In a scene from the movie “Monty Python’s Meaning of Life,” a pregnant woman in labor is seen being wheeled down hospital corridors at freeway speeds, with the bumpers of the gurney crashing through swinging fire doors inches from the top of her head until the delivery room is reached, where an excess of necessary and unnecessary equipment momentarily obscures the location of the patient. While the doctors and nurses prep for the procedure, a crowd of ostensibly qualified strangers (but not the patient’s husband) are invited to observe from a strategic viewpoint. The woman asks, “what do I do?” to which John Cleese’s doctor replies “Nothing darling, you’re NOT QUALIFIED!”
Which is about how our discussions of the controversies of health care reform, health management, Accountable Care Organizations, Scope of Practice Expansion, etc. go. The patient is rarely consulted for an opinion, much less approval.
And why should patients be consulted? They’re not experts, like doctors and nurses, or more to the point, like the MBAs, executives and employees of federal departments who exercise the power. Even more to the point, the patients aren’t the ones paying, at least not directly.
American patient-consumers are not permitted to control how their insurance premium dollars and medical expenditures are spent without interference from government. There is one set of (tax) rules for employees who may get a health plan through an employer, and another set of rules for people purchasing plans individually. With few exceptions, Americans who are not in an employer/employee relationship are not at liberty to freely associate under the First Ammendment for purposes of creating health insurance pools. Farmers, ranchers and other self-employed individuals are forced to fend for themselves alone.
Unlike the normal rules of freedom of commerce whereby any American may buy or sell from or to anyone in any state or country, in health insurance there is one elaborate and rigid set of rules for Californians, another set for New Yorkers, another for Mississippians and so on. Consumers and medical insurance companies are not free to negotiate on mutally agreeable terms as they are (relatively) with auto, home, earthquake, fire or flood insurance. In essence, the consumer’s money is not his or her own but the government’s, to be directed as the elected representatives and unelected administrators and czars determine.
Is it any mystery, then, that costs are out of control and billing patterns and practices are irrational, even diabolical? The people who have the greatest stake in the game – the patients – are hardly consulted in how much they are willing and able to spend on what.
Most of us, if presented with a choice of a BMW 740iL luxury performance sedan or a KIA Forte, would prefer the BMW. But not all of us can afford a BMW, while the KIA is perfectly adequate for getting from Point A to Point B. How many BMWs and KIAs get produced and sold, and to whom, depends upon the resources and preferences of millions of individuals acting on their own account and commanding their own resources, which, at least in the West and to the degree that the free market is permitted to function, are substantial. There is no runaway inflation or gross imbalances of supply and demand of automobiles, bicycles, flat-screen TVs, personal computing devices, clothing or a thousand other products and categories where the footprint of government, regulation and taxation treads relatively lightly. People of the most modest means today have a cornucopia of products and services from around the world available to them at affordable prices, thanks to capitalism. No king, or emperor, or even secretary general of the Supreme Soviet ever enjoyed such abundance even 50 years ago.
What if there existed in the USA a truly free market in health insurance and and health care services, that is, what if the government did not interfere in favoring and then dis-favoring employer-provided insurance? What if the government did not mandate what benefits had to be included in insurance plans; did not interfere with interstate commerce in financial products, thereby limiting consumer choices; did not monopolize medical residencies through Medicare and Congress (number of residencies frozen since 1997 in spite of growth and need for more doctors); did not monopolize medical services to the elderly and then cut reimbursements to a level that makes it a losing proposition to many doctors to accept Medicare patients; did not deliberately put Health Savings Accounts and Flexible Spending Accounts at a disadvantage relative to Health Maintenance Organizations (HMOs) and Accountable Care Organizations (ACOs); and a thousand other interventions, prohibitions, taxes, favoritism, prejudices, fines, penalties and taxes? Then patients and their families would be in far greater command of their own resources and of those being spent on their behalf. Then they, through their choosing and rejecting, spending and withholding, could sort out which of the brilliant ideas of the experts truly have merit, which are nice tries and which are losers. They could and would determine whether mid-level providers may substitute for fully-licensed physicians in the operating room, and whether compliance with evidence-based protocols enforced by bureaucrats and computers or hard-earned professional experience and judgment should govern physician behavior. They will fine-tune to what degrees medicine is a scientific discipline, a production process to be administered, or an art.
The mess that we are in with Medicare (looted), Medicaid (failed; statistically better to have no insurance at all than to be enrolled) and now Obamacare (train wreck, according to one of its prominent sponsors) underscores the perils of “solving problems” instead of pursuing opportunities. Controlling costs by denying treatments and steering patients away from the most trained and qualified professionals, rationing, death panels, the Independent Payment Advisory Board (IPAB) etc. all “solve problems.” On the other hand, our dedicated physicians, nurses, specialists, pharmaceutical research, and medical art, science, creativity and innovation, along with patients in command of the resources that are to be spent on their behalf, are our opportunities. Freedom, voluntary cooperation, liberty of contract and the generosity of American neighbors and friends – unmatched anywhere in the world – are our opportunities. If we Americans will pursue those, we will once again pull ahead in our lead as the world’s foremost medical innovator and most responsive to the needs of the patient, as we have been for at least 50 years.
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