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By Carl Bialik
My print column this week examines a 2000 World Health Organization ranking of national health-care systems that continues to be cited in today’s U.S. health-care debate. I argue that the ranking is outdated and flawed.
I’m not the first to criticize the ranking. The editor-in-chief of the report, who said he wasn’t fully aware of the ranking methodology until after it was published, denounced the rankings in a journal article in 2003, drawing a rebuttal from the creators of the rankings. Glen Whitman, an associate professor of economics at California State University at Northridge, also criticized the rankings in a paper for the conservative Cato Institute.
I asked Whitman how he would have constructed a ranking. He, like many researchers, said he wouldn’t have. “I probably would not have tried, because I think the project is inherently problematic,” Whitman said. “The problem is that the quality of health care has lots of different dimensions: success in treating condition A, success in treating condition B, etc.; speed; convenience; cost; privacy; and so on. People with different values will place different weights on these factors. So any attempt to create a universal index of quality necessarily relies on value-laden assumptions.”
Another criticism noted that the rankings didn’t control for many variables it could have, such as geography (tropical climate, and distance from coast, can affect health). Controlling for such variables materially affected many country’s rankings — but not the U.S.’s. And that points out an important point that many of the WHO ranking’s critics acknowledge: Though the rankings may have been flawed, a ranking of 37th for the U.S. seems reasonable, and the U.S. may have slipped since 2000. For instance, data from the United Nations Population Division show the U.S. falling further behind its peers in life expectancy and preventing mortality of children under age five.
“When it’s good, it’s very, very good, and when it’s bad, it’s horrid,” Mark Pearson, head of health for the Organisation for Economic Co-operation and Development, the 30-member, Paris-based organization of major economies, said of the U.S. health-care system.
Some researchers have attempted to get a firmer handle on the U.S.’s proper health-care ranking by attempting to remove the effects of factors outside the health-care system’s control, such as violent crime. One such effort, which I recounted here two years ago, found that removing such factors greatly improved the U.S.’s standing in life expectancy. However, critics assailed the report for its indirect approach to the problem. One of the authors of the report, John E. Schneider, general manager of U.S. Health Economics for international health-care consultancy Oxford Outcomes, said that its intent was to show that small differences in life expectancy at birth, such as two years, “are too small to be meaningful due to differences in measurement and populations across countries.”
Researchers at the London School of Hygiene and Tropical Medicine have been tracking trends in deaths from causes deemed treatable or preventable by the health-care system, such as bacterial infections, treatable cancers and diabetes. The U.S.’s performance has slipped, falling to last among 19 wealthy nations. “Diabetes is highly correlated with obesity, and it’s not clear how ‘amenable’ obesity is to the health system,” Schneider said, in response to that study. “Can the health system make you get of your [posterior] and turn off the TV, or make you order one Big Mac instead of two? Probably not. … It’s the right general direction to go, but our old point is still relevant because this article demonstrates how methodologically challenging these kinds of analyses can be.”
The debate depends partly on how widely the health-care system is defined. “The health-care system ought to take responsibility,” for disease rates, says Ellen Nolte, director of health and healthcare for RAND Europe and co-author of the mortality-rate study. “It really is a case of integrating prevention and treatment rather than leaving the former to other sectors and only the latter to health care.”
An alternate analysis, focusing on prostate cancer and breast cancer, found signs of improvement in treatment and death prevention for those diseases in the U.S. and concluded that the country’s poor life-expectancy ranking “is not likely to be a result of a poorly functioning health-care system.” Samuel H. Preston, a sociologist at the University of Pennsylvania, pointed out that Nolte’s study focused on mortality by age 75, whereas the U.S. is strongest at later ages. Nolte counters that the Preston study examines only a select set of diseases, not the broader spectrum of her study.
Another problem with comparing countries by disease outcomes is that definitions and measurement “can vary within a country and across countries, even when the true prevalence is identical,” according to Alan Garber, an economist and professor of medicine at Stanford University. “There have been many efforts to standardize disease reporting across nations but it’s a tough challenge.”
Still other studies, though, also rank the U.S. low compared to its peers. “It still looks as if the U.S. is lagging behind,” said Jon Skinner, an economist at Dartmouth.
Further reading: The New York Times recently analyzed one of the newer comparative health-care studies. Here’s the WHO’s press release about its initial report, and a recent Politifact post evaluating the U.S.’s supposed No. 37 ranking.
Sunday, October 25, 2009
To Explain Longevity Gap, Look Past Health System
By JOHN TIERNEY
Published: September 21, 2009
http://www.nytimes.com/2009/09/22/science/22tier.html?_r=1
If you’re not rich and you get sick, in which industrialized country are you likely to get the best treatment?
The conventional answer to this question has been: anywhere but the United States. With its many uninsured citizens and its relatively low life expectancy, the United States has been relegated to the bottom of international health scorecards.
But a prominent researcher, Samuel H. Preston, has taken a closer look at the growing body of international data, and he finds no evidence that America’s health care system is to blame for the longevity gap between it and other industrialized countries. In fact, he concludes, the American system in many ways provides superior treatment even when uninsured Americans are included in the analysis.
“The U.S. actually does a pretty good job of identifying and treating the major diseases,” says Dr. Preston, a demographer at the University of Pennsylvania who is among the leading experts on mortality rates from disease. “The international comparisons don’t show we’re in dire straits.”
No one denies that the American system has problems, including its extraordinarily high costs and unnecessary treatments. But Dr. Preston and other researchers say that the costs aren’t solely due to inefficiency. Americans pay more for health care partly because they get more thorough treatment for some diseases, and partly because they get sick more often than people in Europe and other industrialized countries.
An American’s life expectancy at birth is about 78 years, which is lower than in most other affluent countries. Life expectancy is about 80 in the United Kingdom, 81 in Canada and France, and 83 in Japan, according to the World Health Organization.
This longevity gap, Dr. Preston says, is primarily due to the relatively high rates of sickness and death among middle-aged Americans, chiefly from heart disease and cancer. Many of those deaths have been attributed to the health care system, an especially convenient target for those who favor a European alternative.
But there are many more differences between Europe and the United States than just the health care system. Americans are more ethnically diverse. They eat different food. They are fatter. Perhaps most important, they used to be exceptionally heavy smokers. For four decades, until the mid-1980s, per-capita cigarette consumption was higher in the United States (particularly among women) than anywhere else in the developed world. Dr. Preston and other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries.
As it is, the longevity gap starts at birth and persists through middle age, but then it eventually disappears. If you reach 80 in the United States, your life expectancy is longer than in most other developed countries. The United States is apparently doing something right for its aging population, but what?
One frequent answer has been Medicare. Its universal coverage for people over 65 has often been credited with shrinking the longevity gap between the United States and other developed countries.
But when Dr. Preston and a Penn colleague, Jessica Y. Ho, looked at mortality rates in 1965, before Medicare went into effect, they found an even more pronounced version of today’s pattern: middle-aged people died much more often in the United States than in other developed countries, but the longevity gap shrunk with age even faster than today. In that pre-Medicare era, an American who reached 75 could expect to live longer than most people elsewhere.
Besides smoking, there could be lots of other reasons that Americans are especially unhealthy in middle age. But Dr. Preston says he saw no evidence for the much-quoted estimates that poor health care is responsible for more preventable deaths in the United States than in other developed countries. (Go to nytimes.com/tierneylab for details.)
For all its faults, the American system compares well by some important measures with other developed countries, as Dr. Preston and Ms. Ho enumerate. Americans are more likely to be screened for cancer, and once cancer is detected, they are more likely to survive for five years.
It’s been argued that the survival rate for cancer appears longer in America merely because the disease is detected earlier, but Dr. Preston says that earlier detection can be an advantage in itself, and that Americans might also receive better treatment. He and Ms. Ho conclude that the mortality rates from breast cancer and prostate cancer have been declining significantly faster in the United States than in other industrialized countries.
Americans also do relatively well in surviving heart attacks and strokes, and some studies have found that hypertension is treated more successfully in the United States. Compared with Europeans, Americans are more likely to receive medication if they have heart disease, high cholesterol, lung disease or osteoporosis.
But even if the American system does provide more treatment for more sick people, couldn’t it do something to reduce its workload?
When I brought up Dr. Preston’s work to Ellen Nolte and C. Martin McKee, two prominent European critics of the American system, they suggested that he was taking too limited a view of health care. They said the system should take responsibility for preventing disease, not just treating it.
Dr. Preston acknowledges that the United States might do more to keep young and middle-aged people from getting sick, but he says it’s not clear that other countries’ systems are more effective.
“The U.S. has had one spectacular achievement in preventive medicine,” he says. “It has had the largest drop in cigarette consumption per adult of any developed country since 1985.” If Americans keep shunning cigarettes, the longevity gap could shrink no matter what happens with the health care system.
Published: September 21, 2009
http://www.nytimes.com/2009/09/22/science/22tier.html?_r=1
If you’re not rich and you get sick, in which industrialized country are you likely to get the best treatment?
The conventional answer to this question has been: anywhere but the United States. With its many uninsured citizens and its relatively low life expectancy, the United States has been relegated to the bottom of international health scorecards.
But a prominent researcher, Samuel H. Preston, has taken a closer look at the growing body of international data, and he finds no evidence that America’s health care system is to blame for the longevity gap between it and other industrialized countries. In fact, he concludes, the American system in many ways provides superior treatment even when uninsured Americans are included in the analysis.
“The U.S. actually does a pretty good job of identifying and treating the major diseases,” says Dr. Preston, a demographer at the University of Pennsylvania who is among the leading experts on mortality rates from disease. “The international comparisons don’t show we’re in dire straits.”
No one denies that the American system has problems, including its extraordinarily high costs and unnecessary treatments. But Dr. Preston and other researchers say that the costs aren’t solely due to inefficiency. Americans pay more for health care partly because they get more thorough treatment for some diseases, and partly because they get sick more often than people in Europe and other industrialized countries.
An American’s life expectancy at birth is about 78 years, which is lower than in most other affluent countries. Life expectancy is about 80 in the United Kingdom, 81 in Canada and France, and 83 in Japan, according to the World Health Organization.
This longevity gap, Dr. Preston says, is primarily due to the relatively high rates of sickness and death among middle-aged Americans, chiefly from heart disease and cancer. Many of those deaths have been attributed to the health care system, an especially convenient target for those who favor a European alternative.
But there are many more differences between Europe and the United States than just the health care system. Americans are more ethnically diverse. They eat different food. They are fatter. Perhaps most important, they used to be exceptionally heavy smokers. For four decades, until the mid-1980s, per-capita cigarette consumption was higher in the United States (particularly among women) than anywhere else in the developed world. Dr. Preston and other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries.
As it is, the longevity gap starts at birth and persists through middle age, but then it eventually disappears. If you reach 80 in the United States, your life expectancy is longer than in most other developed countries. The United States is apparently doing something right for its aging population, but what?
One frequent answer has been Medicare. Its universal coverage for people over 65 has often been credited with shrinking the longevity gap between the United States and other developed countries.
But when Dr. Preston and a Penn colleague, Jessica Y. Ho, looked at mortality rates in 1965, before Medicare went into effect, they found an even more pronounced version of today’s pattern: middle-aged people died much more often in the United States than in other developed countries, but the longevity gap shrunk with age even faster than today. In that pre-Medicare era, an American who reached 75 could expect to live longer than most people elsewhere.
Besides smoking, there could be lots of other reasons that Americans are especially unhealthy in middle age. But Dr. Preston says he saw no evidence for the much-quoted estimates that poor health care is responsible for more preventable deaths in the United States than in other developed countries. (Go to nytimes.com/tierneylab for details.)
For all its faults, the American system compares well by some important measures with other developed countries, as Dr. Preston and Ms. Ho enumerate. Americans are more likely to be screened for cancer, and once cancer is detected, they are more likely to survive for five years.
It’s been argued that the survival rate for cancer appears longer in America merely because the disease is detected earlier, but Dr. Preston says that earlier detection can be an advantage in itself, and that Americans might also receive better treatment. He and Ms. Ho conclude that the mortality rates from breast cancer and prostate cancer have been declining significantly faster in the United States than in other industrialized countries.
Americans also do relatively well in surviving heart attacks and strokes, and some studies have found that hypertension is treated more successfully in the United States. Compared with Europeans, Americans are more likely to receive medication if they have heart disease, high cholesterol, lung disease or osteoporosis.
But even if the American system does provide more treatment for more sick people, couldn’t it do something to reduce its workload?
When I brought up Dr. Preston’s work to Ellen Nolte and C. Martin McKee, two prominent European critics of the American system, they suggested that he was taking too limited a view of health care. They said the system should take responsibility for preventing disease, not just treating it.
Dr. Preston acknowledges that the United States might do more to keep young and middle-aged people from getting sick, but he says it’s not clear that other countries’ systems are more effective.
“The U.S. has had one spectacular achievement in preventive medicine,” he says. “It has had the largest drop in cigarette consumption per adult of any developed country since 1985.” If Americans keep shunning cigarettes, the longevity gap could shrink no matter what happens with the health care system.
Thursday, October 15, 2009
What's Wrong With our Health Care Today
The economics of health care is a very complex issue and one that I believe is poorly understood by most, including policymakers, providers, and, more importantly, the consumers.
There are many reasons for the skyrocketing costs of health care and while much of the cost is justifiable and driven by the cost of research and technology and the pursuit of improving quality, there are many less justifiable factors driving up the costs such as greed, waste, and inefficiency.
While all players in the health care arena, including providers, payors, and consumers, will point to each other and lay blame to the greed, waste, and inefficiency, in reality, every one of us is responsible for the present state of affairs.Payors, including HMOs and insurance companies and their executives are making billions of dollars and profit every year while providers waste hundreds of millions of dollars if not billions of dollars in the excessive use of costly technology, over specialization, the overprescribing of medication and other treatments, and the practice of defensive medicine. The consumers, meanwhile, also contribute to the cost crisis by their demand for and overuse of high-tech and high cost medical care as well as their excessive lifestyles (e.g., smoking, drinking, obesity), and their underutilization of prevention and routine health maintenance.
While I do not profess to have all the answers to this complex and vexing problem, I do believe that the solution can only be found in the principles and practices of a free market system. I can envision competition between small and efficient independent medical practices and the ‘corporate giants’ or HMOs and insurance companies that are the only game in town.As we all know, the delivery of care in large corporate systems is very costly, if for no other reason overhead. Someone has to pay for the steel and concrete, the luxurious surroundings, the exorbitant salaries of the executives, legions of worker’s, and so on and so on—much of which has nothing to do with actual care as big shiny buildings with fancy trappings offer little to the care of diabetes or a broken leg. These systems are by their very nature designed to acquire and provide the latest and greatest in technological advances to be one step ahead of their competitors and at par with the Mayo clinic, again—at a price.
The establishment of consumer driven low-cost ambulatory care clinics is a relatively new phenomenon that is popping up throughout the country (these were called family doctor and GP clinics before). In these clinics physicians are returning to their Hippocratic roots and focusing less on providing the ‘latest and the greatest’ (and costliest) in health care, instead refocusing on the ‘art of medicine’ or that aspect of medicine that deals with care and compassion and that costs essentially nothing to provide. They are also eschewing the insurance companies and the ‘corporate giants’ and are returning to fee-for-service practices that are emphasizing the time-honored tradition of the patient-physician relationship—without the insurance company (or government) in the middle. They are rightfully returning the responsibility of health care to where it belongs—the patient and the consumer—and they are doing it with much less cost to the patient and society.
Every doctor in this country and the world knows that most patients do not require high-tech and high-cost medical care. In fact, study after study, both clinical and epidemiological, have shown that over 90% of medical care can be provided in an office based, low-tech setting at very low cost. Yet, we continue to use—and our patients continue to demand—the latest and costliest scanners, tests, and procedures, to diagnose and treat disease when the careful and thoughtful use of our eyes, ears, and hands would provide us with the correct diagnosis over 90% of the time. We continue to overprescribe costly medication and treatments when watchful waiting, an empathetic touch, or sage advice would suffice.
Quite frankly, we have sacrificed the ‘art of medicine’ for the ‘science of medicine’ and it is the glamorization of this insidious transition of medicine in the media and in society that perpetuates such an unfortunate and costly trend.As long as we have a system in which a third party is responsible for paying for the individual’s needs regardless of the commodity and regardless if it is government or privately sponsored, there will always be excesses in terms of waste, greed, and inefficiency at all levels of the system, including the payor, the provider of the service or product, and the consumer. Another way of looking at it is that as long as there is the perception that “someone else is paying for it”, we are all, by human nature, going to want the best there is to offer and the companies that are paying for it and delivering it are going to do everything they can to get us to take something less.
There are many reasons for the skyrocketing costs of health care and while much of the cost is justifiable and driven by the cost of research and technology and the pursuit of improving quality, there are many less justifiable factors driving up the costs such as greed, waste, and inefficiency.
While all players in the health care arena, including providers, payors, and consumers, will point to each other and lay blame to the greed, waste, and inefficiency, in reality, every one of us is responsible for the present state of affairs.Payors, including HMOs and insurance companies and their executives are making billions of dollars and profit every year while providers waste hundreds of millions of dollars if not billions of dollars in the excessive use of costly technology, over specialization, the overprescribing of medication and other treatments, and the practice of defensive medicine. The consumers, meanwhile, also contribute to the cost crisis by their demand for and overuse of high-tech and high cost medical care as well as their excessive lifestyles (e.g., smoking, drinking, obesity), and their underutilization of prevention and routine health maintenance.
While I do not profess to have all the answers to this complex and vexing problem, I do believe that the solution can only be found in the principles and practices of a free market system. I can envision competition between small and efficient independent medical practices and the ‘corporate giants’ or HMOs and insurance companies that are the only game in town.As we all know, the delivery of care in large corporate systems is very costly, if for no other reason overhead. Someone has to pay for the steel and concrete, the luxurious surroundings, the exorbitant salaries of the executives, legions of worker’s, and so on and so on—much of which has nothing to do with actual care as big shiny buildings with fancy trappings offer little to the care of diabetes or a broken leg. These systems are by their very nature designed to acquire and provide the latest and greatest in technological advances to be one step ahead of their competitors and at par with the Mayo clinic, again—at a price.
The establishment of consumer driven low-cost ambulatory care clinics is a relatively new phenomenon that is popping up throughout the country (these were called family doctor and GP clinics before). In these clinics physicians are returning to their Hippocratic roots and focusing less on providing the ‘latest and the greatest’ (and costliest) in health care, instead refocusing on the ‘art of medicine’ or that aspect of medicine that deals with care and compassion and that costs essentially nothing to provide. They are also eschewing the insurance companies and the ‘corporate giants’ and are returning to fee-for-service practices that are emphasizing the time-honored tradition of the patient-physician relationship—without the insurance company (or government) in the middle. They are rightfully returning the responsibility of health care to where it belongs—the patient and the consumer—and they are doing it with much less cost to the patient and society.
Every doctor in this country and the world knows that most patients do not require high-tech and high-cost medical care. In fact, study after study, both clinical and epidemiological, have shown that over 90% of medical care can be provided in an office based, low-tech setting at very low cost. Yet, we continue to use—and our patients continue to demand—the latest and costliest scanners, tests, and procedures, to diagnose and treat disease when the careful and thoughtful use of our eyes, ears, and hands would provide us with the correct diagnosis over 90% of the time. We continue to overprescribe costly medication and treatments when watchful waiting, an empathetic touch, or sage advice would suffice.
Quite frankly, we have sacrificed the ‘art of medicine’ for the ‘science of medicine’ and it is the glamorization of this insidious transition of medicine in the media and in society that perpetuates such an unfortunate and costly trend.As long as we have a system in which a third party is responsible for paying for the individual’s needs regardless of the commodity and regardless if it is government or privately sponsored, there will always be excesses in terms of waste, greed, and inefficiency at all levels of the system, including the payor, the provider of the service or product, and the consumer. Another way of looking at it is that as long as there is the perception that “someone else is paying for it”, we are all, by human nature, going to want the best there is to offer and the companies that are paying for it and delivering it are going to do everything they can to get us to take something less.
If Health Care Were Cars
If health care were cars and cars were indispensable in our lives and we as a society “felt” that it was a right that everyone had a car but each person was responsible to buy their own car, each person would buy a car according to their means with most people buying a modestly priced car that served their needs. There would of course be those on either side of the affluent bell-curve buying either a more or less expensive car, but cars, none-the-less, that served their basic needs. There would of course be those that could not afford a car at all, but I’m sure society (or the government) could come up with a ‘safety net’ for them called “Medicar”. There would be car dealers competing with each other in a free market for those consumers who would of course negotiate with the dealers for a fair market value.
However, introduce a third party payor who comes to the consumer and says; “cars are expensive--pay me a monthly premium each month with a matching amount from your employer and you can have whichever car you want and in fact, you can trade in your car each year and for a little more money, we will even repair it for you at no cost to you should it break down. In such a system, which cars would we as the consumer request and the dealer as a provider recommend? I bet we would be seeing a heck of a lot more late-model Mercedes than Ford Focuses on the road.
Now, let’s say that after a while, the third party payers decided that they were not making enough profits or even—God forbid—losing money in such a system and they decided to limit the type of car you could get and how many times you could take it in for repairs. I would imagine then that there would be less Mercedes, but since there was still competition with other payors, there would be maybe more Cadillacs on the road.
To take the analogy a bit further, let’s say the payors decide that they are still not making enough profits and they come up with the brilliant idea of buying all the dealers and making the salesmen employees who together, are also the producers of the cars. Up to now, the dealers had a fiduciary, legal, and a moral responsibility to the consumer; that is to provide him or her with a safe and dependable car at a fair market price—especially if he or she wanted that consumer to come back. Now as an employee of the dealership and the payor, the salesperson has competing and conflicting responsibilities. He or she still has a moral and legal responsibility to the consumer, but a fiduciary responsibility to the person that signs his or her check. The consumer still expects a high quality car, especially because premiums keep going up, and the salesperson is stuck between recommending a high quality but expensive model and feeling the pressure of his or her employer to keep costs down. I would then imagine the salesperson offering a car of a little less quality or expense or both, but still with plenty of extras to satisfy the consumer like perhaps a Honda or Nissan—especially if he or she was afraid of being sued for recommending a less expensive model.
That is where we are today—with a costly and broken system with everyone expecting at least a late-model Honda and a costlier more high-tech model each year, even though a Ford Focus would be just as functional and a lot less expensive. The payors are trying to maximize profits for their executive bonuses and their shareholders and are doing everything they can to limit the type of car you get and even ration the number of times you can have it repaired or trade it in. The salesmen are perfectly content with their relatively nice salaries and benefits packages their employers—the payors—are providing them, including the fat bonuses they get every time they get you to take a Focus. The people that don’t have a car or one that is not dependable are crying the loudest—even though they represent a minority (about 14% of the total population at best) because they see everyone around them driving new Hondas and Nissans and they want one too. Of course, the individual states along with the government are providing some Yugos which are perfectly functional to some of the poorest of these individuals in a program called “Car-aid”.
Now what if we as a society decided that having a car was now a basic right for everyone—especially because our president said it is so? Would we make everyone buy a car and penalize those (and their employer) that couldn’t or those that just wanted to take a bus or a taxi or even walk? And if we did decide that everyone had to have a car, would we establish a public option system to compete with the private payers but still offer the same expensive and less efficient models as their competitors or would it be better and much less costly to enact legislation that would level the playing field and promote competition between the existing payors who control access, delivery, product, and cost with smaller and more efficient independent dealerships that can negotiate much better rates directly with their consumers and still provide them with a dependable and high quality car that would serve over 90% of their consumers? We could then let the big giants fight for the 10% of those that just have to have the higher end cars.
Lastly, if we decided that we had to go to a single payor car-provider system— would we require everyone to have a Focus or a Mercedes? I don’t know about you, but as a taxpayer, if I had to—I guess I wouldn’t mind paying for all of us to have a Focus if it was functional and served all of our needs, but I sure wouldn’t want to pay for everyone to drive a Mercedes if they don’t need it! I might even begrudgingly pay a little more taxes so our elected officials at the highest levels of government could all drive Mercedes—after all, we are the richest and most powerful nation in the world and we can’t have our politicians driving around in Ford Focuses or Hondas.
Now we haven’t even begun to discuss “Medicar” in our analogy with its huge budget and associated waste, fraud, and inefficiency trying to provide 30 some million elderly people with fully loaded Cadillacs. Nor have we discussed the ridiculous situation that an independent salesman and car producer who wants to sell his cars less expensively could not sell his cars to customers for a price that was fair and profitable—but below that that “Medicar” would pay a ‘participating dealer’ providing the same car— without the risk of being fined and going to jail.
However, introduce a third party payor who comes to the consumer and says; “cars are expensive--pay me a monthly premium each month with a matching amount from your employer and you can have whichever car you want and in fact, you can trade in your car each year and for a little more money, we will even repair it for you at no cost to you should it break down. In such a system, which cars would we as the consumer request and the dealer as a provider recommend? I bet we would be seeing a heck of a lot more late-model Mercedes than Ford Focuses on the road.
Now, let’s say that after a while, the third party payers decided that they were not making enough profits or even—God forbid—losing money in such a system and they decided to limit the type of car you could get and how many times you could take it in for repairs. I would imagine then that there would be less Mercedes, but since there was still competition with other payors, there would be maybe more Cadillacs on the road.
To take the analogy a bit further, let’s say the payors decide that they are still not making enough profits and they come up with the brilliant idea of buying all the dealers and making the salesmen employees who together, are also the producers of the cars. Up to now, the dealers had a fiduciary, legal, and a moral responsibility to the consumer; that is to provide him or her with a safe and dependable car at a fair market price—especially if he or she wanted that consumer to come back. Now as an employee of the dealership and the payor, the salesperson has competing and conflicting responsibilities. He or she still has a moral and legal responsibility to the consumer, but a fiduciary responsibility to the person that signs his or her check. The consumer still expects a high quality car, especially because premiums keep going up, and the salesperson is stuck between recommending a high quality but expensive model and feeling the pressure of his or her employer to keep costs down. I would then imagine the salesperson offering a car of a little less quality or expense or both, but still with plenty of extras to satisfy the consumer like perhaps a Honda or Nissan—especially if he or she was afraid of being sued for recommending a less expensive model.
That is where we are today—with a costly and broken system with everyone expecting at least a late-model Honda and a costlier more high-tech model each year, even though a Ford Focus would be just as functional and a lot less expensive. The payors are trying to maximize profits for their executive bonuses and their shareholders and are doing everything they can to limit the type of car you get and even ration the number of times you can have it repaired or trade it in. The salesmen are perfectly content with their relatively nice salaries and benefits packages their employers—the payors—are providing them, including the fat bonuses they get every time they get you to take a Focus. The people that don’t have a car or one that is not dependable are crying the loudest—even though they represent a minority (about 14% of the total population at best) because they see everyone around them driving new Hondas and Nissans and they want one too. Of course, the individual states along with the government are providing some Yugos which are perfectly functional to some of the poorest of these individuals in a program called “Car-aid”.
Now what if we as a society decided that having a car was now a basic right for everyone—especially because our president said it is so? Would we make everyone buy a car and penalize those (and their employer) that couldn’t or those that just wanted to take a bus or a taxi or even walk? And if we did decide that everyone had to have a car, would we establish a public option system to compete with the private payers but still offer the same expensive and less efficient models as their competitors or would it be better and much less costly to enact legislation that would level the playing field and promote competition between the existing payors who control access, delivery, product, and cost with smaller and more efficient independent dealerships that can negotiate much better rates directly with their consumers and still provide them with a dependable and high quality car that would serve over 90% of their consumers? We could then let the big giants fight for the 10% of those that just have to have the higher end cars.
Lastly, if we decided that we had to go to a single payor car-provider system— would we require everyone to have a Focus or a Mercedes? I don’t know about you, but as a taxpayer, if I had to—I guess I wouldn’t mind paying for all of us to have a Focus if it was functional and served all of our needs, but I sure wouldn’t want to pay for everyone to drive a Mercedes if they don’t need it! I might even begrudgingly pay a little more taxes so our elected officials at the highest levels of government could all drive Mercedes—after all, we are the richest and most powerful nation in the world and we can’t have our politicians driving around in Ford Focuses or Hondas.
Now we haven’t even begun to discuss “Medicar” in our analogy with its huge budget and associated waste, fraud, and inefficiency trying to provide 30 some million elderly people with fully loaded Cadillacs. Nor have we discussed the ridiculous situation that an independent salesman and car producer who wants to sell his cars less expensively could not sell his cars to customers for a price that was fair and profitable—but below that that “Medicar” would pay a ‘participating dealer’ providing the same car— without the risk of being fined and going to jail.
What we need Washington to do
All we need is for our government to enact legislation that levels the playing field and allows small and independent practitioners--primarily primary care/ambulatory care--to compete in a free market entrepeneurial environment without the fear of being smashed like a bug by the huge corporate giants (HMOs). Small, efficient, independent practices can provide the majority of medical care in a community with much less overhead and expense than the huge HMOs. They can also negotiate directly with the patient for payment and with employers. Hospitals and HMOs should be concerned with less than 10% of health care that requires high cost, high-tech care. The specialists can be employed by them, if they so wish, but the primary care physicians should be independent!
Of course, this can not be done without real tort reform and other legislative changes--and without paradigm shift in our collective thinking as physicians. We must get out of the mode of fixing a broken system when we are part of the broken system. We need to think like businessmen/women AND as physicians. Otherwise we are slaves to the corporations that employ us and control us.
How can this occur? 1. Real tort reform with punishment for frivolous law suits and "lose you pay" changes. Caps on damages with payments amortized over calculated lifetimes, just like they do lottery winnings,and limits on contingincey fees for attorneys. 2. Loan repayment, tax credits, and interest free or low interest guaranteed loans for physicians--especially primary care-- to open private practices. 3. Legislation making it unlawful for the big HMOS and other carriers in the state to exclude all willing providers. 4. At least in our state, repeal of the gross receipt tax on medical care.
It is ironic that my small fee-for-service practice has to pay 7% gross receipts tax, yet the insurance companies are exempt! This can be done! I have done it and have been successful in a state that is not particulary doctor friendly with only 3 major players offering coverage and two of them are HMOs--and without any of the reforms that I have listed that would allow small independent practices to thrive and flourish. We need to take back our profession and control what we sacrificed the majority of our lives to attain.
Of course, this can not be done without real tort reform and other legislative changes--and without paradigm shift in our collective thinking as physicians. We must get out of the mode of fixing a broken system when we are part of the broken system. We need to think like businessmen/women AND as physicians. Otherwise we are slaves to the corporations that employ us and control us.
How can this occur? 1. Real tort reform with punishment for frivolous law suits and "lose you pay" changes. Caps on damages with payments amortized over calculated lifetimes, just like they do lottery winnings,and limits on contingincey fees for attorneys. 2. Loan repayment, tax credits, and interest free or low interest guaranteed loans for physicians--especially primary care-- to open private practices. 3. Legislation making it unlawful for the big HMOS and other carriers in the state to exclude all willing providers. 4. At least in our state, repeal of the gross receipt tax on medical care.
It is ironic that my small fee-for-service practice has to pay 7% gross receipts tax, yet the insurance companies are exempt! This can be done! I have done it and have been successful in a state that is not particulary doctor friendly with only 3 major players offering coverage and two of them are HMOs--and without any of the reforms that I have listed that would allow small independent practices to thrive and flourish. We need to take back our profession and control what we sacrificed the majority of our lives to attain.
Health Care Is Not A Right
Health Care Is Not A Rightby Leonard Peikoff (January 23, 1998)Delivered at a Town Hall Meeting on the Clinton Health Plan Red Lion Hotel, Costa Mesa CA December 11, 1993Good morning, ladies and gentlemen: Most people who oppose socialized medicine do so on the grounds that it is moral and well-intentioned, but impractical; i.e., it is a noble idea -- which just somehow does not work. I do not agree that socialized medicine is moral and well-intentioned, but impractical. Of course, it is impractical -- it does not work -- but I hold that it is impractical because it is immoral. This is not a case of noble in theory but a failure in practice; it is a case of vicious in theory and therefore a disaster in practice. So I'm going to leave it to other speakers to concentrate on the practical flaws in the Clinton health plan. I want to focus on the moral issue at stake. So long as people believe that socialized medicine is a noble plan, there is no way to fight it. You cannot stop a noble plan -- not if it really is noble. The only way you can defeat it is to unmask it -- to show that it is the very opposite of noble. Then at least you have a fighting chance.
What is morality in this context? The American concept of it is officially stated in the Declaration of Independence. It upholds man's unalienable, individual rights. The term "rights," note, is a moral (not just a political) term; it tells us that a certain course of behavior is right, sanctioned, proper, a prerogative to be respected by others, not interfered with -- and that anyone who violates a man's rights is: wrong, morally wrong, unsanctioned, evil.
Now our only rights, the American viewpoint continues, are the rights to life, liberty, property, and the pursuit of happiness. That's all. According to the Founding Fathers, we are not born with a right to a trip to Disneyland, or a meal at Mcdonald's, or a kidney dialysis (nor with the 18th-century equivalent of these things). We have certain specific rights -- and only these.
Why only these? Observe that all legitimate rights have one thing in common: they are rights to action, not to rewards from other people. The American rights impose no obligations on other people, merely the negative obligation to leave you alone. The system guarantees you the chance to work for what you want -- not to be given it without effort by somebody else.
The right to life, e.g., does not mean that your neighbors have to feed and clothe you; it means you have the right to earn your food and clothes yourself, if necessary by a hard struggle, and that no one can forcibly stop your struggle for these things or steal them from you if and when you have achieved them. In other words: you have the right to act, and to keep the results of your actions, the products you make, to keep them or to trade them with others, if you wish. But you have no right to the actions or products of others, except on terms to which they voluntarily agree.
To take one more example: the right to the pursuit of happiness is precisely that: the right to the pursuit -- to a certain type of action on your part and its result -- not to any guarantee that other people will make you happy or even try to do so. Otherwise, there would be no liberty in the country: if your mere desire for something, anything, imposes a duty on other people to satisfy you, then they have no choice in their lives, no say in what they do, they have no liberty, they cannot pursue their happiness. Your "right" to happiness at their expense means that they become rightless serfs, i.e., your slaves. Your right to anything at others' expense means that they become rightless.
That is why the U.S. system defines rights as it does, strictly as the rights to action. This was the approach that made the U.S. the first truly free country in all world history -- and, soon afterwards, as a result, the greatest country in history, the richest and the most powerful. It became the most powerful because its view of rights made it the most moral. It was the country of individualism and personal independence.
Today, however, we are seeing the rise of principled immorality in this country. We are seeing a total abandonment by the intellectuals and the politicians of the moral principles on which the U.S. was founded. We are seeing the complete destruction of the concept of rights. The original American idea has been virtually wiped out, ignored as if it had never existed. The rule now is for politicians to ignore and violate men's actual rights, while arguing about a whole list of rights never dreamed of in this country's founding documents -- rights which require no earning, no effort, no action at all on the part of the recipient.
You are entitled to something, the politicians say, simply because it exists and you want or need it -- period. You are entitled to be given it by the government. Where does the government get it from? What does the government have to do to private citizens -- to their individual rights -- to their real rights -- in order to carry out the promise of showering free services on the people?
The answers are obvious. The newfangled rights wipe out real rights -- and turn the people who actually create the goods and services involved into servants of the state. The Russians tried this exact system for many decades. Unfortunately, we have not learned from their experience. Yet the meaning of socialism (this is the right name for Clinton's medical plan) is clearly evident in any field at all -- you don't need to think of health care as a special case; it is just as apparent if the government were to proclaim a universal right to food, or to a vacation, or to a haircut. I mean: a right in the new sense: not that you are free to earn these things by your own effort and trade, but that you have a moral claim to be given these things free of charge, with no action on your part, simply as handouts from a benevolent government.
How would these alleged new rights be fulfilled? Take the simplest case: you are born with a moral right to hair care, let us say, provided by a loving government free of charge to all who want or need it. What would happen under such a moral theory?
Haircuts are free, like the air we breathe, so some people show up every day for an expensive new styling, the government pays out more and more, barbers revel in their huge new incomes, and the profession starts to grow ravenously, bald men start to come in droves for free hair implantations, a school of fancy, specialized eyebrow pluckers develops -- it's all free, the government pays. The dishonest barbers are having a field day, of course -- but so are the honest ones; they are working and spending like mad, trying to give every customer his heart's desire, which is a millionaire's worth of special hair care and services -- the government starts to scream, the budget is out of control. Suddenly directives erupt: we must limit the number of barbers, we must limit the time spent on haircuts, we must limit the permissible type of hair styles; bureaucrats begin to split hairs about how many hairs a barber should be allowed to split. A new computerized office of records filled with inspectors and red tape shoots up; some barbers, it seems, are still getting too rich, they must be getting more than their fair share of the national hair, so barbers have to start applying for Certificates of Need in order to buy razors, while peer review boards are established to assess every stylist's work, both the dishonest and the overly honest alike, to make sure that no one is too bad or too good or too busy or too unbusy. Etc. In the end, there are lines of wretched customers waiting for their chance to be routinely scalped by bored, hog-tied haircutters some of whom remember dreamily the old days when somehow everything was so much better.
Do you think the situation would be improved by having hair-care cooperatives organized by the government? -- having them engage in managed competition, managed by the government, in order to buy haircut insurance from companies controlled by the government?
If this is what would happen under government-managed hair care, what else can possibly happen -- it is already starting to happen -- under the idea of health care as a right? Health care in the modern world is a complex, scientific, technological service. How can anybody be born with a right to such a thing?
Under the American system you have a right to health care if you can pay for it, i.e., if you can earn it by your own action and effort. But nobody has the right to the services of any professional individual or group simply because he wants them and desperately needs them. The very fact that he needs these services so desperately is the proof that he had better respect the freedom, the integrity, and the rights of the people who provide them.
You have a right to work, not to rob others of the fruits of their work, not to turn others into sacrificial, rightless animals laboring to fulfill your needs.
Some of you may ask here: But can people afford health care on their own? Even leaving aside the present government-inflated medical prices, the answer is: Certainly people can afford it. Where do you think the money is coming from right now to pay for it all -- where does the government get its fabled unlimited money? Government is not a productive organization; it has no source of wealth other than confiscation of the citizens' wealth, through taxation, deficit financing or the like.
But, you may say, isn't it the "rich" who are really paying the costs of medical care now -- the rich, not the broad bulk of the people? As has been proved time and again, there are not enough rich anywhere to make a dent in the government's costs; it is the vast middle class in the U.S. that is the only source of the kind of money that national programs like government health care require. A simple example of this is the fact that the Clinton Administration's new program rests squarely on the backs not of Big Business, but of small businessmen who are struggling in today's economy merely to stay alive and in existence. Under any socialized program, it is the "little people" who do most of the paying for it -- under the senseless pretext that "the people" can't afford such and such, so the government must take over. If the people of a country truly couldn't afford a certain service -- as e.g. in Somalia -- neither, for that very reason, could any government in that country afford it, either.
Some people can't afford medical care in the U.S. But they are necessarily a small minority in a free or even semi-free country. If they were the majority, the country would be an utter bankrupt and could not even think of a national medical program. As to this small minority, in a free country they have to rely solely on private, voluntary charity. Yes, charity, the kindness of the doctors or of the better off -- charity, not right, i.e. not their right to the lives or work of others. And such charity, I may say, was always forthcoming in the past in America. The advocates of Medicaid and Medicare under LBJ did not claim that the poor or old in the '60's got bad care; they claimed that it was an affront for anyone to have to depend on charity.
But the fact is: You don't abolish charity by calling it something else. If a person is getting health care for nothing, simply because he is breathing, he is still getting charity, whether or not President Clinton calls it a "right." To call it a Right when the recipient did not earn it is merely to compound the evil. It is charity still -- though now extorted by criminal tactics of force, while hiding under a dishonest name.
As with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call "medical care" a right will merely enslave the doctors and thus destroy the quality of medical care in this country, as socialized medicine has done around the world, wherever it has been tried, including Canada (I was born in Canada and I know a bit about that system first hand).
I would like to clarify the point about socialized medicine enslaving the doctors. Let me quote here from an article I wrote a few years ago: "Medicine: The Death of a Profession." [The Voice of Reason: Essays in Objectivist Thought, NAL Books, c 1988 by the Estate of Ayn Rand and Leonard Peikoff.]"
In medicine, above all, the mind must be left free. Medical treatment involves countless variables and options that must be taken into account, weighed, and summed up by the doctor's mind and subconscious. Your life depends on the private, inner essence of the doctor's function: it depends on the input that enters his brain, and on the processing such input receives from him. What is being thrust now into the equation? It is not only objective medical facts any longer. Today, in one form or another, the following also has to enter that brain: 'The DRG administrator [in effect, the hospital or HMO man trying to control costs] will raise hell if I operate, but the malpractice attorney will have a field day if I don't -- and my rival down the street, who heads the local PRO [Peer Review Organization], favors a CAT scan in these cases, I can't afford to antagonize him, but the CON boys disagree and they won't authorize a CAT scanner for our hospital -- and besides the FDA prohibits the drug I should be prescribing, even though it is widely used in Europe, and the IRS might not allow the patient a tax deduction for it, anyhow, and I can't get a specialist's advice because the latest Medicare rules prohibit a consultation with this diagnosis, and maybe I shouldn't even take this patient, he's so sick -- after all, some doctors are manipulating their slate of patients, they accept only the healthiest ones, so their average costs are coming in lower than mine, and it looks bad for my staff privileges.' Would you like your case to be treated this way -- by a doctor who takes into account your objective medical needs and the contradictory, unintelligible demands of some ninety different state and Federal government agencies? If you were a doctor could you comply with all of it? Could you plan or work around or deal with the unknowable? But how could you not? Those agencies are real and they are rapidly gaining total power over you and your mind and your patients. In this kind of nightmare world, if and when it takes hold fully, thought is helpless; no one can decide by rational means what to do. A doctor either obeys the loudest authority -- or he tries to sneak by unnoticed, bootlegging some good health care occasionally or, as so many are doing now, he simply gives up and quits the field."
The Clinton (Obama) plan will finish off quality medicine in this country -- because it will finish off the medical profession. It will deliver doctors bound hands and feet to the mercies of the bureaucracy.The only hope -- for the doctors, for their patients, for all of us -- is for the doctors to assert a moral principle. I mean: to assert their own personal individual rights -- their real rights in this issue -- their right to their lives, their liberty, their property, their pursuit of happiness.
The Declaration of Independence applies to the medical profession too. We must reject the idea that doctors are slaves destined to serve others at the behest of the state.I'd like to conclude with a sentence from Ayn Rand. Doctors, she wrote, are not servants of their patients. They are "traders, like everyone else in a free society, and they should bear that title proudly, considering the crucial importance of the services they offer."The battle against the Clinton (Obama) plan, in my opinion, depends on the doctors speaking out against the plan -- but not only on practical grounds -- rather, first of all, on moral grounds. The doctors must defend themselves and their own interests as a matter of solemn justice, upholding a moral principle, the first moral principle: self- preservation. If they can do it, all of us will still have a chance. I hope it is not already too late. Thank you.-- Copies of this address in pamphlet form are available from: Americans for Free Choice in Medicine. Almost ten years ago, Leonard Peikoff predicted that our medical system would be dismantled. Looking at the young people in the crowd, he remarked: "If you are looking for a crusade, there is none that is more idealistic or more practical. This one is devoted to protecting some of the greatest [men] in the history of this country. And it is also, literally, a matter of life and death -- -YOUR LIFE, and that of anyone you love. Don't let it go without a fight!" -- From "Medicine: The Death of a Profession" by Leonard Peikoff from concluding remarks from 1985 presentation with Dr. Michael Peikoff. Visit Dr. Peikoff's website at: http://www.peikoff.com/.com
What is morality in this context? The American concept of it is officially stated in the Declaration of Independence. It upholds man's unalienable, individual rights. The term "rights," note, is a moral (not just a political) term; it tells us that a certain course of behavior is right, sanctioned, proper, a prerogative to be respected by others, not interfered with -- and that anyone who violates a man's rights is: wrong, morally wrong, unsanctioned, evil.
Now our only rights, the American viewpoint continues, are the rights to life, liberty, property, and the pursuit of happiness. That's all. According to the Founding Fathers, we are not born with a right to a trip to Disneyland, or a meal at Mcdonald's, or a kidney dialysis (nor with the 18th-century equivalent of these things). We have certain specific rights -- and only these.
Why only these? Observe that all legitimate rights have one thing in common: they are rights to action, not to rewards from other people. The American rights impose no obligations on other people, merely the negative obligation to leave you alone. The system guarantees you the chance to work for what you want -- not to be given it without effort by somebody else.
The right to life, e.g., does not mean that your neighbors have to feed and clothe you; it means you have the right to earn your food and clothes yourself, if necessary by a hard struggle, and that no one can forcibly stop your struggle for these things or steal them from you if and when you have achieved them. In other words: you have the right to act, and to keep the results of your actions, the products you make, to keep them or to trade them with others, if you wish. But you have no right to the actions or products of others, except on terms to which they voluntarily agree.
To take one more example: the right to the pursuit of happiness is precisely that: the right to the pursuit -- to a certain type of action on your part and its result -- not to any guarantee that other people will make you happy or even try to do so. Otherwise, there would be no liberty in the country: if your mere desire for something, anything, imposes a duty on other people to satisfy you, then they have no choice in their lives, no say in what they do, they have no liberty, they cannot pursue their happiness. Your "right" to happiness at their expense means that they become rightless serfs, i.e., your slaves. Your right to anything at others' expense means that they become rightless.
That is why the U.S. system defines rights as it does, strictly as the rights to action. This was the approach that made the U.S. the first truly free country in all world history -- and, soon afterwards, as a result, the greatest country in history, the richest and the most powerful. It became the most powerful because its view of rights made it the most moral. It was the country of individualism and personal independence.
Today, however, we are seeing the rise of principled immorality in this country. We are seeing a total abandonment by the intellectuals and the politicians of the moral principles on which the U.S. was founded. We are seeing the complete destruction of the concept of rights. The original American idea has been virtually wiped out, ignored as if it had never existed. The rule now is for politicians to ignore and violate men's actual rights, while arguing about a whole list of rights never dreamed of in this country's founding documents -- rights which require no earning, no effort, no action at all on the part of the recipient.
You are entitled to something, the politicians say, simply because it exists and you want or need it -- period. You are entitled to be given it by the government. Where does the government get it from? What does the government have to do to private citizens -- to their individual rights -- to their real rights -- in order to carry out the promise of showering free services on the people?
The answers are obvious. The newfangled rights wipe out real rights -- and turn the people who actually create the goods and services involved into servants of the state. The Russians tried this exact system for many decades. Unfortunately, we have not learned from their experience. Yet the meaning of socialism (this is the right name for Clinton's medical plan) is clearly evident in any field at all -- you don't need to think of health care as a special case; it is just as apparent if the government were to proclaim a universal right to food, or to a vacation, or to a haircut. I mean: a right in the new sense: not that you are free to earn these things by your own effort and trade, but that you have a moral claim to be given these things free of charge, with no action on your part, simply as handouts from a benevolent government.
How would these alleged new rights be fulfilled? Take the simplest case: you are born with a moral right to hair care, let us say, provided by a loving government free of charge to all who want or need it. What would happen under such a moral theory?
Haircuts are free, like the air we breathe, so some people show up every day for an expensive new styling, the government pays out more and more, barbers revel in their huge new incomes, and the profession starts to grow ravenously, bald men start to come in droves for free hair implantations, a school of fancy, specialized eyebrow pluckers develops -- it's all free, the government pays. The dishonest barbers are having a field day, of course -- but so are the honest ones; they are working and spending like mad, trying to give every customer his heart's desire, which is a millionaire's worth of special hair care and services -- the government starts to scream, the budget is out of control. Suddenly directives erupt: we must limit the number of barbers, we must limit the time spent on haircuts, we must limit the permissible type of hair styles; bureaucrats begin to split hairs about how many hairs a barber should be allowed to split. A new computerized office of records filled with inspectors and red tape shoots up; some barbers, it seems, are still getting too rich, they must be getting more than their fair share of the national hair, so barbers have to start applying for Certificates of Need in order to buy razors, while peer review boards are established to assess every stylist's work, both the dishonest and the overly honest alike, to make sure that no one is too bad or too good or too busy or too unbusy. Etc. In the end, there are lines of wretched customers waiting for their chance to be routinely scalped by bored, hog-tied haircutters some of whom remember dreamily the old days when somehow everything was so much better.
Do you think the situation would be improved by having hair-care cooperatives organized by the government? -- having them engage in managed competition, managed by the government, in order to buy haircut insurance from companies controlled by the government?
If this is what would happen under government-managed hair care, what else can possibly happen -- it is already starting to happen -- under the idea of health care as a right? Health care in the modern world is a complex, scientific, technological service. How can anybody be born with a right to such a thing?
Under the American system you have a right to health care if you can pay for it, i.e., if you can earn it by your own action and effort. But nobody has the right to the services of any professional individual or group simply because he wants them and desperately needs them. The very fact that he needs these services so desperately is the proof that he had better respect the freedom, the integrity, and the rights of the people who provide them.
You have a right to work, not to rob others of the fruits of their work, not to turn others into sacrificial, rightless animals laboring to fulfill your needs.
Some of you may ask here: But can people afford health care on their own? Even leaving aside the present government-inflated medical prices, the answer is: Certainly people can afford it. Where do you think the money is coming from right now to pay for it all -- where does the government get its fabled unlimited money? Government is not a productive organization; it has no source of wealth other than confiscation of the citizens' wealth, through taxation, deficit financing or the like.
But, you may say, isn't it the "rich" who are really paying the costs of medical care now -- the rich, not the broad bulk of the people? As has been proved time and again, there are not enough rich anywhere to make a dent in the government's costs; it is the vast middle class in the U.S. that is the only source of the kind of money that national programs like government health care require. A simple example of this is the fact that the Clinton Administration's new program rests squarely on the backs not of Big Business, but of small businessmen who are struggling in today's economy merely to stay alive and in existence. Under any socialized program, it is the "little people" who do most of the paying for it -- under the senseless pretext that "the people" can't afford such and such, so the government must take over. If the people of a country truly couldn't afford a certain service -- as e.g. in Somalia -- neither, for that very reason, could any government in that country afford it, either.
Some people can't afford medical care in the U.S. But they are necessarily a small minority in a free or even semi-free country. If they were the majority, the country would be an utter bankrupt and could not even think of a national medical program. As to this small minority, in a free country they have to rely solely on private, voluntary charity. Yes, charity, the kindness of the doctors or of the better off -- charity, not right, i.e. not their right to the lives or work of others. And such charity, I may say, was always forthcoming in the past in America. The advocates of Medicaid and Medicare under LBJ did not claim that the poor or old in the '60's got bad care; they claimed that it was an affront for anyone to have to depend on charity.
But the fact is: You don't abolish charity by calling it something else. If a person is getting health care for nothing, simply because he is breathing, he is still getting charity, whether or not President Clinton calls it a "right." To call it a Right when the recipient did not earn it is merely to compound the evil. It is charity still -- though now extorted by criminal tactics of force, while hiding under a dishonest name.
As with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call "medical care" a right will merely enslave the doctors and thus destroy the quality of medical care in this country, as socialized medicine has done around the world, wherever it has been tried, including Canada (I was born in Canada and I know a bit about that system first hand).
I would like to clarify the point about socialized medicine enslaving the doctors. Let me quote here from an article I wrote a few years ago: "Medicine: The Death of a Profession." [The Voice of Reason: Essays in Objectivist Thought, NAL Books, c 1988 by the Estate of Ayn Rand and Leonard Peikoff.]"
In medicine, above all, the mind must be left free. Medical treatment involves countless variables and options that must be taken into account, weighed, and summed up by the doctor's mind and subconscious. Your life depends on the private, inner essence of the doctor's function: it depends on the input that enters his brain, and on the processing such input receives from him. What is being thrust now into the equation? It is not only objective medical facts any longer. Today, in one form or another, the following also has to enter that brain: 'The DRG administrator [in effect, the hospital or HMO man trying to control costs] will raise hell if I operate, but the malpractice attorney will have a field day if I don't -- and my rival down the street, who heads the local PRO [Peer Review Organization], favors a CAT scan in these cases, I can't afford to antagonize him, but the CON boys disagree and they won't authorize a CAT scanner for our hospital -- and besides the FDA prohibits the drug I should be prescribing, even though it is widely used in Europe, and the IRS might not allow the patient a tax deduction for it, anyhow, and I can't get a specialist's advice because the latest Medicare rules prohibit a consultation with this diagnosis, and maybe I shouldn't even take this patient, he's so sick -- after all, some doctors are manipulating their slate of patients, they accept only the healthiest ones, so their average costs are coming in lower than mine, and it looks bad for my staff privileges.' Would you like your case to be treated this way -- by a doctor who takes into account your objective medical needs and the contradictory, unintelligible demands of some ninety different state and Federal government agencies? If you were a doctor could you comply with all of it? Could you plan or work around or deal with the unknowable? But how could you not? Those agencies are real and they are rapidly gaining total power over you and your mind and your patients. In this kind of nightmare world, if and when it takes hold fully, thought is helpless; no one can decide by rational means what to do. A doctor either obeys the loudest authority -- or he tries to sneak by unnoticed, bootlegging some good health care occasionally or, as so many are doing now, he simply gives up and quits the field."
The Clinton (Obama) plan will finish off quality medicine in this country -- because it will finish off the medical profession. It will deliver doctors bound hands and feet to the mercies of the bureaucracy.The only hope -- for the doctors, for their patients, for all of us -- is for the doctors to assert a moral principle. I mean: to assert their own personal individual rights -- their real rights in this issue -- their right to their lives, their liberty, their property, their pursuit of happiness.
The Declaration of Independence applies to the medical profession too. We must reject the idea that doctors are slaves destined to serve others at the behest of the state.I'd like to conclude with a sentence from Ayn Rand. Doctors, she wrote, are not servants of their patients. They are "traders, like everyone else in a free society, and they should bear that title proudly, considering the crucial importance of the services they offer."The battle against the Clinton (Obama) plan, in my opinion, depends on the doctors speaking out against the plan -- but not only on practical grounds -- rather, first of all, on moral grounds. The doctors must defend themselves and their own interests as a matter of solemn justice, upholding a moral principle, the first moral principle: self- preservation. If they can do it, all of us will still have a chance. I hope it is not already too late. Thank you.-- Copies of this address in pamphlet form are available from: Americans for Free Choice in Medicine. Almost ten years ago, Leonard Peikoff predicted that our medical system would be dismantled. Looking at the young people in the crowd, he remarked: "If you are looking for a crusade, there is none that is more idealistic or more practical. This one is devoted to protecting some of the greatest [men] in the history of this country. And it is also, literally, a matter of life and death -- -YOUR LIFE, and that of anyone you love. Don't let it go without a fight!" -- From "Medicine: The Death of a Profession" by Leonard Peikoff from concluding remarks from 1985 presentation with Dr. Michael Peikoff. Visit Dr. Peikoff's website at: http://www.peikoff.com/.com
Real Reform Must Come From Within The Profession
Real reform is never going to come from Washington. It has to come from us.
When Obama talks about "keeping what works and making it better and getting rid of what doesn't work", he is really talking about remodeling a house with a fundamentally flawed foundation and doing nothing about fixing the unstable foundation.
That unstable foundation is the third party payer system--as long as we have a system in which a third party is paying for an individual's needs regardless of the commodity and regardless if it is government or privately sponsored, there will always be excesses in terms of waste, greed, and inefficiency at all levels of the system, including the payer, the provider of the service or product, and the consumer. As long as there is the perception that someone else is paying for “it”, human nature dictates that we all will want the best while the payer will do everything possible to provide us with something less.
We as physicians need to recognize that we are speaking about fixing a broken system that we are part of and that we are partly responsible for.
No one may want to hear this--especially the specialists but the fact of the matter is that over 90% of all medical care --which does not require high tech or the "latest and the greatest"--in this country can be delivered inexpensively and efficiently in private offices by primary care physicians. However, we are top heavy in this country with specialists and not enough primary care physicians. And, the majority of the primary care physicians are employed--and controlled--by the very system that we all deplore. On top of that, they prefer to work 9-5 and no weekends, take no call, have no admissions, do no hospital work and make as much money as an ophthalmologist doing 50 Lasik procedures a day!
I am in no way saying that primary care physicians don’t work hard or don’t deserve to make a lot of money, I am simply saying that before managed care and before doctors went to work for them, they worked a lot harder and for relatively less money than today. I do however, think that Lasik or LK is ridiculously overpriced!
When I worked in ERs after I retired from surgery, about 70-80% of what I saw did not need to be seen in the ER, especially after hours and on weekends--and, contrary to popular belief, they were not all indigents or uninsured with no place to go--many of them were insured with no other place to go. They had tried to call their doctor and were told to go to the ER or nearest urgent care! Most ambulatory care or urgent care centers are closed by 10pm and so, if the patients are sick—insurance or no insurance—they either wait it out and suffer at home—or they go to the ER and wait it out and suffer there!
So how do we affect reform? We do it by doing what we learned and what we did best in training. We all succeeded because we were trained and were able to work hard and thrive under adverse conditions. We all were able to use intelligence, experience, and ingenuity to get us through difficult situations—especially difficult patient management situations. We relied on each other—both within and outside our specialties—to accomplish a common goal. Of course we still do these things today; however, self-interest has changed how we do these things!
Reform has to begin with us. Plain and simple. We must retake what is rightfully ours—what we worked so hard and sacrificed much of our lives to attain—that is the responsibility of delivering medical care to society. We have abdicated that role which we had for over 2000 years to “big business” and we are dangerously close to having any remnant of that responsibility taken from us by the government.
We don’t need the government crafting and shoving down our throats ridiculous bills that no one can read and much less understand and that will cost us trillions of dollars—only to give us more of the same.
All we need the government to do is to craft legislation that will level the playing field between doctors, plaintiff’s attorneys, and the huge insurance companies. Then and only then can real and meaningful reform take place with physicians leading the way.
For this to happen however, will require real tort reform, which should include penalties for frivolous lawsuits, loser pays costs and damages, amortization over lifetime of awards, caps on awards, and limits on contingency fees.
To reverse the specialist to primary care ratio that exists today, the government (both state and federal) could offer loan repayment incentives, tax credits, and interest free or low interest loans for physicians--especially primary care docs to open practices. They would be protected from predatory and monopolistic practices by the insurance companies who should actually have nothing to do with them as most patients should be paying for their routine primary care out of pocket. They would negotiate and set prices through free market principles and could negotiate with patients and employers individually or through IPAs.
The states could also mandate that the insurance companies would have to pay "any willing provider" that the patient chooses to see.
The over abundance of specialists would work itself out through market forces...the better ones would succeed, some would retire, and others could change professions or practice primary care.
Insurance companies could be required to only cover uncertainty (as it was designed to do) and especially calamitous uncertainty, like a house fire or a car wreck or an MI or costly procedure(s). Routine visits, routine meds, and screening exams should be paid for out of pocket--giving the patient some responsibility in their care. Insurance companies could provide more coverage for routine care if they wished and patients could elect to buy such coverage, but it would be a traditional indemnity type policy where the patient pays out of pocket and gets reimbursed by the insurance company.
Specialists could continue to be employed by the hospitals or HMOs and/or concentrated in certain “centers of excellence” if they wished and the insurance companies would only be required to pay for this aspect of care--high cost, high-tech care and only if medically necessary. Not just because it is available or just because the patient and/or the media wants it.
True reform can happen and for it to happen it will require work and commitment on our part (which we know well)...which means being available to the patient and providing excellent service AND a quality product.
I am successful because I see people when and where they want me to see them. I see the patient that has insurance and tries to get in to see his PCP only to be told he can't get in or to go to the nearest ER or Urgent Care. And when I do see them, I see them with a smile on my face and I do everything I can within my power to not make them wait! If they have to wait more than a half hour to see me or any of my providers (which is extremely rare) we offer to discount their visit or give them a free visit. If they want to be seen in the middle of the night, I or my providers arrange to see them in our offices or in their home--just like the old days. I can often learn much more from seeing a patient in his or her own environment than I can by performing a 30 minute H&P in my office and without asking a single question. But that is not the point, the point is, that we have shifted care from a provider friendly venue to a patient friendly venue....and that takes extra work and commitment..but it is well worth it and our patients love it.
Today's patients want us to know that they are not just passive participants in their health care--they expect us to respect that their time and needs are just as important as ours.
We all know you can be the smartest and ‘best doctor in the world’, but if your service is bad , it doesn't matter much...and that goes for the office staff.
The old-timers called it the three As--affordable, affable, and available and it is just as applicable today as it was 50 years ago. Unfortunately, we have become anything but the 3As--although I have heard (and used) a few pejorative terms that start with A to describe some doctors (including myself) today.
We can affect reform, but it will not come from marching to Washington or writing letters to congress or closing our offices. It must come from within—within each of us and within the profession. It can be done.
John R. Vigil, MD, FACPE
CEO and Medical Director
Doctor On Call
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