From the Impossible to the Inevitable

By John Ballard

This post has two bullet points.

?The focus of health care in America is changing from longevity to quality of life.

?Watch for unexpected abrupt reversals in the political landscape.

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Matthew Holt, blogmaster of The Health Care Blog, published the transcript of an interview he did with Victor Fuchs, Henry J. Kaiser Professor Emeritus at Stanford University. The complete interview and comments that follow are essential reading for anyone following the health care debate so I have no intention of parsing the whole content. Two big points, however, stuck in my mind and are worth passing along.

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First, Dr. Fuchs mentions two demographic transitions with important implications for both health care and social security. The first transition involves adjustments to population growth when fertility and mortality rates become, can we say "out of balance." High fertility rates clearly parallel high mortality rates, so when mortality rates fall if fertility rates don't follow the result is overpopulation relative to resources available.

...the high fertility made sense when mortality was high because you wanted to have at least a couple of children survive to adulthood, but when mortality dropped it didn�t sink into people�s consciousness right away, so it took quite a bit of period which the historians and the demographers referred to as the demographic transition...

This demographic transition leads to a second with serious implications for the future: a growing number of old people relative to the number of those caring for them..

...a very large and increasingly large percentage of the population cohort lives until age 65, whereas at the beginning of the 20th century only a small percentage lived until 65. Now we�re going to 80% and we�ll eventually approach close to a 100% living till 65.

... life expectancy at 65 is increasing and it�s increasing at a quite brisk pace in recent decades. You put those two things together and you find out a very large and growing percentage of all the additional years that are lived if you have increasing life expectancy will be lived after 65.

The beginning of the 20th Century only about 20% or not even 20% of the additional years were lived after 65. Now we�re getting to a point where close to 80% of the additional years are being lived after 65. Now that�s very important because the conditions of people over 65 are very different from the ones under 65.

Rather than belabor the point, the implications of which by now should be clear, I want underscore a larger observation with broad political implications for this year and the next decade.

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Next,  Dr. Fuchs mentioned in passing an American political habit observed by De Tocqueville more than a century ago, a quality that inspired the title to this post.  

...the United States moves from the impossible to the inevitable without ever stopping at the probable.

Another way to put this is that American history is studded with examples of major policy changes that were completely off the radar screen, they were politically infeasible until they became politically possible ...two examples...the emancipation of the slaves. No way that that was going to happen and then suddenly it did happen and the slaves were emancipated. [and] a much more recent example, $1 trillion to bail out the major financial institutions.

...six months before that, no possibility; that was not politically feasible, then in a matter of three weeks the whole thing turned around and it became politically feasible.

So, what I�m saying is that I am trying to weigh out what I think is the best way to go, but the mechanism by which we get there will not be sort of painful, long drawn out discussions, but it�ll be response to a crisis and suddenly everybody; both houses, the President and everybody will realize that they have to do something substantial and they�ll do it and my hope is that they�ll do something sensible. But you see the two examples that I gave illustrate the way my thinking runs on how you get major policy change in America.

The interesting thing is that the De Tocqueville realized that 100 years ago and that was already true in the country. You go from the impossible to the inevitable without ever stopping at the probable.

This is a very keen observation. American politics, being more reactive than proactive, muddles along pretty well as long as the road is not too bumpy, but like the proverbial frog in water being brought to a boil, American politics is at it's most decisive in crisis mode. Maggie Mahar adds another example in the comments of how attitudes about smoking have reversed.

[Note the] sea-change in American attitudes toward smoking. There was a time when no one believed that Americans would give up tobacco, even though it was widely known it is bad for your health--say in the early and mid 1960s. Then, rather suddenly, it became socially unacceptable to smoke, at least among college students, as well as many middle-class and upper-middle class adults. (Though of course we still need to address smoking as a health problem for lower income people--but at least Medicare is now paying for smoking cessation.)

Regarding healthcare I remain optimistic for a grim reason:like the frog in the water, if we don't jump soon and high Americans will be boiled alive in a fee-for-service/insurance and drug larded/profits before outcomes train wreck which will leave the nitwits in Washington with only two options: clean up the train wreck or watch the population of Medicaid become a financial malignancy beyond recovery.

At the end of the interview Matthew Holt carefully frames the sixty-four dollar question:

We�re at about a little over 17% of GDP at the moment, a number that will obviously tick up the worse the recession stays, because health spending is still exceeding the growth of the GDP... and we�re going into double dip recession at the moment and we are having more money coming into the system via the Affordable Care Act and more people coming into the system...[H]ow much more can the economy sustain of increased health spending before the moment is right where that crisis will hit?

Dr. Fuchs didn't take the bait and neither would I.

Everybody and his brother argued until they were blue in the face during the so-called "debate" producing the poorly titled Affordable Care Act. With all other realities set aside the one that will not vanish is that health care costs are unsustainable. Unless and until those costs are brought under control we can expect that the US economy will collapse in a national economic disaster which will make the credit/housing/whatever bubbles look trivial. 

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Backing away from health care we can see a larger political picture taking shape.

It is fair to say that the election of Barack Obama is turning out to be historic in more ways than anyone could have predicted during the campaign. Those of us who enthusiastically contributed to his selection, rejoicing with tears of joy as we watched that family walk out to greet that crowd at Grant Field in Chicago, had no way of knowing how much he would compromise the dreams that had animated our enthusiasm. And even his worst critics could not have crafted a worse scenario than the threat of a global financial meltdown that loomed between then and his inauguration a few weeks later. By inauguration day he had already governed as chief-executive-elect, orchestrating a bi-partisan crisis response not unlike the other two examples mentioned above (emancipation of slaves and the social snubbing of smoking).

Dr. Fuchs was correct. That whiplash moment, not unique in our history, changed the political dynamic overnight. Republicans, already supercharged by Limbaugh's famous "I want him to FAIL" remark, took advantage of the moment to  crystallize as a Party of No. Since that defining moment a flood of irrational behavior has washed over the American public. Millions of citizens have awakened from a lifetime of political indifference to express whatever frustrations afflict them in the latter-day activism of the Tea Party groups. 

The Citizens United decision by the Roberts Court has released unprecedented amounts of money at a time when the Census mandates redistricting at the state level, a time when whatever party is in control of state legislatures all over the country gets to redraw the electoral map to favor themselves for the next ten years when another census will set the same exercise in motion once again. NPR looked closely at that phenomenon this morning.

Meantime, all the pieces are in place that make midterm elections look like something worse than a Republican victory. Party faithfuls from both parties tremble (and obfuscate) as voters embrace nut cases previously dismissed as caricatures now running for elected office. This fall's elections promise to be among the craziest in modern memory.

I want to make some sage point but nothing comes to mind. Every day brings yet another piece of madness and/or disappointment. The only bright spot I see is that  when the dust settles after the election a lot of newly-elected officials with little or no political experience are in for the shock of their lives. Unfortunately, I have every confidence that it won't take long for influential power-brokers with money and agendas, those responsible for getting them elected, won't take long whipping them into line.