Man that is born of a woman hath but a short time to live, and is full of misery. He cometh up, and is cut down like a flower; he fleeth as it were a shadow, and ne’er continueth in one stay
—The Book of Common Prayer (1662)

Diuturnity is a dream and folly of expectation.
—Sir Thomas Browne, Urne Buriall

While of death, there is little to be said that is truly to the point, of dying there is too much.
—Raymond Tallis, The Black Mirror

This morning on NPR’s Saturday Edition Scott Simon announced—portentously, as he so often does—that: “Senior citizens, people over 65, account for 16% of the U.S. population but 75% of deaths from COVID-19, according to the CDC.”

It’s not clear what to make of this factoid. In 2019, according to the CDC, before anyone had heard of COVID, people 65 years of age or older were 16% of the U.S. population and 74% of deaths. And in 2010, old people (among whom I number myself) were 13% of the U.S. population and 73% of deaths.

But, as Scott might say, mercy! it’s even worse than this. In 2020, people 75 years of age or older were just 7% of the population but 54% of deaths. And—oh lordy—people 85 years of age or older were 2% of the population but 30% of deaths!!

This may mean that there is an epidemic of death among the elderly. Or that a leading cause of death is old age. Or that death follows, inevitably, from being born.

For a sobering comparison, compare the statistics for the Republic of South Africa, where people aged 65 or older, in 2017, were 5% of the population but 36% of deaths. People between the ages of 35 and 44 comprised 13% and 14% of the population in the U.S. and the R.S.A., respectively, but accounted for less than 3% of deaths in the U.S. and more than 12% of deaths in the R.S.A.

So perhaps the statistics which seemed to give Scott the vapors mean simply that, in the United States, “senior citizens”—however old they may be—are lucky to be not dead yet.

Psychology which explains everything
explains nothing
and we are still in doubt.

—Marianne Moore, Marriage

I was tempted to title this post “against incentives”. But really my objection isn’t to “incentives” per se. To be “against incentives” makes about as much sense as being “against breathing” or “against food” or “against gravity”. What I’m against is the mindless talk about “incentives” which is now ubiquitous. “Incentives” explain all social, economic, and political behavior — or are the only explanation that is needed. And a reference to “incentives” is all that is required to define the purpose and the goals of public policy. The problems that public policy are concealed by the all-purpose veil of “good incentives”. The causes of those problems remain unidentified and unaddressed once it is “understood” that they are the result of “bad incentives”. Human agency itself is tossed away, as, oddly enough, is the very notion of freedom. All behavior becomes nothing more than an unthinking, involuntary response to incentives. No one chooses how they behave. They just respond to incentives. Some people choose well. Many poorly. The difference between “good choosers” and “bad chooser” simply reflects their ability to compute the incentives.

That which was is that which will be, and that which was done is that which will be done, and there is nothing new under the sun.
There is a thing of which one would say, “See this, it is new.” It already has been in the eons that were before us.
                              —Qohelet 1:9-10

We’ll order now what they ordered then
‘Cause everything old is new again
                              —Peter Allen

“Branding” and “re-branding” is often presented as innovation. But as is true of scientific “revolutions”, innovation worthy of the label occurs infrequently and represents a fundament shift in thinking, practice, and institutions.

In the delivery, organization, and financing of medical care there have been only four moments of fundamental innovation since 1900. The first was the invention of “pre-payment” in the 1920’s. The second was the invention of Pre-paid Group Practice by Kaiser-Permanente in the 1940’s. The third was the adoption of “prospective payment systems” by Medicare in the 1990’s to replace systems of payment based on “reasonable costs” and “usual, customary, and reasonable” fees. The fourth was the replacement by Medicare of “prospective payment” with virtual capitation in the 2010’s.

This “fourth wave” of innovation has one fundamental idea that is more of a return to the notion of pre-paid group practice pioneered by Kaiser-Permanente and the Group Health Cooperative of Puget Sound than the invention of something new. That simple, core idea is all too easily obscured by the rococo proliferation of competing “brands” or “flavors” — the Shared Savings Program, the Pioneer Accountable Care Organization Model, the Next Generation Accountable Care Organization Model, and most recently the Direct Contracting Model.

Running alongside this path of fundamental innovation has been a second path of what might be called extractive or expropriative innovation. Such a label could, of course be condemned as excessively cynical. But the primary offense of the most famous of Cynics, Diogenes of Sinope, was to call things by their proper names.