A parent repeatedly tells a child at the supermarket “No,” as the small child continues to ask and beg for this and that.  Pouting and temper tantrums follow.  Spankings in the grocery store don’t seem to make much difference.  The next time the child asks again and again for this or that, the parent gets an idea.  Instead of “No,” she says, “Not now.” While this doesn’t solve this child’s disciplinary issues, introducing the variable of time (not now) softens the answer in a way that introduces hope, although probably a false hope.  The “time” variable has muddied things for the child, buying some time for the frustrated parent.

I often think about how the introduction of the element of time as a variable, can completely change the context of a discussion or contract.  Take health care for instance.  “Health care is a right,” many say!  What the government in Canada or Great Britain means when they say that health care is a right, is really this:  health care is a right…just not now.  Having waited three years for a hysterectomy or an incontinence procedure drives this home, doesn’t it?  How about watching your child struggle to breathe knowing he must wait three years to have his tonsils removed?  How about watching a loved one die of their heart disease, waiting in line for a life-saving bypass procedure?  Can the Canadian government honestly say this now-deceased cardiac patient has a “right” to health care?  They do, and they do it with a straight face, even though they have contaminated the entire context with the variable of time. 

We have operated on many Canadians whose government, having declared their health care to be a “right,” has failed to deliver on this promise.  Picture a Canadian saying, “I have a right to the free surgery on my brain to remove this tumor.  Just not now.”  Introduction of the variable of time has been useful in Canada (and in all “free” health care countries) to hide the bankruptcy of this health care plan, as any individual refusing to meet financial obligations (for years!) would be declared bankrupt by any definition.  Resources are limited, not infinite.  Lowering the perceived price to zero (free health care) will empty the shelves and result in shortages.  Lines will form for health care just as they did at the gas pump during the Jimmy Carter days.  Health care may be delivered, but only after waiting a few years and by then, the government hopes (for the sake of its own bankrupt balance sheet) it is too late. 

A cardiac bypass surgery is worth more to a patient with chest pain now, than three years from now. The dilution of the value of health care caused by this delay, is the same deceptive technique employed by governments destroying a currency with inflation.  This allows politicians to extract what they want now, leaving future taxpayers to pay for their current promises.  This is how politicians use the element of time to buy votes.  Inflation of currencies (printing money or creating credit out of thin air) results in a reduced purchasing power and a lower standard of living in the future.  Delaying medical care is essentially inflation of medical care, diluting its value, as well.  I believe this is a variation of the economic concept of “marginal utility.”  Simply, the first drink of water delivered to a man dying in the desert is worth more to him now than later, and worth more to him than any subsequent drink of water. A dying man needing a drink of water or heart surgery now, finds little value in the promise of these at a later time, just as a future dollar bill will likely hold even less value than one today.

“You can have your surgery.  We’re not saying ‘no.’  We’re just saying, not now.”  One consequence of “not now,” is that hernia surgery, for instance, if performed early on, is almost certainly uneventful.  But if this surgery is delayed long enough, an “incarceration” can occur. This complication can involve a bowel obstruction, sepsis (generalized infection) and death.  What would have been a routine hernia surgery has now become a life saving emergency procedure.  Surgeons busy with incarceration emergencies have less time to deal with the routine hernias and the initial delay snowballs, the lines for all becoming longer.  Almost any surgical disease if neglected long enough will degenerate into a similar emergent picture, the complications of which can be life altering if not fatal.

Modifying currencies and debts with the element of time results in higher prices and different amortization schedules.  Modifying health care with the element of time results in misery or death as “not now” becomes “never,” as governments, unable to pay their bills and deliver on this “health-care-as-a-right promise,” string out their obligations further and further.

G. Keith Smith, M.D.