The Last Cardinal

Sometimes I think I should stop loading my birdfeeders with seed every day. Mostly I just attract house sparrows and pigeons, two kinds of birds regarded as “nuisance species.” In fact, there’s a big sign posted near the entrance to the local pet store, telling what section of the penal code you are breaking if you feed pigeons. So I’m breaking the law every time I let the pigeons get the bulk of the seed I put out.

Then too, I read recently that the vast majority of birds don’t eat seed. Most birds eat insects. I’d never thought of that before. Most of those insectivores naturally migrate south in the winter. So nine out of ten birds don’t really need me anyway.

But then whenever I think I’ll stop feeding the birds, my regular family of cardinals shows up – and I feel I should load the feeder - one more time, every time. Occasionally some rarer bird will show up too. Lately, I’ve been getting a red-headed woodpecker working away at whatever peanut butter suet I put out there. But it’s the cardinals that really keep me going. They are such a startling splash of color against the white shroud of snow. And all the neighbors comment on the brilliant fluttering of the cardinals in my yard. I wouldn’t want to let the neighbors down.

The cardinals sometimes feed during the day, but mostly they’re notable for being the first ones out at dawn, and the last ones eating at dusk. I’m seldom up at dawn, but I usually am around at dusk, and I make a sort of ritual of going to the window to see “the last cardinal of dusk.” There’s one more dazzling flash of color before the night closes in.

But standing at the window, looking for that last late feeder, I’m reminded of other lasts. I almost never knew they were lasts at the time. There was the last horse-drawn wagon going down my alley. I’d always run out to see the horsie – but then, around 1960, I realized I hadn’t seen a horse in a long time. And there never was a horse clomping past my gate again. All the ragmen, all the salvage men had switched to trucks.

Then of course there is always that “last rose of summer” made famous in song. Every year, after the first frost of winter has hit, there’s always that one flower in the garden that manages to temporarily escape, by hiding under some weeds or by huddling close to a wall.

There was the last time I took my dog Schnoodle for a walk along the lakefront. I could see she wasn’t enjoying her walks much anymore. Her hip was hurting her. So for a few weeks, I didn’t take her on any more walks. I just let her out into the yard and stood by to help her in over the stoop again. And then she died. The last time can only ever be seen in retrospect.

There was the last time my mother said, “I love you.” That was in a message she left on our answering machine. I was just taking the garbage out when she called from the hospital and, not reaching me, left the message on the answering machine. She went into anaphylactic shock sometime in the middle of that night and was intubated. With that tube down her throat, she couldn’t talk any more. While I sat besides her in her hospital room through the following weeks, she would occasionally scribble a request on a notepad. But the doctors never succeeded in weaning her from “the tube,” so she never spoke again.

Which brings me back to each evening’s last cardinal. If there’s a good portion of sunflower seed mixed in the birdseed I put out, either the male or female cardinal might stay over the boundary between dusk and night for a few moments, gorging on the birdseed. Then my yard light will reflect off of it, making its red glow into an eerie, iridescent fuchsia.

As I stand looking at the last cardinal of the evening, I often think how one evening, it will be the last cardinal forever. It’s not that the cardinals won’t be there anymore. It’s that I won’t be there.

Farewell Al Capone; Fade to Oprah

Al Capone used to be the symbol of Chicago. Wherever Chicagoans went in the world and announced themselves, they would be gleefully greeted by the rat-a-tat imitation of a Tommy gun.

Many people deplored this association. They pointed out how Al Capone and his St. Valentine’s Day Massacre were black marks on Chicago. They’d scold people for reducing Chicago to these most brutal moments of the City’s past, when Chicago is so much more and has so much better to offer.

But somehow the association stuck. Al Capone reigned as the quintessential emblem of Chicago, despite its invention of everything from skyscrapers to atomic energy to the urban blues - despite its Magnificent Mile, its lakefront, its Art Institute, its hundred ethnic neighborhoods. Al Capone was still the icon that stood astride all that other.

Gangsters have often been mythologized and elevated to the status of heroes. But Capone’s apotheosis seemed even likelier, even more appropriate. Hadn’t Carl Sandburg memorialized Chicago as “Hog Butcher for the World… Stormy, husky, brawling… City of the Big Shoulders.” And Al Capone was all that – from butcher to brawling. On his Big Shoulders there rested the summary image of all things aggressive, vigorously self-assertive and claiming. Al Capone and Chicago fit together.

But over the last decade or so, I’ve noticed a change. When I travel, I’ve rarely been greeted by references to Capone any more. The air Tommy gun has been stowed away in people’s air violin case and forgotten. Now whenever people anywhere in the world hear I’m from Chicago, they instantly squeal, “Oprah!” and clap their hands.

People clamor around me, wondering if I know Oprah, if I ever met her. They ask if I can get tickets for her Show. Even more urgently, they wonder if I can use my influence with her as a fellow Chicagoan to get all sorts of favors granted from her.

One European woman I met immediately started to tell me tearfully about the horrible oppression her mother had suffered as a Basque native in Spain, especially during Franco’s regime. The woman had written a book about her mother’s suffering. She tried to impress a copy of her manuscript on me so that I could carry the precious pages back to Oprah. “Maybe Oprah can get it published? Maybe Oprah could even make it a ‘Book of the Month?’”

When I was on Mexico’s Yucatan Peninsula and a tour guide heard where I was from, she immediately spoke up on behalf of the children of her village. “Do you think Oprah could come here and start a school, like the one she started in Africa?”

As I settled in to have lunch at a neat, prosperous little restaurant in Canada’s southern Ontario, I thought I would be safe from having to transmit any major, heart-rending appeals to Oprah. So I didn’t gird myself as I usually would have when the pretty woman at the next table started a conversation with me and asked me where I was from. But the word “Chicago” was barely our of my mouth, when she shrieked, “Oh, Chicago! Oh, Oprah! Do you know Oprah? Do you think you could get her to help me? My teeth are bad. Oh, I’ve been suffering so! I need some caps, some implants, something - and our social insurance refuses to cover it. And I just can’t afford to have it done myself. Could you get Oprah to help me - maybe through her ‘Angel Network?’" the woman smiled appealingly at me, revealing a chipped front tooth that listed a little at cross-purpose with its neighbor.

Yes, it’s clear that Oprah has become Chicago. The mention of Chicago evokes immediate worldwide association with Oprah, and consequent hopeful appeals for everything from tickets to teeth. Al Capone’s star has been dimmed by the sunshine glare of Oprah’s popularity and largesse.

I can’t help regretting this at least a little. You see, as Al Capone’s star has declined, so has mine. I have no claim to any connection with Oprah whatsoever. I never met her, never was able to get tickets to her Show, never even passed her on the street - whereas I can lay claim to some connection with Al Capone. Before Oprah, when my announcement of my Chicago citizenship would evoke the predictable excited references to Al Capone, I could be a crowd-pleaser by regaling my audience with my personal knowledge of the man. Well, it’s my personal knowledge once removed. My father worked with Al Capone.

My father helped Al Capone design, print and apply, some of the labels he put on the illicit bottles of whiskey he was producing in his stills. Perhaps their association was a glancing one, but it was enough for me to make capital of when Al Capone was Chicago to the world.

My father was a singularly taciturn person, even more taciturn than most husbands/fathers have a reputation for being. He was an “older father” when he had me, and he had lived a varied, knock-about life that had included the trenches of World War I, piano-playing in silent movie houses and in brothels, a stab at raising greyhounds for racing, as well as his bootlegging and Al Capone interlude. When he met my mother, he would court her in a modified version of the classic gangster pin-stripe suit. And he wore a Panama hat, jauntily tilted to one side in the same way Al Capone wore his signature Panama hat. Capone perhaps tilted his hat to put in shadow the scar on his cheek that he was so ashamed of having become his brand, an integral part of his public identity – Scarface Al Capone. My father tilted his hat as a rakish homage.

So my father reflected and perhaps imitated the times he’d passed through. However he had no gift for narrating them – no aptitude for weaving his life into anecdote for us. There was so much it seemed he could have told my mother and me, even if his participation in these gaudy enterprises was exaggerated and had actually only been tangential. But whatever he had seen, he couldn’t, or wouldn’t, relate.

The only information we got out of him about Al Capone was his assessment that the gangster had been “an amiable guy.” That singularly repeated adjective “amiable” seemed ironic to my mother and me, being applied as it was to one of the most notoriously brutal mobsters of all time. But that probably really was an accurate description of Capone’s demeanor when he was just in casual conversation with his family or friendly associates.

The actor Rod Steiger portrayed Capone in a brilliant 1950’s movie about the gangster. Steiger’s depiction of ruthless, vulgar self-assertion was mesmerizing, but probably not very accurate if applied personally to Capone. Steiger’s performance captured the times more than the individual. It captured the spirit of the Roaring Twenties in general, with all of that era’s diamond-studded, acquisitive, un-corsetted excess. But it wasn’t specifically true to Al Capone. Capone’s family objected to the movie portrayal, saying that quite unike the loud, raw, table-pounding, commanding figure Steiger had projected onto the screen – their uncle/brother/friend had really been a very polite, soft-spoken individual. Putting that picture together with the few general hints I’d gotten about Capone from my father, it did seem that in ordinary conversation Capone was likely a quiet, mellow, polite, and above all “amiable” individual.

I had this personally confirmed information of Capone to retail to the enthused world when Capone was King. I had shaken the hand of someone who shook the hand of … Now I have nothing. Never having met Oprah or having met anyone who met her - I have nothing to tell people who clamor “Oprah” at the sound of my “Chicago.” I don’t even have a nugget of inside information about the amiability of our current icon. I come off a complete disappointment.

But in addition to the diminishing effect this change of Chicago icon’s has had on my status, I have other reasons for being a little regretful about it. Yes, Capone’s influence and actions were reprehensible, while Oprah stands as a benevolent, enlightened symbol for Chicago. And yet, something about the adoption of Oprah as Chicago’s symbol doesn’t seem to be wholly positive. When people used to imitate the action of the St. Valentine’s Day Massacre at the drop of the word “Chicago,” it was unlikely that many of them were expressing any aspiration to go on a shooting spree themselves. Nor were they expressing any admiration for the actual act of killing people. I don’t think most people were even considering the bloody real-life consequences of firing submachine guns at adversaries. Most of them probably wouldn’t really consider breaking the law in any way. No, Al Capone, like all gangsters and outlaws, lit people’s imagination in a more general way.

Al Capone represented the epitome of the can-do, take-charge attitude. While most of us are caught in a Gordian Knot of restrictions and complications, Al Capone simply blasted through all barriers. And oh what fun, oh how exhilarating it would be to assume that kind of right-of-way. You want something? You’re responsible for making it happen. And you CAN make it happen – not by literally disabling or killing other people – but by cutting through all the trivial demands that other people want to tether you to. Does the world say you are too fat, too poor, too dumb to accomplish your goals? You don’t listen. Does the world try to hobble you with endless tasks and taboos - wear a jacket to work, don’t smoke within 100 feet of the condo swimming pool, keep your dog on a leash at all times, sit up straight, smile – and on and on? You blow all that away and clear the field for what you really want, for what’s really important to you. Massacre all the mealy, all the mundane. That’s the kind of empowerment that most people relished in Al Capone’s example. Al Capone was a metaphor for the possibility of rising to command one’s fate by targeted indifference.

Oprah on the other hand has come to stand for acquiring things not through one’s personal, positive action, but through supplication. Whether people make their entreaties to God, to “the energy in the Universe,” or to Oprah herself, she seems to have fostered a passive expectation of deliverance. Oprah assumes and plays into a world of neediness. (More about that in another one of my blog essays). Rather than achieving potency by arrogating to oneself gritty, in-the-world authority – Oprah is the symbol of gaining favors by asking. By contrast, Al Capone, whether rude or polite, whether belligerent or amiable – somehow stood for a vital kind of self-empowerment. He had the image of a man who “Never asked nobody for nothin'.”

So yes, for several reasons I’m a little regretful that Al Capone is no longer the symbol of Chicago. Since Oprah replaced him as emblem of Chicago, I’ve lost considerable cachet. And we’ve all lost something of the proud energy that characterized the early part of the last century.

As I walk down Michigan Avenue, I sometimes picture Al Capone walking ahead of me, with his Panama hat jauntily cocked. But the distance between us gets longer and longer. He at last fades into a barely perceptible figment – off into the mistiness of Chicago history.

And now that Oprah is ending her Show, as she is leaving her most public platform – I wonder who will in turn, in time, replace her as the symbol of Chicago.

J'Accuse! Who Is Really To Blame for the Oil Spill?

Most people blamed abstract entities for the oil spill in the Gulf of Mexico. The entire company of BP was blamed. Tony Hayward, the former CEO of BR, was reviled, but only to the extent that he was seen to represent BP as a whole. Similarly, various government regulatory agencies and governments in general were blamed. Some people have criticized President Obama, but again, only because he stood for the U.S. Government as a whole.

However, my impulse is not to blame any abstract agency or any composite, corporate entity. I want to blame individuals. It’s true that there is such a thing as a corporate culture, and specifically some sick corporate cultures that push employees to all kinds of ruthless expedients just to make a profit. It’s similar to growing up in a bad neighborhood. The bad influences hold sway and eventually push many youths to conform to the criminal standards of their peers.

Judith Rich Harris wrote a controversial, but generally convincing book entitled The Nurture Assumption: Why Children Turn Out the Way They Do; Parents Matter Less Than You Think and Peers Matter More. That title sums up her thesis that peer group influence, rather than parental mores, is the primary determinant of most young people’s behavior. She points out that if you take a juvenile delinquent out of his gang environment and put him in a relatively crime-free school in which criminal behavior is considered an alien, outlandish, and even laughable mode of conduct by most of the student body - chances are the delinquent will literally re-form.

Other authors have extended this concept of the primacy of peer group mores into adult settings. In the classic book The Lonely Crowd, David Riesman argued that most people in Western cultures have long since moved from being “inner-directed” to being outer-directed and “other-directed.” Most people no longer stand stalwart in an individualistic identity transferred to them in the form of the mores and expectations of their parents. There is very seldom any “We Have Always Lived in the Castle” mentality in people. Rather, people are protean, assuming whatever shape fashion and their peers dictate. So now you CAN take the country out of the boy.

Considering the influence of peer pressure from another angle, it’s obvious that a twisted mob psychology can grip people at certain times and turn otherwise civil people into holocaust perpetrators. Everywhere we find instances of the madness of crowds.

So there’s a cogent argument that would blame people’s misdeeds on the pressures they experience from their peers, from their fellow students, from their prevailing neighborhood gangs, from their companies’ established cultures, from their society’s expectations. Nevertheless, I STILL want to blame individuals. I STILL want to name names. I STILL want to point the finger at specific individuals rather than at abstract, faceless groups such as governments or corporations. It’s individuals rather than teams I want to admire; it’s individuals rather than teams I want to accuse.

In a courtroom, we still ultimately convict the individual rather than the society that individual came from. We are more and more taking into consideration bad environments, extenuating circumstances, etc. But in the end, the individual stands alone in the docket. So I want to place each individual involved in any man-made disaster in the docket alone.

That’s why when it comes to the recent oil spill, I felt frustrated not to know the names of the individuals whose actions contributed to the accident. Certain individuals might be in the process of being called to account for the accident and might be prosecuted, but most of society’s blame still has been falling on those abstractions of company, agency, and government. No! I wanted to see the faces of individuals.

The closest that I was able to come to assigning such blame was through the "60 Minutes” interview given by Mike Williams, a chief electronics technician on the oil rig. Williams gave very intelligent testimony about the behavior that piled hazard upon hazard – until the final explosion. He talked about the series of mechanical failures that came about as the result of individual decisions. Williams told how someone okayed a plan to speed up the drilling into the Gulf floor. That caused the bottom of the drill hole to split, the way wood will split when a nail is driven into it at a bad angle or without benefit of a pilot hole. The mud that circulates through the casing around the drill bit and drill pipe to cool these elements consequently spilled into these cracks. The workers had to start drilling a new hole. I blame that individual who thought it was okay to speed up the drilling process.

Then during a test, the drill was carelessly raised out of the hole, causing it to scrape away some of the necessary seal, the “annular,” that has to be kept intact in order to maintain pressure on the gas that will emerge. I blame the individuals who allowed and who executed this haphazard lifting of the drill.

Chunks of the annular started to appear in the liquid circulating to the top of the drill hole. When Williams called these chunks to the attention of some of the supervisors, they pooh-poohed his concerns. They okayed a go-ahead. I blame these indifferent individuals.

Because of the damaged seal, gas rushed out past the seal and was sucked into the rig engines. The rig exploded and eleven people were killed.

Williams reported a more fundamental human failing that preceded all these negligent decisions though. He talked about how BP supervisors and TransOcean supervisors disagreed earlier in this chain of events about what drilling technique to use. Men from the two different major companies involved in the drilling disagreed about procedure and predictably turned their disagreement into a jousting match. The men from each side were only intent on being right, on winning the argument. As TV judge Marilyn Milian says, it became a matter of “Quién es mas macho.” Or as Williams put it, the conference became a “chest-bumping.” I blame the men who let the discussion degenerate into verbal combat.

But that sort of impulse to turn what should be conversation into contest is all too frequent an occurrence, especially when all the conversants are men. This isn’t a sexist comment I’m interjecting out of the blue. There have been many serious sociological studies documenting (as a broad generality with many exceptions, of course) men’s and women’s different conversational styles. Deborah Tannen is one of the sociologists who has documented this difference most convincingly. In books such as You Just Don’t Understand: Women and Men in Conversation, she observed how women tend to make a collaboration of their discussions, while men tend to enjoy pitting themselves against each other until a clear winner of the confrontation can be declared. Even those men who come out on the bottom of any particular exchange prefer to enter the next exchange as a contest, because there’s always a chance they might come out winners in that next verbal fray. Having rules, keeping score, driving towards a central victory, tends to be preferable to them than what strikes them as the indecisive, mealy conciliations of women’s talk.

So here blame gets bounced off the individual from another angle. Here the fault is seen to lie not in ourselves, but in our genetic inheritance from primal ancestors. We are acting out the gender strategies that made our early families most successful.

Deborah Tannen and other authors on the subject usually bend over backwards to make it clear that they don’t feel the women’s conversational style is superior to the men’s. The styles are just different. Tannen emphasizes that men and women simply arrive at resolutions with different shadings. Women’s style reflects the use of a mixed and muted palette. The decision reached is a committee compromise. Men’s style favors vivid primary colors. The dominant man’s view is imposed as a coherent whole, in a winner-takes-all flourish of primacy and consistency.

I don’t think I would be as generous as Tannen and others though in granting what’s defined as men’s conversational style equal validity with what’s defined as women’s typical style. Men’s styles too often do seem to result in a Gulf oil spill, in destruction, in war. The dominant man, having failed to take into consideration any countervailing views for fear that might signal weakness and therefore a loss of face, a losing of the contest – issues a plan that is therefore limited and preemptory. It’s “Damn the torpedoes - full speed ahead” too much of the time when an issue is decided only by men engaged in verbal sport.

But can’t men see how damaging it is to operate by contest, to make every encounter an occasion for a challenge to a duel? Can’t they see how succumbing to this primal instinct to be the alpha male is no longer serving them, their communities, or the world well in most cases? This is where I would like to come in and shake those men who “chest-butted” in order to reach a decision about how to proceed with the drilling in the Gulf of Mexico. This is where I would like to name names, to assign individual blame. Rather than billowing regret about “big corporations,” “corporate culture,” “capitalist greed,” and the like – I would like to bring it all down to a personal level, to point my finger at Tom, Dick, and Harry (and Tony) each in succession and punish them for their destructive competitiveness.

My wish to place individual blame and to punish as a parent or a spouse might – with full frontal finger-pointing - is probably MY counterproductive impulse. When has blame ever really changed a person? When has simply yelling at a person, “Don’t BE that way!” ever spurred anyone to self-improvement?

It is probably better in some ways to hold those larger, more abstract entities responsible for much of the evil that men do. It is probably more productive to try to reform school environments, neighborhood ethics, corporate cultures, and societal presumptions than it is to try to reform individuals independent of the network of influences they operate in. But just as many men will continue to find women’s method of coalition emotionally unsatisfying, so I find putting the blame on abstract organizations emotionally unsatisfying. As futile as it might be, I still long to find out exactly WHO issued the order to speed up drilling in the Gulf of Mexico – and to harangue, blame, prosecute that person into making an apology, into making personal amends, and into becoming a better person in the future.

I don’t want to blame the wheel; I want to blame the faulty cog. I don’t want to blame the system; I want to blame the individual at fault in the system. I don’t want to blame the Devil; I want to blame the person who chose the Devil as mentor.

The 2010 Grammy Awards - More Spectacle than Special

The recent Grammy Awards Show was frightening in its implications. It demonstrated the extent to which public demand for special effects has completely overtaken human interest. The arena has replaced the stage; gladiators have replaced singers. The music has died. The singer and the song have gone down in defeat amidst the roar of the crowds. Personal rendition is lost in extravaganza.

This Awards Show was a three-ring circus raised to the nth degree. We had Lady Gaga and Elton John dressed as futuristic figures, battered from battle in some Terminator-like post-Armageddon of a world. We had dominatrix dresses - women crouching, swinging their hair like lassos – rappers madly declaiming inaudible lyrics – 3-D video projections – and much, much more. Finally, we had the “show-stopping” performance of Pink spinning high up in a harness, spraying water in all directions. But again, where was the music?

Perhaps Taylor Swift won so many awards because, as nondescript as her singing is, she was one of the few nominees still producing anything even remotely identifiable as music – with melody, poetry, and resonance.

In general though, the music has been getting pushed farther and farther into the background for years. Now it has all but vanished. Like the Cheshire cat, only its garish grin is left. It is hard to imagine how the various performers could try to distinguish themselves with any more sensationalism far removed from music the next time around. What’s left to do that could be yet more “daring,” that could “push the envelope” further? I’m reminded of a New Yorker cartoon that appeared years ago – showing a stark naked stripper smilingly dangling her entrails over her arm for the ogling spectators. After she’d appeared completely naked, what else was there left for her to display, to expose to her expectant audience? How else could she top herself?

And why aren’t people protesting this trend toward Roman decadence and decline? The day after the Grammy Awards, everyone was preoccupied critiquing the performers’ various costumes. Commentary focused on the length of the show, on Steven Colbert’s comedy introductions. But no one pointed out that the emperor had no clothes – that there was almost no music being honored at the music awards!

Did this trend toward making the spectacle the message manifest itself so slowly that virtually no one noticed the change? Well, the final shift of emphasis seems to have been compressed into the last decade or so, and that is a short enough time that it should have been evident. The transformation can be traced in the changing style of one particular band – U2.

Musically, the zenith of U2, for me at least, was their 1988 “Rattle and Hum” album and their live performances featuring that collection of songs. That music had enough of the rebel call in it to be clearly rock and roll. It was strident and sensual. But it still had a human face.

One Time magazine essayist who did notice this trend toward over-the-top, once commented on how rock musicians are left struggling to stay ahead of their technical projections, to maintain a presence against the backdrop of all their special effects. For a while, U2 was accomplishing that. Bono and the band members were still human presences on stage, the focus and heart of the music. Bono was an arresting figure on stage, with his black panther prowling through the songs.

With their video “The Fly,” Bono’s singing took back seat to the fractured multiplex presentation. However, his singing was still an integral part of what was still preeminently music. What’s more, the multifaceted screen that dominated the video and the stage performances of this song had a reason for being there and for flashing different scenes in each of the panels. It mimicked what a fly’s world might actually be like, with its compound eyes darting, gleaming beacons into its surroundings for danger and for prey.

But that was the last time that U2 band members came across to me as being salient to their own output. After that, with their “Achtung Baby” and certainly then their “Zooropa” albums and tours, it was multi-screen, fracturing, flashing, fireworks, for their own sake - not in service to the theme of any particular song. Bono, The Edge, Adam Clayton and Larry Mullen all disappeared into their pyrotechnics. They were dwarfed, and then completely drowned by the noise and distraction they had going on behind them all the time – the ultimate concession to short attention spans.

And so most mainstream music has gone in general. These recent Grammies were testimony to how far this appetite for sensation over sense has gone. As performers emoted their pseudo-anguished, unintelligible lyrics into the mikes they were swallowing rather than projecting themselves into – as women stomped the stage in platform shoes – as men in baggy pants pounded out their anger against a background of grindhouse gyrations – as Pink stripped and spun – as the whole three-ring circus spun faster and faster in a “widening gyre” whose center could not hold – I wondered when the music had died.

Curing What Ails Us

Why Universal Health Insurance Isn’t the Answer


Our Health “Insurance” A Misnomer

The only sustainable answer to our health care dilemma is to put the concept of insurance back into health insurance. For decades now, the term “insurance” has been a misnomer when applied to our health care policies and programs. Rather than being true insurance, our health care reimbursements have operated more like subsidies or entitlements.

There are several features that characterize insurance in the classic sense of the word:
1) The event for which an insured person seeks reimbursement must take place in a specific location and from a known cause. For example, life insurance is paid in the event of death. There’s nothing as specific and delimiting as death.
2) The insurance beneficiary should not have contributed to the loss for which a claim is filed. So the claimants have to be able to affirm Billy Joel’s assertion, “We didn’t start the fire…”
3) Premiums must be affordable in relation to the magnitude of the loss being covered. It doesn’t make sense to pay almost as much in premiums as you might anticipate losing.
4) Losses must take place with some statistical predictability and must be quantifiable when they do occur. There can’t be compensation for vague, billowing losses or for open-ended, on-going losses.
5) Most important of all, the size of the loss for which the insured is making a claim must be a significant part of the beneficiary’s overall picture. A small claim can cost an insurance company much more to administer than it pays out. So small claims are rarely worth the trouble for either the insurer or the insured.

Our modern health “insurance” doesn’t meet any of the above criteria, least of all that essential one calling for a loss to be substantial before a claim can be filed.

Early forms of insurance most often covered merchants for the loss of whole consignments of their goods. The Hammurabi Code (1780 BC) stipulated that the State would compensate shippers whose goods were lost or stolen in transit. The claimant had to swear before the ancient Sumerian Gods that he had in fact suffered the grievous loss. In BC China, the principles of insurance took shape around the loss of commercial vessels plying China’s treacherous rivers.

Ancient Greek and Roman guilds did introduce the concept of health and life insurance. Guild members would pay premiums into the guild coffers, then they or their relatives could draw from the pooled funds in case of illness or death. These arrangements were more like benevolent societies though. For the most part, true insurance policies continued to center around the risky business of maritime ventures.

After the Great London Fire of 1666, insurance companies started to more commonly expand their coverage to include such disasters. Ben Franklin is often credited with starting the first official insurance company in the United States, concentrating on insuring against loss by fire. Franklin refused to insure any wooden houses.

Insurance practices, including the formulation of actuarial tables, became a science. The study of statistics was refined throughout the 1600’s and 1700’s in order to calculate the likelihood of losses. Coverage was extended to other kinds of disasters. However except in rare cases, the principle that a loss had to be severe in order to be covered remained the bedrock of standard insurance practice. Payouts weren’t made for splintered masts – only for sunken ships. That’s the concept of insurance we have to get back to in the realm of modern health care.

Current health insurance operates somewhat more like those old guild benevolent societies did - except the pool of money that is available to meet member claims is woefully inadequate – money is meted out routinely for minor claims – and the dispersing agency is distanced from the claimant by layers of bureaucracy.

So our system is the worst of both worlds. It compensates according to minor, minute demand as a guild chairman might have once been prevailed upon to dole out for a fellow worker’s non-emergency needs. But it does so without the old benevolent society’s first-hand knowledge of the individual claimant. The modern insurer has no way of knowing what losses any claimant actually suffered or what services he might actually need to receive in remediation of his loss. All this far-away third party payer can do is try to fit claims to a series of Procrustean beds of categories. The various service providers are correspondingly motivated to define their services so that they fall into the most capacious of these beds. As a result, the pool from which compensation is drawn is strained and drained.

On the other hand, our current system does not operate in the abstract, self-balancing realm of the free-market. It has ended up being neither personally beneficial nor able to self-regulate itself through the constrained operation of supply and demand. It exists as an elaborate system of entitlements in a gray no man’s land where costs can escalate unbounded into the ether.


Paying for the Home Depot Nail

Imagine if all insurance were to operate this way. Imagine if the typical homeowner’s insurance policy were to routinely compensate holders for small repair expenses. People do occasionally put in claims for minor robberies and residential damages. But on the whole, people’s main purpose in buying homeowner’s insurance is to protect themselves against massive damage to a dwelling. They basically want protection against wholesale vandalism, razing fire, torrential rain and flooding, and gale-force winds. For the rest, most homeowners understand that they must be responsible for the expenses entailed in routine home maintenance - for the drip, drip, drip of daily repair in addition to some more costly projects that have to be periodically undertaken. They have to be prepared for the “It’s always something” of home ownership.

If claims were to be made for every faucet washer or nail needed to make a household repair, the cost of these items would spiral out of control in the same way that the cost of health care products and services have spiraled out of control. We’ve all heard the “joke” about the $100 aspirin administered in a hospital. If an individual went to Home Depot to purchase a nail, and instead of paying for it directly then and there, filed an insurance claim for it, that claim would be launched on the same kind of tortuous voyage through channels that the aspirin now makes, accreting barnacles of additional expense with every lap. The result would be a joke about a $100 nail that was all too literally true.

The only, the ONLY, way to retreat from the $100 aspirin and to generally return our health care system to equity, solvency, and practical constraint is to bring it back into the realm of traditional insurance – insurance geared toward paying out only in the event of major, unpredictable losses or losses that would otherwise threaten to seriously compromise an individual’s financial picture. We have to make health insurance operate more like homeowner’s insurance, more like true insurance.


High Deductible Policies Are the Answer

This means that policies with high deductibles should become the standard once again. Whether these policies are made available through government sources or through private institutions, they cannot pay out for near first-dollar losses. It’s difficult to specify exactly how much of a deductible would return a current health insurance policy to the intent and meaning of “insurance” in the classic sense of the word. Naming any figure is likely to date an article immediately. However, for the years 2009-2010, a deductible of $25,000-$50,000 seems reasonable.

I can hear the gasps now. Health care professionals often are shocked if a client has a policy that carries a $1,000 deductible, asserting that such a policy is tantamount to having “no insurance at all.” So I can imagine most people’s initial reaction to any proposal that standard policies have deductibles fifty times that amount.

However, a couple of considerations might temper that reaction a little. First, $25,000 is really only about the cost of a new car now, and if the average working family can manage to finance a new car – they could reasonably expect to finance $25,000 out-of-pocket expense in the event a family member suffers a severe medical problem. Then too, policies with high deductibles would require smaller premiums or withholding – so individuals could start out with considerably more in their pockets when being asked to pay out-of-pocket.

Also, a policy designed along classic lines, operating in the way that true insurance policies are meant to operate, would provide much more protection for individuals in the long run. High deductible policies kick in at exactly the point where people need them the most. They pay when people experience serious health problems that threaten to eat up most of their incomes and savings - that threaten to put them in debt for years.

This is in sharp contrast to the kind of protection provided by most of our current, more favorably perceived policies. Our seemingly more generous first-dollar coverage policies often actually end up abandoning people at the time of their greatest need. A person will find his policy has paid minor claims leading up to the serious problem. It has paid for routine check-ups and examinations. It has paid for all sorts of initial diagnostic procedures, for opinions and pills and probes. But then when the individual finds himself in the midst of some full-blown crisis, his insurance company will often find a way to limit the policy in relevant ways, or to cancel it altogether. The policy might not be renewed because of “prior conditions.” Or it might provide no further compensation because the maximum payout allotted for that condition has already been made. Or the insurance company will involve the individual in such a thick Gordion knot of red tape that not even Alexander the Great could slice his way through it. These scenarios run contrary to the purpose of insurance. Again, true insurance is or should be designed to protect individuals against devastating financial wipeouts. Insurance policies that take people up to the precipice but that then let them plummet down on their own without parachutes – are NOT true insurance policies.

When our politicians speak about enabling every person to have health insurance, they should be thinking in terms of enabling individuals and families to protect themselves against the economic devastation of severe health problems. No one should have to go into debt for significant periods of time in order to pay for health care. No one should be called upon to deplete a life’s savings. No one should have to sell essential assets such as a home in order to pay for health care. Political initiatives should focus on making available the kind of insurance that will protect people against the expense of severely acute conditions or draining chronic conditions. Therefore, whatever insurance arrangements the government fosters should have high deductible policies as their cornerstone. These Government-sponsored health insurance policies should be conceived separately from aid programs. What’s more, if people are to continue buying insurance from private suppliers, they should be awakened to giving priority to policies with high deductibles.


The Real Way to Bring Down Medical Costs

However, the ultimate benefit of putting the true concept of insurance back into our health insurance programs is that ALL medical costs will consequently start to come down to earth again. The vast bulk of our medical complaints are minor complaints involving sprains and aches and rashes. By returning these to the Home Depot world in which the buyer of the nail pays for the nail - we will return those routine medical goods and services to their intrinsic cost of manufacture and application. If the individual who receives the aspirin, the bandage, the splint, or the appendectomy, pays for it directly rather than submitting a claim for reimbursement to a distant, necessarily unwitting insurance agency – those basic medical treatments will once again start to be priced according to their true market value.

Our political officials and most insurance policy holders seem to have lost sight of how it’s primarily the very ubiquity of first dollar insurance that has caused medical costs to spiral out of control in the first place. It’s not the acquisition of high-tech pieces of equipment that has been principally responsible for driving up medical costs. In the real economic world, the more widespread high-tech solutions become, the cheaper they become. Cell phones and computers are prime examples. Nor are doctors and medical personnel particularly greedy, driving up medical costs with exceptional avarice. No, the main engine of inflation in the medical sector over the last decades has been the increasing recourse to near first dollar insurance reimbursements. As third party payers have been called upon to pay more and more of the sum total of medical charges, as billing has gotten further and further removed from oversight by the individual who received and who can best assess the value of the services received - prices have skyrocketed accordingly.


The Time Before Insurance Reimbursements Set the Standard

Let me illustrate the process with an example from my own family experience. My mother was diagnosed with uterine cancer in 1960, although actually, the diagnosis was intimated more than it was ever spelled out. In the end, we were never really sure if she had cancer or not. But either way, a hysterectomy was the routine solution, as it still is now for women suffering almost any “female” disorder. A few days before she was to be released from the hospital, she was presented with an enormous bill and the news that she would have to undergo a lengthy regimen of cobalt treatments (the raw element used for radiation therapy at the time). These twin horrors sent my mother reeling in shock and despair. She registered her distress about the astronomical bill to one of the members of the medical team doing follow-up on her case. She said she frankly didn’t think she could come up with that sort of money in the foreseeable future. That Doctor shrugged off her concerns. He said, “Why should you care? Your insurance will pay for it.”

When my mother told the Doctor that she didn’t have insurance, it was his turn to reel back in shock. In 1960, admission to hospitals was often much more informal than it is today. My mother’s family physician had ordered a room for her based on symptoms he’d noted, and she had been duly admitted as a patient without having her financial situation thoroughly assessed, as it would be today. However, it was common enough even then for people to carry insurance, either through their employers or independently, that the doctors and the hospital probably just assumed my mother carried it. However in 1960, billing hadn’t yet become automated. Billing still had an element of personal discretion about it. So just before my mother was sent home, she was presented with a “revised” bill for her operation. It was about one-third the original bill. What’s more, her family physician took her aside and told her that her medical team had decided it wouldn’t be necessary for her to have any follow-up cobalt treatment after all. “You know,” our family Doctor whispered, “they have these machines, and they like to use them.”

My mother went home and lived another thirty years without any cancer reoccurrence – or occurrence. The new, lower bill that had been calculated for her clearly wasn’t a matter of charity. That revised bill just reflected the more realistic costs that had been involved in performing a hysterectomy. Now however, it would be virtually impossible for any patient to have such a more realistic, down-to-earth tally made. Billing is a strictly mechanical procedure. It is compiled out of sight and out of mind of any individual doctor, any hospital staff member, and the individual patient.

Even though, as our politicians worry, not everyone has medical insurance now, still the amounts that can be billed to insurance companies for procedures have become the computerized, automatic standard. A patient can perhaps have her bill adjusted for errors. She can protest that certain procedures that her insurance company was billed for weren’t really performed, or certain medicines weren’t really administered. But hardly anyone can question the price of services actually rendered. And despite all efforts at cost control, these prices are padded, re-named, re-classified, then padded again until they bear little relation to what that service would cost if its flesh-and-blood recipient were paying for it rather than it being forwarded to some distant, anonymous third-party payer for whom all services appear as disembodied abstractions.


The $1,800 Cup of Orange Juice

Almost all of us can cite recent examples, beyond that typical jesting example of the aspirin, of how minor hospital or doctor services get translated into major medical procedures when they are presented to Medicare, Medicaid, or a private insurance agency to pay. A friend of mine had a lumpectomy several years ago. She was treated on an outpatient basis. She went into the hospital at 7:00 and was out by 2:00 P.M. She was somewhat exceptional only in that she happened to get an itemized bill showing exactly what Medicare was charged for that day. The charges initially came to over $20,000 – and there was more to come after follow-up appointments were taken into consideration.

It’s difficult to argue with the charges made for the medical expertise of the doctors and technicians who actually performed the procedure. Perhaps a lumpectomy really does call for years of study, extraordinary skill, and recourse to extraordinary emergency equipment. However, there were some aspects of the bill that could be judged in terms of everyday experience. For example, after the procedure, my friend was ushered into a “recovery room” where she was asked to stay for two hours. She didn’t feel she needed to recover in any way, but she complied. The room was a regular pared down hospital room. It had an adjustable bed in it, which she was encouraged to occupy, although there was also a rather tattered lounge chair she could have simply plunked down into. Then a nurse came in with some paper slippers for her to put on and a paper cup about half full of orange juice. My friend and I stayed chatting on our own in this somewhat dingy room for the requisite two hours without being attended by any other medical personnel. Then we went home. For this “recovery room” service, Medicare was billed $1,850.

Recovery room experiences such as the one cited above have fostered another common joke. People often exclaim that at those prices, they could have “recovered” in the Presidential Suite at the Waldorf-Astoria for a day – with full room service.


The Cruelty of Price Caps

Of course our officials have also long been aware of how padded most charges made to Medicare and all insurance providers tend to be. So there was a period when the Government tried to put strict cost controls in place. But all cost controls and caps have two profoundly negative side effects. First, the oversight stipulations tend to lead to cruel curtailments and inflexibility just at the point where individual treatment and subtle human judgment is most needed. When my mother went into the hospital that thirty years later, this time with terminal emphysema, she was allotted just a certain amount of time in intensive care and then just so much time in a regular hospital room. After that, on the morning of her last day, she was briskly jostled onto a gurney and removed to what was obviously a “dying room” at the end of a hall – an outpost no staff member ever visited except for one nurse who would perfunctorily enter every other hour or so to take vital signs to see if my mother had died yet. It was heart wrenching to see my mother uprooted and almost literally shoveled into these bleak surroundings for her last hours. But this premature burial was necessary because Medicare had stipulated that a patient entering the hospital with her diagnosis would be allotted only so many days and hours in a “full-service” hospital room. After that, if the prognosis remained unchanged – the patient had to be either discharged or evicted to low-rent quarters.

Unlike my mother’s 1960 hospital experience, there was hardly any way in 1990 to temper or revise either treatment or billing to fit individual circumstances. There didn’t seem to be any practical urgency about moving her, since the hospital wasn’t at “full census” at the time. So, hoping my mother could be allowed to stay in her regular room being attended by the regular nurses she’d become familiar with for a few more hours, I rushed around, beseeching anyone who’d listen to, “Forget about Medicare! We’ll pay cash!” But another joke – Doctors and hospitals wouldn’t take cash.

They wouldn’t have known what to do with it. The entire system had become geared to the receipt of insurance reimbursements for those who had Medicare or other coverage. There was no life outside what insurance would pay for.

Since that period in the early 1990’s, the cost control stipulations have been eased quite a bit. Some of the dangers of allowing distant insurance adjusters to specify what kinds of treatments are justifiable and therefore covered have been recognized. Now medical personnel have again been given more discretion about what kinds of tests to order, what treatment to pursue and how long to pursue it. However the people who recently caused such a commotion at town hall meetings, raising the specters of “rationing” and “death panels” - might have been harkening back to some of those earlier practices. Their protests might have been exaggerated, but still might have had a kernel of cautionary truth in them. Skyrocketing costs always usher in a need for cost containment and cost caps. My mother was caught at a moment when these cost caps were particularly rigid. It happened once; it could happen again.


The Inevitable Failure of Third-Party Payer Systems

To return to the main point about our current pseudo-insurance arrangements though - wherever a third-party payer system is in place, price inflation is the inevitable result. This inflation in turn leads to pressure to institute price controls. Price controls not only have the potential to create the sort of bleak, impersonal treatment my mother suffered at the end – but they deform the entire economic sector where they are operate.

The whole experience of the former Soviet Union’s economy testifies to that. The Central Committee’s specification of prices led to black market gouging, corruption, general inflationary cycles, and a continuous mismatch between the goods that were needed and the goods that were actually supplied. Within our own more immediate experience, we might look at how New York’s rent controls more often lead to exorbitant “move-in” fees being paid to building superintendents than to any actual relief from exorbitant rental prices. You can sit on one end of a large balloon, but that only deforms it and creates explosive pressure at the opposite end of the balloon. And so it will be with the attempts at cost containment that must follow in the wake of expanding insurance coverage for routine health care. Our dependence on widespread, first dollar insurance coverage has created a sort of planned economy in the health care sector, and has brought with it all the woes commonly associated with planned economies.

When our leaders and when individual policy holders cringe away from the idea of high deductible policies, they are thinking of the present cost of even the most routine services rendered in the health care sector. Since having a broken toe set, either in an emergency ward or in a clinic, now can be expected to cost a couple thousand dollars – people reject the idea of high deductible policies because they envision having to shell out chunks of thousands of dollar several times in the course of a year in order to receive care for even the most minor of problems. They envision having to pay almost $25,000 a year, every year, to have their most basic health care needs met. And they are right to anticipate that constant steep drain unless insurance reform is effected across the board to become what insurance was meant to be.


Health Insurance Raises Prices, Breeds the Need for Yet More Insurance

To summarize - the widespread existence of near first dollar policy coverage has removed both responsibility for payment and capacity for assessment from the hands of the individual recipient of the service and has placed it in the realm of distant, automated reimbursement agencies. The padded billings that doctors and hospitals are able to achieve in this environment become the implacable standard prices that can be charged for that service in that location. There can rarely be any more adjustments made for those who do not carry insurance, as an adjustment was made to my mother’s bill in 1960. Everything proceeds on automatic pilot now. If a broken toe can be re-defined in such a way that it can be managed as part of a complex system of entrained treatments – then it can be billed to the tune of several thousand dollars. And that exorbitant price tag becomes the set sum billed for every broken toe in that area. Then as the cost of a broken toe becomes prohibitive, pressure on our leaders to provide means of obtaining still more comprehensive insurance coverage builds. The price inflation caused by prevalent first dollar insurance coverage breeds the need for still more comprehensive coverage. And round-and-round, and onward and upward the spiral of medical costs go, as we have been witnessing.

More widespread, more comprehensive coverage for still more people is not the answer. Across the boards, first-dollar coverage, amounting to a health care subsidy, is not the answer. Only when our health “insurance” once again becomes true insurance - that is, insurance against major loss – can goods and services received in the health care sector be brought down to earth. Only when the individual himself is put in a position to see and to assess the value of particular services rendered to him by paying for those services himself – can the system be brought back to sanity. Only when that happens will an hour spent in a room with a tattered lounge chair and a paper cup of orange juice stop costing thousands of dollars and be priced according to its true worth.

David Goldhill wrote an excellent, eye-opening article published in the September, 2009, issue of the Atlantic Monthly that similarly demonstrates the need of making high deductible insurance policies the cornerstone of our personal and our Government’s health care policy. Mr. Goldhill also outlined a well thought-out system of additional provisions that includes individual savings plans and accommodations for lower-income individuals. I highly recommend this article to anyone interested in reforming the health care system, and I hope many of our elected officials will read it and consider its proposals.


Postponing Treatment Might Not Be Bad

One more problem needs to be addressed though before anyone advocating high deductible policies can hope to gain adherents. Most of those favoring universal first dollar coverage base much of their feeling of necessity on the need to “catch problems early.” They point out that if people are required to pay for basic health care out of their own pockets, they will postpone getting check-ups until small problems become big ones. Then both society and the individual will needlessly suffer.

The argument that society will suffer generally boils down to a concern that society will have to pay for an individual’s neglect of his or her health. Expenditures, ultimately likely to come from taxpayer coffers, will have to be made to reimburse health providers for the truly heroic measures needed to treat the now severely ill person. Also, a lot of productive capacity will be lost as the dilatory individual languishes in a wheelchair rather than being up and at work on the assembly lines. However, social programs that require an individual to act for society’s good, not with relatively limited precautions such as wearing a helmet while driving a motorcycle, but in broader and more constant anticipation of society’s greatest good – can become the seeds of a dangerous social ethic. Programs based on such concerns smack of the spirit of the Third Reich when posters everywhere exhorted people to remember that “Gesundheit ist Pflicht!“ (“Health is Duty!”). Tyranny always starts by putting people under such general social obligation.

Concern over the individual’s own well-being might seem to be a more legitimate reason to urge universal health insurance providing near first dollar coverage. That way, it’s argued, problems can be nipped in the bud. No one would be motivated to delay treatment to save money. No one would have to worry about some health problem arising when he’s low on funds, thus allowing a small problem to mushroom into a big one.

But should the rightful concept of insurance as something to be invoked only in cases of major disaster be perverted in order to accommodate people who can’t or don’t choose to save some money to have minor health problems addressed? It might seem cruel to suggest such a thing. And if Mr. Goldhill’s plan for establishing individual savings accounts to supplement the high deductible policies and to be drawn on for routine health care were to be put into effect, the problem generally wouldn’t arise anyway.


Katie Couric Notwithstanding

However there’s a more fundamental reason that such an argument in favor of first dollar coverage isn’t necessarily valid. We are bombarded at every turn with injunctions to have routine check-ups – colonoscopies, mammograms, prostate exams. If a woman is pregnant, sonograms and all kinds of “pre-natal care” are now seen as essential precautions. Media celebrities impress us at every turn with the efficacy, the necessity, of keeping ourselves under constant surveillance in this way. We hear these check-ups urged so often, that their saving grace is taken for granted by most people.

However, quite a few doctors have published statistical analyses showing that, unless a person has some specific symptoms, routine check-ups of this kind can do more harm than good. Even the most accurate tests produce a proportionally significant number of false positives, which then torture the individuals with worry while all sorts of invasive follow-up diagnostic procedures are performed. The original tests and then the follow-up tests each carry the potential for error and mishap. The risks of submitting oneself for routine check-ups often outweigh the benefits. Morbidity and mortality rates for groups of the medically mindful don’t differ significantly from those rates for socio-economically similar populations of people who don’t get the recommended regular check-ups, who don’t so diligently try to “nip things in the bud.”


The Terrible Toll of Medical Error

However, there’s one easy, overshadowing statistic that eclipses all these somewhat more tricky statistics. An article published in the April 15, 1998, Journal of the American Medical Association (JAMA) concluded that that over 100,000 Americans die prematurely under medical care every year as the result of adverse drug reactions (ADR’s). It can be assumed that many, many more die yearly from other iatrogenic causes, such as hospital-acquired infections. These findings naturally received some criticism because the study was actually a meta-statistical one. That means it reached its conclusions by piecing together the conclusions of a number of other, smaller studies. This overarching JAMA study therefore likely included, among other statistical distortions, some duplication and overlap of the victims of medical care that it was counting. However even critics of the JAMA study conceded that the methods of statistical analysis used might just as easily have resulted in an under-estimation of the numbers of medical victims as an over-estimation of them. Therefore, all-in-all, the figure of 100,000 needless deaths a year seems a reasonable one.

Although this finding of such a staggering annual death toll is occasionally mentioned, it still remains a largely hidden and unrecognized danger every time yet another commentator urges regular medical check-ups. A few organizations have formed to try to reduce this iatrogenic toll by such simple expedients as having coordinated, computerized print-out prescriptions replace the old hand-written scrawls – and by enforcing hand-washing and sterilizing practices on medical staff as they make their rounds. Mr. Goldhill in the article cited above himself urges these reforms, and President Obama has made the extension of such measures a notable adjunct to his health care reform plan. However despite these efforts, the figures probably remain much the same as they were at the time of the 1998 study, in part because of a still very limited awareness of or acknowledgment of the potential damage and risk entailed in submitting oneself to medical care per se.

That figure of 100,000 unnecessary annual deaths remains the 600-pound gorilla in the middle of the room. Not many have been willing to look at it or to consider its implications. Thirty times the number of victims of 9/11 are dying often horrible, needless deaths every year because they submitted themselves to routine medical procedures. So it would seem that for every person who prolongs life and health by nipping something in the bud – there will be many more whose lives are curtailed as a result of going for routine exams. Therefore, the initially counterintuitive and unpopular conclusion is that if requiring individuals to pay for basic health care out of their own pockets sometimes causes them to indefinitely postpone making doctors’ appointments – the net result will actually be a healthier, longer-lived population.

Of course, it’s a gamble. Although the above statistics might indicate that for every person saved by early detection, there might be several who are unnecessarily damaged – who wants to be in the group that might have been saved by early detection? As every poet has attested, a person will more profoundly regret and be haunted by the adverse consequences of what he didn’t do than by what he did do. So we will rue the little lump we neglected and let develop into an overwhelming cancer more than we will rue the routine check-up that resulted in necrotizing fasciitis. At least in the latter case, we can consol ourselves that we did the approved thing, the thing that by all rights in an ideal world should have protected us in the long run.

Either way, it’s a tough, lonely decision, one that each individual will have to make for himself or herself every time a symptom arises or a media personality persuasively urges some routine test or check-up as a preventative care measure. However, the availability of first dollar insurance to cover early detection exams doesn’t necessarily steer one in the right direction or insure greater health. If indeed, as statistics currently indicate, less is more when it comes to submitting oneself to standard medical procedures – it doesn’t matter whether one comes by that reduced consumption through conviction – or through a simple lack of funds.


False Assumptions Behind Universal Health Insurance

But this leads to the most profound and radical objection I have to the extension of health “insurance” coverage to more people for more conditions. This leads to the most important reason I would urge our public officials and our private advocates to re-examine their basic attitudes about what is and what is not necessary when it comes to being healthy. By advocating universal health insurance starting at or near first dollar coverage – our officials are advancing the assumption that each and every one of us needs to stand eternally poised as either actual or potential consumers of health care. They are perpetuating the myth that we can only expect to live long healthy lives if we remain continuously enlisted as patients on the rolls of various doctors and health clinics. It not only assumes that we will need to have constant recourse to medical care when we manifest symptoms – but it also assumes that our very “wellness” can only be managed, validated, and advanced through the ministrations of medical professionals. In short, the advocacy of universal health insurance/universal health care presumes we all need frequent access to medical care for both our good days and bad. It’s that assumption embedded in the drive for extensive health care coverage that I believe will most grievously propel us down the wrong road.

Again, an analogy with a related professional field might be useful. There is currently some effort being made to promote legal insurance policies. In some ways, these are often more like pre-paid plans, but they can legitimately be thought of as insurance. You pay your annual premium, then you will be covered for some estate planning costs, for one or more court advocacies, for some paperwork associated with real estate transactions, etc.

However, despite the earnest efforts on the part of some to market these legal policies, they haven’t gained much traction with the general public. Although attorneys are often seen as being bent on legalizing all aspects of our lives, on bringing every human transaction into their domain, under their aegis – in reality, most of us don’t need an attorney’s services very often. In fact the average citizen might never need an attorney, or might need one only a few times in the course of her lifetime – perhaps to write that Will, to intervene in a dog-bite case, when property is bought or sold, or in the eventuality of a contentious divorce. So most people resist buying these touted legal insurance policies because they believe, rightly in most cases, that they just aren’t likely to be able to consume enough legal service to ever recoup even a fraction of the costs of their annual premiums.

That sort of skepticism should be applied to the push for basic universal health care coverage as well. The average person might want to consider that he or she simply doesn’t need much medical intervention in the course of a lifetime, certainly not enough to warrant our government’s concern over putting into place a massive infrastructure of provisions to cover health care costs. However the medical profession has been much more successful than the legal profession in packaging and re-defining a vast range of human need in terms of a demand for its services. Our lives have become medicalized - from the array of technological interventions often standing ready or actually imposed at the moment of our births, through to the protracted array of interventions, proscriptions, and prescriptions imposed in our last years. So now, while many people believe they can buy and sell a house without the process necessarily being mediated by an attorney - very few believe that they can maintain even basic health without being under a physician’s care.


Our Medicalized Society

A number of philosophers have tried to illuminate how this increasing belief in the necessity of professional services has transformed our lives. Ivan Illich, in his book Medical Nemesis, made the case that consumerism isn’t confined to those of our shopping excesses that often get criticized at Christmastime. He found our worst addiction to consumerism to be based in our belief that we stand in constant need of the services of such professionals as medical personnel. We have come to rely on these professionals to package and “deliver” their goods to us as commodities. They make their essentially irrelevant, adventitious services increasingly in demand, therefore increasingly scarce and costly. And we buy into it.

Other philosophers such as Michel Foucault and Jean Baudrillard have similarly, although more obliquely, included ideas in their works about how natural human processes have increasingly been re-defined as institutional commodities or outputs that we’re told we all need to consume in order to maintain ourselves. However I don’t have to cite these sometimes abstruse philosophies in order to make a case for how artificially manufactured much of our perceived medical need is. Much of my opinion comes from personal experience - as a volunteer driver for senior citizens. I drove senior citizens to their doctors’ and hospital appointments for several decades. And more - I sat with them through most of the medical exams or procedures they were having done. So (the usual disclaimer), while I’m not a doctor, I have racked up perhaps a thousand or so visits to doctors in the company of my friends and colleagues and assigned “clients.” Of those thousand-plus visits, only four seemed necessary or helpful.

Those four visits that justified the difficulties of bringing the patients to and fro were all on behalf of one person. This person (I’ve disguised circumstances to maintain the patients’ privacy, but have retained the essential nature of the appointments) had been suffering from a fistula for over a year. An appointment or two was expended in assessing the situation. Then there was the day of the actual operation when the fistula was removed. Then a follow-up appointment. And, ah! Relief! But those were absolutely the ONLY appointments that could be considered to have accomplished anything. All the rest struck me as having been a waste of time, energy, emotion, and probably millions of dollars in Medicare reimbursements.

I do first want to stipulate that the services of the medical profession are no doubt crucial in the treatment of people who present with acute conditions - with injuries, war wounds, etc. – or of younger people with specific symptoms. Our medical profession does a wonderful job addressing specific stabs of conditions, if the patient can avoid those iatrogenic side-effects of treatment. But as far as the appointments that are merely routine attendances, the kind that seniors are often called upon to keep – these almost all appeared to my educated eye to be utterly pointless. And they account for the largest part of our domestic expenditure on health care.


The Vast Wasteland – A Typical Exam

A typical appointment that I accompanied a senior citizen to and through would go as follows:

The 80-year-old woman spent a sleepless night worrying about the exertions that would be involved in getting to her appointment the following day. She said she had taken a sleeping pill to finally get a little rest, but she believed this unaccustomed pill had made her feel a little extra woozy. But we bundled into the car and drove to the Medical Center where this woman’s Doctor was seeing patients. I couldn’t find street parking, so I had to drive into the high-rise parking lot, going all the way up to the 10th level on the roof before I could find an open slot. I asked the woman to wait while I searched through the parking facility, then all the way down into the Center lobby to find a wheelchair to take her the block-and-a-half to the actual wing where her Doctor had his office. I was lucky, and did find a wheelchair available on this occasion. (Many times, I would either let my febrile companion off at the door of the Medical Center to make her way into the lobby on her own, where she’d sit and wait for me to park. Or else she’d stay with me as I drove into the parking facility and, if no wheelchair could be found, we would walk together slowly, laboriously all the way from the parking facility into the Hospital. In short, a lot of difficult logistics and dishevelment were usually involved in merely getting to the site of any appointment for a check-up.)

Once in the Doctor’s reception area, we were given forms to fill out which once again called for a recounting of my friend’s entire medical history, including the hysterectomy she had in 1978, and a list of current medications she was taking. Oh, we had forgotten to bring all her pill bottles with us! Let’s see – how many milligrams of A… was she taking? We filled out the forms as best we could, then we waited for nearly two hours. My friend was getting really hungry, since she had been too nervous to eat breakfast. When her name was finally called, we were ushered into a cubicle examination room where a young nurse took some preliminaries – weighing her and taking her blood pressure. Her blood reading proved to be alarmingly low, something like 80/60! The nurse sent a distress signal back to the Doctor and we heard some mumbled exchange taking place in an adjoining room. My friend tightened more with worry.

Finally the Doctor swept in with brisk cheer. He glanced at the forms attached to his clipboard, put them aside, and looked intently at my friend. He took her blood pressure again, and this time got a somewhat higher than normal reading. Another mumbled exchange took place between him and the nurse who was hovering nearby. I gathered that because my friend was so thin, under 100 pounds, they needed a special sphygmomanometer to take her pressure. The standard one used by the nurse had been too loose on my friend’s arm.

This higher reading caused the Doctor to write a new prescription for my friend, upping the dosage of blood pressure medication she’d been taking. This dosage incidentally remained unchanged until several years later, when the woman was fading from cancer and her hospice workers got consistently very low blood pressure readings. When I mentioned this to the visiting Doctor assigned by the hospice, and questioned whether she should still be taking pills to lower her blood pressure – that Doctor scanned her charts anew, and perfunctorily agreed that the medicine ought to be cancelled.

But on the day of this typical visit to the Medical Center, there was no further review of my friend’s charts or of the forms we had so studiously labored to fill out. The Doctor looked jovially at her, asked if she had any questions. When she said “No,” he crisply dispatched the clipboard under his arm, shook her hand, and chirped, “See you in three months!” – then swept out of the room in full confidence that something had been accomplished.

I chauffeured my friend home again, driving the difficulties we’d had getting to the Center in reverse. But things were much more pleasant on this return trip. My friend could relax. She’d done her duty of reporting for her regular check-up and had presumably been given a clean bill of health – except for that worrisome high (or was it low?) blood pressure. She was looking forward to getting back into her apartment, to eating a big meal to make up for the breakfast and lunch she’d missed, and to easing down on her couch to watch “Wheel of fortune.”

I was less confident than either the Doctor or my friend that anything had in fact been accomplished that day. I didn’t see the bill issued to Medicare and AARP for this visit, but I’m sure it was steep, no doubt specifying “Complete Physical Exam – Check-Up,” or something that sounded similarly necessary and comprehensive.

And this, almost down to the last detail, was the content of about 75% of the appointments I ushered by friends through. There was always the commotion of getting the elderly person to the site of their appointment – the forms to be filled out – the waiting – the two blood pressure readings which almost NEVER agreed with each other (the first sometimes being high, the second low – or vice versa) – the loosely revised prescription – the tucked-away clipboard – the quick dispatch – the relief at having put a hurdle behind us, of having done our duty. Oh, sometimes the Doctor would have my charge lie back on the examining table and would briefly palpate some part of his or her anatomy – but that was rare. Sometimes there was a concrete point to the visit, such as a mammogram (which also usually produced equivocal results and had to be painfully repeated). Most of the visits though were exact repeats of the tokenism I described above.

However, about 25% of the appointments I accompanied friends to did involve more extensive exams or procedures aimed at addressing some actual physical problem the patient had manifested. But again, to my educated eye, even these presumably targeted rather than routine visits proved to be exercises in futility.


The Green Mile to Radiation Therapy

A 93-year-old man had noted a spill of blood in his stool and was ultimately diagnosed with rectal cancer. He was launched on a regimen of combined chemotherapy/radiation, and there were whispered intimations of re-sectioning and colostomy to follow. We went in for radiation treatment every weekday for six weeks. However, I could never get quite clear on this man’s behalf what the Doctors hoped to accomplish with this arduous treatment. At first we were hopeful that they were aiming for a cure. But after a lot of vague, wandering explanation, I gathered that no, the best that could be hoped for was some shrinking of the tumor. The Doctors assured us though that the treatment was necessary as the only way to shrink the tumor enough to stop the bleeding and dangerous blood loss. That might have been legitimate – except the man had happily reported to me during the week he’d spent in a hospital room before starting this chemotherapy/radiation regimen – that the bleeding had almost completely stopped! The doctors denied this and said he must have been mistaken. Well, maybe.

At any rate, the man miraculously got through the radiation therapy with remarkably few side effects. He did die of cancer when he was 98-years-old, with the bleeding having resumed so that he experienced about the same amount of bleeding every day that had originally caused him to seek treatment.

A woman in her 70’s who had completed a similar regimen of chemotherapy/radiation was then told to report weekly for epoetin shots, presumed to bolster some of the blood factors that get depleted by radiation. (I learned that some athletes also were secretly taking these shots because they believed they enhanced performance.) I accompanied this woman through nine appointments, nine shots. The blood counts for her various blood components never changed during the course of this treatment though. So we privately wondered if the shots were really doing any good.

This woman was also very slim and the large needle used for the injections caused considerable pain. The ninth and last shot she received might have damaged a nerve in her arm, because she complained about pain and limited movement in that arm ever after. Her GP confirmed that her symptoms were consistent with a needle-damaged nerve.

Epoetin was a very expensive hormone extract, and I saw that Medicare was billed $1,200 for each shot. Quite a flurry of consternation surrounded that ninth shot, apart from the especially severe pain my friend experienced receiving it. Although Doctors had confirmed that my friend should report for her regular appointment that ninth time, when we arrived, we were initially told that Medicare would no longer pay for the treatment and that the appointment was cancelled. (Now they tell us!) However ultimately, after some extensive conferring, a phlebotomist was brought forward to administer the shot. That was definitely the last one though. About a year later, we learned that one form of epoetin had been withdrawn from the market and a lawsuit had been launched because of some side effects.


Shock and Awe

Then there was the particularly sad case of the woman in her late 70’s whom I’d been assigned to drive home from the hospital where she’d spent a week being treated for flu-like symptoms, probably walking pneumonia. When I called her early that day, she was ecstatic at the prospect of being “released.” She was gleefully packing.

When her husband and I got to the hospital though, we were shocked to learn that she was in intensive care under Code Blue. She had suffered from anaphylactic shock as she wa preparing to leave, and had been intubated. I drove her husband to visit her every day after that. Her condition waxed and waned. She would improve a little and was miraculously weaned from the breathing machine. She’d just be rallying, when she would suffer another attack of shock and would have to be intubated all over again. After eight weeks of what was overall a torturously downward spiral, she died. Staff members were never able to discover what had triggered these episodes of anaphylactic shock. I suggested the Latex in the hospital gloves might have been the culprit (I’d read that some people have a hypersensitivity to Latex). But the doctors believed they had ruled Latex out as the cause. So, it remains a mystery…


Do the Most First

Another one of my clients had complained of a sore throat. She was living in subsidized senior apartments and mentioned this to the visiting nurse. The nurse in turn phoned the regular Doctor who visited and attended the seniors in this building. He immediately set up an appointment at his Hospital for my friend to have an endoscopy. I was taken aback because this more difficult probe had been ordered before anyone had even cursorily peered down my friend’s throat with a simple, old-fashioned tongue depressor. “Say ‘Aaaaaaaaaa.’” But so be it.

My friend received a sheet of instructions telling her not eat for 12 hours before the test, and listing other precautions she needed to take in preparation. Her appointment was confirmed. After we arrived at the Hospital though (with the usual difficulties involved in getting a barely mobile 90-year-old anywhere) and had completed those perennial pro forma medical history forms, we learned that the procedure was NOT going to be performed that day. This appointment had been made merely to set a date for the main event! It was an appointment to make an appointment! However Medicare was billed for a full check-up exam for the day.

All that was really done that day though was to go through the usual weigh-in and blood pressure check. Nevertheless, I was initially relieved that the endoscopy wouldn’t be then. I thought this would give the doctors a chance to reconnoiter the problem with that low-tech tongue depressor. I was hopeful such a basic inspection would obviate the need for an endoscopy. But no. After the blood pressure check, we were sent home, still with no one having imply glanced down the woman’s throat. The order for an endoscopy stood – for another day. This meant another fast for my friend (who looked forward so much to her midnight snacks). It meant another arduous pilgrimage to the medical center, this time through deep snows, wheels spinning. We narrowly avoided getting stuck in the deep snowdrifts on either side of us all the way there.

The endoscopy revealed nothing out of the ordinary. The doctors toyed with setting up a deeper probe of my friend at a future date. However we never had to take that step because my friend’s sore throat went away after she switched back to the old brand of inhaler she’d been using to relieve her occasional mild asthma attacks.


A Hard Day’s Night in the Emergency Ward

Another woman just shy of being a centenarian got the sniffles and a sore throat, which then developed into a more pronounced cough. The visiting nurse in her seniors’ building called me to immediately take the woman to the emergency ward. I was more than a little dubious about jumping directly to this extreme recourse. I wondered if the building’s Doctor couldn’t make a visit instead, or if the nurse could just arrange an appointment with the woman’s regular GP. But no, the visiting nurse was firm about the immediate need of the emergency ward. And once any qualified member of the medical profession would utter anything, even if it was just an off-handed guess at the right course of action -that utterance became mandate, in the eyes of the patient herself and of the world at large. I couldn’t presume to contravene it.

So off we went to the emergency ward of one of the most respected hospitals in the U.S. We arrived at 11:00 AM. My friend hadn’t eaten breakfast or lunch in the midst of this consternation about how to deploy her, but we assumed she could get something at the hospital. After about forty minutes, she was assessed by the triage nurse. This nurse apparently felt that my friend’s condition warranted hospitalization, especially since this happened at the tail end of a scare about a serious pandemic flu. However her condition wasn’t deemed serious enough to grant her high priority for admission. So we languished in the anterooms of the emergency ward.

After another hour or so, she was taken back into the thick of the emergency room action with the exam cubicles off to one side and commotion all around. She was briefly examined in one of the cubicles and was then sent back out into the general stream of emergency room action. Hours passed. She wanly asked if she could have something to eat. A nurse rushing past promised to scout something. More hours passed. She asked another angel of mercy on the fly. This nurse said that the dinner hour was over, but that maybe she could get something from a vending machine. She promised to come back with something very soon. More hours passed. A gurney was brought out so my friend could lie down and rest. The aisles of the emergency ward were already so crowded though with other people lying on gurneys and with various apparatuses and dispensaries – that my friend’s gurney kept getting pushed toward the back entry doors. As the night deepened, more ambulance drivers and paramedics kept rushing in and out of those doors with victims of shootings, bludgeonings, stabbings, as well as with heart-attack victims and people sinking into diabetic comas. Every time one of these more serious patients was rushed into the ward, more cold night air also rushed in to chill my friend lying there on the gurney. I tried to push the gurney to warmer quarters, but it kept getting jostled back by the doors in the general on-rush. Finally someone brought my friend a blanket to ward off that cold night air. But still no food.

We discussed just getting up and going home. But a nurse, overhearing our plans to defect, strongly advised against that. She said my friend really should be more thoroughly assessed as an in-patient. The hospital was at full census – but “Just a little longer.”

Finally, a little past midnight, they found a room for her. It was an isolation room with a little foyer where any later visitors would be expected to change into protective clothing. I didn’t have to change though since I’d been with the woman all day. She was settled into the bed where she droopily asked if she could get any food. The attending nurse was doubtful, since it was past the time for nighttime snacks. But she said she would try to drum up something.

I stayed with my friend until she dozed off in the wee hours. As I quietly slipped out to go home, there in the little foyer I saw a covered dish on a rolling table. I lifted the lid and saw – a cold hot dog on a bun. I hadn’t thought to look out there! I presume my friend got the regular hospital breakfast, but that would have meant she went over 36 hours without food. How a nearly 100-year-old woman with the flu was able to stand that gaff of no food and repeated blasts of cold night air - I don’t know. I, who was much younger, would have been unlikely to survive.

However my friend came through this in remarkably fine fettle. She was kept in the hospital about five days, during which time they determined that she only had a common garden variety of flu. They tinkered with her blood pressure medication a little and the dosages of a heart pill she had been taking for some years. And then she was out – with an adventure to narrate, but with very little of real substance to show for the ordeal as far as I could see.


Hold the Compresses!

Finally, I’d been accompanying a man in his 70’s to a never-ending series of doctors’ appointments at a big medical center. The man was on Public Aid and he had what seemed even from the start a poorly coordinated host of specialists in attendance on him. One day he’d see the endocrinologist. Later that week, it would be the cardiologist. Then it would be his assigned GP there, and on to the gastroenterologist.

It was concretely established that he had inherited a gene for Leiden Factor V, which causes abnormal blood-clotting and consequent thrombi, which most painfully affected his legs. He was on high dosages of blood thinners.

Then it was decided he needed a stent to open an artery. He was informed of the risks involved in this operation and he actually planned for the worst, meeting with an estranged daughter, for what just might be the last time. He had reduced his intake of blood-thinners to almost nothing I got to his apartment at 4:00 AM because they said he had to be at the hospital to complete the check-in process by 7:00 AM. It was a cold and lonely drive through the rainy pre-dawn streets to the Hospital. But he was duly admitted, given preliminary sedation, and prepped for the operation. We chatted while we waited for him to be wheeled into the operating room. More to make conversation than for any specific reason, I asked if his regular cardiologist knew that this procedure was being performed. I’d heard the names of all sorts of new doctors and surgeons mentioned in connection with this operation, but Dr. S.’s name hadn’t been mentioned.

My friend said he didn’t know. That’s right, he wasn’t sure Dr. S. was in on this. So when the next Doctor/intern team came in to further prep my friend, we asked if Dr. S. would be in the operating room, or if Dr. S. even knew this operation was being performed. The Doctor looked puzzled. He made a note on his chart. A short time later, my friend was wheeled to the operating room.

I prepared to wait several hours to see how the operation turned out. I thought I might be asked to move to a recovery room soon to free up this regular hospital room. So I was partially packing up when I heard the loud clattering of a gurney coming down the corridor. There came my friend, on the gurney, being jostled zigzag back into the room. What? Why?

We never got a clear explanation from any one staff member. But we got snippets of explanations from a variety of interns and nurses. It seemed after our mention of Dr. S., the operating team had realized that my friend’s regular cardiologist had in fact been left out of the loop during the planning of this procedure. When the scheduled surgeon had phoned to apprise him – Dr. S. had urgently ordered that the operation be called off! He said even though my friend had virtually stopped taking blood thinners for the last days, there was no way a stent insertion would be safe. He’d bleed to death on the operating table! The operation was aborted just seconds before the anesthesiologist started to administer the final knock-out drops.

So several hours later, we drove home again. It was still raining.


Blue Zones

Again, these are typical of the appointments I kept with the senior citizens I drove. I haven’t selected the most dramatic or telling of my experiences with the medical profession. Each of these appointments was just “all in a day’s work.” I firmly believe this litany of uselessness is representative of what almost ALL senior citizens and many others without very specific, delimited symptoms experience as they become enmeshed in the medical system. Medicare and other comprehensive insurance coverage reimbursements have promoted this sort of needless consumption of medical services. But beyond that, the belief that health can only be achieved or maintained through the mediation of health-care professionals is what keeps people coming back for more – and more…

Last season Oprah had a show with Dr. Oz that featured the lifestyles of people living in what they called “Blue Zones” around the world. These are patches of communities where the residents seem to be enjoying extraordinary health and longevity. A disproportionate number of residents here were said to be living to 100+, remaining active and productive.

Well, this assertion might also call for a little skepticism. I remember the enthusiasm over the presumed longevity of the residents of Georgia, Russia, several decades ago when these citizens were featured in a variety of yogurt ads. It turned out that their claims of living routinely to 110 and 120 years of age turned out to be false. Birth records weren’t available in most cases, and people’s memories were faulty.

Nevertheless, assuming that the Blue Zones featured on Oprah’s show were a little better researched, or that the residents there live at least as long as the average U.S. citizen – that speaks volumes to how much health care it is necessary to purchase from health care professionals in the course of a normal lifetime in order to remain healthy.

One of these Blue Zones was Loma Linda, California. We can assume that the residents there might be consuming health care services generally up to usual U.S. standards. They’re probably on the rolls as patients at “wellness” centers and get most of the recommended tests and routine check-ups. However the other three featured Blue Zones were in rural or semi-rural areas where traditional lifestyles centered around family and farm and community still existed and where it was unlikely that the residents had not been observing any health regimens even remotely like those advanced as necessities here. These other Blue Zones were in: Nicoya Peninsula, Costa Rica; Okinawa, Japan; and Sardinia, Italy.

Dr. Oz was shown trekking to the Costa Rican site and scything down chafe in competition with the near-centenarian native there. The centenarian at least held his own, and probably outdid Dr. Oz in strength and endurance. But it seemed likely that this elder man would have been completely innocent of the ministrations of modern medicine. Like our great-grandparents, he might have had occasion to consult a local doctor there only a few times in his life – or perhaps not at all.


The Good Life

And so it should be for the average U.S. citizen. Unless a person has a crippling genetic disorder or suffers some specific grievous illness or injury along the way – all our elaborate medical interventions should be irrelevant to him. He should not base his identity on the roll of “patient.” He should not accumulate diagnoses like Boy Scout badges that allow him to advance through successive stages of an elite fraternity. “I received my diagnosis on April 12, 2007.” He should instead rest assured that, again barring unusual misfortune, he too can live most of his life without colonoscopies, endoscopies, pills, sagging sphygmomanometers, continuously fluctuating blood pressure and cholesterol readings, radiation, and rushes to the emergency ward.

Of course we are not living the “simple” lives of a Costa Rican farmer, but that doesn’t mean we can’t be naturally centered in our own environments – balancing some indulgences and joy with difficult, dedicated work – balancing solitude with some embracing fondness.


The Need for Basic Services

But even with that sort of intrinsic wellness, wellness not mediated by any teeming medical establishment - there are still all the little “slings and arrows” of life that we might occasionally seek some comfort against and some help with. For these we should bring back the old-fashioned family doctor, a person who makes house calls and who remains consistently enough on the job to get to know us without having to request that we fill out four sheets of medical history in preparation for each visit. We need to pepper the country with a generous number of small, low-tech, low-cost clinics that are open around-the-clock and that are staffed by one fully qualified doctor and by a variety of paramedics who can stanch a bloody nose, set a broken bone, and reduce the pain of a sprained ankle without enlisting us in lengthy, elaborate, lifelong attendances on any medical establishment. For the rarer, truly major medical problems that arise, we need to enable everyone to have high deductible insurance policies that cover the catastrophe. And we need concomitant watchdog groups to make sure that small problems aren’t therefore routinely inflated into major medical status.

However, we do NOT need to institute a system of medical reimbursements costing billions of dollars. We do NOT need to institute first dollar, universal health “insurance” that carries with it the assumption that we all constantly stand poised in need of medical enrollment, medical defining, and medical intervention.


Disillusionment and Hope

Few, if any, of the people I accompanied through the medical maze became fundamentally skeptical about the necessity of attending the next check-up, and the next… despite the seemingly obvious futility of the exercise they’d just been through. However, after several decades of this volunteer driving, I decided to substantially quit the job. I stood one day looking up at the high-rise parking lot attached to a major medical center and saw tier-on-tier of cars filling every level up to the roof-top. Based on my experience, I imagined the vast majority of those cars had carried people to hours of needless waiting - to needless exams producing equivocal, misleading results - to needless, complicated procedures performed before the simple gesture of one person looking with empathy and personal interest at another person had been given a chance to achieve a diagnosis. I saw a mountain of needlessness. And I thought – we have to do something else!