Opting Out and the Culture of Entitlement   (March 29, 2010)

Doctors are abandoning or avoiding primary care; perhaps we need to look not at technocratic "solutions" but the cultural consequences of entitlement.

It seems my prediction of doctors and nurses opting out of the crazy-making U.S. sickcare system is already happening, at least in primary care. Ishabaka M.D. submitted this link:

Health overhaul likely to strain doctor shortage

Primary care physicians already are in short supply in parts of the country, and the landmark health overhaul that will bring them millions more newly insured patients in the next few years promises extra strain.

Yet recently published reports predict a shortfall of roughly 40,000 primary care doctors over the next decade, a field losing out to the better pay, better hours and higher profile of many other specialties. Provisions in the new law aim to start reversing that tide, from bonus payments for certain physicians to expanded community health centers that will pick up some of the slack.

The rest of the article outlines costly new programs to track patients' test results and so on, and to prompt them with an individually tailored list of wellness steps to consider.

Ishabaka added this comment:

Then consider that President Obama is about to sign a bill next week cutting doctor's Medicare fees by 21%. I am a primary care physician.

Who else, I ask you, is getting a 21% federal pay cut? Oh, but we doctors can afford it, because everyone knows we're all millionaires. Lots of luck to the baby boomers becoming eligible for Medicare.

It is certainly tempting to scapegoat one sickcare cartel/trade group or another--doctors, malpractice attorneys, insurers, Big Pharma, HMOs, take your pick--but that, like any simulacrum analysis, is nothing but a distraction.

The same can be said of various technocrat solutions embedded in the 2,400-page "healthcare" reform bill: "comparative effectiveness research," etc.

In terms of an integrated understanding of the roots of the dysfunctional mess known as U.S. "healthcare," we might start with the "fee for service" model itself. I recently wrote this article for AOL's Daily Finance website: Is Fee-for-Service What Ails America's Health Care System? and followed that up with a look at "improving health" as opposed to "reforming healthcare," which has nothing to do with improving the health of the American citizenry: Improving Americans' Health, With or Without Health Care Reform.

As I research some of the key components of the reform bill, it seems ever more evident that the "healthcare" system is fundamentally a complex network of self-serving corporate welfare. "Healthcare" is just the marketing screen to mask the vast machinery of the greatest corporate welfare machine ever constructed--yes, it exceeds the Pentagon's feared Military-Industrial complex by a factor of three.

How did we as a nation get such a counter-productive, wasteful, make-us-sick system which costs twice as much (as a percentage of GDP) as developed nations like Australia and Japan?

Certainly corporate welfare and the profiteering enabled by lobbying, fraud and collusion are roots, but I am also thinking that the culture of entitlement which has slowly engulfed the American worldview is ontologically bundled wth a radically unhealthy resentment and dependency: now that we now "deserve" "free" treatment as a "right," we find multiple reasons to resent those providing the services, and our dependency angers us even as it disables us and leaves us fragile and powerless.

Those of you who have experienced co-dependent relationships know how terribly debilitating such arrangements inevitably become: resentment flows freely in both directions, both from those crippled by insecurity, self-loathing, passivity and the need to be "saved" constantly, and those imprisoned by the need to "save" the self-destructive dependent who excels at creating endless obstacles to autonomy, self-awareness and personal responsibility.

We as a nation have become the resentful dependents of a corrosive, unsustainable system of corporate welfare which has been packaged as politically popular entitlements, and the abundance of our resentments knows no bounds. We resent other nations for not sublimating their wants and needs to ours, and we resent those who are still in charge of their own lives because they prove passive resentment isn't the only possible state of being in America.

Readers are often puzzled by the term The Politics of Experience, which is the core of the Survival+ analysis. The term comes from psychiatrist/author R.D. Laing, and I use it to describe the subtle ways that our worldview is molded to make certain forms of political and financial dominance so "natural" that we lose awareness of its arbitrary, carefully engineered structure.

Entitlements now seem as "natural" and ubiquitous as the air itself; the Savior State masks both its partnership with the Power Elites Plutocracy and the historical accidents which enabled the illusion of permanently rising entitlements: the demographics of the Baby Boom, the destruction of our global competitors in World War II, and cheap oil.

Social Security was designed when there were 35 workers to every retiree; the ratio has fallen to 3 to 1 and will soon be 2 to 1--a ratio which is financially impossible.

Medicare began as a modest program, and it now is a behemoth which sucks up more money annually than the Pentagon, a program which grows twice as fast as the economy year after year and decade after decade. Simple math shows that this growth is unsustainable.

Entitlement, resentment and dependency are joined at the hub; each reinforces the other two. We "deserve" what is "ours," and we "earned" our dollar in benefits because we paid a dime in.

The pernicious effects of an entitlement mindset are so subtle and pervasive that it is difficult to tease out all the debilitating tendrils. There is no need to pick up litter on the sidewalk because that's somebody's job now. There is no need to become intimately involved in your children's education because that's the school's job. There is no need to nurture one's own health because it's the job of the doctors and nurses to make me well and fix all my chronic illnesses.

Entitlements have been marketed as the crowning benefit of security for the average citizen, and their innate contingency on historical accidents has been masked so as not to alarm a passive citizenry. As the quote from Douglas MacArthur below says, There is no security in life, there is only opportunity. The promise of everlasting security was a false one, and we will experience its collapse within the coming decade.

There are political and financial consequences to the debilitation of the citizenry who have been rendered passive "consumers" and resentful dependents. The dominance that was served by the entitlement mindset is vulnerable now that the entitlement system is careening toward insolvency, and so the Power Elites and Savior State--partners in that dominance--are busy masking the truth behind lies, misprepresentations, marketing, misinformation and propraganda.

Take one part opaque corporate welfare and one part craven Savior State endentured to corporate and Imperial Elites, then add in a citizenry in bondage to entitlement, resentment and dependency, and you have a culture and economy ill with the "sickness unto death."

Dr. David D. submitted this quote from Ivan Illich, and it speaks to the heart of the matter:

Yes, we suffer pain, we become ill, we die. But we also hope, laugh, celebrate; we know the joy of caring for one another; often we are healed and we recover by many means. We do not have to pursue the flattening out of human experience. I invite all to shift their gaze, their thoughts, from worrying about health care to cultivating the art of living. And, today, with equal importance, to the art of suffering, the art of dying.

Ivan Illich

I recommend these three profound books on health and medicine (once again):

Limits to Medicine: Medical Nemesis, the Expropriation of Health by Ivan Illich

The Rise and Fall of Modern Medicine by James Le Fanu M.D.

Before You Take that Pill: Why the Drug Industry May Be Bad for Your Health by Dr. J. Douglas Bremner, M.D.

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