Saturday, October 3, 2009

True Solutions for America's "Status-Quo" Health Care

This is a piece originally written by Rusty Scalpel for publication on another site. Readers of Free Market Physician will recognize common themes accompanied by statistics that have not previously been published on this site. In particular we would point out the author's finding that 24-38 cents of every dollar paid for doctor's visits with health insurance is consumed by the billing process. This number was arrived at through extrapolation of data in a well-known New England Journal of Medicine article. To the best of our knowledge, this figure is not published anywhere else on the Internet.

President Obama says it is time to escape the status quo of the United States health care system. He proposes mandates and funding to provide health insurance for all Americans. Although such a plan may appear reasonable, it will only perpetuate the high costs that now make health care unaffordable. A real solution to high prices is eliminating insurance companies from the doctor-patient relationship. Health care can be made affordable through patients' direct management of their health care expenditures and direct payment for health care services.

Health care plus insurance is more expensive than health care on its own. The price of a health insurance policy is the price of health care, plus the cost of the health insurance industry itself: underwriting, facilities, legal fees, and the salaries of over 469,000 insurance company employees and 881,000 insurance-related employees. Americans pay for these costs, plus the cost of their health care, every time they pay for their health insurance policy. Health insurance cannot make health care cheaper- it inherently adds to the cost.

A classic study published in the New England Journal of Medicine illustrates this point. It shows an average overhead for American health insurance companies of 11.7%, as of 1999. Add to this a very reasonable industry average profit margin of 3.4% and we see that about 15% of money paid to insurers never reaches health care providers. Americans paying for health care with comprehensive health insurance are only using their money at 85% of its potential.

However, this is not the end of money wasted through the use of health insurance. Those involved in health care are acutely aware of how much time and money is spent billing Medicare, Medicaid, and insurance to receive reimbursement for services provided. Many clinics hire as many employees for the billing department as they have doctors and nurses, who also spend significant time in billing. This raises overhead costs, which are passed on to patients.

Doctors offices have an average overhead of 26.9%, according to the NEJM article. Of course, not all of this overhead is due to billing. But the study indicates that a minimum of 10.8% is due to insurance billing. So between 11 and 27 cents of every dollar paid by insurance companies to doctors offices is consumed by the billing process.

A little multiplication (not addition) to combine these losses with the 15% insurance company losses reveals that for every dollar the insured patient spends on health care, only 62 to 76 cents will be applied to true health care costs. The rest is lost in the handoffs between the patient and the insurance company and between the insurance company and the doctor.

This is why President Obama's plan will perpetuate the status quo. It ensures that all Americans will continue to pay into a health care pot that will leak 24 to 38% of the water put into it. His proposed regulations on the industry will not help the situation, either. Profit margins are not high enough to sustain the losses the stick-it-to-the-industry regulations will inflict. The most likely outcome of his health care plan will be the sinking of the insurance industry, with every single American chained to the deck.

What then, is the solution to the status quo? Instead of moving toward a universally insured society, we should be moving to a sparsely insured society. Instead of mandating health insurance for all Americans, we should be liberating Americans to make their own health care decisions. We should allow them to decide whether or not they can afford the additional 24 to 38% they must pay to have health insurance services added to their health care.

Part of the solution requires a cultural shift. America must see health insurance for what it really is. Health insurance does not guarantee health, just as life insurance does not guarantee life. Health insurance is meant to protect finances against health expenditures that would cause a financial wipe out. Most consumers are looking for a plan to protect their finances from a major emergency. A catastrophic (high deductible) plan is what they need and can purchase for well under $100 a month.

Unfortunately, what most consumers purchase is comprehensive health insurance. This insurance costs hundreds of dollars a month. Instead of serving as a rainy-day account for emergencies, it becomes the account through which all health expenditures are paid. The insurance company determines a monthly payment that on average should cover all health expenses, plus operating costs. These plans are too expensive for most Americans. Instead of protecting finances from an emergency, comprehensive plans turn out to be a catastrophe all on their own.

Another part of the cultural shift involves health care providers. They too have fallen into the health insurance net. Involvement with insurance companies proves expensive and painful for them, just as it is for the patients. Not only must they participate in the costly and aggravating billing process, but insurance policies interfere with their treatment plans. Medication and treatment decisions are made not on the basis of patient need, but on the basis of insurance coverage.

The solution to patient problems was catastrophic insurance plans. The solution to doctors' headaches and additional expenses (which they must pass on to the patients) is fee-for-service, cash-only clinics. By eliminating third-party payers these clinics have incredible potential to save patients money. They bill patients directly at the time of service for services received. They restore the patient-doctor relationship. Doctors are able to prescribe and treat based on patients desires and ability to pay, not on insurance companies' payment plans.

Coupling catastrophic insurance plans with fee-for-service clinics can have profound financial effects for patients. Imagine if instead of paying into a comprehensive insurance plan every month, patients paid for catastrophic plans and then deposited the remainder of what would have gone into the comprehensive plan into a savings account. This account could be used to cover routine medical needs and cover the deductible should a true catastrophe occur. The money stays in patients' bank accounts instead of becoming part of the operating budget of the insurance company. Patients earn interest on the account and are actually able to maintain the assets in their accounts from year to year.

Not only are Americans free to grow richer by managing their own medical expenses, but they empower themselves in their relationships with health care providers. They now have bargaining leverage as individuals or groups because they, not insurance companies, are the payers. In addition, instead of getting every possible procedure after a deductible has been met, they become conservative spenders. They analyze whether a service has value to them and spend accordingly. They ration their own health care based on their needs instead of allowing insurance or government to do it for them.

In short, we turn patients into consumers. They are not beggars or government dependents to be seen at the leisure and pity of physicians, politicians and third-party payers. They are empowered American consumers. They are free men and women, masters of their own lives and their own property. Such liberty is not status quo. It is an American phenomenon and America's legacy. Let's not forfeit that legacy for President Obama's status quo government-controlled health insurance.

Rusty Scalpel

Saturday, September 12, 2009

Conservatives Visit Washington for Tea Party

Conservatives- Welcome to Washington DC!

It's obvious that you are new in town. You don't show up for rallies like this one very often. You don't hire former salesmen to represent your voting blocs to the Washington legislators. In fact, the White House doesn't even know who you are.

When questioned about the rally on Friday, White House Spokesman Robert Gibbs shrugged and said, "I don't know who the group is."

Con-serv-a-tives. Yes- they are the ones who wanted the other fellow to be president. Yes they're the rowdy ones at all the town hall meetings recently. No, I guess they weren't convinced by President Obama's speech on Wednesday. Yes, there do seem to be quite a lot of them. Do they vote? I'm sure they do. Yes, I would be worried if I were up for re-election in 2010 as well.

Rusty Scalpel

Friday, August 28, 2009

How is the Health Care System Broken?

The phrase "We all agree that the system is broken" has become common in the health care reform debate. Politicians and commentators invoke it to show that we have a common value or belief that should compel us to desire reform. The phrase has been used to justify every type of reform on the table. But in truth, we agree on very little about this 'broken system.' We can't even agree on what 'the system' is and much less how it is broken.

Imagine a professional basketball team that has trouble winning games. They have defensive and offensive strategies that they prescribe to and develop a rotation for the players. Despite their efforts, they are not winning. The players come to an agreement. "This is not working. We need a change," they tell each other.

But what is not working? Some of them are referring to the defense. Some of them are referring to the offense. Some of them are referring to their player rotation. Little does the team understand, but several of the players are even referring to the sport of basketball. When they say it isn't working, it's because they want to give volleyball or soccer a shot.

Such is the situation in our country. People say the system is broken. But what they mean varies. Some are speaking of the health insurance industry. Some are speaking of the high price of health care. But we are surprised to find out that many refer to the American standard of economic freedom. They suggest that we ought to be playing a whole new game.

Like everyone else, I have my own opinions as to what is broken in the American health care system. I could write pages (I have written pages!) about interferences in the patient-doctor relationship, the money wasted on the insurance industry, and about how government and insurance involvement in the market create artificially high prices. But there is one 'system' that is definitely not broken. There is one 'system' that keeps the industry afloat despite all other missteps. That system is the American 'system' of a free market.

If we are more precise in our description of a free market, we cannot even call it a system. The free market is the state of the economy in a free nation. In a free market there is no government organization that coordinates buying and selling. There are no laws about how much of a product someone can buy or how much it can be sold for. The free market is the economic result of a nation recognizing the God-given, inherent rights of humanity. It is a natural state that allows the rise and fall of man based on his actions.

Anyone involved in the medical field can see that the above description of the market does not completely fit the medical industry. A huge part of health care really has become a government system. There are huge government organizations- Medicare, Medicaid, and even the FDA- that coordinate buying and selling. There are laws governing who can buy health care products and how much they can be sold for. There are laws in place that do not allow man to rise and fall based on his actions, but attempt to enforce a universal mediocrity. In these ways the medical industry has become a controlled system.

However, much of the medical industry is still free- it is not systematized. It is this part of the industry, the free market, that keeps all the rest afloat. The market responds and equilibrates when the federal government refuses to completely reimburse doctors for seeing Medicaid patients. The equilibrium is achieved by paying patients being charged more for their health care. The market responds to FDA regulations on the pharmaceutical industry that make the development of new, lifesaving drugs cost over one billion dollars per drug to develop. The market equilibrates as patients pay incredibly ramped-up prices to pay for the hoops drug-makers must jump through.

It is the free market, and not systematized government intervention, that has brought many recent cost-saving innovations to the market. Surgical centers are popping up all over the nation that perform surgeries at a fraction of the cost of local hospitals. Lower prices for healthcare are appear as midwives, physician assistants, and nurse practitioners become more available. They provide competition that also brings down the price of local doctors. Wal-Mart recently rocked the pharmacy industry by launching their $4 prescription plan, making hundreds of essential medications available for $4 a month. Competing pharmacies nationwide responded immediately by dropping their prices. These and many other occurrences in the free market have helped keep health care afloat despite all other system interventions.

So perhaps we do agree that the system is broken. It does need to change. It needs to release its death-grip on the medical industry and the free market. Sacred freedoms must be preserved and the market must be obstructed. If freedom of the market is preserved and enthroned, health care prices will go down. Patient access to doctors will increase. The poor will be able to afford health care. Health care will not just survive or stay afloat, but thrive.

Rusty Scalpel

Thursday, August 27, 2009

My submitted topic for Senator McCaskill's "Healthcare Listening Forum" (Town Hall Meeting) in West Plains

We hope Senator McCaskill understands that government involvement in either the health care or health insurance industry is the last thing that many of her constituents in the West Plains area want. We keep hearing about industry reform, but it is not just an industry that will be affected. Washington is threatening to take over our jobs and tell us how to do them, to tell us how we have to interact as patients and providers, and even manage our lifestyles to fit their definition of healthy. We consider our freedoms in these aspects sacred and God-given. So we are not looking for Washington to produce the 'right' plan for us to support. We want Washington to stay away from attempting to centrally plan our economy and dedicate their efforts to defending our liberties.

Friday, August 14, 2009

Boogeyman, Wild Misrepresentations, and Blatant Falsehoods

David Axelrod, the Senior White House Advisor, recently sent out an email meant to calm public outrage and 'dispel myths' about health care reform. In it he quoted President Obama at a recent town hall meeting saying, “Where we do disagree, let's disagree over things that are real, not these wild misrepresentations that bear no resemblance to anything that's actually been proposed.”

Here is my disagreement with the President and his staff and the whole Democratic Party. I object to the President and Legislators enslaving an entire industry, stripping Americans of their rights and livelihood, and putting them at the mercy of the government for survival. This may sound like one of the President's 'wild misrepresentations,' but it is a very real claim and the essence of the legislation that the President is promoting. For evidence I quote Mr. Axelrod's email (material also available here) under the heading "8 ways reform provides security and stability to those with or without coverage".

1. Ends Discrimination for Pre-Existing Conditions: Insurance companies will be prohibited from refusing you coverage because of your medical history.
2. Ends Exorbitant Out-of-Pocket Expenses, Deductibles or Co-Pays: Insurance companies will have to abide by yearly caps on how much they can charge for out-of-pocket expenses.
3. Ends Cost-Sharing for Preventive Care: Insurance companies must fully cover, without charge, regular checkups and tests that help you prevent illness, such as mammograms or eye and foot exams for diabetics.
4. Ends Dropping of Coverage for Seriously Ill: Insurance companies will be prohibited from dropping or watering down insurance coverage for those who become seriously ill.
5. Ends Gender Discrimination: Insurance companies will be prohibited from charging you more because of your gender.
6. Ends Annual or Lifetime Caps on Coverage: Insurance companies will be prevented from placing annual or lifetime caps on the coverage you receive.
7. Extends Coverage for Young Adults: Children would continue to be eligible for family coverage through the age of 26.
8. Guarantees Insurance Renewal: Insurance companies will be required to renew any policy as long as the policyholder pays their premium in full. Insurance companies won't be allowed to refuse renewal because someone became sick.

After years of immersion in liberal philosophy, the above proposals may sound like a good thing. Discrimination for pre-existing conditions may be considered unjust. Incomplete coverage due to chronic illness because of lifetime caps may seem unfair. But let's use regular language to explain what the government is trying to do to the insurance industry. Uncle Sam is telling the men and women who make a living by selling insurance policies the following:

You must sell policies to everyone for the same price, no matter how much money you know you will lose in the process (points 1 and 5). You must bear the full burden of their care to extent that the Legislature deems necessary, irregardless of how much it will cost you (points 2 and 3). No matter how much money you lose on the customer, even if it sends your company to bankruptcy and your family to bread lines, you may not decline them coverage (points 4, 6, and 8). Despite the fact your customers are paying much less for their polices than the actual cost of the medical care, you may not increase their out-of-pocket expenses (point 2). Oh, and you've got to cover their adult children too (point 7).

This is slavery. Slavery is what the legislature is proposing for the insurance industry. Imagine such rules being implemented in any other industry. Imagine, for example, if you had the job of mowing lawns and these regulations were established in the lawn mowing industry: Imagine that you were told that you must mow everyone's lawn for the same price, regardless of how many hours it takes to mow or how big the lawn is. Imagine being told you have to accept every customer that came your way for that price, even if you knew you would lose money on the contract. Imagine being told that you had to mow your customers lawn as often as they wanted without charging them any extra. Imagine being told that not only did these customers had lifetime contracts with you, but so did their children. From here it's easy to imagine quitting the business or shooting yourself in the head.

Americans are intelligent enough to realize that the insurance industry cannot continue to exist under the proposed policies. If a company is not allowed to compensate for increased costs by raising prices, what will happen to it? It will cease to exist. Instead of coverage for all, there will be coverage for none. But of course, that may be the true purpose of the legislation- setting our path for true socialization of the entire health care industry.

President Obama and the opponents of freedom in the Legislature figure that Americans won't stir against such abject tyranny because they are picking on a despised industry. President Obama points out that the insurance industry profits have been 'too high.' Apparently he believes it is the job of the government to make sure we don't make too much money. We all have had beefs with insurance companies, so he and our representatives figure we won't mind if the government takes over their jobs. Here they are wrong.

Health insurance providers have been collectively written off as an evil industry in an effort to dehumanize them. We don't think of the reform bill affecting fellow Americans, but that it will punish a greedy profit-seeking industry. But that industry is privately owned and provides employment for over 400,000 Americans who count on those profits to feed their families. They are no different than Americans in any other industry, all of which are profit-seeking. Why should we expect or allow them to roll over and become a national sacrifice?

We will not allow their sacrifice because we know that freedoms taken away from one group of Americans means a loss of freedom for all Americans. If we begin to sacrifice the unalienable rights of some for our comforts and commodities, then our rights will never be safe again. Once we find ourselves outside of the majority interest, we too will find our rights forfeited for the 'good of society.' And so we will fiercely and passionately fight, since our own God-given liberties are at stake, for the rights of the men and women of the insurance industry. We see all too clearly that if they go down, we may find ourselves next on the chopping block of socialism.

Rusty Scalpel

This blog can be submitted for White House correction at

Ronald Reagan Speaks Out Against Socialized Medicine

President Obama certainly has a gift for oration, but he doesn't hold a candle to this Reagan fellow. The guy just seems to make plain sense. In contrast to the nonsensical politically-calculated speeches we hear these days, this appeals to reason and logic. It stirs our better feelings, glorifying instead of condemning the freedom, independence, and national virtue that is our heritage. It is truly refreshing. This Ronald Reagan fellow should run for public office.

Saturday, August 1, 2009

When the Majority of Health Care is Government-Funded

I wish I could say that I believed the Blue Dog Democrats will stand firm on health care reform issues. But I am afraid that the party-line vote in the House Energy and Commerce Committee on Friday night is a preview of what we will see in the final House and Senate votes on health care reform in September.

As I contemplate the bill my heart fills with sorrow. Where are the righteous legislators who should be defending against such a breach of freedom and logic? Have we fallen so far into ignorance and selfishness as to have elected a body who will allow this legislation to pass?

Medicare and Medicaid enrollment already stand at nearly 100 million, about one third of our nation's population. (45 million and 42 million respectively) In many regions (like where I live), Medicare and Medicaid patients already make up the majority of health care visits. With the addition of the government public insurance option and government subsidies of private plans, government control of the health care industry will increase.

As health care providers are painfully aware, the national legislature controls reimbursement rates to physicians for visits from Medicare and Medicaid patients. In perhaps the majority of cases (especially in non-rural designated areas), government reimbursement for care rendered to these patients does not cover the cost of the care. In other words, health care providers lose money every time they see a government patient.

Economically speaking, the legislature has established price controls for over one third of all health care visits. Doctors make up their losses by overcharging their other patients. Thus, patients who pay with cash or through a private insurance plan lose money twice: once when they are overcharged for their visits to compensate for government patients and a second time when their taxes cover the bill for these patients.

We can see that Uncle Sam has already torn a sizable hole in the pocket of self-paying, self-sufficient Americans by forcing them to fund the care of 1/3 of the population. How much more will he siphon from their bank accounts with the addition of the government public insurance option and subsidies to pay for the insurance of millions of more Americans?

We can see that additional government funding of health care will be a major problem. The problem is made much worse when we consider other goodies (check out this link) that have been included in the House Version of the Bill. This bill, laced with measures that strip freedom and human dignity and provisions for future federal power grabs, is a collection of sophisticated price controls. As we have discussed in the past and well understand, such measures must fail, regardless of their sophistication.

I cannot emphasize enough how disastrous the bill will be if passed. American health care survives today even with the existing burden of heavy price control. But the bill is too much. It will not "fix" health care. It will cause the health care industry to grind to a halt, necessitating further government takeover. Please let your legislators know about your feelings on this issue.

Rusty Scalpel

Wednesday, July 22, 2009

Ron Paul: Health Care is a Good, Not a Right

It is incredible to see how much of the health care reform debate is centered around whether health care is a right or a good. It seems that if we understood this simple concept, the role of government in health care would be understood and the reform debates would be over.

I believe that this may be the first American generation even capable of sustaining this good vs. right debate. If our ancestors were asked to name American rights they would have mentioned the right to worship, to right to free speech, and the right to bear arms. If asked, the current generation might mention some of these, but would also include the right to education, the right to Medicare, Medicaid, or Social Security or the right to government disaster aid.

As we have discussed in length in the past (see Health Care: a Right or a Commodity), the Declaration of Independence sheds light on what true rights are: “Men… are endowed by their Creator with certain unalienable Rights.” True rights are endowed by the creator- not distributed or rationed by governments. They are also unalienable or inseparable from the human existence. Neither health care, education, nor any other social program fits this description. They are not God-given, nor are they unalienable.

Ron Paul pegs many of the central issues of the right vs. goods debate in his weekly message. We thank our readers for sending this on to us. You can read the text of his address here.

Rusty Scalpel

Saturday, July 18, 2009

Where Can Virtue be Found?

A while back I found myself in a classroom listening to a self proclaimed “independent” spokesman. He represented the political arm of a religious-affiliated hospital located in an underserved area of a major city. The man was giving a lecture on how he thought medical care should be delivered. He proceeded to present his liberal agenda starting off by laying a philosophical framework which he claimed to be centered, ironically, on the very principle it lacked – virtue.

The man was very well versed in speech, even using ancient philosophers as examples. He stated the framers of the constitution were absolutely wrong because they did not include healthcare as a right (see Rusty Scalpel article - definition of a right - Healthcare is not a right) and that the only way society could be virtuous is if it provided for the healthcare of everyone. He then proceeded to say that one person in society cannot provide all the goods and services for himself (i.e. the farmer has a social responsibility to the doctor and vice-versa.) In the end he claimed the only way to properly take care of the healthcare needs of the society is to have a government mandate.

A government mandate in its simplest form is force. In “The Adventures of Jonathan Gullible” Ken Schoolland pointed out that a government mandate or law is like an "Invisible Gun." If an individual resists complying with the government mandate the ultimate punishment is imprisonment or death. It is invisible because few individuals resist and realize the final punishment.

During the lecture I was reminded of an economic concept which is poorly understood - spontaneous order. (See video below) The lecturer believed that the only way people will act “virtuously” is through government coercion. However reality seems to counter this notion. Every day individuals come together, voluntarily, and make decisions for themselves that in turn benefit society. Adam Smith, the father of economics, referred to this phenomenon as the “Invisible Hand” that would lift society to an optimal state.

It should be asked - Where is virtue derived from? Where can virtue be found? To start, it must be understood that virtue can only exist when there is free choice. Thus an individual’s actions can only be virtuous when preformed voluntarily. Forcing one man to “give” to another is not only immoral- it frustrates the very principle of virtue.

It is very popular to blame the free-market capitalism for the state of healthcare. However realizing that healthcare is the most regulated industry, we can see that free-market capitalism is not failing but only the reverse - the long history government interventionalism is failing. To conclude - virtue in society can only exist by promoting, not limiting free choice, thus encouraging the morally superior “Invisible Hand” instead of frustrating virtue by the immoral and all too often impractical consequences of the “Invisible Gun.”


Saturday, July 4, 2009

Price Controls, Medical Shortage, and Apples

In the face of rising health care prices, price control may appear a reasonable means to keep health care accessible to the masses. If health care is becoming too expensive, why not lock in prices to a rate that will insure that everyone gets the care that they need? To answer the question, let's apply it to a field that appears much more simple and economically fundamental. Let's apply it to apple selling.

Suppose that a late frost killed the blossoms of the apple trees of North America. By late summer, the shortage really starts to show as prices triple what they were in previous years. We understand why prices are high because we remember the supply and demand curves taught us in high school economics courses. The curves really work in the real world. Apple supply has fallen and demand has remained the same. There is a relative shortage of apples and price goes up.

Let's suppose the Secretary of Agriculture declares an apple state of emergency and appeals to Congress for help. The poor who depend on apples for survival are going hungry. The rich who can afford high prices are hording apples for themselves. Congress must recognize that a disaster is at hand and take stringent measures. Congress responds to the national crisis by establishing price controls in the apple industry. By law, apples can not sell above a given price. Problem solved and constituents appeased.

We, with our rudimentary understanding of supply and demand, can anticipate what effect the new law will have on the apple shortage. The past high price of apples had ensured that they stayed stocked in supermarkets. They were available so that those who really needed them got them. As Congress stomps down the price, consumers rush to stores to buy apples. The precious few apples are squandered on ordinary uses. The produce section of grocery stores are emptied and there are no more apples to replace those sold. The prices that kept apples available are now gone and we have a real shortage on our hands.

Empty shelves are evidence enough that demand for apples is greater than available supply. In a free economy, this would push up the price of apples and encourage suppliers to produce more of them. But in our economy, Congress has set the price of apples. It cannot rise. Suppliers had very few to sell in the first place and selling at an artificially low price, they cannot make up their losses and many of them go out of business.

What's more, Congress did not realize that the international trading partners of the United States were shipping apples to our apple-starved country even as the price control was being passed. They had seen the high prices and realized that they could make a profit by selling their apples here. Had those apples arrived, supply would have increased to meet demand and the prices of apples would have fallen. However, when news got out that had Congress passed the price control bill, those apple-laden ships turned around and returned to their own countries without selling a single apple. With price controls in place, it was no longer worth it to sell their apples here.

After the first year of price controls, many apple growers are unable to stay in the market. They leave the business and further decreased the available supply. Those still in the market still face the price control. They are unable to invest in their apple crop as they would other years because they know they will have to sell low. They try to cut production costs to make up for their low selling price. They skimp on fertilizers and pesticides. As a result, it is a crop of puny, wormy apples that hit stores that summer.

It is plain to see that without price controls, the apple market would have soon recovered. The high prices would have rationed the use of apples to the most important uses. The prices would have helped apple growers survive a hard year to be able to grow in the next. The high prices would have ensured that quality apples continue to be grown (with a variety of lower-quality apples available at lower prices). What's more, the high prices would have attracted additional suppliers who would have ended the shortage of supply and brought down the price.

The lessons learned from price controls in the apple market apply to all free markets, even the supposedly impossible-to-understand medical market. As with all other goods and services, the price of health care is determined by the balance of supply and demand. If supply is high compared to demand, prices drop to increase demand for the product. If supply is is low relative to demand, high prices ensue which dictate a natural rationing of the the product. It is reserved for the most urgent purposes and a true shortage never occurs.

Just as in the apple business, the imposition of price controls in the medical market will cause an increase in demand. Artificial low prices will ensure that available medical care is "used up" instead of being reserved for the most important purposes. Here a real shortage will occur (think of the stories of 7 month waits to use an MRI in Canada).

Just like in the apple business, the imposition of price controls will decrease available supply. It will make the delivery of health care services financially unattractive, if not impossible for many providers. They will drop out of business and the shortage will worsen. Remaining available services will drop in quality. What's more, medical providers who would otherwise be willing to come to the rescue for financial motives will no longer have any incentive to do so. The care they would provide and the resulting price relief will never come.

It is interesting to note that government programs that provide "free care" to patients have many of the same effects as price controls. They lead to unbridled consumption of available health care resources by enrolled patients. Reimbursement for these services is a price control- reimbursement rates are set by Congress. These artificially low prices discourage medical care suppliers from providing services and further aggravate the medical "shortage." I would be fascinated to see a study demonstrating how much of the "high" price of health care for privately-paying citizens can be directly attributed to federal aid programs.

We live in a time of rising prices and decreased medical availability. Our legislators may be tempted to consider price-control as a means to improve access to medical care. But we know that price controls will cause true shortages. A free economy regulates itself, increasing supply to meet demand to ensure access to care by all paying customers. The solution to high prices is high prices.

Rusty Scalpel

Wednesday, June 17, 2009

Recommended Reading: A Trillion Dollars in Incompetence by Robert M. Goldberg

Bonaparte famously said to "never ascribe to malice that which can adequately be explained by incompetence."

Thus stands the Kennedy health care bill, placeholder for the hard left dream of a government takeover of the American health system. The bill is a taxpayer-supported monument to the lethal stupidity of this statist objective that will leave Americans with fewer choices, more government control over medical decisions....

Continue reading here at The American Spectator

Tuesday, June 16, 2009

Holding Their Feet to the Fire

Among the disturbing proposals for health care overhaul legislation is the so-called "public insurance option." The idea is to form a state-owned health insurance company that will compete with the currently existing insurance companies. How exactly the program would be administered and run is an idea in flux, but it's purpose is clear.

“If the private insurance companies have to compete with a public option, it will keep them honest and it will help keep their prices down,” President Obama said in a speech last week.

Senator Baucus, chairman of the Senate Finance committee was reluctant to call the new company public or state-owned but was likewise clear as to its purpose: “It’s not going to be public, we won’t call it public, but it will be tough enough to keep insurance companies’ feet to the fire.”

Keep them honest? Keep their feet to the fire? The President and Senator make thinly veiled accusations: 1. Health insurance companies are dishonest. 2. Insurance companies somehow need to be pressured, coerced or punished.

What does President Obama feel the insurance industry has been dishonest about? What law have they broken? If they have used fraudulent practices, it is his duty as chief executive officer in this country to see that they are prosecuted. Have they broken anti-trust laws? If so, it is his duty to see they are prosecuted. Likewise, what has the insurance industry done that requires having their feet held to the fire? Shouldn't whatever action or inaction that justifies government intervention be legally prosecutable? Why doesn't the senator suggest a prosecution?

From hearing and reading much discussion on health care reform, I could make a guess at the crimes alluded to. I believe that they might be the crimes of being expensive and of having exclusion criteria. Insurance companies are guilty of offering policies that cost too much and of having exclusion criteria that limit which customers are eligible for those policies.

Before we condemn the entire insurance industry as being greedy and immoral, let's review why prices are high and why there are exclusion criteria for plans. I say let's review because I believe we already know the reasons. Despite our knowledge we have branded the insurance industry as the enemy. We falsely brand the industry as criminal and strip market rights for our own personal gain. What a sad state for our democracy.

The high prices for health insurance are a direct function of the price of health care itself. Health insurance costs the going rate of health care, plus a little bit. The cost of maternity insurance is the cost of a delivery, plus a little bit for administration, losses, and the risk of emergency procedures. The cost of catastrophic insurance is the average cost of health care due to catastrophes among the policy holders, plus a little bit for administration, employee salaries, etc. The cost of any health insurance from any company that plans on staying around long enough to pay policy holder benefits must be the cost of the health care, plus a little bit.

The high prices for health insurance are also a direct function of regulation of the market. Each time a state legislature mandates that insurance companies cover this or that illness, insurance premiums must go up to compensate for new expenses. Every time a state legislature mandates coverage to see this or that specialist or to receive this or that test, the price of premiums must go up to compensate.

As for exclusion criteria, we know how difficult it is for those who do not qualify for certain insurance programs. But we also know that insurance companies maintain these criteria in order to keep the price of premiums low enough for the general populace to afford. Any plan to enforce removal of exclusion criteria may be noble, but is not based in reality. A plan without exclusion criteria is a plan that most people will not be able to afford.

Health insurance is a business. It is not a charity. There are many wonderful private charities and programs available to help those who cannot afford health care, but the insurance industry is not one of them. This is not a crime. Insurance companies must make a profit so their employees can take money home to feed their families. There may have been criminal acts committed within the industry. There may have been unethical behavior. These should be prosecuted. But the cost of health insurance is no crime. The existence of exclusion criteria is no crime.

When we understand the nature of health insurance and how its price is determined, we begin to see that the institution of a national health insurance plan does little to solve today's health care problems. The best any free and true health insurance company can charge is the true cost of health care, plus a little. The only way a national plan can compete with free market is for it to be non-profit earning. It must become a charity. In order to do so, it will require financial support. And so our tax dollars will go to support a failing insurance company, just as they now go to support failing banks and auto companies.

How will insurance companies owned and run by American citizens compete with such a national company? They can't. They cannot drop their prices enough to compete with a "company" that doesn't care about profit margins or the bottom line. Their customers will slowly trickle to the national insurance policy and one by one they will go out of business. As Americans, we will have the privilege to use our tax dollars to put our fellow countrymen out of business. It won't matter if the government did not initially take over the entire industry, because government will have successfully run its citizens out of the market.

Rusty Scalpel

Monday, May 18, 2009

Review of Mitt Romney's "The Answer is Unleashing Markets- Not Governments"

What is Mitt Thinking?

I believe I have a pretty good feel for Mitt Romney. I share his conservative philosophies. I think I understand his cultural and religious background. But my understanding for who Mitt is does not necessarily translate into an understanding of what Mitt does.

Take the op-ed piece that we're about to critique. Mitt Romney wrote this interesting piece on health care policy that appeared in the May 18 edition of Newsweek. In it he promotes aspects of the Massachusetts Health Care Reform law of 2006 that he helped enact as governor. His views in this editorial may be influential in providing congressional Republicans the backbone for the compromise on health care reform that they will make with Democrats this summer. But why does Mitt, a self-proclaimed free market guy, make the recommendations that he does? For example, why does Mitt claim to support a mandate that every person must be insured? (The first point in his essay.)

Mitt proposes tax penalties for those who by state standards can afford insurance, but do not buy it. That's the sort of argument that should be coming from the managed-market guys, not the free-market guys. The managed-market guys would claim that forcing everyone into the market, especially the healthy and deliberately-uninsured young adults, will bring more people into the insurance pool and bring down the price of premiums for everyone. We would expect Mitt to argue that mandating the use of a certain commodity runs counter to market principles and counter to freedom in general. Obligatory purchase of commodities negates the free in free market.

It turns out that the historical Mitt, the Mitt we think we know, would agree with us. The plan that he proposed as governor of Massachusetts had no individual mandate attached. The state was struggling with free-riders showing up at the emergency room without health insurance and leaving the state with the bill. Mitt proposed that state residents without insurance post a $10,000 bond to cover unpaid hospital bills. Mitt opposed the individual insurance mandate. It was the democratic legislature pushed the compulsory individual insurance mandate.

Why then, is the mandate the first point of his health care proposals? Why not a plan that directly addresses the issues of free-riders at the emergency room or on bankruptcy law instead of a direct attack on the market? In fairness, we point out that the Massachusetts individual mandate was softened with provisions allowing the purchase of catastrophic coverage and Health Savings Accounts to fulfill state requirements. But should we have to have health insurance to be law-abiding Americans? Does Mitt really believe in mandatory health insurance (history says no), or is this just political expediency?

Mitt's plan would use funds once dedicated to the payment of emergency room bills to the payment for health insurance for the Massachusetts's needy and projects huge state savings with the change. Whether this change is financially advantageous for the state in the long run remains to be seen. We have to be wary of any state-provided service. It seems human nature, even for Americans, to like all things "free" and politicians love to win votes with the promises of increased government services. Mitt cites the original Medicaid bill, which was supposed to cost $500 million, but now costs $500 billion to operate. I think we can safely assume that the overall cost of his state-purchased health insurance policies will similarly balloon.

The rest of the essay is more what we would expect from Mitt. He proposed increasing the portability of health insurance, touted the effectiveness of co-insurance plans, supported increasing patient information about cost and quality of care, and recommended reform of Medicaid and Medicare. Very importantly, he states that any health care reform should occur on a state, not a national, level.

So, what are we to think overall of Mitt's proposed plans? Regardless of objections we may have, his proposals are going to be much more conservative and market-oriented than anything that comes out of Congress this summer. And as the Heritage Foundation pointed out, the mandates in Mitt's plan are less problematic than they appear.

And yet, as freedom loving Americans, we should be able to expect something more from conservative leadership. As the editorial title states: the answer is unleashing markets, not government. I believe I speak for true conservatives and freedom-lovers when I say I believe the state has no business whatsoever providing health care for its citizens. Ideal health care reform removes government from health care. Ideal health care reform removes restrictions on the market. Innovation becomes legally possible, the patient is empowered as a consumer, prices are driven down and accessibility increases. The ideal reforms removes tax burdens on Americans and allows them to care for and rely on each other instead of picking their pockets and forcing reliance on Uncle Sam.

These are the principles that should be promoted by conservative leadership. Compromise happens after we champion the ideal. I worry that Mitt may be rejecting the ideal and his past principles in order to embody the compromise. I like Mitt, so I hope I am wrong. Conservatives everywhere are being tempted and taunted to embrace this new moderate Republicanism with which McCain lost the election. I hope that Mitt and other conservative leaders hold to their principles and continue in honorable service promoting the ideal.

Rusty Scalpel

Monday, April 27, 2009

Andrew Lloyd Webber and Ayn Rand on Mob Politics and Targetted Taxation

We live in a time of world-wide economic difficulty, a time when everyone is cutting spending, tightening their belts and budgets, and preparing for some lean times. That is, everyone except for the world governments. They, some some reason, have ballooning budgets and unchecked ambition for expansion. (President Obama promised 3% of the national GDP for development of science technologies today. He forgets that social security and other national obligations of debt already eclipse the GLOBAL gross domestic product.) So where is the funding for these programs to come from, with money so scarce among the citizenry? For politicians who have won office on the vote of the poor, the answer comes easily: tax the wealthy.

But what happens when a majority of voters chooses to strip the rights of the few? What happens when we begin to single out members of society to carry a country's financial burdens? Can a country sustain itself with such policies? Can we escape a recession with such legislative looting?

Andrew Lloyd Webber, the British broadway behemoth, spoke out today against a new 50% income tax on in an editorial in the London Daily Mail. Great Britain has upped their 40% income tax with a 50% income tax on anyone earning over 150,000 pounds. Here's what he had to say:

"The opinion polls have uttered. The country loves the new 50 per cent top rate of income tax. Soak the rich. Smash the bankers. So Government spin doctors are in second heaven...

The next few years are going to be horrendous in the UK. The last thing we need is a Somali pirate-style raid on the few wealth creators who still dare to navigate Britain's gale-force waters...

I write this article because I fear the inevitable exodus of the talent that can dig us out of the hole we find ourselves in. It is inevitable, given that other countries are bidding for entrepreneurs. The Government must modify its proposals...

So I ask the Government to reconsider what it is doing. More than ever before we need to keep high-flying professionals in the UK. We can't, as we have done in the past, dump on them through penal personal taxation."

Andrew Lloyd Webber's points out that not only is such taxation unfair, it is ineffective. Industry leaders and highly-trained professionals, or "High-flyers" as he put it, are not going to stay in a country where they are enslaved. They will take their talents and the jobs and revenue they would generate elsewhere. Individuals who would generously "take one for the team" when done voluntarily may not feel so generous if they feel they are being robbed at gunpoint. They can afford plane tickets and they will leave.

His point is eloquently reinforced by an email titled "Who is John Galt?" sent to me today:

"We all hear about the need to protect patients' so-called "right" to health care. But we don't hear about protecting the rights of the doctors or the doctor-patient relationship. This issue is eloquently summarized by Dr. Thomas Hendricks, one of the characters in Ayn Rand's novel, Atlas Shrugged:

'Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun. I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward. I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything--except the desires of the doctors. Men considered only the "welfare" of the patients, with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter, was regarded as irrelevant selfishness; his is not to choose, they said, only "to serve." . . . I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind--yet what is it that they expect to depend on, when they lie on an operating table under my hands?'

We need to protect the rights of doctors and patients to trade on a free market to mutual benefit. Otherwise we will see more and more doctors silently shrugging off the burdens of being controlled by collectivists."

We've seen historically what happens when a nation tries to enslave portions of its population. The population rebels, especially when the population is already a motivated and hard-working demographic. Look at the American Revolution. When Britain tried to impose taxation without proper representation on its hard-working entrepreunerial colonists, those colonists rebelled. Great Britain lost the incredible wealth and talent that developed from this continent by its targetted taxations. This sort of rebellion and exodus is likely to occur in any democracy where a majority mob vote determines to strip the rights of the minority.

Not only is targetted taxation a formula for economic failure, but it is a sign of a failing democracy. A democracy is a meaningless institution without guranteed rights. When rights are eroded for any portion of population, they are eroded for all. Those who find themselves in power with the majority in one moment are liable to find themselves isolated and enslaved as a minority in the next moment. We cannot expect the good favor of the Creator, or durability as a republic if we trample those rights that we once held to be God-given.

Rusty Scalpel

Friday, April 24, 2009

Helping Patients Take Charge of Their Health (Part II)

Might God help them get better?

Helping patients make life-saving changes can be a challenge. Many of the behaviors that contribute to the development of preventable illness are habitual and some are even addictive. Last week we talked about using money as a motivating factor to help patients to take responsibility for their health. We showed how a fee-for-service system and a personal assumption of medical costs might help diabetes patients to better control their disease. But we acknowledge that even patients who are resolved to make major lifestyle changes may fail to do so. Changes, even the major changes that survival often requires, are often difficult to pull off.

A couple of weeks ago I attended a meeting where visiting physicians talked about their past histories of drug abuse. They talked about how they, even with their understanding of medicine and the body, became desperately addicted to various drugs. They knew the effects of what they were doing. They saw the havoc the drugs were wreaking on their professional lives and on their families, but they would not quit.

One physician told about his addiction to prescription painkillers. At night he would return to the the hospital he worked at and rummage through the garbage and sharps containers looking for old needles and syringes that might have residues of the painkillers he was addicted to. He would collect these residues little by little until he would have enough to take a hit of the drug. Another physician told of a crack house in Detroit that he often visited. He had a credit card with a $100,000 line of credit. Seeing his affluence and his dependence on the drug, the crack house opened a room just for him to stay in during his frequent visits.

But a couple things happened to these physicians to help them turn their lives around. First, they hit rock bottom and realized they had to change. Second, they found God.

The physicians described the desperation they felt when they realized that their lives were out of control. They were losing everything that was dear to them. They realized they had to change and made the decision to change. They told us about the support they received from professional organizations and the Twelve Step Program. The physicians then related, boldly and unabashedly, that only through the help of God were they able to break free from their addictions. Without Him, they would have been lost. Every single day, they told us, they thank Him for helping them escape and remain free from the drugs that once dominated them.

Let's return to our patients who struggle with habits that impact their health and shorten their lives. As physicians we counsel, we educate, we set goals and do everything in our power to help these patients change life habits. But our experience demonstrates that most patients will not change their behavior. Have we come to believe that change is impossible? Are our patients helpless? Are they irreversibly locked in habits of smoking, drinking, over-eating, drugs, inactivity, and damaging sexual practices?

Most physicians and patients believe in God. Do physicians believe that God can help patients overcome their habits? More importantly, do patients believe in a God that would help them change their lives?

As physicians we use all sorts of tools to try to help our patients to change unhealthy habits. Have we tried applying the patient's own faith to the problem? To the patient that is sincerely but unsuccessfully trying to quit smoking, we might ask, "Do you believe that God will help you have the strength to stop smoking?" How powerful it will be if we can follow their affirmative response with, "I know He will."

Change is hard to make, but it is not impossible. We are not treating animals who have no control of their destiny, but Man. He can choose to change. If our patients need help in making change, why not tap into the resource of their faith to help them clinch that change? If our patients believe in a God who watches after the life of each sparrow and cares for the lilies of the field, then perhaps he will help them control their diabetes or quit smoking.

Rusty Scalpel

Friday, April 17, 2009

Helping Patients Take Charge of Their Health (Part I)

Making Money a Motivating Factor

Americans spend hundreds of billions of dollars a year treating preventable illnesses. The sums of money spent on these illnesses are even more breathtaking when we realize that it is money that does not have to be spent. For example, in 2007 Americans spent $116 billion on medical expenses related to diabetes, according to the American Diabetes Association. The average diabetic spends $6649 a year just on diabetes. The numbers force us to ask: what must we do to prevent this preventable disease?

In this post, I'll use diabetes as a case study for all other preventable diseases. When speaking of preventable diabetes, I am referring to most Type II diabetes mellitus. Although it has genetic components, the onset of this type of diabetes is generally brought on by an unhealthy lifestyle. The landmark Diabetes Prevention Program study showed that type II diabetes could be prevented or delayed by diet and exercise in 58% of cases (compared to placebo). This effect was seen in all individuals regardless of race, sex and class. In short, type II diabetes can be prevented in most patients by diet and exercise.

The American physician struggles to help patients prevent and treat diabetes. The first-line treatment for diabetes is exercise and diet. Doctors tell this to their patients. Yet deep in his or her heart, the doctor knows that the patient probably will not change their lifestyle. They will return to the next visit with the same blood glucose level and without having exercised or dieted. The doctor will be left with only pharmacological and surgical means for treating a disease that the patient should be able to treat on his or her own. So instead of pounds being dropped, medications are prescribed and gastric bypasses are performed.

One reason that patients may be unmotivated is that we have attempted to remove money as a motivating factor in our health care system. We want everyone to get the care they need, regardless of their ability to pay. We try to create a health care system where money is not the object, but in so doing we may be harming our patients.

Consider the Medicaid patient who knows that diabetes is shortening their life and ruining their lifestyle, but is unmotivated to personally address their diabetes. Free visits to the clinic and daily insulin shots are much easier than a massive overhaul of diet and daily exercise. Instead of getting healthy, the disease progresses and the taxpayer shoulders the bills. Patients with comprehensive health insurance may likewise put off taking care of their health. If they stay on their current policy, their premiums will not radically change and the disease may not hit their pocketbooks too hard.

But imagine the patient that is directly confronted with the cost of their poor health in every visit and with every prescription. In every medical bill these patients have a concrete, immediate reason to take diabetes into their own hands. As stated above, diabetes will cost the average patient $6649 a year on top of their other medical expenses. These self-paying patients are immediately aware of this cost and will look for ways to reduce it.

The thoughtful doctor could talk finances with a self-paying patient and encourage health lifestyle with a conversation something like this:

"Bob, you know that I'm concerned about your weight, your blood pressure, and your glucose levels. Unless we get these under control, it's not a question of if you'll get diabetes, but when you'll get diabetes. But if we can get your weight and these other things under control, you're going to be healthy for years.

Now I know that work and family keep you busy and you don't feel you have time to take care of yourself. But think of it this way. If you get diabetes, it is going to cost you about $7000 a year to treat. Now that's a lot of money. If we can start preventing the disease now, that's money in your pocket. If we work out the numbers, taking a 30-minute daily walk may save you $20 a day. Earning forty bucks an hour to take care of yourself- that's not bad."

I don't know about you, but if I were Bob, I might start jogging. I could think of a lot better uses for $7000 a year than insulin shots. Seven thousand dollars a year- now that's motivation.

Some might say that having patients to pay for their own care is cruel or unfair. But look at the scenario above- paying his own bill just made Bob healthier. We must pay for our own care. Any other system cannot last- such socialism truly is only a contrivance. When the reality of our personal responsibility for our health is realized (perhaps accompanied with some lessons from the school of hard knocks), we will see the epidemic of preventable disease disappear along with its accompanying epidemic of apathy.

Preventable diseases are prevented when patients are made responsible for their own health. As doctors, we're really missing out on one of our best tools to help patients truly be healthy if we don't make money a motivating factor. As Americans and as children of God, we're not meant to be coddled. When given the responsibility, we take care of ourselves. When entrusted to the system, we all get gastric bypasses.

Rusty Scalpel

Wednesday, April 8, 2009

Wal-Mart offers Electronic Medical Records System

In the past we've praised Wal-Mart's $4 prescription plan and in-store clinics. Wal-Mart continues to drop the price of health care in a recently announced move to enter electronic medical records business. The news is a couple of weeks old, but it is interesting and worth discussing.

Wal-Mart is teaming up with Dell and eClinicalWorks to offer a bundled electronic medical records system that would cost about $44,000 to set up and operate per physician. For most doctors, that's about half the price of setting up other available systems.

Wal-Mart is consistently demonstrating that the market has plenty of solutions to medical care problems. Good business is the answer to the high price of care.

Further analysis of the medical records package is far beyond my expertise, but a good analysis of the product and the Wal-Mart/Dell/eClinicalWorks partnership by Don Fornes of Medical Software Advice is available here.

Rusty Scalpel

Tuesday, March 31, 2009

Those Who Pay the Bills Run the Business

Several news stories and political developments drive home an important point in health care delivery: Money is power. The person who pays the bills runs the business.

Take for example the dwindling autonomy of businesses and industries that accepted government aid over the last couple of months. 1) The Obama Administration forced CEO Rick Wagoner out of GM after rejecting GM's restructuring plans. The Obama Administration paid to keep GM alive and now runs GM. 2) Recently, the House tried to hammer AIG, another bailout recipient, and passed a 90% tax on AIG's executive bonuses. The federal government owns AIG. It's freedom as a business only extends as far as good favor from the government. 3) Now Barney Frank is pushing a bill that would establish government control of the salaries of all businesses that received bailout funds. If the government pays the bills, they run the business.

Health care providers need to decide who they want calling the shots at their own clinics: do they want government-directed care, insurance company-directed care, or patient-directed care? That will be determined by who they allow to pay the bills.

I believe that most physicians truly believe that patients should be their own health care executives. They should have the final say on all medical decisions. Physicians and other health care workers are contracted to the patient to provide services under the patient's direction. Patients can hire and fire physicians at will. That is the ideal in medicine- the patient is in charge.

Experience and reason show that the responsibility of physicians to patients extends only to the degree that patients pay their own bills. The patient remains the health care executive only as long as they pay the medical bills. As soon as they delegate that responsibility of paying, they are no longer in charge of their care.

Patients' and doctors' experience with health insurance companies supports this idea. When clinics begin working with insurance companies, the whole nature of the practice changes. The insurance company is now making the calls. They determine treatment regimens- declaring some treatments acceptable and ruling others out despite patient wishes. They mandate diagnostics, both requiring redundant screenings and denying more expensive essential diagnostics. They even require additional staff hiring at the clinic, requiring the hiring of billing personnel exclusively for correspondence with the insurance company. Insurance-paid medical care is not patient-driven medical care. Many patients are okay with this- they've contracted insurance companies to manage their care. Insurance pays the bills and insurance runs the business.

What about when the government pays the bills for health care? It seems that the federal government has demonstrated a light touch in the cases of Medicare and Medicaid. Here the government is paying the bills, but they have allowed remarkable autonomy to patients and thus practitioners. Thus the common claim: Medicaid is the best health insurance! However, the reality that government-paid health care is government-controlled health care is present in each health care regulation or bill that rolls through the legislature.

Take for example the conscience-clause regulations that President Obama is about to overturn. Which health care providers do conscience-clause laws and regulations actually effect? Only those who receive federal funding through programs including Medicare and Medicaid. For another example, consider the health care legislation that was buried in the February stimulus package. The legislation establishes a National Coordinator of Health Information Technology with potential powers to establish and enforce a national standard of care. What health care providers will be responsible to this Coordinator? As far as I can see in the bill, only "government-sponsored" health care programs (pp 470) and recipients of Medicare, Medicaid, and state children's health insurance programs (pp 481) are currently marked for integration into the HIT program. When the government pays the bills, government runs the business.

If patients want to control their health care, they must pay the bills. If health care providers want patient-driven health care, they must establish practices where patients pay the bills. As government control increases in the health care industry, the best way to maintain autonomy over a practice may be to refuse third-party funding, especially government funding. Cash-only practices may become the only venue where patients remain health care executives and the doctor-patient relationship is preserved.

The federal government is trying to work up a steam push through government-run health care. They don't call it that, in fact many will sell the package as patient-run or patient-centered health care. But those who pay the bills run the business. You can bet that the same House, Senate, and White House that had so much to say about AIG and GM will have plenty to say about health care. Patient control over health care will be as remote as my control of the House of Representatives. After a few unanswered letters to the legislature, they will be left powerless and blogging.

Rusty Scalpel

Thursday, March 26, 2009

Conscience-Clause Law and Religous Freedom in Health Care

Do health care practitioners have the right to refuse treatment based on religious grounds?

On March 10 the Obama Administration announced a 30-day comment period before rescinding (overturning) conscience clause regulation established during the last days of President Bush's term. To put these soon-to-be challenged regulations in perspective, let's quickly look at the recent history conscience clause laws and religious freedom in health care.

When Roe v. Wade was decided in 1973, there was concern that physicians and other care practitioners would be legally compelled to perform abortions or sterilizations even if they found the procedures religiously repugnant. At that time, Senator Frank Church of Idaho sponsored an amendment that protected federally-funded physicians or hospitals who objected to the procedures on a moral or religious basis from having to perform the procedures. The amendment passed the senate 92-1 and became the first conscience-clause law.

The conscious clause laws were popularly accepted and promoted. Over the next years, nearly every state passed conscious-clause laws. Even Supreme Court Justice Harry Blackman, who had authored Roe v. Wade, approved of such laws as appropriate protection for physicians and hospitals.

In December of 2008, the White House announced that it would be enacting new conscience- clause regulation that would further define the 'right of conscience.' As stated in the new regulation, "The Department is concerned about the development of an environment in sectors of the health care field that is intolerant of individual objections to abortion or other individual religious beliefs or moral convictions. Such developments may discourage individuals from entering health care professions. Such developments also promote the mistaken belief that rights of conscience and self-determination extend to all persons, except health care providers..." The regulation also stated a purpose of aiding for religious entities (such as Catholic hospitals) that might suffer penalties for their abstention from objectionable practices. Bush regulation here

The new regulation established that any health care worker with "reasonable connection to the procedure" could refuse to participate if they found it morally objectionable. This could include nurses, technicians, pharmacy techs, etc. The regulations also left the door open for objections to procedures beyond abortion and sterilization. It could be interpreted to apply to any procedure that health care providers morally oppose.

The Bush regulation stirred controversy and were immediately followed by lawsuits in seven states claiming that the regulation "sacrifices the health of patients to the religious beliefs of medical providers." Organizations like Planned Parenthood called for a recision of the regulation to defend "the rights of patients to receive complete and accurate reproductive health information and services, without fear that health care providers will withhold vital information and services based on their personal biases."

On March 10 the Obama Administration announced a 30-day comment period before rescinding the Bush regulations. The recision of the regulation would not annul standing laws like the Frank Amendment or the Weldon Amendments, but would strike down in its entirety the Bush regulations. And so we return to our original question: What right do medical care practitioners have to decline treatment based on religious beliefs?

The Bush regulations also compel us to us ask specifically, should practitioners' choice to deny treatment be limited to certain procedures? Also, should conscience-clause law protection be limited to the primary provider? Do doctors have more of a right than nurses or technicians to refuse to participate in an abortion?

In contemplating these questions, I can't help but agree with the statement of the Bush regulation that there is a "mistaken belief that rights of conscience and self-determination extend to all persons, except health care providers..." I find myself very uncomfortable with the political wrangling and showdowns between the pro-lifers and pro-choicers when the First Amendment of the Constitution is already explicit:

"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof..."

Perhaps the executive branch can get away with these regulations because the Amendment specifies only Congress' limits to such lawmaking. At any rate, the practice of legislating through White House regulations is probably far outside of constitutional limits.

I believe that it is 'self-evident' that these 'God-given', 'inalienable' rights are truly universal. They apply to doctors, the same as nurses, the same as all Americans and all humanity.

To be truthful, I don't know how meaningful these regulations really are. My understanding of the Bush regulation is that it simply enforces current law. With it being struck down, current conscience-clause law still stands and has not been changed. However, I believe that conscience-clause law will continue to be severely trampled if the regulation is rescinded.

With regards to the Bush regulation. I think it should stand. It upholds current laws, whereas striking down the regulation encourages the disregard of standing law. Striking down the regulation will encourage evil organizations in their fear mongering and efforts to subject American health care providers to their practices. I believe that the right to religious expression, in the workplace or elsewhere, is a God-given right. Infringement of that right is tyranny.

The comment period before recision (overturn) of the Bush regulation ends on April 9. Comments can be sent to Or comments can be directly submitted here. Remember that these comments go directly to the Department of Health and Human Services. Demands and impassioned pleas will probably not go as far as well-constructed argument. In particular, the department has asked for:
  • "The scope and nature of the problems giving rise to the federal rulemaking," including specific examples, "and how the current rule would resolve those problems."
  • Information, with examples, to support or refute allegations that the regulation "reduces access to information and health care services, particularly by low-income women."
  • Whether the rule is clear enough "to minimize the potential for any ambiguity and confusion" that might result from it.
  • Whether the objectives of the rule could be accomplished "through nonregulatory means, such as outreach and education."
Rusty Scalpel

Tuesday, March 24, 2009

Letter from Reader

After a couple weeks of break for finals, FMP is back online. We thank Nathan Reed for this submission, with which we wholeheartedly agree.

I've been pretty outraged on a daily basis since January 2009 about the happenings in Washington D.C. Now I'm just sad for our country. What is happening now is the death of the chance for success. That is the “American Dream”; the CHANCE (not guarantee) to raise your lifestyle through dedicated hard work and innovation in any field of your choosing. The “American Dream” is NOT entitlement to free healthcare, housing, etc. It is NOT allowing congress to choose which companies must be saved, which the government should take over, and which companies and EVEN INDIVIDUALS to tax at confiscatory rates. This country is currently on a path that Ayn Rand depicted decades ago. A 90% tax (that members of BOTH parties voted for) on a select few individuals! A confiscatory power that president Obama is now seeking to extend to anything/anyone that our D.C. prima donnas don't like. After legislators ENABLED the behavior they feign outrage about by saving these failing companies in the first place! They are KILLING the wealth, dreams and motivation for anyone aspiring to be more and do more with their lives than merely subsist. Anyone that manages to make a good living is suspect.

Liberals and socialists would like to assume that most people operate from purely humanitarian motivations – that this is how it should be, but our country has proven in the last 230+ years that self-interest is the greatest motivator of the human spirit. This country rose to relative success in the world by refusing to deny that universal truth. Furthermore, self-interest is individual, and the freedom to pursue the goals that tickle our self-interest is another bedrock of our past success. Society cannot reasonably expect an individual to put their all into any task when the effort of their work is not met with some form of compensation that the worker finds acceptable. That is the beauty of money – its buying power allows you to reward yourself in an acceptable way for the job that you completed.

To change tracks due to personal interest, I’d like to predict the consequences of universal healthcare provided by the government. Like with government subsidized housing, costs will inflate as demand increases because going to the doctor is “free”, or at least “cheaper” after D.C. picks up some of the tab. Why go to the family physician in the morning when it costs the same to get fixed right now at the ER? Doctors will be expected to pay off hundreds of thousands in student loans in a payout system that doesn’t rise with inflation, but actually decreases from time to time because government has to squeeze them to help control costs. There will be fewer people that train for the minimum of 11 years to become physicians due to the lack of benefit from that training (that dirty self-interest thing again). After some years comes rationing of care. No, the legislators (not doctors) in charge of deciding what kind of care you can receive won’t come out and say that you’re too old, or the therapy you require is too expensive to be worth saving your life. Instead, they will make people jump through hoops to get their care. You can’t get your lung cancer treatment unless you’ve stopped smoking for at least a year. You can’t have more than one heart surgery every 10 years because it’s been “proven” to congress’ standards that you should be able to go at least 12 years if you had eaten right and lost that extra weight. I know that there are people that don’t believe me, but just look at some of the news coming out of the U.K., our “model system” as touted by Tom Daschle. Good thing he didn’t get the Health and Human Services secretary position he was offered (tax cheat writing/voting for taxing legislation), but do you think the model will change? Yeah, let’s be just like the U.K. because they should be our model, not the other way around? Oh, and throw a little Chavez in there when we don’t like your business.

It’s all just so sad, as well as stressful that I’m going to have to find some place in the not too distant future to make a living doing what I love, and to MY standards. Hopefully it’s here, but then again, who is John Galt?

Nathan Reed

Friday, February 20, 2009

Government Struggles to Grasp Economic Reality

The nation is struggling to understand true economics. We have a presidential administration, legislature, and news media bent on changing our economy into a controlled economy. And yet, they hesitate to pull the trigger, despite their monopoly of power. The plain truth of economics and freedom is hitting hard, and it's hard to ignore.

I've got a collection of economic-related news stories that I would like to highlight. Many of them are stories that you may have already read, especially if you are a news junkie like myself. I don't have much to say about them, other than they demonstrate the gap in between reality and the ideologies and programs that our elected officials and media are trying to push. Some of them may show a glimmer of hope that our newly elected officials may actually be learning something about economics while in office.

1. Wall Street flips at the suggestion of bank nationalization. Stocks plummeted Friday morning at the suggestion that the government may take over failing banks. What is interesting was the White House response. They attempt to reassure, insisting that they never had any plans to nationalize. Is the administration becoming aware that their policies of change to the nation's economic structure may not be plausible?

2. Wholesale inflation takes a leap. It went up 0.8% last month. The story says economists had only expected a 0.2% jump. Those must have been the economists who approved of the last stimulus package as well. Perhaps flooding the economy with freshly-printed and borrowed money does not make the country any wealthier.

3. The Chicago Tea Party. CNBC's Rick Santelli is an internet sensation in his spirited criticisms of the White House mortgage relief bill. The relief bill rewards bad behavior, Santelli says. "How many of you people want to pay for your neighbor's mortgage that has an extra bathroom and can't pay their bills?" he asks. The floor of traders behind him burst a unanimous boo. Santelli looks into the camera, asks if President Obama is listening and...

4. The White House responds. The very next day the White House already feels compelled to respond directly to criticisms in the cable morning news report. "Santelli doesn't know what he's talking about," the spokesman says. Maybe so, but the attention attracted by the tirade of a lower-profile newsman shows that the White House at least found his comments very compelling. It seems that White House response to media criticisms are usually limited to the big dogs- the Rush Limbaugh's, the New York Times- the big media outlets. The fact that they so immediately respond to Santelli is remarkable.

5. Bill Clinton gets some blame for the economic downturn because of his... "free-wheeling capitalism." It's funny that of all the Clinton's Administration acts that would be blamed, Time targets free-wheeling capitalism. That definitely was not the hallmark of the Clinton Administration. Much more pertinent and logical to point at would be the growth of Fannie Mae and the Community Reinvestment Act passed during Clinton's tenure. The attacks on capitalism continue from surprising sources as...

6. Alan Greenspan supports bank nationalization. We've come full circle now and perhaps see part of the reason why we have executive and legislative branches that are attacking capitalism and American freedom at will. Have American conservatives and patriots forgotten the principles this nation stands on? Economic freedom is not a get-rich-quick scheme. Capitalism is not just another economic system along with socialism, communism, etc. It is not to be swapped out for one of the others because of an economic recession. Capitalism is the state of the economy in a state of freedom. As evidenced in the news, it also happens to be the only system under which mankind will find ever prosperity.

Rusty Scalpel

Tuesday, February 10, 2009

Step One of Government Health Care Takeover Hidden In Stimulus Package

Here's the followup on today's earlier post on Bloomberg's piece about hidden health care legislation in the stimulus package. I'm afraid we're a bit behind on this one. My searches today showed that the other bloggers have been talking about it for weeks- we took notice only after Rush and Drudge brought it to national attention yesterday. My only excuse is that the stimulus bill was so depressing that we never looked at it. Maybe that was their strategy all along.

There is a lot of discussion about the hidden health care policy in the bill and I'm not sure how accurate it all has been. I've gone to the bill itself to try to make sure that my description of the health care inclusions in the bill are accurate. I'll also point out that the following discussion is not the only reason to oppose the bill. In principle the whole thing stinks. These are just some of the especially low points. Under the guise of a anything-is-justified-because-the-sky-is-falling stimulus package we usher in the beginning of the Obama socialized medicine era.

The bill establishes a National Coordinator for Health Information Technology. His purpose is to oversee the development of a federal electronic health care system (pp 441). Included among his duties the director ‘‘(2) improves health care quality, reduces medical errors, reduces health disparities, and advances the delivery of patient-centered medical care; ... (4) provides appropriate information to help guide medical decisions at the time and place of care;... (9) promotes prevention of chronic diseases; (10) promotes a more effective marketplace, greater competition, greater systems analysis, increased consumer choice, and improved outcomes in health care services; and (11) improves efforts to reduce health disparities." (pp 442).

Isn't that fantastic? We now will have a government officer, probably to be reverently referred to as Mr. (or Ms.) Coordinator, that will make health care better. He will lovingly "guide medical decisions at the time and place of care." He will promote prevention of chronic disease. He will promote a more effective market place- isn't that great, the federal government will step in to help the market be more of a market! He will help improve health disparity. If we're lucky, he may even turn back death.

‘The National Coordinator shall, in consultation with other appropriate Federal agencies... update the Federal Health IT Strategic Plan... to include specific objectives, milestones, and metrics with respect to... the utilization of an electronic health record for each person in the United States by 2014." (pp 445)

The National Coordinator will appoint the HIT committee (Health Information Technologies Committee) composed of "providers, ancillary healthcare workers, consumers, purchasers, health plans, technology vendors, researchers, relevant Federal agencies, and individuals with technical expertise on health care quality, privacy and security, and on the electronic exchange and use of health information." (pp. 457)

This committee will advise the Coordinator on how to best achieve his stated mission of stepping in to help the market be a safer and more federally-approved market, help doctors make good decisions, etc. Perhaps this group will make the Coordinator's decisions bipartisan if he can't get bipartisan support from democratically elected officials.

The biggest question I have is whether health care practitioners will be forced to use the electronic medical system. Will they will be forced to follow The Coordinator and the People's Committee's recommendations on appropriate medical decisions, having a "more fair" market, spreading the wealth, etc?

I couldn't find a clear answer to that question. The bill talks about paying practitioners to use the electronic system, but those provisions were found under the headings of Indian Health Services and Medicare. However, the following slightly menacing statement is found at least twice in the bill: "The Secretary shall seek to improve the use of electronic health records and health care quality over time by requiring more stringent measures of meaningful use..." (pp 518, pp 541)

I sincerely believe that a national medical database is not a bad idea. It is an idea that deserves discussion. But it's not getting that discussion. It's being ramrodded down senators' throats by President Obama. He tells them we're in a national crisis. Don't think about it- just vote yes.

But this database, and especially the powers attached to the Coordinator, are a big deal. They take up over 100 pages of the 680 page stimulus package. This is Phase One of Obama's Change for socialized medicine. Why is it buried in the stimulus bill? Is the Democratic Force for Change afraid America wouldn't support it in open discussion?

Rusty Scalpel