CHAPTER SUMMARIES for Who Owns Your Body?
by Madeleine Cosman, PhD, Esq
INTRODUCTION: WHO OWNS YOUR BODY?
This introductory chapter suggests that the sharp four-word question "Who Owns Your Body?" enables each of us to cut through complexities of law and philosophy to assert the same ownership control over our anatomy as over our cars and our houses. Who decides what for whom? Who decides whether and how to repair your car’s bad brakes? Who decides whether and how to repair your home’s leaky roof? Who decides whether and how to repair your sick or injured body? If you own it, it is yours to decide if, how, and when to repair and to which expert to entrust your valuable property.
Suppose government decreed that for cars of your car's age and quality, brake repairs and brake replacements are "vehicularly unnecessary" because too costly, and recommended slow driving plus deceleration plus wheel blocking. You would react with incredulous anger. It’s your car, your money, and your life at risk. Suppose government decreed that for your leaking roof you are forbidden to directly call a roofer but first must consult your general construction "gatekeeper" who if deeming your roof requires a roofer will refer you for specialty care. You would react to such restriction with shocked fury. It’s your house’s roof, your money, your life, and your property at stake.
Medicare and insurance companies pay only for "medically necessary" services, without defining who decides what for whom. Physician "gatekeepers" prevent us from getting through the gate guarding expensive diagnostic tests, treatments, and surgery. Insurance companies, states, and the federal government usurp your rights to decide, control, treat, or withhold treatment of your body, whether you are healthy, diseased, injured, or fatally ill.
Jewish and Christian traditions of body ownership affect control and disposal of bodily parts. Alive we donate blood and spare organs, such as a cornea, kidney, or, if a woman, fertile eggs. After death we donate residual organs such as liver and heart for transplant, education, therapy, and research. We give informed consent to surgery, refuse medical treatment, and decline heroic resuscitation measures. Since we control our bodily parts, why would we not have ownership dominion over the whole body?
The question is vital now because from 1965 until today American medical law has slowly and subtly shifted from civil law to criminal law. Aiming to eliminate fraud in the government medical system, medical criminal law lurches wildly into personal rights of each American physician and each American patient. This law criminalizes physicians, imperiling their professional integrity, personal freedom, and rights to practice their profession. This new criminal law collectivizes patients, placing at risk their privacy, confidentiality of medical records, individual medical choices, personal liberty, and bodily integrity. Medical costs are at the center of the legal whirlwind. Whoever pays, controls. Whoever pays decides who gets what. America’s medicine now is controlled by the bill-payer who decides who is paid, what is paid, when, and what is paid for whom.
If you do not own your body, who owns it? Who should decide whether or how much money should be spent to save your life? Do you have the right to spend your own money to protect what you own?
Who Owns Your Body? America’s 9 Deadly Medical Myths provides the tools to help Americans explore the question, answer it with courage, and take their medical and financial future into their own hands.
MYTH 1: AMERICAN MEDICINE IS RIDDLED WITH FRAUD
(TRUTH 1:Medical Fraud Figures are Based on Figment not Fact. American Medicine is Riddled with Regulation)
Congress, the media, and the public agree that at least 10% of all payments to physicians are fraudulent and that if the billions could be grabbed back, then money would be plentiful for the uninsured and for more generous entitlements for Medicare and Medicaid.
A formidable army of federal and state fraud agents chases then nabs that 10%. Investigators and armed agents rooting out medical fraud work for:
In 2000 Congress spent:
Those who seek shall find. Thousands of well-funded federal investigators and zealous prosecutors with False Claims Act fire-power caught for Medicare Fraud Control in 2000:
No one knows for sure where the 10% fraud idea came from. Learned estimates from the 1970s, guesses, inspirations, suppositions, and gut feelings are augmented by annual review of a mere 600 out of 41,000,000 Medicare fee-for-service patients’ confidential records. No valid statistics fuel the fire of prosecutors’ wrath against physicians and surgeons. Fraud might represent only 1% or 15%. But 10% is a political proportion not a statistical certainty.
Rather than being riddled with fraud, American medicine is riddled with regulation. Medical practitioners must abide by voluminous federal and state laws and regulations often mutually contradictory, vague, and arbitrary. Medicare and other statutes that necessarily must be studied, understood, and meticulously followed include:
In these circumstances even the most ethical, careful, scrupulous physician of integrity will err. If investigated, hospitals, clinics, and physicians treating Medicare and Medicaid patients risk professional devastation and fiscal death. Practitioners and hospitals customarily admit to small infractions of arbitrary, vague laws and though not guilty of any crime or fraud will settle cases for millions rather than risk full-scale audit or court case with ruinous statutory penalties.
The zeal to root out medical fraud has also rooted out fundamental criminal law protections for the innocent. An arsonist, rapist, or murderer has more protective criminal procedures guarding Constitutional rights than our best physicians.
MYTH 2: WHITE COAT CRIME INJURES MEDICARE AND MEDICAID PATIENTS
(TRUTH 2: White Coat Crime Injures Medicare and Medicaid Physicians and Programs)
White Coat Crime is the new criminal law strangling American medicine. This new medical law differs drastically from regular civil law, from White Collar Crime, and from common criminal law. Doctors on trial for the major White Coat Crime of Medicare fraud almost never are accused of physically injuring patients but are convicted of injuring the Medicare program because they charge it money. Physicians themselves are chief targets of ferocious medical fraud law. Most of America’s 761,000 physicians and surgeons who treat 41,000,000 Medicare patients and 47,000,000 adults and children on Medicaid do not yet understand the perils of White Coat Crime for their professional lives and for their personal liberty.
Ordinary criminals must act criminally and intend their actions. White-coat-wearers need not intend to commit their alleged crimes nor know that their acts are criminal. Wearers of white coats need not be physically present nor personally commit the crime. The accused doctor should have known that certain acts were forbidden. Ordinary fraud is defined as intentional misrepresentation of material fact for the purpose of causing a person’s injurious reliance and damage. Medical fraud can be unintentional, trivial and not material, not harm and actually help the patient if the crime hurts the medical program by billing it for the patient’s care. Drug dealers, murderers, and arsonists who are tried, convicted, then sentenced under the Federal Sentencing Guidelines are likely to get shorter less savage prison sentences than convicted physicians and surgeons.
Ordinary criminals have Constitutionally-protected rights to defense. Vigorous White Coat Crime defense is difficult when the doctor’s assets are frozen then taken under Forfeiture laws. White Coat defense lawyers correctly fear being accused and indicted for conspiracy in the medical crime. Ordinary criminals cannot be prosecuted under ex post facto rules. No murderer, arsonist, or rapist can be convicted of a crime that he perpetrated before the law made his specific act a crime. Physicians, however, can be prosecuted under ex post facto laws that define acts not prohibited and not called crimes until the doctor does it.
Medical law wasn’t always this vicious. Law by law, incrementally from Medicare’s inception in 1965, the law shifted slowly and surreptitiously from civil law to criminal law, and each law became more draconian, arbitrary, and punitive than the one before. This chapter reviews seven White Coat Crime threats to physicians’ medical liberty:
Exemplifying these deadly devices are cases ranging across national geography and medical specialties in which excellent, efficient practitioners were caught in technical infractions of capricious laws literally interpreted and retroactively enforced. A California ophthalmologist convicted of medically unnecessary surgery totaling $65,140 was fined $16,200,000 and originally sentenced to 11 years in prison, reduced on appeal to five years. Family physicians from Kansas were convicted of referral crimes and sentenced to 10 to 40 years in the federal penitentiary. Billing crimes earned an internist from Seattle, Washington, and a psychiatrist from Wisconsin 3-year jail sentences. A Washington, D.C., psychiatrist was convicted of billing improperly under an unknown standard, originally fining him $245,392 and threatening $81,000,000 in penalty.
MYTH 3: LEGISLATION CRIMINALIZING PHYSICIANS PROTECTS PATIENTS FROM INJURY AND INJUSTICE
(TRUTH 3: Legislation Criminalizing Physicians Protects the Programs and Their Budgets)
In 1965 the law creating Medicare was gentle civil law established to provide excellent medical care to America’s vulnerable elderly and disabled. Medicaid was established to extend medical welfare benefits to the very poor. The medical law was not coercive and did not meddle in physicians’ decisions or office practices. This chapter examines seven laws governing modern American medicine, starting with changes in the Social Security Act in 1965 that created Medicare and Medicaid to the stunningly restrictive Health Insurance Portability and Accountability Act (HIPAA) of 1996, the most brutal law of them all. Each law increasingly restricts physicians’ rights to practice ethical, independent medicine. Each law holds the physician to a more unreasonable legal requirement to know and understand the laws. In 1965 no doctor could be prosecuted unless he knew a particular act was wrong and he did it willingly and intentionally. Now doctors are prosecuted because they should have known and they are convicted and jailed even when not intending to do wrong. The physician treating by best ethical judgment for the patient’s best interests who knows specific treatment is medically necessary nevertheless is indicted by the government for providing "medically unnecessary" care, which, in translation, means whatever Medicare refuses to pay for.
From the civil lariat of the first Medicare law in 1965 through the criminal noose of current HIPAA, each of seven major laws becomes more restrictive, oppressive, and punitive:
Nine cases demonstrate armored links in a litigation chain that has become a weapon in zealous prosecutors’ arsenals. The infamous Greber One Purpose rule viciously extends the long arm of the law to hook many types of otherwise reasonable and legitimate referrals to hospitals and referrals to diagnostic and treatment centers. Medical law as written and as interpreted in the courts includes patients in the criminality of their prosecuted and convicted doctors. These cases, like those the cases discussed in the previous chapter, implicate patients in:
MYTH 4: COLLECTIVIZING PATIENTS PROTECTS INDEPENDENCE AND CONFIDENTIALITY
(TRUTH 4: Collectivizing Patients Destroys Independence and Confidentiality)
Treating patients as members of groups or by diagnosis, rather than as individuals, diminishes their autonomy, destroys their privacy, and violates patient-physician confidentiality. This chapter introduces five methods for collectivizing patients:
These have potentially devastating results on patients’ medical treatments and prognoses. Collectivizing patients directly affects their quality of life and sometimes influences whether they live or die.
Indirect effects of collectivizing patients are evident when their doctors are sued under criminal laws. Laws fingering doctors point also to their patients. White Coat Crime prosecutions of physicians under Medicare and Medicaid law could propel patients into jail cells with their doctors. Just as a doctor can be prosecuted, tried, and jailed for providing medically unnecessary medicine or surgery, so a patient may be similarly at risk for having received the care and collaborated in the "crime." Three clear and present dangers to patients are:
This chapter calls patients to alarmed alert. No patients have as yet been convicted and sentenced to jail. But the stated law that now snares physicians also could claw their patients.
MYTH 5: MEDICALIZING SELECT SOCIAL HAZARDS BENEFITS SOCIETY
(TRUTH 5: Medicalizing Detrimentally Confuses Medical Effects with Social Causes and Harms Patients)
All collectivized medical patients in the same group get the same treatments no matter what each individual truly needs. One size fits all. Collectivizing patients has ominous consequences in public health law and practice. This chapter reviews the three interrelated phenomena of Congressional and public health experts’ demands
Medicalization is the process of studying, paying for, and directly intervening in a volitional social action by calling it a disease. In public health lingo, drug addiction, obesity, teenage pregnancy, and ghetto violence are epidemics we must be inoculated against to avoid contagion. Medical effects are clumped together with volitional causes. Volitional acts such as using heroin and methamphetamines are disconnected from medical consequences. Physicians diagnose, prognose, and treat select social dilemmas as if they are contagious diseases or accidental injuries. Treating social dilemmas as disease is fund-worthy. Treating social dilemmas as disease also vastly expands the ranks of Medicaid beneficiaries. Medicalizing is said to benefit patients, compassionately honoring their humanity without blame and without stigma.
Single standard medical care for all Americans is said to be necessary for democratic fairness, for eliminating health disparities, and for fiscal necessity. Medical single standardists forget that America has no single standard for any commodity or any asset. Americans do not eat one standard of American food, requiring everyone daily to swallow McDonald's hamburgers or Chicken Chop Suey. Americans do not wear one standard uniform with all people clothed in same jacket style plus routine jewelry ration. Americans do not live in single standard 800-square-foot houses. Yet few people are protesting single standard medicine.
In Congress and in public health programs there is ominous convergence among medicalizing of select social hazards, creating single standard medicine, and eliminating health disparities. Two recent examples are mental health legislation and public health anti-terrorism guidelines. Mental health provisions of the failed Clinton American Health Security Act (many parts of which now are enacted in the Health Insurance Portability and Accountability Act and other sections are written into laws currently awaiting Congress’s approval) yoke the mentally ill suffering from depression, schizophrenia, and autism, with drug addicts. Mental illness is half of the routine medical law phrase Mental Health and Substance Abuse. This yoking unjustly adds to burdens of mental illness the heavy freight of addicts’ criminality to support drug habits and places the two groups in competition for the same limited funds.
Even terrorism is medicalized. One month after the September 11th terrorist atrocities, the American Public Health Association (APHA) met in Atlanta and publicized its 12 Guiding Principles for a Public Health Response to Terrorism. Americans expecting their public health guardians to recommend new vaccines and antidotes to biological, chemical, and nuclear warfare, to set standards for disaster preparations and city evacuations, and to propose safety measures for integrity of America’s water, food, medicine, and fuel supplies discovered instead that APHA’s #1 guiding principle is: to address poverty, social injustice, and health disparities that may contribute to the development of terrorism.
APHA’s stated mission is "equity in health status for all" in a "healthy global society" where everyone has "right" to medicine and even a "right" to health. What rights? Whose responsibility? Who decides what for whom? Who pays? Health defense of the nation and the health of each citizen depend on bold, clear answers to those questions and to the sentinel question: Who owns your body?
MYTH 6: EVERY AMERICAN HAS A RIGHT TO MEDICAL CARE
(TRUTH 6: There is No Enumerated or Implied Constitutional Right to Medical Care)
This chapter presents the legal background of Americans’ medical rights of privacy and physical autonomy. It explores perceived rights to Medicare and to Medicaid. Congressmen, medical experts, and the media constantly refer to health care rights. They describe monies and surpluses in our Medicare Trust Funds. With Trust Fund money Congress offers to pay for generous prescription drug benefits for all American seniors. Despite impassioned political rhetoric asserting rights to medical care, four critical questions provide alarming answers.
If medical care, Medicare, and Medicaid are not rights, what are they? What is the difference between a liberty right and a welfare benefit? What distinguishes a substantive right from a mere procedural right?
There is no right to medical care in any of the seven articles of the U.S. Constitution, or in the first ten amendments called the Bill of Rights, or in the seventeen subsequent amendments. No state provides a right to medical care. Likewise, there is no Constitutional right to food, to clothes, or to housing. The Constitution guarantees such rights as to vote, to speak freely, and to be fairly compensated if the government takes our private property for public use. Our rights prevent government and other people from taking our freedom and our goods. No right provides free goods.
Welfare benefits are free goods. Our rich, compassionate nation provides welfare food benefits, housing, clothing, and medical benefits for those who cannot provide for themselves. Those benefits are not rights. If they were rights then you, I, and your wealthy aunt Jeannie could collect a monthly check for food. Or rent. Or clothes. We cannot. We should not. Why should we get free medical care? We cannot and we should not.
For every right, someone or some government entity has a legally enforceable responsibility to assure the right. If there were a right to food, every restaurant owner and every farmer would be obligated to provide food to anyone who demanded it. If medical care were a right, every physician and surgeon would be obligated to provide medical goods and services. Suppose a doctor was not willing or not able to treat a patient. Suppose the pay was too little to cover costs and expenses. Under a system with a right to health care the government could compel the physician to supply services under threat of prison.
Medicare Trust Funds violate the legal and linguistic meanings of "trust." Each payday working Americans pay to a Medicare Trust Fund money withheld from their paychecks. The implication is that each employee has a personal account invested for his benefit. Medicare Trust Funds are brutal deceptions. No Americans who paid into the Medicare program at any time from 1965 until today have paid into a Medicare Trust Fund for themselves or for others. No one owns a Medicare Trust Fund. None of the money they paid has been invested for their future or anyone else’s future medical care. They paid for anonymous retirees claiming Medicare benefits. Medicare always has been a pay as you go program. There is no money in the two Medicare Trust Funds now and there will be none later except for withholdings from future paychecks of future workers. While in 1965 the ratio of workers to retirees was 7 to 1, now it is fewer than 4 to 1, and soon will be 2 to 1. In fewer than a dozen years, the 41,000,000 people currently on Medicare and the 47,000,000 on Medicaid will suffer a tidal wave of new fervent competitors for "free" medical care. The first wave of 77,000,000 Baby Boomers hits shore in 2010. Who will be left working to pay for Medicare?
Now in 2003 Medicare is functionally bankrupt. It is running a deficit that according to the Congressional Budget Office (CBO) exceeds $1.1 trillion dollars. We neither see that number nor hear about it because CBO keeps the sinking Medicare ship afloat with general tax revenues. Accountancy tricks split the costs and revenues of the two sections of Medicare (Part A devoted to hospital costs is called Hospital Insurance and Part B dedicated to medical office expenses is called Supplemental Medical Insurance). The result is mythical trust accounts that have mythical revenues that generate mythical surpluses. Even the most fervent mythmakers will be shocked at the projections of the Medicare Trustees in their Annual Report of 2003. If current financial manipulations continue, our grandchildren will pay 71% of each paycheck to support Medicare’s aged and disabled. Medicare’s hazardous financial antics are far more pernicious than current, prosecuted corporate frauds and deceptions.
Americans who understand the perilous truth will act prudently, logically, and responsibly or suffer inevitable exploding costs, crushing taxation, and savage benefit cuts.
MYTH 7: EVERY EMPLOYER MUST PAY FOR EMPLOYEES’ HEALTH INSURANCE
(TRUTH 7: Employee Health Insurance Began as a Salary-Substitute during World War II )
This chapter explores the history of employer-sponsored health insurance resulting in each employee’s lower wages and restricted medical choice.
No employer in the USA pays for medical insurance. Every employee’s health insurance is a tax-advantaged salary-substitute. The employer gets the advantage under the Internal Revenue Code Section 106 exclusion.
World War II wage and price controls made it necessary for employers to offer more salary without offering more money. Medical insurance was the hidden way to sneak valuable benefits to employees without violating the wage control law. Half a century later, every employee still actually pays 100% of his or her medical insurance policy by salary-substitute.
Today employees threaten to strike because their employer, for example, General Electric or Verizon, requires them to pay a larger percentage of health care "insurance" costs. The workers do not understand that no matter what percentage they think they pay, it is always 100%.
Employees who volitionally pay for medical care with their own money might or might not select HMOs. Few employees freely would buy "employer-provided medical insurance" and pay 100% of the cost in lost wages and 100% of the cost in lost choice. Employees who volitionally elect HMOs with their own money merit admiration for their tolerance of risk or for their own certitude of their good health. Apparently only 16 % of people with freedom to elect or reject HMOs select HMOs, low cost being the dominant reason. That is valid freedom of choice.
For those forced into HMOs because their employer offers nothing else, if the HMO refuses necessary care the employee can sue both the HMO and his employer via the deeply flawed Patients’ Bill of Rights. The employer who selects an HMO that denies medicine or surgery to an injured or sick employee also takes on an unwitting moral liability for he has used the employee’s own money to prevent care of the employee’s own body.
One method for restoring order and body ownership is to change the tax code to allow employees a tax advantage as opposed to employers. Employers who will have no tax incentive to continue in the medical care business will be glad to see their employees deal with medical professionals directly. Workers need a tax incentive to buy their own care, such as simple tax deduction for all medical expenses, as opposed to the Tax Code’s current requirement that only medical expenses over 7.5% of adjusted annual gross income qualify for deduction. Working people with a tax incentive to buy medical care the way they buy all other assets and services will then stop demanding that employers who are amateurs in medicine provide medical care.
Government tax exclusion for employers costs America about 140 billion dollars annually. That amount could provide $1000 per individual American in tax advantage for individually bought, personally owned, and autonomously selected medical care.
MYTH 8: INSURANCE IS DISCOUNTED PREPAID MANDATED MEDICAL CARE
(TRUTH 8: Insurance is Asset Protection for Events We Hope Won’t Happen)
This chapter details the misconceptions about insurance and the false crutches that "health insurance" creates in the American medical system.
Insurance, like automobile, fire, and theft insurance, even life insurance, is a risk contract that protects our assets from events we hope will not happen. But they might happen. Prudence requires our providing for our potential losses of assets if disasters occur. Insurance companies make their profit by their actuaries predicting that disasters will not occur for large numbers of premium-payers. Insurance pays for disasters that small numbers of insured people suffer.
The ABCs of true insurance protect people against astronomical costs of unusual or bizarre events that people consider catastrophic. Insured occurrences are expensive, unusual, and undesired. Our car insurance insures against thefts and crashes, but not against routine maintenance of changing oil and filling the tank with gasoline. Our household insurance insures against fires, floods, and burglary, but not against changing light bulbs and filling the refrigerator with food.
Payment for routine medical maintenance, for mandated medical services, and for known required services is not insurance. Payment is payment. The only true medical insurance is Catastrophic Medical insurance coverage for major expensive, unusual, undesired diseases of injuries. Catastrophic policies have very high "deductibles," such as $2000, because the policies are only for catastrophes, not routine body maintenance. About 80% of Americans spend less than $2000 annually for healthcare. They pay far more for pseudo-insurance premiums than the value of the medical care they get.
Insurance-related myths are that must be dispelled are:
Current "medical insurance" truly is prepaid discounted medical fees. The physician is paid a discounted amount of customary fees negotiated in advance with the "insurance company" or the doctor is paid monthly a small amount of money per head of citizen by capitation, no matter how much or how little medical care the body attached to the head requires. Whether the patient arrives daily for care and expensive medication or never comes for care at all, the doctor is paid no more and no less. Medical payment remains inflexible whether the patient’s treatment is comprehensive for pulmonary edema or cursory with one Ace bandage for ankle sprain. The physician risks profit for time and talent. This exploits intelligent, productive physicians, and dissociates patients from real costs of their care. Worse, pseudo-insurance falsely promises patients asset-protection that it cannot and will not fulfill.
Catastrophic medical insurance, however, is the foundation for ethical, excellent, consumer-driven medicine that protects people against terrible, expensive, and devastating diseases and injuries while nevertheless giving them control, choice, and responsibility for everything else. Medical Savings Accounts are among a dozen such programs.
MYTH 9: AMERICANS ARE INCAPABLE OF MAKING MEDICAL CHOICES AND NEED GOVERNMENT TO SUPPLY MEDICINE
(TRUTH 9: Americans Will Thrive on Medical Savings Accounts and Free-Market, Patient-Driven Medicine)
This chapter offers immediately applicable, common sense solutions for Americans who will not meekly accept loss of their body ownership rights. Rational, feasible, legal methods for reasserting individual body ownership are open to all Americans rich or poor, young or old:
These are among dozens of consumer-driven methods consistent with body-ownership, self-responsibility, innovative achievement, and other values of a free society.
MSAs, created in 1996 via HIPAA, are especially important. Though imperfect, MSAs empower medical consumers with individual choice and control over money. MSAs celebrate intelligence, initiative, industry, and bodily integrity. This chapter compares the many exciting new consumer-driven products and answers such questions as:
MSAs, like many other consumer-driven medical methods, diminish, almost extinguish, the eight severest intrusions upon patient freedoms imposed by medical laws governing managed care, health maintenance organizations (HMOs), and Medicare. Consumer-driven medicine:
MSAs and other consumer-driven medical modalities are rational, logical, responsible, judicious celebrations of the intelligence, individuality, and common sense of Americans. MSAs and other consumer-driven medical modalities are important for all who cherish medical freedom. MSAs encourage individual patients’ medical prudence. Almost everyone benefits. Patients freely select their doctors and make reasoned decisions about their own care. Employers pay considerably less for MSAs plus catastrophic health insurance than for other health plans. With consumer-driven health care everyone wins except social engineers who protect people against personal freedom, who control quality and quantity of medical care, and who redefine as medically necessary whatever their arrogance demands.
Who Owns Your Body? America’s 9 Deadly Medical Myths refutes customary arguments against MSAs and free-market, consumer-driven medical care such as:
MSAs and other free-market, consumer-driven medical programs will expand medical excellence, physical integrity, and responsible body ownership for all Americans.
Criminalizing physicians, collectivizing patients, and medicalizing select social dilemmas all result from the paradigm shift beginning in 1965 placing government and other third-parties at the center of medical responsibility. Perhaps well-intentioned and perhaps compassionate, the shift from individual to government control has had vicious consequences. Costs erupted, care decayed, choice evaporated, and physicians and surgeons have been exploited and brutalized.
Consumer-driven medicine will provide the necessary paradigm shift to place the individual American at the center of decision-making. Whoever pays, controls. Whoever pays, decides what shall be done or not done to the body luxuriating in vigorous health or debilitated by injury or disease. If that body is your body, do you prefer to assert the same ownership control for your anatomy as for your car and your house? Who decides what for whom?
Americans merit the best medicine of a free society. They have the courage, the intelligence, and the rights to buy it. Who Owns Your Body? America’s 9 Deadly Medical Myths reveals deceptions and misconceptions in modern American medicine and charts the path to medical abundance, medical integrity, and medical excellence.
The Glory of Choice: Unshackling American Medicine with Patient-Centered Care
Madeleine Pelner Cosman, Ph.D., Esq.
Americans will resist the lure of free health care even though our nation has lurched with seemingly unstoppable momentum towards a "social protectorate" that could make America the land of the dependent and the home of the entitled. Health care has become a spectacular instrument for manipulating and expanding federal power by nurturing dependence on government and quelling resistance to any change that might reduce "benefits." But Americans who cherish liberty will celebrate choice.
The Biblical Hebrew word timshel means you may choose. God offers free will. We are not destined only to obey. Choice is the foundation of morality and ethics. We have the glory of choice to elect what is right and reject what is wrong. John Steinbeck in East of Eden noted that to decide, to choose, may be "the most important word in the world…[It] says the way is open. That throws it right back on a man . . . [T]hink of the glory of the choice! That makes a man a man." Choices of doctors, medications, hospitals, therapies, locations of medical care, and whether or not to initiate and to continue medical care are essential to those who will not meekly accept loss of their body ownership rights. Rational, feasible, legal methods for reasserting individual body ownership now are open to all Americans, rich or poor, young or old. Ingenious patient-centered, consumer-driven medical methods are consistent with body ownership, self-responsibility, innovative achievement, and other values of a free society. The range of consumer-directed medical techniques includes:
To enjoy any of these mechanisms of medical choice requires an underlying ethical decision to choose responsible freedom and reject phony free goods. In December 2003, federal legislation created new programs to promote consumer-directed health care. These should help scientific medicine to flourish and personal liberty to prosper.
HEALTH SAVINGS ACCOUNTS AND MEDICAL SAVINGS ACCOUNTS
The most exciting new medical instruments for all Americans are Health Savings Accounts (HSAs), the brand-new free-market medical mechanisms legislated into law in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. HSAs closely resemble Medical Savings Accounts (MSAs) that were created in 1996 by HIPAA, the Health Insurance Portability and Accountability Act. But HSAs are superior. HSAs and MSAs credit each American's intelligence, individuality, discretion, and responsibility. Every HSA or MSA has two distinct but interconnected parts:
Visualize an HSA as a benevolent handshake. One hand is the actual HSA savings account. The other hand is catastrophic medical insurance, whose high deductible equals the amount of money annually placed in the HSA savings account. If you prefer, think of an HSA as a pair of pliers. One plier arm is the HSA savings account. The other is the high deductible medical catastrophe insurance. The two arms of this tool move in synchrony and together expand the reach and power of the HSA owner’s hand.
HSAs are not discounted prepayments of medical care. HSAs utilize true medical insurance that protects assets against expenses for physical catastrophes we hope will not happen. Since HSAs will be far more popular and available than MSAs, I shall refer only to HSAs, but any description here of an HSA pertains also to an MSA. The older MSAs intentionally were restricted by Congress to 750,000 people and dedicated to those who are self-employed or who work in companies of fewer than 50 employees. MSAs in theory are open to people who qualify for Medicare but in actuality, no Medicare MSAs exist because no insurance companies have had the corporate courage to leap the huge number of federal and state legal hurdles to create catastrophic polices that will conform to Medicare law. The new HSAs emulate the best of MSAs with few restrictions on who can buy them. One irony is that these magnificent consumer-directed, patient-centered HSAs created by the Medicare bill exclude people covered by Medicare. But in due time we shall fix that folly.
Companies began offering the new accounts on January 1, 2004 to thousands who applied. Both parts of HSAs are established at the same time. Anyone under age 65 is enabled to deposit into an HSA tax-free up to $2,600 for individuals and $5,150 for families. Some of the same banks and companies that establish the HSA savings account will sell or arrange for the consumer’s purchase of a catastrophic health insurance policy. You can make your own contribution to your HSA savings account. Your employer can provide the annual amount. Or you and your employer each can contribute funds. Again, the amount in the savings account will be roughly equal to the high deductible of the insurance policy.
President Bush clearly made HSAs "a cornerstone of his health reform plan," said Greg Scandlen, director of Galen Institute’s Center for Consumer Driven Health Care. The president’s plan allows 100% above-the-line tax deductibility of premiums for catastrophic insurance associated with HSAs. People who purchase catastrophic policies on their own are able to deduct 100% of the premiums. This full tax deductibility of premiums for catastrophic health insurance "will supercharge HSAs and make them an even more attractive option for millions of Americans, including the uninsured." Under current law, the health insurance is tax-favored if individuals are self-employed or their employer purchases the policy for them.
With money from your HSA savings account, you pay directly any physician you choose and you pay directly any pharmacist for any medicine you choose for whatever minor medical problems you reason it worth paying a practitioner to solve. If you have a medical disaster that costs more than the amount in the account and that equals your deductible, then your catastrophic insurance takes over payments.
You, who own your body and mind, decide what is medically necessary along with the doctor providing medical care. No one tells you whether you are permitted to go to a specific doctor or when or how or why. You decide. No one tells you what treatment is or is not "covered." You and your doctor decide. No one tells your employer why you went to a physician or that you went and where. No one transmits your confidential medical records to an insurance company adjuster. You maintain confidentiality of your medical record for all routine medical problems. Only if and when your catastrophic insurance policy starts to pay for care is there any reason for anyone but you and your physician to know what is in or not in your medical record.
Moreover, you totally own your HSA savings account. You can deduct from it small or large sums to pay directly or you can use a debit card to pay any valid medical expense. What is a valid medical expense? Do you prefer acupuncture for recurrent back pain rather than anti-inflammatory drugs or opiates? Fine. Buy it. Do you prefer to try two months of physical therapy for your herniated lumbar disk rather than sign in for spine surgery? Buy the therapy. Your only restriction on what is a justifiable medical expense is the alphabetical list in IRS Code Section 213 (d) that identifies valid medical deductions on taxes.
Since what you do not spend you keep, some call such a medical account a SIKI, Spend It or Keep It. That is a powerful incentive to prudent spending. HSAs respect your intelligence, individuality, initiative, and good financial judgment. You determine the benefit versus the cost of each medicine or procedure before consent. Do you prefer the generic or the brand-name drug? Do you prefer the expensive, aggressive, invasive method or the inexpensive, conservative, non-invasive technique? You decide. It is your body, your money, and your life.
Because you are paying cash, many practitioners will welcome you with enthusiasm and provide a cash discount on their fees because you honor their talent by directly exchanging your valuable money for their valuable skill, the customary capitalistic method of exchange in America. Furthermore, by paying cash at time and place of service you are saving the doctors’ precious time and money. The physicians do not have to pay a billing service or keep on staff insurance billing secretaries to submit claims for reimbursement. The doctors do not have to wait weeks, months, or years for their money from the insurance company or the government. Good cardiologists, internists, dermatologists, and urologists have the same market incentives to behave justly and fairly when selling their medical talents and services as do other American professionals, craftsmen, and purveyors of honest product.
The money in your HSA savings account is tax-favored. The deposits are tax-free, the earnings are tax-free, and the expenditures are tax-free. HSA money is not taxed until you reach age 65 or unless you withdraw it for nonmedical purposes. Inappropriate use, just as with an IRA from which money is removed before the statutory time, generates both tax and penalty. Since it is your money, not your employer’s and not the government’s, you can roll over whatever is left over in your account at year’s end and let it earn interest. Again, that is comparable to an IRA.
Furthermore, even if you suffered a medical disaster after a healthy year in which you rolled over your unused money, you would spend no more from the HSA account than the stipulated deductible for that particular year. If, for instance, the deductible is $3,000, even if by that time you have $79,000 accumulated in your HSA, you still will pay only $3,000 cash before the catastrophic medical insurance takes over the medical payments. A reasonably healthy person cannot fail to make money with an HSA prudently invested. Customary health insurance, the bogus insurance that is discounted prepayment for medical services, produces for the policyholder at year's end nothing but a canceled check.
The HSA is yours no matter where you work, no matter whether you change from job to job, and whether or not you work. It is completely portable. Like other personal property that you own, you can will it to your family so that after your death the money in the account will serve those you select. As an HSA owner you have rights to have, to hold, to quietly enjoy, and to convey your property.
With HSAs, people have the same legal protections and ethical incentives as elsewhere in the American economy. Medical law controls behavior of doctors and patients just as American law guides and guards other important commodities of life and other owned property. HSAs assume tort law protection for patients against medical malpractice. HSAs are predicated on contract law protection against false promises and overpayments. HSAs diminish the eight severest intrusions upon freedoms of physicians and patients imposed by health laws governing managed care, health maintenance organizations (HMOs), and Medicare. HSAs:
HSAs encourage individual medical prudence. HSAs place personal rights and responsibilities in the minds and hands of Americans requiring medical care. HSAs have no need of a Medicare Operation Restore Trust with its harsh penalties, fines, forfeitures, and prison terms for physicians and surgeons. Under HSAs the physician's allegiance is to the patient who pays, not to a third-party payer. Trust not violated needs no restoration.
HSAs are rational, logical, responsible salutes to the intelligence and comparative good health of America. Everyone benefits. Patients freely select their doctors and make reasoned decisions about their own care. Employers pay no more, usually much less, for HSAs plus catastrophic health insurance than for other health insurances. Doctors favor HSAs for allowing them to practice good medicine without threats of costly litigation and protective measures required against accidentally violating criminal laws. Medical innovation and medical entrepreneurship benefit the medical market. Insurance carriers, insurance marketers, and insurance agents benefit. Banks benefit. With HSAs everyone wins except the social engineers who want to impose protections against personal freedom. Their intent is to control quality and quantity of medical care, and redefine "medically necessary" as whatever they think is medically best.
FLEXIBLE SPENDING ACCOUNTS (FSAs)
Of the four types of "Medical Spending Accounts," the most free-market, patient-centered, and consumer-driven are Health Savings Accounts and their precursors, Medical Savings Accounts. Two other types of medical accounts invite consumer participation but corrupt the possibilities to truly influence spending choice because the account users are not the account owners. Flexible Spending Accounts (FSAs) and Health-Reimbursement Arrangements (HRAs) are beneficial but forfeit the privileges of ownership.
FSAs, HRAs, MSAs, and HSAs, however, all are creatures of federal law that marry health insurance plans to tax-favored cash accounts to pay for medical expenses. They all have potential to control medical inflation. They all give patients as consumers some control over their own health care choices. They require patients as consumers to take some financial responsibility for consequences of their decisions. But only the MSAs and HSAs achieve the rationality and savings of private ownership and free-market medical decisions.
Flexible Spending Accounts, the so-called Cafeteria Plans, permit employees to divert a portion of their paycheck, tax-free, to pay medical expenses not covered by insurance. IRS Section 125 controls contributions of pretax dollars for spending on medical care. FSAs are sponsored only by employers. The self-employed or those who work for an employer who does not provide FSAs cannot create FSAs. They are purely company perquisites.
In theory, FSAs should encourage thoughtful, circumspect use of medical money because the employee as consumer is using his own money, rather than the insurance company's, to pay for routine care. In practice, however, FSAs promote wasteful spending because the IRS code makes FSAs "Use It or Lose It" money. Unused funds at year-end revert to the employer. Employees usually go on an annual end-of-year lavish medical spending spree. President Bush has proposed eliminating this perverse incentive by allowing unused funds to roll over to the following years.
HEALTH REIMBURSEMENT ARRANGEMENTS
Health Reimbursement Arrangements (HRAs), created in June 2002, resemble FSAs. HRAs are not available to the self-employed. Companies set up HRA plans for their employees and, using employer funds only, permit employees to pay with tax-free dollars medical expenses not covered by insurance. HRAs became valuable when the IRS issued revised regulations allowing unused dollars in HRAs to roll over from year to year, mitigating "Use It or Lose It" binges.
Nonetheless, HRA monies are not employee-owned and are not "portable." If an employee changes jobs his HRA cannot be moved to a new employer. In some instances the employee with a new job may have rights to use the HRA in the former employer’s company. Furthermore, since the sponsoring employer owns and controls the accounts, there is little incentive for employees to control spending. As with FSAs, the best way for an employee to gain value from an HRA is to spend every penny in the account. Like FSAs, HRAs inject common sense into health care choices, but not enough control. Consumers, not government or insurance company bureaucrats, have power over some costs and exert some financial responsibility for medical expenditures. Still, only HSAs and MSAs provide direct control, financial responsibility, and the glory of choice.
CASH (OR CREDIT) AT TIME AND PLACE OF MEDICAL CARE
A simple, effective way to reduce routine medical costs is to have everyone pay for primary medical care at point-of-care. The usual way we buy most goods and services in America is to pay in full at time and at place of service. We exchange our valuable money for valuable items we consider more important than retaining the money. That simple basic exchange is the foundation of economics’ supply and demand. Exchange of value for value is the genius of capitalism and the inspiration for personal liberty.
Most able-bodied Americans who pay for their own food, clothing, entertainment, liquor, and cigarettes have the ability but not the will to pay for their own routine medical care. Small medical costs escalate to large because of the administrative burdens of billing government and insurance companies. Certainly Americans who are self-sufficient and independent have the capability to pay for medicine and for medical care just as they pay for almost all other important assets, at the point of purchase. Americans who need help with daily costs, such as most people on Medicaid, could pay something towards their care.
Even the wealthiest people do not necessarily pay the total price in cash at time of purchase. For substantial items such as cars and houses, no seller will willingly transfer rights of ownership to us as buyers until we pay a down payment and pledge by contract to pay off the remainder of the debt as and when due. If we pledge to pay our money into an unknown future to buy a car that will transport us from place to place, we can similarly pledge to pay out a medical debt for a cardiac rehabilitation that will extend our lives from today to the future. If we finance the Steinway piano, we can finance the repair of the dislocated shoulder and broken hand to play Chopin and Bach or Scott Joplin and jazz on those piano keys. We finance many important assets that we cannot pay for in cash at time of purchase. We finance houses and real estate with mortgages. We finance personal property with credit cards, loans, and other contractual promises to pay in the future for goods and services we get right now. We buy expensive jewelry, furniture, and vacation voyages and pay off our debt over time either to the seller of product and service or to a bank from which we borrow money to exchange with the seller. Likewise, we could buy for cash, check, or credit card or otherwise finance our medical care.
Critics of medical independence claim that the poor cannot use freedom to choose because they are not smart enough and because they do not have money enough. This phony excuse daily is refuted by the behavior of many poor people who, having no incentive to pay for what they can get for free, spend their limited money on other items they select. While medical care is expensive, entertainment often costs even more. The rich are not the only Americans who go to movies, amusement parks, casinos, bars, and fast-food restaurants, and who buy big-screen televisions with VCRs at discount stores. Nor are rich women and men the only people who buy surgical face lifts, tummy tucks, buttocks contouring, and varicose vein removals.
Furthermore, Americans do not necessarily spend "too much on medical care" if we get good value for what we spend. Expensive medical procedures and prescription drugs lengthen our lives, help us conquer life-threatening diseases, enable us to avoid disfiguring operations, and enhance our health, well-being, and happiness. As a nation we spend a lot for a lot of excellence. Surely it is not a national disgrace to spend more on medical care than other industrialized nations. Millions of American health care consumers, especially those who pay part of their bills in cash and who buy drugs and treatments "over the counter," make millions of buying decisions using some of their own money in the form of cash, premiums, and taxes. In 1998, American personal consumption of health care was $1,000 billion. But American personal consumption of transportation was $647 billion; recreation $495 billion; household operation $646 billion; housing $855 billion; clothing $368 billion; food and tobacco $907 billion. Why is it that only health care spending is viewed as a crisis? In 1982, the numbers were health care, $733 billion; transportation $472 billion; recreation a mere $311 billion; household expenses $471 billion; housing $647 billion; clothing $284 billion; food $710 billion. While spending increased 41% for health, it soared a whopping 59% for recreation. Few complain of a terrible crisis in recreation in the United States!
PATMOS, SIMPLECARE, AND INDOC
An advertisement in Greeneville, Tennessee, newspapers with a photo of a strong, dark-haired, whimsically-smiling physician with a stethoscope around his neck standing in front of a row of books, asks: High Co-Pay? High Deductible? Uninsured? Try PATMOS EmergiClinic. Robert S. Berry, M.D. is Board Certified in Internal Medicine, Board Certified in Emergency Medicine, and the Recipient of 2002 Cup of Kindness Award for Innovation. He charges:
Open Everyday Mornings for Walk-ins, Mondays through Fridays, 8 a.m. through 1 p.m., and Saturdays 9 a.m. through 1 p.m., Sundays 1 p.m. through 4 p.m. Appointments weekday afternoons, by request.
PATMOS as the name of the clinic describes its technique for creating inexpensive, simple care: Pay At The Moment Of Service. Dr. Berry also enjoys the Biblical reference to the exquisite volcanic island of Patmos in the Aegean Sea, where St. John wrote the Book of Revelation (or the Apocalypse) while exiled there "for the word of God." Patmos also was the island to which ancient Rome banished its political prisoners, a reference Dr. Berry appreciates since more than half of his patients are among the uninsured and discontent exiles from modern managed care. The success of this medical clinic is so remarkable that in 2003 it was featured on page one of the Wall Street Journal as the exemplary IFMC — insurance-free medical clinic.
This cash clinic serves the self-employed and the uninsured. Many who come to Patmos easily pay the reasonable prices and are charmed by the speed and excellence of their care. About 30% of the patients have insurance or are members of HMOs but refuse the long waiting times in their own doctors’ offices. Patients appreciate the ability to walk in, be treated by the doctor, pay, and leave. Dr. Berry gets for his patients state-of-the-art x-rays and imaging through colleagues who greet his patients quickly and who provide immediate results. A patient’s MRI may be read offshore (some practitioners use online services of Israeli clinicians) and the results transferred by computer within hours.
Patmos provides prompt care at a fraction of the cost for many injuries and illnesses otherwise treated in emergency rooms. Patmos also cares for chronic problems such as diabetes, hypertension, and arthritis, and provides many emergency services such as suturing complex lacerations, splinting fractures, and treating asthma attacks. Dr. Berry keeps many patients out of the hospital by giving intravenous therapy in his clinic. Since opening in January 2001, Patmos has treated more than 6,000 patients. Typical charges are usually between the cost of an oil change and a brake job.
Dr. Berry praises the way simple exchange of cash for service liberates the medical mind. "Our thinking used to be molded by the semantics of ‘discounts,’ ‘allowables,’ ‘customary charges,’" he said. "Not any more… I am free from the irrational and coercive semantics of contracts with third party payers…I can now think as a free person and not as a slave. When the master third-party payer issues commands now, I don't hear him. But I know he's still pulling the strings, because I see other physicians jumping through his hoops. I am free -- free to take care of the patient as I would want to be taken care of and to refer them to the physicians and hospitals where I would want to be treated, free to charge what I want for my services (although this is determined by patients' willingness to pay…), free to give my services away should I so desire, free to refuse care to disruptive patients, free from having to scrutinize coercive contracts, free from worry that I am unknowingly breaching a contract, free from audits of my patients’ records, free from having to keep up with and fund accounts receivable, free from arbitrary documentation requirements set down by people who have chosen for themselves comfortable desk jobs over frontline patient care, free from having to justify my professional recommendations before such petty tyrants, free from having to find others to share call who also have signed their freedom away, free to find joy once again in caring for patients, unhindered."
Dr. Berry encourages patients to buy high deductible catastrophic health insurance and HSAs. Making his patients intelligent medical consumers, Dr. Berry provides office handouts in which he asks, "What would happen if you had a large medical claim (over $25,000)? Would you be able to cover this amount by taking a second mortgage on your house or would you end up bankrupt? Almost half of personal bankruptcies are due to medical expenses. Insurance is for catastrophes, and you need a policy that limits your exposure to a certain, fixed amount (called a deductible) that you can afford in a year if you had large medical expenses. Insurance premiums for high deductible policies are much more affordable than premiums for policies with low deductibles…HSAs are portable so that if you leave or lose your job, this policy goes with you…" Without promoting any one method, Dr. Berry recommends insurance agents, Internet insurance sources such as www.ehealthinsurance.com, and a noninsurance medical cost-covering method that will appeal to those who practice a "basic Biblical morality." More about this religious medical innovation in a moment.
For an extra $10, Dr. Berry offers the patient a chance to be reimbursed for the amount already paid. But the insurance company pays the patient, not the doctor, and the patient pays for the billing service that makes the request.
Dr. Berry has proved that even patients on Medicaid benefit from paying cash at point of service. People on Tennessee’s Medicaid — called TennCare — are glad to get medical help when they need it and grateful to pay the competent physician who offers it. Tennessee’s Governor Phil Bredesen, in attempting to save the bankrupt TennCare program, initiated a fundamental shift in policy, insisting on greater patient accountability at the point–of care. The governor said, "The only way you manage utilization effectively is to have some economic skin in the game at the point of sale," calling on "able-bodied adults … to pay something."
The consulting group McKinsey & Company proposed increasing physician visit copays up to $32 for this able-bodied population. During his four years of working in a Tennessee emergency room, Dr. Berry noted that about 80% of adult TennCare patients smoke cigarettes. Given that a pack-a-day habit costs roughly $1,000 per year, it doesn't seem too much to ask these Tennesseans to share more fully in the cost of their medical care. Objections to a $32 copay would be more a problem of priorities than price. Dr. Berry also suggested requiring all able-bodied TennCare patients to pay all primary care physician fees at the time of service. "Let's not fool ourselves," he said, "the costs of administering small medical claims for routine office visits — for TennCare and for commercial insurance — increase the final cost of all goods and services Tennessee produces. This waste contributes significantly to jobs lost to foreign countries."
The solution is simple. Settle all primary care costs of able-bodied people directly at thepoint –of care. By eliminating billing costs, medical practices throughout the country — including Patmos EmergiCenter — already are offering primary care physician services for little more than the proposed TennCare copay.
At SimpleCare in Renton, Washington, Dr. Vern Cherewatenko sells his time and talent during one of five classes of office visits:
He accepts no insurance, is an IFMC, and has an all-cash practice. About half of his patients, however, have insurance. Patients themselves bill the insurance company and quickly learn first hand that the billing process is slow, stingy, and stupid. Simple Care sets its own fees, and patients pay exactly what it asks. All immunizations, DPT, flu, hepatitis B, cost $5. A blood draw is $10, a CBC with differential also is $10, a urine culture is $14, and a thyroid profile $40. Injection in a joint costs $50 and an EKG with interpretation costs $40. At Great Smokies Laboratory, Genovations will do a complete genetic profile for a Simple Care patient for $1,495.
How do patients find the clinic? The phone book is the patients’ list of doctors. Patients pick whom they want for what they want, when, how, and why they want.
Dr. Cherewatenko and colleagues are also working with insurers to craft insurance products that are specific to particular major medical events. To use an analogy with automobile insurance, the deductible is only applicable when a major event occurs. Just as gasoline receipts do not count toward the deductible for a car accident, so upper respiratory infection receipts do not count toward payment for a heart attack.
A cash medical practice liberates doctors professionally and places patients at the center of choice. As Dr. Cherewatenko describes it: "I am 100% free to take care of my patients any way they want me to. I see patients who come to see me because they want to, not because they have to. I recommend the drugs and/or supplements I feel in my professional medical opinion is in their best interest and the patients make the final decision on what they want. I recommend the consultants that I go to myself or refer my family members to or the health care practitioners that the patient feels the most comfortable with. I go home at the end of the day with zero accounts receivable . We bill no one. I give away care to patients who are short on funds. They volunteer time in several locations under our "Cares for America" program and we credit them $10 per hour of volunteer time against their visit. My patients are happy. I pay my bills. I am practicing the best care I have ever done during my career. I love being a physician again.
About 2000 physicians are members of the SimpleCare network of independent doctors who accept no insurance and require payment in full at time of service, PIFATOS. Other groups of physicians also are breaking free of third-party payers and accepting money only from patients. INDOC of California and the related Independent Doctors of California are nonprofit patient-centered doctor referral networks for advancing personalized, private, "unmanaged" healthcare. INDOC began in 1997 as a vigorous group of clinicians who share the philosophy: Third party interference between patient and doctor should have no place in the practice of medicine. INDOC invites patients disillusioned with "managed" care to meet quality doctors dedicated to personalized medicine, and to use MSAs, HSAs, and personal healthcare dollars directly and responsibly. Intending to restore and promote the once-sacred direct relationship between patient and doctor, Dr. Thomas LaGrelius, President of INDOC of the South Bay, summons patients to "join us as we make the best healthcare system in the world more responsive to you. Be a part of the healthcare solution!"
CASH FLAT FEES AND THE DOC TALKER
A variation upon these pay at time of service clinics is the flat-fee cash clinic called on the street "The 45 Dollar Medical Mart" but formally known as Memorial Hermann Neighborhood Health Center in Houston, Texas. It charges a flat basic fee of $45. Its audience is the uninsured and underinsured who with their modest resources are able to pay some reasonable amount for their health care. These are the people who would otherwise go to the emergency room at the local hospital for their primary medical care. Memorial Hermann treats no one for free. It offers no services on a sliding fee scale. And it files no insurance claims. In addition to the basic $45 fee, it charges for necessary lab tests, immunizations, and therapeutic injections such as antibiotics. Accepting cash, checks, and credit cards, the clinic is open seven days a week, 7 a.m. to 7 p.m. on weekdays, and 9 a.m. to 3 p.m. on Saturday and Sunday.
Dr. Alan Dappen believes his patients are intelligent and independent. His patients prize the sound of his medical services. This board-certified family practitioner, who earlier had worked with a large group practice near Washington, D.C., created the "Doc Talker," a telephone and e-mail medical service called Doctokr Family Medicine. Dr. Dappen concluded that many problems that drive patients to doctors' offices are obvious and straightforward. Dr. Dappen says, "Patients usually know what they need and I know what they need in a few minutes. Why should I demand that they ruin the rest of their day" by coming into a medical office? One banker patient used Dr. Dappen's services three times during six months, once each for a routine lingering cough, a rash, and an infection, without ever having to schedule an office visit. "[Dr. Dappen] diagnosed and prescribed very quickly, and he's saved me loads and loads of time," The banker said. Though this is a cash practice paid at time of service, since the patient-physician encounters are over the phone or Internet, each patient deposits $150 in a Doctokr account and for each call is charged $5 per minute. The banker’s cost of services was about $35 per telephone consultation, similar to the cost of a customary copayment under other non-cash-at-point-of-service methods. All cash balances left over in a Doctokr account are applicable to more doc talking, an office visit by appointment, and further e-mail consultation.
Busy practitioners often become telephone consultants during the nights and weekends. Dr. Dappen noted that when on call for his former large group practice, he routinely fielded 60 telephone calls on a weekend, prescribing drugs and treatments for patients he did not know and never saw. Doctokr sees every new patient once before prescribing drugs or therapies by phone. All Doctokr patients' records are stored in Dr. Dappen’s ever-present laptop computer, carefully protected with a firewall. His cell phone that is with him 24 hours every day alerts him to calls to his answering service. He works from his home, makes house calls with a well-stocked black medical bag, and sublets a small office for occasional scheduled office visits and the preliminary office examinations he requires when accepting a new patient. Reasonably healthy busy people who want first-rate care and who know their own minds and bodies love the Doc Talker.
Boutique medical practices require that the patient pay a monthly or annual premium for special services such as access to a particular practitioner, immediate attention by phone, guaranteed appointment to be seen in the office, or house calls by the physician. Boutique hospitals charge patients for the ability to enter a hospital for acute care on demand without waiting for a bed and for such premium amenities as luxurious decor, gourmet food, terry robes, and a room with a view. Some boutiques provide general medical care with the physician on call daily, available day and night by phone or Internet or e-mail for consultation. To achieve accessibility, some family practitioners limit their practices to several hundred families and treat everyone in that family but accept no other patients. Since boutique practices are a free-market innovation, the range of costs extends from the modest to the magnificent. Practitioners in retirement cities such as Fort Lauderdale, San Diego, and Tucson experiment with what the market will bear. Intelligent patients and physicians have found $1,000 through $30,000 an annual price worth paying. The premium pays the doctor for access to him, a form of pre-reserving time and attention. Some people willingly will pay to visit a cardiologist or dermatologist whose medical offices are more convenient, more elegant, more courteous, better equipped, better staffed, and more congenial.
HSAs and other medical spending accounts make boutique practices reasonable to those who choose Mercedes medicine over Volkswagen medicine. However, wealthier people may prefer the simpler, stripped down model of care or the luxurious technologically richer medical vehicle. Poorer people have the choice of faster arthroscopic surgery and willingly will buy it from a medical boutique practice even if they must mortgage their home to pay the price. Plastic surgeons reduce the noses, firm the faces, augment the breasts, and contour the hips of waitresses and store clerks as well as Hollywood actresses and social luminaries. Ophthalmologists advertise Lasik eye surgery on radio, television, and billboards where they list their medical education, state-of-the-art lasers, number of procedures performed, and price per eye. They name famous athletes and actors whose Lasik-improved eyes now see with exemplary eyesight and insight to inspire ordinary men and women, truck drivers and soccer moms, to pay cash and entrust their precious eyes to the ophthalmologist’s steady laser beam. A boutique medical practice in La Jolla, California, unites the best of scientific allopathic medicine with alternative medical techniques that include yoga, meditation, Aryuvedic diets and cookery, massage therapy, monitored exercise in the gym next door, and a nearby "healthy heart" restaurant for energizing drinks and food. The medical doctor leads the treatment team that includes the nutritionist and the massage therapist. Men and women on Medicare choose to pay out of pocket for the privilege of fast, comprehensive medical service, monthly lectures, and an encouraging health spa ambience. When one of the boutique internist’s patients needs surgery or specialty care, the doctor refers the patient to a specialist in the nearby hospital and follows up on the patient’s progress. Medicare pays for the specialist physicians’ treatments in the customary way, determining whether those items are "medically necessary." Patients pay cash for the boutique internist’s service.
Some people willingly pay for potential performance such as selecting the credentials and experience of medical experts who work in specialty hospitals. Others pay for process: the access, availability, attention, and amenities. Other boutique medical structures charge primarily for results, such as reducing blood glucose levels among diabetics, thereby decreasing diabetic retinopathy and other disease complications; curing a patient of cancer; or enabling an infertile couple to create a baby. Others charge for health-related "quality of life" accomplishments such as minimizing diabetic monitoring and medication intrusions; enabling patients to look and feel well during cancer chemotherapy; or achieving a durable weight loss.
Boutique medical practices offer performance pricing. They utilize one of three variations upon the routine business methods of guarantee, warranty, and graduated pricing. Since customers apparently rate risk of failure as twice as bad as success is good, some practitioners and hospitals promise a civilized medical process, such as to guarantee an available hospital room and examination by a doctor within 30 minutes of arrival. Fertility centers guarantee parents will create a baby or the couple pays nothing. Warranties promise to achieve a particular standard of medical success. If the goal is not met, after the patient pays the bill the practitioner will continue to work free of charge until the promise is made good. A fertility center offers additional trials after a basic three trials are complete, paid for, and have failed. A cosmetic surgeon will redo the rhinoplasty that does not conform to promised nose shape. A laser refractive ophthalmologist will touch up the eye until it sees with a particular clarity of vision. Graduated payments also can be tied directly to performance such as a weight-loss service priced "by the pound" of weight lost and not gained back, or a pain management program priced "by the day" based on number of days and weeks pain-free.
HSAs will expand Americans’ use of specialty hospitals that treat a single disease such as cancer, an organ such as the heart, or an anatomical system such as muscular and skeletal system injuries and illnesses. Specialty hospitals have helped patients for centuries. Medieval Europe’s leprosariums treated people with leprosy or Hansens’s Disease. In 19th century Europe and America, patients with lung disease and tuberculosis went to sanitariums. During the New York polio epidemics of the 1940s and 1950s one friend who contracted the paralyzing disease recovered enough ability to walk with crutches, thanks to years of training at Valhalla Orthopedic Hospital, and another less lucky lived in an iron lung at the House of St. Giles the Cripple. (As a youngster I sang Christmas concerts for patients there.) There are at least 92 medical specialty facilities in the United States, an actively enlarging share of the national hospital market. By May of 2003 the number of such hospitals had tripled since 1990, according to the government’s General Accounting Office, and another 20 facilities were under development. Just in metropolitan Milwaukee, two brand new physician-owned, for-profit heart care hospitals opened in 2003 and a specialty orthopedic hospital opened for business in 2001.
Patients come to specialty hospitals because if one must entrust one’s body for delicate spine surgery or a massive abdominal operation for malignant lymphoma one wants a surgeon and a support staff that meticulously handle heroic surgery routinely. Those who operate daily generally complete simple cases with greater speed and less morbidity than those who operate rarely. In case of crisis, experience usually controls the excellent versus flawed result or life versus death. From the physicians’ and surgeons’ viewpoints, collaborations among specialists are intellectually energizing. Large numbers of patients with the same disease or injury connected to one facility make a fine population for clinical experiment and clinical protocols to determine successes, failures, treatment side effects, and influences on long-term survival. Expensive high-tech machines, operating theaters, and therapy centers become cost-effective if shared and frequently used. Nurses, technicians, therapists, training fellows, and ancillary personnel are more skilled at familiar specialty jobs than equally intelligent professionals unaccustomed to the craft. "Cooperation among physicians on technology, program development, and management at specialty hospitals results in lower costs and better patient outcomes," maintains James King, chief medical officer of the Wisconsin Heart Hospital.
Many early specialty hospitals were charities that gave patient care for free. Unintended consequences of modern medical laws make such benevolence illegal. Hospital administrations are liable for prosecution for false claims and fraud, forced to pay confiscatory fines, and suffer the possibility of closing their doors forever. The 161-bed heart hospital in rural Browns Mills, New Jersey, for instance, started its life 78 years ago with the simple philosophy that "there should be no price tag on life." Then it was a tuberculosis sanitarium for poor immigrant Jews from Manhattan's Lower East Side tenements. Dora Moness Shapiro and her husband, a garment manufacturer, created the institution that never charged patients for their excellent care. Originally called the Jewish Consumptive Relief Society, the facility became Deborah Hospital that has run massive fundraising campaigns on the premise that wealth should not decide who gets good medical care.
But the U.S. Department of Health and Human Services prosecuted Deborah over the course of four years because Deborah accepts Medicare payments without requiring patient copayments and therefore violates a slew of civil and criminal laws. By following its own three-quarter-century-old mandate to never charge patients, Deborah Hospital was accused of granting incentives for referrals, submitting false claims to the government, unfairly competing with community and other specialty hospitals, and generally flouting White Coat Crime laws. Stark and Medicare antikickback laws prohibit "remuneration" in exchange for Medicare business, and in the bizarre definition of HHS, a copayment waiver counts as remuneration. Inducements to influence patients are punishable offenses. Since HHS persists in the false classification of Medicare as "insurance," Medicare has no obligation to pay for hospital care that the patient gets as a free gift. If Medicare insurance covers potential "financial losses," technically there can be no loss to either patient or hospital if the hospital volitionally gives away valuable care. Deborah therefore was alleged to be filing false claims barred by the False Claims Act, punishable by triple damages and a $10,000 penalty per incident. Every Deborah patient’s care is at least one incident. Moreover, the office of the Inspector General considered Deborah’s routine waiving of copayments an unfair competitive practice violating antitrust law. Unlike City of Hope Cancer Center in Los Angeles, which now bills to keep on the right side of the law, and St. Jude Children's Research Hospital in Memphis, Tennessee, which has a waiver to treat for free that until now has endured HHS scrutiny, Deborah’s refusal to violate its free care mandate that defies medical law nearly forced the generous doors and charity operating rooms to close shut. In 2003, Deborah Hospital finally got a reprieve, a waiver enabling them to continue their tradition of not charging copayments.
New York’s Sloan-Kettering Cancer Center, Manhattan Eye and Ear, and The Hospital for Joint Diseases long have served the world as places for specialized medical excellence. Some specialty hospitals started as physician-owned facilities established to achieve higher standards, avoid waste, circumvent bureaucratic hassle, and retain profits. Specialty hospital ownership nowadays is perilous. Physician owners of specialty hospitals must take great pains to avoid conflicts of interest and accidentally transgressing any White Coat Crime laws. Elaborate safeguards must prevent even the imputation of conflicts of interest. Medical staff utilization reviews, peer review of morbidity and mortality, and multiple quality controls are stringent.
In a last-minute amendment to the Medicare Modernization bill in 2003, the Senate Finance Committee attempted to end physician ownership of specialty hospitals, ostensibly because they skim profits from the larger hospital systems. Critics of the specialty facilities accuse them of being boutique hospitals that serve the rich and deprive community hospitals of needed revenue to run unprofitable programs, such as emergency rooms. On March 19, 2004, the Centers for Medicare and Medicaid Services issued a five-page moratorium called a "change request" prohibiting physicians from referring patients to specialty hospitals in which they hold financial interests. The ban applies to hospitals whose primary or exclusive work is cardiac care, orthopedics, surgical procedures, and "other specialized types of services that CMS may designate," but does not affect hospitals dedicated to psychiatry, rehabilitation, children, long-term care, and cancer hospitals not paid under the prospective payment system. This moratorium (that will expire in June of 2005) created havoc among specialty hospital owners and builders.
Strident opponents of specialty hospitals allege that they deliberately pick and choose healthier patients in order to reduce costs and maximize physician owners’ profits. This is nonsense. Most specialty hospitals get better results for particular procedures than general hospitals because of the inherent efficiency in the division of labor.
Adam Smith long ago noted in The Wealth of Nations that specialists usually are far more efficient, productive, and innovative than generalists. Specialists usually create specific techniques and instruments to make their work more precise. Repetitions of particular actions and routines enable them to work faster. Specialists are likely to develop special expertise and avoid the lingering and sauntering in intellectual change from subject to subject. Even so humble a craft as the manufacture of wooden matches is a small marvel of the productiveness and wealth-generating division of labor. When one worker in a factory makes a complete match he can produce only a relatively few items per day. But when the factory separates the cutting and sizing of the match sticks from the acts of making the incendiary tip, then setting of the match head on the stick, then sorting, packing, and packaging the boxes of matches, productivity increases by several hundred percent. Medical specialists and specialty hospitals are focused factories that usually are better, faster, safer, and have a vested interest in the newest science and deepest clinical experience. Some specialty hospital care costs more, with the added premium for their specialist capabilities. Usually they cost less because of economies of scale.
Medical focused factories would be effective for treating asthma, diabetes, AIDS, and other chronic diseases that consume 80 percent of our health care dollars, and ideal for underserved populations. Regina Herzlinger at Harvard Business School demonstrated that specialty hospitals such as MedCath have "higher quality, lower costs, and greater patient satisfaction than traditional hospitals…Consumers want choice, control, convenience, and good value for their money, and their insistence on obtaining these things is a big factor driving specialized facilities and bringing down integrated health systems. Consumers are very bright people, especially when they are spending their own money, and they recognize value when they see it."
MINUTECLINICS IN SUPERSTORES AND CRITICAL ILLNESS ALLOWANCES
Disruptive Innovation is the title that Harvard Business School’s Prof. Clayton Christensen gave to the process of changing an established industry that has overshot its mark by making more products and services than most customers need and by charging too high a price that excludes large portions of the market. Inc. Magazine featured examples of Disruptive Innovation in American medicine. Not everyone who comes to a hospital needs its expensive technology, and many who consult a doctor could make do with a nurse. Technology innovatively disrupts the health care system, allowing people to do in their homes what formerly they did in a doctor's office, and to do in a doctor's office what formerly they did in a hospital.
MinuteClinic, for instance, is the Minneapolis company that has placed a dozen health care kiosks in local Target and Club Food stores. Staffed by nurses, each MinuteClinic offers diagnosis and treatment for a circumscribed list of common conditions, including strep throat, ear infection, and sinus infection, plus testing for cholesterol levels and blood pressure. As a limited form of medical office, each kiosk has convenient walk-in service, with a typical waiting time of 15 minutes or less, and costs only $41 or an insurance copay per visit. "Entrepreneurial companies can create their own markets. They can experiment and explore in terrain that big companies fear," Inc. said. Their new products and services will undercut the market by their being simpler, cheaper, handier, and friendlier.
Critical Illness Allowance policy (CIA) is an example of what I call Retrospective Innovation, a revivification of an old idea to serve a new purpose cost-effectively. A CIA is an insurance policy that pays you a specific lump sum if and when you are diagnosed with a particular stated serious illness such as cancer, kidney failure, heart disease, diabetes, or Alzheimer’s. Diagnosis determines payout. The benefit begins at diagnosis. No matter where you are treated for the illness, in an office or in a hospital, or by whom, and no matter how inexpensive or how pricey the therapy, the CIA policy pays the allowance in a single sum of money, no more and no less. Half a century ago such policies were called tables of allowances and were sold widely before the concept of first-dollar coverage was instituted for routine and preventive services.
CIAs are affordable because the maximum benefit for each diagnostic category is much lower than the limits on a modern major medical policy or first dollar policy. Some CIA policies protect against one critical illness, such as cancer or heart disease; others are available for clusters of illnesses. Nowadays a CIA should appeal to those who do not want to accept the up-front risk of a very high deductible major medical policy. The CIA does not interfere with the doctor’s or hospital’s fees because the physician or hospital has to justify to the patient any charge above the allowance. The patient pays after the patient decides, then buys whatever care he finds necessary and desirable. In a medical market where the individual is fully empowered to choose where he wishes to be treated and by whom, CIAs become a force for competitive pricing and for cost containment. They also eliminate nuisances and games played with deductibles and copays. CIAs fit well with HSAs.
Typical CIA coverage includes:
* Alzheimer's Disease before age 65
* Aorta Graft Surgery
* Benign Brain Tumor
* Cancer (most malignant types)
* Coronary Artery Bypass Surgery
* Heart Attack
* HIV / AIDS (with restricted, named groups, as a hazard of employment, as for emergency room physicians accidentally infected by sharps contaminated by fluids of patients they treat)
* Kidney Failure
* Loss of Limbs
* Loss of Speech
* Major Organ Transplant
* Motor Neuron Disease before age 65
* Multiple Sclerosis
* Paralysis and or Paraplegia
* Parkinson's Disease before age 65
* Permanent and Total Disability before age 65
* Pre-Senile Dementia before age 65
* Third Degree Burns
The insurer may refuse to pay or stop paying if the claim results from a criminal act, failure to follow medical advice, HIV/AIDS (except for the permitted named groups), self-inflicted injury, war, or civil commotion. The benefit is not taxable. CIA insurance is bought either as a Level Benefit, where premiums and claims amount remain the same during the time of insurance, or as an Indexed Benefit linked to the Retail Price Index and adjusted yearly. In America and England these policies have great promise by stripping down the insurance complexity, making CIAs cheap to own, simple to understand, and certain to serve well for expensive illnesses. CIAs function best when combined with an HSA savings account and high-deductible catastrophic medical care policy.
CORPORATE DIRECT CASH CONTRACTING
Chicken and ice cream workers share the benefits of their employers’ paying cash at time of service to physicians and to hospitals. Ice cream manufacturer Blue Bell Creameries -- with 2,300 employees and their families at 40 sites making a total of 5,172 people in 14 states -- and Perdue Farms -- with 20,000 workers at 18 facilities in nine states -- directly contract with physicians and hospitals for their self-funded and self-administered medical services. No insurance company intrudes on the corporate missions to keep workers and their families healthy for good financial results: to reduce absenteeism, to increase esprit and productivity, to avoid chronic diseases caused by lifestyle choices (smoking, heavy drinking, excessive eating), and to save money on medical benefits. Direct negotiating with doctors and clinics to pay cash and to pay promptly got the employers generous discounts. Blue Bell, from the time of its first direct contract in 1994 to the year 2003, found that while other companies were suffering double digit medical increases over the nine years, the dairy’s costs declined by 20%, and the company enjoyed a 20 to 1 return on its investment in its own medical network.
At Perdue Farms, direct cash contracting is paired to 12 onsite medical facilities to treat nonoccupational illnesses, chronic problems, and acute diseases. The workers pay $10 deducted from paychecks to encourage utilization. Since the workforce consists of 70% Hispanic workers at some facilities, onsite clinics employ Spanish-speaking staff. Dr. Roger Merrill, Perdue’s corporate medical director, believes that most catastrophic medical costs are preventable, such as high costs of heart disease, low birth weight babies, strokes, and kidney failure. Therefore he invests in disease management to prevent escalation of symptoms and to cure when possible. He says, "It's cheap and easy to treat high blood pressure and diabetes. It's easy to prevent patients from suffering kidney failure." Merrill’s Health Improvement Program targets obesity, high blood pressure, high cholesterol, diabetes, and smoking, and, in addition to treatment and "lifestyle modification programs," demands annual appraisals of progress.
PRESCRIPTION DRUGS AND MEDICARE DISCOUNT CARDS
Many monitoring the drafting of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 anticipated that seniors would have the rights and responsibilities of HSAs or MSAs and therefore could spend their own money on whatever drugs they and their doctors deemed necessary. Only the very poor who needed help would have received government money to pay for drugs. We were wrong. HSAs at the moment are forbidden to seniors, the drug benefit includes far too many new beneficiaries than is reasonable for Medicare, teetering on bankruptcy, and the program restricts drug choice.
Senator Larry Craig’s amendment to the Medicare bill failed, but in June 2003, he attempted to grant consumer-directed care to seniors enrolled in the MedicareAdvantage program. Seniors would have controlled their prescription drug expenditures. Senator Craig modeled his recommendations on the example of the American Postal Workers Union’s consumer-driven health care plan under the Federal Employees Health Benefits Program. That provides
Money in the Medicare account would have rolled over every year, enabling higher deductibles, and lower MedicareAdvantage payments and premiums for enrollees.
In rousing testimony to Congress on the positive effects of a free medical market on American longevity, Newt Gingrich suggested how seniors trained to buy their plane trips and hotel rooms on Travelocity and Expedia could save money and dignity buying prescription medications. A Travelocity-inspired pharmacy would work with speed and efficiency in four basic steps.
Travelocity-pharmacy would give consumers incentives to spend less but would not take from them choice of what they can or cannot buy. With Medicare paying the cost for the least expensive drug, whoever wants first-class prescription drug accommodations would buy them while whoever wants to travel drug coach saves his own money.
But the Medicare Prescription Drug law lamentably is not free-market nor consumer-directed. Instead, the new law represents a compromise between the House of Representatives’ 749-page "Medicare Prescription Drug and Modernization Act of 2003" and the Senate’s 1,044-page "'Prescription Drug and Medicare Improvement Act of 2003."' Originally estimated to cost about $40 billion over the next 10 years, some economists assume the Medicare drug program costs will soar to between $3 trillion and $4 trillion over time, all financed by payroll taxes.
Between two-thirds and three-quarters of all seniors already have decent, good, or excellent private drug coverage. But now, the government’s plan seems so generous and seems to offer such inexpensive medicines that seniors who already are covered will elect to take what is offered. Many companies that now are paying the private drug insurance for their retirees will consider it fiscally prudent to jettison that heavy burden. Private corporate "elephants" -- large companies such as automobile manufacturers whose unions have extracted luxurious medical benefits -- will dump their load of expensive retiree drug benefits on the government. The Joint Economic Committee estimates that nearly 40% of private plans will drop prescription drug coverage for their retired employees. This percentage will skyrocket as more companies respond to the perverse incentive to let government handle escalating drug costs.
To participate in the prescription drug program, seniors must choose between staying in traditional Medicare or joining an HMO or PPO medical group. Beginning in 2006, seniors and the disabled will use drug discount cards that will reduce prescription drug bills by as much as 25%. Low-income seniors, about one-third of the Medicare population, will have virtually all medication costs covered, and will pay a $2 to $5 copayment. Seniors will pay a premium of $35 a month and a $250 annual deductible. Medicare will pay 75% of all drug costs up to $2,250 (the approximate drug costs for two-thirds of the senior population), and pay 95 % of catastrophic drug costs above $3,600.
But before 2006, seniors get help with drug payments via a voluntary Interim Medicare-Approved Drug Discount program beginning in June 2004. This Interim Medicare Drug Discount card is modeled on an idea originally proposed by the Galen Institute. While not a complete drug benefit, the voluntary drug card program is "an important first step in providing Medicare beneficiaries with the tools they need to better afford the cost of prescription drugs," Acting Medicare Administrator Dennis Smith testified at a hearing before the U.S. Senate Special Committee on Aging.
For seniors without drug coverage the Interim program should save between 10% and 25% of prescription drug costs. In 2004, low-income seniors receive an additional $600 added to the card that operates like a debit card from a bank. For purchasing needed medications, the card "will truly help seniors who need help the most," said Committee Chairman Larry Craig. Jim Firman, of the National Council on the Aging, suggested that the 2004-05 savings to low-income participants could be worth far more than $600, an idea corroborated by Forest Harper of Pfizer: "Every day, we donate well more than $1 million in medicines through our U.S. outreach programs…we are actively working with other companies to create a cooperative program which brings together leading health care organizations to offer America's 40 million Medicare beneficiaries immediate assistance in getting needed medicines through the Interim Medicare-Approved Drug Discount program," Harper said.
Government most likely shall decide which drugs to prescribe, how much they shall cost, and who shall have them. Since subsidized drugs will not be limited to the poor, drug rationing will be inevitable, as it is in every nation with a national health plan, with newer and more expensive drugs most drastically curtailed. Bureaucrats are likely to forbid seniors from buying with their own money drugs otherwise covered by Medicare or deemed "medically unnecessary." That paternalistic prohibition already afflicts Medicare patients for medical services. Fewer choices among specific new drugs, fewer choices of drug therapies, and fewer pharmacies to dispense drugs are likely results. Just as doctors are rebelling against the restraints of White Coat Crime laws and the low payments of Medicare and Medicaid, so pharmacies and the pharmaceutical industry similarly will be riddled with regulation, afflicted by criminal sanctions, and forced to opt out of business if they cannot make a fair profit on good drugs.
Restrictive drug formularies that prohibit patient choice and promote government drug decisions will increase major health care costs by favoring older drugs over newer ones. Newer drugs do a better job of keeping people healthy, out of hospitals, and happier living with their chronic diseases. New drugs reduce suffering. Most seniors and their physicians who now have a choice of drugs elect new drugs rather than old. Pennsylvania, for instance, runs one of the largest prescription drug subsidy programs in the United States, called PACE, for low-income people over age 65 not covered by Medicaid who presumably badly need drugs. There is no deductible. Copays are $6 per prescription. Income limits are up to $14,000 for a single person, $17,200 for a married couple. Since income is not tied to inflation, the number of people enrolled has declined as Social Security income has risen. Pennsylvania also operates a smaller companion program called PACENET for people with higher incomes. In 2001, 83% of PACE beneficiaries were female, 78% were single or widowed, and 72% were over age 75. Almost 50% of the quarter of a million people enrolled owned their own homes. People with low incomes often have substantial assets. A strong 50% of participants had annual claims of less than $1,000; 15% had claims over $3,000. Average spending per participant was $1,560. These figures are consistent with the national experience: small populations run up big bills.
Cardiac drugs accounted for 17.4% of total spending, followed by gastrointestinal agents (11.9%), lipid-lowering drugs (10.7%), analgesics and antipyretics (8.5%), and antidiabetic medicines (6.2%). Twenty percent of total spending was on the top 10 drugs. Only one of those medicines had come to market before 1990. The top 10 in order were Prilosec, Prevacid, Celebrex, Zocor, Plavix, Lipitor 10 mg, Lipitor 20 mg, Norvasc 5mg, Vioxx, and Norvasc 10mg. Pennsylvania’s numbers comport with national findings that newer drugs with better side-effect profiles are the drugs of choice for the elderly and that many drugs the elderly spend money on are used for prevention.
Because most seniors already have some form of drug insurance that insulates them from paying the real costs of the drugs they buy, most people on Medicare tend to forget that the medicines that guard their physical vigor are marvelous new pricey drugs that are worth every cent paid, and that without them they might die. Trendy books describe drug ripoffs. Pharma-bashing essays in magazines and incendiary Internet articles accuse greedy pharmaceutical houses and pharmacies of stealing from America’s vulnerable elderly and ill. One such Internet screed called "What Drugs Really Cost" contemptuously describes offshore chemical synthesizers that supply active ingredients for FDA-approved drugs such as Lipitor, Claritin, Celebrex, Prilosec, and Zocor. The few pennies for active ingredients versus the selling price per pill appalled observers. With drug ingredients dirt cheap, drug profits seem obscenely astronomical.
However, statistics contrived to raise readers’ blood pressures require us to answer three fundamental questions that are structural girders for philosophy’s metaphysics, epistemology, and ethics.
The text reveals that the source of the article is intentional misrepresentation to sell a product. "We did a search of offshore chemical synthesizers that supply the active ingredients found in drugs approved by the FDA. As we have revealed in…Life Extension." Was the "search" of offshore chemical synthesizers an Internet search or onsite visit to labs in the Amazon, Kenya, or Bangladesh? Are ingredients that create Celebrex, Prilosec, and Zocor actually made offshore? "Life Extension" is the name of a magazine from The Life Extension Foundation that sells mail-order vitamins and supplements that the FDA does not examine, license, or approve for safety or for efficacy. Their retail store is in Fort Lauderdale, Florida.
How do I know what I know? Facts about drug costs can be found in the scientific and medical literature online or in print, the FDA publications, and the annual reports of the big pharma houses themselves. Of course the active ingredients in a popular drug are cheap. That is not what we pay for. We pay for the science, the laboratories, the scientists’ salaries, the experiments on animals before the tests on human beings, the brilliant ideas that are original and that can be patented for 20 years. We pay for a scientific intelligence having discovered a chemical substance that might prevent, treat, or cure an illness, injury, disease, or disability, that in a particular dosage will do good, not harm. We pay for a pharmaceutical company taking financial risks that the scientist is right, not wrong. For every drug that reaches the market, 5,000 to 10,000 drugs are tested and never make it. We pay also for the pharma laboratory’s adhering to stringent requirements of the Food and Drug Administration. From first offering to the FDA for approval to a drug’s actually hitting pharmacy shelves, it takes an average nine years. A pharmaceutical company with a 20-year patent has only 11 years to sell the name-brand drug and recoup its huge costs for Research and Development. Actual costs of one drug coming to market average $900 million. A recent Tufts University study showed that each company invests per "miracle drug" like Lipitor and Claritin a cool $900 million. A lot of pills must be sold to make up such R&D costs.
How come people in Canada and Mexico buy our American-made drugs cheaper than you and I can get them? Those countries, like England and Germany, have drug price controls. You and I pay for foreign free-riders. America’s Medicaid, MediCal, and some government-inspired HMOs enforce price controls. You and I pay for welfare free-loaders.
After the 20-year drug patent expires, generics copy the chemical formulae from the original brand-name drugs. Generics now make up about half of all prescriptions. Companies making generics do not do the inventing, the testing, or the spending of arduous years seeking FDA approvals. Generics imitate the brand-name drug’s active ingredient. Generics need only to be "bioequivalent" to the brand-names. In 1984, when 19% of drugs were generic, the Hatch-Waxman Act made generics easier and cheaper to market because copycat drugs were spared the extensive, expensive FDA process. Some generics are virtually identical to the originals. Some differ in active or inactive ingredients, in effect, and in potential and actual side effects. Generic companies do not create miracle drugs. They make good or bad knockoffs.
Popular brand-name drugs are high-priced but actually reduce medical costs, not inflate them.
Professor Frank Lichtenberg of Columbia University demonstrated that between 1996 and 1998 the extra monies spent on brand-name drugs reduced other medical costs by seven times the amount spent on the drugs. Brand-name patented drugs extend life, reduce necessity for hospitalizations, prevent surgical operations, increase pleasures of life, and enhance quality of living.
People who want to regulate drug prices, provide free drugs, and adhere to drug formularies also promote centrally planned, government-controlled, single-payer medicine. Any government program that gives free goods destroys the recipients’ freedom and responsibility. People who cherish the liberties of excellent health in activities in the office, kitchen, car, and bedroom know that brand-name patented drugs are worth praising and worth paying for. When not, not. So long as each of us pays cash or a cash equivalent, the glory of choice enables the rich to elect the generic and the working poor to select the prescription drug or vice versa.
As soon as seniors are enabled to create HSAs and MSAs they will be able to exercise responsible drug choice, prudently spending their own money for whatever drugs they and their physicians deem necessary and proper. HSAs will celebrate their intelligence and independence and save the government money. Baby boomers soon to inundate the Medicare system are quintessential pickers and choosers, accustomed to selecting among their many favorite brands of breakfast cereals, varieties of computers, styles of automobiles, and boutique drinking waters in clear or blue bottles. Unaccustomed to collective regimentation, these new Medicare recipients will help promote medical individuality so long as they avoid temptations to try out a little socialism by accepting a drug card that promises free goods. Future Medicare beneficiaries poised to enter the system around 2010 are accustomed to the Internet expanding their world of choice. Their habits of researching, price-comparing, and bargain-shopping will encourage benevolent self-interest in protecting their bodies and minds.
MEDICAL COST SHARING
Lifestyle choices affect medical costs but few people are willing to insist on adherence to physical and moral standards until they are directly responsible for paying the medical bills for physical consequences of permissiveness. Popular, dependable, and inexpensive religion-based medical plans are not insurance but rather shared-risk arrangements that cover hundreds of thousands of Americans. Risk-sharers also are medical cost-sharers. There are no insurance contracts and no insurance premiums. Each individual or family pays an annual membership fee plus a specific monthly contribution and pledges to help pay the medical bills of other group members. They act on the Biblical command to "Bear one another’s burdens and so fulfill the law of Christ" (Galatians 6:2). Most Christian medical plans require their members to be regular churchgoers, to abstain from smoking, to live a "Christian lifestyle" free of adultery and homosexuality, to not use illegal drugs, and to moderate or, in some instances, to abstain from alcoholic beverages. As one physician member said, " We are simply not interested in subsidizing the vices of others through our own family health care dollars. We would prefer to help them through appropriate charities. This is the best form of health security…" Remarkably, though none of these medical sharing programs guarantees payment of medical expenses, they all report that they have paid all submitted expenses. None has gone bankrupt.
One of the three best known groups, Christian Brotherhood Newsletter (CBN), now has 25,000 families as members. A preacher started the group in 1982. To suggest how such a sharing plan works, Dr. Alieta Eck of New Jersey describes how she, her physician husband, and their five children dropped their health insurance coverage in 1997. "The most reasonable indemnity insurance…had just gone up to $800 per month, and we weren’t about to join an HMO. We didn’t believe HMOs were ethical for physicians, nor smart for patients. In New Jersey we were unable to find health insurance with a high deductible greater than $5,000 because they were illegal. We stumbled upon the Christian Brotherhood Newsletter right around then. This is not insurance…it is a commitment of Christian people…Every month, people turn in bills for medical events that have exceeded a threshold ($5,000, $1,000, $500, representing the Gold, Silver, and Bronze plans respectively). Every month, each subscriber to the Newsletter makes a donation, either directly to the person with the medical bill or to an escrow account that pays the larger bills. This prescribed monthly donation has been $134, $68 or $34 per person for the three plans. Families of three or more contribute each month $405, $203 or $102."
The Christian Care Ministry (CCM), a division of the American Evangelistic Association, founded in 1954, operates Christian Care Medi-Share that enrolls about 50,000 people. Their two programs are Medi 250 and Medi 911. In Medi 250, a member pays the first $250 of a medical incident. Thereafter other members share 100% of the costs from $250 to $50,000. The monthly cost or share for the Medi 250 is $100 for one person, $190 for two people, and $245 for three or more people.
The Medi 911 program requires families to pay the first $911 of a medical incident. Then members share 80% ofthe costs to 20% paid by the family to $5,000. All costs from $5,000 to $50,000 are shared 100% by all members. The monthly contribution for this program is $75 for a single person, $115 for two people, and $145 for three or more people. CCM buys group insurance to cover costs over $50,000 up to $1 million. The group does not welcome people with the customary expensive "pre-existing" diseases such as cancer, diabetes, and heart disease.
Both programs are reinforced with a trust that has bought "stop loss" insurance from a major A+ rated insurance carrier. Insurance begins paying once the medical incident exceeds $50,000 for an individual member. The lifetime maximum is $5 million. Modest monthly CCM contributions include the stop loss premiums. Medical expenses associated with auto-related accidents are shared with an additional contribution of a mere $8.
Christian Health Care Newsletter (CHCN), run by Samaritan Ministries International, reported 6,000 families subscribing in December 2000, and welcoming 100 to 150 families per month thereafter. CHCN was incorporated in 1991 and began its medical sharing program in 1994. The subscriber pays the first $200 of a medical incident. Then CHCN subscribers share 100% of the expenses up to $100,000 per incident, per person. CHCN recommends each person purchase an inexpensive $100,000 deductible health insurance policy from Mutual of Omaha to cover all medical costs over $100,000. Monthly contributions are $50 for singles, $100 for couples, $125 for single parents, and $150 for families.
Many people who subscribe to Christian medical share plans also have MSAs and now will be able to create HSAs. People budget for the smaller medical bills and get help from others only for large bills. Many healthy families with MSAs accumulate valuable nest eggs even if the MSAs are not "qualified" according to the IRS. These savings accounts earn interest and their owners pay taxes on the interest. Yet nonqualified MSAs with no IRS tax deduction still have enormous benefits in the substantial savings over customary "insurance" costs. The Medi-share members who own MSAs earn interest on their incremental savings. They buy medical care that eliminates breaches of confidentiality, claim forms, and all third-party interventions.
These self-selected, disciplined groups counter American cultural permissiveness that has physical sequels. These medical sharers are creating a quiet medical revolution nationwide that has much to teach to free-marketers about principled voluntary assemblies of like-minded people for a medical purpose. Christian medical sharers discriminate against people with diseases such as cancer or diabetes and against people whose lives embrace adultery and homosexuality. The groups’ exclusions do not condemn or reject the people, but simply refuse to pay for their almost invariably expensive care. Note that all medically protected people in Christian medical share plans technically are considered medically uninsured. This immediately removes several hundred thousand from the rolls of the uninsured. For a decade, the 50,000 people in CCM have made choices between outrageously expensive fake "medical insurance" that does not distinguish between monogamous and adulterous marriages, and does not classify as impractical all sex outside of marriage. Medical sharers achieve substantial financial freedom within moral restraint. Responsibility trumps liberty to abuse the body and independence to cheat on marital vows of fidelity.
In New Jersey in 2003, at the same time and place that the Eck family increased its medical bank accounts thanks to its effective and inexpensive membership in CCM, equally well educated medical neighbors, also self-employed, were faced with these potential bills from their insurance carrier, Blue Cross-Blue Shield:
Competing companies offered other New Jerseyites during the same months health insurance with premiums costing $250,000. Causes of such insurance madness are New Jersey’s insistence on community rating, guaranteed issue, mandated preventive care, mandated treatments, illegalization of high deductibles, and costly, conflicting government regulations and laws. While insurance lunacy raged, the calm, assured, self-selected CCM family members paid the low noninsurance contribution of about $200 per month, confident that others would help them if necessary to pay all of that family’s medical bills over $911.
Who other than Conservative Christians can do this successfully? The legal stigma of "selling insurance without a license" would shut down any medical cost-sharing group without a "religious exemption." What groups could qualify for this type of self-selection? Jews could create a medical cost-share group under a religious exemption. So could Muslims, Buddhists, and Zoroastrians. What about sheriff’s deputies, architects, retired physicians, antique car buffs? What cluster of people acting in their financial self-interest will pledge to no sex outside of marriage, no drugs, no homosexuality, no smoking, no excessive drinking?
While medical sharers provide no guarantees, they grant physicians, hospitals, and patients a reasonable medical certainty that all members and the group will pay medical bills as and when due. In some ways, medical sharing resembles the pre-1965 pre-Medicare era. People pay cash at time and place of medical service for bills they can afford to pay. For bills above cash at hand, they arrange to pay out over time or borrow and repay lenders. Thereafter they ask friends and neighbors to help with what they cannot afford, and offer in return to help others in need. This concept called subsidiarity is a mutually beneficial community exchange of promises to help others as one wishes to be helped. Subsidiarity (from the Latin subsidiarius, helping to aid, support, and supplement) is the Golden Rule shining in mundane American kitchens, bedrooms, and clinics. Thereafter for cataclysmic medical bills a catastrophic insurance policy usually is available to help in payments. The last resort is to ask for charity.
Charity is not altruism that requires
one to sacrifice self for others. Charity is free-market compassion.
It cannot be demanded. It cannot be extracted. It cannot be
centrally controlled. Charity results from volitional self-interest. Whoever
gives charity gets reward. The giver feels good, enjoys gratitude of the
receiver, believes that doing the right thing is virtuous. Charity
inspires pleasing confirmation from others that doing good is doing well.
Religious people store up good works on earth now for Heavenly reward later.
Some people give charity with expectation of an income tax deduction.
Remarkably, charity resembles Adam Smith's reminder that we do not get our dinner from the benevolence of the butcher, the baker, and the brewer but rather from their self-interest. Each exchanges value for value and in so doing expands the good. By working in one's self-interest one also serves the greater community by making more product, more choice, more items for more exchange. By exchanging, each has vested interest in peace and basic fairness and ethics. Self-interest is the key to perpetuating charitable achievements, just as it is for capitalism.
Just as achievements and products of the free market are close to infinite, so is true charity. Markets work best when uncoerced, unregulated, and rewarded. Likewise, charity.
Charity may be the only 100% health care coverage. Free-market medicine cannot be 100% coverage because a truly free system allows some to elect not to be treated, not to be helped, and recognizes that some are beyond help. Charity inherently has the same limitations: some potential receivers will refuse help and some help will not help. Charity stimulates ingenuity. Charity initiates innovation. Because charity is rewarded, unlike altruism that is coerced, charity expands and inspires.
Charity may the only 100% health insurance. It may be all that is left after conventional insurances fail. The ideal HSAs savings account plus high deductible catastrophic health insurance should cover almost every medical disaster. But for those without HSAs, charity may be the only recourse. Insurance through an employer vanishes when the employee gets too sick to work and loses his job. Private COBRA payments to the corporate health plan seem cruelly expensive when one is out of work. Insurance the self-employed buy disappears when they are too sick to work and cannot pay the premiums. Big companies that provide "insurance" are quick to lay off employees when they must downsize or go bankrupt. Government workers are insured while employed but if they get too sick to work lose their jobs and their insurance. Medicare is perilous to count on for it will go bankrupt in 20 years. The next generation of workers will have little patience with the old and infirm who will not be able to convincingly demand expensive health care. Medicaid is equally dangerous to rely on since access to care will be severely compromised. As more Medicaid bureaucrats deem physician caregivers as unworthy of good money, fewer and fewer physicians will give good care. The only real insurance is charity, as Dr. Alieta Eck phrased it, fueled by love of families and kindness of communities.
Medical volunteer programs throughout the nation use charity as the impetus and mutual benefit as dignified reward. Delaware’s Voluntary Initiative Program (VIP) that originally was dedicated to the state’s neediest in the mid-1990s now is in VIP Phase Two, launched in 2002, to help the working poor who are uninsured. The program includes 334 physician volunteers, of whom 196 are specialists. VIP determines patients' eligibility for public coverage, finds them a doctor, refers them to specialists or imaging services, and helps them get medication and laboratory tests. Physicians provide charity care for medically indigent patients without being inundated, overwhelmed, or forced into bankruptcy because of too many nonpaying people. Doctors determine independently how many patients they will accept and on what financial terms: giving free care or charging some vastly reduced fee on a sliding scale. A popular service of the project is a sliding-scale "calculator" that enables doctors to analyze how truly poor their patients are and how financially capable. Doctors who treat for free expect thanks and get it. Patients who are discovered to be eligible for Medicaid, veterans benefits, or other public programs sometimes are transformed into paying patients.
Dial-a-Doctor or the Doctors Day Call-In is the Arizona Medical Association’s annual donation to Arizona’s needy patients who desire to speak with physicians about their symptoms and get advice on physical and mental health. With the cooperation of local television and radio stations, a Phoenix internist, Dr. Anita Murcko, has recruited more than 100 physicians to man 30 phones during 12 hours. The seven-year-old program is popular with patients and pleases physicians who can talk substantively with patients without the usual time restraints of their offices. Patients are especially grateful. Dr. Mark Wallace, an internist who has volunteered for the phone bank for the past six years, described the psychic return on his charitable investment of time and talent:"The patients expressed their appreciation more than I ever heard in any other setting."
In Northeastern Indiana, hit hard with factory closures and business recession, family practitioner Dr. Thomas Miller of Angola, Indiana, and six colleagues created a simple voucher program for those with no insurance and limited ability to pay. Patients with no money no longer need to run to the hospital emergency department for primary care. Rather, patients present themselves to the group of seven, ask for care, and are given vouchers and recommendations. The Steuben County Health Resources Committee administers the vouchers. No one is turned away. Each physician agrees to take two patients with vouchers per week. The community's two surgeons and one obstetrician-gynecologist treat the voucher patients without charge. It costs the government no money. It costs the physicians no billing hassles. As Dr. Miller said, "To do it this way and not send a bill to someone who can't pay it, I think that's great. If people know going into it that it's an entirely charitable act, I think the relationship is a lot better."
Dr. Jack McConnell is the guiding spirit behind The Volunteers In Medicine (VIM) Clinic that provides free medical and dental services to families and people with no other health care who live or work on Hilton Head Island and Daufuskie Island, South Carolina. VIM serves between 9,000 and 11,000 citizens and their households in a sparkling 7,000 square foot building that opened in 1994. Equipped with six exam rooms, two dental exam rooms, an ophthalmology room, a small lab, an x-ray suite, and administrative offices, the clinic was built debt-free on an acre lot leased to VIM by the Town of Hilton Head Island. More than 100 local retired medical professionals -- doctors, dentists, nurses and other specialists -- donate their services augmented by those currently practicing who also volunteer time and service. Nonmedical community volunteers called "partners in care" support the six paid staff. VIM provides general medicine, pediatrics, dentistry, immunizations, ophthalmology, otolaryngology, cardiology, gynecology, dermatology, neurology, orthopedics, urology, radiology, laboratory work, minor surgery, nutrition, chiropractic, social services, and counseling. VIM’s mission is "to understand and serve the health and wellness needs of the medically underserved population" who live and work on Hilton Head. VIM’s vision reinforces the values of charity work: May we have eyes to see those who are rendered invisible and excluded, open arms and hearts to reach out and include them, healing hands to touch their lives with love, and in the process heal ourselves.
President Bush’s 2004 economic report to the nation describes the breadth and pace of American medical innovation over the past few decades as "no less than astounding." Technological marvels in new medical knowledge, medicines, treatments, and medical devices have enabled Americans and people worldwide to live longer, healthier lives. As new scientific treatments become available, the United States has lavished more and more money on medical care. Remarkably, between 50 and 75 percent of the growth rate in health expenditures is attributable to technological progress in medical goods and services. "A strong reliance on market mechanisms," the president said, will ensure innovation while providing excellent care cost-efficiently. "Americans should have more choices, more information, and more control over their health care decisions," he said.
The Medicare Modernization Act’s most exhilarating proposals for modernizing the medical market are the health insurance reforms to enable patients to deal directly with physicians and the creation of Health Savings Accounts open to all under the age of 65. Currently disappointing but reparable is the Medicare prescription drug benefit. Other proposals that promise to stimulate medical innovation are:
New knowledge, innovative products, and lifesaving medical procedures are the results of our relatively free American medical marketplace. The American engine of innovation has created diagnostic tools such as magnetic resonance imaging and computed tomography scanning, surgical advances such as balloon angioplasty, minimally invasive arthroscopy, and restorative hip and knee replacements. New pharmaceuticals treat conditions previously intractable. Genetic-specific medications, thanks to the sequencing of the human genetic code, promise personal disease-specific treatments.
Biotechnology products and services are so pervasive that city telephone books have commercial listings for hundreds of private biotech companies. San Diego’s 2002 Pacific Bell Yellow Pages listed, among others, A.G. Scientific, Acadia Pharmaceuticals, Access Biomedical and Diagnostics, Acon Labs, Ativx Biosciences, Althea Technologies, Andro Science Corp, Angiogen, AntiCancer, Inc., Applied Gene Technologies, Attenuon, B&A Environmental Bio Equipment, Biacor, BioQuant, BioAge, Bioclone, Biokwitech, Biologics Process Development, BioScience Ventures, Bioservice Solutions, Biosignature Diagnostics, Biosystems Insitute, Biozak, CIStem Molecular Corp, Cell Applications, Chemnavigator, Ciblex, Clincyte Center for Innovative Technologies, Conforma Therapeutics, Cosmederm Technologies, CroMedica, Cytometry Research, Ebioscience, Egea Biosciences, Genemay, GenBase, Genetronics, Genomic Solutions, Genset, GenWay Biotech, HemoSaga Diagnosis, IDEC Pharmaceuticals, Imgenex, Immusol, Invivogen, Jackson Engineering, [N.B.]Jennifer Entriken, Kanda Met Biotech, Maxim Pharmaceuticals, Metastat, Morphogen, Neurogenetics, Nova Rx, Omnicare, Oncosis, Optimer Pharmaceuticals, Orbigen, Pan Probe, Pharmigen, Plus Orthopedics, ProSci, ProteinLabs, Quidel Corp, ScienCell, Selective Genetics, Selegen, Senomyx, Solutech, Targeted Molecules, Trega Biosciences, TriLink Biotechnologies, Universal Preservations Technologies, Urogen, ValiGen, Vitagen, and X-Ceptor Therapeutics.
At the confluence of biotechnology with nanotechnology Americans are likely to find future cures to their illnesses and injuries and extensions of their longevity. Nanoscience and nanotechnology are among the astounding innovation engines of the past quarter-century. Nanoscientists manipulate ideas in a world so infinitesimally small that it requires new intellectual instruments and application of different laws of physics to the works of atoms and molecules. Nano means one-billionth and nanoscale is the space between one atom and about four hundred atoms in which quantum behavior replaces Newtonian physics. New tools and techniques will enable medical scientists to "grow" materials by adding the right atoms and molecules together. Nanotechnology has the potential to grow molecular "helpers." An anti-cancer nanohelper molecule could "hunt and kill" a cancer before it grew larger than a single cell. Nanotools and nanohelpers are likely to dramatically expand human control over the human body nanoworld: making new retinas for blind eyes, regenerating new spinal cords for parts severed in accidents, and growing a new heart, not transplanting a used heart, in the chest of a patient with a heart that failed.
Free-market, consumer-driven medical businesses will create genetic-specific drugs and nano-biotechnological organs. Such medical innovations honor the most profoundly individualistic, scientific, patient-centered medicine. These have no place in a collective and no philosophical legitimacy in a socialist structure that values the group and its needs over the rights of individuals, personal talents, and personal property.
That America is one of the only industrial nations without a socialized national health system should be a source of national pride, not guilt. America is one of the only extant capitalist democracies that has not silently succumbed to socialism. America respects individuality and private property. Though body ownership is not an enumerated right in the U.S. Constitution, body ownership is an inalienable natural right foundational to all American political philosophy and all our property law. We cannot say he took what is mine unless we know that what is mine is mine. There can be no fraud, trespass, invasion, or murder until we acknowledge who is the rightful original owner of the attacked property. America’s founders and writers of the Constitution knew classical natural law and the writings of John Locke, especially his famous "Second Treatise on Government." From such theory, the founding Americans explored basic ideas of each individual’s place in the world, the rights and responsibilities of the people, and then formulated the limitations on the acts of government that the people intended to establish to secure their rights with their consent.
Human beings act to achieve goals with scarce goods. This human condition is the basis for government, for economics, and for free markets. We start with our own private property. The most essential is our body. Each of us owns his own physical body, his mind, and the works of his hands. He owns all "nature-given goods" which he puts to use with the help of his body, before someone else does, providing that he does not violate another person’s physical integrity or another’s private property without his consent. The first user is the first owner. Locke said: "Every man has a property in his own person. This no man has any right to but himself. The labour of his body and the work of his hands…are properly his. Whatsoever then that he removes out of the state that nature hath provided, and left it in, he hath mixed his labour with, and joined to it something that is his own, and thereby makes it his property…. For this labour being the unquestionable property of the labourer, no man but he can have a right to what that [labour] is once joined to…."
To take what belongs to another is tyranny and to take and use the works of another’s body and mind is slavery. In fact, natural rights theory on body ownership helped Americans abolish slavery in our land, then in most of the world. The fiery abolitionist William Lloyd Garrison argued that the right to enjoy liberty is inalienable. "Every man has a right to his own body — to the products of his own labor [and] — to the protection of law." For government to force physicians to give their time and talent and not to sell it for fair price violates the professional liberties of physicians. For government to decide who shall do what to Americans’ healthy or diseased bodies violates the personal liberties of American patients. Criminalizing physicians, collectivizing patients, and medicalizing select social dilemmas all result from the social paradigm shift beginning in 1965 that placed government and other third parties at the center of medical responsibility. Neither well intentioned nor compassionate, the shift from individual control to government control has had vicious consequences. Costs erupted, care decayed, physicians and surgeons are exploited and brutalized, and choice vaporized.
Patient-centered, consumer-driven medicine encourages the necessary paradigm shift to place the individual American once again at the center of medical decision-making. Health Savings Accounts and similar mechanisms honor individual choice. HSAs and other patient-centered instruments will attract those already "insured" and also large numbers of the uninsured. About 70 % of those who have bought MSAs had been uninsured in the past. Whoever pays, controls. Whoever pays decides what shall be done or not done to the body luxuriating in vigorous health or debilitated by injury or disease. If that body is your body, you merit the same ownership control over your anatomy as for your car and your house. Only you ought to decide what medicine or surgery is right or wrong for you.
Americans merit the best medicine of a free society. They have the courage, the intelligence, and the rights to buy it. With their courage and cash to buy the best from the best, Americans will enjoy medical abundance, medical integrity, and medical excellence.