Strategies For the Battle Over Universal Healthcare

Posted on December 29, 2008
Filed Under New business models for healthcare |

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DrRich is sorry that the title of this post may be somewhat misleading. The idea of a “battle over universal healthcare,” for most readers, probably conjures up the image of conservatives battling liberals, or Republicans battling Democrats, or Gekkonians battling Wonkonians, over the notion of whether we ought to have a single, national, overarching healthcare system that covers all Americans, and that is entirely run by, or at least heavily regulated by, the government.

But that’s not the battle DrRich is referring to at all. That battle is already pretty much decided. Of course, the details still need to be worked out. Will we jump directly to a single-payer system, or indirectly evolve to one (by creating a Medicare-for-anyone plan that “competes” with private insurance, under a system of complex and onerous rules established by the government, i.e., by the most powerful competitor)? Will we arrive at universal healthcare via some process of relatively organized healthcare reform, or rather by the more precipitous means of the health insurance industry suddenly throwing in the towel and handing the entire mess over to the feds?

So, yes, the method by which we arrive at universal healthcare will be a matter of great interest to many of us, and will indeed be worthy of battles. But at least for the purpose of this post, DrRich is not concerned with the method by which we finally arrive at universal healthcare, but rather, he is concerned with the implications of the word “universal.”

The fundamental question - the “battle” to which DrRich herein refers - is this: Under our system of universal healthcare, will Americans be permitted to spend their own money on their own health?

For many who are proponents of universal healthcare, the answer to this question is clearly “No.” To allow otherwise would permit those with money or connections access to a level of healthcare that is not available to the average citizen. It would allow the formation of a two-tiered healthcare system. In order to achieve a result that is sufficiently fair under universal healthcare, the freedom of individual Americans to expend their own resources on their own well-being will have to be curtailed by whatever means necessary.

This, DrRich submits, is to be the real battle over universal healthcare.  All else is a mere distraction.

Proponents of universal healthcare have clearly recognized the fundamental importance of this question, and have already joined the battle with great vigor. They are organized, dedicated and fierce, and DrRich has little doubt that they will get their way.

Item: The state of Maryland has recognized the threat posed by concierge physicians (where doctors and patients enter into a private contract with one another) to the concept of universal healthcare, and, accordingly, are exploring steps to make the practice of concierge medicine illegal.

Item: In Arizona during the recent election, Proposition 101 (The Freedom of Choice in Health Care Act), was apparently narrowly defeated. Prop 101 was a citizen-initiated constitutional amendment that would have disallowed certain legislative actions that would limit an individual’s rights regarding their own healthcare, including any interference “with a person’s or entity’s right to pay directly for lawful medical services.”  Opponents of Prop 101 descended on Arizona in force to help defeat the bill, with more than four times the funding of proponents, and wielding well-tailored arguments (such as the promise that passing Prop 101 would threaten Medicare and Medicaid) to frighten Arizona citizens.

DrRich is a realist and sees the writing on the wall. Mrs. Clinton’s healthcare plan in the 1990s offered severe penalties to doctors who sought to provide medical care outside the official “system,” and he suffers no illusions. Whatever plan Mr. Obama’s administration comes up with will almost certainly provide for the same thing.

On the other hand, DrRich is a student of history, and believes that any political system whose success requires a fundamental change in human nature is doomed to failure.  While we can certainly make it illegal for Americans to buy healthcare outside the sanctioned universal healthcare system, just as certainly we will not be able to prevent determined Americans from actually doing so.

DrRich, being a classic liberal (that is, one who believes in individual rights, freedom from restraint, free markets, property rights, human rationality, and the constitutional limitation of government), does not think that individuals should be unreasonably restrained from using their own resources to protect their own well-being, and does not find anything ethically objectionable (whatever the law might actually say) to helping them discover ways of doing so.

So in view of his nostalgic interest in classic liberalism, and of his quaint interpretation of the Declaration of Independence and the Constitution (which he supposes to be our founder’s attempts to embody the ideals of classic liberalism into a new form of government), and further, before it is rendered illegal to express such ideas publicly, DrRich now offers some strategies that might be undertaken in the real battle over universal healthcare - namely, the battle over whether the rights of the individual will finally be subsumed to the interests of the collective.

These strategies rely on two laws of human nature which DrRich believes he has identified:

1) When there is a population of individuals who desperately want a particular product or service, and there is another population of individuals who are able to supply that product or service, no force on the face of the earth can keep them apart.

2) Progressively bad laws invariably lead to progressively greater contempt for authority, and to a progressively generalized willingness to ignore the rules - even, finally, by the authorities themselves.

Keeping these two laws of human nature in mind, let us now suggest a few strategies for preserving the ability of individuals to act in their own medical self-interest, despite universal healthcare.

Strategy A: Develop Medical Tourism

Here is an obvious and entirely legitimate choice for those who can afford it. In his consulting work, for instance, DrRich has encountered organizations such as ParkwayHealth Global, a concern that has established absolutely supurb state-of-the art medical institutions in Singapore, India, China and elsewhere in Asia, expressly for the purpose of attracting citizens of the world whose own healthcare systems cannot (or will not) provide the level of care provided by Parkway, or can only do so at many times the cost. Under universal healthcare it is likely that Americans will become much more willing to avail themselves of the opportunities provided by such institutions. New companies can be established to expedite the process for Americans, to help them match their needs to the best institutions across the globe, and to assure themselves of the best deal. Under even ideal circumstances, however, this option will be suitable to only a small minority of Americans who are desirous of more or better healthcare than the “system” is willing to provide.  So more “creative” strategies will be needed.

Strategy B: Black Market Healthcare

DrRich has discussed this idea before, in a slightly different context. Doctors operating in this new, blacker healthcare sphere would offer patients completely clandestine, direct fee-for-service medical care. Their patients would be comprised mainly of otherwise law-abiding individuals who want or need medical care of a quality not provided by the universal system, and who are willing to pay for it.  Physicians wishing to establish such practices but who are uncomfortable with the idea of setting up and maintaining illegal medical clinics might wish to study the methodologies employed by bootleggers and speakeasies during Prohibition.  It was apparently quite common to run permanent or semi-permanent establishments during that time, often right out in the open, which were frequented by very prominent citizens, and which were clandestinely protected or at least ignored by the authorities. Perhaps it would be possible to set up such black market medical practices without actually creating a new Medical Mafia to support and organize the endeavor, or perhaps not. But given the inherent bloodthirstiness and ruthlessness of some physicians, adequately staffing such a new mafia, if it became necessary, would probably not prove an insurmountable challenge.

Strategy C: Offshore Medical Centers

This is similar to medical tourism, but much closer to home - literally, right offshore.  DrRich envisions groups of investors purchasing mothballed nuclear-powered aircraft carriers from, say, the former Soviet Union, registering them in Liberia, and converting them into floating, state-of-the-art medical and research institutions, on a par with, say, the Mayo Clinic or Cleveland Clinic. The floating medical institutions would ply the international waters just off the east and west coasts of the United States. Helicopters would provide regular shuttle service from several major coastal cities.

Strategy D: Native American Casinos and Medical Centers

Based on the same legal theory that permits native American tribes to establish gambling casinos within the sovereignty of their reservations, tribe-operated medical centers could also be established that function outside the constraints of the universal healthcare system. Of course, it is absolutely certain that the Church of Universal Healthcare would pull out all the stops to prevent such an eventuality. But, though DrRich is no lawyer, the sanctioning of reservation-based casinos offers a compelling precedent for the idea that native American tribes may choose to furnish American citizens with certain highly-desired services that the government (in its wisdom) has decided to withhold.  Furthermore, the legitimate arguments which native Americans might invoke for special consideration - for instance, the past systematic injustices they have endured (up to and including genocide), and their own continued spotty access to quality healthcare, which would most certainly be cured by the establishment of their own ultra-modern medical institutions - could be parlayed into a powerful legal and political case for allowing native Americans to operate “off-the-grid” healthcare centers.

The futility of healthcare prohibition

DrRich is certain that others will devise strategies that are even more out-of-the box than these. But one way or another, human nature will win out. One way or another, methods will be invented to couple the desire for medical care that is forbidden or unavailable under our new universal system, with the means of providing it. While he continues to believe that it would be much better to devise a system right up front that allows individuals to use their own resources to supplement universal healthcare, DrRich holds out no real hope that the people who have habitually ignored basic laws of human nature in the past will willingly make concessions to it in the future.

That being the case, opportunity will abound for creative entrepreneurs to provide “work-arounds,” whether employing one of the strategies offered by DrRich or some other strategy, and whether those strategies are legal, quasi-legal, or entirely outside the law. Prohibition did not work for alcohol, is not working for drugs, and will certainly not work for healthcare.

Comments

16 Responses to “Strategies For the Battle Over Universal Healthcare”

  1. Annie on December 29th, 2008 3:09 pm

    Wowza! When you last left us, we were waiting with bated breath to learn whither table thou wouldst be holding forth at yuletide: the big people’s, the little people’s adjacent, or the chopping block in the nether out kitchen.

    What happened? Was mistletoe involved?

    What was the inspiration for this post relative to that context?

  2. DrRich on December 29th, 2008 4:35 pm

    Annie,

    My family’s Christmas dinner was, thankfully, unremarkable, and was held indoors, even for me. The main topics of conversation were the Steelers and the weather, and as I do not consider myself particularly expert at either, there was no “holding forth.” This post, accordingly, is unrelated.

    Rich

  3. NG on December 29th, 2008 7:38 pm

    I believe your post to be logical if actually proven highly effective treatments are indeed withheld by the universal system from those who could otherwise afford them with their own funds. However, I also believe the best argument by the universal system proponents to counter this trend would be to make it very clear just what highly effective means! It could be pointed out that in the past a great deal of snake oil, caveat emptor market forces were used in healthcare to mostly separate desperate patients from their dollars! If this effectiveness campaign was done correctly, I am not sure just how much demand for maybe effective processes there would really be.

    I certainly hope that truly highly effective processes could be made available to those that qualify in the universal system, however!

  4. James gaulte on December 30th, 2008 7:09 am

    Certain recent trends in Canada suggest that maybe their never-a two-tier system is becoming one and that Canada might become a refuge for medical refugees from the U.S.I recall I had a few patients who were British on assignment in the U.S. who regularly went to France where they could buy medical care apparently thought superior to even the private care in England.

  5. BladeDoc on December 30th, 2008 8:36 am

    I am right with you but figured the place to set up shop was Tijuana. High security costs but the travel and entertainment expenses are low.

  6. DrRich on December 30th, 2008 9:35 am

    NG,

    Your comment deserves a thoughtful reply, and I will probably do so with a formal post.

    Rich

  7. DrRich on December 30th, 2008 9:44 am

    Dr. Gaulte and BladeDoc,

    You are both correct - there are many options available to us, including those just across both of our borders.

    Reversing the flow of patients seeking healthcare between Canada and the US is a remarkable enough vision to contemplate. But trying to imagine Americans sneaking across our Southern border into Mexico to seek illegal healthcare services is truly mind blowing! THAT reversal of flow would finally induce Congress to seal our borders once and for all - with fences, security cameras, minefields, and high concentrations of the regular military.

    I hope you are well, Dr. Gaulte. We miss you.

    Rich

  8. James gaulte on December 30th, 2008 11:45 am

    I appreciate your concern I am well and starting to start up again.I hopeful you will return me to your blog roll.

  9. Dr. Bobbs on December 31st, 2008 5:59 pm

    Color me skeptical, but I have a bit of difficulty envisioning a health care financing strategy that includes “purchasing mothballed nuclear-powered aircraft carriers”.

    An alternative scenario: a few states try to regulate or ban outright so-called concierge medicine. As a result, whatever primary care shortage existed in these states become immediately exacerbated as PCPs flee to states that have no such ban. Policy makers also quickly learn that you don’t have to pay physicians out of government coffers when the doctor charges the patient directly. Bans on such practice arrangements become very unpopular very quickly.

    Of course, no one can predict the future. But I generally bet against health care scenarios where doctors have to have Geiger counters and scopolamine patches as standard office expenses.

  10. DrRich on December 31st, 2008 6:54 pm

    Dr. Bobbs,

    I’m terribly sorry you don’t like my aircraft carrier idea. I’ll scratch your name off the list of potential investors. I am gratified, however, (by your specific omission of criticism) that you apparently like the Black Market/Medical Mafia and the Native American Casino/Medical Center ideas.

    Also, your point about what might happen if a few states ban concierge medicine is indeed a very good one, and I hadn’t thought of it. Of course, if the feds are reading this blog, we’ve just prompted them that they ought to just go ahead and federalize the ban on direct doctor-patient contracting immediately.

    Rich

  11. Bad Medicine, Good Solutions on January 1st, 2009 2:30 pm

    Nicely done. Good comprehensive evaluation of the potential future outcomes. Let’s hope they don’t come true.

  12. jenga on January 2nd, 2009 8:22 pm

    Scary indeed. Maybe the most compelling arguement I’ve seen for getting out of medicine altogether and giving such wonks the middle finger. They can have no care and like it.

  13. Seamus Muldoon MD on January 9th, 2009 8:19 pm

    Dr. Rich,
    You have hit the nail on the head. The Prohibition analogy is quite apt. I would like to expand on the speak easy concept. Envision a “state-run” clinic with a “state-run” doctor who sees his quota of “state-run” patients from 9:00 to 12:00 and from 1:30 to 4:00. An unmarked back door and a rarely-used back exam room however are used for “cash-paying” customers for 1/2 hour at lunch and maybe an hour or two after “closing time”. Probably will need a secret code knock (Shave and a haircut, two bits?) Two tiered? you bet –Dr. Seamus

  14. Jeremy on March 10th, 2009 12:46 am

    I would like to see Obama change the Health Care Industry but I am a Skeptic. In my opinion I don’t believe it is the government’s job to provide universal health care. With over half our nation being obese I think people should start there!

  15. suek on April 4th, 2009 11:04 am

    If the nuclear aircraft carrier idea doesn’t fly (though at this time, since Obama wants to get rid of all nuclear bombs, I don’t see why they wouldn’t be available) you might consider the possibility of medical cruises. Staffed by medical teams, booked based on the length of time required for diagnosis, medical process required and recovery time, it could be quite pleasant. See your doctor, see the world!

  16. Maurice on April 4th, 2009 11:18 pm

    How will physicians get medications? They won’t be able to write prescriptions..and alt med is good for some things, not for others. Prescriptions for medications will be intensely monitored. So doctors will also have to start finding ways of having medications available, and have them illegally?

    Nope, universal health care of the kind Obama and his communist minions want will be the end of decent healthcare. The rich will fly away for tourist medicine, as will be the Party members (Dem or Repub. politicians and their toadies). The rest of us will take our place in the ever-lengthening lines to get a procedure done, as is going on in Britain, in substandard hospitals, by healthcare workers that don’t give much of a crap.

    Like all socialist wet dreams, “universal” health care is about power of the State over individuals. Orwell’s 1984 had it correctly. Power for the sake of power.

    There has been no true free market for health care for >50 years..and what semblance of a free market there has been is going by the wayside.

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