There’s one thing we can agree upon Mr. Silver. I have written several blogs in San Diego, stating clearly that insurance itself is a major contributor to healthcare inflation. 50% of healthcare inflation is new drugs, and new technology. Thus to attack healthcare inflation, you must either restrict care, and/or stop innovation. Good luck with Pharma, etc. Further, you assume that the average US citizen will follow the right course regarding healthy habits, etc. 🤔
We could go on and on with this repartee
but I will close with another thing we can agree upon: and that is the current system is broken, but the blame can’ be spread throughout the system and not solely on the government per se. I come from the school, that the government does only two things well: collect taxes, and make war.
I think this is one of the only places on-line where I actually seek out the comments! Just a question for the Americans. All the discussions of govt involvement seem to be related to the Feds, and for some obvious reasons. How are states involved, if at all? Would it be beneficial to have more or less state involvement?
Doctors and clinics should post cash prices. Health insurance should be for catastrophic events, purchasable by parents when the baby is born, and uncoupled from employment. There should be no regulatory limits on the number of medical school students and number of beds in hospitals. It's amazing to me that we would consider anchoring ourselves to a government-run healthcare system before trying the good ol' free market.
In the retail sector (think IVF, LASIK, and other services for which consumers pay directly), providers post prices voluntarily because they attract patients by doing so. Meanwhile, in the traditional, insurance and government dominated sector, hospitals refuse to post prices even after being ordered to.
I'm a computer scientist, not a healthcare professional, and more-or-less a "libertarian free-marketeer". I think that these days many (if not most) people in the U.S. and elsewhere have been led to believe in socialist-style universal single-payer government run healthcare with no private option. This makes them even more socialist than the UK, with its beloved NHS, since the UK also has a system of private doctors and clinics (e.g. on London's Harley Street) that provide services in exchange for "cash on the barrel head", and sometimes can do so better and/or faster than the NHS even for patients of modest means. How many politicians, legislators and public officials would dare to publicly disagree with the principle "Health care is a human right and a public good, and should be provided to people according to their needs, not according to how much wealth they possess." Under this principle people cannot be allowed to purchase even a portion of their healthcare. In fact, trying to do so would be like trying to bribe a public official.
I think it's important to remember that "He who pays the piper calls the tune". The third party payer, whether a private company or a government agency, is stuck in the position of having to justify payments, and because it doesn't have unlimited resources this inevitably means lots of bureaucracy, red tape, and disappointment for payers, providers, and patients.
Great article! I don't have an answer, but I'd love to read articles here on Sensible Medicine about libertarian solutions for healthcare. For starters, a lot more drugs should be over (or behind) the counter.
Something that frustrates me is that we are getting a few individual meds switched over, like naloxone and birth control, but mainly for political reasons and we’re not getting any wider discussion. We need medical organizations to collaborate and evaluate the entirety then make recommendations.
Top on my list is injectable epinephrine, inhalers, and expansion to all insulins.
As someone with broadly libertarian views, I share your concerns, but am not surprised that few health policy commentators are libertarian. Apart from my time in training and the military, I have spent my career in the private sector. There, many physicians have views that tend to be pro-market and government-skeptical. In my experience, surgeons and other practitioners who do procedures, are more likely hold such views.
Such views are consistent with, even if not synonymous with, libertarian principles. However, private practice physicians generally don't have the academic credentials that provide a public platform for commenting on health policy. And, painting with a broad brush, those in academia seem to be more trusting in government intervention. In part, this may be because most don't have a reason to value competitive forces, and they are usually salaried with at most a very limited performance bonus available.
When I was a candidate for U.S. House in 2016 and 2018, I was able to promote a more market-oriented health policy which received some positive attention at the time. Unfortunately, I lost. Since then, my libertarian views have become, I think, more practical. It's likely impossible to eliminate all government involvement in healthcare, and probably also unwise. The key is striking a balance between market forces and government oversight, and optimizing incentives so that our patients will benefit most.
I'm putting some finishing touches on a revised version of my previous policy recommendations. The working title is Market-Driven Universal Health Care, though that might change. If Professor Silver would be interested in reviewing and making recommendations on my policy ideas once I get them cleaned up, I would be delighted!
RFK Jr is right about Tylenol, psychotropic drugs, vaccines, and statins. FDA and CDC are completely in the pockets of Big Pharma who pays for over 75% of the FDA budget. We have been lied to and mislead by the institutions we naively believed were operating in the best interest of our patients. The FDA has "approved" over 3,000 toxic chemicals that are allowed in our food supply. These chemicals are all self-reported by the Big Food companies as GRAS (Generally regarded as Safe). Yet, no long-term studies have been conducted and neither have these chemicals been tested in combination with other GRAS chemicals. The US government pays Coca-Cola $10 Billion per year to supply their sugar-drinks to kids through the Food Stamp Program.
The FDA cannot be trusted. They protect Big Pharma and Big Food. Our medical system and public health agencies are badly broken. RFK Jr has been able to make more progress against this egregious system than all of us practicing doctors combined over the past 30 years. We need a fresh start in the best interest of our patients. Yes! It is time we completely overhaul the FDA and CDC and stop trusting government.
The CDC and FDA are part of the massive medical / pharmaceutical complex designed to keep us sick.
I think the more fundamental problem is that we've accepted the concept that medical care, unlike pretty much everything else essential that we buy like food and shelter, should be paid for through third parties, as if we're incapable of making prudent evaluations of what we want and need in this area.
Since Lyndon Johnson we've been doing this for everyone over 65 through the government, which has been an exceedingly destructive policy, but for younger workers we also do it through "insurance" which we expect our employers to provide, as if it's something we get for free instead of in place of payment for our labors. Of course, that situation is partially also caused by federal government tax policy that treats medical "insurance" as nontaxable. So, in this case employees demand the most they can get, thereby assuring that in a great many cases a significant part of their salaries go to insurance companies.
Between the two, public vs private, patients and doctors generally prefer the former more blatantly government-controlled scheme which is somewhat less troublesome seeing that the government does not have to make a profit to stay in existence but can push off its losses to the general tax fund and the national debt. In time however even that device will have to be faced up to.
Of course, paying for medical care, like food and shelter, may become problematic for those with misfortune or other need out of the ordinary and both charity and government should step in. But most of us would be much better off by not giving our money to the third parties and paying directly for ordinary lower cost medical expenses. Insurance should be for high-cost unexpected expenses as in every other area and saving for the inevitable infirmities of older age should be as routine as it is for retirement.
Subjecting medical care to the market would make it far less costly and more appropriate to our needs.
I agree with most of your comment, Anthony, but for a long time the government has been getting increasingly involved in regulating and subsidizing other "essential" goods and services besides medical care, including food, shelter, and education. There is a widespread belief on the part of the media, politicians, legislators, and public officials that a large percentage of "ordinary people" are, as you put it, "incapable of making prudent evaluations of what we want and need in this area." Also, I think that even main-stream liberals tend to be more socialist in their opinions than they are willing to admit, even to themselves, and as a consequence believe that the money that people possess to pay for goods and services has been so unfairly distributed that no one should be allowed to buy anything important with it, at least not until after a massive redistribution of wealth from rich to poor takes place.
I think medical care differs from the rest in that federal government involvement via Medicare for those over 65 and tax policy for employee medical insurance is not means tested but is directed to the entire public, including the majority of us who are capable of paying our own way. Subjecting the majority of us to a third-party payment scheme has resulted in severe increases and distortions in cost, deterioration in the quality of medical care delivery, and is especially problematic for the 15% or so left out of the system, which has given credence to the universal government control pushed by the leftists. But it's not just liberals who believe in this idea! It's frustrating to talk to people who are not ordinarily left leaning who believe that Medicare and all-inclusive employer sponsored medical insurance are useful and beneficial ideas instead of the financially ruinous and market distorting programs which they truly are. The public has been immersed in them for so long that they accept them as natural, like the proverbial frogs in the heating up water pot. I'll be putting something up soon on the impact of Medicare on physician practice. I started in medicine before Medicare and watched the whole sorry mess develop.
Perhaps the best way to answer the question is to turn it around and ask why more libertarians are not commentators on medical care policies. The short answer is that the only acceptable policy is for the government to stay out of the medical care field. I try to avoid using the term "health care". I don't know whether the term is an oxymoron, a non sequitur or something in between. Health doesn't need care---illness does. Health is our natural condition and no one knows how to provide or maintain it despite the assertions of those that think they can. Libertarians understand that applying collectivist thinking to individual problems is a bad idea. And medical care is certainly one of the most highly individualistic disciplines of all.
Just saw your comment about the "healthcare" term. That's been bugging me for years. We all have a right to do what we can to stay healthy. We don't have a "right" to the medical goods and services provided by others.
You are right. I am a Libertarian and I know beyond doubt that we (private enterprise) can do a much better job of promoting health and avoiding diseases than all the CDC, FDA, NIH, WHO, and insurance companies combined.
This screed ignores the fact that medicine is no longer that libertarian myth of the doctor putting out his shingle and getting paid by his patients. It went corporate decades ago, as catalogued in the book, The Social Transforamtion of American Medicine. Currently the choice is between government medicine and medicine run by corporations and hedge funds out to maximize their profits. There is a reason that everybody I know is happy to reach 65 when they can get medicare. Your essay ignores the fact of successful goevernment run prograns in the rest of the world. The problem with Obama care is that it workd tjhrough the private sector, corporations. Fofr one recent counter example, look at the reduction in cost when Ohio no ponger use private pharmacy intermediaries.
Your analysis is flawed. The corporations you refer to all operate in the traditional sector, where THE GOVERNMENT creates terrible incentives that lead to terrible business practices and results. For markets to work, CONSUMERS must control the money, as I have explained many, many times. You should study the retail health sector, as I have. Think LASIK, IVF, and other services people pay for directly, typically because the services are not covered by insurance. I think you'll be amazed at how well the retail sector works.
What you call the traditional sector is what most people mean when they refer to medical care, the sector where decisions and care take place with life and death consequences. Sure, if everyone were a multi-millionaire or billionaire then they could control where the money goes, but most people don’t have a few hundred thousand dollars around to take care of their angiogram, or cancer care, or ICU stay. That’s why insurance exists, to socialize the costs of individual misadventure. That’s why even with insurance covering most of the cost, medical costs are by far the number one cause of bankrupcy. The things you talk about _- Lasik, plastic surgery, IVF – are nice to have but not essential for health which is why they are often not covered by insurance and available to those with money. Even then they are imperfect markets, because knowledge of quality of care etc is assymetric. But these areas too are targeted by private equity with resultant consolidation and inevitable tendency to monopoly (not your Adam Smith perfect competition).
You make many points with which I disagree, but I'll start by noting that insurance is good at handling low probablility events that entail high costs when they occur. As I explained in Overcharged, I would encourage people to buy catastrophic care coverage. (I would not give them tax breaks for buying insurance, though. Nor would I force them to purchase coverage they do not want.)
But insurance is a terrible way of paying for everything else. It just adds costs and creates agency problems that do not exist when people pay directly. You've obviously not read the chapters in Overcharged titled "Health Care is Expensive Because It's Insured" (ch. 15) and "Catastropic Coverage is Good Coverage" (ch. 21). I'm not going to repeat the analyses here.
People don't have to be millionaires or billionaires to afford most medical treatments. That would include many surgeries in a direct-pay world. See the Surgery Center of Oklahoma for examples. (If you'd read Overcharged, you'd have known about it, too.)
I could say a lot more, but I've written about all these issues elsewhere. Anyone who wants to know what I think can find my stuff on the internet and go from there.
Nice rant about the federal government inflicting harm on medicine, but you’re dead wrong about RFK Jr and the new ACIP. Sorry that TDS has blinded you into parroting the parasitic credentialed class talking points. Science is belief in the ignorance of so-called consensus experts—do your homework which should start with Aaron Siri deposing Plotkin.
Bon Kwi Kwi, You hit the nail on the head. Thank God for RFD Jr. At last someone has the guts to push back against an egregious, corrupted system controlled by Big Pharma and Big Food. Time for us doctors to wake up.
The US health system is generally known for its exorbitant overall cost in exchange for relatively mediocre overall health outcomes. So arguing for doing less of the same does appear to be the sane position to take. But the author seems to lump the disparate eggs of health policy (HHS, CDC), regulation (FDA), funding (CMS, Medicare), research (NIH), and insurance (ADA), all in with direct care provision into a single “centralized government control” basket.
Full disclosure: I work in the single-payer Canadian system, and that’s certainly not rainbows and butterflies all day every day either.
I think most can agree that, just as government doesn’t belong in our bedroom, it doesn’t belong in the exam room wedged btw doctor and patient in their relationship either.
But one of the prior US issues, as I understand it from afar, was the number of uninsured people. And to say that people “can get what they want at prices they can afford” seems to ignore that some people previously could not afford to get what they needed. And if the solution for that is “social security” and “child tax credit”….that is not only still very much a central government line item (and a fairly large one at that), but also ignores childless non-elderly people in need.
It is lamentable that various parts of the health system have become politicized, much like seemingly every other aspect of society. The author’s example of the ballooning of the OBBBA illustrates that. The current shutdown- straw that is breaking the bulging health system-camel’s back is very much a product of politics. It would be preferable if politicians did less politicking and more governing for the greater good. It would be preferable if health policy, regulation, and research decisions, were purely evidence based and overseen by Dr. JMM’s posse of neutral martians. But such a system doesn’t exist. Nor will it ever.
In the end, I tend to agree with the author that “more government” is not the answer. And since “better politicians” aren’t coming, “better government” likely isn’t on offer either.
Politicians will never stop politicking. That is what they do. If we want a health care system that isn't subject to the whims of politicians, the only option is to privatize.
Finally, markets are great at finding ways to make goods and services cheaper. As I explain in Overcharged, in the retail health sector real prices fall. Can't say that about the prices in the traditional (goverment dominated) sector.
My understanding was that SS is for the elderly. Which is why my question was about how to address non-elderly people who might be in need of health care but were unable to afford it.
Isn’t most of the US health system already “privatized”? Or “market driven”? I understand that to mean “for-profit”, which I equate to the US health system status quo.
But you’ve also lumped “policy” and “regulation” aspects in with funding and insurance. And I’m not sure how “privatization” helps in the realms of health policy and regulation.
In theory, markets and competition lower prices. But as practiced in the US in the realm of health care, it’s expensive with mediocre results.
Thanks for the follow-up. I guess I misread your first post, and if so, I'm sorry. I thought you were asking about the elderly poor.
We can help any population group we desire by means of a negative income tax. That is what I and many others have proposed. Get rid of Medicare, Medicaid, and other programs that pay providers and give the money to needy consumers in the form of tax credits. Consumers would then be in charge and market forces would work. Consumers could then purchase insurance for catastrophic needs and pay for most services directly.
Lastly, it is a myth that the US system is privatized and market based. The US government controls or influences a larger fraction of the dollars spent on health care than most developed countries. Michael Cannon provides the support in Recovery. See Fig. 4.1 and the related discussion. Here's a link to a free download:
In general, patients do better saving their money and staying away from the US health System (except for serous emergencies). The USA pays the most and is the sickest on the planet. It is all intentional to keep us sick.
I appreciated Mr. Silver’s arguments. The problem in this country is the duality of healthcare services: government (Medicare/Medicaid) versus the private health plans.
I spent decades along with six very sharp nurses challenging insurance companies, both in the government as well as private health plans regarding denial of payments for hospital services provided in good faith and medically indicated.
The private health plans take approximately 20% of the healthcare dollar premium for overhead/administrative cost. They list the $0.80 dollars they spend on medical care as the “medical loss ratio“🤔 😁-interesting.
My best quick story is a denial for a very functional elderly female who was admitted in septic shock (90% mortality) and died after four days in the ICU. The response from one of the largest private health insurers: denied, could have been treated in a skilled nursing facility!
The health plans teach their medical directors, one thing; how to say “no.” Needless to say I was so pissed after submitting my challenge,I demanded to speak to the National medical director who obviously agreed to pay for the hospitalization as billed-I asked him why would they deny payment for such an obvious case resulting in death? As he was retiring in a few weeks, he said because of the float and the unbelievable millions the health plan makes by delaying payment six months to a year.😢
Yes, Mr. Silver the government is grossly inefficient, but the private sector is run by acute, subacute, and chronic avarice. they must kiss the ring of the investor. Both the public and private sector has multiple warts.
Libertarians believe in small government and let the humanity of humans along with common sense, be the law of the land. The problem is individuals, as well as groups of citizens/private companies are not as benevolent or altruistic and as you might think.
Two incompetent entities, government and private, are responsible for the broken healthcare system we have.
Thanks for the comment. In a libertarian health care system, people would rely on insurance only to cover catastrophes, because that's the only thing insurance is good at doing. They'd pay for routine stuff out of pocket, as they do for nearly all other goods and services.
I urge you to ignore your experience with the "actue, subacture, and chronic avarice" business people who operate in the traditional sector. They perform badly because the GOVERNMENT creates terrible incentives. Look at businesses operating in the retail sector, where the government's influence is lowest. I think you'll be surprised to learn how well it works. There's a chapter in Overcharged you can read to start with.
Thank you for your rebuttal. One cannot equate retail to healthcare. Your comment at Harkins back to the days of high deductibles and HSA accounts. The problem is the majority of people cannot afford “out-of-pocket expenses for Minor injuries/illnesses. I believe the latest data suggest that 60% of people live from paycheck to paycheck -the laws of supply demand, although almost always govern economics. do not hold up to muster in healthcare.. The demand for healthcare varies greatly from person to person and one can never assess what if scenarios as you do in a typical business, both the government role in healthcare as well as the health plans hold equal responsibility.
Can businesses plan for the equivalent of the next pandemic that will adversely affect healthcare services no matter who’s running the show.
I have confronted hundreds if not thousands of health plan denials with a 90% recovery rate. Trust me, the concern for the well-being of their “enrollee“ is far from their number one priority.
Thanks for your follow-up. Overcharged contains a chapter entitled "Health care is expensive because it's insured." There are tons of examples. In a competitive system in which insurance played its proper role as a means of protecting people from catastrophic costs, most goods and services would be much cheaper.
And why isn't retail health care? We're talking about IVF, Lasik, vasectomies, cosmetic surgeries, surgeries performed at the Surgery Center of Oklahoma (which operates mostly on the basis of cash), and other services. Your assertion that "one cannot equate retail to healthcare" seems like a defensive retort rather than a well considered one.
Lastly, I agree that demand for medical treatments varies greatly and that many people live from paycheck to paycheck. The former fact supports my belief that people should be able to plan for their own needs and preferences instead of being stuck with a one-size-fits-none solution that is government-imposed. The latter problem exists partly because regulations (including but not only health care regulations) impede economic prosperity and drive down wages. A world in which the average family pays $24K/year for health insurance is a world in which people are going to struggle financially. The best thing we can do is let market forces pressure all parties on the supply side to charge less and operate more efficiently.
Yes, the private sector is a problem (both insurance and pharma), but the government enables it. So many people want the government to fix it by taking it over, rather than realize the governmemt is part of the problem.
I very much support removing the government from health care. I had the privilege of taking nursing students to London on 2 occasions. We visited NHS hospitals, a private hospital, and other nursing-related organizations. Not a single nurse came out in support of the NHS-they either avoided answering or openly discussed the failings.
A long time ago, when I was a young adult, healthcare insurance was pretty much limited to the unforeseen catastrophe. I paid out of pocket for doctor's office visits, immunizations for my daughter and all medications BUT THEY WERE AFFORDABLE. I had to be judicious with my decisions, and had to adjust my priorities to accommodate, but you have to make good choices because you can only spend your money once, so if it was time for an MMR, I skipped going out to lunch, or put off the new pair of shoes. People don't seem to understand this principle anymore. As soon as insurance started paying for things, the prices went way up. People went to the doctor's office for splinters or a fever blisters, or for sniffles. Doctors needed to hire office help to process the complicated forms for insurance reimbursement and to review all of the government regulations. Suppliers realized they could charge whatever they wanted for medicine and supplies, because people wouldn't have to open up their wallets and so they thought everything was free. A good comparison, is how college tuition sky-rocketed when government loans became easy to get. I want to go back to 1975.
There’s one thing we can agree upon Mr. Silver. I have written several blogs in San Diego, stating clearly that insurance itself is a major contributor to healthcare inflation. 50% of healthcare inflation is new drugs, and new technology. Thus to attack healthcare inflation, you must either restrict care, and/or stop innovation. Good luck with Pharma, etc. Further, you assume that the average US citizen will follow the right course regarding healthy habits, etc. 🤔
We could go on and on with this repartee
but I will close with another thing we can agree upon: and that is the current system is broken, but the blame can’ be spread throughout the system and not solely on the government per se. I come from the school, that the government does only two things well: collect taxes, and make war.
Ben Hourani MDMBA.
I think this is one of the only places on-line where I actually seek out the comments! Just a question for the Americans. All the discussions of govt involvement seem to be related to the Feds, and for some obvious reasons. How are states involved, if at all? Would it be beneficial to have more or less state involvement?
Doctors and clinics should post cash prices. Health insurance should be for catastrophic events, purchasable by parents when the baby is born, and uncoupled from employment. There should be no regulatory limits on the number of medical school students and number of beds in hospitals. It's amazing to me that we would consider anchoring ourselves to a government-run healthcare system before trying the good ol' free market.
In the retail sector (think IVF, LASIK, and other services for which consumers pay directly), providers post prices voluntarily because they attract patients by doing so. Meanwhile, in the traditional, insurance and government dominated sector, hospitals refuse to post prices even after being ordered to.
I'm a computer scientist, not a healthcare professional, and more-or-less a "libertarian free-marketeer". I think that these days many (if not most) people in the U.S. and elsewhere have been led to believe in socialist-style universal single-payer government run healthcare with no private option. This makes them even more socialist than the UK, with its beloved NHS, since the UK also has a system of private doctors and clinics (e.g. on London's Harley Street) that provide services in exchange for "cash on the barrel head", and sometimes can do so better and/or faster than the NHS even for patients of modest means. How many politicians, legislators and public officials would dare to publicly disagree with the principle "Health care is a human right and a public good, and should be provided to people according to their needs, not according to how much wealth they possess." Under this principle people cannot be allowed to purchase even a portion of their healthcare. In fact, trying to do so would be like trying to bribe a public official.
I think it's important to remember that "He who pays the piper calls the tune". The third party payer, whether a private company or a government agency, is stuck in the position of having to justify payments, and because it doesn't have unlimited resources this inevitably means lots of bureaucracy, red tape, and disappointment for payers, providers, and patients.
Great article! I don't have an answer, but I'd love to read articles here on Sensible Medicine about libertarian solutions for healthcare. For starters, a lot more drugs should be over (or behind) the counter.
I published a column saying the same thing. https://www.cato.org/commentary/its-time-over-counter-ozempic
Thanks for sharing!
Something that frustrates me is that we are getting a few individual meds switched over, like naloxone and birth control, but mainly for political reasons and we’re not getting any wider discussion. We need medical organizations to collaborate and evaluate the entirety then make recommendations.
Top on my list is injectable epinephrine, inhalers, and expansion to all insulins.
As someone with broadly libertarian views, I share your concerns, but am not surprised that few health policy commentators are libertarian. Apart from my time in training and the military, I have spent my career in the private sector. There, many physicians have views that tend to be pro-market and government-skeptical. In my experience, surgeons and other practitioners who do procedures, are more likely hold such views.
Such views are consistent with, even if not synonymous with, libertarian principles. However, private practice physicians generally don't have the academic credentials that provide a public platform for commenting on health policy. And, painting with a broad brush, those in academia seem to be more trusting in government intervention. In part, this may be because most don't have a reason to value competitive forces, and they are usually salaried with at most a very limited performance bonus available.
When I was a candidate for U.S. House in 2016 and 2018, I was able to promote a more market-oriented health policy which received some positive attention at the time. Unfortunately, I lost. Since then, my libertarian views have become, I think, more practical. It's likely impossible to eliminate all government involvement in healthcare, and probably also unwise. The key is striking a balance between market forces and government oversight, and optimizing incentives so that our patients will benefit most.
I'm putting some finishing touches on a revised version of my previous policy recommendations. The working title is Market-Driven Universal Health Care, though that might change. If Professor Silver would be interested in reviewing and making recommendations on my policy ideas once I get them cleaned up, I would be delighted!
RFK Jr is right about Tylenol, psychotropic drugs, vaccines, and statins. FDA and CDC are completely in the pockets of Big Pharma who pays for over 75% of the FDA budget. We have been lied to and mislead by the institutions we naively believed were operating in the best interest of our patients. The FDA has "approved" over 3,000 toxic chemicals that are allowed in our food supply. These chemicals are all self-reported by the Big Food companies as GRAS (Generally regarded as Safe). Yet, no long-term studies have been conducted and neither have these chemicals been tested in combination with other GRAS chemicals. The US government pays Coca-Cola $10 Billion per year to supply their sugar-drinks to kids through the Food Stamp Program.
The FDA cannot be trusted. They protect Big Pharma and Big Food. Our medical system and public health agencies are badly broken. RFK Jr has been able to make more progress against this egregious system than all of us practicing doctors combined over the past 30 years. We need a fresh start in the best interest of our patients. Yes! It is time we completely overhaul the FDA and CDC and stop trusting government.
The CDC and FDA are part of the massive medical / pharmaceutical complex designed to keep us sick.
I would prefer private regulation of drugs and devices to public regulation, which is subject to capture and ruled by bad incentives. See my prior column in SM: https://www.sensible-med.com/p/using-contracts-to-encourage-post
I think the more fundamental problem is that we've accepted the concept that medical care, unlike pretty much everything else essential that we buy like food and shelter, should be paid for through third parties, as if we're incapable of making prudent evaluations of what we want and need in this area.
Since Lyndon Johnson we've been doing this for everyone over 65 through the government, which has been an exceedingly destructive policy, but for younger workers we also do it through "insurance" which we expect our employers to provide, as if it's something we get for free instead of in place of payment for our labors. Of course, that situation is partially also caused by federal government tax policy that treats medical "insurance" as nontaxable. So, in this case employees demand the most they can get, thereby assuring that in a great many cases a significant part of their salaries go to insurance companies.
Between the two, public vs private, patients and doctors generally prefer the former more blatantly government-controlled scheme which is somewhat less troublesome seeing that the government does not have to make a profit to stay in existence but can push off its losses to the general tax fund and the national debt. In time however even that device will have to be faced up to.
Of course, paying for medical care, like food and shelter, may become problematic for those with misfortune or other need out of the ordinary and both charity and government should step in. But most of us would be much better off by not giving our money to the third parties and paying directly for ordinary lower cost medical expenses. Insurance should be for high-cost unexpected expenses as in every other area and saving for the inevitable infirmities of older age should be as routine as it is for retirement.
Subjecting medical care to the market would make it far less costly and more appropriate to our needs.
I agree with most of your comment, Anthony, but for a long time the government has been getting increasingly involved in regulating and subsidizing other "essential" goods and services besides medical care, including food, shelter, and education. There is a widespread belief on the part of the media, politicians, legislators, and public officials that a large percentage of "ordinary people" are, as you put it, "incapable of making prudent evaluations of what we want and need in this area." Also, I think that even main-stream liberals tend to be more socialist in their opinions than they are willing to admit, even to themselves, and as a consequence believe that the money that people possess to pay for goods and services has been so unfairly distributed that no one should be allowed to buy anything important with it, at least not until after a massive redistribution of wealth from rich to poor takes place.
I think medical care differs from the rest in that federal government involvement via Medicare for those over 65 and tax policy for employee medical insurance is not means tested but is directed to the entire public, including the majority of us who are capable of paying our own way. Subjecting the majority of us to a third-party payment scheme has resulted in severe increases and distortions in cost, deterioration in the quality of medical care delivery, and is especially problematic for the 15% or so left out of the system, which has given credence to the universal government control pushed by the leftists. But it's not just liberals who believe in this idea! It's frustrating to talk to people who are not ordinarily left leaning who believe that Medicare and all-inclusive employer sponsored medical insurance are useful and beneficial ideas instead of the financially ruinous and market distorting programs which they truly are. The public has been immersed in them for so long that they accept them as natural, like the proverbial frogs in the heating up water pot. I'll be putting something up soon on the impact of Medicare on physician practice. I started in medicine before Medicare and watched the whole sorry mess develop.
Bravo!
Perhaps the best way to answer the question is to turn it around and ask why more libertarians are not commentators on medical care policies. The short answer is that the only acceptable policy is for the government to stay out of the medical care field. I try to avoid using the term "health care". I don't know whether the term is an oxymoron, a non sequitur or something in between. Health doesn't need care---illness does. Health is our natural condition and no one knows how to provide or maintain it despite the assertions of those that think they can. Libertarians understand that applying collectivist thinking to individual problems is a bad idea. And medical care is certainly one of the most highly individualistic disciplines of all.
Just saw your comment about the "healthcare" term. That's been bugging me for years. We all have a right to do what we can to stay healthy. We don't have a "right" to the medical goods and services provided by others.
That is a great way to phrase it!
You are right. I am a Libertarian and I know beyond doubt that we (private enterprise) can do a much better job of promoting health and avoiding diseases than all the CDC, FDA, NIH, WHO, and insurance companies combined.
Thank you. It is a real pleasure to hear from a fellow libertarian. Our views are misunderstood by most people.
This screed ignores the fact that medicine is no longer that libertarian myth of the doctor putting out his shingle and getting paid by his patients. It went corporate decades ago, as catalogued in the book, The Social Transforamtion of American Medicine. Currently the choice is between government medicine and medicine run by corporations and hedge funds out to maximize their profits. There is a reason that everybody I know is happy to reach 65 when they can get medicare. Your essay ignores the fact of successful goevernment run prograns in the rest of the world. The problem with Obama care is that it workd tjhrough the private sector, corporations. Fofr one recent counter example, look at the reduction in cost when Ohio no ponger use private pharmacy intermediaries.
Your analysis is flawed. The corporations you refer to all operate in the traditional sector, where THE GOVERNMENT creates terrible incentives that lead to terrible business practices and results. For markets to work, CONSUMERS must control the money, as I have explained many, many times. You should study the retail health sector, as I have. Think LASIK, IVF, and other services people pay for directly, typically because the services are not covered by insurance. I think you'll be amazed at how well the retail sector works.
What you call the traditional sector is what most people mean when they refer to medical care, the sector where decisions and care take place with life and death consequences. Sure, if everyone were a multi-millionaire or billionaire then they could control where the money goes, but most people don’t have a few hundred thousand dollars around to take care of their angiogram, or cancer care, or ICU stay. That’s why insurance exists, to socialize the costs of individual misadventure. That’s why even with insurance covering most of the cost, medical costs are by far the number one cause of bankrupcy. The things you talk about _- Lasik, plastic surgery, IVF – are nice to have but not essential for health which is why they are often not covered by insurance and available to those with money. Even then they are imperfect markets, because knowledge of quality of care etc is assymetric. But these areas too are targeted by private equity with resultant consolidation and inevitable tendency to monopoly (not your Adam Smith perfect competition).
They are already undergoing consolidation in IVF
https://www.westcove.com/private-equity-in-fertility-services-industry-2/#:~:text=In%20recent%20years%2C%20the%20fertility,backed%20platforms%20within%20the%20space.
LASIK surgery
https://kffhealthnews.org/news/article/private-equity-ophthalmology-eye-care-high-profit-procedures/
And pastic surgery
https://academic.oup.com/asj/article-abstract/45/7/715/8066290#google_vignette .
You make many points with which I disagree, but I'll start by noting that insurance is good at handling low probablility events that entail high costs when they occur. As I explained in Overcharged, I would encourage people to buy catastrophic care coverage. (I would not give them tax breaks for buying insurance, though. Nor would I force them to purchase coverage they do not want.)
But insurance is a terrible way of paying for everything else. It just adds costs and creates agency problems that do not exist when people pay directly. You've obviously not read the chapters in Overcharged titled "Health Care is Expensive Because It's Insured" (ch. 15) and "Catastropic Coverage is Good Coverage" (ch. 21). I'm not going to repeat the analyses here.
People don't have to be millionaires or billionaires to afford most medical treatments. That would include many surgeries in a direct-pay world. See the Surgery Center of Oklahoma for examples. (If you'd read Overcharged, you'd have known about it, too.)
I could say a lot more, but I've written about all these issues elsewhere. Anyone who wants to know what I think can find my stuff on the internet and go from there.
Nice rant about the federal government inflicting harm on medicine, but you’re dead wrong about RFK Jr and the new ACIP. Sorry that TDS has blinded you into parroting the parasitic credentialed class talking points. Science is belief in the ignorance of so-called consensus experts—do your homework which should start with Aaron Siri deposing Plotkin.
Bon Kwi Kwi, You hit the nail on the head. Thank God for RFD Jr. At last someone has the guts to push back against an egregious, corrupted system controlled by Big Pharma and Big Food. Time for us doctors to wake up.
The US health system is generally known for its exorbitant overall cost in exchange for relatively mediocre overall health outcomes. So arguing for doing less of the same does appear to be the sane position to take. But the author seems to lump the disparate eggs of health policy (HHS, CDC), regulation (FDA), funding (CMS, Medicare), research (NIH), and insurance (ADA), all in with direct care provision into a single “centralized government control” basket.
Full disclosure: I work in the single-payer Canadian system, and that’s certainly not rainbows and butterflies all day every day either.
I think most can agree that, just as government doesn’t belong in our bedroom, it doesn’t belong in the exam room wedged btw doctor and patient in their relationship either.
But one of the prior US issues, as I understand it from afar, was the number of uninsured people. And to say that people “can get what they want at prices they can afford” seems to ignore that some people previously could not afford to get what they needed. And if the solution for that is “social security” and “child tax credit”….that is not only still very much a central government line item (and a fairly large one at that), but also ignores childless non-elderly people in need.
It is lamentable that various parts of the health system have become politicized, much like seemingly every other aspect of society. The author’s example of the ballooning of the OBBBA illustrates that. The current shutdown- straw that is breaking the bulging health system-camel’s back is very much a product of politics. It would be preferable if politicians did less politicking and more governing for the greater good. It would be preferable if health policy, regulation, and research decisions, were purely evidence based and overseen by Dr. JMM’s posse of neutral martians. But such a system doesn’t exist. Nor will it ever.
In the end, I tend to agree with the author that “more government” is not the answer. And since “better politicians” aren’t coming, “better government” likely isn’t on offer either.
I think you are confused about Social Security. Its main beneficiaries are elderly people, including those who are needy. I've written elsewhere that SS is the most effective system we have for raising people out of poverty. https://www.law.georgetown.edu/public-policy-journal/wp-content/uploads/sites/23/2020/04/18-1-Silver-Hyman.pdf
Politicians will never stop politicking. That is what they do. If we want a health care system that isn't subject to the whims of politicians, the only option is to privatize.
Finally, markets are great at finding ways to make goods and services cheaper. As I explain in Overcharged, in the retail health sector real prices fall. Can't say that about the prices in the traditional (goverment dominated) sector.
My understanding was that SS is for the elderly. Which is why my question was about how to address non-elderly people who might be in need of health care but were unable to afford it.
Isn’t most of the US health system already “privatized”? Or “market driven”? I understand that to mean “for-profit”, which I equate to the US health system status quo.
But you’ve also lumped “policy” and “regulation” aspects in with funding and insurance. And I’m not sure how “privatization” helps in the realms of health policy and regulation.
In theory, markets and competition lower prices. But as practiced in the US in the realm of health care, it’s expensive with mediocre results.
Thanks for the follow-up. I guess I misread your first post, and if so, I'm sorry. I thought you were asking about the elderly poor.
We can help any population group we desire by means of a negative income tax. That is what I and many others have proposed. Get rid of Medicare, Medicaid, and other programs that pay providers and give the money to needy consumers in the form of tax credits. Consumers would then be in charge and market forces would work. Consumers could then purchase insurance for catastrophic needs and pay for most services directly.
You can find my proposal and the supporting analysis here: https://www.law.georgetown.edu/public-policy-journal/in-print-2/volume-18-number-1-winter-2020/there-is-a-better-way-make-medicaid-and-medicare-more-like-social-security/
Lastly, it is a myth that the US system is privatized and market based. The US government controls or influences a larger fraction of the dollars spent on health care than most developed countries. Michael Cannon provides the support in Recovery. See Fig. 4.1 and the related discussion. Here's a link to a free download:
https://www.cato.org/sites/cato.org/files/ebookfiles/michael-f-cannon-recovery.pdf
In general, patients do better saving their money and staying away from the US health System (except for serous emergencies). The USA pays the most and is the sickest on the planet. It is all intentional to keep us sick.
Healthcare should not be a for profit venture. Is the DOD for profit?
Of course the DOD is for corporate profit. They even require repairs to be done exclusively by their companies, not by in the field soldiers.
I appreciated Mr. Silver’s arguments. The problem in this country is the duality of healthcare services: government (Medicare/Medicaid) versus the private health plans.
I spent decades along with six very sharp nurses challenging insurance companies, both in the government as well as private health plans regarding denial of payments for hospital services provided in good faith and medically indicated.
The private health plans take approximately 20% of the healthcare dollar premium for overhead/administrative cost. They list the $0.80 dollars they spend on medical care as the “medical loss ratio“🤔 😁-interesting.
My best quick story is a denial for a very functional elderly female who was admitted in septic shock (90% mortality) and died after four days in the ICU. The response from one of the largest private health insurers: denied, could have been treated in a skilled nursing facility!
The health plans teach their medical directors, one thing; how to say “no.” Needless to say I was so pissed after submitting my challenge,I demanded to speak to the National medical director who obviously agreed to pay for the hospitalization as billed-I asked him why would they deny payment for such an obvious case resulting in death? As he was retiring in a few weeks, he said because of the float and the unbelievable millions the health plan makes by delaying payment six months to a year.😢
Yes, Mr. Silver the government is grossly inefficient, but the private sector is run by acute, subacute, and chronic avarice. they must kiss the ring of the investor. Both the public and private sector has multiple warts.
Libertarians believe in small government and let the humanity of humans along with common sense, be the law of the land. The problem is individuals, as well as groups of citizens/private companies are not as benevolent or altruistic and as you might think.
Two incompetent entities, government and private, are responsible for the broken healthcare system we have.
Ben Hourani MD, MBA.
Thanks for the comment. In a libertarian health care system, people would rely on insurance only to cover catastrophes, because that's the only thing insurance is good at doing. They'd pay for routine stuff out of pocket, as they do for nearly all other goods and services.
I urge you to ignore your experience with the "actue, subacture, and chronic avarice" business people who operate in the traditional sector. They perform badly because the GOVERNMENT creates terrible incentives. Look at businesses operating in the retail sector, where the government's influence is lowest. I think you'll be surprised to learn how well it works. There's a chapter in Overcharged you can read to start with.
Thank you for your rebuttal. One cannot equate retail to healthcare. Your comment at Harkins back to the days of high deductibles and HSA accounts. The problem is the majority of people cannot afford “out-of-pocket expenses for Minor injuries/illnesses. I believe the latest data suggest that 60% of people live from paycheck to paycheck -the laws of supply demand, although almost always govern economics. do not hold up to muster in healthcare.. The demand for healthcare varies greatly from person to person and one can never assess what if scenarios as you do in a typical business, both the government role in healthcare as well as the health plans hold equal responsibility.
Can businesses plan for the equivalent of the next pandemic that will adversely affect healthcare services no matter who’s running the show.
I have confronted hundreds if not thousands of health plan denials with a 90% recovery rate. Trust me, the concern for the well-being of their “enrollee“ is far from their number one priority.
Ben Hourani, MDMBA.
Thanks for your follow-up. Overcharged contains a chapter entitled "Health care is expensive because it's insured." There are tons of examples. In a competitive system in which insurance played its proper role as a means of protecting people from catastrophic costs, most goods and services would be much cheaper.
And why isn't retail health care? We're talking about IVF, Lasik, vasectomies, cosmetic surgeries, surgeries performed at the Surgery Center of Oklahoma (which operates mostly on the basis of cash), and other services. Your assertion that "one cannot equate retail to healthcare" seems like a defensive retort rather than a well considered one.
Lastly, I agree that demand for medical treatments varies greatly and that many people live from paycheck to paycheck. The former fact supports my belief that people should be able to plan for their own needs and preferences instead of being stuck with a one-size-fits-none solution that is government-imposed. The latter problem exists partly because regulations (including but not only health care regulations) impede economic prosperity and drive down wages. A world in which the average family pays $24K/year for health insurance is a world in which people are going to struggle financially. The best thing we can do is let market forces pressure all parties on the supply side to charge less and operate more efficiently.
Yes, the private sector is a problem (both insurance and pharma), but the government enables it. So many people want the government to fix it by taking it over, rather than realize the governmemt is part of the problem.
I very much support removing the government from health care. I had the privilege of taking nursing students to London on 2 occasions. We visited NHS hospitals, a private hospital, and other nursing-related organizations. Not a single nurse came out in support of the NHS-they either avoided answering or openly discussed the failings.
A long time ago, when I was a young adult, healthcare insurance was pretty much limited to the unforeseen catastrophe. I paid out of pocket for doctor's office visits, immunizations for my daughter and all medications BUT THEY WERE AFFORDABLE. I had to be judicious with my decisions, and had to adjust my priorities to accommodate, but you have to make good choices because you can only spend your money once, so if it was time for an MMR, I skipped going out to lunch, or put off the new pair of shoes. People don't seem to understand this principle anymore. As soon as insurance started paying for things, the prices went way up. People went to the doctor's office for splinters or a fever blisters, or for sniffles. Doctors needed to hire office help to process the complicated forms for insurance reimbursement and to review all of the government regulations. Suppliers realized they could charge whatever they wanted for medicine and supplies, because people wouldn't have to open up their wallets and so they thought everything was free. A good comparison, is how college tuition sky-rocketed when government loans became easy to get. I want to go back to 1975.
Perfectly correct!