Where to Begin with Healthcare Reform (Hint: Look in the Mirror)

Posted on 17. Jun, 2009 by in activism, Politics, society

“Life is tough, but it’s tougher when you’re stupid.”

John Wayne

Brent Pottenger (aka, Epistemocrat) served-up a great post last week about the illusion of the best-fix for the nation’s healthcare woes (writ large) being a purely individual, free-market enterprise.  Now I am as free-market as any social-liberal, financial -conservative Libertarian out there; and initially, my position here may seem at odds both with what I am politically, and with what I am implying by this post’s title; it’s not, though.  Let me explain.  Better yet, let me expound just a bit on what Brent has already so thoroughly opined.

Now, if it’s one thing I utterly despise about politics in general (and this coming from a PoliSci major well versed in the art of debate), and of this particular issue specifically, it’s that neither the right nor the left political centers of gravity will “cave” and tell you the truth. And the truth is that the only real and lasting fix for this issue is a mix of both personal and social responsibility.  Yes, you are most certainly accountable for your own health and your own heath choices.  And yes, too — if we are to be a vibrant and progressive society, we are responsible (at least to some extent) to each other for those catastrophic illnesses/accidents that are (depending on your take) acts of God, or luck of the draw.

Of course, some ideas are best left to the ether-world realm of theory and debate, as the real world tends to make so much confetti of of such clean, neatly-packaged thought.  And the same applies here.  What to make, for example, of diabetes?  Is it a preventable disease?  In my opinion, yes.  So should we, as a society, absorb the resultant costs of someone’s poor dietary choices?  What about the 80 year old who now requires a knee replacement due to the cumulative trauma of a youth spent training for and playing rugby?  What if the diabetic was not the stereotypical obese, averse-to-exercise, slovenly individual, but a former endurance athlete?  What then?

I guess the truth of the matter is that, just as in many of the most important issues in life, there is no “right” answer, and we’re likely, as a nation, to tilt too far one way or the other.  Personally, I try not to worry about those things I can’t affect.  What I can affect, though, is the state of my own health.  I’m of the notion that it’s not only a personal and societal responsibility, but a spiritual responsibility to take care of my health to the best of my ability and knowledge.  And part of this responsibility is to never become stagnent — either physically or mentally.  Times change and science progresses, and it’s imperative that each of us continually measure the “new” against a counter-balance of healthy skepticism in order to discern the good and useful from the dead-ends.

TTP is an extention of my “healthy skepticism”, and I hope we can all learn a little about taking care of our health through the continuing give-and-take on these pages.

In health,

Keith

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63 Responses to “Where to Begin with Healthcare Reform (Hint: Look in the Mirror)”

  1. Ryon Day

    17. Jun, 2009

    I personally find it difficult to reconcile Pottenger’s opinion with the fact that at least three of my friends without medical insurance accrued well over 10,000 dollars in medical debt from things such as broken arms and bacterial infections. I’m not sure if he would file those under ‘catastrophic’ or not.

    I certainly agree that our society today is a vicious cycle of our government encouraging and funding via subsidies our current carbohydrate-fueled illnesses, and then wanting to cure them via conventional medical practices. This rubs me the wrong way in a fundamental way.

    However, to leave a diabetic suffering with kidney failure, with his or her only option lifelong debt to “punish” them for their moral choices seems medieval to me as well.

    As someone who feels beholden to a large employer almost exclusively because of the excellent health insurance it provides, I definitely feel that entrepreneurship would be encouraged by the removal of constantly worrying if you’re going to go into bankruptcy if you sprain your ankle. Therefore it would create a huge amount of societal value from that standpoint alone.

    There has to be a way to avoid bankruptcy via a broken arm!

    Reply to this comment
    • theorytopractice

      17. Jun, 2009

      “…I definitely feel that entrepreneurship would be encouraged by the removal of constantly worrying if you’re going to go into bankruptcy if you sprain your ankle.”

      Agreed, ++

      Reply to this comment
  2. Dave

    18. Jun, 2009

    “if we are to be a vibrant and progressive society, we are responsible (at least to some extent) to each other”

    I have no problem with people arguing that we have a personal responsibility to each other, as long as they don’t use the force of the state to steal another’s productivity.

    I would certainly have no problem helping out diabetics, or those with broken arms, sprained ankles, etc., but I don’t know anyone (personally) that would be willing to use force on me (or the threat of force, jail, etc.) in order to help out a poor bloke down on his luck (or whoever they thought was worthy of receiving the booty). We would refer to such a person as a thug. Yet somehow modern politics (and sloppy thinking) has convinced some that taxation is a form of voluntary charity, and that using a third party to extract (or extort) money from others is somehow ‘progressive’. It boggles me.

    I believe in the principles of paleo and personal responsibility for health because it fits completely with individualism. I don’t eat and exercise the way I do because of some allegiance to the herd or to keep down the average cost to the system. I also respect other people’s property, which is why I think socialized medicine is ethically repugnant.

    Health care reform? Stop stealing people’s money, or start by calling it what it is.

    Dave

    PS You are doing great work here, Keith. Please keep it up.

    Reply to this comment
  3. Brent Pottenger

    18. Jun, 2009

    “I personally find it difficult to reconcile Pottenger’s opinion with the fact that at least three of my friends without medical insurance accrued well over 10,000 dollars in medical debt from things such as broken arms and bacterial infections. I’m not sure if he would file those under ‘catastrophic’ or not.”

    Answer: I would!

    Certainly: the goal is to make health insurance actual insurance and thus protect people from bankruptcy at all costs. Your friends would have hit their income/wealth-scaled deductibles long before they accrued $10,000 in debt (now, if your friends were high-income earners, say above $250,000, just to pick a number, a $10,000 deductible would be appropriate, in my opinion). Imagine pairing personal health savings accounts with income-scaled high-deductible, catastrophic (social) insurance. Room for entrepreneurship emerges in most health service domains because you pay your healthcare providers directly. You also are incentivized and rewarded to stay healthy (cash stays in your pockets). Meanwhile, if catastrophe strikes, such as a broken ankle or bacterial infection, your downside risk is clipped (at a known quantity; your deductible) and you know that you are covered.

    Yes, society would have to decide exactly what high cost events and catastrophes we are willing to insure and how we want to scale the deductibles, but removing many of the middlemen (who exist because we buy pre-paid health via bloated “insurance” plans) from healthcare via more direct transactions with practitioners and pairing this with an all-encompassing, single-payer nationalized health INSURANCE system (low-overhead and essentially a transaction system, as Nassim proposes banks should function) may strike the balance needed to increase individual responsibility while preventing your friends’ situations.

    Thoughts? I don’t know the answer, but it makes sense to me.

    Reply to this comment
    • Dave

      18. Jun, 2009

      “an all-encompassing, single-payer nationalized health INSURANCE system”

      Yeah, that’s worked so well up here in Canada:

      When the state starts to ration health care (which is exactly what happens, even when you call it insurance), forcing people to wait, and deciding what basket of services is available, is the prime directive to contain costs.

      I rarely use the mainstream medical system up here, and when I went in for some blood work (I see a conventional doctor every three years or so), I asked if I could get my vitamin d levels checked. Doc’s reply: THEY don’t like us to order that test. End of discussion.

      Careful what you wish for, and remember, ïf you think health care is expensive now, wait until it’s free.”

      Dave

      Dave

      Reply to this comment
      • Brent Pottenger

        18. Jun, 2009

        The ‘Canada’ stuff is nothing new.

        We already ration care in the US.

        Canada pays for everything.

        I am suggesting a different model:

        People pay for most of their care directly.

        Insurance only covers insurable events.

        Insurance kicks in after high-deductible is met.

        This realm would ration openly, not covertly.

        Covert rationing is the worst.

        Give people freedom of choice on >80% of their care.

        The illusion of individual responsibility will turn a completeley ‘free-market’ system upside down when we simply socialize the costs through bailouts.

        Reply to this comment
        • Dave

          18. Jun, 2009

          Canada pays for everything? Uh, no. Try living here, and preferring a naturopath to a medical doctor. Or try getting some chelation therapy, or as I said in my post, a vitamin d blood test. In Canada, where we “pay for everything”, I get to pay for the stuff I want out of pocket and all the stuff I don’t want or use out of taxes.

          Who gets to decide what constitutes an “insurable event”? Your single-payer, nationalized health insurance system, ie. Obama’s magic wand. Never mind all the eloi who will immediately begin to saddle up to the cannibal pot to demand more “insurable events”, lower deductibles and that YOU should be the one to pony up the tab. See if they don’t.

          This is exactly what Ayn Rand talked about in her essay Anatomy of Compromise. When both sides of the issue are open about their motives, it is the more rational side that wins. But when one side hides their motives (most socialists fit the bill, and certainly take a long term view of this whole adventure), it will be to the advantage of the irrational side.

          First, you convince everyone that a single-payer system for a few “insurable events” is the moral thing to do. Anyone who disagrees with helping out the poor bloke with the broken ankle or the diabetic is obviously a callous jerk (also check out Rand’s ‘Extremism’ and the Art of Smearing for a take on that tactic), even though the only disagreement is that anyone should be forced to do it, ie. through government coercion. Then, once the principle of government intervention is established (and all private insurers (ie. competition) are removed), move on to the next compromise.

          I say start with the means, and the ends will take care of themselves. Stop stealing people’s money, and start convincing them of their ‘social responsibility’ to help others out, without holding the gun to their head.

          Dave

          Reply to this comment
  4. Robert M.

    18. Jun, 2009

    It is important to distinguish between the objectives of: (1) maximizing the health (i.e. minimizing morbidity) of the population at large, and (2) maximizing health industry profits. These two objectives are, by and large, at odds with each other. By its very nature, seeking profit in delivering medical services corrupts the user outcomes. Why bother attacking the cause of heart disease when you can sell a patient a statin for the rest of his/her life?

    http://heartscanblog.blogspot.com/2009/06/drug-industry-deep-throat.html

    This is why, in my opinion, Americans spend more per capita than anyone else on health care but yet by any metric have the worst outcomes. Health care is, in my opinion, is one of the natural monopolies of the world.

    Reply to this comment
  5. Brent Pottenger

    18. Jun, 2009

    10-4

    That is all well-known.

    “pays for everything” = what the nation defines as the ‘healthcare system’.

    Goal would be to give people more freedom to pay a Naturopath or MD, however they see fit.

    Expound on the means, please.

    Reply to this comment
    • Dave

      18. Jun, 2009

      “what the nation defines as the ‘healthcare system’ is exactly the problem. A nation doesn’t define anything – you are using the logical fallacy of the ambiguous collective.

      The fact is that elites decide what my ‘healthcare system’ gets to be, whether I like it or not. Giving me the ‘privilege’ of voting for a different bunch of jokers every few years doesn’t cut it, either.

      Your goal is my goal, more freedom to choose.

      I expounded on the means already: stop stealing people’s money, forcing them to pay for what others want. With the full benefit of what I produce (as in my private property), I think I can decide what goals to support, etc.

      Get the government out of everything, and let markets work, ie. let people engage in voluntary transactions. Stop the government-enforced monopolies (insurance companies, banks, even who gets to call themselves a ‘doctor’).

      To borrow from Heinlein, TANSTAAFL – there ain’t no such thing as a free lunch, and the sooner we realize that (and begin treating people with respect they deserve, and stop treating them like invalids), the sooner we will have more freedom.

      As I said, start with the means (stop stealing people’s money), and the ends (more freedom, healthcare provider choice, real demand-driven charity, etc) will take care of themselves.

      As long as you keep stealing money from people (no matter how noble you believe the use of that money is), results are always tainted. No matter how you sugar-coat it, you are still dealing with the product of theft.

      I would never do that to my neighbor, or even a stranger, yet all this talk about what the ‘nation’ ‘decides’ is simply condoning theft. If you want to do it, call it what it is.

      Dave

      Reply to this comment
  6. Brent Pottenger

    18. Jun, 2009

    Then the nation state must be abolished. It’s just a historical line in the sand.

    But, the reality is that is not going to happen. What to do in light of this reality is what this discussion is about.

    Reply to this comment
  7. Dave

    18. Jun, 2009

    Not abolished, just ignored, and allowed to wither ;-P

    “But, the reality is that is not going to happen.”

    Seriously though, do you think that your 80% direct pay, 20% high-deductible government coverage is going to happen? Seriously?

    The reality is that is not going to happen. What to do in light of THAT reality is what this discussion SHOULD BE about.

    Reply to this comment
  8. Brent Pottenger

    18. Jun, 2009

    Build better business models like Hello Health:

    http://www.hellohealth.com

    Innovate outside the system.

    Reply to this comment
  9. Dave

    18. Jun, 2009

    Do everything outside the system!

    http://www.cafepress.com/doubleplusungov.77901162

    >;-P

    Reply to this comment
  10. Brent Pottenger

    18. Jun, 2009

    A piece about what’s going on in the mainstream world, inside the system:

    http://u.nu/3k6d

    Ultimate goal: Take care of your health so you don’t have to access the mainstream health system, regardless of what that ‘system’ looks like.

    Cheers.

    Reply to this comment
  11. Brent Pottenger

    19. Jun, 2009

    Here is a discussion within the ‘system’.

    http://www.nytimes.com/2009/06/17/business/economy/17leonhardt.html?_r=1&emc=eta1

    Regardless of what the ‘system’ is, the goal is to be healthy so that you don’t have to access it.

    We need to achieve health to reduce demand for health services.

    Reply to this comment
    • theorytopractice

      19. Jun, 2009

      I just happen to have heard this today; it’s germane to the subject at hand. And it sounds like a fascinating book.

      Reply to this comment
    • Dave

      20. Jun, 2009

      I’m not sure if Leonhardt is being facetious with the line that access to health care is a fundamental right, but if he is being serious, then he is a stark raving idiot, rather than just an idiot.

      Having a right to the fruits of someone else’s production (medical expertise and care) is utter nonsense.

      And the difference between rationing goods and services in a free society and one where gubmint decides who gets what is the difference between freedom and serfdom.

      In a free society, supply and demand determine the price of goods and services. When government interferes with both, the price mechanism (and therefore the value) of those things is distorted.

      Case in point: in Canada (and elsewhere I bet), when some become ill, rather than wait to see their family doctor (if they have one after all the tinkering government has done to create a false shortage of doctors) or go to a walk in clinic, many just go to the emergency room, which is much more expensive and much more susceptible to medical error. But because “Canada pays for everything” (sorry Brent), there is no need to determine whether the supply of that service (emergency room medical care) is worth it to those demanding it (the patient).

      I could go on and on (eg. try comparing the IOM’s estimate of people dying for lack of health insurance to the estimate of those who die from medical error, including what is termed as ‘highly preventable’ medical error), but this pretty much sums it up: Leonhardt is an idiot, and in a truly free, thinking society he would be lambasted as such, and sent packing.

      Dave

      Reply to this comment
      • theorytopractice

        20. Jun, 2009

        I’ve always been of the mindset that Not-For-Profits (not the government) would be the natural go-to in establishing catastrophic insurance plans for those “in need”. A good model for this is the way that certain college scholarship foundations are set up. I agree that government intervention is a slippery slope — human nature being what it is. After hearing his interview on Milt’s show, I really want to get my hands on Rahe’s book.

        Reply to this comment
        • Dave

          21. Jun, 2009

          The NFP model is probably the way to go, depending on the government hoops necessary to establish it. Government control of NFP status is still government control.

          Rahe’s book does look interesting; I like both Montesquieu and Tocqueville, but don’t care much for Rousseau, though he (rightly, in my opinion) praised Machiavelli for being a republican rather than the ‘teacher of evil’ that many call him (like Leo Strauss).

          If you’re looking for another critique of democracy (the horror!?!), check out Hans-Herman Hoppe’s Democracy: The God That Failed. Here’s a nice overview by Hoppe:

          http://www.lewrockwell.com/hoppe/hoppe4.html

          Dave

          Reply to this comment
          • theorytopractice

            21. Jun, 2009

            I would love to be a fly on the wall at the Ayn Rand, Karl Marx, Jesus, and Buddha healthcare debate. Really, this is what (in my mind, at least) it essentially boils down to; which “philosophy” do we most ascribe to. Me? I’m torn, really torn on this issue. It really tests the limits of what is sensible, what is compassionate.

  12. Brent Pottenger

    20. Jun, 2009

    One cultural dynamic that must be addressed is a better understanding of the limits of medicine.

    Medicine has a role in health, but my hope is that if people understood the limits of the ‘healthcare system’, then they might be more inclined to look out for their own health states daily.

    I am still concerned that any form of health insurance/prepaid healthcare confers a free option that will eventually result in bailout. Besides letting government wilt away, what can be done to alleviate people from their dire health states?

    The ‘no-smoking’ efforts is one such systemic public health initiative that has worked fairly well and improved people’s lives.

    Please chime in.

    Reply to this comment
    • theorytopractice

      20. Jun, 2009

      I think one thing that will help empower people to make sensible, daily health choices, thereby lessening the load on the healthcare system as a whole, is the power of social media. Check out this clip of Clay Shirky’s recent talk to the State Department. There is just a sheer proliferation of “truth” out there to be had, and it’s available simply for the asking. And yes, there is a lot of noise as well, but intelligent people have a way of sifting through that quickly. Unfortunately, there will always be that percentage of people who do not care to look after their own health even with ample and free information at their fingertips. It’s common knowledge now that smoking is detrimental to one’s health, and yet a certain percentage of people continue to do so. What to do with these types of people when they show up for some form of catastrophic care? I talked to a friend just tonight who recently lost her husband to a brain tumor. The guy was in excellent health, an 8th degree blackbelt; what to do with someone in that situation? Auto insurance works because of the relative ease in assigning fault. This is really a perplexing question to me; it pits my worldly Libertairianism against my more spiritual side like few other questions can.

      Reply to this comment
  13. Brent Pottenger

    21. Jun, 2009

    Thanks, Keith.

    One thing is for certain: medicine and healthcare demand ethical ‘public service’, regardless of whether the service is private (non-profit or for-profit) or public (government).

    Catastophic health coverage is something we don’t think we need, until we get sick.

    I think some form of social nudge and safety net is appropriate if crafted the right way. I think social media is one source of innovation fuel that can help turn the cultural tide toward ancestral fitness. With people like Keith, Mark Sisson, Art De Vany and others all contributing to the public health cause, we can influence people positively to make lifestyle choices that actually work and make them feel better about themselves in a practical manner.

    Let prices reign and capture information in 80% of the health market where freedom of choice and individual risk/accountability is appropriate. But, if you get in a car accident and need trauma care, it’s time to rely on public service and humans striving to do the best they can to save your life.

    This issue cuts to the core of so many elements of the human condition. True leadership will emerge from innovating outside the system and improving health information on the one hand, while contributing to mainstream perspectives as well.

    To good health.

    Reply to this comment
    • Dave

      21. Jun, 2009

      Brent,

      I appreciate your perspective, but this is how I read your plan:

      “Let prices reign and capture information in 80% of the health market where freedom of choice and individual risk/accountability is appropriate. But, if you get in a car accident and need trauma care, it’s time to rely on …{paying for emergency medical services with money taken by force, which any adult would call theft}… and humans striving to do the best they can to save your life.”

      Now, the problem I have is with you calling this plunder “public service”. I think that by calling it what it truly is, perhaps there would be a little more responsibility attached to how it is spent. Calling it a public service makes it sound like some sort of charity where money appears out of thin air to do the people’s work. It doesn’t, and acting (and talking) like it does merely reinforces politicians’ sense of entitlement.

      Put it this way: in what other area of your life do you consider talking about how to dispose of something taken against the rightful owner’s will a mainstream perspective? Would you personally threaten your neighbor that if he didn’t cough up what you thought appropriate to fund someone’s medical care (call it the 20%, 30% or even 1%), you would throw him in jail? That is what you are advocating with your talk about contributing to mainstream perspectives.

      Talking about what to do with stolen money without acknowledgment of the devastation the IRS causes in people’s lives is exactly what politicians want. When you start calling a theft a theft, the politicians know their gig is up.

      As you stated:

      “This issue cuts to the core of so many elements of the human condition.”

      I respect you too much to let you forget that you are talking about using stolen money.

      Dave

      Reply to this comment
  14. Brent Pottenger

    21. Jun, 2009

    Trust me, I understand the stealing concept.

    I could write all the Ron Paul (libertarian) rhetoric; it’s great–there is a lot of value. Volunteer, charity, no government intervention (which, of course, fuels further intervention), no taxes, no compulsory education, no empire building, no nation states (they have little validity in a globalized world anyways and are simply lines in the sand), and a renewed focus on localism and developing people to incorporate social responsibility into their daily lives. That is a good goal.

    Public Service with stolen money exists in our contemporary societies: we handle disasters, employ police and firemen, etc. Our US healthcare system is already mostly government paid and the biggest health system in the country is the VA. If we are going to steal people’s money (IRS, Medicare taxes, etc.), then I define ‘Public Service’ as limiting the amount stolen and generating the most return for these resources.

    It’s never going to be perfect. I know Canada does not pay for everything–Canada is nowhere near the answer–Canada pays for hardly anything and probably many of the wrong things, but so does the US. But, if we are going to take stolen money and allocate it for health services, somewhere, someone and some groups of people have to decide what we are going to pay for; there is a process involved in doing this as best as possible, whatever you want to call it. Maximizing defined contributions (medical savings account deposits) with necessary defined benefits (catastrophic coverage according to income-scaled deductibles) is a possible process.

    Question: Do you trust that males would purchase insurance plans that would cross-subsidize maternity care for females if left to their own choices? Is it ethical for this cost to be completely shifted to females?

    Reply to this comment
    • Dave

      21. Jun, 2009

      Why wouldn’t people carry adequate insurance for all sorts of situations? We trust people to do it in other areas of their life, why not health care?

      To play the devil’s advocate here, you seem to be (essentially) okay with the theft that pays for medical care, why isn’t it okay that the cost be shifted to females? Is it ethical that you should pay the costs for maternity care for a female you neither know nor (bluntly) care about? It seems to me to be an ethical double standard.

      My take: sex that creates life is akin to signing on the dotted line of a contract, and when one party bails on that contract, the other has grounds to pursue compensation with him. Not a perfect system, but one that respects people, and allows them the privilege to feel the full consequences of their decisions.

      If there was no legalized theft, I would also have nearly twice my current disposable income (in Canada, probably even more!). I would be happy to help those I could, and convince others to do so as well.

      Dave

      Reply to this comment
  15. Brent Pottenger

    21. Jun, 2009

    Another piece to add to this thread:

    http://online.wsj.com/article_email/SB10001424052970204005504574235751720822322-lMyQjAxMDA5MDIwMDEyNDAyWj.html

    This is turning out to be quite a fruitful ‘comments section’ discussion; others please chime in as well.

    Reply to this comment
    • theorytopractice

      21. Jun, 2009

      Great article. And something that struck me: compare this line, “The bottom line is that our health care is costly because it is costly, not because we deliver more care, better care or special care.” to Taubes’ “one is not overweight because they overeat, they overeat because they are overweight.” (my paraphrase). This is much, much more than a crafty play on words.

      Reply to this comment
  16. Brent Pottenger

    21. Jun, 2009

    Jay Parkinson adds to the debate insightfully:

    http://blog.jayparkinsonmd.com/post/127624538/22-tuition-increase

    Reply to this comment
  17. Doug McGuff, MD

    21. Jun, 2009

    Dave,

    You are my freakin’ hero. As an emergency physician looking at this from ground zero, I must say you have hit the nail on the head…particularly with how this sort of system affects the emergency departments in such a system.

    Doug McGuff

    Reply to this comment
    • Dave

      21. Jun, 2009

      Aw, shucks, Doc, now you’ve got me blushing. I just started with the BBS protocol, and you and John Little are my freakin’ heroes. It really seems to be the missing link for me, and I can’t believe the progress I’ve made in so little time (I’m on about my fifth week).

      Thank you, sir.

      Dave

      Reply to this comment
  18. Brent Pottenger

    21. Jun, 2009

    Dr. McGuff,

    So while we wait for the government to wilt away and for the IRS to be removed from society (Dave’s suggestion), what can be done to improve the emergency departments, in your opinion?

    Thanks,

    Brent

    Reply to this comment
    • Brent Pottenger

      21. Jun, 2009

      i.e. How do we innovate outside the system in terms of emergency medical care?

      Reply to this comment
    • theorytopractice

      21. Jun, 2009

      Yes, I think we can all agree on the ultimate fix — it’s the “bridge to get there”, it seems, that has us flummoxed.

      Reply to this comment
      • Brent Pottenger

        21. Jun, 2009

        Exactly.

        Reply to this comment
        • Dave

          21. Jun, 2009

          Sorry guys, but if we can agree on the ultimate fix, why did neither of you mention it, even in passing, in your original posts?

          The more that influential people (like yourselves) keep reminding others about the foundational problems in our system, the more the idea becomes a ‘mainstream perspective.’

          Remind people that the FDA serves little, if any, valid purpose:

          http://www.cafehayek.com/hayek/2004/11/im_not_joking_a.html

          Remind people that government-granted monopolies destroy, not encourage, innovation:

          http://www.dklevine.com/general/intellectual/againstfinal.htm

          Remind people the very real risks involved in accessing health care (Canadian example, but I expect the comparison transfers):

          http://www.cihr-irsc.gc.ca/e/22697.html

          How’s that for starters?

          Dave

          Reply to this comment
          • Brent Pottenger

            21. Jun, 2009

            Fantastic, Dave.

            All your insights are very valuable and well thought out. Much appreciated.

            The framework and perspective was implied in the discussion, maybe not overtly enough, but we need to figure out ‘how to get ourselves out of this mess’, and that process involves some form of a transitional bridge. What that bridge looks like is what I refer to when discussing the fact that exemplary leadership will keep one foot outside the system, innovating, and the other foot inside the mainstream policy, political, and administrative affairs (as frustrating as this ‘public service’ may be). With this foot stuck in the ‘system’, communicating those reminders is certainly valuable and helpful (thanks for the links, BTW).

            Thus, one bridge is to let the system collapse. Another bridge looks something like the one I suggested, which is similar to how Nassim Taleb, a libertarian who views government as ‘bad medicine’, has suggested we employ in order to transition out of our financial mess, moving to Capitalism 2.0 in the process.

            What is another possible ‘bridge’?

            Ultimately, we need more insightful, mature, and well developed humans to make any ‘system’ work, and that starts with reworking just how we educate, raise, and develop people.

            Just like any disaster relief effort, measures must be taken to take care of the people during the transition to safety.

          • theorytopractice

            22. Jun, 2009

            In my mind, this is analogous to — and probably much more convoluted as — finding consensus/agreement on the appropriate “bridge” to carry our society from a petro-based economy to an alternate fuel based economy. Natural gas “bridge”, hydrogen “bridge”? Lots of competing interests in the mix; plenty of power being wielded.

          • Brent Pottenger

            22. Jun, 2009

            Great analogy, Keith.

            Very fitting.

  19. Brent Pottenger

    22. Jun, 2009

    I do see an asymmetry in ‘assigning fault’ to health conditions. Lifestyle choice maladies are easier to assign individual responsibility measures. Random brain tumors for diligent, conscientious people, for instance, fall under the realm of social responsibility, whether through charity or some other means.

    Reply to this comment
  20. Brent Pottenger

    22. Jun, 2009

    Reply to this comment
  21. Brent Pottenger

    22. Jun, 2009

    Iatrogenesis:

    http://en.wikipedia.org/wiki/Iatrogenesis

    Well-done Wikipedia entry.

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  22. Brent Pottenger

    22. Jun, 2009

    Reply to this comment
  23. Brent Pottenger

    22. Jun, 2009

    John Goodman weighs in:

    http://www.john-goodman-blog.com/why-health-reform-is-bound-to-fail/

    Hayekian perspective.

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  24. Brent Pottenger

    23. Jun, 2009

    Another good thread to follow and reflect on:

    http://news.ycombinator.com/item?id=667411

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  25. Doug McGuff, MD

    27. Jun, 2009

    Brent, Dave,

    My solutions for emergency care will not happen. Two major problems are….

    1) Price controls from the Govt on the inpatient side of medicine (DRG’s) have created a shortage of inpatient beds and doctors. When you force doctors and hospitals to provide services for less money than cover their costs, then they shift to outpatient medicine. The result for ER’s is less beds to admit their sickest patients to….patients then end up being held in the ER because there is no inpatient bed to send them to. My 20 bed ER quickly becomes an 8 bed ER and the constant flow of walking patients through the front door, and ambulance patients through the back door have no place to go. Last night around 3am, we had all 20 beds full, 5 hall beds and 21 patients in the waiting room.

    2) Repeal the EMTALA law which forces ER’s to see all patients regardless of their ability (or intention) of paying. Looters have quickly learned to game the system WRT this law. 70% of the care I give goes uncompensated. 85%-90% of the care I do get paid for is from Govt. payors who grossly undercompensate without any opportunity to negotiate. The reason medical care (and insurance) is so expensive is because of the cost-shifting that must occur to compensate for these two areas of loss. Then the governement blames the private sector for rising prices when they are in fact the genesis of the problem. WRT the EMTALA law, non-emergency physicians are now refusing to take call for ER’s because they don’t want to be subject to this law. If the government doesn’t want to repeal EMTALA, I think they should provide a tax forgiveness (refund) to physicians and hospitals equal to the amount of uncompensated care provided under the law.

    The only real solution is for the entire system to crump and for free-market health care to re-emerge. In areas of the economy not regulated, new technology starts out expensive, then quickly becomes affordable to the masses. Cell phones and flat-screen TV’s are all afforded by the very people who cannnot afford medical care.

    If Obama’s plan comes to fruition, problems 1 & 2 will not have any “escape valve” of cost shifting and the system will implode, causing prolonged waits and shortages. Canada will implode, because it will lose its safety valve across the border (when I lived in Ohio, we would have 8-10 Canadians a day show up with decompensating illness who were on waiting lists). Lastly the best doctors (including yours truly)will quit.

    Doug McGuff

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    • Brent Pottenger

      28. Jun, 2009

      Thanks, Dr. McGuff.

      These are vitally important insights; the ER really is the pulse of the real status of the ‘health system’. In my view, the ER is where medicine starts, and health policy should build its foundation upon measures that make emergency medical services work well for communities and their hard-working practitioners (like yourself).

      Are there examples in other countries or places where emergency medical services are provided in a free-market environment? Are there successful social experiments that we can look to as support for this model of care (to provide support in our debates against top-down detractors)?

      Best,

      Brent

      Reply to this comment
  26. Doug McGuff, MD

    28. Jun, 2009

    Brent,

    To my knowledge there are NO countries on the face of the Earth that have free-market medicine. I come to this conclusion through a diligent search for alternative countries to practice in should the Obama plan get passed. Even countries highest on the index of economic freedom (Singapore and New Zealand for instance) have socialized systems. Singaporan hospitals have webcams where you can view their ER waiting rooms real-time, and I must say it looks no better than here.

    My own ER is already seeing a big jump in volume that appears to be just in anticipation of the Obama plan coming to fruition. I dread what will happen when it actually passes. When the perceived price is “zero”, the demand for services becomes “infinity”. A provider’s only defense in this scenario is to slow down and pace themselves as any attempt to keep up is futile.

    Many of the best doctors have seen this coming and have formulated exit strategies. As a result, this huge rise in demand will coincide with an exodus of the “service providers” leaving practice. This massive increase in demand will be met with an equally massive decrease in supply. Combine this with government price-controls and you will have shortages and wait-lists that will be hard to imagine.

    Doug McGuff

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  27. Brent Pottenger

    28. Jun, 2009

    Thanks, Dr. McGuff.

    Well, then, as a tribute to our founding concepts and frameworks, we should be the first to conduct this social experiment and show that a bottom-up, locally built and focused ‘free-market’ healthcare system works.

    Getting there from here is going to require disruptive innovation, which, as Seth Roberts suggests (and I agree), will come from outside of the mainstream system; read Seth’s thoughts here in his post, ‘The American Health Paradox: What Causes It?’ ( http://www.blog.sethroberts.net/2009/05/29/the-american-health-paradox-what-causes-it/ ):

    “In his New Yorker article, Gawande fails to understand Jacobs’s point that farmers didn’t invent tractors; the big improvements to American (and world) health are not going to come from doctors or anyone now powerful in healthcare. They are too wedded to the status quo. (Notice that this recent innovation in affordable housing, the nano home, comes from a car company — an Indian one.) Gawande, being a doctor, surrounded by the powerful at Harvard (where he teaches), is in a poor position to figure this out. Where will the big improvements in health actually arise? From people who benefit from change. A reasonable healthcare policy would try to empower them.”

    Safeway (*see my post here: http://epistemocrat.blogspot.com/2009/06/important-empirical-result-safeways.html ) is one such example of promising work outside the system to innovate creatively and locally, and, of course, Hello Health (www.HelloHealth.com) is another one. Are there any examples at all here in the US to look to for empirical support that some form of free-market emergency medical approaches are innovative and effective? Or, is the ER, unfortunately (due to legal restrictions like EMTALA and other means like price-controls), so government dependent that these types of experiments are not feasible nor possible?

    Thanks,

    Brent

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  28. Patrik

    28. Jun, 2009

    [Many of the best doctors have seen this coming and have formulated exit strategies. As a result, this huge rise in demand will coincide with an exodus of the “service providers” leaving practice.]

    As Doug states, this is exactly what my brother is doing. He is finishing his residency and already exploring becoming a professional expert witness and leaving medicine altogether if ObamaCare passes — this is after college, medical school and his residency.

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    • theorytopractice

      30. Jun, 2009

      Just a thought — maybe a little fuel for the fire. It seems to me that most people who go into medicine currently, do so for the money, with the “serving humanity” aspect of the work being an “oh yeah, and…” aspect. Note that I said “most”, not “all” — note as well that this is just one person’s observation. It may be that medicine will go the way of the arts, or teaching — a field to go into for love, not for money. This is a naive/Utopian idea, I realize — but, like I said, just fodder for the fire.

      Reply to this comment
  29. Doug McGuff, MD

    28. Jun, 2009

    Brent,

    EMTALA essentially prohibits any free market practice of emergency medicine. If you were to open a free-standing cash only ER you need to have somewhere to admit your patients. Hospitals are subject to Hill-Burton laws and EMTALA and must have ER’s that provide unfunded care. If a private ER were to spring up, most local hospitals would view this entity as “cherry picking” the best patients and would likely be unwilling to provide backup support for the private ER needing to admit patients.

    There are numerous free-market examples of items that are technically complex, not understood by the lay public, and essential for daily life that are affordable to the masses. You and I are communicating on one of these examples now. If the Governmenet determined that computers and internet access were an essential right and began to legislate computer access, it would not be long before a situation similar to healthcare developed. Patients who “cannot afford basic healthcare” can afford cellphones that take pictures and afford internet and twitter access. The reason…these technologies developed in a free market. Before the Hill-Burton act of 1965, medical care was affordable and accessable to all and almost every hospital had a charity wing for those less fortunate. But really, we don’t need specific examples if you understand the basic principle that “free markets work”.

    One of my partners took his dog to a veterinary emergency room in a nearby city. It had on site CT scan, MRI and ultrasound as well as a full-service lab. The interior was beautifully decorated. At a volume of 16,000 visits per year, it had night time double coverage. It was cash only and very affordable. At a volume of 40,000 visits per year, my group can only afford single coverage on night shift, and I spent all day transferring patients 45 minutes away for CT scans because ours was broken.

    By the way, the Emergency Vets prior career before going to Vet school…Emergency Physician.

    Perhaps we can find a model and turn things around. The fact that Patrik and I are on the same page proves that miracles do happen. Thanks for the props Patrik. Best of luck to your brother.

    Doug McGuff

    Reply to this comment
    • Brent Pottenger

      29. Jun, 2009

      Thanks, Dr. McGuff.

      Very informative; much appreciated.

      How would you envision ‘insurance’ being used in a ‘free-market’ healthcare system; specifically, in the realm of emergency medicine? Would most people self-insure under this model? Charity would certainly provide the safety-net. Some folks I imagine would still purchase some package of catastrophic coverage?

      How would pricing and payment for services operate? I have not been to a Vet ER, so I suspect we would adopt practices from that discipline.

      Thanks,

      Brent

      Reply to this comment
  30. Patrik

    28. Jun, 2009

    @Doug

    I will pass on your wishes to my brother. BTW while I remain skeptical of your methods, I just purchased a copy of your book via Amazon.

    Partially because I am a gadfly skeptical of others, I am also skeptical of my own bullshit, as it were.

    The strength of your arguments for the free-market* also impressed me.

    Well done.

    Question for you: as far as exercises/methodology is concerned, what would you suggest that I try/apply from your book that would be most empirically persuasive to me?

    Reply to this comment
  31. Dave

    29. Jun, 2009

    @Doug

    “My solutions for emergency care will not happen.”

    Correct.

    “The only real solution is for the entire system to crump and for free-market health care to re-emerge.”

    Almost certainly, though there is always the possibility of a tandem black/gray market emerging alongside the collapse.

    And to reiterate what I wrote earlier:

    What to do in light of THAT reality is what this discussion SHOULD BE about.

    Patrik’s brother is on the right track, and I am sure that a doc like Doug will be okay too, with his Ultimate Exercise facility, his future book deals (I suspect) and the lecture circuit.

    Question for Brent:

    What will you do when the government finally tells you who to see and how much you get paid for it?

    Up here, some docs just work less, see more patients for shorter appointments (got another issue you want to discuss? You will have to rebook), or join the rest of the hordes elbowing for a bigger serving at the cannibal pot.

    Me, I’ve spent 7 years in national politics (hypocrite!!!) and I am done. All I got was fat and a wake-up call. I am seriously starting to envy my friends that chose the trades…

    Dave

    Reply to this comment
    • Brent Pottenger

      29. Jun, 2009

      I understand the danger of the police-state.

      I guess there is nothing else to discuss since the consensus is to just let everything fall apart.

      Energy is better spent working in practice to build better financing and delivery methods, primarily in the cash-only market.

      Reply to this comment
  32. Doug McGuff, MD

    29. Jun, 2009

    Patrik,

    I would suggest reducing the volume of your workouts to the point it produces a little angst. Then observe what a big boost extra recovery can provide.

    Perhaps try a Big 5 for a period of time but at a every 10 day frequency intermingled with what you normally do. Allow time for recovery and check your performance on one of your usual benchmark workouts to see how well BBS conditioning tranfers to something you are already skilled at.

    Regardless of what you try, I hope you find something useful in the book to apply to your own workouts.

    Dave,

    I will always keep my hand somewhat in medicine (as opposed to completely quitting) just so that I can navigate the medical landscape for the benefit of my family.

    Brent,

    Thanks for all your stimulating work and discussion. It feels really good to be able to vent. Thanks to all for listening.

    Doug McGuff

    Doug McGuff

    Reply to this comment
  33. Brent Pottenger

    30. Jun, 2009

    Yes, good work all around.

    Thanks, Dr. McGuff, Dave, Patrik, and Keith for weighing in and venting openly about the social challenges we face in healthcare and beyond. In true ‘Body by Science’ fashion, this was a good, intense discussion that will have lasting positive benefits.

    To good health, continual reflection, and sustained energy to keep up the work to improve people’s health (while taking care of ourselves and our families, as first priority, along the way).

    Warm regards,

    Brent

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  34. Brent Pottenger

    30. Jun, 2009

    PS

    A fitting end, capping Keith’s original motivation for his fine, well-composed and reflective essay above (I just ‘Tweeted’ this):

    “When we lose individuality, we lose spirituality. When we lose spirituality, we lose accountability. Ergo, loss of individuality equates to loss of accountability.”

    We need more accountability in society, across the board, but especially in health affairs. Excellent ‘public servants’ like Dr. McGuff only have so much to give before we spread them too thin (we are already there, of course).

    A return to individuality is in order, regardless of whether the bridge to get there is still under construction.

    Perhaps, a Positive Black Swan hit will strike; but, in the meantime, all we can do is do our best locally, in the niche and neighborhoods that we serve and are accountable to–that, by itself, is worthy of high praise and respect.

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