OP-ED

American Healthcare X

“A decent provision for the poor is the true test of civilization.”
~Samuel Johnson

“Joe” has been on the streets now for two months. He’s 35, unmarried, and diagnosed with chronic schizophrenia since age 19. His illness is difficult to manage, even with regular medication, and Joe is subject to hallucinations telling him to “fight off the evil ones”. Like most people with psychiatric disorders, Joe has never been violent—but when his illness is not well-controlled, he can become loud and belligerent.

Despite his many tries at holding down a job, the economic downturn and his worsening psychosis have left Joe jobless and homeless.  Joe’s family thinks he is “faking” his symptoms and they are “fed up” with him. They have refused to take him in or help him with his medical care. Joe has no friends willing to help him and survives on the streets by panhandling and dropping in at soup kitchens. The local shelters won’t accept Joe, because he is “too agitated.” Joe sleeps in alleyways, or, when lucky, in ATM stations. In the past month, he’s been beaten up twice by members of youth gangs.  Recently,  Joe was diagnosed with type 2 diabetes, requiring daily medication and monitoring. Joe says he doesn’t want “charity”, and would like to work again, but doesn’t see how he can.

“Joe” represents many patients I’ve cared for during nearly 30 years of medical practice, and typifies thousands of Americans with severe mental illness.   In my previous blog entitled, “The Libertarian Mind”, I posed this question: what is the moral responsibility of federal and state government to help care for people like Joe? I argued that the Libertarian Party platform—calling for the abolition of “the entire social welfare system”, including food stamps—is neither humane nor compassionate.

And, I argued in favor of a publicly-funded, single-payer insurance system, as advocated by PNHP (Physicians for a National Health Plan).  Although a few readers wrote in support of my position, many (mostly anonymous) commentators were very critical. Nobody who wrote in really answered my question directly. I’d now like to address some of the criticisms of my piece, as well as to debunk some myths surrounding the history of the health care in this country. First, though, I need to sketch the general health care picture in the U.S. today.

Many commentators of all political stripes would agree that the U.S. health care system is in deep trouble. Despite our tremendous progress in medical research and technological innovation, our health care system is not “delivering” to those who need it most: the very poor and sick, whose friends, family, or community cannot or will not help them. Far from having “the best health care system in the world”—as some politicians have claimed—our system is failing in the most basic measures of medical care. This is not for lack of spending. As Victor Fuchs PhD, of Stanford University recently wrote in the New England Journal of Medicine (Dec. 2, 2010), the U.S. government “…currently spends more per capita for health care than eight European countries spend from all sources on health care. Though life expectancy is far from a perfect measure of the quality of care…life expectancy at birth in every one of these eight countries is higher than that in the U.S.”  And, in a recent Commonwealth Fund-supported study comparing “preventable deaths” in 19 industrialized countries, researchers found that the United States placed last.

The huge amount of money spent on administrative costs in the U.S. –rather than on direct care—is a major factor in these disparities. At the same time, mental health care is badly under-funded, even allowing for the recent recession. More and more of the burden of caring for the destitute and homeless with mental illness is falling on our police force. As the New York Times recently reported (Dec. 5, 2010), “A lot of people view calling the police  as the only way to get loved ones any kind of treatment…” with the result that “…many patients who need a doctor get a law officer instead.”  People like Joe are barely able to scrape by in the best of times, with the aid of state and federally-funded programs like Medicaid. Abolishing such programs, as the Libertarian Party advocates, would likely be a death sentence for thousands of people like Joe.

But the prospect of such deaths does not seem to trouble some individuals who proclaim a “libertarian” ideology. One person who wrote to criticize my previous blog argued that  “…Libertarianism accepts that life happens and some people will live less fulfilling lives and die early, but overall, everyone will live better…” Furthermore, this reader argued that the voluntary efforts of private groups and individuals have been far more reliable than government aid, pointing to the government’s response during Hurricane Katrina. This same reader also worried what would happen in a “liberal utopia” when “government support doesn’t materialize.” Let’s leave aside the question of how many more people would have died during Katrina, had the federal government not intervened, and consider this reader’s basic premise: it’s sad when some people die of starvation and neglect, but, hey—that’s life. It’s all in the service of the greater good. Presumably—and in an indirect response to my question—this reader believes that the federal and state government owes nothing to the destitute sick and hungry, even when their family and friends have deserted them. I was wrong, in my first article, to characterize such an attitude as one of “narcissism.” The correct term is “depraved indifference.”  Now, I happen to believe that this particular reader, like most Americans, would “do the right thing” for someone like Joe. In general, I find that most people are better than some of their cockamamie theories. But the savage irony of   libertarianism is that it pretends to honor the individual, while actually viewing any particular individual as a potential pawn—readily sacrificed in the name of the greater good.  Libertarians are welcome to this predacious view of “governance”. I for one would not wish it on a pack of jackals.

As for that “liberal utopia”— “utopia” literally means, “no place”–it is striking that no place on earth has ever demonstrated that a purely libertarian form of governance can succeed, much less provide adequate health care for the destitute sick. I am not a political philosopher, but I consider caring for the destitute sick a profoundly conservative act. It conserves the most precious resource we have—our fellow citizens—and helps them return to health, work, and productivity.  I am not talking about “charity” for someone like Joe—I am talking about food, shelter, and health care.  I’m talking about a vocational rehabilitation program to help Joe get back into the work force.

Some self-described libertarians argue that a government that finances such services may eventually go bankrupt. I say that a government that shirks its obligations to the destitute poor is morally bankrupt and deserves no support from its citizens.  When we pass by a river and see someone drowning, we take it upon ourselves to throw that person a life preserver. We do not protest, “But I might wrench my shoulder, if I have to do this three or four more times today!” Governments are not abstractions: they are collections of individuals. I do not want to hold government in the aggregate to a lower moral standard than the one I expect of individuals. The hypothetical fear of “bankruptcy” does not negate the government’s moral duty to protect the health and safety of its most vulnerable citizens.

Another critic of my first essay asked plaintively that we remember America during its “first 150 years” of existence. “Remember that America?” he wrote. “The land of the free? The land of opportunity? You ask for evidence that families, friends, churches, communities, and charity organizations would be enough to support the needs of society, discounting the fact that we successfully existed on such a system for the majority of our nation’s existence.”

Ah, yes—I do remember. I saw that America portrayed on an old TV show called “The Waltons”, in which a tough, decent family used to take in needy strangers during the worst years of the Great Depression. Perhaps the commentator I’m quoting would act in the same, decent manner.  But there is little in the history of American health care that accords with that Hollywood script. (By the way, as regards “the land of the free” and “the land of opportunity”: did the writer forget that until 1865, 4 million black Americans were in chains? And that women did not get the vote until 1920?).

For most of the 18th century, prior to the rise of “poor houses” in this country, many paupers who could not secure family or community support were auctioned off like cattle. They were actually sold to the lowest bidder–the person who would agree to provide room and board for the lowest price—and effectively became indentured servants (see http://www.poorhousestory.com).

Prior to the Social Security Act of 1935, and for much of the 18th and 19th centuries,

“…most poverty relief was provided in the almshouses and poorhouses. Relief was made as unpleasant as possible in order to “discourage” dependency. Those receiving relief could lose their personal property, the right to vote, the right to move, and in some cases were required to wear a large “P” on their clothing to announce their status.” [http://www.ssa.gov/history/briefhistory3.html].

As for the destitute sick who lacked families to care for them, for much of the 19th century, they were dependent largely on “charity hospitals”, supported by generous donors, in which doctors provided care free of charge. This might seem to support the claim that we “successfully existed” with a charity-based system of health care. Unfortunately, charity hospitals were subject to the whims and means of their donors. For example, the Boston Lying-in Hospital (later, Brigham and Women’s Hospital) provided free care for indigent women, but had to close in 1856 because it could not meet expenses. It was not able to re-open until 1873. In our own time, similar financial problems forced closure of New Orleans’ famed “Charity Hospital” after Hurricane Katrina—an institution that cared for tens of thousands of the uninsured sick.  In such circumstances, do we really want to say that the state and federal government have no obligations whatsoever, and no right to raise any revenues in behalf of the destitute sick?

As a nation, we can and must do better. There are feasible economic plans, described on PNHP website, that will allow us to provide basic health care to all Americans, without breaking the bank. “Joe” is not a lazy, ne’er-do-well, nor are the thousands like him in this country. Joe is your neighbor, your friend, or your cousin. More important: Joe is your brother.

References and readings

Victor R. Fuchs: Government payment for health care—causes and consequences. New England Journal of Medicine, Dec. 2, 2010.

Ellen Nolte, Ph.D, C. Martin McKee, M.D “Measuring the Health of Nations: Updating an Earlier Analysis” (Health Affairs, Jan./Feb. 2008),.e

Katie Zezima: State cuts put officers on front lines of mental care. New York Times, Dec. 5, 2010.

Boston Lying-in Hospital. Records, 1855–1983. Francis A. Countway Library of Medicine. Accessed at: http://oasis.lib.harvard.edu/oasis/deliver/~med00056

Judith W. Leavitt , Ronald L. Numbers:  Sickness and Health in America: Readings in the History of Medicine and Public Health. University of Wisconsin Press, 1997.

Pies R: Health Care is a Human Rights Issue. Psychiatric Times. Nov. 15, 2010. Accessible at: http://www.pnhp.org/news/2010/november/health-care-is-a-human-rights-issue

Single-Payer FAQ: Physicians for a National Health Program. Accessed at: http://www.pnhp.org/facts/single-payer-faq#costs_down

Libertarian Party Platform, 2010. Accessed at: http://www.lp.org/platform

Ronald Pies, MD, is Professor of Psychiatry and Lecturer on Bioethics at SUNY Upstate Medical University; and Clinical Professor of Psychiatry at Tufts University School of Medicine. He is the author of several books on comparative religious ethics, including Becoming a Mensch (Hamilton Books). Dr. Pies reports no financial arrangements or professional affiliations with any political party.

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29 replies »

  1. As Nate Ogden points out above, Dr. Pies evaluates intent and not actual results. And I would hardly point to UNICEF as a guide. It is very hard to find any examples where libertarianism in health care and social services in industrialized nations because they do not exist. However we do see as examples in every country that has these “social safety nets” the net actually serves to trap the individual as nets are designed to do.

    As DeterminedMD points out below, “meaning well does not infer you will do well” is quite appropriate. But “a man convinced against his will, is of the same opinion still” is a quote taught by Masons. It also shows that if you try to take from me by force because you believe in something [like society has some unwritten moral code which we all need to abide by and you are the person qualified to put that unwritten code to words] you are somehow authorized to take from me by force.

    The whole concept of left-center-right in political thought is by definition, faulty. As the Advocates for Self Government points out (www.theadvocates.org) political thought is at least two-dimensional. Visit their website and take “the worlds smallest political quiz” to see what I am talking about.

    Finally, I am Jewish and was the Libertarian Party of New Hampshire’s nominee for governor in 2006. Two days before the election I was speaking at Temple Adath Yeshurun in Manchester, NH, with several other candidates for various state and federal offices. After the forum, the rabbi comes up to me and asks “How can you be a Jew and a Libertarian at the same time?” She was referring to the Hebrew mitzvah “Tikkun Olam” which means “healing our world.” I couldn’t see how one could be a Jew and not be a Libertarian. How? I suggest the book (surprise!) “Healing Our World” by Dr. Mary Ruwart.

  2. I have appreciated the chance to post my views here, and I hope that all THCB readers–whatever their point of view on health care–have a pleasant holiday!–Regards, Ron Pies MD

  3. “Readers who truly want to examine “actual results”, rather than abstract theories,”
    And how do you scientifically measure happiness and health? A kid from a wealthy family is happy when they get a new DS, a kid in poverty is happy when there is no shootings for a week, these polls, they are nothing more, are scientifically worthless.
    “–I developed quite the case of the giggles after reading that!).”
    So it was the giggles that prevented you from any meaningful responce? I’ll rememeber that next time I can’t support an argument or back up a claim, it was the giggles that prevented me from defending my stance.
    “I would respectfully submit that there is no credible evidence from international data that”
    Don’t doctors take science classes? Who exactly would publish such data Pies? Most “international” studies are done by or for governemnt, which government is spending money to prove their public programs are counter produtive? The ansence of a study doesn’t begin to prove something doesn’t exist.
    ” Ireland, Canada, and Switzerland all exceeded the US in terms of % of population giving money to charities;”
    More terrible logic Pies. How large of an illegal population living in an undergroud economy does Ireland, Canada, and Switzerland have? Your comparing apples and oranges and expect us to be surprised they taste different. We have completly different population make up and histories leaving your comparison worthless.
    You call this science? This isn’t worth the paper it is written on.
    “Gallup surveys of 195,000 people in 153 nations, and asked people whether they had given money to charity or volunteered or helped a stranger in the last month. It also asked respondents to rank how happy they are with life.”
    come up with some quantifiable numbers then peddle this BS. Real actual science studies have shown countless times when polled on voting, church attendance, and charity giving, people lie and do so in significant numbers. This was real science where they actually verified the results.
    ” But for those with “broken legs” or no legs at all, we must first ensure–yes, ensure!–a basic level of health care.”
    Then why have none of the liberal programs proposed or passed since 1965 done this? Medicare didn’t help the 13% of seniors that needed help with catostrophic care instead it burdended 100% of seniors with changes to routine care they didn’t need. PPACA didn’t improve Medicaid it screwed up private insurance and made it more expensive. This is how liberals passed Medicare, they claimed to be doing one thing then passed another, even Democrats at the time said they hoodwinked the public. Not nearly as easy to do with the internet around is it Pies?
    ” I believe that each of us has a civic responsibility to support publicly-funded health and welfare programs.”
    Then why don’t you beleive those publicly funded health and welfare programs should be short term solutions until someone can be taught instead of generational enslavement? 3-4 generations of families have grown up in public housing and on welfare, obviously your programs are failing or your lieing about their role.

  4. So, I lack courage and personal responsibility by not putting my name on my comments.
    Bit of a projective comment on your part, eh, Doctor?
    I will enjoy your break from this blog. Thanks for your part of the mob mentality.
    Signed, board certified physician in the United States

  5. Readers who truly want to examine “actual results”, rather than abstract theories, should closely inspect Unicef’s recent report on children’s health, safety, and well-being in various wealthy countries
    [www.unicef.org/media/files/ChildPovertyReport.pdf].
    The Unicef findings clearly show that, in general, countries with the most progressive national health and welfare systems (like Denmark and the Netherlands) foster the healthiest and happiest children. The country that most closely approximates a “libertarian” or “free market” approach–the U.S.–is among the worst performers, when it comes to children’s health, safety and happiness. (As for the notion that the real killers in this country are “liberal” programs like Medicaid and public housing–I developed quite the case of the giggles after reading that!).
    I do respect Mary Ritenour’s community activism, as well appreciating her disappointing experience with a very unhelpful publicly-funded senior center. However, I think it is hazardous to reach sweeping generalizations from one or two bad experiences. I would respectfully submit that there is no credible evidence from international data that “…the presence of such public programs tends to disincent private charity…” or that “If we as a people are required to contribute “for the public good”, it creates an environment where we are LESS charitable toward our neighbors…”
    If that were generally true, we would expect to find an inverse relationship between publicly-funded social welfare programs and private charitable giving; i.e., the more publicly-financed social welfare in a given country, the less private charity donated per person. Yet the data I cited earlier from Charities Aid foundation do not support that thesis: e.g., Ireland, Canada, and Switzerland all exceeded the US in terms of % of population giving money to charities; all 3 countries have strong systems of publicly-funded
    health and welfare. See:
    http://www.guardian.co.uk/news/datablog/2010/sep/08/charitable-giving-country#data.
    Similarly, the Global Humanitarian Assistance data I cited earlier–looking at donations (converted to dollars) per citizen–found that private contributions in Luxembourg, Norway, Sweden and Ireland all exceeded those from U.S. citizens. None of these data support the claim that the presence of public aid programs removes incentives for private giving.
    http://en.wikipedia.org/wiki/List_of_most_charitable_countries
    That said, I did appreciate Mary Ritenour’s referring me to the video clip of Chimamanda Adichie. This Nigerian woman makes clear that “a single story” about a people or a nation is likely to be misleading. She talks about “the resilience of people who thrive despite the government rather than because of it.” I fully agree with the spirit of individual initiative and free enterprise, and I do not believe that underprivileged people are well-served by governments that merely “throw money” or social programs at them. That’s one reason I mentioned vocational rehabilitation for “Joe”, in my blog. We do need to encourage people to stand on their own two feet. But for those with “broken legs” or no legs at all, we must first ensure–yes, ensure!–a basic level of health care. I agree with the Chinese adage that says, “Give a man a fish and you feed him for a day. Teach a man to fish and you
    feed him for a lifetime.” But before anyone can be taught such self-sustaining skills, he or she must be healthy enough to learn. And while it is not the “single story”, I believe that each of us has a civic responsibility to support publicly-funded health and welfare programs.
    With that, I think I’ve gone on quite long enough! Thanks to those who showed the courage and personal responsibility to go on record with their names. I will probably take a break from further exchanges, at least for now, and I thank John Irvine for the opportunity to contribute.
    Regards, Ron Pies MD
    Posted by: Ronald Pies MD

  6. The public programs also weaken the family, if people were more dependent on their family I don’t think we would have so many broken homes. Kids don’t need their parents the government will feed and house them. Then when the parents get old the kids have their own life and let the government take care of their paretns.
    Medicare is just one example of government trying to solve a problem that didn’t exist and failing instead of addressing the small problem that did exist and actually doing something productive. Most government programs suffer the same grandious objective with no or minimial success.

  7. If I may, two points from my personal experience with the public “safety net” that I believe are relevant.
    During the lowest point, I was, as a single mom, supporting 4 children ages 12 and under. My income barely provided us with housing and food. I reached out to the local school in the hopes that my kids could take advantage of a free lunch program and ease the strain on our finances. After a lengthy application process I was told that my family did not qualify for the program because my income was $21 a month TOO HIGH.
    Publicly funded charity programs are administered by well meaning folks who are there to see that the letter of the law is followed. They do not have the incentive or the ability to be flexible in their response to aid situations. “THE RULES SAY….” is mantra that keeps these folks employed and safe from accusations of mismanagement of public funds. I do not fault them – they have a tough job. But due to the nature of their position, they cannot respond rapidly or with flexibility to changing situations. So, there is money for shoes, but not coats, or lunches but not babysitters, or electric bills but not food. Each situation is alittle different; each aid need is specific to a particular person’s situation. There are no perfect cookie cutter solutions, but public programs, by their nature tend to offer cookie cutter answers.
    Additionally, the presence of such public programs tends to disincent private charity. I reached out to a local Senior Center to see if there was anyone interested in watching my children during the after school hours until I got home from work, 2-3 hrs a day. I was told, in no uncertain terms, that the folks at the center “had made their contribution to society and were not interested in such work”. While I prefer to believe that not EVERYONE in that Senior Center felt that way, the administrator wouldn’t even consider that option.
    If we as a people are required to contribute “for the public good”, it creates an environment where we are LESS charitable toward our neighbors because we believe it is no longer our responsibility – that we have PAID for someone else to take care of that problem. “Surely there is some program that will help you?!?! Don’t come to me…”
    This lessening of the charitable spirit is the most disastrous of all, I believe. It weakens our communities, and our ability to be resilient and responsive in times of troubles. And, indeed, if there is an “unconscionable neglect of the poor, homeless, and disabled”, perhaps public funding of programs creates and thus bears at least part of the moral responsibility for this systemic weakness.

  8. As a fellow jewish person, if Dr Pies was raised the way I know I was, we instinctively both from our religion and our oath as physicians want to give and preserve a healthy community. But, what has probably corrupted his thinking is this overtolerance of liberalism I have come to realize has failed the public.
    How can you as a doctor not step back and see the overt pratfalls of single payor systems? And let politicians dictate the pace? You were trained in an era that guarded outside interferences much better than what I was taught years later. Was it convenience that made you forget those points, or, insulated from the realities of day to day life while living in an ivory tower for those decades?
    Meaning well does not infer you will do well. Hey, keep ignoring my comments, it just reinforces my perspectives of what your agenda really is.
    Where will you be professionally as of 2014? I’ll bet if you would answer with candor, it is “not practicing active psychiatry.”
    Welcome to the realities of writing at blogs. Not everyone will just clap and say “thank you” for your commentary. And, anonymity has limitations, but to just dismiss it as unfair or expect the right to scrutinize one who is wary to speak freely when discourse is now being viewed as treasonous or libelous, well, be ready for more anonymous signatures!

  9. “To be sure: the U.S. did not do badly—overall, we were tied for third place. However, as you’ll see, many countries exceeded the U.S. in % of the population giving money to charities.”
    Remove those self described as liberal and see how our score sky rockets, countless stuides have shown a distinct portion of the population that only engages in charity when it is giving away someone elses money, sadly they bring down the score for the entire country when compared that way.
    ” and the callous indifference to the most vulnerable members of our society, reflected in the Libertarian Party platform.”
    As people like Pies are prone to do they measure intent and not actual results. He doesn’t understand how a conservative philsophy can aid people without a direct handout so he assumes the results will be negative, no manifestation of this happening need accur he is happy to project his opinion of the result. At the same time he will gloat in his charity for program like public housing that on paper and shollow review appear to help people but actually do far more damage then they do good.
    The liberal programs of Medicaid and public housing killed more people then a strict libeterian policy ever would, but again actual results don’t matter to people like Pies.
    Pies thankfully backs this up for me;
    “I think a publicly-funded plan of the sort PNHP proposes creates shared societal responsibility for the care of our sickest and most vulnerable citizens.”
    Publicly funded Medicare was suppose to stop grandma from losing the shirt off her back if she had a serious illness, it didn’t, and public housing was suppose to give the poor a stable foundation to build themself up from, it was a trap plumeting them into a bottomless pit of pverty instead. The actual outcome of a publicly funded plan of the sort PNHP proposes doesn’t matter, just by passing it Pies will fulfill his self indulgness and need to feel like he did something, even if it doesn’t work out and destroys millions of lives.
    ” the Veterans Administration is at least taking considerable responsibility for its own disabled soldiers,”
    Yet Pies ignores the huge private saftey net wrapped around it that catches most of those that fall through. It is also the private saftey net that has driven the VA to where it is today and pushes it to where it should have been all along. The VA is a failure as a public plan, it is only mildly as successful as it is becuase of private charity and giving.
    As I think Mary is saying if you create a soup line you will have people line up for soup for the rest of their life. If you force them to learn to care for themself they will feed themselves for the rest of their life with only short periods of assistance needed. Pies things to think anything short of nursing the public from birth to death is neglict.

  10. Dr Pies, thanks for your response.
    I am aware of those problems and and am part of my community’s efforts to alleviate and assist those who are struggling. My question was more toward the triggering event(s) that caused the fervor of your posts – some precipitating event?
    In any case, there are “safety nets” in place, but like all nets, there are holes. I have, myself, fallen through those holes, but had friends and family that offered support and encouragement, and I was able to pull myself and my children up out of poverty.
    While it is important that we offer those safety nets, it is as important, if not MORE important, to look for the structural causes that create the need for those nets; to examine clearly our own premises and biases that may contribute to these “unconscionable” failures.
    For example, many of my fellow community activists are so in love with their “white knight” role, that they act in ways that perpetuate the “victim’s” status; doing as much harm as good. That vicious cycle is important to break; here in the US, and in our Aid abroad. Again, one way forward is outlined in this TED talk: http://www.ted.com/talks/lang/eng/chimamanda_adichie_the_danger_of_a_single_story.html

  11. Dear Ms. Ritenour:
    Thank you for taking the time and effort to write. I do understand that there are many ways one can calculate charitable giving, and certainly a “total volume” measure of a country’s charity is one way. That means that if a country has a million people in it who give one dollar per year, it will far exceed the “generosity” of a country with 10,000 people in it, each of whom gives $50. To me, this seems an odd way of looking at the personal generosity of any particular group of citizens. If you are not persuaded by the previous data I cited from GHA, you might take a look at the data from the Charities Aid foundation, which you can find at
    http://www.guardian.co.uk/news/datablog/2010/sep/08/charitable-giving-country#data
    CAF compared many industrialized countries on the basis of % of the population giving money to charities; % of the population who have volunteered time for an organization in the last month; % of the population who have helped a stranger in the last month; and overall score. To be sure: the U.S. did not do badly—overall, we were tied for third place. However, as you’ll see, many countries exceeded the U.S. in % of the population giving money to charities.
    All this said, I think the “Who’s Most Generous?” debate steers us away from the main issues my two blogs have sought to address: the inadequate delivery of health care services in the U.S., with its consequent negative effects on infant mortality, life expectancy, etc.; the inadequate health care for the “destitute sick” for whom no family, friends or community services are available; and the callous indifference to the most vulnerable members of our society, reflected in the Libertarian Party platform. And, to reiterate, I believe that while there are no easy, painless, or perfect solutions to these problems, the best hope is via a single-payer, publicly-funded insurance program. I don’t believe this proposal amounts to saying, “I want you to pay for him…so I don’t have to be faced with it”. I think a publicly-funded plan of the sort PNHP proposes creates shared societal responsibility for the care of our sickest and most vulnerable citizens.
    You ask, “I’m not sure where the “unconscionable neglect of the poor, homeless, and disabled” is coming from. If you are seeing such neglect, what have you personally done to alleviate the situation?”
    As a physician in the Boston area for nearly 30 years, I could tell you of the countless, homeless people I have seen, sleeping on heating grates in the winter; the number of people with severe mental illness who , like “Joe”, are out living on the streets; and the numerous barriers to health care for disabled veterans returning from Iraq or Afghanistan with PTSD and terrible physical injuries (Ironically, for all its problems and shortcomings, the Veterans Administration is at least taking considerable responsibility for its own disabled soldiers, and providing care under a publicly-funded system. See: Wilson NJ, Kizer KW, The VA health care system: an unrecognized national safety net Health Aff (Millwood). 1997 Jul-Aug;16(4):200-4).
    But if you are unfamiliar with these problems, you needn’t take my word for it. You should read the 2009 report on “Hunger and Homelessness in US Cities,” from the US Conference of Mayors.
    http://www.usmayors.org/…/hungerhomelessnessreport_121208.pdf
    Among the findings, based on 21 U.S. cities:
    • All 21 cities with available data cited an increase in the number of persons requesting food assistance for the first-time. The increase was particularly notable among working families.
    • The increased cost of food and fuel has made it difficult for food banks to expand or even maintain their normal supply of food. Meanwhile, the economic downturn and rising unemployment have increased the demand for food assistance while decreasing the number of donations from individual donors.
    • The increase in demand for food assistance exceeded the increase in the amount of food distributed in eighty percent of the cities surveyed.
    • Nineteen cities (83 percent) reported an increase in homelessness over the past year. On average, cities reported a 12 percent increase.
    Meanwhile, in their report “Hunger in America, 2010”, Mathematica Policy Research reports that 46% of clients served by the FA National Network report having to choose between paying for food and paying for utilities or heating fuel. This compares to 42% in 2005. 39% had to choose between paying for food and paying their rent or mortgage. This compares to 35% in 2005.
    http://www.mathematica-mpr.com/nutrition/hungerinamerica2009.asp
    In one of the richest countries in the world [http://www.worldsrichestcountries.com/%5D, do I find this overall picture “unconscionable”? You bet I do! What have I personally done to alleviate the situation? Not nearly enough. How about you, Ms. Ritenour? And how about our government officials and legislators? No—we don’t need “socialism” or a “government takeover” of health care. We do need a nationwide “safety net” that extends to all our citizens–and especially to those least able to manage on their own. –Best regards, Ron Pies MD

  12. Dr. Pies,
    The Wikipedia source you mentioned specifically describes Official Development Assistance (defined in the article) and Humanitarian Aid, as defined by GHA who interestingly comments that tracking and reporting on Humanitarian aid is problematic due to the self-reporting nature of the process. They warn specifically about comparing donors because of the incompleteness of the data. They also are looking at governmental aid/donors, citing specifically:
    “Local communities and families, national and local government, civil society and the private sector almost always prove the most immediate deliverers of humanitarian aid.
    No analysis of resources for humanitarian assistance can be complete without taking account of this domestic humanitarian response, yet it is rarely, if ever, considered. This immediate humanitarian assistance, originating in-country and beyond the gaze of international actors and global media, is in many cases sizeable but remains largely unreported and uncounted.”
    So, my position remains; Americans are the most privately charitable people; by volume. I certainly agree that there are many ways to statically slice the data (by % of GDP, by % of mean income, etc) but Red Cross is not going to prefer getting $5 from a ten yr olds allowance (50% of monthly income) over a Warren Buffet’s contribution of $5Million (1% of month income – I’m guessing here). To say that Americans don’t contribute a sufficient percentage is to ignore the hugely larger pie we are contributing from.
    I’m not sure where the “unconscionable neglect of the poor, homeless, and disabled” is coming from. If you are seeing such neglect, what have you personally done to alleviate the situation?
    I am suspect of “We should do something” proposals; they usually translate to “I want you to pay for him to take care of this so I don’t have to be faced with it”.

  13. Interesting Blog, even though this was not what i was looking for (I am in search of clinics like this one> http://www.ccsviclinic.ca/ )… I certainly plan on visiting again! By the way, if anyone knows of a good clinic that does CCSVI Screenings? BTW..thanks a lot and i will bookmark your article: American Healthcare X…

  14. Wonderful, play the numbers game many of the commenters here do to displace and deflect from the real issue here: instead of problem solving the biopsychosocial dilemmas that drive the health care crisis, focus rather on political party lines, here one you espouse as pure liberal, if not socialistic philosophy that equally fails what your opponents preach as conservative insensitivity, and just repeat the rhetorical nonsense that is extreme political bents of 2010.
    I don’t get why you post here. Is this what I have to look forward to as I age, that wisdom is a given just because one has a position at a university, and gets to be editor at a fairly well read publication? Doesn’t impress nor validate your point of view to me.
    I go by DeterminedMD, used to be ExhaustedMD, as I was tired and frustrated by the sheer incompetence and lack of reliable leadership in medicine, mostly by non clinicians of late, and now I have to look forward to colleagues taking what amounts to cheap shots at political ideologies.
    Shame on you Dr Pies, you should know better. From a man who looks to the old testament for direction? Ask your Rabbi to read these posts, I doubt he would support you in this commentary!

  15. Thanks to Dr. Craig Vickstrom, Mary Ritenour and others for their comments. Of course, I agree with Dr. Vickstrom that “Libertarianism is a failure in the provision of essential services”, at least as formulated on the Libertarian Party (LP) website. To be sure, there are many “stripes” of libertarianism, but if the LP social agenda were ever carried out (God forbid!), the sickest and poorest among us would literally be dying in the streets.
    I must correct a popular–and, in my mind, self-comforting– myth that Ms. Ritenour repeats here; i.e., namely, that “Americans lead the world in private charitable giving.” This is true only if you use the most misleading statistic; i.e., absolute dollar amount per country (which would favor
    the most populous and wealthy countries). When charitable giving is computed as a a percentage of gross national income, the US lags far behind. The UK-based, non-profit organization, Global Humanitarian Assistance
    http://en.wikipedia.org/wiki/List_of_most_charitable_countries
    lists the countries giving the highest amounts of money (in absolute terms) are as follows:
    * 1. United States – $28.67 billion
    * 2. France – $12.43 billion
    * 3. Germany – $11.98 billion
    * 4. United Kingdom – $11.50 billion
    * 5. Japan – $9.48 billion
    However, here is the list of countries by the amount of money they give as a percentage of their gross national income. The U.S. comes in at number 19 [0.47%]
    * 1. Sweden – 1.12%
    * 2. Norway – 1.06%
    * 3. Luxembourg – 1.01%
    * 4. Denmark – 0.88%
    * 5. Netherlands – 0.82%
    The GHA July 2010 report also lists countries ranked by generosity as donation per citizen from data collected in 2008.
    * 1. Luxembourg – $114/citizen
    * 2. Norway – $96/citizen
    * 3. Sweden – $66/citizen
    * 4. Ireland – $66/citizen
    * 5. Kuwait – $33/citizen
    * 6. Saudi Arabia – $29/citizen
    * 7. United Arab Emirates – $25/citizen
    * 8. United Kingdom – $17/citizen
    * 9. United States – $14/citizen
    The U.S. is a wonderful place to live and work, and I could rhapsodize more on this point–especially after a month in France, where everything seems to close down between 2 and 7 pm! But we cannot rationalize our unconscionable neglect of the poor, homeless, and disabled by patting ourselves on the back over how “generous” we are in giving charity.
    Ron Pies MD

  16. “Tell that to Greece, Ireland, California, and others which have gone beyond “hypothetical” bankruptcy to facing the real thing. The cost of their social programs is a clear factor in their looming insolvencies.”
    If you mean aid to those in need at least here in the U.S. it is certainly NOT our “social programs” that has gotten us into trouble. The home mortgage tax deduction does not benefit middle/low income earners (standard deduction), social security, like any pension, just needs higher contributions, Medicare needs medical costs controlled (provider payments/utilization) and higher contributions from those who can afford it. The financial meltdown was not because poor people were getting a free ride, on the contrary, rich people were getting the free ride. Then there’s all those corporate tax concessions local communities are blackmailed to pay. More good points here: http://www.ctj.org/index.php

  17. I believe that the basic purpose of the state (of any state) is the protection of its citizens and their lives. This is true whether the threat is a foreign army, a violent criminal, a fire, or a virus. This does not mean nationalizing the economy or mobilizing infinite resources. It does mean that society takes some limited responsibility to protect those who cannot take care of themselves.
    Social order breaks down when there is no sense of social responsibility.

  18. Regarding the comment: “Ultimately, with the libertarian model, you come up against the reality that some people will be left to die in the street of sickness, starvation, or exposure.”
    One could say that about nearly every social/political model. Even with the current social/political model, there are people “left to die in the street”, in the US, and elsewhere in the world. No one is happy about it; few confronted with that reality can be indifferent to it. In fact, Americans lead the world in private charitable giving. The US leads the world in foreign aid. And yet, people starve and die.
    The NGO/Aid community is deeply involved in discussions about How To Do Aid Better; after billions and billions of dollars, they are coming to the realization that what they are currently doing does not have much long term impact. The honest ones admit that often their efforts have made things worse. So, rather than flinging ideological mud pies, there are the beginnings of an honest dialog about What Works.
    Discussions regarding Health Care in the US could benefit from their example, and their discussions.
    Read:
    http://goodintents.org/
    http://www.how-matters.org/2010/09/02/initial-findings-listening-project/
    http://aidwatchers.com/

  19. “The hypothetical fear of “bankruptcy” does not negate the government’s moral duty to protect the health and safety of its most vulnerable citizens.”
    Tell that to Greece, Ireland, California, and others which have gone beyond “hypothetical” bankruptcy to facing the real thing. The cost of their social programs is a clear factor in their looming insolvencies.
    The dangers posed by the steadily mounting trillions in direct national debt and unfunded social program liabilities are also not “theoretical” to students of history or economics. Really bad things can happen when your government lives beyond its means for an extended period of time. Real people are literally dying in riots around the world as goverments are running out of cash to pay various social benefits.
    Also, you seem to be trotting out Libertarians as kind of a straw man alternative to socialized medicine. However, the founders of this nation were NOT libertarians. They were, instead, strongly and openly in favor of limited goverment operated as a constitutional republic. There is a considerable difference between the limited goverment views of the Founders (a limited set of federal responsibilities tightly spelled out in a constitution) and the views of hard-core libertarians.
    Most people concerned with the growth and overreach of the federal goverment see themselves as aligning with the Founder’s wisdom regarding how to preserve freedom and prevent the collapse of a democratic republic via plundering of the treasury.
    The choice is not between libertarianism and socialism. That is a false dichotomy.
    The actual debate revolves around how expanding social welfare programs and the unprecedented growth of the federal goverment can be squared with a founding vision of maximum liberty for the citizens (including freedom to keep the bulk of their earnings) and a constitution based on small central government with a limited set of responsibilities.

  20. Ultimately, with the libertarian model, you come up against the reality that some people will be left to die in the street of sickness, starvation, or exposure. When you come up against that, you either find this acceptable or not. If it is acceptable, then you can go about your life with your libertarian philosophy intact. If it is not acceptable, then your libertarian philosophy explodes. One it explodes, then you enter the realm of social welfare or compulsive charity, whichever you wish to call it. And so, once the principle is breached, we are now only arguing over price, introduce a certain metaphor.
    I was highly influenced by the objectivist writings of Ayn Rand in my young adult years. I still am. However, I just couldn’t swallow the people dying in the street scenario. That being said, I am all for democratic socialism in the European model. I think that medicine should join the courts, prisons, military, roads, and schools as part of the civil services. My colleagues may hate my guts, but I cannot see any other way of conscience. Libertarianism is a failure in the provision of essential services. Let it rest.

  21. Albeit I use an alias, make no mistake I always send a personal email to the owner of a blog site to document who I am so the owner can define whether to allow me to comment further (which was done here), so I assume having been doing so for the year justifies my intent.
    That said, I just want to inform readers of what this MD has been through in my career when challenging the KOLs/hierarchy of medicine, and it is nothing less than retaliation, belittling, and plain denial by said “leaders” of what I raise in my concerns and objections. Dr Pies, while having much distinguished writings in his past, also has taken what I consider less than responsible positions in psychiatry of late, that when criticized, seems to basically dismiss such criticism. One of them, what I interpret as aggressive and blurring of boundaries leading to overtreatment of grief, he wants to quickly label depression and offer medication a bit too earlier in the grief process. I offer the readers to go to Psych Central and Psychiatric Times as a start, and search out his posts this year on this matter alone, and decide how you read what he has offered.
    As a physician in the “trenches”, I still am miffed that you write positions like the above and give the impression that we, as a society, “owe” it to the public at large to foster dependency, sometimes at great risk to the providers, and equally to the families who get this false impression we as doctors can have the profound positive impact on illnesses that at best at times marginally respond to the best of standards of care we can offer.
    Schizophrenia as example is probably one of the most difficult illnesses to treat in ANY SOCIETY, and here is no different. You need to hear, Dr Pies, I know that the majority of doctors who accept the Hippocratic Oath as basic principle to health care do not abandon or minimize patient care, but, WHEN it is time to say “I’ve done my best, a new set of eyes and ears need to replace mine.” I still listen to colleagues in your generation group tell me that I am out of line, and yet how interesting many of these opinions come from doctors who don’t practice public mental health, much less see patients with any sizeable regularity, and now many are retired yst keep these positions of Emeritus Professor or some other title to maintain ties to teaching institutions.
    This is not the leadership we as active providers, planning to practice for another 15 or more years at this time, need as setting direction from what I deem are less than valuable guides and teachers, who by the way also played a large role in the compromise of mental health in colluding with both the managed care and pharmaceutical industries in oversimplifying psychiatry as a biological model alone.
    I know you, Dr Pies, have argued against the biological model alone in your professional writings, but, many of your peer equivalent colleagues have not. For other readers, read Daniel Carlat’s blog and get a sense what he has commented on for the past couple of years to see this is a concern by other providers who share my current path as a provider.
    I would love to see everyone get the same access and care options, whether it be the President of the US as much as a homeless person. But, funding is not an endless resource, and single payor systems still ration and discriminate, so the answer is not what is the best insurance system, it is how to better educate and advise against discriminating, minimizing, and downright belittling of clinical care opinions being offered by non providers, as much as by colleagues who are out of touch with care as of 2010.
    Figure that one out and you will be beyond the mensch, you might rank up there with Moses.
    Written by a fellow jew.

  22. Hi, Bobby–Thanks again. I missed the URL for your website earlier, and I have since checked it out–very nice! I appreciate the support for disclosure on the internet, too.
    You may have seen the piece in the NY Times, by Julie Zhuo, on this topic:
    http://www.nytimes.com/2010/11/30/opinion/30zhuo.html
    It’s worth reading.
    Best regards, Ron Pies MD

  23. @Ronald –
    Just fyi- While I routinely simply use the screen name “BobbyG” (short for and in lieu of Bobby Gladd), rest assured that I have never posted anonymously. I’ve had the same website for about 14 years, and I am fully accountable for everything I say online. I am readily searchable. Neither do I have any use for people who post anonymously, particularly when the handles are used to throw flames.
    I also appreciate your approach as that of bioethics. My grad degree is in a variant of “Applied Ethics” (notwithstanding that my work history is largely that of a quantitative risk analyst).
    Just fyi.
    Keep up the good fight.

  24. I very much appreciate the above comments and references–many thanks, guys! I also recommend taking a close look at the FAQ section of the PNHP website, which answers many questions and debunks many myths about a single-payer plan. But again: I approach this issue from the position of a bio-ethicist, not a health care economist. I do agree that we should not write off all libertarians, as the philosophy/movement encompasses a very wide range of ideas–and “reasonableness”!
    Just a reminder to readers: I have a standing policy of not responding directly to postings that lack a full name. I understand there are many reasons why some folks want to remain “anonymous”, but I am trying to encourage full identity disclosure on the internet. I think it improves
    the level of discourse and dialogue, and–particularly for medical professionals–just seems to me the “right thing” to do.
    That said, I once again thank you all for the thoughtful
    comments! –Best, Ron Pies MD

  25. Here in NC Libertarians get about 1% of the vote. Don’t worry, they won’t get to exercise their beliefs in the form of the dissolution of organized society.

  26. You should read Paul Starr’s book. He presents a better picture of what unregulated, charity based medicine looked like. It was not pretty. Part of the problem is that some libertarians have a fantasy vision of life in the 1800s that is nothing like reality. I loved Caplan’s assertion that women were more free in the 1800s than they are now. Oddly, few women agreed.
    That said, there are libertarians who make a lot of sense. Many of their concepts should be integrated into policy. Government does tend to grow unless someone is watching. Let me recommend that you look for stuff like this from two libertarian writers.
    http://reason.com/archives/2010/01/13/five-reasons-why-libertarians/print
    Steve

  27. Nice post. Just as was your prior one. To people who drag out the Straw Man to claim there’s no “right” to health care, I have written
    ___
    “How can we say that people have an “intrinsic right” to military defense, or to police and fire protection, (or to safe food and water, or to otherwise safe products that won’t electrocute us when we plug them in)? Well, we simply SAY it. And then we codify it. And, then, having codified it, we don’t lie awake nights worrying that everyone will demand a Special Forces FOB dug into his or her front yard, or an occupied Metro PD Black & White, an ambulance, and a hook & ladder truck parked at the curb 24/7.”
    http://bgladd.blogspot.com/2009/08/public-optional.html

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