The murmur of the snarkmatrix…

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Catastrophic Thinking

I remember years ago, when I was dating a girl, getting into a conversation with her cantankerous grandfather about health care. He was a remarkable man – had been a principal in Detroit public high schools for years, and had seen a lot.

Anyways, to Mr Anderson, it was simple. All you had to do was take care of people when something really terrible happened to them. He would tell a story about watching someone fall down and crack his head open on the sidewalk. He and a few other strangers picked the man up and carried him to the hospital a block away. “Nobody asked or worried if he could pay,” he said. “They just saved his life and sent him home.”

That’s some people’s idea of health care — the nurses and doctors in the ER patching you up, so you don’t bleed to death in the street. This is usually because they’ve never gone for a prenatal visit or vaccinations, and they think routine screenings are a waste of time. They don’t ask their doctos about suspicious moles, or what they should be eating, or if they’ve started to have some trouble making it all the way to the bathroom.

This was me, too, not long ago. I once had to go to the emergency room for a terrible nosebleed that wouldn’t stop on its own. I later joked to friends, “I only go to see the doctor exactly when I’m bleeding from an important part of my body for more than a few hours.”

This kind of thinking comes particularly naturally to young men, where they’ve stupidly been told to hide their pain (emotion, too) and to valorize athletes and movie characters who play through pain. The only time you’re allowed to cry is when you’re watching the end of The Natural — not because the main character is slowly bleeding to death, but because he hit a home run anyways.

We’re dumbasses, really. But there are a lot of us.

Anyways, the resident young guy at the NYT op-ed page, Ross Douthat, floats an idea — universal catastrophic health care coverage — that could be kind of a good one, or a totally dumbass one, depending on how it breaks. I’m suspicious, however, that Douthat’s preferred implementation probably leans dumbass.

See, it’s all in the details. If “catastrophe” is defined as health care costs exceeding a defined percentage of one’s income in a calendar year, it plays one way. I’m actually kinda sympathetic to this, although I see problems.

If, however, it’s defined as coverage for really bad things that happen to you, as opposed to “routine” care, that’s actually really problematic. Because – and I think, as someone who’s recently had a catastrophic health care condition, I can say this – catastrophic care and routine care are completely interdependent.

Here’s how it works, in both directions.

Routine care prevents catastrophes from happening. Or, it catches them before they become hard and expensive to treat. I think this is relatively well-understood, so I’m not going to say as much about it.

Catastrophic care demands routine follow-ups. After you’re diagnosed with AIDS, or cancer, you need to meet with your doctor regularly and take steps to stave off infections. After you break your arm and leg, you need extensive physical therapy before you can work (or walk) again. After a C-section delivery, both mom and baby need regular check-ups. That’s most of what your health care is after something major — just people checking up on you, to make sure that whatever they did to put you back together again took, and that you’re not going to get swooped up by something else while you’re vulnerable.

That, and you take a lot of pills. Which usually counts as “routine care” even if your pills are keeping your skin from turning inside out.

I forgot to finish my almost-grandpa-in-law’s story. Later, he asked about the guy with the cracked skull that he’d brought to the hospital. About a week after he was released, he caught pneumonia and died. “After all that, he couldn’t take care of himself,” Mr Anderson sniffed, sad and disgusted, wise and blind, all the same time.

Now, go read Malcolm Gladwell’s “Million Dollar Murray,” and then tell me whether Douthat makes any sense, for anyone other than himself and guys like him.


This article, as well as the ‘Million Dollare Murray’ article, have made me really sad for some reason! Well, I guess it’s not super cheerful stuff but it really seems like there is not muchhope for us humans out there…

Good story, and your bold epigrams about the dichotomies of care (“Cat­a­strophic care demands rou­tine follow-ups.“) are extremely well put and could use repeating.

I do think part of the problem with Douthat’s proposal is that it’s not a proposal, it’s rhetoric; in his rhetorical deployment of seeming synonyms (everyday, routine) we get lost in the difference between ordinary and frequent. The mud created by willful confusing the time/frequency domain and the intensity/rarity/dangerousness domain ruins the piece.

The Gladwell article seems very interesting, but in a slightly different vein. It speaks of a conceptual confusion that’s less willfull. Your prospective in-law’s perspective seemed to have a specific world view valuing self-sufficiency and toughness, and blind to the physicality of chronic illness or addiction. That seems very much a matter of culture, philosophy, and social mores to me. Other cultural viewpoints have different values, different blind spots. Gladwell points out more fundamental, quantitative cognitive deficiencies—ways we humans are all bad at grasping large scale phenomna. I’m not sure there’s any society that has successfully incorporated multi-scale numeric thinking into all layers of its aesthetics and philosophies. And I say that as someone in a religious tradition that is slightly obsessed orders of magnitude.

Tim Carmody says…

I think the common thing that both Laura’s grandpa and critics of the Las Vegas homeless program need to get over is the ethos of rugged individualism and just deserts, barely leavened by a carefully circumscribed sense of charity.

That’s what many, many Americans need to get over – the notion that if you don’t have health care, it’s either because you didn’t want it or couldn’t earn it, and that either way, you deserve what you get.

The numbers, for Gladwell, are a way to outflank this ethos. But it’s too hard. That’s why the politics of an apartment for Murray don’t work – even if the utilitarian calculus works, the ethical optics fail.

“The ethical optics fail.” Sadly awesome clause.

Since I posted that comment, I’ve mentioned the article to a number of people, some of whom remember it when it came out, and the common reaction (among my rather lefty set) is that the problem it highlights is the conservative notion that “you deserve what you get.” Maybe that’s true, and I was misreading the article as more neutrally directed at everyone, including those (like me and my friends) who tend to eschew such a sensibility. What struck me about the article was that even for people who maximally valued compassion, many conventional systems were in fact less compassionate than they appeared–not just ethical optics, but really deep conceptual optics.

Tim says…

Well, as Gladwell mentions in the article, the Murray solution also is pretty rough on liberal/progressive ethics too, especially regarding universality. We can’t give every chronically homeless person an apartment; it’s hard for liberals to give themselves over to the utilitarian calculus that says “if we can do something about only the toughest cases, then we’re really doing something.”

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