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Musings Report 2024-5 2-3-24 Where We Are: Layers of Dysfunction
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Where We Are: Layers of Dysfunction
There's a meme floating around that scarcity is an unfounded fear, as we'll have plenty of everything to fuel the Waste Is Growth economy for a long time to come. This is the "abundance" or "super-abundance" meme, based on the limitless advances of technology.
This presumes the problem is scarcity, so abundance driven by technology is the solution.
But what if the problem isn't so much scarcity but dysfunction in our essential systems? If that's the problem, abundance won't solve it.
As for technology solving all problems: what if technology enables new layers of dysfunction rather than solutions?
If we simply observe what's happening around us, it's clear that we're enmeshed in multiple layers of dysfunction that are interconnected and seemingly impervious to change.
What's abundant is dysfunction and sclerosis, what's scarce is truly leisure time, as we're forced to spend increasing amounts of time and energy sorting through increasingly complex, increasingly broken systems.
Consider healthcare in the U.S., which I have called "sickcare" because the entire system is predicated on the profit motive, which distills down to this: healthy patients who don't need meds and procedures don't generate any profit, while chronically ill patients generate steady streams of profit.
Is it any wonder promoting "healthy lifestyles" receives lip-service but little actual attention? Yes, the literature that accompanies weight-loss meds includes the sort of disclosures we're accustomed to ignoring: patients should maintain a healthy diet and fitness program, blah-blah-blah, despite living in a cacophony of adverts for junk food, snacks, alcohol and medications: "ask your doctor about..."
I cannot vouch for the accuracy of this, but I read that only the U.S. and New Zealand allow direct advertising of medications to consumers. In every other developed nation, these meds can only be hawked to physicians and other professionals. Not that long ago, it was not allowed in the U.S., either.
What I observe is individuals working within each layer of dysfunction are doing their best to do good work, but the system hobbles and frustrates them, leading to burnout. Each individual within the system sees what needs to be changed, but each is absolutely powerless to change anything: each inhabits a Kafkaesque world in which those supposedly empowered to change things are inaccessible. Or equally Kafkaesque, maybe even those in the Castle (the title of Kafka's novel I read recently) don't actually have the power to change anything, either.
Consider the many layers of dysfunction in healthcare.
We all know something changed in the past 25 years: 25 years ago, the majority of adults and children were of normal weight. Now 70% of American adults are obese or overweight, i.e. prediabetic.
What changed? The list of factors is daunting: addiction to screens, the decline of the nutritional content of food, the rise of highly processed food (a.k.a. junk food, snacks and high-calorie drinks, fast food), and an increasingly sedentary lifestyle.
But this isn't the entire list by any means. We have to add food deserts, neighborhoods with few outlets selling real food, unwalkable cities that are designed for vehicles not humans, the decline of fitness programs in public schools, the concentration of food manufacture and distribution into a few mega-corporations, and the cultural inclination to see "delicious food" as what we indulge in and "healthy food" as unappetizing penance for our over-indulgence, the unhappy diet we give up to resume our indulgences.
Then there's the confusing mix of ever-changing dietary advice: seed oils are toxic, carbohydrates are the source of obesity, paleo, vegan, and so on. Oh for the good old days of wacky celebrity diets (grapefruit and steak, etc.).
Is it possible to change any of these sources of dysfunction from within the status quo? No. Each is profitable to powerful interests with a strong incentive to resist any change that reduces their sales and profits.
Even if there are no well-funded lobbies motivated to smother any truly consequential reforms, there's institutional inertia and the friction of complexity thickets. Our essential systems all claim to be responsive to demands for change, but the reality is these systems are not designed for fast adaptation or evolution, they're designed to protect and maintain the status quo, i.e. the way things operate now.
Next, consider how we pay for healthcare in the U.S. Once again, Kafka is our reference point: have you actually gone through one of those multi-page billings you receive? Let's see: somebody bills somebody else $52,000 for a few days of care, and that somebody pays $26,000, and your share is $X.
It's been estimated that 30% of the $4.7 trillion Americans spend on healthcare is wasted on billing complexities, disputes, fraudulent claims, overbilling, and all the other dysfunctional manifestations of a for-profit "pay-for-service" system that's incentivized to increase dysfunction and opacity because if nobody can figure out what things actually cost, profits can be nudged higher behind an impenetrable screen of complexity.
WHY THE AMERICAN HEALTHCARE SYSTEM UNDERPERFORMS:
"Healthcare in the United States is very expensive — but spending on healthcare does not match its outcomes.
The United States will spend a projected $4.7 trillion — or 18 percent of the national economy — on healthcare in 2023. On a per capita basis, the United States spends nearly double the average of similarly wealthy countries. Nonetheless, health outcomes are generally no better than those of other countries, and in some cases, are worse, including in areas like life expectancy, infant mortality, and diabetes.
The underperforming healthcare system lacks some of the factors that fuel innovation in other industries and countries:
-- Consumers have not been cost sensitive because their employers and health plans often cover a large share of their costs, and because they lack the information required to assess quality and cost.
-- Providers generally operate under a fee-for-service model in which they are compensated based on the volume of their services, rather than the value of the care they provide.
-- Improvements in technology often make healthcare more expensive.
The result is a system in which, without reform, costs will continue to increase."
Is anything in this convoluted, wasteful system open to transformational change? No. Everyone trapped in it has to obey its dysfunctional--and quite frankly, pathological--dictates.
Then there's the frontline of healthcare--the physicians, nurses, nurses aids, admittance and discharge clerks, and so on. I have a significant number of physicians and nurses as correspondents, some retired, some still working, and the frontline reports of how the system is functioning are not encouraging.
I haven't confirmed this--or if it can even be confirmed--but it seems the system isn't producing enough newly minted MDs in psychiatry to replace the large number that are retiring. Without sufficient replacement psychiatrists, it will be impossible to meet the growing demand for mental health services.
A great many female physicians quit in their early to mid-30s, as it's becoming increasingly difficult to have a family and work the long, grueling hours the system demands of most young-to-middle-age physicians. So they quit, as there's no other way to have a family.
Turnover appears to be soaring, as doctors and nurses seek less crazy working conditions, more freedom to provide the care they feel patients deserve and higher pay. I have personally heard MDs say they left private practice due to the cost/time pressures of malpractice insurance and billing / compliance paperwork (now all digital--as noted above, technology hasn't solved anything, it's only added additional layers of complexity and dysfunction), only to find the large healthcare providers that take care of all the crazy busy-work demand an assembly-line level of "production" that means it's impossible to give patients the care the physician was trained to provide.
So they go back to the burdens of private practice, or give government agencies a try (the Veterans Administration, etc.).
As the Kafkaesque system demands more compliance record-keeping and training, etc., people burn out and either quit or cut their hours (if they can find an employer that allows that option). This increases the burden on those senior / experienced people still coping within the system.
As if all this isn't enough dysfunction, the system pressures caregivers to respond to crises rather than invest time in resolving healthcare problems before they arise via preventative care (by transforming patients' understanding of food, diet, fitness, lifestyle and selfcare). So the U.S. healthcare system is in effect designed to generate (profitable) medical crises / chronic conditions that then pressure caregivers so they're unable to spend much time on preventative healthcare.
There are many feedback loops in all these layers of dysfunction that feed back into one or more other layers. For example, the constant demands for more compliance record-keeping exposes frontline workers to more claims of malpractice even as these digital demands take away from the limited time available to see patients.
The troublingly complex rise in obesity and metabolic disorders means tens of millions of people are at much higher risk for a host of chronic diseases, which means the demands for healthcare will rise far beyond the increase in population. Who is going to be left standing to treat this tsunami of demand for essentially limitless care of chronic lifestyle illnesses?
Everyone is wringing their hands about soaring federal spending and debt, but few seem to realize that Social Security, Medicare, Medicaid and the other federal healthcare programs consume roughly half the federal budget. These entitlements are ballooning as the population ages and becomes increasingly prone to the chronic lifestyle illnesses caused by the metabolic disorders that come with being obese / overweight.
These entitlements are collectively the Third Rail of U.S. politics: touch them and you die politically. As the public costs of healthcare soar, this is a major factor in higher federal debt and the risks of borrowing tens of trillions of dollars to avoid higher taxes and / or cutting federal spending.
OK, let's reform healthcare. Which layer of dysfunction, institutional inertia, regulatory capture, corporate lobbies, complexity thickets, perverse incentives and technological overload do you want to start with? And what about all the other layers that are interconnected with whatever layer you're starting with?
The danger is not so much collapse--which as I noted last week, would be positive because it would open the possibility for a new system--but a continuing expansion of the bureaucracy while the delivery of care atrophies. In this scenario--again, straight from the pages of a Kafka novel, where the Castle is busy 24/7 with bureaucratic work while nothing gets done in the real world-- as all care becomes triage, with care being distributed by a system and workforce under impossible stress, as there is no longer any way to meet the soaring demand for care.
Here's our promised "abundance": unfortunately it's an abundance of dysfunction, inertia, complexity, perverse incentives and powerlessness to do anything about it.
Solutions Only Arise Outside the Status Quo (3/21/18)
Highlights of the Blog
Inflation Hits Us All, Even Of Two Minds 2/1/24
The Era of Easy Money Ruined Us 1/30/24
Our Tax System Is an Unfair Mess: Here's How to Fix It 1/29/24
The Vision Series – Dr. Titus Gebel and Charles Hugh Smith on the Opportunities and Benefits of International Cities (49 min)
Best Thing That Happened To Me This Week
When we're seeking culinary inspiration, we often ask, what do other people make for dinner every night? It's not easy to get an answer, so I turn to cookbooks and recipes online.
One constant source of inspiration is what's coming out of the gardens: what else can we do with... ? We harvested a large Japanese pumpkin (kabocha) recently and I hit upon Kabocha Soup as a new option. After scanning recipes online, I chose this one, and the result was delicious: One-Pot Coconut Curry Kabocha Squash Soup.
As for cookbooks, we have many, but one I always reach for (along with The Modern Art of Chinese Cooking by Barbara Tropp) for ideas is Essentials of Classic Italian Cooking by Marcella Hazan. I rarely have the energy for complicated, fussy recipes, so I was delighted to find Chicken Cacciatora, New Version (page 331) that is the simplest possible recipe for pasta sauce from scratch: dollops of olive oil and white wine, onion, garlic, salt and pepper and diced tomatoes, fresh or canned. I added sprigs of rosemary and lavender from our herb garden when cooking the chicken pieces. The results were excellent. Just grate some parmesan cheese and you're done.
Classic Chicken Cacciatora is generally deep-fried, but a bit of olive oil is enough--just add the wine or light broth after the chicken has been seared on both sides.
From Left Field
NOTE TO NEW READERS: This list is not comprised of articles I agree with or that I judge to be correct or of the highest quality. It is representative of the content I find interesting as reflections of the current zeitgeist. The list is intended to be perused with an open, critical, occasionally amused mind.
Many links are behind paywalls. Most paywalled sites allow a few free articles per month if you register. It's the New Normal.
I was young and fit, and suddenly too exhausted to get out of bed (via Cheryl A.)
Transforming Fertilizer Production: True Mechanism of Ammonia Catalysis Revealed (via Tom D.)
The Genius Of Ivan Illich (book review/essay)
Sick to Death: Unhealthy Food and Failed Technologies (via Cheryl A.) -- the decline of nutrients in food since the Green Revolution....
The Unintuitive Secret to Happiness: "Always Play the Long Game" -- making progress is more important than reaching the goal...
The Elite 1 Percent Behind The Cultural Civil War
The long sleep of capitalism's watchdogs: "Self-regulation is to regulation as self-importance is to importance."
The Cutter Incident: How America's First Polio Vaccine Led to a Growing Vaccine Crisis (nih.gov)
We're DINKs struggling to make ends meet — our 6-figure salaries aren't enough to support our lifestyle anymore.
Financial Blogger Says $230,000 A Year Isn't Enough Money For His Family Of Four — 'Desire Is The Cause Of All Suffering.'
"My fascination with letting images repeat and repeat – or in film’s case 'run on' – manifests my belief that we spend much of our lives seeing without observing." Andy Warhol
Thanks for reading--
charles |
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