One for the history books

In the United States History courses I took in college, the emphasis was squarely on political history: the political and military efforts to create our country, the effect of electing this candidate rather than his opponent as President, the transformation that World War II wrought on the world geopolitical stage and our emergence as a global power.  I learned also about the concept of historical perspective: that historians cannot speak intelligently about the effect of a given action until decades have passed and the ripples can be seen.

That still leaves us with the enjoyable pastime of speculation.

Just as the destructive force of post-tropical storm Sandy was amplified by merging with a North Atlantic system before making landfall, the economic and military fear, uncertainty, and doubt provoked by the possibility of sequestration, which strikes me as the United States’ self-imposed withdrawal from its role as a major military power, is coupled with what has become an annual Congressional tradition of holding the nation hostage, with each party and representative seeking to maximize the political and economic ransom in exchange for a continuing resolution to keep the government operating. Back when the Congress still performed its Constitutional duty to pass an annual budget, that opportunity to play chicken with (pig-)earmarked spending and unrelated amendments that would never pass on their own merits came only once a year.

The sequestration bill, the idea of Congress motivating itself by creating an alternative default scenario so dreadful that no sane person would allow it to come to pass, may make sense at first glance, but what it reveals to me is a Congress that lacks an awareness of its own capacity for stupidity and that considers brinksmanship as the default method for dispute resolution. The federal government has become so accustomed to unthinkable things, such as a war over personal animosity or abandoning our most fundamental ethical principles, our rights, and legal obligations for the sake of expediency and the perception of security, that it has lost that healthy fear of the repercussions of its own actions.

Regardless of what happens with the looming budgetary crises, there will be negative fallout for the Armed Forces and vital defense contractors. Infrastructure will go unmaintained or even be dismantled. Personnel training and equipment maintenance will be delayed or canceled. Our government is failing us in its most important duty: defending us. The degree and result of that failure cannot be foreseen. It is worth noting that a nation along our porous border is in a state of open war between the federal government and drug cartels, and some have speculated that it is in danger of becoming a failed state.

One would think that our elected officials should be spending all of their energy resolving the government’s immediate fiscal problems and mitigating the impact on the readiness of our Armed Forces. Instead, they have chosen this time to try to limit the American people’s access to firearms. Why, they ask, would a person need military-style weapons? As our politicians eviscerate our military in a way that no adversary ever could, that question pretty much answers itself!

It will be…interesting…to see how this plays out in the coming months and years. Perhaps historians will look back on this year as the beginning of the end of the United States’ status as a superpower.

 

Some Thoughts on Healthcare

As a brief preface, this post was precipitated by the current disagreement within the United States about President Obama’s healthcare proposal. As with any writing on a political “current events” subject, it is doomed to eventual irrelevance. I must confess at the outset that I have not read President Obama’s proposed bill, in part for reasons based on MY source of healthcare.

I am a disabled Navy veteran. For two years now, I have received all of my medical care from the Veterans Administration (VA) at a VA Medical Center in a major city. I interact with my healthcare providers far more than the average person (merely intuitive assumption) and have for over a decade, and I feel as though my more frequent interactions with a broad spectrum of providers gives me a bit more insight than the average bear on at least a comparison between HMO care and VA care. There are a few things that are the same: one will not always agree with one’s doctor, specialist appointments take longer to get than primary care appointments, and PCPs are the gatekeepers for specialists. There are also some differences: though both can change doctors, the VA has a smaller pool than an HMO in all but the most rural areas, specialist appointments are generally much faster in the VA, all of my VA providers, as well as the pharmacy, work from and contribute back to a master electronic medical record, which contains documents as well as all labs and diagnostic imagery I have ever had, the VA is quicker to adopt evidence-based procedures and standards of care, and if I am dissatisfied with a situation and cannot resolve it with my doctor or his/her clinical supervisor, I can go beyond them to a patient advocate who can navigate the bureaucracy much better than an outsider such as a patient.

In general, I am more satisfied with VA care, though I miss several of my former providers personally. I have heard it suggested that a solution for Medicare might be to give Medicare patients access to VA facilities. I don’t support that particular idea, though some of my reasons are purely personal, such as the sense of cameraderie with other patients, and some VA staff, as fellow veterans.

I think that requiring those hospitals that are significantly subsidized by federal funds be brought to VA standards would vastly improve the care experience, and outcomes, for patients who, perhaps due to “falling through the cracks” between heath insurance and Medicare eligibility, use the county hospital-of-last-resort as their primary source of care. Mandating that hospitals use VA-style electronic medical record and prescription system would improve care/outcomes and reduce errors.

Having said all that, I DO NOT support required government healthcare (or being able to decline it only at your disadvantage or peril). My VA care is a benefit of a specific contract between me and the federal government, basically “Workers’ Compensation” for the Armed Forces. It is a valuable benefit to me, but I am still free to seek care anywhere, from anyone. If the government required me to surrender that liberty in order to avail myself of VA care, the VA wouldn’t know I exist.

If one wants to improve healthcare, don’t start by thinking about what liberties you must take away from the American people. I do not believe, however, that the free market will fix this as long as the current HMO system exists, where people pay their premium, then feel entitled to consume all the medical resources they want for a $20 copay. The economics of paying, say, a $40 copay for a medication that costs $900 just don’t work. There is no free lunch. So the choices appear to be status quo, government regulation, or quite a bit of temporary pain if we want the free market to shift the system of medical payment to something closer to reality. Even the status quo is, I think, merely delaying deciding between the other two.

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