• Vascular Specialist Newspaper
• Volume 5 - 2009
• Number 9 online
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• Volume 4 - 2008
• Number 6
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• Volume 3 - 2007
• Number 6
• Number 5
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• Volume 2 - 2006
• Number 6
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• Volume 1 - 2005
• Number 2
• Number 1

Two weekly news magazines recently got it right in cover stories that recognized the great expectations that Mr. Obama brings to his presidency. In the novel Great Expectations, Charles Dickens explored the hazards that accompany vast opportunity. But I believe the message for these times comes instead from Mr. Micawber in another Dickens novel, David Copperfield. Micawber reckoned that one was destined for trouble if one spent more than one earned: "Annual income twenty pounds, annual expenditure nineteen-nineteen-six, result happiness. Annual income twenty pounds, annual expenditure twenty pounds-ought and six, result misery."

George Andros, M.D.

Although our overspending is considerably more than Mr. Micawber's sixpence, such unremitting imbalance has pushed the American economy to its current dismal fiscal state. If last year's $18 billion in Wall Street bonuses are to be believed, those guilty of the worst excesses show the least evidence of misery, or remorse.

The American economy was plundered in the nation's banks and other cathedrals of capitalism. Its demise began, however, in the halls of Congress and in the Oval Office, where elected officials behaved irresponsibly in the matters of our happiness and misery. I have long since abandoned any hope that our government will repay the taxpayer instead of rewarding the financially powerful and their potent lobbyists. That inequity has been inescapable since the mid-20th century, when both the government and the governed became addicted to debt. Consumer consumption, for many years the engine of the international economy, now encumbers and endangers our nation's democracy. Will our democracy sink along with our consumer confidence? Right now no one can say.

I have faith in our democracy. What's more, I trust the ballot box. When we elect irresponsible officials, we are usually smart enough, sooner or later, to throw the rascals out. That power, however, requires two safeguards: first, a free, unbiased press that reports accurately and honestly; and second, an unwavering commitment to that most naive of concepts, a balanced federal budget. I care that our elected representatives are duty-bound to allocate and appropriate within the limits of a balanced budget. Believe it or not, precisely how the money is spent is less important. Balanced budget first, priorities second.

The news media tend to focus on misfortune--if it bleeds, it leads--but in an informed society, both good and bad outcomes are hard to conceal. If money goes to infrastructure and the bridges fall down, the press need only show us the pictures and we can figure out the rest. If we engage in foolish wars, the fiscal and human damage will eventually be obvious to all. When education declines and citizens complain that immigration politics are to blame, we need only assess the report cards of all children.

In each of these cases, because the fiscal accounting has already been done, we can respond rationally to the decisions that elected representatives made on our behalf. With a balanced budget, if we make poor choices, prioritize imprudently, or misallocate our revenues, at least we will not have risked someone else's money. I am unafraid of how legislatures spend our money, as long as they don't spend "one farthing" more than they collect in taxes. Unfortunately, at the local, state, and national levels, our public servants lack this kind of basic fiscal discipline.

Ignore for a moment that legislators on both sides of the aisle are compelled to overspend because of the money that lobbyists lavish on them. What cannot be overlooked is that the money we spend now will come due, and that our children and our grandchildren will have to pay it back. Will they be happy with the choices we have made? Will they be as easily deluded that we can finance trillions of dollars of our debt through foreign governments that have questionable democratic credentials and might turn on us at any moment? Thomas Jefferson spoke of a wise and frugal government. What would he say about these sorts of entangling alliances?

Just what have we acquired by feeding our appetites with borrowed foreign capital? What good has this resulting illusion of prosperity done us? Have we lessened class conflict by buying cheap products made in Asia, only to store them in public storage facilities or discard them in overburdened and disappearing public landfills? Have we strengthened our economy by driving SUVs fueled by Middle Eastern oil? Will these transitory material pleasures make us less resentful of CEOs who are paid 300 times more than their average workers, while shareholders are beset with stagnating, or plummeting, stock prices? Has the health of our society improved with costlier drugs or high-technology medical devices that nonetheless fail to improve the mortality figures of our senior citizens, or to combat chronic problems like obesity or diabetes?

If we believe that we are entitled to any of these goods and services, then let us pay for them. Indisputably, we are even less entitled to the health care we consume because we ask foreigners to pay for it and imported health care workers to deliver it. The ultimate debtors--our unborn children--might derive some benefit from that new road or bridge but they will have to share it with others, on an overheated and overcrowded planet. Let us not ask future citizens to pay for our present indulgences. Further, let there be no question that much of what we spend is the result of the rest of the world indulging the United States.

Here is what I believe. We can spend 4% or 40% of our GDP on health care, if that is what we choose to do. If that money is filtered through the sticky hands of insurance companies so that only a fraction actually winds up going to patient care, we have only ourselves to blame. Because, if we are informed and that's what we decide, we--not our children--will face the consequences.

Many of our medical priorities bewilder me. Are there better uses for the money that we spend for expensive AICDs? Will our senior citizens be healthier or less frightened of the risk of rupture if every 4-cm aneurysm gets an endograft? After all, we are Americans--are we not entitled? Yet somehow at the end of the spectrum we seem to lack the motivation to move our country into the top five in the world of countries with the lowest infant mortality. We'll need to look after those children because it is they who will be paying for our fiscal profligacy. Please don't ask me, however, to subsidize your prescription drug benefit at the expense of funding my trauma center.

You see, we cannot have it all. And our legislators cannot get it all for us even if we push them hard enough and help them to pay for their reelection campaigns. Happiness may be just around the corner. But, if we fail to balance the budget and see no need to do so, we will never develop an informed set of priorities. So we had better start lowering our expectations or we will have the next crisis around the corner do it for us. Rest assured, if we think we're entitled to more than can we pay for, you can be certain we are in for a lot more misery.