Bad Medicine

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, Continue reading

License, Not Freedom

It is quite difficult to get people who are used to modern city or suburban life to move into the villages and small towns of bush alaska.  While these places have acquired many of the technological features of the rest of the united states, such as television, phones, indoor heating, and so on, they remain difficult to get into or out of, especially in the winter, and lack many modern conveniences.  It has been especially difficult to attract dentists. Continue reading

I’m From the Government—I’m Here to Heal You

A couple of months ago, I was sitting in a webinar about coding for outpatient medical and nursing procedures billed to Medicare.  As I was led through the maze of arcane formulas and requirements, I got to thinking about how much Medicare has inflated the costs of health care.  Here I was, being paid $40 an hour, as were seven or eight of my nurse colleagues, to listen to consultants (who were surely getting paid way more than I), quote from other consultants (more $$$) about how to fill out papers to maximize the amount of reimbursement the hospital I work for can receive from Medicare.  And this is all because the people who work for Medicare ($$$) issue coding guidelines that are vague and open to interpretation, so that bills are constantly bounced back to providers for more processing ($$$) to justify or explain the charges so they can be rebilled.  What a ridiculously expensive and inefficient process. Continue reading

The Health Care Crisis in the US

American politicians and news reporters frequently claim there is a health care crisis in the united states.  While enormous, and steadily increasing, amounts of money are spent on medical care, research, so-called public health measures, and pharmaceuticals, people born in the united states continue to have a shorter life expectancy and higher chance of dying as infants than residents of a number of other countries that spend less money in these areas.  This sorry state of affairs is generally attributed, at least in part, to the fact that a large number of people lack medical insurance.  It is assumed that such people are completely priced out of the medical care market, and thereby denied access to essential medical services.  This leads some to advocate one form or another of government-run medical care and/or insurance.       While americans are less healthy than one would expect from the gross medical expenditures, the problem is more complex than one of lack of insurance and access to care.  Most people in the united states have medical insurance, and a large number of those are served by one or another government-provided program, such as medicaid, medicare, or a military-associated plan.  For those without insurance, there are some physicians who do not take insurance and instead charge lower fees, as well as free or very inexpensive clinics located all over the country that provide at least basic primary care, and often comprehensive care for some medical conditions, charging people, when they charge at all, according to their income.  Of course, some people fall totally outside any of these parts of the medical system, but they are few and far between.  Even in these worst case scenarios, however, some combination of government intervention, charity care, and corporate free drug programs generally insures that people get taken care of and obtain the medications they need.

Clearly there are people who have a tough time obtaining and paying for health care services.  But the fact that someone does not receive medical care, does not necessarily mean they lack “access” to it, as is presumed in many public health articles and reports.  Just because someone can not necessarily obtain the services they want at the time they want them and for free does not mean that such services are inaccessible or that there are “barriers” to receiving care, anymore than the fact that one has to pay for groceries, or that many stores close at night, presents a “barrier” to obtaining food, or makes food inaccessible.  Many choose to spend what money they do have on things other than medical care, while relying on hospital emergency rooms when they get acutely ill.  Others, who have or are eligible for either private or government insurance, simply choose not to obtain routine care in a timely fashion because they are more interested in doing other things with their time and, despite protestations to the contrary, don’t see their health as more important than many other things in their lives.  People play a key role in their own health, and the way they choose to interact with the medical care system greatly affects both the cost and the effectiveness of medical care.

The Role of Individual Choice and Action in Health Maintenance

Although some diseases require specialized treatment and care and are difficult to prevent, many of the most common health problems people encounter are largely avoidable by prudent living and sensible choices in diet, activity, and recreation.  And, to be fair, despite their largely pernicious effects on the medical care system, even government agencies do encourage people to make more healthful decisions in some areas of their lives.  Living in ways that promote illness increases people’s dependence on a flawed medical care system and makes this care more and more expensive. While the state can rightly be criticized for some of the shortcomings of the medical care system, bad choices on the part of regular people contribute greatly to the problem.

If people remain lean, exercise regularly, eat fatty animal foods in moderation (if at all), and avoid tobacco they are likely to be much healthier than they would otherwise be.  And these methods of maintaining or restoring one’s health are either inexpensive or would save people money.  But exercising self-control and taking responsibility for the condition of one’s own body interests far too few people, with around two thirds of americans overweight or obese.  Apparently they would prefer to eat too much and move too little and then turn to the medical system to fix the problems they have created for themselves.

Most deaths and much of the illness in the united states are a result of heart disease, strokes, cancer, and diabetes.  Of these, it is likely that most strokes, heart attacks, and diabetes can be prevented by more healthy living.  Modifying one’s diet and exercising regularly will usually reduce blood pressure and cholesterol levels, both of which lead to heart attacks and strokes, and it is unusual for people who control their weight and are physically active to develop diabetes.  In the case of cancer, the causes are often not yet clear, but diet appears to play a role in the development of at least some cancers, and the likely cause of many cases of the biggest killer, lung cancer, is not only known, but easily avoidable.  One has only to not smoke or stop smoking to greatly reduce one’s risk of this disease, as well as a number of others that are linked to tobacco use.

Many of the less common illnesses people experience are also preventable.  This is true of HIV infection acquired through needle-sharing or risky sex, liver disease from excess alcohol intake or Hepatitis B or C infection (acquired via the same routes as HIV), or even the joint problems caused or exacerbated by obesity.  Exercising care in our eating habits, physical activity, and sexual and recreational practices is key to preserving our health and increasing our years of healthy life.

Although much of people’s ill health is a result of their own activities (or lack thereof), when people get sick they require treatment.  But here, also, many people wish to avoid personal responsibility.  Instead of seeking advice and increasing their knowledge of their disease in order to best treat it, they put themselves in the hands of a physician (or even a chiropractor) and ask or demand to be healed.   Since so many practitioners enjoy playing god, this relationship can be comforting to both parties.  But it does not make for good care, or restoration of health.

Presumably most medical practitioners counsel patients with new diagnoses of high blood pressure, or heart disease, or diabetes that altering their food intake and exercise habits are likely to improve their outcome, but the mainstay of treatment usually becomes medicine or surgery, since people whose bad habits have produced serious illness frequently remain unwilling to lose weight or work out, preferring what they see as a quick fix like cholesterol-lowering drugs or anti-diabetes medications to the hard work of taking better care of their bodies.  And it is not unusual for people to get progressively sicker, adding on more and more medicines, and then developing health problems from some of their drugs.  In fact, for some, chronic illness becomes a sort of occupation which dominates their activities and conversation, and with which they become quite comfortable.

While it has become standard procedure to rely on sometimes harmful drugs and medical/surgical procedures instead of healthier practices to prevent or treat the diseases caused by unhealthful living, many illness-causing activities have themselves come to be considered diseases requiring “treatment” by medical specialists.  Those who eat too much seek care from bariatric physicians, who treat the disease of obesity with drugs, surgery or a combination of both.  Smoking cigarettes is considered an “addiction,” and thus a disease to be treated with drugs and nicotine patches, on the model of heroin use or drinking too much.  By turning bad habits into illnesses, people are again led to rely on the medical establishment instead of themselves, while helping fill the pockets of drug companies, hospitals, and physicians with money.

The Costs of Medical Care

Even when people take good care of themselves and use the medical system wisely, medical care is expensive.  The costs of office visits to doctors, surgery, medications, and insurance premiums all continue to rise.  This is partly because research and development for medicines and devices is costly, but is also the result of monopoly/oligopoly conditions in the medical industries which allow practitioners, hospitals, and drug companies to charge higher prices than they would be able to in a truly competitive market.

Costs are increased by unwise use of these resources and medications, as well.  Using emergency departments (EDs) for routine care, avoiding routine preventative consultations and testing, and patients’ demands for medications even when they are either ineffective, unnecessary, or harmful, all contribute to making medical care more expensive than it should be.  But consumers are not the only ones at fault in driving up medical costs and expenditures.

Drug companies spend a lot of money developing so-called “me too” drugs, like the “new purple pill,” which do not really work better than older and cheaper drugs, but are patentable and therefore generate new profits for managers and owners, while providing little or no benefit to consumers.  The prescription system in association with drug company advertising and widespread medical insurance coverage encourage excessive and inappropriate use of medications, which become increasingly expensive.

Medical providers have extended the range of their practice way beyond  the areas to which they once limited themselves.  Physicians and other practitioners have a tendency to see themselves (and are often viewed by their clients) as not only healers, but as counselors and latter day priests, with social and spiritual “histories” now considered a routine part of a health assessment.  Instead of simply being experts is helping us fix or maintain our bodies, doctors are now expected to repair people’s disordered lives.  Something as vague as “frequent mental distress” is now a sign of poor mental health, and bad habits, bad moods, and even shyness are all redefined as diseases for which medications and therapy are prescribed.  This vast expansion of what is considered medical care means more money spent and more resources consumed.

While physicians’ and hospitals’ roles in people’s lives have expanded, the expectations for the outcome of interactions with medical providers have changed, as well.  If they do not get exactly what they want from a procedure or treatment, or if they have a bad outcome, regardless of the reason, people are all too willing to sue their doctor and/or health care institution.  While doctors, nurses, and hospitals make mistakes and are surely at fault in some bad outcomes, lawsuits frequently target innocent providers.  More litigation had led to increased, and sometimes prohibitive, prices for malpractice insurance.  This has driven many providers out of certain lines of practice, like delivering babies, which increases prices by limiting the number of providers.  And, in addition, those who remain in practice raise their fees even more to cover the increases in their insurance premiums.

Paying for Health Care

Naturally, someone has to pay for all these medical consultations, diagnostic procedures, medications, and malpractice insurance payments.  But a lot of people believe it should be someone other than themselves.  Most people in this country have some form of health insurance, but usually feel they pay too much for it, no matter how much they use.  Although newspaper reports on medical insurance bear headlines such as “Americans spend more on health care, get less,” subscribers want their insurance to cover more and more “treatments” like fat surgery, diet pills, and addiction therapy, but don’t want to cover the increased costs.  Medical care, unlike true essentials such as food and housing, is seen as some sort of entitlement that should come free or cheaply to the consumer, no matter how costly it is to create and deliver.  This attitude is summed up in the slogan, “health care is a right, not a privilege,” that is sometimes used by activists.  It is assumed that people’s health is so important to them and so basic to their having a decent quality of life that they shouldn’t have to pay to maintain it.

However, the fact that so many do so little to maintain their health and prevent illness indicates that health is far less important to them than one is led to believe.  Not only are most people unwilling to eat better and be more physically active, but people’s spending practices also indicate that many things take priority over health maintenance in many people’s lives.  Although people complain about the high costs of medications and insurance and sometimes avoid routine medical and dental care to save money, they usually are able to buy that new SUV, have that second child, buy cell phones for all the kids, maintain a winter residence in florida, or take those semi-annual trips to Puerto Vallarta.  Even those who are without health insurance and are assumed to be incapable of paying for even basic health maintenance services, generally manage to pay for their cable TV, car, pet food, and other non-necessary, but expensive, items.  To paraphrase a speaker I once heard in Boston, people pay for what they want, but beg for what they need.

(It is of interest that the justification for buying an SUV is often that it is safer than a car, or that parents buy cell phones for the whole family on the assumption that this somehow makes them safer.  But for some reason this concern with safety usually doesn’t lead people to work out more or eat less even though that would likely improve their health and make them safer from heart disease and diabetes.  Besides, people are probably safer on buses than in either cars or SUVs, but most reject that option as well.)

Even basic health care or insurance premiums cost money, but the price of a yearly physical examination or dental hygiene visit is less than what many pay in monthly car loan and insurance payments.  I worked for many years in a government hospital in Boston, and daily took care of people who claimed they were  unable to pay for even the cheapest treatments or medications, but could afford leather coats, automobiles, cell phones, or cigarettes.  Right now in Anchorage, a pack a day cigarette habit can cost a smoker $180 per month.  Stopping smoking would not only make a smoker less likely to get sick with heart disease or cancer, but would free up $2160 per year for medical and dental expenses.

Since people have been convinced that they shouldn’t have to pay for their own medical care if they can avoid it, many have taken to using hospital emergency departments as walk-in clinics.  Because government rules require that EDs provide at least a minimal amount of assessment and care to anyone who shows up there, regardless of ability (or willingness) to pay, people will go to an ED instead of a private doctor’s office because they know they will not have to pay the bill, even though an ED visit often entails a wait of several hours for treatment.  Similarly, people, including those who could easily afford to pay, will wait for hours to get free flu shots, even when they don’t really need them.  Although people are willing to spend money to save time in other circumstances, such as buying a car instead of riding the bus or train, when it comes to health care, avoiding paying often takes precedence over time and convenience.

But it is not just avoiding payment that draws people to hospital EDs.  Poor health maintenance practices also contribute to the problem.  Many people, including those with insurance, do not have primary physicians whom they can see when they become ill, so that when they develop a sickness, they are unable to see a practitioner in a timely fashion unless they use an ED or urgent care center of some sort.  And for others, it is simply they want what they want when they want it, and since they are not paying, there is no disincentive to using the ED as their primary care center.  Again, at the hospital at which I worked in Boston, all comers to the urgent care center were offered  appointments (free to the uninsured) with a physician within a couple of months, but it was common for people not to keep their appointments and then show up again in the urgent care center or ED next time they had a health problem.

Inappropriate use of EDs is an expensive way to provide routine medical care, and use of EDs by people without emergency or truly urgent needs (or wants) makes it more difficult to deliver care to those who are experiencing true emergency health problems.  When the cost of providing non-urgent care in this way is not borne by those who receive it, there is no disincentive to misuse of EDs and the problem is likely to continue.

Part of the reason that people are hesitant to pay for health care is that they perceive that physicians, hospital executives, and drug company stockholders are receiving excessive financial benefits from providing medical care to people who are much less well off economically.  While this is true, it is no less true of those who own the car factories, restaurants, and cable TV companies, whose products and services poor and working people seem able to afford more easily than basic health care.  But medical care, although arguably more important to the quality of people’s lives, is apparently not important enough to pay for.

State Control and Funding of Medical Care

The american medical care system is a mixed network of both government and non-government institutions and practitioners.  But the drug manufacturers, insurance companies, practitioners, and hospitals that are not owned by the government are so hemmed in and controlled by government laws, rules, and regulations that they can hardly be considered true “private” enterprises.  Intervention by state and federal authorities in the provision and funding of medical care contributes to both the high costs and poor outcomes people experience in their dealings with medical providers.

The states license doctors, nurses, and other medical care providers, regulating their practice and restricting their numbers.  They then outlaw provision of medical care by alternative practitioners and force those seeking assistance with their health to utilize only government-approved providers.  As with any monopoly/ oligopoly situation, prices and profits go up, the prestige of the service providers increases, the quality of service can suffer, and people’s choices in providers and treatments are limited.

Government bureaucracies determine what drugs are available in the united states and whether or not they require a doctor’s note (prescription) for purchase.  People are thus denied access to a number of medicines which are safely in use in other countries, and are kept from freely using most of those that can be obtained legally here.  They are forced to incur the expense of seeing a doctor if they wish to obtain a prescription drug even when they are knowledgeable enough to know it is the right treatment for them.  And despite the fact that all these restrictions are in place allegedly to protect them, they still run the risk of taking government-approved drugs, like vioxx and baycol, that the manufacturers have known for years (but have not disclosed) can be dangerous.

While restrictions on access to pharmaceuticals has not served people well, the government’s role in drug research and development has been even more problematic.  Much of the study of potentially marketable drugs is initially financed by government agencies, but when drugs go on the commercial market, they are sold by private companies which have been issued patents allowing them to charge extortionate prices.  The drug companies then argue that the vast profits they make on new medicines are justified by the high costs of developing these drugs, expenses which were, in fact, financed by taxes extorted from working people.  People thus frequently pay twice for the medicines they buy.

Government programs in other health-related areas are open to criticism, as well.  Largely taxpayer-funded universal vaccination of children for an ever-increasing number of infectious diseases (including Hepatitis B, of which the vast majority of children are at minimal risk) may well be contributing to the rising number of cases of auto-immune diseases like asthma and Crohn’s disease, both of which are lifelong illnesses that are costly to treat and cause much disability and even death.  The federal government oversees and funds an indian health “service” that is expensive, inefficient, and riddled with ethnic discrimination, creating medical facilities where people are segregated based on their ancestry.  And its funding of research is often driven by politics, not science, with NCI research on breast and prostate cancer funded much more generously than research on lung cancer, which is responsible for twice as many deaths each year as the other two cancers combined.

In the area of medical insurance, government plays a dual role.  It not only regulates the “private” portion of the industry, but it also provides a significant amount of health insurance directly, through medicare, medicaid, and the military medical care systems.  State governments set prices that allow private company owners and executives to prosper while customers pay through the nose, putting the interests of company stockholders above those of the people who purchase policies.  These insurance companies then do their best to avoid paying claims whenever they can get away with it, further increasing profits.

Government insurance programs, which many believe should be expanded to fix the present crisis, are no prize either.  Medicare still leaves many old and/or disabled people with significant bills to pay, either for supplemental “private” insurance policies, or for pricey co-pays.  In addition, medicare “reform” has resulted in payments to providers caring for medicare clients that are sometimes too low to cover their costs, leading a number of practitioners to either stop providing some services to medicare clients, or drop them as customers altogether.  Medicaid coverage, while providing better reimbursement in general, is difficult or impossible for many in need to obtain.  And while government insurance leaves much to be desired, the bureaucracies charged with administering it are so incompetent that states have been forced to return some of the funds they have received from the feds to provide health insurance for poor children, because they were too inefficient to spend it all on those who needed it.  And of course, government insurance, like that provided by private companies, will not pay for services provided by unlicensed practitioners or for medications not prescribed by them.

An essential part of all these specific ways in which government interferes with, and often sabotages, medical care delivery is the requirement for reams of paperwork from every individual and institution involved in providing medical care.  Whether it is periodic relicensure of providers, the regular inspections and reinspections of hospitals and clinics by the Joint Commission for the Accreditation of Health Care Organizations, or filing and refiling of medicare and medicaid claims, enormous amounts of resources, time, and effort are consumed with bureaucratic reporting requirements and documentation of compliance with the often arbitrary standards of JCAHO or other government-authorized or mandated overseers.

The rationale for all of this interference, all these rules, regulations, and requirements is, of course, that we are not capable of adequately taking care of ourselves, and that we need the government to choose our medical care providers and insurers and then protect us from their ill intentions and/or greed.  Of course many people take poor care of themselves, and many providers and institutions are not to be trusted, but the government, through its licensing/certification programs and the prescription system has in large part created both problems.  By empowering government-approved experts and institutions to control and restrict access to treatments and medications, it encourages people to rely on experts, instead of themselves, to manage and maintain their health.  And then, like any monopoly or oligopoly, the state-sanctioned providers, protected from competition, have little incentive to contain costs or treat their customers respectfully.  While bureaucrats and the providers and corporations they license and protect may talk of patient-centered care, their unwillingness to allow people to choose their providers and treatments for themselves, shows what they really believe: that we need to be taken care of by the beneficent government.

One Way Out of This Mess

Despite its dismal record in overseeing medical care in the united states, many still look to government to fix the problems that it is largely responsible for creating.  Advocates of this approach generally regard the medical systems in europe or canada as models of how medical care should be managed and provided, but they often fail to acknowledge the problems with these systems, from long waiting lists for procedures and surgery, to lower wages for health care workers, to inadequate and disrespectful care in hospitals.  Additionally, countries that provide universal medical care also have higher taxes than does the united states.  It is far from clear that a national health care system would be cheaper for most americans or maintain a level of quality and efficiency comparable to what people now experience and expect.  Given the politicos’ and bureaucrats’ sorry performance in running the present medical system, granting the state even more power to manage our health is unlikely to provide the solution to the current “crisis.”

Instead, the anarchist approach of getting rid of government entirely, in all its meddling forms, is the only means of providing an environment in which free people would be able to address their health and medical needs and wants in whatever way suits them.  The barriers to practitioners providing services and people obtaining drugs and treatments would disappear, allowing people new, real choices in their medical care and making it genuinely patient-centered.

Although the increased supply of providers and availability of remedies would result in a drop in costs and prices, medical care in an anarchist society would still have a price tag.  Producing drugs, performing surgery, and testing blood specimens all require time and money.  While voluntary mutual insurance programs and charities would be formed by interested people to assist in cases of extraordinary expense, just as happened commonly before the welfare state, people would still have to make decisions about how and where to spend their money or exchange their goods and give priority to some needs and wants over others.  Buying insurance or putting aside savings for unforeseen medical needs would be just as prudent in a free society as it is now.

Other social and economic changes in an anarchist society would also affect people’s ability to improve their health and purchase medical care. Individuals’ wealth would increase, and hours of work decrease, since a large portion of the value of what they produce will no longer be stolen from them by governments and employers.  They would then have the opportunity to dedicate more of their money and time to maintaining or improving their health.

Just because they will be better able both to purchase medical services and to take care of themselves, there is no guarantee that people will make wiser decisions about their health or medical care in an anarchist future than they do today.  Getting rid of the true barriers to access to medical services that the state creates and maintains would allow interested and motivated people the opportunity to take control of their medical care and their health.  But unless individuals make a commitment to healthful living, chronic preventable illnesses will continue to burden people both physically and financially.

Anarchy will not make everyone healthy, wealthy, or wise.  It will simply allow everyone the freedom to live their lives in whatever peaceful way they choose.  It will then be up to each individual to decide for themselves if their health really is important to them.

(For a more detailed account of how free market medical care might operate, see the article, “Health Care Without the State,” on the Bad Press website.)

Healthcare Without Government

The Therapeutic State

Health care systems all over the world are, to varying extents, dominated by government intervention. Whether it is a largely ‘private’ system driven by state funding and regulation, like that in the US, or a ‘socialized’ model like those of Canada and the UK, the state manages to insinuate itself into the most intimate contacts between individuals and their medical providers.  Continue reading