During the recent election campaign, much lip service was given by the candidates to fixing the american health care system. The politicians, the experts, and the news analysts discussed various methods of reducing the costs, increasing access, and better utilizing information technologies. But despite all the specific differences in the various plans designed to right all the wrongs of american medicine, there was consensus on three points: the government should control things, costs should at least appear to be shifted to someone other than the person receiving care, and individuals should not be expected to show any kind of responsibility for themselves and their health.
Such an approach is typical of how most people in this country envision remedies to any problem they face. Despite the image people in the united states have of themselves as self-reliant and independent folk, their default response to a perceived injustice or inequity is to seek out a political solution and do their best to get what they want for free. But state action rarely produces a result that is either just, equitable, or cheap. The government taxes working people and then gives agricultural subsidies to millionaire farmers, fights “terrorism” by murdering and terrorizing peaceable people in iraq and afghanistan, and rewards avaricious bankers for their profligacy while allowing these same thieves to foreclose on regular people’s mortgages. The state time after time has shown its inability or unwillingness to exercise good stewardship of the money it extorts from working people with the promise of providing essential services in return. But for some reason lots of people remain caught up in the fantasy that greater state control and funding of health care will give good value for money.
Medicare for All?
Simply looking at how current state interventions in health care provision and funding have worked should make people think twice before asking the politicians and bureaucrats for more of the same. Medicare payments are so inadequate to cover the real costs of primary care that many physicians in alaska will no longer take on new Medicare patients, since they cannot afford to provide quality services to them. Oncologists are forced to refer their Medicare patients to hospital infusion centers for chemotherapy treatment because Medicare will not cover the costs of administering the drugs in their offices. And since any provider who accepts Medicare is prohibited from taking additional payments from patients who are able and willing to top-up Medicare reimbursements, some doctors are opting out of the Medicare program altogether.
So, unable to use the insurance forced on them by their overseers in government to pay for cheaper community-based health care, old people are being pushed into hospital emergency rooms and urgent care clinics for basic medical services. Since obtaining care in such settings is inconvenient and time-consuming, these people often put off seeking care for chronic illnesses or initially minor acute problems until they become quite sick. This not only drives up the costs of the care provided, but also increases the risks to the consumer, since delaying treatment can lead to an otherwise avoidable hospital admission for some of these people, with the attendant dangers of institutionally-acquired infections and injuries.
In addition, Medicare picks and choose what lab tests, medications, diagnostic tests, and treatments it will pay for, how much it will pay for them, and how often. To get payment for anything they do, physicians, hospitals, and other providers are forced to fill out reams of forms, documenting everything they do according to arbitrary standards. Then, when the Medicare bureaucrats and clerks routinely reject their claims because they have failed to cross a t or dot an i, they or their staff must refile all this paper again and again. Meanwhile, the quality of patient care suffers as nurses and physicians spend their time pushing papers instead of actually caring for their customers.
All of this is supposedly being done to contain costs, but is actually more about control and political patronage. If the feds were really interested in controlling health care costs, they would make sure they bought medical equipment for Medicare patients from the cheapest suppliers. But they don’t. Or they could negotiate lower prices from the drug manufacturers. But they won’t. However, having a huge bureaucracy creates jobs—unnecessary jobs—but jobs nonetheless. And once you have a bureaucracy with the power to make decisions that affect others’ lives, the control freaks who thrive in these job believe they have found their calling. If they can come up with some regulation or provision that will enable them to push someone else around, you can be assured that they will use it to do so.
Some advocates of a single-payer national health care program claim that almost a third of the money spent on health care in the united states goes to bureaucratic and administrative costs which they blame on private insurers. These critics fail either to recognize or to admit that Medicare is the key player in this deluge of paperwork. Private insurers generally have adopted the same billing and diagnostic codes that Medicare requires and often follow Medicare’s lead in deciding what services they will pay for. It is preposterous to put the blame for the high administrative costs of american health care on private insurers when Medicare is the very model on which they base their wasteful procedures.
A recent innovation on the part of Medicare, which allegedly is aimed at saving costs, is a plan to deny payment to hospitals for treatment of “preventable” conditions acquired by patients during hospital stays. These are such things as catheter-associated urinary tract infections, bedsores, fall-related injuries, and IV catheter-associated blood stream infections. These are all preventable in the sense that under ideal conditions and with adequate staff, patients would get all the care they deserve and these would be rare events. But in the real world they will continue to happen more frequently than one would like. Cutting payment for their treatment when they do happen, with the intent of motivating institutions to prevent them, will likely lead to the hospitals cutting costs or raising prices elsewhere, resulting in poorer care for everyone and/or fatter bills for other customers. It seems counterintuitive to penalize providers (who in turn will penalize customers) for mistakes, when so many treatments they do pay for are for conditions brought on by patients’ own mistakes, such as smoking-related cancers, diet-related diabetes, laziness-related heart disease, or injection drug-related hepatitis.
Medicare restricts patients in their choice of providers and treatments. It is a primary player in driving up the costs of health care. It increases the risks patients face in receiving care. It channels physicians and nurses away from patient care and towards the desk and computer terminal. It costs lots of money and badly serves those it covers. But that has not stopped some advocates of increasing government’s role in health care from adopting “Medicare for All” as their organizing slogan. This shows how out of touch with the real results of state intervention in medical care health care reformers tend to be.
While Medicare is fatally flawed, my intent is in no way to apologize for the destructive role of the private sector in what passes for the health care market place. As profit-making corporations, private insurance companies try to maximize their income and minimize their costs. This is done by charging what the market will bear for policies while restricting what services they pay for as much as they can get away with. They use various methods to pay as little as possible on claims, such as elaborate coding, drug formularies, restrictions on reimbursable diagnostic testing, etc. They divert large sums of money from actual medical and nursing care to paperwork and bureaucracies. They serve some well and others poorly.
In other words, the private insurers are a lot like Medicare. And for the same reason: they are creatures of government action as surely as is Medicare. Various statutes and regulations govern the activities of the private insurers, allowing only certain companies to provide policies and deciding what kinds of policies are allowable, where they can be provided, and to whom. It is the politicians and bureaucrats who decide what kinds of organizations are eligible to purchase group health insurance plans, and are thus responsible for the current system where insurance is tied to employment instead of membership in voluntary societies.
Insurers are forced to offer certain benefits in certain places to certain people by state mandates. They are limited by the FDA in their choice of whom they can contract with to provide medication to their clients. And they are happy to base their decisions to deny coverage of certain effective treatments and medications on the fact that their use, although common, accepted, and even recommended, is often not officially approved by the feds. All the reform plans proposed by those who ran for president would have involved even tighter regulation and control of this “private” health insurance system by the state.
Then there are the partnerships between the government and private health insurance systems, where Medicare contracts with the privates to provide services. This is in addition to the system in which the feds contract with private companies to administer Medicare reimbursement (or lack thereof). In fact, the two systems, public and private, are in so many ways intertwined, it is at times difficult to figure out where one begins and the other leaves off. Just as is the case with so many other industries (as the government once again demonstrated in its recent welfare payments to the banking and auto manufacturing executives and stockholders), there is no genuine private sector in health care in the united states. There has been no market failure because there has been no market.
Whatever official form a new national health service ends up taking—single-payer, universal Medicare, public-private partnership—there will be no fundamental change in this relationship between government and corporation. Even if fully nationalized, the new system, like the current Medicare system, would contract with “private” companies to actually do the work, so that the people who run the health care system, whether employed by the state or by some allegedly private entity would continue to make money by dictating to others what health care they may have. And the ultimate control of the system will remain in the hands of the government.
Paying the Piper
Even in the unlikely event that the graft and perverse incentives associated with political and corporate control of health insurance were eliminated, there would continue to be real costs to maintaining health and treating illness. Providers must learn their trade, pay their expenses, and make a decent living. Hospitals have to be built, machines produced and maintained, and medicines paid for. No matter how health care and insurance are structured and managed, the money to pay for all this has to come from somewhere. While the costs of actually providing care are inflated for all sorts of reasons, some of the expenses associated with medical care, just like those for any other good or service, are unavoidable. But no one seems to want to pay for them.
One of the common sayings among those calling for change in health care is that health care is a right not a privilege. Those who use this construction never define either right or privilege in any substantive way, however. It is simply a slogan which really means the speaker or writer believes that health care should be free or cheap and that considering it a right will make that happen.
But rights are a problematic concept in any setting. If one believes that such things exist, the assumption is usually that such rights require—or should require—some sort of action on the part of others. If jobs are a right, someone therefore must provide them for those who are unemployed. If housing is a right someone has to build homes for those seeking shelter. And if health care is a right, someone is required to treat those who are (or claim to be) ill. And for any of these rights there is a corollary: that these rights must be fulfilled regardless of ability—or willingness—to pay for services or products rendered.
So making health care into a right means someone else is bound to provide it. Naturally, advocates of this approach then turn to the state to make sure this happens, since that is what government does: it makes people do what they otherwise might not under the threat of violence or imprisonment for non-compliance. Thus it is no surprise that the concept of a right to health care goes hand in hand with a demand for an increased role for government in realizing this supposed right. And since the state has the power to extort money from its subjects at will, it is also the obvious institution to turn to to provide this perceived entitlement either cheaply or gratis at the point of service.
Of course, a government guarantee of “affordable” health care will not really make this care inexpensive or free. It will simply be a shell game where most people will pay more in taxes to support the medical care and insurance establishments while paying less when they purchase health care services. While the state can create money, it cannot similarly create wealth or produce anything of real value. Its only means of acquiring resources is theft. So to make medical care appear cheaper for consumers, it must take more money from its victims. While some will end up paying less in increased taxes or other imposed costs than they save in other health care expenses, in order for this confidence game to work most people will ending paying around what they currently do.
This scenario would be different if the state made other changes in its practices at the same time. For instance, shutting down the pentagon and withdrawing imperial troops from iraq, afghanistan, germany, etc, etc., would free up billions of dollars that are either used in lethal enterprises or wasted in bureaucratic processes associated with the death machine. Or it could end the drug war and liquidate the DEA, releasing further billions for more humanitarian purposes. If that happened, there really would be more money available to take care of sick people without making people pay more for it.
But that ain’t gonna happen. The Obama regime will follow in the footsteps of all its predecessors and continue to spread murder and mayhem around the world and harass peaceful people who use and sell prohibited chemicals. Since the state will never give up the coercive enterprises which truly define it, health care will remain simply one, and certainly not the most important, of the programs it administers. Thus, there will only be more and better medical care under a state-run system if people are forced to pay more, one way or another, for it.
Money for Nothin’
Political decisions to spend money for destructive purposes instead of healing ones result in less money that can be used to subsidize medical care, increasing costs to consumers. But another reason the prices people end up paying for health services are high is that the costs are inflated by other government actions, as well. The list of ways in which the state makes health care more expensive is long, but I’ll touch on a few of them here.
Restricting the supply and types of health care providers is a major means of driving up the price of services. Forcing medical and nursing education into rigid formulas has made training programs much too long and expensive, creating logjams in the supply of these types of providers. There are too few nurses and physicians available, but licensing laws prevent other kinds of healers like lay midwives from practicing and force people to rely on more expensive and often unavailable government-approved practitioners. Prescription laws prohibiting people from unsupervised access to drugs also leave people with no other option than to deal with these state-certified doctors and nurses as well.
The drug companies are another driver of inflated costs, largely because of government-created and -enforced patent laws. These companies have a sate-sponsored monopoly on their products for years, which allows them to charge extortionate amounts of money for their medicines. The government further props up these avaricious corporations by barring people from obtaining drugs from other countries where they are often cheaper than in the united states.
Government officials and bureaucrats tightly control hospitals and other health care institutions through local and state regulations and the joint commission for accreditation of health care organizations. States and localities decide who can open a hospital where and force them to function according to bureaucratic regulations. Frequently the decisions of regulators about whether a new hospital or clinic building, or an innovative bit of diagnostic technology, will be permitted are driven by the interests of the politicians’ allies and benefactors in the private health care sector. Powerful medical corporations use their influence on regulators to promote their own businesses and suppress competition. In service to the health needs of the community, needless to say.
The joint commission is the enforcer for the feds, and its influence is much farther-reaching than that of any local overseers. In order to qualify for Medicare reimbursement, which is a large part of the revenue of most hospitals, these institutions must submit to periodic visits by a troop of capricious joint commission inspectors. These bullies come into a care unit at any time they choose, order people around, interrupt patient care to interrogate nurses and other workers, and dictate what providers do and how they document it down to the most minute details. While some of this may yield improvements in providing care, most of it is bureaucratic and controlling nonsense which does nothing but inconvenience patients and nurses and increase the cost of doing business. They are more concerned about a hospital’s “cultural competence plan” than whether patients of all ethnicities are deprived of care by the hospital’s diversion of staff and funds away from patient service and towards compliance with the silliest joint commission directives. And the hospitals, furthermore, have to pay these Medicare nazis for the pleasure of submitting to their periodic visits. Resistance is futile.
I could go on, but you get the point. Government rules and laws limit the supply of hospital beds and impose arbitrary rules on providers, reducing competition, limiting people’s options, and driving up costs. The very institution so many look to as the mechanism for controlling the costs of health care and increasing its availability is the cause of much of the expense and scarcity of medical care. Delegating more power and responsibility to such an institution is as wise as giving more tax money to profligate investment bankers and greedy, inept auto executives.
I have argued above that health care is expensive and difficult to obtain because of Medicare, private insurers, and government interference in virtually every aspect of health care provision from training of providers to the functioning of hospitals to the sale of medications. But this is only part of the story. Though few reformers are willing to talk about it, there is another thing that drives up costs: people’s growing expectations that all of life’s problems can be fixed by doctors, drugs, chiropractors, therapists, or some other form of healer. And all of this costs someone money.
America has become victim nation in countless ways, but one of the more obvious ones is that every complaint or disorder has become a disease to be treated. You or your child has a runny nose and a cough? You need to visit the emergency room and demand antibiotics. Your kid hates sitting in a classroom being pushed around by a teacher all day? He has ADHD and needs ritalin. Someone is sad because her partner has died? She has a grieving disorder which requires a licensed therapist. Someone is fat? They qualify for “bariatric” surgery. And smokers naturally experience tobacco dependence which can be cured only by counseling and pharmaceutical nicotine or other drugs.
People expect treatment for minor illnesses that neither require nor benefit from medical interventions. But they also expect expensive therapies for things which are not even true diseases. Hating school, smoking, eating too much, and being sad are not illnesses. However, they are being considered as such and are being treated with drugs and operations.
The fact that personal problems (or in the case of rowdy kids, simply an inconvenience to parents and teachers) can be treated and “cured” does not make them medical disorders. They remain problems in living amenable to changes in personal behavior by those willing to make them. But people are increasingly unwilling to take responsibility for their own behavior and health. Instead they do what they like, consume what they want, and dwell on their personal difficulties, then seek out physicians, nurses, therapists and others to fix them. And they want these remedies to be inexpensive. Insurers frequently cover the costs of treatments for non-existent diseases, which encourages people to seek treatment for them, increasing the overall costs of insurance and healthcare.
Whatever has contributed to the expense and other problems of the american health care system, however, treatment for many real diseases and medical conditions remains costly. As the population ages, cancer is diagnosed more frequently and more and more people undergo expensive therapies to cure or control this disease. Heart disease is prevalent as well, and the cost of treatments for cardiac and vascular problems is high. People clearly need a means of getting and paying for very expensive care for many medical conditions. But relying on the standard solution of calling on big brother to fix things is certainly not the right approach. Many, many people will be less than happy in the end should any version of a single-payer system be rolled out in the united states.
People have been sold a bill-of-goods concerning how well national health care systems function in canada, the united kingdom, cuba and other countries. While basic preventative care may be free or very cheap in these countries, access to more advanced and expensive treatments is less easy to get. People experience long waits for specialist appointments and surgery and often have limited access to drugs which are routinely used in the united states. I have written in the past how the FDA has often prevented americans from being able to obtain therapeutic drugs available in other countries, but people in britain can be denied access to prohibitively expensive drugs that are standard of care and covered by insurance in the united states, unless they can afford to pay out of pocket. Up until just a few months ago, british people were unable to get the drug bevacizumab on the NHS. Besides having to pay for this very costly drug on their own, they also had to pay for any nursing services required during its use, being penalized twice for having the audacity to circumvent the rulings of their betters about what drugs they should be taking.
Similarly, americans have not been told the whole story of health care in the united states. Here, people without insurance are, despite the hype, generally able to get health care, including expensive chemotherapy and radiation therapy for cancer treatment. There are hospitals, physicians, and other providers all over the country that provide free or cheap care to those who are uninsured and have limited means. Most drug companies, despite the greed of those who own and run them, also have programs to provide free drugs for those unable to pay for them. The health care system in this country is fatally flawed, but the picture is not nearly as grim as what one hears from many critics.
Part of the problem is the deliberately vague terms in which the discussion of health care reform takes place. Affordable and accessible, two words heard quite frequently when medical reform is talked about are never defined. Whether something is affordable is often in the eye of the beholder. The same person may consider a $30,000 pickup affordable, but a $300 dentist bill less so. Or a $75 haircut and $40 manicure may fit nicely into one’s budget, while the $120 charge for a mammogram makes this test inaccessible. It depends to a large extent on what is important to the individual.
But even the word important is open to interpretation. Most everyone would claim that their health is an important, often the most important, thing to them. When someone shows up at an emergency room, no matter how minor or serious their problem, their desire for health care is seen by both them and others as very important; challenging their right to be seen in the emergency room, even if they can’t or won’t pay, would be considered cold-hearted at best and inhumane or illegal at worst. However, in light of the fact that so many americans have health problems related to overeating, lack of exercise, smoking, and excessive use of alcohol, it is not at all clear that people’s health is as important as they claim it is when they demand that others give them health care.
This reminds me of something I heard from a speaker at Faneuil Hall in Boston years ago. To paraphrase, he said that people pay for what they want and beg for what they need. While not true of everyone, by any means, this approach to life is remarkably prevalent when it comes to medical care and treatment. It is so common, in fact, that a medical journal reported in early 2008 that even a small copay, as low as $12 in the study cited, resulted in fewer women having mammograms than when such procedures were provided for free. And it is not uncommon for people to lay out money for (often pricy) “alternative” remedies while claiming they are unable to pay for more conventional forms for treatment.
This goes on because people know full well, despite the american health care “crisis,” that if they show up in an emergency room they will get taken care of for free. Or if they wait long enough they can take advantage of no-charge mammogram or prostate screening programs. Or if they say they have no money they can get that antibiotic with having to pay for it. Unlike if they showed up in the GM show room and tried to cadge a free pickup out of the salesperson, or tried to get a complimentary pair of jeans at Target. People know they have to purchase vehicles and clothes, and budget their money appropriately so they can do so. Not so much when it comes to their all-important health.
However costly many types of treatments and testing may be, basic preventive health care, including physical exams, dental hygiene, and prostate and cervical cancer screenings, is not prohibitively expensive. It is, nonetheless, perceived to be so my many people, simply because it is not free. Were this same standard applied to clothes, and food, there’d be an awful lot of naked hungry people walking the streets of america’s cities. And if applied to cars, there wouldn’t be any rush hour traffic jams, either. There may not be any such thing as a free lunch, but apparently there should be free health care.
Picking and Choosing
Despite all the unwarranted assumptions that are made about how health care is or should be organized and provided in the united states, I understand that there are treatments that remain prohibitively expensive, even for those with insurance. Providing a means of enabling people to have these procedures and medications without impoverishing themselves and their families is the real challenge to any society, whether our current hierarchical and exploitative one or some future anarchistic and equitable one. And there is no simple solution.
Canada, the united kingdom, and many other countries have a frankly state-oriented approach, but some of these countries have a large private component as well. The united states has a larger private sector in health care than the other industrial/developed countries, but has an enormous government piece too, though one wouldn’t necessarily know that from listening to politicians and reformers. Most people get most of their health care needs, whether cheap or costly, met in all of these systems.
Drugs and basic care may be cheap in canada, but people wait months for surgeries and appointments that most americans, including poor ones, get in weeks. People in the united kingdom get most of their care free at point-of-service but can’t get any coverage for some standard american medications. And people in the united states have been getting herceptin and avastin for years, but often have to pay for all or most of their dental care. In none of these systems is everybody who could benefit from a bone marrow, kidney, or liver transplant going to get one. Each system has its good points as well as its bad points. And none will meet everyone’s needs and wants.
This is seldom made clear by politicians and the news media, however. That has created a situation where many people are advocating or supporting changes in health care insurance and delivery that, if adopted, they may later regret. Americans value the ability to choose any provider they wish and resent having to pay more for “out-of-network” care. They want to be able to decide what medications to take for their conditions. They want to see doctors and get procedures in a timely fashion. And they want to pay little or nothing for all of this. However dissatisfied folks are with the state of american health care as it is today, they had best look long and hard at what happens up north (or down east if you are in alaska) or across the pond.
A more socialized or nationalized system will improve things for some, make things worse for others, and end up as a wash for most. Political solutions always end up the same way . When people take the democratic approach of imposing their preferred system on others and trying to socialize the benefits and costs, there are winners and losers. But in an environment where voluntary and individual approaches are never considered and the state is looked toward with admiration, this is all we can expect to happen. Those seeking health care reform should be careful what they ask for.
Supply and Demand
While the idea may not be palatable, not everyone is going to get every bit of medical care they might desire or that could be helpful to them. And some will die sooner than they otherwise would have because of that. Even were we to change the world and bring on the libertarian millennium, there would still not be unlimited resources, for health care or for anything else. People have many wants and needs: food, sex, medicine, living space, companionship, clothing, transportation, and so on. Sometimes we will get the dinner, the apartment, the lover, the medication we want, but sometimes we won’t. That is the way of the world. So even if there were a right to health care—a proposition I would dispute—it is and will continue to be impossible to fulfill the implied obligation to provide that the desired or expected care to everyone in every situation.
One hopes that in an anarchist world priorities would be differently oriented and both resources and people redirected from either wasteful or destructive ventures to productive and humane endeavors. An enormous portion of the value currently produced by working people pays for bureaucracy in both the public and private sectors, is siphoned off into the pockets of the non-productive wealthy, or feeds the machinery of control and death embodied by the military, the police of all sorts, and the prisons and jails of this country. Starving these institutions to death by cutting off the flow of money would free up vast amounts of wealth that could be used to improve the health and other living conditions of everyone. It would also liberate millions of people from non-productive and antihuman jobs, allowing them to pursue lines of work more in keeping with a voluntary, cooperative society. Perhaps as nurses, doctors, or other kinds of healers? Eliminating state imposed laws, rules, and regs would make it easier and cheaper to learn the healing trades, increase the supply of providers, and make treatments and medications cheaper. But there will still be unmet needs and wants.
While I advocate the abolition of every trace of government, I am under no illusion that that would create a cornucopia which could readily and cheaply supply a remedy for every medical need that exists now or in the future. There are other jobs people want to do besides being doctors and nurses, other things we all want to consume besides medications, and other uses for buildings besides being hospitals or nursing homes. As long as we need to eat and breathe and want to party and fuck, there will not be an endless supply of health care, despite an infinite demand for it. And when there is more demand for something than there is supply of it, some will go without things they want or need.
That is how life is, and will remain, whether people wish to acknowledge it or not. And therein lies the biggest challenge to any effort to improve health care delivery. If someone does not get something to which they feel entitled, they will consider the system that denies them what they want unfair. But there is no way everyone will be happy under any system. Failure to acknowledge this encourages unrealistic expectations and promises to create even more dissatisfaction than would exist if people were presented with an honest picture of what can be accomplished and provided. Instead, absurd fantasies are put forward by those who propose to fix the dysfunctional american health care enterprise and the sheep just follow along, hoping that this time, at long last, they won’t be disappointed. Dream on.
Here’s to Your Health
I don’t have any bright ideas on the best approach to solving difficult questions like who gets the next liver or whose cardiac bypass surgery should be performed first. These are tough decisions that need to be made carefully and thoughtfully. But one thing is certain, trusting the state to do the right thing is absolutely the wrong way to go.
Instead of worrying about out how to ration expensive treatments, however, people’s time would be better spent figuring out how to take responsibility for themselves and live in healthier ways, thus making it less likely that they will ever need these costly and scarce procedures. The current system doesn’t encourage people to do that, nor will any other system where health care is seen as a right and individuals feel entitled to live in any way they wish under the assumption that someone else will repair the damage whenever the consumer decides the time is right. A system dedicated to repairing sick bodies instead of maintaining healthy ones is not only expensive, but is unsustainable. The virtually unlimited “need” it creates for services will always outstrip the supply of healers, hospital beds, and available treatments.
People are reluctant to think and act for themselves. Just like the banking and auto execs and stockholders, the average american is looking to the government to bail them out. No one seems to want to make changes in their life and avoid doing the things that make them ill. Instead, people hope that letting politicians tinker with the way health care is funded and provided in the united states will provide them with better medical care for less money. This is unrealistic. Disappointment, continuing ill health, and an ever more obnoxious and controlling bureaucracy is what they will get instead.