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Thoughts from the Frontline

The Road to a New Medical Order

October 5, 2013

There is no doubt that the single most contentious topic I can bring up in a small group discussion or speech is the Affordable Care Act, otherwise known as Obamacare. You can feel the tension rise, as everyone has an opinion they want to express – most of them based essentially on preconceived philosophical positions, nearly all of which can be can seen through their own eyes as reasonable and consistent with civilized behavior. And the facts that can be trotted out to support their positions, pro and con, could fill up a document almost as long as the original 2,300+ page bill. I have avoided writing about the Affordable Care Act (ACA) for a variety of reasons but primarily because it is so difficult for us to get our heads around the economic implications.

Today I will try, though some of my readers may conclude that I have failed, to avoid coming to political conclusions about the ACA. Instead, I will aim to dwell simply on the economic ramifications of the implementation of the bill as it exists today. We are changing the plumbing on 17.9% of the US GDP in profound ways. Many, if not most, of the changes are absolutely necessary.

This letter has grown out of a rather lengthy, ongoing conversation I have had with my very close friend and personal doctor, Mike Roizen, about his perceptions of changes that his institution, the Cleveland Clinic, and others like it have to make concerning the delivery of medicine in the near future, and the Clinic's expectations regarding the income they will receive for providing their services. The Cleveland Clinic is one of the largest and most respected hospital groups in the world (heck, Obama and Romney even cited it in their first debate as an institution providing great care very efficiently – the only institution so cited). The Clinic has 43,000 employees and a healthcare budget of over $6 billion. Looking at the future budget considerations of the Cleveland Clinic and similar institutions outlined below, there is both reason to be both optimistic and reason to be deeply concerned about the changes that are coming to US society in the immediate future.

I asked Mike if he would be willing to provide me with some notes concerning the future of healthcare in our nation and the Clinic's own future. He kindly obliged, and I have edited and expanded upon what he wrote and shared with me in our conversations. This following should not be read as a policy statement or an official analysis from the Cleveland Clinic itself; instead, it is an essay that grew out of an exchange between two friends, a doctor and an economist, trying to make sense of how things will change.

For those not familiar with Mike, he is quite the medical celebrity. He is an anesthesiologist and an internist, an award-winning author, and the chief wellness officer of the Cleveland Clinic. He has completed a tour of duty in the US Public Health Service and has written more than 170 peer-reviewed papers and 100 medical chapters, filed 14 US patents, started 12 companies, served on Food and Drug Administration (FDA) advisory committees as a committee member or as a consultant to them for 16 years, and chaired an FDA advisory committee. He also co-invented a drug that is now FDA-approved.

He first became famous for developing the RealAge concept and has authored or coauthored five number-one New York Times best sellers, including RealAge and three titles in the YOU series, with Dr. Mehmet Oz. Possibly, he is best-known for being Oprah’s doctor. He has been praised for encouraginge Americans to exercise, eat healthier, manage stress, and live healthier lives. He has been an outspoken critic of politicians who use healthcare funds for other purposes, and particularly of states’ taking tobacco settlement money and using it wrongly for projects in no way related to tobacco prevention programs. Besides advocating for a healthier lifestyle today, Dr. Roizen has controversially speculated that by 2023 one of the 14 areas of aging research might see a breakthrough that will allow us to live until 160 with the same quality of life we enjoyed at age 45.

Mike wants to be sure you know that we are talking here about what may happens to hospital systems similar in size to the Cleveland Clinic. The views he expressed in preparation for this letter are his and his alone and are not necessarily reflective of anyone else's at the Cleveland Clinic.

This letter is somewhat longer than usual, but I was simply not willing to break it up into two letters. It was written to be read as one essay, and this topic is too important and timely to serve up by halves. I think you will find the conclusion thought-provoking, as we come at this issue from a bit of a different angle than you normally encounter. Mike and I welcome your comments and will read them and perhaps do a follow-up letter with our responses.

The Road to a New Medical Order

We want to make something very clear right at the beginning. The US healthcare system as it stands is dysfunctional and can no longer continue as it currently operates. With or without Obamacare, profound change is required to deal with the dysfunctionality, and that change will happen, one way or another. Obamacare is simply one method for “encouraging” that necessary change.

The US currently…

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Peter J Taylor

Oct. 18, 2013, 9:55 a.m.

As a mere Brit, I was intrigued by the process of charging for care provided by the Cleveland Clinic, which is presumably typical. It does look weird and wonderful that only one third of the invoiced charges are actually received.
In order to receive annual revenues of $6 billion the clinic triples its invoices to $18 billion, because it knows that medicaid will only pay 18% of the invoice, Medicare 23% and private insurers 38%. With Obamacare fewer people will have private insurance, so 76% of the invoiced amounts will remain unpaid instead of the present 67%.
Surely they could maintain their $6 billion revenue by inflating their invoices from $18 billion to $24.5 billion, to take into account the higher discount (or default) rate.
John, you admit “The US healthcare system as it stands is dysfunctional and can no longer continue as it currently operates. With or without Obamacare, profound change is required to deal with the dysfunctionality, and that change will happen, one way or another.” But you suggest no alternative to Obamacare. Surely critics of it, like you and Ron Paul, need an alternative plan, instead of just rubbishing Obamacare. As you imply, an increase in US healthcare costs from 17.9% to 22% is not sustainable.

Ronald Nimmo

Oct. 12, 2013, 6:56 a.m.

“Thus, instead of having the patient seen by any one of five different physicians – a family practictioner, internist, pain management specialist, spine specialist in medicine, or spine specialist in orthopedic or neurosurgery surgery – those patients will now all go to a physical/occupational therapist who will teach them how to do exercises progressively and if possible put a system on their smartphone that will alert them every four hours to do the exercises.”

The problem with this approach is that if a patient has a more serious back problem, doing physical therapy without an MRI or spine specialist consultation will result in aggravating , possibly with severe damage, the underlying condition. This example does not illustrate a personal demand for “concierge care” but exemplifies why non-medical personnel (like John Mauldin) should not be making medical decisions.      Aside from the personal tragedies involved, the people who are victimized by this kind of shortcut will require treatment that is much more expensive than if the proper medical procedures had been followed in the first place.

Michael Gorback

Oct. 10, 2013, 7:35 a.m.

The fastest and most dramatic decrease in health care costs would be achieved by making health insurance illegal. That is not a socially acceptable solution but any solution that - like insurance - disconnects people from cost will fail to control costs. The patient MUST have skin in the game.

One of the problems you’ll see with Obamacare is that for certain income levels the premium is capped by the subsidy. If your premium is $1,000/yr no matter what, why would you shop around for a good price? Gotta have skin in the game!

I wonder how Dr. Roizen will feel when he blows out a disk and has excruciating pain that will be managed by a low-level provider for 3-6 weeks with only anti-inflammatory medication and PT. I suspect he will go outside of the loop.

The article fails to address the hideous markups on medication and equipment. The ACA exacerbates this by putting a tax on medical equipment.

When they passed Medicare Part D they should have enacted price controls as part of the legislation. Part D was a huge gift to Big Pharma. When I ran out of BP meds in Italy I paid $30 for a supply of medication would have been $100 here in the US. Drugs in Europe cost far less because the governments of those socialized systems negotiate prices. If you want to sell your drugs in Canada or Sweden you negotiate price with the government. Congress could have told the drug makers, “Your product can be included in the Part D formulary if you will sell it at this price. Otherwise, you will be excluded from this market”. Is anyone surprised that didn’t happen given the influence of Pharma lobbyists?

Finally, I’d like to point out that any system that pays a doctor the same whether s/he does something or not is clueless about human nature. If you think a system where doctors are paid to do things is bad, wait til you see a system where they’re paid NOT to do something. It’s called an ACO and it’s coming soon.

Rob Caire

Oct. 10, 2013, 7:07 a.m.

John,
As you state in the article, 70% of health care costs are related to chronic diseases. And it’s scientifically proven that chronic disease can be prevented and in many instances reversed with a healthy lifestyle. This has been proven in a 20 year study by Cleveland Clinic’s own Dr. Caldwell Esselstyn. As a country we are fighting about health care to treat illness when we should all be screaming about prevention of illness.
Just take a look at the farm bill to see how our government subsidizes meat, dairy, grain production, and sugar to the detriment of our health. In many instances farmers are paid to leave their land fallow versus growing health giving fruits(including berries) and vegetables. We make it uneconomical for farmers to grow anything other than corn, soybeans and wheat – the foundations of processed foods and now the unnatural feed forced on factory farmed cows, chickens and farm raised fish. The standard American diet (SAD) has resulted in the highest levels of chronic disease and obesity in the world, and you can see that impact happening in other countries as our diet gets exported. The government has created a subsidy system which creates cheap, high calorie, low nutrition food to the benefit of chemical and pharmaceutical companies who spend huge dollars influencing our supposed ‘representatives’ for their profit and to the detriment of our health.
You express concern about how long it will take people to change their lifestyle habits to be healthier, but it won’t happen without subsidy changes. In surveys people admit they know fast food and processed foods are bad for them but they eat based on convenience and low cost. If we flipped the subisidies to have fruits and vegetables be cheaper than processed foods, people would be incented to make different choices. New York has a program where doctors are “prescribing “ fruits and vegetables and people receive vouchers to use at local farmer’s markets. It is having a positive impact on the health of people taking advantage of the program.
Additionally, healthy people are now being forced through ACA to cover many people who have made poor lifestyle choices and now are sick. Again this is up to 70% of the occurrences – so do not blast me for being heartless as I realize some illness is genetic and needs to be considered in the equation. Lately healthcare is referenced as a human right. This is not true. Healthcare is a service provided by others – access to a service is not a human right. Our rights include life, liberty, the pursuit of happiness and the right to make good or bad decisions. A person should lose their right to make poor decisions when others are required to bear the cost of those decisions. But instead our politicians look for more ways to make people dependent on the government rather than expecting accountability.
I know you and Pat have great hope for transformational technologies in this area. I have followed the Biotime story and know the marketing around Anatabloc and its impact on inflammation (and inflammation is the root cause of all chronic disease). Yet it is scientifically proven that consumption of fruits and vegetables as a diet mainstay can prevent, and even reverse, chronic disease. Rather than spending so much money on research and lobbying for drugs and chemicals, we only need to make fruits and vegetables more available and less costly than the alternatives. Hippocrates, over 2,000 years ago, knew the answer:
“Let food be thy medicine and medicine be thy food”
“It is far more important to know what person the disease has than what disease the person has.”
“The natural healing force within each of us is the greatest force in getting well.”
Remove the money and politics from the equation and it really is as simple as he says for the 70% of preventable diseases.
There are so many additional concerns related to this issue. I know you relish the thought of living to 160. We will need the money spent on healthcare today to solve the environmental issues of a growing population, especially if lifespans double. And adding more people to the illness treatment industry will further bankrupt this country if we don’t start focusing on wellness and prevention.
Thanks for the thought provoking article. It has given me additional perspective on the impacts of ACA and confirms that there are many unintended consequences yet to be revealed.
Hippocrates also said – “Walking is man’s best medicine. ” Take a walk today and stay healthy.

Thanks,
Rob

g_a_a@frontier.com

Oct. 10, 2013, 6:07 a.m.

John,

I appreciate your thoughtful analysis of the healthcare cost numbers but I must respectfully disagree with your conclusion that “a successful outcome is probable over time”.  I think that a successful implementation of the ACA is unlikely because it’s fundamentally unworkable and the mandated “solution” was passed by just half of the Congress and is already opposed by more than half of the population. 

Consider the Y2K forecast that you attribute to Harry Brown[e] in your letter, “John, it won’t be a problem. Each company will solve their own problem, and they will get it done on time, given the cost of failure. That’s what a free market system does”.  A Y2K crisis was averted because each company did what was in its own best interests.  Far from being a free market solution to a dysfunctional system, the ACA is a top-down, government-fiat, micro-managing approach which can’t even process a relatively small number of initial pre-qualification inquiries after spending $600+ million on just the software. 

As you note, U.S. healthcare costs have risen from 5.2% in 1960 (before Medicare and the predominance of third-party payers) to around 18% today.  I believe that one basic cause of the increase is the predominance of third-party payers, both government and employer-provided insurers, which isolate the patient from any cost consideration.  ACA simply doubles down on this basic cause by providing “insurance” (actually “pre-paid medical care”) to more patients at the expense of other premium payers.

I suspect that the ACA was designed to fail, so that it could ultimately be replaced by the universal single payer (government) system that Obama is on record as favoring.  Whether ACA is ultimately replaced by a single-payer system or a true free market system remains to be seen. 

William Dixon

Oct. 9, 2013, 10:20 a.m.

John,
The major problem driving US healthcare costs is third party payments for services - private insurance and government programs - reducing the cost to consumers and increasing demand for services and prices for services. There has not been a “free” market for healthcare services since 1945 when companies, facing a wage freeze by government, got around the freeze by offering employee free healthcare insurance.

In 1964 under Lyndon Johnson the federal government - Medicare and Medicaid - got into the health insurance business. Doctors got paid for what, heretofore, they had been giving away. Utilization of medical services increased exponentially every year. The only positive spin off was the dramatic advance in medical technology and new treatments fueled by massive new revenues.

I have read all of the ACA including the cross references to existing Social Security law. You have not, nor could you possibly understand it fully. It is an abomination riven with affirmative action and so complex that mere mortals will be unable to implement it. Unelected bureaucrats are given power over both patients and healthcare providers at all levels. The IPAD - Palin’s “death squad” will make unchallengeable decisions limiting care and limiting choices for patients and doctors. Young people, those who are not stupid or fawning ideologues, will not buy insurance policies at the “exchange” rates. Money will not be forthcoming as big hospital corporations and big pharma anticipated when they threw their support behind the ACA. Obamacare will go bust before the hospitals must or are able to make the changes your friend at the Cleveland clinic suggested. There will be a massive shortage of doctors as those in their late fifties who have invested well leave medicine or opt for a limited concierge type practice. Only foolish young college graduates and missionary types, certainly not the best and brightest,  will opt for a career in medicine to become regulated public utilities, practicing at the whim of bureaucrats.

What becomes of healthcare in America will depend upon whether the voting public shakes off its current love of progressivism. If not, if Democrats (progressives) control government, will are going to a single payer system like those of Canada or Great Britain. Medical expenditures as a percent of GDP will fall as the result of rationing of services and the increased waiting time to access services.

If conservatives control government, we will have a voucher system wherein patients limit their demand for medical services based upon cost and value to them of the service. Healthcare, as a percent of GDP, will fall, but the reduction will come from consumer decisions, not bureaucratic mandates and long waits for care.

Thanks!
W. L. Dixon, M.D., MBA

fjroeh@yahoo.com

Oct. 9, 2013, 6:03 a.m.

Happy Birthday young man! I want to thank you and all those who have provided input for you to develop your article. We need a calm and considerate focus on this topic and a society that needs much better insight to the issues than it currently has. With this said, I would like to submit the following comments.

I believe that healthcare delivery reimbursement needs to be based more on results and prevention, than treatment delivered and that the bottom line is that good health is an individual issue and can only be accomplished when each individual accepts first responsibility for their own health and demands preventative healthcare information from society and their healthcare providers and incorporates this into their lifestyle.

Y2K cannot be compared to ACA as Y2K was handled BY the individual companies and not dictated by a government with a law that NONE of those voting for knew what was in it and many (if most) still do not, with things like student loans thrown in to supposedly make it budget neutral. Instead of most decisions being determined by individuals, I now fear the government’s involvement and government will now make most of the major decisions. This will likely make this a twenty (or more) year train wreck.

I applaud the adjustments that Cleveland Clinic has made and I hope that this process can be applied by others as well, but as you indicate that these solutions made by individual providers are only a part of the solution. The major adjustments need to be made by the individuals who must change their life styles. Anyone who has watched drug addiction in this country will surely realize that the food addictions our society has, will be much harder to change and will likely meet with little success as we watch state after state decide to legalize and tax marijuana.

This country needs an attitude change to take responsibility for their lives that has been going the opposite way with more and more people wanting someone else to provide their food, housing, etc. I hope that there will be sufficient population in the corporate insurance programs that are willing to enter wellness programs and demonstrate their worth to the rest of the population to do the same.

On the reimbursement rate being below costs (which only the government could dictate), who are we kidding? Without money to cover cost, something will have to give and we know the first thing will be quality. I would also believe that there will be far fewer people entering health care vocations, compounding this issue.

Eric Herndon

Oct. 9, 2013, 2:38 a.m.

I like what the article says and agree with many of the points made.  I do want to point out that in our country most treat the medical community like an engineering firm that builds cars rather than a firm that treat patients who all respond differently to the same medication.  Doctors everyday feel like they are playing roulette in getting many of their treatments correct given a complex response for the person being treated.  Are mistakes made, sure but the way the legal community climbs on the monetary roulette wheel is criminal in this country.  The medical community is still discovering more every day about the human body that we are still trying to understand.  If you have been a long time reader of John Mauldins we all have been given a hint here and there of the things that are right around the corner in medicine.  As for now though I shared this article with my son Carl, who is a secondyear med student and is on the front lines of the changes coming.  He sent me back a great response which I will share un edited with all of you.

“There in lies the kicker to this whole thing, that not even Obama has ever spoken about:
1) The ACA adds more people to insurance plans that already are underperforming in paying the bills in these hospitals ($.18 on the dollar)

2) Many of these hospitals will manage to survive that drop in revenue but cutting out the fat and stream-lining (like the Cleaveland Clinic in this piece).  Those hospitals will continue to operate, although in a much different way.  But, there are lots of hospitals out there (like Mt. Sinai on the west side of Chicago) that won’t without some major help.  They don’t in fact, even today, because they have to see so many medicaid patients and the majority of their ER visits go completely un-reimbursed.  Hospitals like that (our “safety net” hospitals), already receive massive state funding.  Which means that states have to foot the bill.  Which means that citizens foot the bill through taxes.  So, in order to make hospitals like the Clinic (which I imagine sees plenty of commercial insurance right now) afloat, they’re going to have to cut costs (which I think was quite astutely quoted as cutting personnel) or they’ll need bailouts (see: Goldmann Sachs).  Places like Cleaveland Clinic see 100,000+ patients a year, and if they can’t figure out how to do that, if they start going under, what’s the point of having all those people insured when there isn’t anywhere for them to get care?

3) I like what this article said about the state of the current system: it is BROKEN.  (he said dysfunctional, which is like calling a giant man-eating bear a teddy).  The excess, the red tape, the over-the-top costs.  All of it is bullshit.  And I totally agree that something had to be done and I congratulate Obama and his administration on doing something about it.  But we are REALLY gonna have to tighten our belts in medicine, and basically become slaves in a system that people already think is too much just in order to keep our heads above water.  More and more doctors will have to join super-groups or become employees of large hospital organizations, which then will become larger super-groups and larger corporations, until eventually the government is essentially paying a handful of corporations big bucks to do all our medicine.  Which then makes those companies start cutting costs on things that are more important, like quality of care and which drugs we can prescribe, etc.

4) This also trickles down to me in just 2 short years.  As these hospitals have to keep cutting costs and as the government realizes how much money all of this costs, GME (graduate medical education) funding, which is gov’t money that goes to hospitals as compensation for the increased cost for training residents will go out the window (FYI, it already is getting cut), and there will be fewer residency spots available.  So not only will we be in a physician shortage, but we won’t be able to afford to train them either, which gives us no healthcare in the pipeline.  None.  Which means, simple supply and demand, we’ve increased the demand for healthcare (with more people insured), and reduced supply (fewer doctors), THAT MEANS PRICES GO UP NOT DOWN YOU ASSHOLES!

5) Caveat to that last statement: there are plenty of things that doctors are doing right now that could very easily be handled by other people lower on the totem pole/pay scale.  PA’s, NP’s, RN’s, all those “mid-level” providers have the ability to help us out BIG TIME, by seeing our follow-up appts, by taking care of the easy stuff for us, and for doing all the clinical paperwork and charting that needs to be done.  A good PA right now is solid gold.

6) If I could change something, I would incentiveize medical school and residency in conjunction with all these extra people getting insurance and also somehow tie the rate of reimbursement to a market standard.  Right now, because the gov’t makes laws (duh) and will be paying for 40-50% of the medical care in this country, it’s like they’re the quarterback of the Bears, and also the head referee and the NFL office.  You can’t play the game and write the rules at the same time, the market cannot work like that.  Because as costs rise and the government gets even more strapped, what if all of a sudden they knock a penny off that reimbursement rate, then another, then another….HOSPITALS CLOSE.  CARE IS NOT PROVIDED.  And me and all my classmates and all the other physicians in my generation are graduating with $167,000 (that was the average last year) in debt.  At a ridiculous 8% interest.  We won’t be able to pay that back, and we’re all smart people, we’ll leave medicine and go work in some other sector.  Or, medicine won’t have room for us because of personnel cuts and residency cuts and everything else.  I just don’t understand how that wasn’t addressed at all in this law.  Sure, I totally agree that people should have access to care.  I totally agree that the system we have right now is broken and more costly than it needs to be.  And sometimes a little bloodletting is what it takes to spark sweeping change.  But even if all of that happens in the best case scenario, we still may not have enough physicians out there to take care of the A) number of people they’ll need to see in order to make a dent in the health of our nation or B) all of them will be so slammed with work and so underpaid that they’ll burn out.

I’m only 24 and I don’t have a lot of life experience, and I’m no economist or philosopher, but that’s what I think.”

tom@farrarlaw.net

Oct. 8, 2013, 2:34 a.m.

It is interesting to note there is not a single reference to trial lawyers (I am NOT one of them) driving up healthcare costs, which I have always thought is BS.  David Goldhill in Bloomberg predicts that the insurance exchanges will limit competition among insurance companies (not that there is much now), will not sensitize recipients of Obamacare to costs (because they are insulated from policy cost considerations), and that if premiums are pegged too high, insurance itself can drive up costs because of requirements of minimum percentage spending on health care.  I expect there are many more missed assumptions and unintended consequences in the ACA.

geoffsomebody@yahoo.com

Oct. 8, 2013, 1:44 a.m.

Dear Mr. Mauldin,

My perspective is that the Obamacare changes are not really changes but instead represent an extension of the thinking that got us to the position we are in now, and as Einstein said, “We cannot solve our problems with the same thinking we used when we created them.”

The problem we are facing is not fiscal failure but rather paradigm failure, and the paradigm that is failing is the last gasp of industrialization.  Our current conception of the nature of systems of organized complexity is badly flawed, as evidenced by our approach towards agriculture, the economy, society, and our bodies.  All of these represent systems of organized complexity, and we make the same conceptual mistakes repeatedly in our dealings with all of them. 

The industrial mindset is that reality is formless, and that we can rearrange the pieces of our world at will to create any future we wish.  All that is lacking is the vision to do so.  This leads us to perceive the systems that support us as being comprised of random associations lacking any real systematic arrangement or functionality.  The industrial mindset is that by imposing structural and procedural order on these random associations, we can improve the capability of these systems to crank out the things we want them to crank out, whether we are talking about the economy and jobs, the environment and food production, society and interpersonal relations, or our bodies and health and longevity.

Thus we march our children through assembly line school in lockstep with their chronologic peers, even though the most casual observation by parents should lead us to realize that this system does not fit the reality of children who each mature at different rates, excell at different capabilities, and have different learning styles.

Thus we try to force the economic system, whose organic spontaneously emergent order is precisely what a collection of unique and independent individuals would create as they interact with each other to improve their lives, to follow rules such as fixed prices and regulations, without any understanding of how this imposition of “order” actually blocks and interferes with the feedback loops the economic system would otherwise utilize to stay balanced and stable.

Thus we eradicate the “chaos” of nature and impose our factory mindset on it in the form of regular squares of plowed land and animal feedlots, because we see soil as simply a sponge to hold synthetic fertilizers and herbicides and fungicides and our own proprietary GMO hybrids, and we see animals as walking meat factories whose output we can ramp up with the right combination of hormones, antibiotics, and industrial byproduct feed stocks. 

We do this because our simplistic analysis leads us to believe that anything that looks like a tomato is, well, a tomato, and if we can tweak a tomato such that we can double production while extending its shelf life so that we can ship it from a different country at half the price and still have it appear flawlessly red and unblemished, then everyone wins. 

We tend to ignore the fact that tomatoes such as these taste like cardboard, and the nearly complete absence of flavor is screaming out that this tomato is lacking all sorts of vitamins and antioxidants and nutrients, which we should realize are really the only reason we are eating the tomato in the first place.

This mindset is why Obamacare simplistically presumes that if it can get blood pressure medications to everyone cheaper, then all will be well and we will all be healthier, without stopping to ask exactly what causes high blood pressure in the first place.  It doesn’t stop to consider that if a deficiency of high blood pressure medication didn’t cause the hypertension, then providing high blood pressure medication will be unlikely to fix the problem whose symptom is elevated blood pressure.  All it will do is try to force the body into certain superficial parameters that soothes our belief that order equals health, without any understanding of the more complex reality that our bodies represent.

The economy is more than a simple sponge that holds fiat currency and regulations.  Society is more than a collection of sponges who hold political correctness and trained behaviors.  Nature is more than a sponge that holds synthetic fertilizers and hormones and antibiotics, and our bodies are more than sponges to hold medications.

Our paradigm has failed.  Our paradigm has created citizens who have been trained rather than educated, a society ruled by political correctness rather than skill at voluntary interactions with other independent humans, and a political process dedicated to winning control of the people rather than protecting their freedom to be independent of political control.  Our paradigm has created food that is cheap and plentiful instead of healthy, an economy dedicated to soothing the citizens through the endless purchase of trinkets rather than independent self-sufficiency and thus freedom from manipulation by other countries, and a population that steadily requires more and more medical interactions yet is getting sicker and sicker.

Obamacare does represent a step forward, but it is a step forward in the wrong direction.  It will eventually and inevitably collapse under its own weight, but my hope is that before this happens, the citizens will wake up from their stupor and begin to consider more than the immediate and superficial results of the manipulation of complex systems, because when it does collapse, people who have learned how to think will be the ones that help keep us from reflexively giving total control to anyone who promises to save us.

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