“We are now contemplating, Heaven save the mark, a bill that would tax the well for the benefit of the ill.”
That’s not a quote from oral arguments at the Supreme Court over the constitutionality of the Affordable Care Act or from one of the earnest conservatives demonstrating against it outside. It’s actually the beginning of an editorial in the Aug. 15, 1949 issue of The New York State Journal of Medicine denouncing the pernicious effects of health insurance. To be clear: not government-mandated health insurance, but all third-party health insurance.
I wrote about that editorial in a July 16, 2009 blog entitled, “GOP to Uninsured: Drop Dead.” My blog was prompted by a Wall Street Journal op-ed the previous day from Dr. Thomas Szasz, an emeritus professor of psychiatry, who counseled readers not to confuse ethics and economics:
The idea that every life is infinitely precious and therefore everyone deserves the same kind of optimal medical care is a fine religious sentiment and moral ideal. As political and economic policy, it is vainglorious delusion….We must stop talking about “health care” as if it were some kind of collective public service, like fire protection, provided equally to everyone who needs it….If we persevere in our quixotic quest for a fetishized medical equality we will sacrifice personal freedom as its price.
This was a month before Oklahoma GOP Sen. Tom Coburn, a physician, told a sobbing, middle-aged woman that “government is not the answer” after she confessed she couldn’t afford care for her brain-injured husband. The crowd of Coburn constituents gathered to discuss health care reform applauded. And it was before Texas Rep. Ron Paul, also a physician, responded evasively when asked by moderator Wolf Blitzer at a September, 2011 GOP presidential debate what should be done about an uninsured 30-year-old working man in a coma.
“What he should do is whatever he wants to do and assume responsibility for himself,” Paul responded, adding, “That’s what freedom is all about, taking your own risk.” When Blitzer followed up by asking, “Congressman, are you saying that society should just let him die?”, a group of audience members in the Tampa auditorium began audibly cheering, “Yeah!”
The individual’s responsibility for “taking your own risk” was precisely what the New York State Medical Society worried that health insurance would undermine. As the Aug. 15, 1949 editorial put it:
Any experienced general practitioner will agree that what keeps the great majority of people well is the fact that they can’t afford to be ill. That is a harsh, stern dictum and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor? That in order to get their money’s worth they should be sick at every available opportunity? They will find out in time that the services they think they get for nothing – but which the whole people of the United States would pay for – are also worth nothing.
Of course, today’s liberty lovers are not denouncing health insurance per se, nor even calling directly for the abolition of government-funded health insurance for the elderly, the poor and veterans. Still, faint footfalls of this same fend-for-yourself argument, if not so bluntly stated, can be heard in GOP plans to control Medicare costs by turning it into a “premium support” program that risks leaving those too sick, too poor or not savvy enough shoppers for private insurance to fend for themselves.
Certainly, creating a situation where “the great majority of people…can’t afford to be ill” is an effective cost-control mechanism. In 1949, when 90 percent of the American population had no health insurance, medical expenditures were a tiny percentage of the gross national product. In our day, when medical technology is far more advanced, the economic principle remains the same. The Great Recession prompted a sharp drop in doctor’s office visits and even caused some individuals with cancer to stop taking their medications simply because they couldn’t afford it. Someone with Ron Paul’s flair for phrase-making might call this a case of “give me liberty and give me death.”
The Wall Street Journal op-ed by Szasz was entitled, “Universal Health Care Isn’t Worth Our Freedom.” That sentiment was vociferously endorsed by the anti-Obamacare demonstrators outside the Court and, oral arguments suggested, by some justices within it. Freedom, too, was on the minds of New York State physicians in this Sept. 15, 1949 commentary advocating what might be termed a robust medical consumerism:
It is time that someone – everyone – should hoist Mr. Charles Darwin from his grave and blow life into his ashes so that they could proclaim again to the world his tough but practical doctrine of survival of the fittest…The Declaration of Independence said that man was entitled to the “pursuit of happiness.” Any man who wishes to pursue happiness had better be able to stand on his own feet. He will not be successful if he feels that he can afford to be ill.
That no Republican presidential candidate has ever presented a serious plan to cover all the uninsured – after all, isn’t that why we have hospital emergency rooms? – is irrelevant to the legal issues but is highly relevant to the political context of the legal debate. The difference between Democrats and this generation of Republicans – unfortunately including even the GOP Doctors Caucus – is not at its core a disagreement on what government can legitimately do to help create universal access to health care for the 50 million Americans without it, but whether the goal itself is worth pursuing.
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We increased greatly the cost of a medical education from what it once was. At one time doctors learned medicine by working with another doctor. We trained nurses much the same way. Then we went to a split system of classroom work and using what you learned in patient care so the student actually saw the application of what they had learned there on the job. However this wasn’t very profitable for the educational system, so we went to the sort of a system that we have today. The problem with a medical education is that people only retain what they use. How much of what you learned in grade school, high school, college do you retain now? Most likely not very much considering you spent so many years in school. I have already discovered that “Google” knows more than my doctor does. Reason is that computers don’t “forget” (unless the hard drive dies). We on the other hand do. And there’s where the problem is today…
The ACA does nothing to reduce the cost of health care. All it does is to provide the health insurance industry with lots more customers while the government helps people pay for it. As the government has no money of its own (unless it prints it), the money to pay for the financial help that is called for in the ACA has to come from either the taxpayers in the form of higher taxes (repeal of the Bush tax cuts) or in the form of deficit spending which in turn means the national debt has to go up.
Libertarians have the solution to this in the form of repeal of laws and regulations that make health care so expensive because the medical profession holds a legal government enforced monopoly over access to medical drugs. As for diagnosis of medical problems, my experience has been that doctors do not do that great a job of it now. Especially if the problem is one out of the ordinary. Nor do they take the time to actually investigate the cause of the problem by actually checking for side effects of prescribed medications they themselves have prescribed. Take the “government” out of the picture and lots of good things happen. For example, there is no good reason that every hospital have every last bit of high tech medical equipment that duplicates what every other hospital has. Only in the USA do you find this. This is also why our hospitalization costs are so high. We have “gold plated health care” where it isn’t often needed. But the patient gets charged for stuff he or she might never use. The hospitals have to spread the cost of their high tech equipment over the entire patient population. Otherwise the equipment wouldn’t be even “affordable”. Charging only those who use it would also create problems as a great deal of such use is done for “covering one’s butt”. (fear of malpractice). Again, take government laws and regulation out of the health care system and the cost starts dropping right down to the point that such care might once again become affordable without insurance…
There is another “solution”, but the medical profession wouldn’t like because it would cut their incomes. That is to take away from doctors their present legal monopoly over access to medical drugs. Under such a system, people would be free to purchase the medical drug of their choice without a prescription. (except for narcotics and mood altering drugs) The person purchasing the medical drug would have to sign a legal document that states they are purchasing this drug without advice or a prescription from a doctor. In this way people would be able to control their blood pressure (as an example) for about $40 a year, the current price charged by Walmart for a common blood pressure medication. A somewhat higher cost would pay for a common cholesterol medication, which would run $40 to $80 a year. Again at Walmart prices. As high blood pressure and high cholesterol are the most common causes of heart attacks and strokes, it would appear that for $10 a month everyone could control these conditions. Of course the doctors would be unhappy because a great deal of income received by primary care physicians is from writing prescriptions, regarding patients to make office visits, have lab tests, etc. Without prescription laws, doctors would no longer hold “power” over their patients as they do now. Their incomes would be less, the “shortage” of primary physicians would be “history”. And there would be likely fewer people who would buy health insurance if instead they could take care of these sort of problems themselves without involving medical professionals.
Yes, we went astray when we allowed anyone, insurers, doctors or hospitals, to make a PROFIT from anyone’s illness. Healthcare should always have been socialized. We, as a society, face responsibility for the death of every individual who dies because they couldn’t afford to see a doctor.
Had the medical profession never seen the huge salaries that doctors draw, had the hospital never measured it’s success by the number of beds filled, and had insurers never been allowed to bet on anyone’s health, this country would have been so much better off!
Instead of becoming a doctor for the wealth it may bring, doctors would be drawn by the prospect of healing the sick. It would change the mindset of many of our physicians.
Instead of closing hospitals because they had too many empty rooms, administrators would applaud an empty hospital.
Don’t even get me started about insurance companies. Just knowing that their profits were based solely on delving out healthcare as they see fit, picking and choosing how much each person is to pay, it’s far worse than a loan shark or a pimp.
Fact check: According to a chart produced by the Economic History Association, about 60 million Americans had health insurance in 1950 (http://eh.net/encyclopedia/article/thomasson.insurance.health.us). That would be about 40 percent of the population insured, and 60 percent – not 90 percent – uninsured. By 1960, the incidence of insurance was about 80 percent. So, Medicare and Medicaid were not saviors of the nation, but johnny-come-latelies.
Well, I’m not a politician. However, if I were, I would not feel compelled to offer up a plan to “cover all the uninsured.” “Covering the uninsured” is not something that the federal government should do – neither practically nor (thanks to the Founding Fathers) constitutionally.
I agree with you that democrats erred in adopting a conservative solution – the mandate – as the centerpiece for their health reform, and I find it bizarre that this is now an ideological fight, because the warriors are lined up on the wrong sides of the issue, and whoever ends up scoring here, will be scoring for the other side. This is sheer insanity.
I agree that the drivers for partisanship were not entirely ideological – on either side, but disagree about the mandate – that one was ideologically opposed on the republican side. I would argue that had the democrates stuck more to their goal of providing care for the uninsured we might have gotten closer to a real step forward.
Ok, sorry if I missed your suggestions for reform, but if you have nothing other than “yeah for the PPACA” and “boo for the GOP” then I’m afraid my criticism does follow. I interpreted your piece as applying to congress, still don’t see much in it about the current GOP presidential candidates. It would be silly for any one of them to present an alternative to the PPACA prior to a ruling from the supreme court striking it down.
Let’s see, Dr. Mike. I say that the GOP presidential candidates have not provided any ideas for universal coverage and you accuse me of partisanship for not debating ideas. Not sure I have any reply to that non-sequitur, except that, over at John Goodman’s blog, I’ve been having a polite debate with conservatives who do have ideas. [Well, at least I’VE been polite. 🙂 ]
ACA was passed on a partisan vote after months of delay when trying to get a bipartisan plan out of Senate Finance went nowhere. GOP threatened Sen. Snowe with sanctions for even voting it out of committee to the floor. GOP intellectuals whose ideas gave rise to many of the parts of the bill were cowed into not saying anything nice even about those parts they supported; instead, it was all dread, “Obamacare.”
It’s not that the Dems can’t be as viciously partisan as the Republicans; they can and are. It’s that in this instance, on this issue, the GOP politicians decided that partisanship was better than bipartisanship, even about an idea that was originally from a GOP think tank and was essentially the same as the GOP governor in Massachusetts passed. Hey, no reason for all conservatives to like it or support it, but no reason for the vitriol, either.
I’m not certain that it is enough to note that there was partisanship involved. I think it is also important to look at the drivers for partisanship, and I don’t think that these were ideological in nature.
Perhaps a public option could elicit strong ideological reactions on both sides, but a mandate to purchase services on the private market should not (at least not along the lines it is manifesting today).
I think it is equally important to examine the root causes for partisanship, and frankly those seem a bit frivolous to me. At some point election results must be accepted and real work should begin.
Except, as has been pointed out, it did contain some elements that should have been viewed as bipartisan. The problem was the lack of debate. Proponents seem to have trouble seeing this, but it seems to me that there was very little debate about the core components and there was no consideration given to alternative ideas other than whether or not to include the public option. The manner in which PPACA was passed was extremely partisan. The individual elements contained within the law less so.
Dr. Mike…”Raise your voice against partisanship instead of contributing to it and maybe we will see some progress.”
I suggest that the passage of ACA was the most partisan action of the past 100 years. I raise my voice against it.
“It clearly says that we none of the GOP candidates for president have come up with any plan…”
Why yes it does say that, and that is the problem with the article. It does NOTHING to advance the cause for providing options for the working poor. Blame blame blame. How many terabytes of hard drive space are collectively wasted by such partisan rants that do nothing to move the debate forward. There are so many options that are simply not getting discussed for this very reason – we judge ideas not on their merit, but on who puts them forward into the public space. Both sides do this. Raise your voice against partisanship instead of contributing to it and maybe we will see some progress. You are angry (obviously) and that is ridiculous. Debate their ideas, respond to their criticisms with reasoned responses based on evidence. Acknowledge when the evidence is weak. Don’t overlook the failings of your own favored politicians. I know, that’s probably asking too much.
Freedom is just another word for Medicare for all….
Slavery is just another word for your life & limb being another entry on someone’s balance sheet…..
Freedom’s just another word for dying of a pre-existing condition…
I”m not sure why this article would piss you off, Dr. MIke. It clearly says that we none of the GOP candidates for president have come up with any plan to cover all the uninsured. Period. Never. Closest attempt: Theodore
Roosevelt, running on the Bull Moose Party (unsuccessfully), not as a Republican.
I’m all in favor of private-public partnerships. What I’m not in favor of is vicious attacks on a private-public partnership by those who offer no alternative. By way of background, I’ve been personally vilified by the single-payer folks, too. In this case, the fault is not equal. It’s the right-wingers who are at fault.
And, of course, the fact that costs go up when purchasing care for the poor ignores the fact that them NOT getting care causes other non-medical costs to go up, hurts productivity, transfers the costs to the poor, etc. The goal is not to keep medical costs down for the middle class or rich or poor. The goal is better value.
I responded to this at my blog: http://healthblog.ncpa.org/
Sorry for the rant but these kind of partisan articles alwasy piss me off. Stupid Republicans. Stupid Democrats. blah blah blah.
Do you want health care for those without it or don’t you? It would be nice if those of you standing on your soap boxes about the uninsured would stop for a minute and think about what it is you really want. THEN we will be able to have a real debate. Trying to make the failed third party insurance system the mechanism by which we reach out to those without health care is just, well, stupid. Using a risk-mitigation strategy when there is very little risk is wasteful. They were exactly right in 1949 – health insurance is pernicious. Because of health insurance the costs for routine health care have skyrocketed. EVERY single time the government attempts to purchase private services on behalf of the poor costs go up. You don’t purchase services – you provide them. Do you hate or love the VA system? How does the care our military members receive compare to that of the citizens of Europe? Is the Indian Health Service a total failure? I say each of these is resoundingly successful compared to how the “uninsured” are treated. And I say that providing each of these groups “insurance” in place of their current benefit would provide little if any benefit at a cost orders of magnitude higher.
One of the greatest obstacles to real progress is your obstinate belief in equality. Well how equal is it when the average working poor family is left with nothing? Give them health care already. To H3LL with insurance.
The thing is, I meet with our GOP congressman yearly, with a group of docs. I really dont think he wants people to drop dead. However, he also supports repeal without very definite plans for replace. He got pretty evasive about this the last time we met. I would like to see the GOP put forth a real reform plan, and have it scored by the CBO. How much will it cost, and how many people will it cover? Then we can debate the merits of their plan. I am disappointed at their failure to do so.
“control Medicare costs by turning it into a “premium support” program that risks leaving those too sick, too poor or not savvy enough shoppers for private insurance to fend for themselves.”
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WHO, precisely, is going to write profitable yet affordable “coverage” for the elderly or the otherwise clinically debilitated that comprise the high UTIL pool?
Without, say, “socializing” the risk by pooling it, which cannot but raise the premiums within the low risk strata?
This whole “premium support” idea is beyond absurd.