The Real Crisis in Healthcare Expenditure Growth

In 2011 the U.S. spent an estimated $2.7 trillion on healthcare, accounting for just under 20% of our total GDP. This figure–and projections of future growth in healthcare spending–is being described in terms of a mounting national crisis. (Healthcare spending is a “national threat”, according to the CBO.) Healthcare spending is growing far faster than our national GDP, and far faster than individual incomes. This is growth, not a crisis. Something that, given the feeble state of our economy, we could be glad for. But there is a looming crisis…

Healthcare expenditures outstripping income reflects two realities: 1) individuals are choosing to spend more of their income on healthcare (which could be explained, at least in part, by an increase in the quality and availability of healthcare). 2) The increase in healthcare expenditures, in part, has hampered wage growth. That is, since most health insurance is paid for by employers, and because the cost of providing health insurance has increased rapidly in recent years, a portion of compensation increases have been allocated to paying for employee health insurance, rather than taxable income. Since income does not account for non-monetary compensation (i.e. benefits, including health insurance), growth in taxed earnings has lagged behind real wage growth.

The growth of healthcare expenditures, in and of itself, isn’t a bad thing. Increased expenditures are due to 1) increased consumption and 2) higher costs. Increased consumption results from an aging population, but also from improved quality and availability of healthcare. Higher costs, in turn, are explained in part by increased administrative costs, but also by also better (albeit more expensive) treatments.

In the face of sluggish national growth, rapid growth in the healthcare sector should, seemingly, be celebrated (at least one sector of our economy is booming!). That the healthcare sector is growing faster that our overall economy simply indicates that individuals are choosing to spend more of their income on healthcare (and less on other things). (And for those who worry that we’re not getting our money’s worth, I would refer to to Scott Atlas’s In Good Health, summarized in this discussion.)

The crisis comes in the fact that the government pays for about one third of all U.S. healthcare spending ($847b in 2011, or 31% of total healthcare expenditures). That is, in 2011, 5.5% of our GDP was government expenditures on healthcare!

Growth in healthcare expenditures is not a crisis–it’s a change (and a positive change to the extent that the growth in any industry promotes our national economy). The crisis, rather, is the growth of government healthcare expenditures. This matter urgently demands our national attention–but should be considered separately from overall growth in expenditures.

On Life, Expectations, and America

Imagine that, in life, one paints oneself (or one’s life, rather) upon a canvas. One paints legs of adolescense. A torso of family and career. Arms of offspring, accomplishments. A head formed at leisure in retirement, crowned with the jewels of grand-children, repose, of wisdom, the respect accorded to the elderly. And then? On into the sky.

While painterly (and not without a certain poetry), the a metaphor of painting one’s life upon a blank canvas is trite and, if you’ll pardon the adjective, Panglossian.

Truer to life, I think, would be a metaphor of drawing one’s life upon the page of a coloring book.

Like the open invitation of a canvas, the coloring book presents a broad sheet to be filled. But, unlike a canvas, the page is not entirely blank. It waits to be colored by a human hand, but comes pre-stamped with the dark ink of some mechanically reproduced shape. That is, the page is your own to fill, but the general outline of how you ought fill your page is already given.

I find life to be similarly bounded. The shape of what one is to become is given–by the black ink of familial expectations, by social norms, by the opportunities of your social class, by values given to you by your parents and your faith, and finally by your personality and disposition. (This shape, more often than not, is simply an enlarged pattern of our parents’ own lives.)

But, we each choose the extent to which we color and remain within the lines. A toddler’s drawings exceed the lines of a coloring book not principally for the lack of fine motor skills (though this, too), but rather because a toddler has not yet learned the expectation of staying within the lines. As we grow older, we’re taught–and we learn–to drawn within the lines.

But not all. Some draw beyond the lines–seeing beyond, perhaps, a form more to their liking. And these, who form their own shapes, become our celebrated heroes. Perhaps because their shape is extraordinary, they draw the eye and inspire our wonder, our respect. Images of rags to riches, images of artists, images of innovators, inventors, rebels,  industrialists, revolutionaries. These ride roughshod over the preordained. Between these images, no two are alike. There’s no pattern for breaking the pattern. Some are drawn with fits and starts. Others are drawn with strong lines and a steady hand. All challenge (an exult) the shapes of our pre-prescribed drawings.

Breaking the bounds isn’t always easy, or necessarily desirable. When you go beyond the lines, there’s no guarantee of a beautiful outcome. There’s no guarantee of fashioning one’s self into something which accords with personal satisfaction, or inspires the admiration of others. Counter-point to artists and industrialists, there are junkies, felons, louts, dissolute–perhaps in equal number. For these, adherence to bounds would mean redemption.

I don’t write this to suggest that one should live life outside its prescribed bounds–or within. I write, rather, simply to reflect that life is bounded–and that we each make decisions which push us outside those bounds, or help us flourish within them.

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My impression of life in Sweden is this: vis-á-vis life in America, life is Sweden is more fair, more civil, but also more constrained. Constrained not in that its land is filled and its people live in close quarters (though this, too), but rather that life–what is could be, what it should be–itself has narrower bounds.

Which brings me back to Sweden. Here, the lines exist, just as anywhere. Only, compared to America, they’re drawn with thicker line. Certainly, one can still go beyond them–but perhaps not so readily as in America. The assortment of forms is less varied.

I delight in America, and being American. America, where you can be anything you want. America, where you can do anything you wish (provided you have sufficient ambition). America, where you can do anything, and–if you’re so inclined–you can do everything. There’s no experience “off limits” or beyond the reach of an aspiring American. And, we’re encouraged to think these thoughts, to dream big dreams. Among Americans, I think most fill the form expected of them. Others exceed these bounds and fall off into dissolution. And still others exceed these bounds and achieve much. Such is life in America. It’s a proud, perilous, and limitless way of life.

et två tre fyra

Ordnign och reda, which I’ll translate as “order and synonym-for-order”, is an important concept in Sweden. And, indeed, I find the country remarkably orderly.

For example: I went and saw The Tallest Man on Earth perform in Stockholm last Friday. The show was at 7:00 pm–and to my continued astonishment, the opening act walked on stage at 7:00 pm. Yup. 7:00 pm.

The Tallest Man on Earth was on stage by 8:00 pm. (It’s lucky I had to be there by 7:00 pm to get my secondary-market ticket. If I’d shown up at 9:00 pm–conservatively early for a show in the ‘States–I’d have missed all but the last 45 minutes!)

Or, for another example: it’s the only place I’ve been where people routinely stand on the right-hand side of escalators so those who wish to walk may. It’s a delight.

Waiting (in a shop for service, for example) is controlled by ticket number. You enter the shop, take a ticket, and wait for your number. Example: I ducked into a tiny (no more than 10′ x 15’) electronics shop to search for an outlet adapter. I saw the red paper ticket dispenser but no tickets–so I assumed (wrongly) it was not in use (there were only a few people in the shop).  The next person to enter–a local, took one look at the dispenser, opened it (as though this were routine), retrieved the next ticket which was stuck inside, handed it to me, and took one himself. (Given the pervasiveness of these ticket systems, I’m almost surprised you still have to stand in line to get a drink at the bar.)

(As an aside, the ticket system resolves the single-line (think: Wendy’s) versus multi-line (think: grocery store) debate. Single-line systems are more efficient, but are perceived by their participants–despite actually being faster–as being a longer wait than multiple lines. Using tickets avoids the psychological trauma inherent to multi-line queues when you “choose the wrong line.”)

It’s as though the country’s systems were designed by introverts, with the specific aim of minimizing any possibility of conflict or confrontation with another individual–and also a system where timid introverts (such as myself) are at no disadvantage to large, loud extroverts.

Customs customs

I flew to Stockholm by way of Mexico City and Frankfurt. (Frankfurt, at least, makes sense.)

Arriving in Mexico City, I completed two Customs forms. After deplaning, I presented these to a dour official with limited English, and discovered that, despite my best efforts, I hadn’t filled them out quite correctly. Two mistakes. These were corrected, and I was given a copy of one form to keep, being necessary later to pass through security and leave the country.

In Frankfurt, Customs was easier. I walked (no forms, no line) to a friendly official who, after inquiring about my German (“Nein sprechen sie deutsch!), spoke wonderful English. I presented my passport, he scanned it, and I was on my way. Easy!

In Stockholm, I landed, collected my bags from the carousel, and walked through a revolving door into a cool but sunny northern afternoon.

(I worried that I might have somehow entered the country illegally until I confirmed this experience with another traveler.)

They’re trusting, here.

Protections against theft (of many kinds) are limited. At the aforementioned Tallest Man on Earth concert, I collected my ticket from Will Call–but the ticket was never checked. I seated myself, and enjoyed the show.

Bikes are common in Stockholm (it’s a compact city, streets have bike lanes, and the traffic is courteous of cyclists). Most bikes are locked, but it’s not uncommon to see bikes just by themselves, waiting patiently and unrestrained near this entrance or that building.

All of this reflects a curious absence of an “us-versus-the-system” (/”damn the man!”) mentality. In America, (speaking very generally, of course) the system is perceived as trying to take advantage of the average person. Any opportunity, then, to turn the tables is relished (and generally exploited).

Here, the perception seems to be more of being participants in systems designed by others for the participant’s sake.

Each day I walk around, I see dozens of opportunities “to take advantage of the system.” Walk into the museum without buying a ticket (there are multiple entrances, and no-one is checking anyway). Slip into the metro with the person in front of you. Pour a cup of coffee from the cafe’s self-serve station around the corner without paying. Slip the cup and saucer into your bag on the way out–no one is watching. Grab that bike and take a ride.

And yet, seemingly, no one does these things. It’s as though these systems are designed with the assumption that their users are honest and responsible adults. It’s as though their customers are … customers. Not adversaries.

As an American, it’s strange to walk into a shop, a cafe, a museum, and to feel trusted. It’s strange, and delightful.

The Tallest Man on Earth (Part 2)

Still slight and unprepossessing, The Tallest Man on Earth stands just a little taller than he once did. Three full length albums (the third, There’s No Leaving Now, releases June 11th) and two EPs since his 2006 debut, The Tallest Man on Earth has built a small but hugely deserved following (he’s counts over 16,000,000 plays on last.fm).

Just back from two week of “fishing and wearing his ugliest clothes” in nearby Dalarna, tonight in Stockholm The Tallest Man on Earth kicked off the first stop of his 2012 tour supporting There’s No Leaving Now. 

His latest album builds on his previous work–it’s quiet, introspective, sung in a raw (if not quite plaintive) tones over a guitar with opening tuning. The album feel more upbeat than his previous work. The imagery of his lyrics is more subtle, but less arresting.

On stage, he looks confident, comfortable. One gets the sense that, perhaps, he’s unsure of why he’s such a celebrity–but accepts it with equanimity (and gives the crowd what they came for). He plays passionately. Most songs (even his oldest) feel fresh, impassioned, anew, though a few songs in the set feel as though played by rote.

He plays Stockholm again tomorrow night–then it’s off to the United States. He plays Boulder on June 10th. If you can make it, go. It’ll be a wonderful show.

—

I last saw The Tallest Man on Earth three years ago, in Phoenix. Then, he was opening for John Vanderslice. Now, he’s his own headliner. I blithely compared him to Bob Dylan after last seeing him. From reading some other blogs, apparently (*gasp*) I’m not the first to draw the comparison. But it’s the best comparison that presents itself. When he sings, it’s as though he throws his words upon a canvas, creating for his listener image after beautiful image (a blizzard that’s never met the desert sand, a shiver from a fallen tear). He doesn’t sing experiences, emotions. He sings the blues, in open tuning.