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Quarterly Newsletter, January 2005
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In This Issue:
1. Austrian Economics for the Medical MarketPlace
2. Health Care - The Problem
3.Health Care - The Solution
4.The Tyranny of Choice - Medi Disaster
5.Health Plan Gluttony - Working at Cross Purposes in HealthCare Insurance
6. Medical Myths - Preventive Care and Screening Tests are Insurable?
7. Overheard In the Capital Rotunda
8. Quarterly Review of HealthPlanUSA - Regaining Control
* * * * *
1. Austrian Economics for
the Medical MarketPlace
Chris Leithner reports in Le Québécois Libre that an important strand of the
To mainstream economists, the decisions entailed by buying and selling in the market are mere mathematical derivations. A decision, in other words, is made by a given model, probability distribution and data. The mainstream model thus eliminates the real-life, flesh-and-blood decision-maker the heart of the Mises-Hayek-Rothbard theory from the market. Market automatons do not err; accordingly, it is unthinkable that an opportunity for pure profit is not instantly noticed and grasped. The mainstream economist, goes the revealing joke, does not take the $10 note lying on the floor because he believes that if it were really there then somebody would already have grabbed it.
In sharp contrast, Austrians recognize that
decisions are taken by real people whose plans are imperfectly clear,
indistinctly ranked, quite often
internally-inconsistent and always subject to continual change. Further, at
any given moment a market participant will be largely unaware of other market
participants present and future plans. It is participation in the market that
makes buyers and sellers a bit more knowledgeable about their own plans and
slightly less unaware of others’ plans. Accordingly, they will inevitably
make mistakes and not automatically notice them. It is not just possible, it
is typical that opportunities for gain (pure profit) appear but are not
instantly detected. Recognizing the obvious, namely that he has possibly been
the first to notice it the
Human error is as perennial as the grass. But unlike entrepreneurs, a government (or an entity privileged by government) has no incentive to detect and correct errors. In an unfettered market, errors are detected and rectified; but when governments supplant markets, errors are ignored and denied, and grow into problems, crises and eventually catastrophes (see in particular Thomas Sowell, The Vision of the Anointed: Self-Congratulation as a Basis for Social Policy, Basic Books, 1995). In a market, competition among producers improves the quality of goods and services; and consumers reward good producers and punish the poor ones such that consumers and good producers prosper. In politics, however, the contest to hold the reins of power generates perverse results. Quality constantly declines and innovations occur only with respect to lying, cheating, manipulating, stealing and killing. The price of political services constantly increases and there is no obsolescence - planned or otherwise. In politics, as Friedrich Hayek demonstrated in The Road to Serfdom (see Leithner Letter 57), the worst get on top. The paradox for mainstream economists, then, is that one requires the “anarchy” (in the proper sense of that term) of entrepreneurship in order to explain the relatively smooth, systematic and peaceful character of real-world market processes. To read the entire article, please go to http://www.quebecoislibre.org/04/041215-5.htm.
The corollary in health care is that with increasing bureaucracy and mandates, errors grow into problems, crises and eventually catastrophes with continual decrease in quality of health care. When the worst hospitals and doctors are paid the same as the best hospitals and doctors, quality of care given by the worst hospital and the worst doctor necessarily deteriorates. This explains the increasing emphasis on quality by the government and HMO bureaucracy to amend this decreasing quality they produced by restricting the physician, whose middle name is quality. What is necessary is the return of the Medical MarketPlace, with unlimited choices of doctors and hospitals. The highest quality of health care will then be provided by the best hospitals and the best doctors, without further bureaucratic or quality improvement programs that are generally ineffective or even perverse.
* * * * *
2. Health Care - The Problem
Harry Browne, in his treatise, Why Government Doesn't Work, has a chapter on Health Care - The Problem. If the road to Hell is paved with good intentions, he says, the road to big government is paved with small steps - each of which seems harmless in itself.
The pattern rarely
A. There is widespread publicity about a crisis.
B. Politicians float a drastic proposal to solve the problem with new, far-reaching, bureaucratic program.
C. "Moderates" in Congress and the public mount opposition to the government takeover.
D. Eventually the politicians arrive at a compromise - to fix the problem without radical overhaul.
E. Although the moderates congratulate themselves on holding the line against big government, the compromise makes government bigger, more powerful, and more damaging - making the next crisis inevitable.
Because politicians refuse to recognize that government doesn't work, they never blame the current problem on the program they passed earlier. Instead, while professing their undying faith in free enterprise, they note regretfully that the market has failed to work in this instance. So they propose to fix it with a larger, more bureaucratic system - and the cycle continues with a compromise, more government, more damage, and another proposal.
Health care is an excellent example. From the passage of Medicare in 1965 to a health-care system run completely by the government a few years from now, the politicians have led us along step by innocuous step. Although each step has been presented as the end of the journey, each has added to the problem and made the next step seem necessary.
Government has been involved in medicine since before any of us was born. And over the past 30 years its involvement has grown rapidly. Its policies are the cause of medical care's high cost and the difficulty of obtaining health insurance - the two problems the politicians now propose to cure with more government.
For a persuasive demonstration of why government programs: a) Have a failure rate over 99%, b) Never live up to their promises, c) Too often do the exact opposite of what was promised for them, d) Always cost far more than their initial estimates, and e) Create the conditions that justify enlarging themselves and adding more government programs, you may begin to download the book at http://www.libertyfree.com/.
A good citizen doesn't rely on government. Government relies on him.
* * * * *
3. Health Care - The Solution
In Harry Browne's treatise, Why Government Doesn't Work, there is also a chapter on Health Care - The Solution. Browne notes that in the health-care debate of 1992-94, words like compassion, right, need and fairness showed up frequently. But a number of relevant words were ignored.
Browne states that he never heard the words force or coercion in public discussion about the issue. And yet the Health Security Act, the President's 1993 proposal for universal health insurance, had a great deal to do with force. There are some revealing terms in the proposal-such as prison (which shows up seven times), penalty (111 times), fine (six), enforce (83), prohibit (47), mandatory (24), limit (31), obligation (51), require (901), and so on. A person withholding information about his medical history could go to prison for five years.
That was the Democrats' proposal. But lest you think the Republicans don't believe in forcing people to do the right thing, their principal proposal included the terms prison (one time), enforce (37), penalty (64), fine (12), prohibit (19), and require (482).
Even the plan publicized as the most "free market" of the eight major proposals contains the words penalty (five times), prohibit (five), require (54), enforce (one), and so on.
But coercion is nothing new in government-run health care. Medicare already has plenty of fines and penalties. For example, a doctor is fined merely for filing the wrong form - or failing to file a form for every visit by a patient.
The health-care debate has ignored the most important factor: government involvement in health care means forcing people and institutions - doctors, patients, hospitals, insurance companies - to do what they don't want to do. And such plans never work as promised.
Ignoring the coercion lets the health-care advocates seem compassionate - as attempting to help people get insurance or better medical care. But if there were no brass knuckles inside the velvet glove, the government wouldn't be wearing it.
Coercion is present, and that means the
outcome will differ considerably from the rosy future the politicians
Read another chapter in the book at http://www.libertyfree.com/WGDW/Chapter6.htm.
The Greatest Mistake in American History:
Letting Government Educate our Children
- Harry Browne
* * * * *
4. The Tyranny of Choice - Medi Disaster
Barry Schwartz (author of The Paradox of Choice: Why More is Less) reports in Scientific American that Americans today choose among more options in more parts of life than has ever been possible before. To an extent, the opportunity to choose enhances our lives. It is only logical to think that if some choice is good, more is better; people who care about having infinite options will benefit from them, and those who do not can always just ignore the 273 versions of cereal they have never tried. Yet recent research strongly suggests that, psychologically, this assumption is wrong. Although some choice is undoubtedly better than none, more is not always better than less.
This evidence is consistent with large-scale
social trends. Assessments of well-being by various social scientists--among
them, David G. Myers of
Dr Schwartz, along with colleagues, has conducted research that offers insight into why many people end up unhappy rather than pleased when their options expand. He makes a distinction between "maximizers" (those who aim to make the best possible choice) and "satisficers" (those who aim for "good enough"). They developed schemata of how feelings of well-being initially rise as choices increase, then level off quickly, and then evoke virtually infinite unhappiness and bad feelings as choices become too many.
Read the entire story in the April 2004 issue of Scientific American or go to http://www.scientificamerican.com/article.cfm?chanID=sa006&colID=1&articleID=0006AD38-D9FB-1055-973683414B7F0000.
This idea also applies to health care and to
most spheres of living. For instance, my cell phone company offered me a
$10/month savings to upgrade my calling plan. Since I would continue to
receive the current benefits in addition to receiving more minutes, I couldn't
find any objections. When I received the statement the next month, it wasn't
$10 less, but $125 more. After reviewing the many choices, the phone company
representative had overlooked the fact that "the entire country" and
* * * * *
5. Health Plan Gluttony - Working at Cross
Purposes in HealthCare Insurance
When Medicare began in 1965, physicians held on to some market-based aspects that kept patients informed of health care costs. There was a deductible payment due upon any hospital admission that prevented much unnecessary utilization. There was a 20 percent copayment on all out-patient health care. Thus, if a patient was admitted to the hospital, before Medicare paid the $4,000 for a week stay, the patient had to pay the $500 deductible. This would always present the economic realities of the hospital cost. If he went to a doctor for a $50 office visit, the 20 percent copayment of $10 would always make the patient evaluate the necessity and value of those outpatient services. If the doctor ordered lipid and chemistry panels costing about $200, the 20 percent copayment of $40 would immediately remind the patient of the cost of health care and its relationship to his personal health. For instance, if he had not even begun his low fat diet since the previous year's panel, he would tell the doctor to wait to check his cholesterol levels after being on the diet for 6 or 12 months. If a consultant had recently obtained tests and had not yet sent them to the patient’s personal physician, he would tell his doctor, who could then obtain the results rather than unnecessarily repeat the test, as is currently the practice. In my anecdotal experience, if patients were aware of their health care costs we could eliminate about 10 percent of hospitalizations, about 10 percent of office calls, about 20 percent of requested consultations and about 40 percent of the requested laboratory work.
If the deductibles and the 20 percent copayment had not been tampered with, we may have seen a government system that would have worked. We would not be experiencing the Gestapo intrusion of government that looks at every office call, prescription and hospitalization to determine whether they were really medically necessary. The patient would have done his own policing purely because of the deductible payments and co-payments. Doctors would not be prosecuted and hospitals fined, precipitated by the unsustainable 100 percent to 800 percent increase in costs over initial budgets, because there would not have been the costs overrun.
Patients, not understanding basic economics, took the most expensive route possible. A second Medigap insurance on top of the Medicare insurance eliminated the small market-based, cost-controlling aspect of Medicare. Nothing is more expensive than two insurance policies covering the same risks. The second one just eliminates the small financial risks that make it operable, working at cross purposes to the Medicare system.
This month, we are beginning another huge Medicare entitlement, the prescription drug benefit, that brings the long arm of the law further into the doctor-patient relationship, with a cost projected to be even more excessive than past programs. Some predict that this is the final straw in the bankruptcy and total demise of the Medicare program and secondarily of the entire Social Security program, which by some projections will occur about 2011.
There is a very simple cost-effective solution that could be implemented. For any Medicare recipient that would be willing to return to the original program and make the deductible and co-payments by giving up the Medigap insurance, an outpatient drug benefit would be added for a 30 percent copayment. This would be cost effective because every patient would obtain his preferred prescriptions based on his own preferences without any hostility to his insurance carrier or Medicare program or prescribing physician. For instance, if a "statin" was prescribed to lower his cholesterol, the patient would make his own decision on whether to purchase the latest proprietary "statin" for approximate 30 percent of $180 ($54 copayment) or the generic version at 30 percent of $60 ($18 copayment). In my personal experience, when given the option, 90 percent of my patients would voluntarily choose the generic version. The 10 percent that choose the proprietary costly version would not distort health care costs. It would be cheaper than the cost of the vast bureaucracy that is currently policing all aspects of medicine. It would save pharmacy time, doctor time and patient time, improving health care efficiency and conserving costs. The patient would be happy with his decision instead of blaming the government or the doctor or the health care system for not providing the best and the latest. Health care would again become a pleasant and brotherly endeavor. We would no longer be working at cross purposes. We would again live in harmony with each other.
You may want to reread Harry Browne treatise above as to why the government is not interested in solutions.
Politicians can't seem to tell the
difference between insurance and medical care, even though
they don't seem to confuse cars with auto insurance or houses with homeowners insurance.
Politicians who can't tell the difference between a payment method and a service
should not be trusted to tinker with the system.
Almost everybody in
What they lack there is X-ray machines, operating rooms, nurses and doctors.
* * * * *
6. Medical Myths - Preventive Care and
Screening Tests are Insurable?
A recurring complaint is that if a screening test, immunization or a specialized exam is helpful in reducing disease, then it should be covered by health insurance. What is overlooked is that this is acquiescence to someone else, the insurance carrier who is interested in providing coverage for a profit, the HMO who is trying to establish a record of performance, or the government that is trying to purchase your vote to be responsible for your future health. None have any real interest in you or your health for its own sake. There are a number of patients who decline prostatic exams, mammograms, pap smears, cholesterol level checks, or a number of other tests for a variety of reasons that the HMO or insurance carrier or government mandates don't accept as valid excuses. Although they penalize doctors for not providing these services against the patient’s will, they are not interested in the patient’s health - only in the record made for public scrutiny and public relations, showing the number of doctors they have reprimanded or hospitals they have fined.
As Dr Madeleine Cosman points out in her book about to be released, no one has a genuine interest in Your Body other than you. I know a mother who let her son's teeth totally deteriorate by age six to the point that relatives had to pay $5000 to have the teeth restored. The mother's excuse? My job didn't provide dental insurance. Therefore, I couldn’t take my son to the dentist. She also forgot to show him how to brush his teeth. We have to assume control of our own body and its health. Preventing disease is not insurable. Insurance is only for the costly things that happen, such as our house being destroyed by an earthquake or hurricane, our car being destroyed in an accident, or our bodies having a catastrophic occurrence such as cancer, heart attacks, strokes or major surgery. The rest is preventive maintenance and routine care. Only we can do it cost effectively. No insurance company is remotely interested in preventing a disease 10 or 30 years away when the patient may no longer be their insured risk. They only pretend interest in preventive care to avoid adverse public opinion. With the resources available to our patients on their own, most will be fully able to assess their risks which they can then discuss with their personal physician for a cost effective solution.
* * * * *
7. Overheard in the Capital Rotunda
When the late State Senator LeRoy Greene retired a number of years ago from the Capital Rotunda, after twenty years in the California Assembly and sixteen years in the State Senate, he commented on the more than one thousand bills that were passed during the current year by the Legislature. He felt that essentially all of them restricted individual human freedom. He even confessed that during his long tenure, he probably sponsored more than a thousand bills himself. He stated, as I recall, that this kind of sponsorship was necessary in order for the public to be aware of his involvement and thus help him to win re-elections. In retrospect, he felt that essentially all of his own bills, with the exception of one or two, essentially restricted individual human freedom. His bill to legalize prostitution failed to pass.
Senator Greene's deprecation of his own value to the improvement of human life did not dissuade the state archivist from placing 32 linear feet of his record for his 36 years of injury to the citizens of the state in the library of the California State University at Sacramento.
During 2004, there were only 844 bills sent to Governor Arnold Schwarzenegger who vetoed 273 of them, cutting the number of new laws nearly in half. To preserve freedom and avoid living with the constant threat of prosecution for not following laws, which even attorneys can't keep up with, we need to go to part-time legislatures who meet every January for three months and return every October for a month to complete the year's work. The legislators would then have to keep their previous jobs and continue to be involved in their local arena and thus be more effective lawmakers and repealers of laws. Salaries could then be discontinued so that legislators, our representatives, would remain loyal to the people, rather than to the government that currently pays their salary. (Just as doctors who obtain their salaries from hospitals or insurance carriers, change their loyalties from their patients and their profession to the hospitals or insurance carriers.)
There aught to be a law against saying
"There aught to be a law!"
- Ronald Reagan
* * * * *
8. Quarterly Review of HealthPlan
Lewis M Andrews, Executive Director of the Yankee Institute for Public Policy in
Andrews notes that since the early 1990s, and even through the collapse of the stock-market bubble, the American economy has continued to experience remarkable increases in worker productivity, both in manufacturing, which now accounts for 14 percent of the nation's output, and in many service sectors as well.
The author notes that the efficiencies that
propelled the American economy for more than a decade have evaded an important
segment of the workforce. He focuses on high-level professionals, including
those employed in education and medicine. As a result, tuition at the average
four-year private college in the
He feels that Professionals are adept at manipulating the political process, inflating the cost of many services with direct and indirect government subsidies. The two most inflated service sectors in the American economy, public-school education and Medicare, are both characterized by a system of third-party payments - which is to say that the cost of educating a child or of treating a sick senior is not borne directly by the consumer, but by a large and faceless pool of taxpayers. The result is that the consumers of these services have no personal incentive to insure that they are provided at the best possible price.
The ability of professional elites to lobby government for special privilege is strengthened by the fact that, to a large extent, these elites have become the government. Not only do lawyers dominate state legislatures and Congress; but politicians have also extended their oversight of education, health care, the environment, transportation, and commerce to such a degree that the rules under which many professionals operate are increasingly written by colleagues inside some government bureau or department. Not surprisingly, these regulations tend to reinforce the notion of professionals as high-priced hourly labor, perhaps burdened with obligations "to society," but with little responsibility or incentive to improve their own productivity.
And when any program which the government itself directly manages begins to falter, the legislative response is typically to employ even more professionals to provide supplemental services on the same inefficient basis - effectively spreading the government's largess among an interlocking web of diverse knowledge workers.
The good news is that advances in information
technology and management science are beginning to make it possible for nearly
every profession to become more efficient. The author contends already there
are signs that some professionals see the need to make their respective
disciplines more responsive to market forces. Although he cites many
innovations in education, in view of our focus on health care, one of the
fastest growing trends among family physicians in private practice is
drastically discounting the cost of their services to patients who pay out of
pocket. Pay-as-you-go medicine is "a phenomenon that certainly isn't in
the mainstream yet," says William Jessee, president of the Medical Group
Management Association in Englewood, Colorado, "but it seems to be
becoming more visible and perhaps more common." To review Andrews
entire article, please go to
This newsletter has been featuring on a monthly basis the "Doctor is In, Insurance is Out" type of family physicians and surgeons since inception nearly three years ago. A number of cost savings have been reported by these physicians and surgeons. The cost of insurance or patient billing is eliminated. Many of these have forgone hospital practices doing primarily office and surgicenter work, which reduces malpractice insurance costs. Additional savings in the cost of malpractice insurance is likely to occur because the personal relationship with the doctor will reduce malpractice, which will be actuarial verified as further experience occurs. Because patients have control of the payment and have freely chosen the doctor, they can refuse to pay if not satisfied. Many doctors in this group have a policy to see them again “free of charge” if they are not satisfied. This is almost unheard of in today's medicine where everything that needs to be redone for any reason is recharged. Most doctors see not doing so as an admission of incompetence, when in most cases it’s because it does not meet the standard the doctor sets for himself or it’s simply to please the patients. These “pay-as-you-go” doctors are essentially experiencing no malpractice cases.
How does patient- or consumer-directed health
care play out in real life? We had a
We also received a Christmas letter last week
from a member who reported that on
In government or HMO medicine, these patients would have little or no choice in choosing a better doctor because they have to choose from a restricted panel with the worst and the best doctors getting the same payment. In private medicine, the patient chooses and quality immediately rises and frequently the costs decrease as noted by the pay-as-you-go doctors above, which allows the professional fees to sometimes drop to half. When patients have choices, the worst or insensitive doctors will soon find their waiting rooms empty. Unless they improve their quality, they will be looking for other jobs. Quality is never an issue in private free-market medicine.
I know of one surgeon from the 1970s who became a used car salesman. If his incompetence could have survived another decade until the HMO insurgency became established in the 1980s, he would have done quite well. On an HMO panel, incompetent surgeons make the same living as competent surgeons.
The ideal HealthPlan for the
Beware of all politicians at all times, but
beware of them most sharply when
they talk of reforming and improving the constitution.
- H. L. Mencken
* * * * *
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Words of Wisdom
Government is the great fiction, through which everybody endeavors to live at the expense of everybody else. - Frederic Bastiat, French political economist, (1801-1850) Essays on Political Economy, 1846.
Words of Prophecy
Premier Kruschev stated that our grandchildren will live under communism. I say to you . . . your grandchildren will live under democracy. - Barry M Goldwater, Presidential candidate, 1964.
URL References for Your Perusal or Study at Leisure.
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and political perspectives, make one hour every Tuesday your MedicalTuesday
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For MedicalTuesday Archives, see http://www.medicaltuesday.net/index.aspx.
Quarterly HealthPlanUSA Newsletter Archives
HealthPlanUSA Intro http://www.healthplanusa.net/NewsLetterIntro.htm
April 2002 Newsletter http://www.healthplanusa.net/April02.htm
October 2002 Newsletter http://www.healthplanusa.net/October02.htm
January 2003 Newsletter: http://www.healthplanusa.net/Dec2002.htm
April 2003 Newsletter: http://www.healthplanusa.net/April2003.htm
July 2003 Newsletter: http://www.healthplanusa.net/July03.html
October 2003 Newsletter: http://www.healthplanusa.net/October2003.htm
January 2004 Newsletter: http://www.healthplanusa.net/Jan04.htm
April 2004 Newsletter: http://www.healthplanusa.net/April2004.htm
July 2004 Newsletter: http://www.healthplanusa.net/July04.htm
October 2004 Newsletter: http://www.healthplanusa.net/October04.htm
SomePostings of Other Articles on Health Care Issues
Medical News Headlines:
Single-Payer Initiatives: http://www.healthcarecom.net/EditorialNov94.html
David Gibson, MD, National Health Care Consultant: http://healthplanusa.net/DavidGibson.htm
Single Payer: http://www.healthplanusa.net/DGSinglePayer.htm
Why are the uninsured, uninsured: http://www.healthplanusa.net/DGUninsured.htm
What’s behind health care costs: http://www.healthplanusa.net/DGRisingHealthCareCosts.htm
Pharmacy costs: http://www.healthplanusa.net/DGPharmacyCosts.htm
This Month in History
Our Theme for This Month in
History - January - Year in History
January is the month that we look back at the year that has been. The newspapers give us hundreds of notables that have passed this life in 2004. In health care, we cannot fail to highlight the passing of Elizabeth Kubler-Ross on
In a culture that is determined to sweep death under
a carpet and hide it there, Kuebler-Ross consistently defied common practice
to bring it out and hold it there for us to see. As she faced her own death
This Year in the Future
Llewellyn H. Rockwell, Jr., President of Ludwig von Mises Institute, requests that we please accept the Mises Institute's "Freedom Calendar" for 2005 as a gift. He states, "We created this after noticing that most on-this-day-style calendars are dominated by events that mark victories for the state (legislation passed, battles won, presidents elected, etc.) versus victories for liberty. So we tried to stick to noting dates that represented hopeful events for liberty (tax revolts, legislation repeals, great intellectuals born, important new inventions, government failures ....) Throughout the year, Mises.org provides commentary, audio files, great books online, important scholarly work, classroom syllabi, study guides, bibliographies, and so much more--enough to make us the number one most trafficked nonprofit economics site in the world. We hope you enjoy the Freedom Calendar. Let us work together toward ever more victories on behalf of liberty." Lew invites us to become members of Mises at http://www.mises.org/ and invites us as partners in the defense of freedom, prosperity, and peace. He wishes us a Merry Christmas and joyful holiday season.
You may download the freedom calendar at http://www.mises.org/calendar/freedom2005l.pdf.
You will note that on this date,