Within the past few years I have read repeatedly in the opinion sections of newspapers the call for the federal government to provide a "single payer" system for America's medical care. These proposals are classics of left-wing thinking – they work out beautifully in the heads of those doing the proposing. The comedy occurs when they are subjected to the scrutiny of reality; the tragedy when they become reality. Government involvement in medicine exacerbates rather than alleviates its ills. HMOs and the government are pre-paid systems that are the cause of the financial crisis facing health care (I mean in addition to the contribution of greedy lawyers and irrational juries).
A caller on a talk show recently commented: "The rest of the world has a one-payer government system, so why don't we?" The answer: Because then we'll have the same quality of care of the rest of the world. Socialized medical care is a disaster worldwide for patients who need attention now or tomorrow or by next week, especially if that attention entails a procedure or surgery. I offer the perspective of a practitioner who has lived through the changes in the system. The cost of health care has increased alarmingly during the decades of my career because of third-party payer systems: HMOs and the government. Health care costs will increase and quality decrease with every increase in government involvement.
The working citizen pays for health care regardless of the system: entirely government, entirely private, or HMO. Therefore, we the people should have access to the most efficient system possible, "efficient" meaning the most cost-effective and most free in terms of the patient’s right to choose. It's a happy coincidence that such a system would also be the most health-efficient (health-promoting) and most fair – the best plan from both moral and practical standpoints.
In the HMO system, the patient has turned over to the HMO – or rather the employer has done so for the employee-patient – what would have been the employee's larger salary. That is, the employee pays by forgoing a larger salary or another benefit. That's because employers are not in the business of printing money. They can pay the employee one way or another, but not both. The HMO must then ration care in order to make a profit – profit being a requisite for the survival of a private business. The employee, the patient, is naturally motivated to squeeze what he or she can from the third-party payer. Under a "single payer" system (rhetorical code for federal socialized medicine), the citizen pays through taxes. Government and HMO are third-party, pre-paid payers. The patient's position is, under those two systems, "I have already paid, so I want only the most and the best – and today." That demand is independent of medical need, independent of fairness, and independent of any thought about the effect on overall cost. That's all natural; it is not a reflection of sinister attitude. Under a pre-paid system, seeking attention for trivialities or requesting a sub-specialist for a problem that can be handled quite competently by a physician's assistant or a nurse-practitioner is only natural. Thirty years of experience have led me to the following conclusions on how to solve existing problems of health care and forestall new ones.
Under a sensible – meaning private – plan, the patient can go anywhere he or she wants. Private insurance is "third party," but it is a mutually voluntary contract negotiated to cover whatever the patient selects and pays for. The patient's premiums depend upon – or should depend upon – his or her life-style. That is, the cost to the patient of the protection from medical expenses should depend on the patient's health habits, and his or her premiums should be adjusted accordingly. The patient can request and pay for all the benefits and "rights" he or she chooses, from catastrophic to weekly drop-ins for reassurance. Catastrophic would be the least expensive, weekly visits the most expensive. The patient would be free to go to a sub-specialist at any time for any problem that could be handled quite handsomely at the primary-care office. But the patient usually would not, since the cost will be multiples of the cost of primary-care, and the patient will pay this out of pocket or his or her premiums will rise accordingly. Under a sane system, instead of pressuring the doctor for an expensive procedure under the slightest pretext, the patient would ask what the chances are of this procedure (say an MRI) being positive. When the doctor answers, "Approximately five percent," then the patient will respond, "Then I'll take your suggestions for treatment and get back with you if any of the symptoms or criteria you listed occur."
The numerically most significant (the most common) killers are diseases that are by and large self-inflicted – caused by lifestyle. The vast majority of cardiovascular disease (heart disease, stroke, peripheral vascular disease), and a significant amount of (and perhaps most) cancer, kidney disease, osteoporosis and large-joint arthritis are self-inflicted by smoking, dietary malfeasance, obesity, lack of exercise, alcohol and other substance abuse, and by their resultant, intermediate disorders – hypertension, hyperlipidemia (blood fats, including cholesterol), and diabetes (90% of diabetics have the self-inflicted Type 2, which is exclusive to overweight people). Not only life-threatening diseases are self-inflicted. Numerous others less deadly but as costly in lost productivity and needless suffering are also, including disorders of the gallbladder, back – muscular and spinal – and those transmitted sexually.
If you believe people with bad health-habits are motivated by longevity, you are clearly someone with good health habits. People with bad habits are motivated only by cost. If we reward people for irresponsible behavior we reap a bumper harvest of irresponsible behavior. Paying people (by a "third-party" system) to continue their bad health habits negates any potential motivation to live healthfully. When we physicians bring up the subject of making crucial changes in behavior, most patients who live unhealthfully listen with the face of the deer whose eyes are fixed on the headlights; they look at us – or respond – with the thought, "If this guy doesn't quit hassling me about the way I live, I'm going to switch to a real doctor who will cut out the prevention noise and give me my pills." Why live healthfully when you get pre-paid care and can take free or subsidized medications? The HMO and government systems serve as "enablers" by rewarding and subsidizing those bad habits, thus reinforcing them. The employee who lives responsibly pays for the expenses of his or her fellow employee who lives irresponsibly by foregoing what would have been a bigger salary but was withheld so that the employer can pay the HMO for the care of the irresponsible. This increases costs both by the exacerbation of the illnesses, and by patients' tendencies to abuse the prepaid system.
Six to twelve times per day at the clinic where I work in Ventura-Oxnard, California I hand out to obese patients a copy of my one-page detailed diet protocol: physical work-out daily, low-fat, high-fiber diet including just say no to the cheeseburgers and other fast foods. Regularly another patient comes in to announce that his or her insurance no longer covers the cost of prescription drugs. "Therefore, may I have another copy of the diet and exercise protocol you gave me last year?" Translation: "As soon as I exited your clinic last year I dumped your guide in the trash. Now that I have to pay for my medicines, I believe I just might be interested after all in getting rid of my diabetes, my high blood pressure, and my [go down the list]." I recall suggesting to one obese couch potato that he take and live by my diet protocol. "Those are fighting words, doctor." Well fine, live and die as you desire, but the idea of responsible taxpayers paying for that attitude and behavior is unfair, immoral, and counterproductive in terms of health and economics.
A) Infinite and arbitrary demand because of third-party payer, and B) just as arbitrary bureaucratic rationing to control the resulting mushroom cloud of costs – these are the reasons Medicare's budget is (adjusted for inflation), let's see, about twelve or fifteen times that predicted by its founders, and would be much worse if it were not for bureaucratic restrictions placed upon the patient – call that the deletion of the patient's freedom. These faults would increase geometrically under a government system-for-all because of infinite demand and ever-expanding bureaucracy to deal with the inevitable rationing. The only effective approach is a system in which the doctor can say, "Mr. Lipidus, aren't you tired of paying $5 or $10 per pill? Aren't you tired of your insurance premiums going up annually because of your medical-care outlay? If you will eat properly and exercise daily as we discussed, you probably won't need these pills at all, and you certainly won't require this frequency of office-visits and hospital admissions, and your premiums are going to plummet." I have never heard this crucial factor in the cost of medical care discussed on Capitol Hill. Genuine reform would provide that a patient’s pay-in per year would depend on his or her habits – automobile insurance style.
In the movie As Good as It Gets (I don't recall the names of the characters, so we'll call them Jack Nicholson and Helen Hunt), Jack has funded a rescue of Helen's asthmatic eight-year-old son from the "greedy" restrictions of the "evil" corporate HMO. Helen makes a disgusted reference to the HMO, to which the audience responds with spirited approbation for her sentiments and derision for the HMO. HMOs were resorted to by employers as a means of controlling costs, which is to say rationing under the euphemism of "managed care." It's private socialism, so to speak and it's the wrong approach since it costs the patient his or her freedom and penalizes those who live healthfully as they pay for it with smaller salaries and restricted access to care. Let's sing the refrain one more time: Costs should be controlled by coupling patient cost to patient behavior. Do away with government and HMO involvement. Provide the needy with the means to buy private insurance. Have laws against price conspiracies and monopoly by the insurance companies. People with unhealthy habits, now faced with high premiums and expensive pills, are going to find themselves suddenly very interested in Prevention. Costs will plummet. Now those with innocent bystander diseases such as asthma (except that some asthmatics smoke; no, I'm not kidding) will not have to call upon Jack to bail them out.
California's Medi-Cal program is a huge microcosm – a paradox that helps make the point – of the bane of federal involvement in medicine. The average wait for a patient at the clinic where I work is about 90 minutes and is often several hours because the waiting room is overrun with Medi-Cal moms bringing in their children with stuffy noses and stubbed toes. Whenever I see two or three charts waiting at the same treatment-room door, I know it's a Medi-Cal family. One of the kids seems sick, so why not bring in all the kids? Another of them had a touch of diarrhea a few days ago. Still another bruised his knee last week. Bringing one? Bring them all. Why not?! Service is "free." Demand skyrockets. To compound the tragi-comedy, Medi-Cal is rife with ridiculous and costly rules. Government further escalates the cost of medical care as bureaucrats require procedures for those who don't need them. If the primary-care physician wants a $150 referral to a specialist, the rules dictate that a $1000 MRI is required in advance, when part of the point of the referral was to obtain the specialist's agreement that the MRI is not needed. With unlimited demand and irrational rules, no wonder it takes several weeks for the patient to reach the specialist she should have seen within a day or three of the referral. How are costs of demand and diktat to be controlled? Here's how: by the arbitrary rationing of those same bureaucrats, who place restrictions on procedures for those who do need them. Welcome to the land of buronic wisdom.
How does the new plan to have Medicare pay for the pharmacy costs of seniors affect a young working couple? Let's suppose he is a heating-air conditioning specialist and she the manager of a store, both living responsibly and healthfully and doing their best to raise a child or two. Along comes the government and confiscates their income to pay for the $5 per pill medicines for a well-to-do 68- or 78-year-old who refuses to cure his diabetes, or to give up his cigars, or to walk from tee to green at the country club, or even to use the exercise room on the cruise ship. Nice going, government! How's that for social justice? The same principles hold if the patient with bad habits, instead of enjoying a cruise, is on Medicaid or Medi-Cal. The system is just as pragmatically backward and morally reprehensible whether the one who refuses to change his or her habits is rich or poor. This subsidy of destructive habits, this enabling and rewarding those who choose not to live healthfully, is grossly unfair to those who live responsibly – who live healthfully. It escalates demand; it escalates costs. In short, it is counterproductive in every respect of health and cost. The third-party payer system is a disaster for everyone concerned except for HMOs and politicians who derive power from citizen dependency upon government. The more prevalent the HMO or government pre-pay system, the greater the demand. The only way a "single-payer" (Medicare for all) universal government system is going to control stratospheric demand and costs is rationing that will make HMOs look like a genie fulfilling your every wish.
Private medical savings accounts would beat the Medicare system in every respect. MSAs are pro-choice: seniors would have more freedom to select their care; they would be motivated to live healthfully, since the excess MSA money would be theirs to enjoy; and there would be greater availability of care since demand would be determined by need as agreed to by patient and physician. The best system for poor and marginal-income people would be state-provided vouchers or cash with which to buy private insurance. As the recipient's health habits improve, he or she would be allowed to keep the difference (for a certain number of years) as the insurance premiums decreased because of those improved health habits. There could be decreasing coverage for every year the individual refuses to cooperate by living healthfully. Now you're going to see smokers, substance-abusers and couch-potatoes suddenly discovering a new life style. This plan increases individual choice and decreases dependency on the government and will therefore be fiercely opposed by left-wing political forces, their politicians, and certain lobbies.
By financing health care through a private patient-controlled system, the cost of health care will be as high or as low as the public wants. If the American public has a lapse of intellect and judgment serious enough to elect the politicians who want to socialize our medical care, I have a health advisory for you: get rich, or don't get sick. On second thought, don't bother getting rich: there will probably be laws against going outside the system – unless, of course, you're a member of Congress.
February 22, 2005
