The Doctor is Not In (Part 6)-A Matter of Life And Death



A Personal Story Turns Universal

Now we come to the crux of the matter, if K's experience, described in Part 1, Part 2, Part 3, Part 4 and Part 5 was simply a story of a person who faced difficult health challenges, her friends and family would care, but there would be no reason for me to share her story with you.  But her story of unavailable doctors, managed care denial, inexplicable and unresponsive systems is not unique. It is a universal story. The difficulty of finding a doctor, the role of managed care companies and the unavailability of common prescriptions were all events that were not only predictable, but were predicted.
The authors whose books are discussed below did predict the outcomes we are currently experiencing and even have suggestions for how to avoid ever increasing costs and ever diminishing care options. 
Regarding Public Policy
There are great resources available for lay readers who want to participate in the conversation regarding health care delivery. This is not a place where one wants to rely on one’s instincts. If you want to inform yourself, I recommend that you begin by reading at least the following three books  as an introduction to the current health care/insurance situation.
There’s No Free Lunch and there is no Free Health Care with Single Payer 
The United States is on the cusp of adopting single payer health care. The ACA is failing and it is failing in exactly the ways that it was predicted it would fail. The very sickest people are joining and the healthier people are dropping out since they premiums are increasing. To understand how impossible it is for the US government to deliver “free” health care to the masses, consider the following:
Every entitlement program created by the United States government costs significantly more than it was projected to cost. When Medicaid and Medicare were created in 1965, it was anticipated they would cost $12 Billion by 1990. The actual cost that year was $90 Billion.
According to the Trustee for Medicaid, Medicare and Social Security, in order to meet existing obligations coming due over the next 75 years, the USG would have needed to invest $45 Trillion in 2014. This needed $45 Trillion is in addition to the streams of income from FICA and Medicaid payments from payroll taxes. Consider that the total GDP in 2014 was $14.4 Trillion. So the USG needed to invest 3Xs the entire GDP of 2014 in order to pay currently promised SSI, Medicare and Medicaid expenses. The figures are drawn from page 202 of 2009 Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.
The foregoing information is drawn from The Primal Prescription, by Doug McGuff, M.D. and Robert P. Murphy, PhD. They discredit the idea that the ACA provided universal coverage (it left more than 30 million Americans without health insurance) or that it was affordable (it will cost well over 1 Trillion Dollars in the first 10 years). Buy The Primal Prescription here
Health Care is Rationed Today
Many Americans who support single payer health care believe that countries who have single payer health care have universal coverage. Nothing could be further from the truth. Rationing is omnipresent and is increasing. In September 2016, British NHS announced that those having a BMI of 30 or above and/or smokers will be barred from most surgery up to a year. Canada also rations care through long wait times. According to the foregoing article, Canadians wait on average 9.8 weeks for medically necessary treatment. Now, go back and review the symptoms that K experienced in Part 1, Part 2 and Part 3 and determine for yourself if such wait times constitute acceptable medical treatment.
As Mary Ruwart discussed in Chapter 6 of Healing Our World, The Compassion of Libertarianism, licensing laws restricting practitioners drive up the cost of care and limit options for palliative and restorative care. This video presentation gives an excellent overview of how and why the AMA sought to restrict people’s access to medical care in the early 20th Century. We are all living with restrictions on access to care today that started 100 years ago. Nothing in the ACA or single payer will reduce or eliminate those restrictions on access to care.
Common Drugs (such as Epinephrine) may become difficult or impossible to obtain
As this recent Forbes article discusses, the FDA drove up the cost of the EpiPen (and many other drugs) through the grant of a monopoly to the producer of the product.
Unavailability of common drugs (such as K experienced regarding her leg wound, Part 3) is more common that I realized. The Primal Prescription discussed how the 2003 Medicare Modernization Act adjusted the payment formulas to limit the speed at which drug prices could rise. This had the same effect that price controls always have, shortages developed. As the authors' note, "hospitals routinely find that they simply lack generic drugs that their staff have been using for years." [Page 91]
The ACA was, in part, paid for by increasing the costs of Middle American’s insurance
Initially, so-called Cadillac Plan insurance plans were going to be subject to a 40% tax commencing in 2017. This tax increase on these plans was part of the method of paying for the ACA. The date for implementing the increase originally planned for 2017 has now been pushed back to 2020. I urge you to read this Atlantic article describing what is meant by a Cadillac plan. If Congress ever allows this to be implemented, and it is so politically unpalatable that they may never allow it to be implemented, many more plans may be classified as “Cadillac Plans,” than one would think. This may be because the plan has one or more very sick individual, members live in an area with high health care costs or inflation makes health care more expensive.  All of these events increases the value of the plan and make it more likely that it would be classed as a Cadillac Plan.  
Managed Care Panel
Managed Care Panel
What if Managed Care Turns into Mandated Care?
Soon we will be hearing more and more about evidenced based medicine. What could be wrong with that? As John C. Goodman, asked in Priceless: Curing The Healthcare Crisis (Independent Studies in Political Economy, “[D]on't you want your doctors to base their advice on scientific evidence? Don’t you want them to follow guidelines that have been written by reputable scholars who have surveyed all the relevant literature?” Then he gives six reasons that such guidelines can reduce the quality of care you receive:
  • First, in most areas of medicine, there are no treatment guidelines, and where there are, they are often unreliable, conflicting, and incomplete.”  Faced with conflicting information, insurers (whether private or public) will choose the cheapest option.
  • Second, the guidelines are written for the average patient. Patients who aren’t average will receive less than optimal treatment. 
  • Third, guidelines are written by interested parties, insurance companies, pharmaceutical companies and medical device companies.
  • Fourth, the guidelines are based upon studies, which often exclude entire segments of the population, for instance elderly or obese people or women or people who are on medications for other conditions.
  • Fifth, randomized controlled studies are considered the “gold standard;” however, they always involve identifying the salient factors to be tested. Other factors may be at work which influence the outcome, but aren’t identified by researchers.
  • Sixth, “individuals are individuals.” People do not respond to treatment in the same way. 
Moral of the Story: Today we can see a path towards financial ruin and mandated care (less personal choice) if we continue on the current trajectory of increasing public direction of health insurance and health care. All of the authors cited in this post provide realistic alternatives to that path. Their alternatives all require that people assume more, not less, responsibility for their health and the use of their health care dollars. There is no such thing as free healthcare.  



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