Possibilities, Tough Choices, and the Other
Here's John Stossel going all transgressive on us with one of his subjects you're not even allowed to talk about:
America Needs to Do Less for Its Senior Citizens: Stossel reports when Medicare was created, senior citizens did not live as long, and medicine offered fewer wonderful but expensive treatments. Now Medicare is headed towards bankruptcy. Government has promised seniors $34 trillion dollars more than it has funded. It amounts to generational theft, says Andrew Biggs of the American Enterprise Institute. "The government spends around $6 on seniors for every dollar it spends on children, and yet the poverty rate among children is far higher than it is among seniors," he says. Stossel confronts seniors about it. Some say, "we've paid our dues" and "every paycheck, money was deducted." But in fact, today the average Medicare beneficiary collects two to three times more than they paid in. Why do even wealthy seniors feel entitled to have taxpayer-subsidized access to state of the art medical care?
I'm sure that my standard disclaimer that I don't want to get into a discussion about the merits of Medicare, that I'm really going somewhere else with this, will be ignored. Please consider the disclaimer nonetheless issued.
There are some pretty startling ideas asserted in the paragraph I quoted, and I'd like to deal with a few of the supporting arguments by way of getting to the real problem. Let's begin with that final question:
Why do even wealthy seniors feel entitled to have taxpayer-subsidized access to state of the art medical care?
Well, gosh. That is a stumper, now isn't it? But maybe it's because under the system as it currently exists they are entitled to that care? (Isn't that why they call them "entitlements?") If one believes that strict means-testing should be applied to Medicare payouts and that there should be severe caps on how much gets spent, then one really ought to say that. Painting people as villains because they take advantage of coverage that they've paid into and that -- hey, at least in the technical sense -- they are entitled to seems an odd choice.
But there's a reason for putting these folks in the position of the bad guy, as we'll see.
Working our way back, we come to this:
The government spends around $6 on seniors for every dollar it spends on children, and yet the poverty rate among children is far higher than it is among seniors...
There's a simple explanation for why government spends so much more on seniors than on children, and no, I don't think it has anything to do with the fact that seniors have a powerful political lobby and that "no one will speak for the children." I'll get to that explanation in a minute. But first, please don't misunderstand me. I'm not arguing in favor of this 6:1 ratio, nor am I saying there should be a different ratio. I offer no opinion on how much or how little the government should spend on either seniors or children. I merely note that we get a somewhat broader vilification here than in the previous quote. It isn't just mean old rich people helping themselves to government services they shouldn't feel "entitled" to, its old people in general greedily taking dibs on big piles of money that probably otherwise would have gone to buying shiny red bicycles for neglected poor kids.
Okay, so the reason that we spend so much on seniors is that seniors are the people who do most of the dying in our population, and dying is an expensive proposition when you're (pardon the expression) dead-set against it.
The U.S. statistics are based on aging Medicare patients who account for about 70 percent of all deaths each year. Five percent of all Medicare patients die per year and spend almost 30 percent ($143 billion in 2009) of the Medicare budget. Medicare patients who die spend about six times more in their last year of life than those who do not, which comes to about $25,000 for each person who dies, compared with the almost $4,000 spent per year for those Medicare patients who do not die.
Sadly, even those Medicare patients who don't spend the last six months of their lives in a given year are queuing up to do so eventually. There is apparently no getting around it. The long, slow, painful decline of the human body costs a bundle. Kids just aren't that expensive by comparison. And once again, I take no position on whether more money should be spent on children and less on seniors. I simply point at that the educational, nutritional, and housing expenses of poor kids are a bargain compared to what it costs to keep dying people alive a little while longer. So comparing the number of dollars spent on one versus the other is apples and oranges.
In any case, this long process of death need not be so expensive. We could just accept death rather than trying to fend it off. That's what Stossel is apparently arguing for. Just find people who are in the most expensive phase -- that last six months, say -- and tell them that if they can afford treatment by some other means, okay. But otherwise they're on their own. Medicare can't afford to cover them. It sounds harsh, but look: they're in their last six months anyway. We're really doing them a favor by not prolonging their agony, right?
To be fair, Stossel doesn't come right out and say that. He just says this:
America Needs to Do Less for Its Senior Citizens
So, per my comments above, we might put in strict means tests and caps on coverage. But ultimately, whether you call it "means testing" or "caps on coverage" or just "doing less," somebody doesn't get covered for something. And the logical place to start making cuts would be where the expenses are greatest and the ability to do any good would be the least, right? So that puts us right back in the last six months.
Well, here's the problem with "the last six months."
My father, now age 76, went through series of long and difficult cancer treatments last year. Right now he's doing quite well, but there was a time when things were looking pretty bleak. Around this time last year he might well have been pegged as someone in the final six months of his life. And then, with treatments cut off, he actually would have been.
But he is alive today. He met his new granddaughter last month and, for all we know, he'll be at her high school graduation.
With that in mind, I think it's important to restate Stossel's argument as follows:
America Needs to Let More of Its Senior Citizens Die
That's the ultimate meaning of "do less for our senior citizens." Of course, I doubt ABC would have allowed him to run his 20/20 segment if he had come out and sad that.
Does Stossel have a point? Should we be letting more of our senior citizens die? After all, there is the issue of that 34 trillion dollars mentioned above. (Some recent math I've done -- see comments -- informs me that that's enough money to give a million dollars to each of 34 million people. It's a lot of money, in other words.) Am I suggesting that all other considerations need to be put aside so that we can pay for every possible heroic medical intervention on behalf of terminal seniors?
I am not.
One of my favorite ideas about the future, and one of the most controversial ideas that we talk about here at The Speculist, is the notion that humanity might actually be improving morally. There is some evidence to suggest this might be the case, while (obviously) evidence that people are no damn good remains all too readily available. Putting the latter aside for a moment, it's been observed that people living today are much less likely to die at the hands of their fellow human beings than they were in earlier stages of human history. Horrifying atrocities of the past century notwithstanding, most of humanity has taken a sharp turn away from cruelty towards and mistreatment of our fellow humans.
Why is this happening? The turning point in making humanity better occurs each time we find it possible to stop regarding some segment of humanity as the Other. And it is technology that opens up these new possibilities.
50,000 years ago, when we were 10 or 20 times more likely to die by way of homicide than we are today, human beings lived in small highly self-sufficient family clans. There could be friendly interactions with the clan a couple miles up the river, or the one that showed up on a nearby hilltop one morning, but ultimately they were all the Other. The Other was a threat and needed to be treated as such in order for "humanity" -- that is, the clan -- to survive. Each group of a couple dozen or so people was essentially at war with the entire rest of the human race.
Then agriculture came along, opening up new possibilities. Human beings could now begin to see themselves as part of communities and eventually nations. The scope of the group with which we identified increased massively, from less than 30 to tens of thousands. The Other was still out there, in other communities and other nations, but interactions with these others were not as frequent. Life became more peaceful than it had been in the pre-agrarian past.
Let's jump ahead several thousand years.
In England, the end of the slave trade coincided with the dawn of the industrial revolution. The story of the Abolition movement that we're most familiar with tells us that public consciousness was raised by Enlightenment philosophy and Quaker activism. And that's true. But what set the stage for this awakening of the conscience? What made it all but inevitable? When machines began to provide a level of productivity that would never have been achieved via slave labor, England could afford to do the right thing. (That same basic conflict played out in a much more costly and tragic way 60 years later in the US Civil War fought between the industrialized Union and the agrarian slave-holding Confederacy.)
A pre-industrial society had fewer choices available to it than an industrial society. It saw fewer possibilities. It treated Africans as Others who were not truly human, but property to be used as needed, because there was no viable economic alternative. Industrialization presented the alternative and allowed English and then American society to hear the voices of conscience.
This tension between a world of possibility in which we can do the right thing and a world filled with Others in which we are constrained in terms of how good we can be has been with us all along, and is with us today. Let me be clear that I generally like John Stossel and I don't mean to pick on him. On the one hand, I don't want to be misunderstood as putting him in the same league as our murderous or slave-holding ancestors. On the other hand, I do want to point out that he is making use of a somewhat milder version of the their thought processes in order to make his argument more palatable.
Stossel doesn't like the idea of arguing that we should let old people die, so he finds another way to phrase it. And then to help make his case, he talks about greedy rich old people "feeling entitled" to things, and greedy old people in general taking six times as much government money as poor children. He talks about generational theft. What he's doing is casting seniors as the bad guys, which of course is one of our most familiar varieties of Other.
In fairness to Stossel, let's note that making someone out to be the Other in order to reduce empathy for that person (or group) does not originate with him, and is in fact a widespread practice. P J Manney points out that many of the technologies designed to bring people together which have skyrocketed in popularity over the past couple of years do little or nothing to increase empathy between the known and the Other, and in fact may work to make us less empathetic. One of the reasons I personally have become disenchanted with politics is that so much discourse related to it -- particularly on the web, but in other media as well -- has to do with caricaturing the opposing side, making them out to be as offensive and undeserving of empathy as possible. (This is hardly a new trend in American politics, but it seems that in the past there was a more clearly defined limit to the extent to which we would regard the opposition as the Other. At some point, we would fall back to we're all Americans, or we all want many of the same things, or we have many of the same values in common, or some other final acknowledgment of commonality. That seems to have been lost, and very much to our detriment.)
But Stossel is wrong to cast seniors as the Other. Seniors are our parents, our grandparents, and our friends. And all too soon, for those for whom it is not already true, they will be us. The answer to the problems he cites is not to start calculating how many seniors we should let die and steeling our resolve to do so by making them out to the bad guys.
The answer is to look for new possibilities enabled by new technologies. Aubrey de Grey tells us that there are seven basic biochemical problems -- engineering problems, as he likes to frame the situation -- which, if solved, would eliminate human aging as we know it. Eliminate aging and we do away with the pain and devastation that it causes directly, as well as the pain and devastation that it enables via accompanying diseases such as cancer, diabetes, and heart disease.
Eliminate aging and we do away with that long treacherous death march of people lining up for their last six months of life and all the expensive medical care that goes with it.
Eliminate aging and we slash that 34 trillion dollars mentioned above to a tiny fraction of that amount.
In fact -- and now I will go ahead and throw out an idea as to how money might be spent on caring for seniors -- that 34 trillion which would otherwise be spent ushering the Baby Boomers (and their elders) through their painful final six months might be put to better use. Let's add just one more trillion and make it 35: that would give us 5 trillion dollars in research money for each of Aubrey's seven engineering problems.
Call me a cockeyed optimist, but I think that would get us there, or at least get us pretty close.
But where do we get the money to pay for that, especially if while the research is being done we still have millions of seniors using Medicare for expensive, final-six-month treatments?
I don't know.
But I do know that if we're looking to have to come up with 34 trillion as it is, we might as well double down and truly solve the problem once and for all. We'll save about 40 million lives (that's the population of Americans aged 50 and up) in the short term, and well over 300 million lives in the long term -- and that's just in this country.
Even if we have to borrow or print the money to do it, down the road we could always put some kind of special tax on wage earners aged 100 and up to pay off the debt. After all, they promise to be some of the most highly skilled, productive, and best paid members of the future work force.
So rather than arguing to let people die, maybe John Stossel needs to do a truly transgressive segment on an upcoming 20/20:
America Needs to Cure Aging.
I think we'd all tune in to that one.
UPDATE II: Okay, gang, seriously. Some people think big government programs are a swell idea and should be better funded. Good for them. Others believe that taxation for social programs -- as well as most other things -- is a basic violation of our rights and needs to be eliminated. I'm very happy for them, too.
I do not take a position on that question. It is irrelevant to what I'm talking about.
I merely point out that changing payouts to the system as it currently exists will result in some people dying who otherwise would have lived. When I personalize the story, it's not to argue for one policy or another -- maybe Medicare should be made bigger; maybe it should be eliminated altogether; maybe having lots more people die is the only way to keep the program and our government solvent. I use it to point out the fallacy of trying to catch people in their final six months and and to back up the idea that seniors are anything but the Other.
Apparently, to some, Medicare is so intrinsically evil that it's wrong even to note that its dismantling may result in human suffering. One commenter turns me into a Medicare advocate simply because I noted that I'm glad my father is still alive! Guess what: I'd be equally glad had he been treated through private funds in a world where Medicare doesn't exist. And even if I were a pure libertarian 100% opposed to all federal programs, I'd still be glad to have my father alive even if his life was saved by Medicare.
Call me a freaking hypocrite.
A quick scan of this piece will show that I didn't come up with the 34 trillion figure. And my one and only certain statement as to how we could ever come up with that kind of money runs three words long: I don't know. But I know this: if the choice the current system presents us is "come up with 34 trillion bucks or let a bunch of old people die," then I would call that the quintessential "tough choice." In fact, I believe it would take a lot less money than that to make significant progress in extending human lifespan -- and, yes, that could come from private rather than public sources. Per Dave Gobel's comments, this isn't really a financial issue at all.
I do find it disheartening that so many are so eager to leap to a political debate that's getting plenty of airtime elsewhere, or fret that words are being put into poor John Stossel's mouth -- for crying out loud, the guy's whole shtick is to be this outspoken and somewhat obnoxious source of rough-edged, you-can't-handle-the-truth; stating the undeniable implications of one his arguments ought to at least be in line with the kind of stuff he does -- rather than be part of a discussion about how new possibilities might radically alter the situation for the better.