What’s Wrong with the World

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The Gordian Knot Untied

Shortly before I gave up entirely on the world, the flesh, and even the devil, I spent two years as an intern in the Department of Clinical Bioethics at the National Institutes of Health, where my immediate boss was Dr. Zeke Emanuel - one of the architects of Obamacare (and also, as it happens, a great guy - even if he does happen to have a brother named Rahm). So I've been around all this health-care policy stuff for more years than I care to remember. In fact, I've been around it for so long that I can hardly stand to think or talk or write or read about it anymore.

Which, I guess, is why I missed this absolutely terrific article by David Goldhill, published in last September's issue of The Atlantic. Big, big tip o' the hat to Stephen Spruiell, at The Corner, for bringing this to my attention. He quotes Goldhill:

"'I'm a Democrat, and have long been concerned about America's lack of a health safety net. But based on my own work experience, I also believe that unless we fix the problems at the foundation of our health system - largely problems of incentives - our reforms won't do much good, and may do harm. To achieve maximum coverage at acceptable cost with acceptable quality, health care will need to become subject to the same forces that have boosted efficiency and value throughout the economy. We will need to reduce, rather than expand the role of insurance; focus the government's role exclusively on things that only government can do...overcome our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and rely more on ourselves, the consumers, as the ultimate guarantors of good service, reasonable prices and sensible trade-offs between health-care spending and spending on all the other good things money can buy." [Emphasis added.]

Spruiell comments: "If you want one single statement summing up what conservatives' guiding principles on health care should be, that is it. And if you want to know why most conservatives that I know hated this bill, let me explain: It expands, rather than reduces, the role of insurance; widens the government's role to include things that the government shouldn't be doing...deepens our addiction to Ponzi-scheme financing, hidden subsidies, manipulated prices, and undisclosed results; and reduces the role of the consumer as guarantor of good service, reasonable prices, and sensible trade-offs."


Consider the point about insurance. Many conservatives, I think, have a reflexive tendency to defend the health insurance business against criticism - simply because it's a business, I guess. But, in its present form, it's a totally crazy, misbegotten horror of a business. Goldhill again:

"...health insurance is different from every other type of insurance. Health insurance is the primary payment mechanism not just for expenses that are unexpected and large, but for nearly all health-care expenses. We've become so used to health insurance that we don't realize how absurd that is. We can't imagine paying for gas wih our auto-insurance policy, or for our electric bills with our homeowners insurance, but we all assume that our regular checkups and dental cleanings will be covered at least partially by insurance. Most pregnancies are planned, and delieveries are predictable many months in advance, yet they're financed the same way we finance fixing a car after a wreck - through an insurance claim...

"Insurance is probably the most complex, costly, and distortional method of financing any activity; that's why it is otherwise used to fund only rare, unexpected, and large costs. Imagine sending your weekly grocery bill to an insurance clerk for review, and having the grocer reimbursed by the insurer to whom you've paid your share. An expensive and wasteful absurdity, no?"

Well, indeed. And Obamacare doubles down on such expensive and wasteful absurdity. Instead of reducing our dependence on insurance coverage for day-to-day expenses, with all the perverse incentives and moral hazard that entails, it forces millions more into the system.

Lunacy. Utter, hopeless lunacy.

It's hard to choose a favorite insight from Goldhill's article, but I particularly liked his damning discussion of hospitals and their malign political influence, including this refreshingly skeptical passage about "the oft-quoted 'statistic' that emergency-room care is the most expensive form of treatment." He writes:

"Has anyone who believes this ever actually been to an emergency room? My sister is an emergency-medicine physician; unlike most other specialists, ER docs usually work on scheduled shifts and are paid fixed salaries that place them in the lower ranks of physician compensation. The doctors and other workers are hardly underemployed: typically, ERs are unbelievably crowded. They have access to the facilities and equipment of the entire hospital, but require very few dedicated resources of their own. They benefit from the group buying power of the entire institution. No expensive art decorates the walls, and the waiting rooms resemble train-station waiting areas. So what exactly makes an ER more expensive than other forms of treatment?

"Perhaps its accounting. Since charity care, which is often performed in the ER, is one justification for hospitals' protected place in law and regulation, it's in hospitals' interest to shift costs from overhead and other parts of the hospital to the ER, so that the costs of charity care - the public service that hospitals are providing - will appear to be high. Hospitals certainly lose money on their ERs; after all, many of their customers pay nothing. But to argue that ERs are costly compared with other treatment options, hospitals need to claim expenses well beyond the marginal (or incremental) cost of serving ER patients."

I mean, whoah. Did I say damning? Or did I say damning?

Goldhill concludes his article with some eminently sensible practical suggestions, which he summarizes as follows:

"A more consumer-centered health-care system would not rely on a single form of financing for health-care purchases; it would make use of different sorts of financing for different elements of care - with routine care funded largely out of our incomes; major, predictable expenses (including much end-of-life care) funded by savings and credit; and massive, unpredictable expenses funded by insurance."

I'm not in love with all of the details of his plan (which includes individual mandates.) But there's just no doubt that his general approach would be infinitely preferable to the monstrosity that we all just got stuck with.

So RTWT, already.

It's a beginning.

Comments (22)

Excellent, Steve. Thanks.

I don't believe any human in the world is a "great guy."

I especially don't believe that any one who is lacking in something as simple as the Truth is near to being any thing great.

I don't think that any one who scorns God and his commandments can in the least way be called great.

So some jerk is personable? Big deal. Abortionists are personable. Hitler was personable. Julius Caesar was a great guy, who slaughtered, oh, 2-3 million people in Gaul and enslaved the rest, but Caesar was a brilliant and charming man.

People are such suckers and so thoroughly gullible; men are so easily fooled and impressed.

There isn't a person on the planet who isn't a teeming pile of scum and sinfulness, yet we call each other good at the drop of a hat. Lord, what fools these mortals be!

Mr. Butterworth: Zeke Emanuel is a great guy. And, by that, I don't just mean a "personable" guy.

I was there, you weren't. I knew him, you don't.

And the phrase "great guy" has a colloquial meaning. Why torture it?

Well, then Steve, exactly what makes him "great". Personable? Charming? Considerate? Charitable? Saint-like? Sympathetic? Healing? Generous, kind, compassionate, long suffering, witty, pleasing, wise, sagacious and so on.

Steve, I know that we pass on colloquial judgments of the most superficial kind about each other, and maybe that's part of the social grease that lubricates our various encounters, but I find most Christians and men to be far too weighted on the shallow side of things than the more penetrating view of our fellows and lives.

You see, I think Jesus of Nazareth set the standard for a great guy, in every sense of the word from colloquial to profound. That's the guy I'd prefer to hang around everyday; and all the men I've encountered in this life have never been people I'd want to hang around every day.

In fact, anybody whom I could never discuss the nature of God with seriously in any way, share something of faith in ultimate good, judgment, and truth is somebody I'd rather spend little time with regardless how superficially pleasant they were, otherwise.

Zeke Emanuel is a classic liberal do-gooder who believes that he and few others like him could overhaul the US health system at other people's expense and make it near perfect. He's against euthanasia Netherlands style yet refuses to acknowledge his health care system must inevitably lead to both rationing and de facto euthanasia a la Great Britain, and a deterioration in service that might make a third world nation blush.

As I said before, Emanuel is invincibly ignorant of Truth, no doubt a supporter of abortion for women (could not find direct quotes but he favors embryonic stem cell research and considers the fetus at various stages as having relative worth, and of no legal value of inviolability after conception until the cells begin to differentiate).

Emanuel maintains, I would conclude, a very modern Jewish regard for the unborn. That is, no particular regard.


In my experience with humanity and men, Steve, I often find that my regard for other men often takes a dip, no matter how personable and likable I find them, after I learn they are divorced, have no qualms about the murder of the unborn, believe the US Constitution isn't really worth the paper it's written on when it interferes with their visions and schemes for masses of people; that such men have no basic respect for wisdom in the ancients or the Bible.

Frankly, Steve, I have about as much respect for other men in accordance with their respect for ultimate otherness - God.

Steve, if you don't quite get the fact that human beings are steaming piles of crap, self-delusion, weakness, and sin - then what part of the encounter with holiness do you get?

Do you think Emanuel or Obama want to provide universal health care to every human on the planet because they are well intentioned, full of good will, and the milk of human kindness?

They have schemes for the good of everyone because they are thoroughly at odds with reality; they are distorted by the wounds of their childhood, and victims of an unconsciousness full sickness, distortion, calamity, fear, greed, need, compensation - a brood of vipers, so to speak.

The fact the Emanuel spends more time preaching than healing says a good deal in itself.

Mark --

I tend to operate under the assumption that I am the chief of the sinners, given that one of the truly greatest men said the same himself.

Steve wrote: I spent two years as an intern in the Department of Clinical Bioethics at the National Institutes of Health, where my immediate boss was Dr. Zeke Emanuel

So Steve knew this man on more than just a personal level, but from the perspective of someone under his authority. The colloquialism he used tends to suggest some excellence in professionalism, collegiality, justice -- the sort of thing that makes one compliment one's former boss. That's just speculation on my part.

Philippians 2:3

Let nothing be done through contention, neither by vain glory: but in humility, let each esteem others better than themselves:

Translation: "... let each esteem others better steaming piles of crap, scum, and sinfulness than themselves."

Mark, have you converted to the religion of John Calvin?


I well understand that we find people in this world we admire for such reasons are you cite and which I listed, too. But this is superficial. Steve doesn't "know" Zeke Emanuel any more than he knows me or you. He's seen a personality or even a character, and that's about it.

Yes, I'm probably being peevish (as Samuel Johnson would be). Lately, I've become fed up to here (hand up to my forehead) with the infinite shallowness of humanity in action and perception.

And for all of Dr. Zeke's apparent good qualities, how does that alter the fact that Emanuel is a creep who places no more value on an unborn child than I do when stepping on an ant?


Paul was referring, of course, to Christians among Christians. He was not so charitable towards pagans except that he hoped to persuade them of the Truth.

I don't know about Calvin, but I know what Jesus said about scribes and pharisees, whitewashed tombs, woe to a bunch of folks.

I'm all for an irenic countenance as we pass through life treating other people well, but I see no reason to buy into a bunch of BS that other people have bought into.

I know a lot of people (most people) whom I think are better than me in numerous and fundamental aspects as they maneuver their way through life. I think most soldiers by dint of their service under authority and near possibility of loss of life or limbs are better than me - nurses, doctors, EMTs, police and so on.

I think most people who toil hard are better than me.

But then I hear about my really, great guy of a neighbor who's arrested for having child porn of his computer; or the cops on the take, nurses who pilfer supplies and drugs, doctors who perform abortions, and on and on.

Then I think, there but for the grace of God, go I.

And I think, people are fools if they really think they know other people. Heck, I can't even say I know my wife or daughter as much as I'd like to.

How much cant, facile illusions, and daily BS are we expected to pay heed and lip service to?

Shouldn't Christians be iconoclasts? If were not being treated like a**holes by non-believers, aren't we doing something wrong, to some extent?

I'm not saying we should be rude or obnoxious, but there should be some steel in our mien. Steel sharpens steel. And there should be a hardness, a determination to stand against the world and all its delusions.

The church and the Republican party is full of "nice" guys and look where that's gotten us?

"They will know we are Christians by our love." Love for each other. Not love for the world and all the engaging distractions in it, nor affection for its many fools.

The Amish do not preserve their faith and culture by going along to get along. They do it by being hard hearted towards those that reject their faith and ways. They shun.

But all in all, they lead rich lives, better lives than we do (in all likelihood). Maybe, its atavistic and somewhat parasitical, but it appears a bit more real, too.

Let me rephrase a previous statement, If you look inside anybody closely, see their inmost motivations, raw emotion, natural reactions, learned responses, desires, despair, pride, and so on - you will see someone struggling in a sea of steaming crap, scum, and sinfulness notwithstanding the occasional oasis of goodness, sincerity, and joy.

And finally, why are so few of us bored with the world? So much of what surrounds and engages us is immeasurably trite, childish, foolish, thin, contrived, vapid, thrill seeking.

When are we ever going to be serious enough to know what real delight, foolishness, pleasure, and excellence is?

Ah, well, this world is what is -- one temptation after another and human failure on a grand scale.

Jeph Jacques

"What's the point of havin' a rapier wit if I can't use it to stab people?"

Not that I am witty, as I'm certain others find me a mere scold.

But to continue one thought about how boring the world is.

Since civilization began some 15,000 years or so ago, I can put on a single, five foot bookshelf all the greatest books, and on another shelf, all the greatest music on CDs, and on a short shelf, a few books containing pictures of the greatest art and architecture.

Since 15,000 years ago, maybe a couple hundred billion people have lived; and all we have to show for it in terms of humanity's profound creative output is a single shelf of literature or music.

Why isn't every book I pick up not as fine as the Bible, Homer, Shakespeare, Plato, or Dante?

I'm serious. Billions upon billions of people have produced jack s**t.

Out of at lest a hundred billion people, humanity has produced mere handfuls. Truly, just handfuls of indispensable books from a dozen or two or three.

Does that not boggle the mind?

What does this mean? It means that almost no one in all of human history ever plumbed the depths of their being and that of Nature's God to return with an account that is immemorially worthwhile.

Billions and billions and billions of stars and only one fertile Earth.

Since Adam, the things you are looking for cannot and shall not be done. Our best falls inevitably short. In the end, therefore, the great works of art are not the things we make, but the things God makes of us.

Look, I think it's not a good idea for the thread to be about Emanuel. I got hold of the paper about "not guaranteeing healthcare" to people with dementia, and the quotation wasn't taken out of context. I read the article about assisted suicide, and I could not disagree with him more profoundly. To me he looks like one of the relatively more humane of the mainstream type of bioethicists. That he should have been a great guy in some non-trivial sense when Steve knew him is highly plausible, but that doesn't mean that he and I live anywhere on the same side of the ethical universe.

However, I think that should be ignored for the sake of this post, which *is about what should be the conservative response to criticisms of the healthcare system*. The comment about Emmanuel was in passing. This post puts on this blog site something that hasn't been here before in any detail (because I've been too discouraged about the whole topic)--namely, a free-market statement about what's going on here. As I've said repeatedly on other threads, the two approaches to what is wrong and how we should fix it (the one we got and this one) are totally incompatible. This one is by far the economically wiser.


I read and loved that article when it came out and made sure my liberal wife read it carefully so she would have at least some appreciation for how ridiculous it was to claim that Obamacare was an attempt to "reform" our current healthcare system.

I also want to echo what Lydia says above -- she has in fact repeatedly made the case in other posts (and she's not even a highly paid "Atlantic Monthly" journalist!) that transforming healthcare into more of a true consumer market should have profound effects on bringing down costs and transforming the efficiency of the healthcare market. This will then allow more Americans to afford reasonable care and at the same time allow us to help subsidize care for the truly needy. I should also note somewhat mischievously, that these types of reforms are also what David Frum called for in his book Comeback (I think the book was read by me and three other fans) and what the excellent scholar David Gratzer has written about in his books and articles:


If you want sensible ideas on how to move forward with respect to healthcare reform you should be reading everything written by Dr. Gratzer.

Steve, when that article came out I printed a copy and brought it to my House representative's (Tom Perriello (D), VA-5) "town hall" meeting back when the Senate was writing the original bill last Fall. I waited in line for 4 hours and then handed it to him personally; he said he'd read it, and said it made some good points.

Fast forward to last Sunday, and Perriello votes for the health care reform bill that doesn't actually reform health care.

More information won't help these misguided politicos.

Steve and gang,

More on markets and health care from one of the greatest living economists today, Gary Becker:


Jeff Singer, my heart is the higher for seeing you and Steve discussing these things here.

Mr. Butterworth: I suspect that you, too, are, in your own way, what I would call "a great guy."

But enough, already.

Albert - well, ain't it the truth?

This isn't a struggle for "information." It's a struggle for power.

Jeff Singer - oh, for heaven's sake. You mean I have to read some *more* about this infinitely tedious & depressing topic?

When I *could* be comparing recordings of Così fan tutte?


Okay, to the article. I read most of it awhile back. I sympathized, but noticed that the author woke up as most people do to the condition of our health care all at once.

What killed his father was complacency and laziness. There is a system in place in a few clinics and hospitals today where sensors "sniff" the hands of doctors and nurses regularly to see if they've used the alcohol based hand cleaners. Infections in hospitals where the system has been installed has gone down to 0%.

As for his recommendations, yeah sure, except the debate is over. He and we lost and here comes rationing, death panels, and negligence on a third world level. Give it time.

You will not reverse the flow, turn the tide of what the Dems have done. Repeal it? Not a chance. Starve it of funds? Possibly, but unlikely.

We have lost our country, but we lost it long ago when the Capitalists were free to import all the cheap labor they wanted to make themselves filthy rich; and then the immigrants and "progressive" do-gooders decided America was unfit for loyalty and decided to organize its end and destruction.

At the end of the Western Roman Empire, a highly specialized and complex society fought the barbarians at the frontier by paying taxes for mercenary Roman armies to defend them. Continually weakened by civil war over who would be the next emperor, the State could either fight the barbarians or fight to establish an emperor for awhile. It couldn't do both.

Thus, provinces were whittled away, and the taxes used to pay armies lost. No taxes, no armies, more whittling until cities and towns were forced to take up arms (which were long banned from them having) to defend themselves.

It wasn't enough. Too little, too late did the citizens muster a militia.

It's too late to save the United States, but it's not too late to save a couple of states, the ice states where no one lives.

I'm old enough where I will see the decay of this nation into something like England but not have to long endure it. But most of you will see your wages, lifestyle, property plummet in value like my daughter will.

The time for planning the next American Revolution is now. You must reconcile yourselves to the use of violence as the possible outcome of intrepid defiance of a Fed Govt. at a State level.

People, you have been and will continue to be raped. You ought to fight, really fight and be thoroughly hateful just as the North considered the Southern patriots to be.

And Steve, if you like dynamic, impressive people like Zeke Emanuel, I guarantee you would not think me a "great guy". You wouldn't give the time of day to a schlub such as I. You might, at best, find me a pleasant enough chap, but a real nothing and nobody. I would leave no impression on you.

Every other day I go to the dog park with my German Shepherds and pass the time talking to other people about dogs - their dogs, my dogs, the nature of dogs. And we fill the air with our BS because BS is the only thing we have enough of in common with each other.

We are as motley a crew as the pack of dogs that sniff, run around, wrestle, challenge, assert, aggress, retreat, slink, and so on.

We might as well be ants for all nothingness or pride we have in common. This is why everyone hates reading Ecclesiates.

Ever notice that there is only one activity of a man that is not shredded to bits by the Preacher? The activity of prayer that unites a man to God. That is the only thing that is not found to be vain.

Also, I reread Lamentations the other day. I recommend y'all familiarize yourselves with it. That is the song of the day, and the days to come.

Lamentations 1

1 How doth the city sit solitary, that was full of people! how is she become as a widow! she that was great among the nations, and princess among the provinces, how is she become tributary!

2 She weepeth sore in the night, and her tears are on her cheeks: among all her lovers she hath none to comfort her: all her friends have dealt treacherously with her, they are become her enemies.

3 Judah is gone into captivity because of affliction, and because of great servitude: she dwelleth among the heathen, she findeth no rest: all her persecutors overtook her between the straits.

4 The ways of Zion do mourn, because none come to the solemn feasts: all her gates are desolate: her priests sigh, her virgins are afflicted, and she is in bitterness.

5 Her adversaries are the chief, her enemies prosper; for the LORD hath afflicted her for the multitude of her transgressions: her children are gone into captivity before the enemy.


I appreciate the sentiment, and agree with the gist of it. We are meant to become great more than make great things, but the two go hand in hand. As we ascend in understanding, so too, both our practice of virtue and the works of our hands, hearts, and minds ought to equally improve. A devout tailor would not foist an ill fitting suit on a customer, would he?

I am an artist as a man as I am a disciple of Jesus. His excellence, must become my excellence. His brilliance in storytelling should eventually be mine, also, if he has built his home in me. My mind is a portion of God's mind, His beauty is that which I must recreate, so to speak.

I would amend your statement: In the end, great works of art are not our purpose, but what God makes of us so that when we turn to make art our works are indeed, great.

Does that seem fair to you?

It's too late to save the United States, but it's not too late to save a couple of states, the ice states where no one lives.

I'm old enough where I will see the decay of this nation into something like England but not have to long endure it. But most of you will see your wages, lifestyle, property plummet in value like my daughter will.

The time for planning the next American Revolution is now. You must reconcile yourselves to the use of violence as the possible outcome of intrepid defiance of a Fed Govt. at a State level.

Mark, I am with you. Which states, when how?

You forgot: we also need to prepare to become martyrs. While it may not be widespread, it will be exactly that battle for some of us. Woe to we who have not prepared.

Mark, Tony - oh, for heaven's sake. This hysterical talk about "the use of violence" is just ridiculous.

Shame on both of you.

I put up a perfectly sensible post on a perfectly sensible essay on what's wrong with Obamacare, and how things could be done better, and it ends in this?



Put down your Così fan tutte recordings for just a couple more minutes and read this brilliant post on the financial unsustainability of the recently passed healthcare bill which will somehow save the U.S. money if you listen to Obama and the Democrats:


The example of how medium sized firms will dump their employee coverage, pay the new "fines", and leave the government with the tab because it makes perfect economic sense is just so clear-headed that it is tragic that a single U.S. Congressman voted for this ridiculous legislation. The costs of this bill will be enormous and we will all pay via higher taxes unless the bill is repealed.

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