engaged, or failed to engage, in certain behaviors, prior to being extended heath care benefits by the government?

We indicated that we would generate some thoughts after entertaining those of others. Here are five arguments which can be advanced to support the notion that we should not have a national healthcare system, or perhaps that America is not yet ready to have such a system.

1. All relationships are about expectations. An argument can be made that the American public has an unreasonable expectation about what it takes to manage and operate a large organization and its accompanying bureaucracy. Most interestingly, those who have never run a large organization seem to think that they have all the answers. The criticism of the various executives, associated with the Big Three American Automakers, suggests to us that we as a nation do not fully comprehend the complexities and difficulties associated with management of a large organization in an everchanging, global environment. We are apparently “qualified” to criticize others who do not achieve the results that we expect.

2. In contemplating a national healthcare system, it appears that most proponents suggest that it provide benefits to all of our nation’s citizens, namely 300 million people. We do not have the capability to manage anything involving 300 million people. We don’t do it with respect to the other “essentials” of civilized life, food, housing, clothing, or education, which are arguably more simplistic in nature, and which at least have components around which we can wrap our arms. What makes us think that we can do it with respect to arguably the most complex of issues, namely human health? To borrow a phrase from Dirty Harry, “A country has to know its limitations.”

3. We do not have anyone, or any board or committee for that matter, with the capabilities, sophistication, and experience to manage a 300 million recipient organization. Furthermore, as noted earlier, as an organization grows in size, its sense of “reality” changes to ensure the advancement of its interests and its continued survival. We’re setting ourselves up for failure and unnecessary criticism.

4. Any system delivering services to 300 million people will undoubtedly parcel out its services in unfair and inequitable ways during the course of the execution of its policies. It’s not like an engine with simple, mechanical, moving parts. Humans do not function in accordance with the rules of physics. They’re emotional, and they have minds of their own. No one has yet discovered how to manage emotion. At least in the military, they understand what needs to be done to craft humans into fungible, interchangeable units, for management purposes, and even they have difficulties.

5. What makes us think that we can devise a system to provide benefits or services to recipients who essentially do whatever they want or desire to do, from a health perspective, and then have an expectation that the system should address the negative ramifications flowing therefrom? It doesn’t make sense. What makes us believe that we can “herd cats,” each with their own goals, motivations, and selfish interests, and deliver some nebulous, unspecified level of service resulting in what we refer to as “good health?” As a general proposition, Americans are not “sufficiently motivated” to maintain a state of good health. We don’t want it badly enough. The only proven way to get humans to adhere to a policy or approach is to force/ prod them, or have them buy into it voluntarily.

Although some ambitious and very thoughtful suggestions were put forth in your comments, no one, who responded to our challenge about reforming the health care system, really explained how they planned to address the uncertainties and complexities associated with the human side of the equation, and each individual’s responsibility to the system.

As a practical matter, it can’t be done in America, at least not under our current political philosophy. Any attempt in that regard will be regarded as socialist, or even worse, communist, in nature. As we all saw during the most recent election, we can’t have that.

This is a country built on social Darwinism or survival of the fittest. If you happen to be one of the fittest and you survive, kudos to you. If you are one of the not so fit, we leave it you to fend on your own, perhaps with the gratuitous assistance of non-profits, the religious community, and the kindness of others. Many in our country feel that if we assist the not so fit, or guarantee certain things to the masses, we play into their weaknesses and thus become enabling agents.

This is neither a culture nor governance model which has as its goal the equal treatment of its citizens or the equality of the services or opportunities available to them. It is a culture that simply guarantees that each individual citizen has a chance to pursue whatever they might so desire. That has nothing to do with results.

We don’t guarantee results in America.

Simply put, a national healthcare system does not fit within our governance model, nor does it fit within our cultural philosophy. This is not to suggest that it should not, just that it does not. It’s just that it would require a significant paradigm shift in our way of thinking about our role as citizens.

Don’t you think?

© 2008 and 2013, the Institute for Applied Common Sense


  1. Is this piece an example of a well-educated writer role-playing a poorly informed and defeated nobody?

    A country has to know its limitations? If you agree, dear reader, you are defeated. A 'country' does not KNOW anything. Limitations also extend into the future - they change with time. No individual knows the future.

    Scandinavian and many other European countries, all enjoy better health than America, and have 'socialistic' health-care systems. They also have lazy, cheating, simple-minded individuals, all entitled to health-care, or free accommodation in prisons. (With enforced health-care.)

    Are you saying, IC, that America is TOO BIG to be governed, or to benefit from a fair health system? Perhaps it is; perhaps people are working on a plan to make it much smaller - people with a vision of the future that will prove to be wise. Perhaps people who don't care about their own health (or that of others) can fairly be treated as harmful bacteria. Eradicated for the sake of the whole organism. And what could be wrong with that? Of course, silly me, future generations don't actually matter...

    Doesn't a government have to do what is good for most people whether they like it or not? And whether the self-centred individuals of your political right want it or not? Survival of the fittest is a barbaric principle to apply to a society of humans.

  2. Oh! I forgot "What responsibility should be placed on the citizens themselves........." (to look after themselves) What a pointless question. Young children are not expected to know about this, but often parents and other minders do a grand job of destroying the young person's ability to avoid crime, drug-taking, obesity, etc., and to learn foresight; to be 'responsible'.

    The US does not even put priority on training enough educators to counter bad influences, and create social awareness. You think 'freedom' takes care of this, do you IC?

    You think good health is 'nebulous'? For sure, the dishonest can fake ill health, and doctors don't always have time to check things out, but a system can allow for this. Society can learn to punish lying and deception, not reward it like the 'exceptional' US of A.

  3. Bob, having read both your comments, I am left with the idea that citizens are but children and government must treat them as such; that there is no such thing as the dignity of of the individual and, perhaps, that such a concept is dangerous... maybe even anti-social.

    By the way, survival of the fittest is how man evolved from the ape. Truly barbaric, truly.
    Citizens are clearly the property of the state, there to serve their masters and nothing more.

  4. Good to hear from you again, Douglas, as always. This article was originally posted in December of 2008. The ACA was signed into law in March of 2010.

    When we generated the piece, it was our intention to simply raise some issues associated with trying to provide health care to all of the citizens of our nation. Although it may appear that we were taking a side, that was not our intention. We just thought that the United Sates, as a nation, was not ready for such a concept, and the ongoing intense debate in which we find ourselves engaged just days before it becomes effective, strongly suggests that we were correct in our assessment.

    You made reference to the fact that the Administration had over 4 years to prepare for its implementation, although we are sure how they could have done that if the law was not even signed until 3-1/2 years ago.Be that as it may, I'm not sure that 3-1/2 years is even sufficient to work through the complexity of such a massive and monumental effort, which goes to our original management argument. Anything which has as its goal, the provision of health care to such a large number of people, is going to be complex, problematic, and ultimately unfair.

    Our "herding cats / freedom governance model has inherent limitations, and thus the title of our piece.

    BTW, kudos to you for admitting that you have no idea what the ACA will cost you or others. Neither do we. What we have been unable to understand is how both sides in the debate are so cock sure, even before it goes into effect, what the costs are !!!!!

  5. CorfuBob:

    You've been a follower of this blog long enough to know that we often refer to the governance model here in the US as the "herding cat governance model." When you give people certain freedoms, and the ability to make their own choices.there is only so much that government can do to assist them.

    We do not believe that individuals have limitations, at least not intellectually. However they are restrained by lots of factors, including education, poverty, and other institutional complications.

    However, we do believe that our current governance model has limitations. There are pros and cons, and we have made the choice to live with them. That doesn't mean that we can not strive to improve it; it just means that it is far more difficult here to control our collective destiny, despite the fact that individuals may have that ability.

    One other point. At least as to those health conditions that are brought about by lifestyle choices, why should any one, or any entity, or any government have to foot the bill for the health care of those who are older than 18 years of age?

  6. You are correct, aside from the fact that it was a foregone conclusion that it would be enacted (Democrats had majorities in both houses), it was in fact signed into law in March of 2010. And so, the administration has only had three and a half years rather than the four plus I claimed. We are beginning to learn what the costs will be in terms of lost earnings (restricting hours of employees to reassign them as "part-time", holding off on employee hiring, and possible layoffs), increased premiums, and so on. We still do not know what these things will cost us long term. I suspect it will not be as bad as some say nor as good as others say. Politics cares little for reality, just image. The debate, as I see it, should be over the impact such an upheaval in how health insurance is handled will have on a weak and poorly recovering economy and the national debt. There are a number of promises inherent to the law which are fine but all of these will increase costs (and, therefore, premiums)... this is not good but, like the ever increasing cost of gas, the public will eventually become enured to. The shock will hit when the average citizen learns about the high premiums tied with the high deductibles but, by then, it will be too late. This is not like Medicare where the cost to individuals has been relatively small but large for the program (causing some of that increase in debt and deficits) and the government and adding pressure to raise taxes while not cutting spending. I am concerned because of how it might impact me... one of millions of retirees living on fixed incomes with some subsidy on health insurance from my former employer... and on the company I used to work for. Will their increased costs for current employees force them to reduce my benefits? That's the big unknown, for me, at this point.

  7. Herding cats? My 14 cats have taught me something about that! But i love them all as family. I also cannot afford the health-care to treat them all equally in this respect. I am limited by a small pension.

    Your freedom/lifestyle argument is powerful. Why should we bother when individuals inflict damage to their own health? I don't, and i don't see why you should IC. BUT, society is not an individual, and a great society cares about the stupid as well as the poor.

    Government works for society. Statistical science alone can inform government honestly as to the needs of its people. You have allowed lobbyists and vested interests to scream into the ear of government, and now you are paying the price. America is diseased, but it has the brightest and worthiest 'cells' in the world. (scientists, artists, thinkers, carers...)

    The concept of 'freedom' is the most insidious disease of them all, greed and dishonesty are in need of treatment but Exceptionally...virulent in your country.

    You even 'dream' of greed (the American dream) - of making your way to the top - of succeeding over others - of being FREE to do what it takes to get there.
    Groups who want to limit this ambition, to subsidise the less able, to give the ailing a decent life, are given some demeaning label - socialist - communist (you know the labels)

    If the greedy were not led by the loud-mouth stupid they would see that paying more for public health now, would pay off eventually with a more able and productive workforce.

    YES it's the 'government's responsibility to provide good health....' and shut the mouths of the selfish right who care only for their own health, and can afford to pay for it.

  8. I welcome your comment Douglas. By 'left with the idea' do you mean you agree?

    There is something of the parent/child relationship here. The government can have access to tons of statistics that individuals cannot consider, and can pay for all the teachers one child will need, and build the hospital it may need one day.

    Survival of the fittest is also how the ape evolved from the salamander etc. etc. The observation is without meaning for modern man who is cheating evolution through morals and especially medicine.

    "Citizens are clearly the property of the state" Irony? nonsense?

  9. "lifestyle choices" Please IC, you are parroting the question of an idiot. I hope.

    Society means people sharing space, and acting as an entity of some kind. Do you agree?

    Society has members over 18 years of age. If they make mistakes and lose control, are they then outside society?

    I may be soft in the head IC (my avatar is reasonably honest) but not as soft as you on this question. I would like to see a society where hopeless druggies, criminals, psychopaths, etc are REMOVED to their own society, or from the land of the living, depending. You have space to build secure enclosures, and could find money to equip them humanely. Gradually they will work to support themselves reasonably, change their habits, earn some respect, etc. But NOT be free to impose their nastiness on us outside their society.

    Choice barely exists, and choices vary month by month. Minds are damaged, and cannot always repair themselves by the age of 18.

  10. No, I do not agree. It means that I concluded (or, I inferred) something from your words. The underlying theme of the founding of this country (and from its revolution against the Crown) is that the individual person has value above and beyond his position in (or usefulness to) in the political hierarchy. I do not believe that modern man (who is still evolving) is cheating evolution at all. But that what he does is a part of social evolution.

    Not "irony" but "sarcasm" or, possibly, "derision." You seem to think the State (and, therefore, the "rulers") are superior to those they rule. I disagree most vehemently.

  11. Douglas:

    Assuming purely for the sake of argument that we are, as you contend, "begging to learn what the costs will be...," we would ask you two questions:

    (a) Would you agree that there are numerous unknown factors which have not yet come into play, and that the costs upon examination on December 31, 2013 might not be the same costs in 2014, 2016, etc.?

    (b) Since the sole purpose of most corporations is to maximize profits for its shareholders, should the policy of the country be dictated or arguably manipulated by corporate employers trying to pursue their corporate goals; and

    We lied, (c) Would it be far to say that corporate employers, with their accountants, lawyers, HR people and tax specialist have a better ability to change and adjust their tactics and policies, than an individual faced with health care choices?

  12. CorfuBob:

    You make a very good point in your last paragraph, to the effect that for some, choices are scarce, and that the human damage can be so significant by 18, that they forever function with compromised systems.

    That is exactly why we have long argued that the money collected by governments should be focused more on the children and education, and that the adults will better prepared and suited to take care of themselves without as much governmental intervention. We also believe that it is less expensive to take care of the younger citizen than the older citizen who failed to receive proper "whatever" during his or her youth.

  13. I mistyped... that should be "beginning to learn...", not "begging" (though there seems to be a bit of that too). Changes the meaning of the sentence, does it not? We know that some of the cost will change automatically (and by design) in the following years. The amount of the tax/fine for not having health insurance, for example. And we can find that information. What we cannot determine is the changes in cost of premiums since we have no crystal ball and the (as the song goes) "the future is not ours to see."

    This is an interesting concept, "should the policy of the country be dictated or arguably manipulated by corporate employers trying to pursue their corporate goals"
    Will you grant that such agents will, regardless of what should or should not be, endeavor to do just that? Just as agents have done so in every form of governance man has tried? And haven't they always, throughout history, had a "better ability to change and adjust their tactics and policies, than an individual..." in all things, not just the current issue of health care choices? But I must remind you that the most current issue concerns not health care choices but health insurance choices. A fine distinction, I admit, but a distinction nonetheless.

  14. I should have said "You misread", not "I mistyped".

  15. Douglas: You 'deride' my comment, but you seem unable to debate the points as well. I have to infer that you do not understand them, for which i have to take some of the blame. You certainly don't understand what Darwinian evolution is about, or you would understand why modern man is cheating the process through medicine and moral attitudes to usefulness (for which we can be grateful)

    Social evolution refers to the evolution of society, NOT evolution of the animal who created it. But that you know more than i will ever know about the facts of American history is beyond dispute. I believe you and IC are admirable people, and not to blame for your sickening society. Let's hope the US decides to pay for its own treatment - it may have to print some money. The world needs you all, but Islam is winning the numbers race.

  16. CorfuBob:

    We spent almost an hour responding to your post, only to hit some button inadvertently and lose it all.

    We'll just raise some bullet points:

    1. For all the talk by all sides
    to this discussion, we seem to has lost sight of the fact that we will arguably
    be a healthier nation, with a more productive work force, happier, and spend
    less money on poor health related issues.

    2. Many use "society" and "government" interchangeably. They are not. Most importantly, society does not raise taxes.

    3. Brits are dramatically different than Yanks in their worldviews. Yanks, probably more than anything, want to be left alone, even if their decisions end you negatively impacting their long term interests.

    4. We will always recall a "Today" show many years ago where Matt Lauer visited some Scandinavian countries. If we remember correctly, 75% of the income of most citizens was taken in taxes. Mr. Lauer asked a citizen what more he wanted in life, since food, housing, education and healthcare were virtually guaranteed. His response surprised us and stuck with us until this day: "The ability to make a choice."

    We just generated this response in 2-3 minutes. It makes us wonder whether we wasted an hour in the preparation of the response that we lost earlier!!

  17. Our bad, Douglas. WE mistyped, and inserted "begging" instead of "beginning." :) Freudian?

  18. Here's another way to look at this issue, CorfuBob. Should the government (which collects taxes) pay for the healthcare costs of its citizens, just because society (which is not the government and does not collect taxes) feels that it should?

    We're not sure whether the underlying assumption is true; however, it forces one to view the issue from a different perspective.

  19. Douglas and IC: Whether beginning or begging to learn about the costs, the problem for you two seems to be knowing what 'the cost' actually means. You talk about the money you have to spend, and the money society needs to provide a service as 'costs' - like they are the same thing! Loss of earnings is a cost to the sick worker, but a saving to the employer who can manage without him.

    The cost of health care (health insurance) can be met by spending less on armaments UNTIL the weakened country gets over-run by some enemy or other. (And becoming 'nice' won't save you) What is the balance of costs/benefits in this scenario?)

    You can print money for your big bankers - so why not for your doctors? You are becoming one of the West's unhealthiest countries.

  20. Government is a subset of Society. People prefer to be healthy. Some people prefer to have work. Hardly anyone knows how a health system works, and like me, don't have the capacity to know anything so complicated. Do i give a damn what society or voters 'feel' about the subject?


    But i feel for those who are sick - whether in mind or body, and hate the money-grabbing sociopaths who consider the 'costs' (of treating the sick people that they don't happen to need), are costs they can do without. Thus i want to live under a government that will devise a fair health system;
    ignoring its critics. (again)

  21. But it certainly changes the meaning of the sentence, does it not? Possibly making those questions somewhat moot.

  22. The Scandinavian said (............but I would like more freedom of choice)

    An individuals's comment is hardly worth remembering IC. Give them everything, then they want 'choice' Give them choice, then they want more of the things they can chose from.

    Give them health, and then they can be more effective.

    But give them 'freedom' and then they can abuse the law, the conventions, the weak, and still not be satisfied.

  23. CorfuBob:

    We saw this earlier today on a post by a friend on Facebook. We thought that you might find it interesting:


    We have bigger houses but smaller families;
    more conveniences, but less time;
    We have more degrees, but less sense;
    more knowledge, but less judgement;
    more experts, but more problems;
    more medicines, but less healthiness;
    We've been all the way to the moon and back,
    but have trouble crossing the street to meet
    the new neighbor.
    We build more computers to hold more
    information to produce more copies then ever,
    but have less communication;
    We have become long on quantity,
    but short on quality.
    These are times of fast foods
    but slow digestion;
    Tall men but short character;
    Steep profits but shallow relationships.
    It's a time when there is much in the window,
    but nothing in the room.

  24. i quote IC "We do not believe that individuals have limitations, at least not intellectually."

    Individuals have a huge variety of limitations - including the confidence to TRY. Cranial capacity, intellectual capacity, memory, damage, all limit the individual. Most young people 'could do better' (to quote the school report), but to tell them their intellect is not limited invites disbelief. Motivators don't need that, do they?

  25. Corfubob:

    You wrote: "Cranial capacity, intellectual capacity, memory, damage, all limit the individual."

    Actually the research conducted over the past 20 years reveals just the opposite. We now know that intelligence is not static, but rather dynamic, and that we can improve intelligence over time, along with continue to generate new brain cells as we age.

  26. We have read different research. Movement of intelligence and memory is negligible, determination can vary with mood and health. You may have to tell people what you think will help them, for me the truth is more interesting.

    The individual is limited, however much anything grows over time.


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