The Anarchist in the Cancer Center

There are certainly frustrations associated with being an anarchist and working as a nurse.  The entire health care system, like the rest of society, is riddled with authoritarian relationships, corporate penny-pinching and profit-taking, and intrusive government regulations.  The state believes that individuals are not capable of taking care of themselves so it requires licensing of healthcare providers and institutions and prevents people from purchasing most drugs without a doctor’s note.  Besides restricting the number of health care providers and limiting people’s choices in seeking treatment, licensing and prescribing laws institutionalize the hierarchical relationships between doctors and nurses, nurses and patient care techs, and, perhaps most importantly, between those providing care and those receiving it.

I had evolved into an anarchist and individualist before I graduated from nursing school, so I knew what I was up against from the beginning of my career.  But, 40 years later, I remain happy with my choice of an occupation.  I love the work I do and enjoy my relationships with most of my patients and some of my co-workers, including physicians and even some of the administrators.  Besides enjoying my day-to-day work duties and the interactions with patients, I find my areas of specialty, cancer care and infusion nursing, intellectually stimulating, as well.  I get to work in a chemotherapy infusion center, a radiation oncology department and in the office of a group of gynecologic oncologists.  In these various roles I do all sorts of nursing work: I educate, counsel and comfort patients; I support and educate other health care workers: and I work closely—largely collegially—with physicians, nurse practitioners and physician assistants in planning and managing patient care.  This job works for me.

Promoting Autonomy

Over the years I have tried to live out, as well as I can within the constraints of statist health care, my individualist and anarchist values.  In my relationships with my patients, this largely takes the form of making sure the people I care for are knowledgeable enough about their illness and their care options to play a role in determining their treatment.  All too often patients blindly follow the orders of their physicians, simply because they are physicians.  While their treatment plans are generally ones I agree with, I believe people should know why they are getting the drugs or radiation they are receiving, how the treatment works, and what the side effects or other downsides are.

Patients sign form after form declaring they are giving informed consent to this or that treatment or procedure, but most of them are ill-informed, at best.  This is usually not the fault of any individual, but the result of a combination of things: physicians unable to take the time to fully explain treatments, other health care workers who are not knowledgeable enough to answer patient’s questions, and patients who are overwhelmed by their diagnosis and really do not hear or understand what they are being told.  I see it as my job to make sure patients get the information they need when they are most ready to absorb it, so they can understand what is happening to them and make truly educated decisions.

I spend a lot of time explaining to people how to prevent or treat symptoms caused either by their disease or by the treatment they receive from me and others.  Again, whether because they weren’t told how to respond to them or didn’t “hear” what they were told, patients often tolerate treatable conditions, including significant pain, without seeking help from their physician or other healthcare workers.  Something that complicates this piece of my work are the widespread myths about pain medication and addiction, made much worse recently by the so-called “opioid epidemic” which I wrote about in this zine last year.  It is not uncommon for doctors to undertreat people’s pain and for patients to avoid taking narcotic analgesics because they are afraid they will become “addicted.”   This is largely because of the crap the government has been peddling for years about “dangerous” drugs, as well as the punitive laws which sometimes scare well-meaning physicians into denying their patients adequate treatment.  I consider counteracting misconceptions about pain relievers to be a key part of serving my patients well.

I like to think that by encouraging patients to be active participants in treatment planning, enabling them to take charge of maintaining their own health and comfort, and prompting them to question the prevailing myths and “expert” opinions with which they are presented, I promote their independence and autonomy, even if it is only in this one area of their lives.

Nurses as Workers

The other part of my working life where I try to put at least a little anarchy into action is as a union activist.  When I was a grievance officer in my chapter, I spent a fair amount of time advocating for nurses who had gotten into some form of trouble with the boss.  I sat in on disciplinary meetings with nurses and managers, filed grievances as needed and helped people navigate the human resources and payroll bureaucracy when errors were made or people’s contractual rights were violated.  There is a huge disparity in power between management and labor, and unions, for all their faults, add a bit of protection for workers so that some limits can be placed on the ability of managers to discipline, discharge, and generally beat up on workers.  While I no longer work as an “official” grievance officer, I still take part in particularly difficult grievance cases, and continue to be on the union team during contract negotiations and related discussions.  Helping folks out and standing up to the powers that be can be enjoyable. 

But there are also problems with traditional trade unions.  For one thing the contract we sign with the hospital enshrines management rights and the power differential between those who own and run the hospital and the rest of us.  The union is left in the position of just making sure that the boss doesn’t go too far.  We can never challenge, at least through contractual means, the hospital’s power to manage and give orders to the people who do the real work.

Perhaps the biggest problem is that few members actually take part in the life of the union.  A few of us do all the work and negotiating and phone calls, while most people never do any more than vote for officers or participate in contract ratification, if they do even that.  Unions, even traditional AFL-CIO organizations, often have relatively democratic structures, at least on the local level, and have the potential to be a means to fight hierarchical organization and increase the power of individual workers, but they never seem to actually achieve this.  Just as in other institutions and organizations in society at large, there are those in the unions who seek to wield power and influence over others while fattening off the (often mandatory) dues of members, and those who are unwilling or unable to speak truth to power and stand up for themselves.  Corrupt union officials and passive, apathetic members are both to blame for the sorry, hierarchical internal state of most unions.

And finally, the relationship between union and management is regulated extensively by the government, so both sides can appeal to the state to settle disputes when they can’t come to an agreement on their own.  Sometimes the resolution favors the hospital and sometimes it works to the advantage of the union, but in either case it serves to reinforce the control of the process by government, something that is anathema to this anarchist.

What I Would Change?

Inasmuch as I think that the philosophy and scientific basis of allopathic medicine are largely valid, I would hope that much of the work I do would still be done in some form in a free society.  People will still get cancer and require treatment, and, however ineffective allopathic therapies are at times, there is no system of healing that works better.  Of course, preventing illness in the first place works even better at preserving health, but that requires effort on the part of individuals.  While I like to think that free people might take more responsibility for their own well-being and live more healthily in order to stay well and avoid having to deal with physicians and nurses, I’ll believe it only when I see it.

What must change, however is the hierarchical way in which this care is provided.  That will require getting rid of professional licensure and other barriers to entering the healing occupations.  Eliminating licensing by the state and regulation of practice by government boards would do away with the enforced doctor‑nurse-technician-patient hierarchy and allow consumers and providers of health care to contract for services however, wherever, whenever and with whomever they like.  It would also allow providers to team up and practice jointly without one or some giving orders and others simply obeying.

We also have to eliminate the prescription system which keeps individuals from choosing and using the treatments they would like.  This system forces patient to see state-licensed providers for even the simplest and safest medications, driving up costs and bolstering the image of the physician or other provider as parent or priest.  People should be free to ingest, inject or smoke whatever they like without having to get the approval of a state-appointed expert before doing so.  This would include all drugs, including narcotics, stimulants, hallucinogens and other medications which are and have been irrationally demonized by the state, the news media and much of the medical establishment.  Besides freeing up access to medicines in this way, we should also do away with laws granting patent protection and other intellectual “property” rights.  These statutes allow drug manufacturers to charge exorbitant fees for the medicines they produce, an expense which is a key driver in the ever-increasing cost of health care.

Labor laws should be abolished, as well, so that in situations where there are bosses and bossed, the bossed would not be prevented by the government and its police from really taking on the powers that be.  This society and its laws have institutionalized the concept that some people involved in a business should have the legal right to own it and run it, while everyone else is relegated to the status of mere employees who can be dismissed at will.  This idea that some stake-holders in an enterprise should have powers and privileges that are denied to others, including the ones who do the actual work and bring in the money which the bosses pocket disproportionately, is widely believed in this society.  This belief needs to be challenged by anarchists so that people begin to question and reject it.  Once people have come to see the injustice of capitalist ownership and management, the legal framework and enforcement mechanisms which uphold and defend this economic system can be confronted and defeated by those who are its victims.

Until Then

I have laid out above a few basic components of a strategy for changing the current model of health care in the united states into one more suited to free, autonomous individuals, whether they are receiving or providing care.  I recognize that it is unlikely any or all of these changes could take place without a more widespread, revolutionary, change in the rest of society.  Abolishing government, and with it the hierarchy and inequality it enforces, is the only way I can see any real, sustainable change taking place.  Meanwhile, I intend to keep on caring for and empowering my patients and their families, and doing my best to make people think about how health care could be provided in a more humane, respectful, and libertarian way.

The Body Count in the War on Drugs Continues to Rise

We are told daily that there is an epidemic of opioid-related deaths in the united states. Those to blame, according to our would-be masters and their loyal servants in the news media, are the usual suspects: unethical drug dealers, greedy pharmaceutical manufacturers, reckless doctors, and careless patients.  The approved script is that the drug companies market narcotics too aggressively, physicians and other healthcare providers prescribe too casually, and the recipients then become habituated to and dependent on these drugs and/or allow the medications to fall into the hands of friends and relatives who do not have a medical need for them.  Once hooked, the “addicts” then turn to illegal sources to feed their habit where they risk injury and death from using drugs whose contents they are unable to verify, mixtures which often include drugs like fentanyl, which is more easily to cause an accidental overdose than heroin.

Assigning Blame

While there is some truth to this story, it is far from a complete explanation of how the current state of affairs came to be.  The increase in medical prescriptions for narcotics over time was primarily a result of a needed change in the approach to pain management among medical and nursing health care providers.  Sure, Pharma marketed their products heavily, but it was to a willing audience who were free to prescribe such drugs or not.  Instead of demonizing opioids, providers came to see them as largely safe and effective tools to control pain, especially in the setting of chronic and cancer-related pain.  Narcotics can be used with minimal risk of harm and great benefit in those experiencing pain, but since they create a pleasurable experience for some, they are also commonly used by people not in pain to get high.  And that is the rub.  The government—and all too many people in general—believe it is OK for people in pain to use these drugs but not OK for those who simply want the rush. That is why there is a war on drugs. And the commanders and soldiers in that war bear a large portion of the blame for the deaths we are now seeing among narcotics users.

Of course, the ultimate responsibility for any harm suffered lies with the users of opioids.  While the conventional wisdom is that these users are addicts, compelled by their “disease” to use opioids at any cost, there are many, including this writer, who reject out-of-hand the medical model of drug use.  While it is pretty clear that some people are more prone to using these drugs unsafely, there is no reason to believe they have an illness, or that their drug use is out of their control.  Sustained use of narcotics produces tolerance and dependence, so that increasing doses are sometimes needed to maintain a desired effect, and weaning off them is necessary to prevent withdrawal effects. But they do not take over one’s mind and body and compel the user to consume more and more.  People make choices, often bad ones, but they are still choices.

Primum non nocere

Even though the numbers of people using, and dying from the effects of, narcotics have been steadily increasing, it is also just as true that narcotics are essential to providing relief to the large numbers of people with chronic pain, including many people with cancer.  So any ethical attempts to reduce the harm caused by narcotics must at the same time ensure that those in pain are not deprived of an effective remedy.  And the statist approach of more regulation of the prescription of opioids, suing drug companies, and criminalizing non-medical users of narcotics is not only unethical, but counter-productive.

The government is trying to restrict the legal supply of narcotics by scrutinizing the practices of medical and nursing providers and frightening them into prescribing fewer opioids.  The result is that more people in pain are suffering.  In addition, less than ideal medications, such as those that include acetaminophen as well as a narcotic, are being used in situations where a pure opioid is more appropriate because the combination product limits the total safe daily dose of the combination drug, even though this results in inadequate pain control. These drugs are also less lucrative when sold on the black market, which delights the drug warriors.  Pain management strategies are now often driven by the desire to avoid the notice of the DEA, instead of the goal of optimizing the relief of suffering while minimizing adverse effects.  When it comes to medical treatment of people in pain, instead of “first, do no harm,” the new operating principle for doctors and nurses is “first, cover your arse.”

The statist approach to the illegal market is just as flawed—and destructive.  Dealers and users will always find a way to get opioids of one sort or another. Restricting the flow of pharmaceutical grade drugs simply promotes the use of black market concoctions made up of unpredictable ingredients and with unknown potency.  This is why people are dying.  By criminalizing the non-medical drug market, the government prevents people from openly testing drugs for contents and strength so that users can make an informed decision.  Instead, consumers of illegal opioids are forced to take the word of the supplier, who in a non-competitive and illegal trade has less incentive to deal honestly with customers than they would in an open and transparent market.

A New Anti-war Movement

The anarchist solution to the opioid “crisis” is simple.  Stop the drug war.  Keep the state out of the business of regulating medication prescription and use. Eliminate the DEA and police drug squads.  Let people to purchase any drug they like on an open market.  Such an approach is not popular, largely because people have believed the lies about addiction and narcotics that have been spread by the state and the medical authorities for so long.  But opioids are just another chemical, like alcohol or caffeine or marijuana or nicotine.  They are not uniquely demonic.  Marijuana was, until recently, considered as nefarious as heroin, but I can now buy it openly at my local herb shop.  That took a sea-change in public opinion to bring about, and was the result of years and years of agitation to show that pot could be used safely and that the reefer madness which drove the campaign against cannabis was nonsense based on junk science. The similar lies that drive the current attack on opioid users need to be confronted and similarly demolished.

I have been a nurse for 40 years, and an oncology nurse for half of them.  I have personally seen the havoc that has been wrought by the drug war.  I have cared for people whose bodies were ruined by using illegal drugs.  I have seen unintentional overdoses.  I provide services to people infected with HIV and hepatitis C from sharing needles and syringes.  I constantly speak with people with cancer-related pain and other chronic pain symptoms who struggle to live full lives because the government has kept the appropriate pain medications out of their hands.  Politicians and regulators have taken it upon themselves to be our overseers and determine who can have narcotics and who cannot, and under what circumstances.  This is an unacceptable infringement of people’s freedom to control their own bodies and what they wish to put into them.

Prohibition has never been an effective approach to preventing the use of chemicals that people enjoy taking.  In the case of the war on opioids, it promotes dangerous behavior among both dealers and consumers in the illegal market and deprives others of an effective means of mitigating their suffering.  And besides the awful results in the united states, the international drug war, driven largely by the american government, creates suffering worldwide.  Because of a misplaced concern about “addiction,” poor people in much of africa commonly have little or no access to narcotics to ease the pain of cancer and injury, while opium produced in afghanistan and elsewhere, which could easily and cheaply fill their and others’ need for relief, is either destroyed by the united states military and its allies or funneled into the lucrative illegal trade.  It is outrageous that people stand by and cheer while the drug warriors deprive others of access to cheap narcotics in the name of their (remarkably ineffective) fight against addiction.

The only beneficiaries of the drug war are those in government who have made careers out of regulating and policing opium use, and those who have made fortunes in the illegal markets created by drug laws. They are far outnumbered by the victims: those who accidentally overdose, people with unrelieved cancer pain, people murdered by the governments of many countries for the non-violent use or sale of narcotics, those killed daily in latin america by participants in the illegal drug trade—a trade that exists only because of prohibitory drug laws.

As an anarchist I oppose any intervention by the state in my life or that of others.  But that is clearly a minority opinion.  Drug laws, like so many other statist interventions, promise protection from harm at the expense of personal freedom.  And even though these laws actually cause more harm than good, while severely restricting individual liberty, most people appear to believe the hype and kowtow to the authorities.  They are unwilling to think and act for themselves and would rather just accept the information fed to them by the government and its supporters without question.  Unless people reject the authority of the state and start taking responsibility for themselves we will never see the end of the drug war and the bodies will continue to pile up.

The Drug War is Hell

Legalization of possession and use of marijuana is spreading gradually from state to state, but this should not be taken as a sign that the drug warriors have declared a truce in their murderous attempts to control what people smoke, ingest or inject. They have simply conceded one battle in this war, one that was becoming harder and harder to justify to the people of this country whose extorted tax payments fund this misguided adventure. Just as re-legalization of alcohol after prohibition was repealed did not lead to deregulation and free individual choice in when, where, and how people were allowed to imbibe, now-legal marijuana use is and will be regulated, controlled, limited, and taxed by those who feel it is their responsibility—no, right—to tell the rest of us how to live. Continue reading

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