Sunday, September 29, 2013

Government Shutdown.  Beyond Human Scale?
A large organization that does not make effective use of its human resources will inevitably suffer further erosion of its position. It will no longer be able to enhance its values and its goals.
Eli Ginsberg and George Voyta, Beyond Human Scale,  Basic Books, 1983
Early this morning the House passed a bill funding the government through December 15 but defunding Obamacare, delaying its implementation for a year, repealing the medical device tax, and  assuring pay for the military.  
Harry Reid, the Senate majority leader,  has already said the Senate will not approve it, and President Obama says if passed by the Senate,  he will veto it.  Government shutdown, without a  last minute compromise, seems inevitable.
This shutdown is understandable when one considers the fixed ideological positions of the political combatants – one believing big government can fix all social ills, the other saying the solution lies in the marketplace. 
Both may be wrong.  The complexities of managing and constraining the costs  of  health and economic affairs of a large national society, complicated by its interaction with the global economy, and the peoples’ desire for the best health care, particularly if ti comes at somebody else’s expense, namely, the federal government,  may be beyond human scale.
The official name of Obamacare,  the Patient Protection and Affordable Care Act,  may be an oxymoron.   Because of complexities of the human condition and the quest of humans to prolong and improve their lives at any cost,  it is difficult to control costs while protecting us against all eventualities.   Containing costs while expanding access to all may be an unrealistic goal.
This is not the fault of either political party.  It is inherent in our biological destinies and our yearning for the best health and the best lives we can possibly have.  As Milton Berle, the American comedian said, “When it comes to my health, money is no object.”
As for the President,  it may be beyond his human  capacity to expect him to downgrade his signature domestic achievement, and to make complex, often contradictory decisions, that grow the economy, manage a huge bureaucracy, keep his subordinates in line, and please his critics, foreign and domestic.
Patient protection and health care affordability are noble, praiseworthy goals.  They are worth working towards, but in the end they may be unachievable.
Disease prevention and wellness are admirable movements, but in the end,  we shall all develop chronic diseases, and we shall all die.  The limits of human life and longevity are fixed, and no amount of money or investment in research are going to avoid chronic conditions or death.   Managing prevention and promoting wellness will help at the margins, but cancer and arteriosclerosis and other life-shortening conditions,  will always be with us.
It may be that government rationing  with all the bells and whistles of modern management science and big data apps  will decrease costs to a manageable level by making health care more efficient.   It may be that cutting $700 billion out of entitlement programs and transferring the money to Obamacare will redistribute benefits and give everybody a “fair share” of federal monies and  health benefits.  It may be that accountable care organizations,  bundled payments, comparative outcome data, paying only for what works,  ending fee-for-service,  putting doctors on salaries paying them less,  replacing them with coordinated teams,  and reimbursing hospitals for episodes of care, will decrease strains on the federal budget.
That said,  none of these governmental steps will significantly change human behavior.   People will continue to engage in activities harmful to their health, they will eat the wrong foods,  exercise too little, and they will continue to want choices of doctors, hospitals, and health plans; to  insist upon the best treatments that medicine has to offer.  

Physicians will continue to enter specialties that give them the best prospects for paying off their educational debts and their creditors, maximize their incomes, master the knowledge for their fields, maximize the health of their patients.  and allow them to  lead balanced lives.   Innovators and entrepreneurs will continue to innovate and to seek venture capital to promote their ideas and to improve care,  no matter how disruptive or inconvenient  to the government or health establishment.   
Tweet:  Preventing a government shutdown due to entitlement and health costs may be impossible given the human scale and desires for the best care.

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