Bureaucracies are rarely blamed in the description of the collapse of American Medicine. Bureaucracies deserve attention; although they are not the principal driving force of collapse, they are effectual parasites weakening the system.
American Medicine, as it was practiced thirty years ago, required a certain degree of prosperity within the domestic economy. Prosperity can be considered akin to profit. It is the unspent earnings of productive effort.
In 1985, the aggregate savings rate for the median American family was about 11%, a level that had remained consistent for 20 years or so. It began to drop steadily by ½%-1% per year, until by about 2000, the median savings rate was zero. The housing bubble allowed median savings to go negative for several years; then that ability collapsed.
Societal survival without savings is perpetuated by keeping the interest rate at par. There is no financial benefit to thrift; nor is there a drawback to individual spending. There is no detriment to borrowing; there is no burden of choice to spend wisely.
The absence of apparent cost of borrowing money, or benefit from holding it, drives the economy to apparent prosperity, as the velocity of money spent remains high. Housing prices, under the promise of near-zero interest payments, remain high; that pleases the purchasers, who otherwise might not be able to qualify for housing purchase.
Leasing a $75,000 vehicle doesn’t seem like wild spending, with interest rates at zero percent. There is no need to question – what makes this car have a value of $75,000 to me or anyone else? No matter, it all comes out in the monthly payment.
The lack of productivity, and its resulting prosperity, can be disguised under the shadow of the velocity of money. That is the same trick that played out in the 1920’s. Swifter communication led to faster choices regarding investment; swifter decisions make for swifter money, and a dollar that trades hands every hour makes the economy seem bigger than one which took a day to trade that dollar.
Modern bureaucracies thrive in times like this. Bureaucracies do several things, which we take for granted:
- They control by measuring.
- They control by reporting.
- They control by assessing.
- They control by expenditure beyond their limits.
Every bureaucracy is designed to measure things. Perhaps we are fundamentally confused by the antiquities which archaeologists study regarding civilizations past. The Fertile Crest cultures with complex societies have masses of bureaucratic records regarding the locations, timing and movements of goods. The actions and motivations of the actual producers – dismissed as the peasants – do not survive. Thus, we may be confusing ourselves by thinking that complex societies require bureaucracies to measure internal productivity; whereas the bureaucracies simply leave far more artifacts behind.
What is to be measured? In reporting on modern medicine, Joseph Tainter – that’s the fellow I’m reading – showed a shocking graph on modern medicine. He described the collapse in modern medicine in the postulate of diminishing returns – that’s credible.
But his measured variable was MEDIAN AMERICAN LIFE SPAN. That has soared upwards, but stagnated around 1940.
I can wag my finger at Tainter for picking a stupid measure. But the Bureaucracy of Medicine can pick any measure it wants. “Mistakes in Hospitals” was one that the IOM picked in 1999, to the eternal detriment of American medicine.
The consequence of their choice of measurement:
- Nobody can make a mistake if nobody makes a decision.
- Nobody can be blamed if nobody’s responsible.
- You cant die in a hospital you can’t get into.
(to be continued)