Chapter 17 – What We Need To Do

This is Chapter 17, the final chapter of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters.
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Update – September 1, 2012

Open Wide and Say Moo! is now revised and published!

 

You can find it on Kindle here.

 

Now available in the audiobook version!

 

 

 

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Chapter 17 – What We Need To Do

Whatever Conservatives do in their efforts to overturn Obamacare, whatever Progressives do to uphold it, whether Republicans win at the polls, or whether Democrats do, herd medicine can only work if we citizens agree to become bovines.

This is the key.

As we have seen, Obamacare – and any Progressive healthcare system – absolutely requires centralizing major healthcare decisions; it requires removing those decisions away from the doctors and the patients who are immediately affected by them. Hence, Obamacare is constructed to utterly control the behavior of physicians. And this is why so much has been done already to prevent individuals from being able to bypass the official healthcare system, to purchase medical services the Central Authority thinks they should not have. The reason Progressives must suffocate individual prerogatives is not, as many claim, because they are power-hungry. While many of them (being human) do indeed become power hungry, that is not their primary motivation. Their primary motivation is to achieve the perfect society envisioned by the Progressive Program, a goal that requires society to be directed by enlightened experts. There is simply no room to allow individuals – imperfect, self-interested individuals with nothing grander on their minds than their own comfort and happiness – to make their own decisions in areas that are critical to the Progressive Program.

And healthcare is critical to the Program.

It is thus necessary for the sake of the Program for the people to sacrifice certain of their individual prerogatives. Progressives invariably begin with enticement; they attempt to induce the people to make this sacrifice not with force, but with persuasion. In this case, they offer healthcare security – insurance for the uninsured, access for the disenfranchised, equal care for everyone. And because our healthcare system is indeed rife with injustices, absurd practices, abuses and waste, when Progressives proclaim with supreme confidence that they know the only way to fix all these problems, they invariably gain a lot of support*.

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*Progressives never allow that there are actually four ways to fix our healthcare problems – they simply present Method Two as the only possible solution, without any further discussion. (See Chapter 4.)
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Those of us who are not persuaded by simple enticements are subjected to other persuasions. We are told that when we insist on our autonomous right to make our own choices – to exercise healthcare options beyond those prescribed by the Central Authority’s expert panels – we are really advocating for a two-tiered system, one in which we (likely being successful or rich, or otherwise “other”), will have access to better stuff. Therefore, we are pointed to – and pointed out – as being “unethical.” We want something other than the Progressive solution of a perfectly fair, perfectly efficient, and perfectly affordable healthcare system – and this makes what we want inherently unfair, inefficient, and wasteful. It makes us evil. This ethical argument is the chief method by which we are to be “dissuaded” from using our own resources to make healthcare decisions for ourselves. The threat, should we persist in our beliefs, may eventually become more than just implied. After all, taking the necessary steps to keep unethical, evil elitists from bringing down the system would be entirely justifiable, and no more than prudent.

To say it another way, for people to insist on their individual autonomy, when it comes to something as important to society as healthcare, is unrealistic, counterproductive, and ultimately, just plain selfish. It’s unethical, and we who think this way should be ashamed of ourselves.

The Ethics of Individual Autonomy

Individual autonomy is the bedrock of the Great American Experiment. Our founders believed – and asserted – that we are all equally endowed by our Creator with certain unalienable rights that, added together, amounted to an unalienable right to individual autonomy. This belief is the bedrock of our founding.

What Progressives and their forebears noticed was that when you have a society where millions of people are each striving for their own best interests, even if you allow that, over time, those societies (occasionally or often) make improvements that benefit everybody, if you look at the details you see a lot of inequity, failure, cheating, cruelty, poverty and all other manner of suffering. And so, the proto-Progressives concluded, whatever the (occasional or frequent) successes you’ll see in societies where individual autonomy is predominant, nobody can possibly argue that all the human suffering that goes along with it is ethical. It follows, then, that there has got to be a better way, and that whatever the best solution turns out to be, individual autonomy cannot possibly be the primary ethical imperative of the perfect society.

This is a foundational belief of Progressivism, just as the opposite is a foundational belief of Conservatism. (And this is why I personally do not understand what it means to be a “moderate,” or what moderates mean when they implore Progressives and Conservatives to compromise with one another on issues of fundamental importance.)

So the impasse is over whether the right to individual autonomy is, or ought to be, the highest ethical imperative. In trying to resolve this impasse, it is instructive to notice what the Nuremberg tribunal concluded about it when they wrote the Nuremberg Code in 1947.

The Nuremberg Code was a statement of ethics which the tribunal felt obligated to promulgate after it passed judgment upon the Nazi doctors following World War II. The Nazi doctors had conducted horrifying medical experiments on people who were held in concentration camps, justifying their actions by the fact that these people were going to die anyway, so for the sake of humanity one might as well use their already forfeit bodies to advance medical knowledge. (This species of thinking ought to be recognizable to anyone familiar with the utilitarian ethics espoused by many prominent medical ethicists today.)

The Nuremberg tribunal was interested not only in punishing the Nazi doctors, but also in laying out some universal principles of ethics that (if followed) would prevent such a travesty from ever happening again. In searching for such principles, they took note of the fact that when the decisions were made to conduct these experiments, neither society as a whole, nor the central government, nor the local authorities, nor any religion, nor the medical profession, took any steps to prevent or to stop them from happening, and indeed, many of these institutions (including the medical profession) found ways to rationalize these experiments. So any ethical precept that would rely on society, governments, religions or the medical profession to prevent similar atrocities in the future was demonstrably insufficient. Somewhat reluctantly, the tribunal concluded that the only ethical precept that could be relied upon in this regard is the precept of individual autonomy; that is, on the idea that no human experimentation can be performed ethically without the explicit, fully-informed, free consent of the human subject him-or-herself. This irreducible, primary ethical precept – ultimate respect for the autonomy of the individual – was therefore written into the Nuremberg Code. And the Nuremberg Code was the foundation for the Declaration of Helsinki, a statement of medical ethics in human research that has been adopted by virtually every country around the world.

What is particularly noteworthy about this formulation of ethics is that individual autonomy was recognized as primary not for any positive reason – not because individual autonomy represents the highest state of human existence, or because it is a God-given right. Rather, individual autonomy was declared primary for a negative reason – there really is no other choice. No entity – no institution, organization, government, or panel – can be trusted, under duress, to do the right thing. Individual autonomy must be the primary ethical precept because it is a line in the sand, a backstop, the only ethical precept that, at the end of the day, can offer to prevent the official abuse of individuals in service to a purported higher cause.

Progressivism inherently subsumes individual autonomy to the needs of the whole, and thereby inherently defeats this ethical line in the sand. Progressivism removes that ethical barrier, the only possible ethical barrier, and exposes individuals to official – and officially “ethical” – abuse in advancement of the higher collective cause of the day.

Even people who object to the primacy of individual autonomy as formulated in the Declaration of Independence, on the grounds that there is no Creator, or that they have discovered a truth that is even more unalienable than the one stated therein, cannot argue with the formulation of the Nuremberg Code. That latter formulation was not based on some lofty ideal, or on an assertion of some pinnacle of Western philosophy, but was a simple statement of cold, hard, sad, scientific logic, derived from painfully objective evidence, evidence paid for in human blood, tears, suffering and untold anguish. It is as evidence-based an ethical precept as is ever possible to have.

We now know two things. First, Obamacare cannot work if enough of us refuse to acquiesce to herd medicine. And second, whatever vituperations, innuendos, accusations and castigations are thrown at us, our non-cooperation with herd medicine is not only ethically justifiable, but for the sake of our progeny it is the only truly ethical path we can take.

How Can We Assert Our Individual Autonomy In Healthcare?

There are two general strategies for reversing herd medicine and restoring the rights of individuals within our healthcare system. The first is the political strategy – collective action aimed at electing political leaders who are dedicated to overturning Obamacare, undoing the restrictions to individual prerogatives already present in our pre-Obamacare healthcare system, and establishing a healthcare system that recognizes freedom of individual action as a foundational principle. I believe such a system would be based on a “Method 3″ model, as described in Chapter 4.

I, for one, hope very much that this happens.

But I think it is likely that, no matter what happens politically, we will need to use the second general strategy for reversing herd medicine. Even politicians who truly “get it” will find it difficult to reverse the Progressive tide. Any dedication they express in support of individual prerogatives (and its necessary partner, individual responsibility) will be loudly advertised by their political opponents and the American media as having proven themselves to be elitist, selfish, hard-hearted caterers to the rich, and oppressors of the poor. They will be painted as evil, stupid, and/or crazy. Politicians generally cannot survive such attacks, and realistically we should not expect them to try.

This leaves us with the strategy of individual action. We, as individuals, need to understand the “bargain” which Obamacare represents – an assurance (ultimately false) of healthcare security in exchange for our individual prerogatives – and then act in our own, enlightened self-interest. In the battle for individual autonomy, individual action is a fitting and proper strategy.

In adopting this strategy, we will need to rely on the bedrock precept of individual autonomy the same way the Nuremberg tribunal did – as the last possible bulwark against tyranny. And it is this ethical precept, so derived, upon which we must stand. We must draw our own line in the sand, and declare: “I assert my right to act in my own best interests, in any way that does not impinge on the rights of others to do the same. Accordingly, I will not allow any human authority to restrict my right to protect my own well being, as long as I am using my own resources to do so.”

If enough of us make this simple declaration, and act aggressively upon it, and if we make it clear that by doing so we are merely asserting humanity’s primary ethical right, Obamacare cannot stand, any Progressive healthcare system cannot stand, and the Progressive Program itself cannot prevail.

Unfortunately, Obamacare is carefully designed to utterly suffocate individual prerogatives. Every step we or our doctors attempt to take that is not officially sanctioned by the Central Authority will be snuffed. This means that we may ultimately have to operate largely outside the official healthcare system, in the places where the grasping tentacles of Obamacare do not yet quite reach.

What Doctors Should Do

The medical profession is in a truly sorry state. As far back as 2002, under exceeding duress for more than a decade to place the interests of the payers ahead of the interests of their patients, and “guided” by their Progressive-minded leaders, the medical profession abandoned over two thousand years of tradition, law and ethics, and formally adopted a New Age medical ethics that obligates them to work for “social justice.” That is, doctors have charged themselves with an ethical obligation to distribute medical resources equitably. They have accepted the task of covertly rationing healthcare at the bedside. (See Chapter 3.)

New Age medical ethics renders the classic doctor-patient relationship entirely moot, and leaves sick people – as they attempt to navigate an increasingly hostile and parsimonious healthcare system – without the dedicated professional who, until now, has been obligated to act as their personal agent. Worse, doctors have not made explicit to patients their new mixed (at best) loyalties. Indeed, doctors are trained to hide that fact. When young doctors today learn about the doctor-patient relationship, they are no longer learning classic medical ethics. Rather, they are learning techniques for fruitful communication and subtle manipulation, in order to better induce patients to “comply” with the expert-guided medical recommendations they are handing out these days.

By abandoning their sacred fiduciary obligation to their patients – the one ethical precept that renders the practice of medicine a true profession in the first place – doctors have committed the original sin. They are now professionals only in the sense that master plumbers are professionals – that is, by virtue of their special training in some field of work. They are no longer members of a true Profession, as attorneys are, for instance. (While doctors may disparage lawyers as ambulance chasers, at least lawyers have not abandoned their sacred fiduciary obligation to their clients.)

In the perpetual struggle over the use of resources, doctors have officially thrown in with the payers. It should be obvious that this leaves their abandoned patients in a bad place. But for the purposes of the immediate discussion, we should note that by this capitulation doctors have set themselves adrift. As a profession they have no moral anchor. And because they have abandoned their sacred professional obligations, they find themselves at the mercy of the payers who induced their capitulation.

While this change has profoundly affected every American doctor, the doctors who are most directly and severely affected, so far at least, have been the primary care physicians.

This Is Your PCP On Obamacare

For most Americans, the most important person in the healthcare system is our primary care physician. These are the doctors we see first if we have a new medical problem, who (theoretically, at least) stick with us through the ups and downs of our chronic medical conditions, and who direct traffic for us if we need to see a specialist. Our PCPs are the doctors we know the best, and who care about us the most (which, admittedly, might not be saying much today). It is our PCPs, more than anyone else, who will determine how well we are going to fare in our encounters with the American healthcare system.

PCPs are equally important to the Central Authority. To a large extent PCPs drive the overall cost of healthcare, and decide how much of the Central Authority’s healthcare dollars are spent, and on whom, and when, and how. Among other things, PCPs are the gatekeepers who determine to a very large extent which patients will see specialists, how aggressively and how well patients’ chronic and acute illnesses are to be managed, and which patients receive which preventive services. To control healthcare costs, therefore, it is absolutely essential for the Central Authority to control the behavior of PCPs.

In Chapter 8, we saw how Obamacare’s infrastructure is designed specifically to control the behavior of physicians. And while this control will greatly affect every American doctor, it is primarily the PCP upon whom the screws of oversight will be ungently turned. Every move they make on our behalf will be carefully monitored, measured, scrutinized, analyzed, and compared against the lists of guidelines, processes, procedures, rules and dictates under which they must operate. Even locally they will no longer be independent agents, whose medical knowledge and ethical precepts must guide their decisions. Rather, they will be just one member of a “healthcare team,” consisting largely of non-physicians, which will make decisions jointly. They will no longer be primarily accountable to their patients for their actions. Rather, their patients will become merely objects of their accountability. PCPs will be held accountable first to their teams, then to the Accountable Care Organizations which employ their teams, and, ultimately, to the Central Authority itself.

When it comes to independent thinking, much less to independent action, our PCPs will be on a very short leash. Their real jobs will be to act as the most proximate agent of the Central Authority.

However, I don’t want to give the impression that it is Obamacare which has wrecked primary care medicine. That job had been pretty much completed before anyone had ever heard of Obamacare. For many years now PCPs have been a downtrodden and beleaguered lot, unhappy, dissatisfied and demoralized. Large numbers of them can think only about retiring at the earliest possible date, or if retirement is too far away, changing careers – perhaps becoming corporate executives, or deep-sea fishermen. And even though a majority of entering medical students claim that they aspire to become PCPs, only a tiny minority actually end up doing so.

It is instructive to have a look at why all those medical students are changing their minds. Part of the reason, of course, is the relatively low pay of PCPs. But PCPs have always made substantially less money than specialists, and in the past a lot of doctors still chose primary care. The larger part of the reason is that today, when motivated and idealistic medical students spend a little time interacting with actual PCPs during the course of their training, they are horrified at what they see.

There are numerous reasons why few doctors in their right minds would choose primary care medicine as a career today.

- The pay of PCPs is determined arbitrarily (and literally) by Acts of Congress, not by what they’re worth to their patients or to the market, and indeed in this way PCPs have a lot in common with workers in the old Soviet collectives.

- While all doctors these days are directed to “practice medicine” by guidelines and directives which are handed down from On High, the centralized control is particularly focused on PCPs. They have as little latitude in making medical decisions as the Central Authority can possibly arrange. Indeed, it is the unspoken policy of the Central Authority to dumb-down the practice of primary care medicine, to reduce it to a series of reproducible and robotic activities that almost anyone with a modicum of training can do.

- PCPs are forcibly limited to between 7.5 and 12.5 minutes per patient encounter, and the specific content of what must occur during those 7.5 minutes is strictly determined by sundry Pay for Performance checklists, so as to severely limit any ad hoc discussions that might occur between doctor and patient, discussions which might introduce new spending opportunities, and which do not meet the approved agenda for such encounters.

- Everything a PCP does must be carefully documented according to incomprehensible rules, on innumerable forms and documents, that confound patient care but that greatly further the convenience of healthcare accountants and other stone-witted bureaucrats who are employed specifically to second-guess every clinical decision and every action the PCP takes.

- PCPs are expected to operate flawlessly under a system of federal rules, regulations and guidelines that cover hundreds of thousands of pages in immeasurable volumes that are never available in any readily accessible form. If they do not operate flawlessly according to those rules, regulations and guidelines, they are guilty of the federal crime of healthcare fraud. Furthermore, the specific meanings of these rules, regulations and guidelines are not merely opaque and difficult to ascertain, but indeed they are fundamentally indeterminate – that is, no individual or group of individuals in existence can say what they mean. So, PCPs operate under a massive quantum cloud of rules as best they can, but their actual status (regarding healthcare fraud) is, like Schrodinger’s cat, fundamentally unknowable – until the “box is opened” (perhaps through criminal prosecution), whereupon the meaning of the rules is finally crystallized in a court of law, and doctors who had been practicing in good faith find that they have at least a 50- 50 chance (like the cat) of learning that they are actually professionally dead.

- Worst of all, PCPs have been charged with the duty of covertly rationing their patients’ healthcare at the bedside, and they have been pressed to nullify the classic doctor-patient relationship by the healthcare bureaucracy that determines their professional viability, by the United States Supreme Court*, and by the bankrupt, new-age ethics of their own profession.

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Pegram et al. vs Herdrich(98-1940), 530 US211 (2000)
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It is small wonder that few young doctors are anxious to sign up for this duty, or that our existing PCPs are demoralized and are desperately seeking the nearest exit. Any of us who are lucky enough to have a PCP who remains dedicated to our welfare, despite the heavy bureaucratic burden under which they are all struggling, should regard them with the same sense of awe and wonder with which we would regard the nun who chooses to live and serve in a leper colony.

How Obamacare “Fixes” the PCP Shortage

During the Obamacare debate in 2009, the President and his supporters repeatedly proclaimed that their new law would solve the PCP shortage. The legislation provides two explicit methods for doing so – and one less-explicit method.

First, Obamacare promises to address some of the pay discrepancy which punishes doctors for going into primary care specialties. And second, it proposes to fund new training opportunities for PCPs.

Regarding the modest pay increase, I will merely repeat that over a period of years the Central Authority has intentionally rendered primary care medicine such a soul-wrenching, personally and professionally demeaning endeavor that it has pushed most PCPs beyond mere anger, frustration, or resignation. Since it is not primarily their relatively low pay that has caused all this anguish, a modest boost in pay cannot overcome it. Indeed, tossing this bone to PCPs, in light of what the payers have done to their profession, constitutes no more than a grave insult.

And while increasing training slots for PCPs may sound nice, one must wonder what effect it will have, when existing training programs cannot come close to filling the slots that exist today.

It should be clear to everyone that these proposed “fixes” cannot possibly provide anything approaching an actual solution to the PCP shortage. I for one cannot accept that the authors of Obamacare can possibly believe they will.

To find out what our leaders are really up to with regard to our PCPs, we must look a little deeper.

And sure enough, the real answer to the PCP shortage – at least, the answer our political leaders are actually relying upon – is revealed deep within the bill, buried in Section 5501 (which I believe very few humans have ever read), where the definition of “Primary Care Practitioner” is actually provided. Note, first of all, that Obamacare now being the law of the land, “PCP” no longer means “primary care physician,” but rather, indicates “primary care practitioner.”

And here’s how the new law defines Primary Care Practitioners:

The term ‘primary care practitioner’ means an individual who —

(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or

(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in 9 section 1861(aa)(5))

And so it is my sad duty to report to American PCPs the real “fix” our political leaders have devised for the shortage of people who practice primary care medicine is to declare you and nurses to be functionally (and legally) equivalent.

This, I submit, is all a PCP really needs to know about Obamacare. What this means is that today there are two pathways to becoming a PCP. You can spend four years in college, four years in medical school and three years in a clinical residency – or you can go to nursing school and do another year or two of clinical training. Given this established fact, one can hardly fault the wisdom of medical students for choosing another career.

All this should be expected. Having painstakingly reduced you unfortunate practitioners of primary care medicine to tools of the state, to people whose job is to rotely follow checklists of centralized directives, it is only natural for the Central Authority to eventually notice that you really don’t need all that training to do the kind of job they have invented for you. Nurses – who can be “trained up” much more rapidly than you, who will work for much less money than you, and who (they think) will be much less recalcitrant about following handed-down directives than you – will fill the gap.

And the reason so much effort has been taken to render primary care medicine such an excruciatingly frustrating and enervating profession now becomes entirely clear. The Central Authority does not really want its PCPs to be physicians at all. It wants the people functioning as the critical gateway to the American healthcare system to be people it believes will be easier to control than physicians.*

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*This statement is not intended to be an insult to nurses, but only reflects what I have concluded is the Central Authority’s intention. I have worked along side a great many nurses in my career, and I find them to be at least as dedicated to the welfare of patients as any doctor. Perhaps more so, since to the best of my knowledge the nursing profession has yet to water down its ethical standards in the way that doctors have done. I believe that at the end of the day our Progressive leadership will find nurses far more difficult to “manage” than they seem to believe.
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But I have even more bad news for primary care doctors. Even if doctors had perfect control of the healthcare system and the political realities, primary care medicine (as we know it) would still be in trouble.

This is because of an axiomatic truth revealed by the annals of human progress, to wit: As knowledge increases and technology improves, activities that used to require the services of highly-trained experts become available to non-experts who have much less training. A lot of what PCPs have traditionally done – check-ups of well patients, screening for occult disease, controlling cholesterol, advising on diet, weight loss and exercise, managing routine hypertension and diabetes – really can be reduced to a series of guidelines and checklists, which can be adequately followed by individuals with much less training than these doctors receive.

When any area of expertise evolves to this level, it is inevitable (in a free economy) that lesser-trained individuals will inherit it. This event greatly increases productivity, makes the services in question more readily available to many people at lower cost, and (ideally) frees up the experts to take on more challenging endeavors. While this kind of transition is nearly inevitable, it is often painful and disruptive. The pain and disruption are being experienced by PCPs today.

Primary care medicine has advanced to the point where it really would make sense to turn over many of the routine, mundane, and reducible-to-checklist tasks that PCPs typically perform to non-physicians. PCPs who are fighting against this inevitability are wasting their time and energy. They are fighting not only Obamacare, but also both history and the laws of economics, so in the end it is a losing battle. It is time for PCPs to move on.

So, in this way of looking at it, it was really only a formality for the Obamacare legislation to make the death of primary care medicine official.

What Enlightened PCPs Should Do

It is time for PCPs to abandon what has become “primary care medicine” altogether. It is time to move on.

Walking away from primary care should not be a loss, because actually, primary care has long since abandoned you. Whatever “primary care” may have once been, it has now been reduced to something that, by law, can be done by a lot of people who are not physicians. Primary care has been dumbed down to the point where abandoning it is no loss; indeed, it ought to be liberating to walk away from it.

So walk away from it.

The beauty is that to survive and flourish, you don’t really need to change your medical ideals or even your medical behavior (unless, of course, you have bought in to the New Age ethics, and the strict adherence to guidelines, checklists, &c.) You simply need to practice medicine exactly as you were trained to practice it all those years ago – taking all the time needed for careful, thoughtful attention to detail; seeking out the meaningful nuances in your patients’ medical conditions; personalizing both diagnostic and therapeutic recommendations not only for your patient’s medical problems, but also for their psychosocial and economic circumstances; relishing the challenge of making the difficult diagnoses, and managing the complex medical disorders that so often break from the designated norm; and treating guidelines as just that, as often-helpful guideposts, rather than mandates; and most important of all, embracing the classic doctor-patient relationship in all its particulars, and having the latitude to become a true advocate for your individual patients within a hostile healthcare system. In short, you can go back to being a real doctor, and not a cipher in some bureaucrat’s database.

There are only two things you need to do to move in this direction.

First, abandon the “primary care” label. Remember, primary care is now the standards-based, checklist-driven, one-size-fits all, “high-quality” system of practice imposed by government bureaucrats, a practice which is now open to both doctors and nurses (and, in the future, most likely to others). That’s not what you do any more. So find a new name for yourself.

The choice of nomenclature is yours, of course, but I humbly suggest “Advanced Care Physician.”

What you do is not primary care; it’s far more advanced than that, and nobody could do it without the sort of extensive training you have. “Advanced Care” captures that notion. This name also opens the possibility of referrals from the new-style, government-sanctioned “PCPs,” some of whom undoubtedly will come to recognize that at least 20% of their patients will present as clinical puzzles that do not fit very well with any of the standard medical diagnoses with which they are familiar, and another 20% will not respond to the recommended therapy as the guidelines say they must. These patients obviously will need advanced management, management beyond what a modern primary care practitioner is able (or allowed) to offer. Why not refer them to an ACP?

Second, you need to establish practices whereby you are paid directly by your patients. You need to do this because it is the only method available for avoiding the bureaucratic nightmare that wrecked your former profession of primary care in the first place. Payment models can be established that will allow most patients – anyone, say, who can afford a cell phone contract or cable TV – to participate. (Making your services readily available may help blunt the obligatory attacks of “elitist!” which will be aimed your way in the attempt to shame you back into the primary care gulag). There really ought to be nothing particularly revolutionary about this kind of practice, since it was the norm throughout most of the history of medicine until 40 years ago. It is likely that many patients who today would never consider paying any doctor out of pocket will eventually change their minds, once it becomes apparent to them the depths to which primary care medicine has fallen in the United States, and that as a result their lives are on the line.

In any case, when you are paid by your patients, you answer to your patients (not some hostile bureaucrat), and the quality of the care you deliver is measured by your patients (and not some other hostile bureaucrat). There are no externally imposed time-limits to your office visits, no checklists you must complete, no bizarre documentation rules you must follow for reimbursement, no guidelines you must obey even if it makes no sense for your patient. Those things are for the modern, government-approved “PCPs” to concern themselves with, poor souls, and you do not dwell among these unfortunates anymore.

And happy it is that primary care medicine is killed off now, at this time – because time is of the essence. I have described (Chapter 7) how an essential feature of our new Progressive healthcare system will be to make it illegal (in the name of fairness) for individuals to spend their own money on their own healthcare. For Advanced Care Medicine to become a viable path, you’ve got to begin immediately to make it a fait accompli – to establish it as something patients value, and which they fully expect as a personal healthcare option, and furthermore, as an indispensable referral resource for those sad souls – physicians, nurses and others – who retain the label “PCP,” and who will be powerless (if not clueless) when it comes to providing complex medical care to patients who come in with a difficult diagnosis, or more than one diagnosis, or who otherwise display guideline-unfriendliness.

So at the end of the day, the fact that Obamacare has formally brought primary care medicine to a merciful end may turn out to be a positive thing.

How Advanced Care Physicians Should Answer The Whiners

Precisely because ACPs will gravely threaten the whole paradigm of Progressive healthcare, these new-style physicians will need to be ready to answer the complaints and accusations that will rise up against them. Progressives will be extremely threatened by the idea that the physicians formerly known as PCPs are dropping out of the dysfunctional healthcare system altogether (the system that has, purposefully and with malice aforethought, wrecked their chosen careers), and are striking out on their own, establishing private practices in which they are paid directly by their patients.

Great and loud protests will be raised, in an attempt to create a general public hatred toward these physicians, to label what they are doing unethical, and finally to render it illegal.

The general proposition opponents will be arguing, with far more vituperation than employed here, can be reduced to this: For doctors to demand that patients pay them directly is elitist and unethical; only the rich will be able to afford this kind of care; a two-tiered healthcare system will develop, and public health will suffer.

ACPs need to be prepared with a compelling answer, an answer that does not offer any apologies, but that boldy explains why what they are doing is the ONLY ethical way for them to practice their profession. What ACPs need is a John Galt speech.

A John Galt Speech For Direct-Pay Physicians*

“You demand to know what has happened to us, the primary care physicians you thought you controlled.  You have cried that our sins are destroying the world and you have cursed us for our unwillingness to practice the virtues you demanded. Since virtue, to you, consists of sacrifice, you have demanded more sacrifices at every successive disaster. You have sacrificed all those evils which you held as the cause of your plight. You have sacrificed justice to mercy. You have sacrificed independence to unity. You have sacrificed wealth to need. You have sacrificed self-esteem to self-denial. You have sacrificed happiness to duty.

“While you were dragging us to your sacrificial altars, we physicians who value justice, independence, reason, and self-esteem – we finally came to see the nature of the game you were playing, which we had previously been too innocently generous to grasp. And we have chosen to play no longer.

“All the physicians who have vanished from your system, the doctors you hated, yet dreaded to lose, we are gone from you. Do not cry that it is our duty to serve you. We do not recognize such duty. Do not cry that you need us. We do not consider your need a claim. Do not cry that you own us. You don’t. Do not beg us to return. We are making our own way, apart from you.

“In your cynical attempt to control the healthcare system, you have coerced us – with your threats to our livelihood, threats of massive fines, threats of jail – to abandon our sacred obligation to our patients. Society must come first, you say. The needs of the collective are paramount, you insist. We must do what the experts tell us to do, you demand. And in the process you have destroyed the doctor-patient relationship which is the backbone of our profession. You have reduced physicians to ciphers, to puppets. And you have reduced our patients – the living, loving, hoping, striving people who come to us, who place their trust in us and their lives in our hands – to interchangeable members of a vast herd. You have demanded that we guard society’s interests, and abandon our sick to their own devices in your cruel and parsimonious healthcare system.

“Your process is now firmly established. Your methods have been legislated by Congress, embodied in volumes of rules, regulations and “guidelines” (strictly and ruthlessly enforced), upheld by the courts, and finally (and most tellingly) sanctioned as being entirely “ethical” by your allies, the leadership of our own professional organizations. You have made the healthcare system untenable for doctors who value true medical ethics.

“You have placed us into a position where we must either resign ourselves to an unethical, demeaning, health-destroying style of practice, or get out. We have gotten out.

“We have gotten out. We have left your Program. We refuse to sacrifice ourselves for you any longer. We will not sacrifice our livelihoods, our morals, our independence, our minds, or our patients for your bastardized idea of virtue.

“We will practice medicine in the only manner that still permits us to behave ethically toward our patients, in the only way that we can honor the true doctor-patient relationship, in the only way we can legitimately regain the title of professional. We have chosen to be paid directly by the people to whom we provide our services, by the people to whom we dedicate ourselves as professionals. We have chosen to cut you out.

“To argue that direct-pay practices are unethical – to argue that any innovation that would somehow restore both our professional integrity and the patient’s rightful advocate is unethical – is completely upside down. This argument only reveals your own inner corruption. What we are doing is the only viable pathway toward restoring the true foundation of medical ethics – of always placing the patient first.

“To argue that direct-pay practices threaten the general welfare completely ignores reality. We are doing the only thing we can do to begin restoring protections that people are supposed to have when they are sick and facing a healthcare system that is utterly bent on withholding their care whenever it can be gotten away with.

“To argue that direct-pay medicine will create a two-tiered healthcare system is absurd on its face. It provides a mechanism by which at least some of your intended victims can escape the deadly obstacles you have laid before them. Saying that it amounts to a two-tiered healthcare system is as absurd as arguing that slaveholders were wrong to free their slaves before Emancipation, because doing so would create an elite subpopulation of former slaves; that until all slaves are freed, no slaves should be freed. But when a few slaves were freed and walked the earth as free men, that action was not only ethical, but it also showed others what was possible. Over time, it created a widespread expectation for freedom that eventually could no longer be ignored, and that, at huge cost, was finally fulfilled.

“You wouldn’t understand this – you who already know everything, you whose experts already have all the answers – but any innovation that can potentially spare patients from some of the harm you have in store for them will necessarily be applicable to only a few patients at first. That is how disruptive processes work. In your proposed perfect system, of course, disruptive processes are anathema – because they disrupt. But in the real world disruptive processes are creative processes, processes of growth, processes of rejuvination, processes that create opportunity. This is why you always try to suffocate disruptive processes, with your cries of “unfair!”

“Disruptive processes always begin as niche products or services, attractive only to a few high-end users; too expensive or too marginal for the vast majority; ignored, ridiculed or castigated by current providers. But if at their core they are offering something fundamentally useful, they will slowly demonstrate their worth – and eventually all the potential users will see the light, and demand for the product will become explosive. At this stage the means are invariably found to make the new product affordable and available to meet the demand, while preserving the core benefits. And when that happens, the traditional providers (who never saw it coming) are suddenly out of business.

We are a disruptive process, and the process we are disrupting is yours.

“We are not playing your game any longer. We will no longer be victims; we will no longer subject ourselves to your attempts to make us guilty. We will no longer walk, heads bent down, to your altar of sacrifice.

“You no longer have any hold on us. We have done our time. We are getting out. If we decided to leave medicine and open a road-side fruit stand, or become lumberjacks, or just spend our time puttering around in the basement, you would have no objection to that. So by what right do you object if we hang out our shingles, and see a few patients who voluntarily come to us, using their own resources to do so? You can have no rightful objection to such a thing. So be quiet about it, or admit to your own corruption.”

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*To put this speech into the correct frame of mind, I have borrowed parts of the first three paragraphs from the actual John Galt speech in Atlas Shrugged. The blame for the rest of it falls solely upon your faithful author.
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To this final argument Progressives will either have to withdraw from the field, or reveal the true extent of their aims. For, if they reply that PCPs not only must not become direct-pay practitioners, but also they “owe” society a duty not to change careers at all, then they are admitting that they consider physicians to be their captives, people who, in exchange for a government-issued license to practice medicine, have signed up for a lifetime of indentured servitude. This, in fact, is the only logical conclusion one can reach when listening to Progressives’ angry indignation over the idea of direct-pay practitioners.

I would urge PCPs who decide on the direct-pay, ACP route to explicitly offer a new pact with their patients. They need to do this. They cannot succeed on their own, as their enemies will be terrible. But if they offer, as part of their service, a new doctor-patient compact – based on traditional medical ethics, where the patient agrees to hold nothing important back from their physician, and the physician agrees to place the interest of the individual patient above all other considerations, and fight for the patient’s well-being against all the hostile forces aligned against them – they and their patients, together, will become invulnerable.

There is a limited window of opportunity to establish direct-pay practices. The vociferousness of the complaints we are already hearing against them indicates just how threatening these are to the Progressive program. Unless this practice model gains a sufficient toehold, and quickly, it will be made illegal. Because Americans cannot be permitted to spend their own money on their own healthcare.

And so, on behalf of my children and projected grandchildren, and on behalf of the Great American Experiment, I implore American PCPs to consider these arguments.

What About Specialist Physicians?

I have addressed my comments to PCPs because their plight is most acute, and the means of escape and redemption is more readily available to them than it is for most specialists. Specialists, to a great extent, rely on the entire healthcare system not only for their referrals, but also for the expensive equipment and the armies of support personnel necessary to do their sophisticated procedures. It is much more difficult for specialists to leave the system.

But there are probably things you can do. Remember that the key to saving your profession is to individualize the healthcare your patients receive, and, perhaps more importantly, to create an expectation among your patients for individualized care. So at the very least, tell your patients the truth. “I think that in your case the best thing to do would be X. But the IPAB says I can’t offer X to men over the age of 75. So in my judgment the next best thing is Y. Let’s hope for the best.” You will only be telling them the truth, and at the very least your patient has a right to the truth. If you can’t practice medicine exactly the way you think is right, at least let the patient know the reason this is the case – that under Obamacare they are interchangeable members of a herd. If enough patients hear that message perhaps some day they will insist that something be done about it.

Whenever possible, consider suggesting to your patients who have complex medical problems that they should think about seeing a direct-pay, advanced care physician, a doctor who will be able to spend the time necessary to help them to manage their conditions as they should be managed. Many patients, of course, will be unwilling to pay out of their own pockets for this service, at least at first. But you will still do them a favor by notifying them that such a service is out there, and that Obamacare does not have to be the only variety of care. Further, you will be helping to create an expectation for this kind of care. It will help re-introduce people to the idea that, even in healthcare, you get what you pay for.

Particularly creative specialists undoubtedly will be able to imagine ways of advancing individualized healthcare with new products or services that address a particular need, and in so doing may gain themselves a large dollop of independence, and perhaps even extricate themselves from the healthcare morass. While there is little chance that such an escape route will be realized by more than a handful of specialists, the ones who are successful can have a big impact on the general direction of our healthcare system.

In general, however, the more specialized you are, the fewer options you have in regaining your prerogatives for independent action without making a substantial change in your field of practice.

What Biomedical Entrepreneurs Should Do

The American healthcare system as it has operated since World War II has been a tremendous boon to the biomedical industry, since, as long as its products promised some measurable (or perceived) benefit to patients, the Tooth Fairy would pay for them. This “if you build it, they will come” paradigm led to explosive growth within the biomedical industry over the last 50 years, and to remarkable progress in our understanding and management of a host of diseases. Unfortunately, it also led to one of the most convoluted business models that capitalism has ever produced.

The biomedical industry is unlike any other. To successfully sell a medical product within the American healthcare system, a business must: a) invent, develop and build the product; b) convince the FDA, often with evidence from randomized clinical trials (each one at a cost of $100 million or so and several years of effort), that the product is sufficiently safe and effective; c) once FDA approval is gained, convince insurance carriers and Medicare that they ought to pay for it; and finally, d) convince doctors to prescribe it.

Each one of these steps is immensely costly and complicated. Both the business risk and the cost of overhead involved in operating within such a business model are massive, and these costs guarantee that any products this industry sells, even if the “unit cost” of manufacturing an item is quite small, will be very expensive.

Nobody would design a business model like this on purpose. But a few score of large biomedical companies have adapted to it, and over the decades successful companies have developed all the processes and subsystems necessary to function within this complex model. Companies that have learned to operate under this model are often not anxious to change it, since it creates a huge barrier to entry for new competitors.

Threats To The Biomedical Industry

We have seen how, ironically, the entire idea of medical progress is a threat to Progressives, and needs to be stifled. (Chapter 14.) But of all the threats posed by medical progress, none is greater than that posed by innovations that advance individualized healthcare. It is virtually axiomatic that, one way or another, our Progressive leaders will have to act to suppress companies that aim with their technology to enable the individualized care of patients.

The biomedical industry as it now exists is particularly vulnerable. The built-in complexity of their business model, combined with their utter dependence on hostile third-party payers, makes these companies highly susceptible targets for suppression. Even a small tweak in regulatory requirements can delay a new product for years, or cause management to remove it from the product map, or, in the case of smaller entities, cause a company to go belly-up. And since the tweaks in regulatory requirements – small and large – that lead to such results are common and unpredictable, investors are already extremely reluctant to bet on new categories of products, whose pathway to market has not been traveled many times before.

Another vulnerability suffered is that these businesses usually have little or no direct contact with those who actually reap the benefits of their products – the patients. Their chief potential allies in any efforts to develop products that would empower individual decision making, therefore, are largely indifferent to them.

Biomedical companies often have great difficulty articulating exactly who their customers are. This is because they have, out of necessity, very many customers, including the FDA, Medicare, other federal agencies, insurance companies, HMOs, professional organizations and societies, and, most especially, the prescribing doctors. But patients have very little to do with the decision to purchase the products these companies make, and so (while virtually every biomedical company’s mission statement, to be sure, solemnly proclaim that patients are their primary reason for existence), in general patients are no more the customers of the biomedical industry than al Qaeda terrorists are of the companies that make unmanned drones.

The distance between the industry and the patients who benefit from their products is not merely an accident. Biomedical companies have found it in their best interests to avoid a close relationship with patients. Keeping patients at a distance has been an essential part of their business because doctors (their chief customers) have traditionally insisted on it. (In insisting that everyone else keep their hands off their patients, that is, to stop telling their patients things, doctors ironically invoke the sanctity of the doctor-patient relationship.) Partly as a result of the companies’ arm’s-length relationship with their end-users, the public is at best indifferent toward them, and are often more than ready to become quite angry at them.

This, unfortunately, leaves the biomedical industry extremely vulnerable to efforts at demonization. Many executives in this industry are taking note of this growing and disturbing phenomenon. Drug companies especially, but increasingly others as well, are no longer spoken of as good corporate citizens, or as the institutions whose dedicated efforts provide ever-improved methods of curing disease and alleviating suffering. Instead, they are increasingly painted as evil and corrupt, as all too willing to satisfy their own greed by means of graft, double-dealing, lying, cheating, stealing, animal abuse, and even manslaughter.

Demonizing the biomedical industry (whether they deserve it or not) is a key strategy of the Progressives and of their allies in the American press. This strategy seems to have great traction with the public, and creates support for new laws and regulations ostensibly aimed at bringing the out-of-control biomedical industry to heel, but is actually aimed at making the business so risky that few would be stupid enough to enter it.

In the battle over its future, the biomedical industry has few allies. Many of its customers – especially the federal government and insurance companies – are customers only reluctantly and resentfully, and are indeed chief among its demonizers. The industry’s other main customers, the doctors, may not be actively hostile toward the industry, but are engaged in a battle for survival themselves, and are not likely to be effective or focused allies.

The industry’s only natural allies in this fight are those who are directly helped by its products, and who ought to have good cause to defend it from destruction. It is the patients. Patients would be extremely powerful allies, indeed almost invincible, if they rose up in the industry’s defense. But, as we have seen, the public in general and patients in particular do not usually have warm feelings for the industry, and are all too happy to line up with its persecutors.

For the most part, the biomedical industry just doesn’t get it yet. They don’t realize that they are in a battle for survival, one that will determine whether they are to continue as innovating enterprises, or instead as mere assembly lines, churning out government-approved quotas of government-approved widgets and pills. While the industry continues playing under the old rules, keeping patients at arm’s length, the Progressives and their allies are filling the public’s head with horror stories, trying to work the public into a frenzied cry for those in the greedy and callous biomedical industry to be tossed to the lions – or at least regulated into utter docility.

The outcome looks quite inevitable. Unless the biomedical industry wakes up and figures out how to get the public on its side, it faces something like ruin.

How Can The Biomedical Industry Recruit Patients To Its Cause?

This is not something that can be accomplished with multi-million dollar public relations campaigns. The public is already convinced that biomedical companies are routinely engaged in price gouging, in withholding vital information to keep their unsafe products on the market, in lying about the supposed benefits of their products, and in bribing doctors. The public is being fed this story every day in a hundred ways by prestigious newspapers, medical journals, politicians, medical experts, cable news channels, and talk show hosts. (Admittedly, by their actions companies often enough provide plenty of fodder for this story.) Against this unrelenting attack, even the slickest advertising campaign seems pretty futile. Battling the press in the press is rarely a winning strategy.

A better way to win patients over would be to provide them with something they desperately want and need, and cannot easily get. That something is empowerment.

Empowering Patients

Biomedical companies that want to assure their long-term survival as fully independent and self-directed enterprises should strongly consider partnering with patients in their quest. They need to work with the growing minority of patients who understand the dangers of herd medicine, and whose goal is to become self-empowered. Simply put, businesses that learn how to enable patient empowerment will be effectively immunizing themselves against subjugation by the Progressives. Empowered patients will not stand by and watch the destruction of the entities that make their empowerment possible.

Many companies in the biomedical industry will find this hard to do. They don’t sell products directly to patients, or know how to interact with patients. They don’t know what patients want. Instead, they are fully geared up for the much more complicated task of selling things to the healthcare system. They are intimidated by actual patients.

Even the remote contacts they do sometimes have with patients, such as producing educational materials or running TV commercials, are viewed as controversial or inappropriate (since the doctors reserve the authority to determine what patients ought to know, and the Central Authority – which now has the doctors under its thrall – supports them strongly in this). Avoiding direct contact with patients is often deeply embedded into their corporate cultures, and many companies will find the idea of starting a “patient empowerment” business counter to their core values.

Still, successful companies that want to remain successful over the long term will have to find ways to work around this barrier. There is a huge and untapped demand for empowerment tools among the public, and therefore a massive business opportunity exists.

I am not suggesting here that biomedical companies should abandon their current businesses altogether in order to concentrate on patient empowerment. Rather, I am suggesting they should engage in patient empowerment so they have a better chance of continuing their core businesses. In many cases this might require establishing “spin-off” enterprises that can develop and market patient empowerment tools without “contaminating” the core business. But they should take this effort seriously, as if some day, the patient empowerment side of the business might be their chief source of revenue. Because some day it might just come to that.

What Will Patient Empowerment Look Like?

Nobody knows what patient empowerment will actually look like, of course, because it hasn’t been invented yet. Like most entries into new markets, this one will probably begin with a few relatively tentative and primitive forays, exploring the landscape, and seeing what patients will respond to and not respond to. When they recognize the possibilities, patients will begin asking for specific products, services, and features – that is, the customers will begin to better “define” the market. And, seeing the growing demand, more and more entrepreneurs will jump into the fray, testing an increasing array of ideas. Sooner or later, there may come a “killer app,” a VisiCalc of patient empowerment, that forever changes expectations and makes the empowered patient as common as the smartphone. If we reach this stage, herd medicine will be doomed.

We already know some of the things patients want. Older people want tools to keep themselves independent and out of institutions. Patients with chronic illnesses that need a lot of management – diabetes, heart failure, and difficult-to-control hypertension immediately come to mind – want the tools to help them do most of that management themselves. And those at high risk for treatable cardiovascular emergencies – heart attack and stroke – want to prevent these emergencies, and, if they cannot be prevented, to immediately detect and treat them whenever and wherever they occur. These are among the things that people will pay for themselves (admittedly only a few high-end users at first, but eventually, as expectations change, large numbers of people).

There are diagnostic tools that can be miniaturized and reduced to a smartphone app, that will make the lives of direct-pay physicians and their patients easier and more convenient. Indeed, partnering with direct-pay physicians, and working to fulfill their needs as they work to re-establish the classic doctor-patient relationship outside the “real” healthcare system, will be a fruitful area for innovation.

A lot of tools can be brought to bear to begin meeting these needs, including a multitude of technologies, sophisticated communication systems, and data management and decision support systems, all aimed at providing remote monitoring, self-monitoring, effective diagnostics, and novel therapies and services. I described many of these in Chapter 15. But the possibilities are endless, and as the market defines itself those possibilities will come to seem obvious.

How To Start?

In Chapter 15, I described the ways in which the Central Authority, wielding its regulatory muscle, seems to have all but stopped the development of personal biosensors, a key technology for individualized healthcare. It is now extremely difficult, bordering on completely impracticable, for companies to introduce products based on personal biosensors into the healthcare market place. If you are such a company, your future does not appear bright.

And so, I humbly suggest, companies who are working with these sensors should not even try bringing them into the healthcare market place. Instead, they should bring them into the consumer market place.

Develop these products for non-medical use, and sell them to regular people. You will have the huge advantage of not having to jump through all the regulatory hoops; the advantage of being able to sell your product without having to convince two different third parties (doctors and payers) that its purchase is absolutely necessary and cannot be avoided; the advantage of typical, normal, understandable and predictable market forces determining the success or failure of your product; the advantage of selling your product without government-imposed pricing, so that you can discover the optimal price-point in the normal way; the advantage of a potentially huge and unrestricted market; the advantage of being able to iterate multiple successive versions of your product, based on customer response, without having to repeat all the regulatory hoops with each iteration; and the advantage of introducing your technology directly to the broad public, and making it seem commonplace and normal for people to use it. Pretty soon, people will be asking: “Say! Why can’t we just use this stuff to help us manage our (fill in the blank here with your chronic illness of choice)?”

Imagination is called for here, but I will give you two obvious ideas just to get you started.

Elder care. More than increased longevity, we Old Farts want to remain healthy and independent into our old age. We want to avoid disability and institutionalization. Our kids, members of the “sandwich generation,” want the tools to help keep their aging parents out of institutions, without neglecting their own young families. So think of ways to make it feasible for old people to continue living at home.

Wearable biosensors can be adapted to monitor the activity levels of the elderly – the amount of time they spend up and about versus sitting or lying down, the level of activity they perform, and when and how often they are active. Trends of such activity parameters may alert a family member that a loved one may be going downhill, early enough that something can still be done about it. Biosensors can also detect episodes of falling, and can send out an alert if a person does not get up in a specified period of time after they have fallen. Degrees of tremulousness can be measured. In many cases – far more often than doctors know – the medications which elderly people are taking can disrupt their sleep, leading to general deterioration. Biosensors can easily monitor sleep quality on an ongoing basis. Biosensors can also help detect whether the elderly person is taking his or her medications regularly – at least whether they unscrew the pill bottle or open the medication dispenser.

Athletics. Athletes are vitally concerned about their performance. Are they overtraining? Undertraining? Are they allowing themselves to break down? Are they pushing themselves into dehydration, heat cramps or heat stroke? Are they developing potentially dangerous heart rhythm problems? All these things can be monitored in real time in active athletes – under the rubric of athletic performance aids, and not medical products.

For instance, sensors can monitor specific levels of activity, and correlate these with heart rate and breathing rate. The “slope” of the change in heart rate and/or breathing rate as a function of activity is a reflection of cardiovascular efficiency, and thus, of the level of training. Deteriorations in that slope can indicate overtraining. In summer football camp, or in endurance events such as a marathon, a dehydration sensor and core body temperature sensor (both of which can be implemented in an adhesive skin patch) can monitor for early signs of impending collapse – and a trainer or the athlete him/herself can intervene in time to prevent a potentially dangerous event.

All of the sensors that you would use to make products for athletes or elder care can be easily adapted for use in patients with heart failure and other chronic medical conditions. Putting them into formal medical products today would be nearly out of the question. But putting them into medical products would become an obvious step after they have become commonplace in applications people encounter every day. And, since the sensors are the same ones that would be used in medical applications, smart patients will figure out how to apply them to help manage their own illnesses – and social networks will take care of disseminating that knowledge.

Indeed, when people begin asking you why you haven’t adapted these sensors for obvious medical conditions, you can simply tell the truth – the Progressive healthcare system has erected insurmountable obstacles to your doing so. This is something people have a right to know.

So: learn about the needs of your true end-users, and design to their needs, and market your products directly to them. You may find the consumer market so dynamic and lucrative and welcoming of innovation that you may decide to abandon medical products altogether. In any case, the pathways you establish can always be employed, should our healthcare system regain its sanity, to devise products that will directly benefit patients.

What The Good Citizen Should Do

Ultimately, the viability of Obamacare depends entirely on a credulous public, and on “well-behaved” patients. Maintaining a Progressive healthcare system requires citizens to ignore the necessity and the reality of covert rationing imbedded in herd medicine, and to believe that any apparent limits in on healthcare result from corruption, waste, and inefficiency, which, thanks to the efforts of the Progressives, are slowly being rooted out. More importantly, when citizens become patients themselves, Obamacare requires them to rely serenely and without further question on the information their doctors give them, and on the treatments their doctors say are right for them.

This requirement is the Achilles’ heel of Progressive healthcare. When you think about it, it is actually astounding that Progressives expect Good Citizens to limit their scope in this way, in our present era, where information about everything is ubiquitous and readily available. The majority of Americans who receive a new diagnosis today will go to the Internet to learn what they can about it. And once Americans understand the personal dangers to which herd medicine exposes them, they will be especially interested in learning whatever they can about their medical conditions. For, once you become a patient, behaving as Obamacare expects you to behave will produce an immediate threat to your own life and limb. Complete acquiescence with the dictates of herd medicine, without questioning whether what’s good for the collective herd is actually good for you, requires that citizens act in a manner that is clearly against their own best interests. It simply does not comport with human nature.

People who understand this – that it is probably not in their best interests to rely entirely on the advice of their Obamadocs – can take immediate steps to protect themselves. Instead of passively accepting at face value the diagnoses and treatment recommendations that are presented to them, these individuals will check things out for themselves, and seek independent confirmation that nothing is being overlooked, missed, ignored or “forgotten.” If individual citizens begin confronting their “providers” with objective evidence that the recommendations they are receiving are dangerous to their well-being, it will become very difficult indeed for Obamacare to work the way it is designed to.

If enough people acted this way, the infrastructure of Obamacare would collapse under the weight of tens of thousands of self-empowered individuals, acting independently in their own enlightened self-interest. And when that happens we would be presented with another opportunity to reform our healthcare system.

Those new reforms will have a far different foundation than the reforms of Obamacare. This is because Obamacare will have failed specifically thanks to a new multitude of self-empowered Americans. The American populace will fit even less than it does today the profile necessary to establish a paternalistic, top-down, government-controlled healthcare system. Whatever system we would establish at that point to replace Obamacare, whether or not it resembled the system I discussed in Chapter 4, it would have to honor the now self-actualized, self-empowered, autonomous American patient. It would have to be compatible with the Great American Experiment.

The catalyst to a uniquely American solution to the problem of Obamacare, then, is the empowered patient. Americans – not all Americans, not even necessarily a majority of Americans, but simply a critical mass of Americans – are going to have to begin taking their healthcare matters into their own hands. For this to become possible, a sufficient number of doctors will have to recognize that empowered patients are their last, best hope for salvaging their profession,, and they will have to take the difficult and risky steps necessary to support those patients. And entrepreneurs in the American biomedical industry will have to understand that their own survival may depend on their finding ways of helping patients to become self-empowered.

But the ultimate catalyst is the average American citizen – enough of them at any rate – refusing to subject themselves to herd medicine, and taking the steps necessary to protect themselves and their loved ones from it.

How Do You Get The Information You Will Need?

There is a tremendous amount of information on the Internet on just about any medical disorder you can think of. And the information ranges in quality from solid to absolutely ridiculous. So it is very easy to be misled. Still, gaining the right kind of knowledge is the indispensable key to empowering yourself within the healthcare system.

It shouldn’t be this way. Individuals shouldn’t have to figure out the best approach to their medical conditions themselves. That’s what your doctor is supposed to be for. Your doctor is supposed to have enough basic medical knowledge – which options are available, what works and what doesn’t, which information is over-hyped or quackery and which is solid and proven – to make recommendations that are particularly suited to your own individual needs. But under Obamacare your doctor cannot – must not, if he knows what’s good for him – do that any more.

And so it behooves you to learn what you can about the medical conditions you or your loved ones have. You may have devised your own methods for doing this, or you may come up with your own method as you work through a topic you are researching. But here are some general thoughts I have on the matter.

First, get a good, general grounding on the medical condition you are researching. For this step, instead of just Googling the topic, go to a few sources that you can be pretty sure are reasonably objective and which generally provide useful information.

One site I personally find useful is the Merck Manual site (merckmanuals.com). The Merck Manuals cover most topics in medicine very well, are very readable, and to my eye are quite objective. There are manuals written for patients, and manuals written for physicians. You should read both. The manuals are free on the Internet. (The Merck Manuals are supported by Merck & Co, Inc., which is said to be one of those evil biomedical outfits. So keep that in mind.)

Other sites that are often helpful for grounding yourself include Wikipedia (which has obvious shortcomings, but whose coverage of medical topics usually – but not always – turn out to be reasonably straightforward and objective), WebMD, mayoclinic.org, and health.nih.gov.

Be skeptical of everything you read on the Internet, including information on these sites. But if you read about your topic on several of these sites, you will usually be able to discern without too much trouble the kind of basic information that is universally accepted, and therefore, which information appears likely to be correct.

Second, after you have a good, general grounding, then look for sites that might have more specific information regarding your area of interest. You might try the sites of specialty organizations, like the American Heart Association website, or the website of the American Cancer Society. Organizations dedicated to general consumer advocacy, like the Consumers Union (consumersunion.org) can also be helpful.

In recent years focused patient advocacy groups have launched websites that can offer valuable information that is difficult for non-specialist physicians to find anywhere else. Websites like KnowBreastCancer.org, the Michael J. Fox Foundation for Parkinson’s Research (michaeljfox.org), and the National Dysautonomia Research Foundation (ndrf.org) not only provide insights on the basics, but also keep up with – and help you interpret – the latest research on the medical disorder you’re researching. They also provide resources for advocacy and policy, and (perhaps most importantly) can connect you with a community of people who are also vitally concerned with the same disease you or a loved one are dealing with.

Third, look for social networking sites that deal with the medical disorder you are researching. Recently, the Huffington Post published an article entitled, “Are Doctors Losing Their Relevance Due to Social Media Health Sites?”* (www.huffingtonpost.com/riva-greenberg/are-doctors-losing-their_b_596060.html) This article describes a host of social media websites dedicated to various medical conditions, and the advantages they provide – including information, support, community, and advice. The author notes the rise of new “patient-experts” who are emerging from these social media sites, and describes how social media is helping patients move from a “tell and instruct” paradigm to an “explore and partner” model.
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*My answer to this question is, No. Instead, doctors are losing their relevance due to their abandonment of medical ethics, and their subjugation by the Central Authority. The social media health sites are simply springing up to fill the vacuum.
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Social media health sites are still in their infancy, but they have the potential to drastically reduce the knowledge gap between patients and their doctors, and to remove patients from the role of a mere supplicant, a mere receiver of instructions, in their encounters with their doctors. It is difficult to envision patients equipped with such knowledge simply opening wide and saying moo.

Fourth, learn to recognize the really crazy stuff. Once you branch away from trusted sources on the Internet, you will have entered the Wild West, where anything goes. Here is a tip on how to recognize much of the quackery and charlatanism on Internet health sites: Such sites typically claim that the great medical-industrial complex is intentionally withholding vital – usually curative – information from the public; the writer/company/organization publishing the site exclusively knows the real cure; the same writer/company/organization offers exclusively to sell you the secret cure. Now, I’ll have to admit that this system smacks at least a little of what I’ve been saying in this book – that the Central Authority and insurance companies have coerced doctors into withholding information that may be vital to their patient’s care. The difference is that the information which the Central Authority wants withheld at the bedside is usually readily available from reputable sources on the Internet (like the ones I’ve mentioned), and the information which doctors are coerced to withhold would, if divulged, lead to some form of expensive medical service that the entire healthcare system would be expected to provide and to pay for. The secret cures offered by the shills, in contrast, can only be provided by the shills themselves.

So, finding the information you need is not entirely straightforward, but it is most often do-able with effort, patience, and care.

Find Allies

No matter how knowledgeable you are, empowering yourself as an individual under Obamacare will be very difficult without allies.

The best “ally” you could have when you are sick, of course, is a good doctor. It is entirely possible that, despite the coercions placed upon him or her by the Progressive healthcare system, your own doctor is still able to function as your personal advocate. If so, nurture that doctor with every means at your disposal. Because even if this doctor has managed to hold onto the classic ethical standards of the medical profession, it is very likely he or she will be able to really go to bat only for a few selected patients who really need the help. So try to be the patient for whom the doctor would be willing to go out on a limb. This is not a book on nurturing relationships, so I hope you know how to do that already. If not, here’s a tip: brownies help.

A better bet – since the unfortunate truth is that doctors as a group have been completely cowed by the Central Authority – is to find yourself a direct-pay physician. These are the only doctors remaining who have at least the inherent capacity to become a personal advocate for every one of his or her patients. They depend for their livelihood on doing right by you – not on doing right by the Central Authority or health insurance companies. Their stock in trade is to tell you the truth about your medical conditions, to describe all the options that exist for addressing your health problems, and to help you sort through the options to pick the one that is best for you. They can treat guidelines as guidelines – as helpful general guidance in managing a particular kind of medical problem – and not as an absolute directive whose violation will lead to punishment. A direct-pay physician is really the only kind of doctor today you can reasonably trust, as a matter of course, to honor the classic doctor-patient relationship.

When your legislators or the executive branch move to render direct-pay medical practices illegal or unfeasible – as they are already beginning to do – take it personally. They are moving to rob you of the only kind of physician left who can routinely try to do what is right for you as an individual, instead of treating you as an interchangeable member of the herd. Let your political leaders know that you will not take kindly to this sort of life-threatening action.

If you cannot find a direct-pay physician, or if the day arrives when direct-pay physicians can only ply their trade to fellow inmates while serving their life sentences, you still might be able to find a professional advocate who can help you navigate through the healthcare system. Two organizations that provide such services are My Nurse First (http://www.mynursefirst.com) and AdvoConnections (http://www.advoconnection.com). A professional advocate does not practice medicine, but can give you guidance when you need it, and can even go to bat for you with recalcitrant providers or insurance companies.

Be Willing To Pay For Empowerment

Commerce is a wonderful thing. If some people have a strong desire to acquire an item, and some other people have a strong desire to sell that item, nothing on the face of the earth can keep the transaction from occurring. This is why Prohibition did not work, why marijuana is California’s biggest cash crop, why the Orthodox Church re-emerged in Russia even after several generations of Soviet-sponsored suppression, and why there will always be pornography on the Internet.

And it is why, if people demonstrate their willingness to pay for the means to control their own healthcare destiny, entrepreneurs (sooner or later) will trip over themselves to provide the products and services that enable them to do so.

People who understand just how vulnerable they are within a healthcare system that will do almost anything to avoid having to spend money on them, and who understand that placing all their trust in such a system is dangerous to their health and survival, will also understand that it might be necessary to invest some of their own funds to safeguard their medical welfare. The demand for products and services that provide these safeguards will grow in direct proportion to the public’s awareness of just how vulnerable they are.

This awareness is increasing daily.

We are just seeing the beginnings of the “self-empowerment” industry, and most of it is still below the radar at this point. It is critical to know two rules that are necessary to make real self-empowerment possible. We will need to remember these rules when our Progressive leaders notice what is going on and then, recognizing the greatest threat they can ever face, stop at nothing to put an end to it.

The first rule of empowerment: Only you can pay for your own empowerment. In our entitlement society, whenever anything “good” shows up that is in any way related to healthcare, people expect it to be provided for “free.” This will no doubt be true for products and services that are developed that advance patient empowerment. No sooner will such things appear than people will start calling for it to be “covered.” I am very sorry, but this cannot be allowed to happen. When the central authorities agree to pay for empowerment services and technologies, they will control them. And when they control the means to empowerment, they will destroy their usefulness. They will have to destroy it – because individual empowerment wrecks Progressive healthcare.

The most obvious example of this is physician services. Doctors are designated by tradition, ethics, and law to be the patient’s advocate. In other words, they are the original empowerment tool for patients. But not only has the Central Authority strangled the advocacy role of physicians, it has actually converted doctors from a tool for patient empowerment into a tool for centrally-directed covert rationing.

If we allow the new empowerment tools that are just now being invented to be co-opted by the government or third-party payers, the same thing will happen. Indeed, how they will co-opt the new empowerment tools is readily predictable. When the Progressives notice the swelling movement toward individual empowerment, they will initially try to stifle it altogether by making it illegal or unfeasible. Should these stifling efforts prove ineffective, they will shortly change tactics. “You are right,” they will say, “these methods for improving individual empowerment are vitally important. They’re so important, in fact, that it would be unfair of us not to provide them, so as to guarantee equal access to everyone.”

We simply cannot allow this to happen, or patient empowerment will go the way of the doctor-patient relationship – to the dust bin of medical history. Individuals must be responsible for their own empowerment.

The second rule of empowerment: Self-empowerment is not a sin. You will be told that by using the tools of self-empowerment, by going “outside” the designated and approved pathways for your own healthcare, you are contributing to societal discord; that you are an elitist, helping to create a two-tiered healthcare system; that you are broadening the gulf between the haves and the have-nots, between the privileged and the underclass; that you are joining with the cigar-smoking, brandy-quaffing, expense-account-consuming, numb-hearted oppressors of the masses. You and your kind will be the subject of news articles in the New York Times and exposés on 60 Minutes. There is no way around it – you are evil.

Do not listen to these aspersions. They are not genuine; they are desperate attempts to bring you back into the herd. Remember: You are spending your own money to protect yourself and your loved ones from people who are trying to kill you (or, to be less unkind, who are at least willing to let you die).

And remember something else: While the primary reason you’re empowering yourself is (and should be) self-preservation, by doing so you are also taking up a higher cause. You are joining an army that is fighting with the only weapon at its disposal against an opponent that is choking the life out of patients, the public, and the principle of individual autonomy. By fighting for your own individual prerogatives you are not leaving others behind – you are showing them the way, clearing a path to safety, and helping to preserve the Great American Experiment for future generations.

And If It All Goes South

There is a realistic chance, of course, that Obamacare will not be repealed; that direct-pay physicians will be driven out of practice; that biomedical entrepreneurs who want to advance individualized healthcare will be driven out of business; and that for citizens to empower themselves with medical knowledge will lead only to increased frustration, and not to improved healthcare. This, after all, is the plan. It’s the Progressive Program.

Critics of my writings on Progressive healthcare have always insisted that I am simply making too much of the Central Authority’s aversion to individual autonomy. Our government, they insist, whatever its tendencies, will not really act to curb individuals from their freedom of action within the healthcare system, for the simple reason that Americans would never put up with such limitations. And in fact, I fundamentally agree with these critics, at least to this extent: Americans – many of us, anyhow – just won’t put up with it.

Where I quibble is in the specifics. Most moderates will insist that our government (presumably, taking the American character they so deeply believe in into account) would never actually try to limit the freedom of Americans in such egregious ways as I have described. But I have attempted to carefully demonstrate that the government has already begun using every means at its disposal to make it illegal, infeasible, or both, for Americans to spend their own money on their own healthcare. (Chapter 7). And I fear, sadly, that the many Americans who “won’t put up with it” will eventually find themselves having to act counter to the wishes (and laws and regulations) of their government. That is, Americans who insist on exercising their natural right to become “the proper guardians of their own health,” may have to do so extra-legally.

To say it even more bluntly, Americans wishing to enjoy the individual liberties which our Constitution promises us will, in this instance, need to engage in black market healthcare.

Black Market Healthcare

Black markets develop naturally whenever a society’s controlling authority attempts to prevent its citizens from acquiring an otherwise available good or service which they very much want (or need). In fact, as we have noted it is a law of nature that, wherever a group of people exists who badly desire a certain product, and another group of people exists who very much want to provide that product, there is no force in the universe – governmental or divine – which can keep those two groups from engaging in commerce.

To see what is likely to happen when the government institutes its prohibitions on individual prerogatives in healthcare, we ought to think about what happened when that same government instituted its alcohol prohibition (i.e., Prohibition). The 18th Amendment (one of the big triumphs of the Progressive Era, and one which, quite typically, relied for its ultimate success entirely on a fundamental change in human nature), went into effect at midnight, January 1, 1920. By noon that day, an entirely new industry had sprung up. This industry – the alcohol black market – eventually employed hundreds of thousands of Americans in various capacities, such as distillers, alcohol “re-naturizers,” bootleggers, rum-runners, speakeasy proprietors, accountants, individuals who today might be called “lobbyists,” and various species of “muscle.”

My own dear grandfather, who had only recently arrived from Eastern Europe to work in the steel mills, found more profitable employment instead, through the ’20′s and into the Great Depression, as a distiller and gun-toting rum-runner. Each weekend he filled the hidden tank under the back seat of his big Buick sedan with 100 gallons of his prime home-made spirits, and would place my young grandmother (as documented in photos, wearing an impressive hat) next to him, and their three innocent little children (among them my toddler mother) would be perched over the hidden contraband in the back – the very picture of a happy young family out for a Sunday drive – and in this guise would make his deliveries across northeastern Ohio. I will never understand why, at the end of Prohibition, Grandpa ended up as a laborer for the city street department, instead of the filthy-rich Ambassador to England like his fellow bootlegger, Joe Kennedy. (But on second thought perhaps it is better this way. If Grandpa had ended up like Ambassador Kennedy, I today would be spouting the Progressive mantra, like all those other guilt-ridden souls burdened by unearned wealth.)

In any case, the government took great issue with the new bootleg industry that had been created, overnight, by Prohibition, and attempted to end this black market by employing the ultimate expression of any sovereign authority – the legal exertion of violence. (The enforcers, it happens, were Treasury Agents, the very same enforcers who now will be ensuring compliance with certain mandates being imposed by our new healthcare system.) This effort on the government’s part led to an organized response, and resulted in the maturation of American organized crime. (Interestingly, this organized crime effort happened to be centered in Chicago, a happenstance which resulted in a persistent and evolving thugocracy within that city, whose ultimate ramifications – some say – are today influencing current events on a much broader scale).

When its concerted application of force against the bootleggers failed to end the black market, our government turned to applying a different kind of force, this time to the consumers. The recalcitrant consumers of illicit alcohol were, after all, guilty of failing to change their behavior, despite all the heroic efforts which were being made to educate them about the pitfalls of demon rum. The understandable frustration this caused finally led our government to resort to deadly force against the obstinate public itself. Author Deborah Blum has recently documented how the U. S. government caused poisonous substances to be added to the alcohol supply, an act that is estimated to have eventually killed 10,000 people. (http://www.slate.com/articles/health_and_science/medical_examiner/2010/02/the_chemists_war.html) The chief medical examiner of New York City at the time called this action “our national experiment in extermination.” And in 1927, the Chicago Tribune said, “It is only in the curious fanaticism of Prohibition that any means, however barbarous, are considered justified.”* It was partly the revulsion against such official atrocities that forced the end of Prohibition in 1933.

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*The “curious fanaticism of Prohibition,” of course, is the curious fanaticism of Progressivism.
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I relate this little-remembered tragic episode merely to illustrate the lengths to which our Central Authority will go when its attempts to control human nature through legislation fail. This is worth keeping in mind as we conjure up ways to establish what I hope we will not need, but fear we’ll not be able to avoid, namely, a black market in healthcare.

Black market healthcare will not be for the faint of heart. But then, no great human endeavor ever is. Let us consider some specifics.

First, however, I must first assure readers (and any government officials who may inadvertently stumble upon this book) that I am a strictly a law-abiding citizen, and do not condone illegal activities. So I will suggest here only activities for black market healthcare which, strictly speaking, will not be illegal under American law; though not so much by complying with the law, but by avoiding it.

I have complete trust in my readers that they can think up the more illegal kinds of black market activities for themselves, and thus they do not need my help with this aspect of the endeavor. Many of these more obvious illegal forms of black market healthcare (e.g., “medical speakeasies,” located in back alleys for the proletariat, and in swanky office buildings for public officials; rolling surgical suites hidden in semi-trucks; smuggling rings for drugs and medical equipment; an “underground-railroad-style” transport system for itinerant physicians who need to ply their illicit trade while on the move; &c.), can be established by individuals, or by relatively small groups of entrepreneurs, and with relatively little up-front capital or lead time – and with no coaching necessary from your humble author.

But the varieties of black market healthcare which I have in mind – certain “less illegal” activities, which will drive the US government into states of apoplexy but over which it will have little legal jurisdiction – will require a much larger scale, and a significant investment in time and energy. So anyone who is interested ought to get started with the necessary organizational activities right away.

I have three such suggestions. With all three of them, I envision that implementation would be driven by a major private healthcare organization (or a consortium of them) which has a record of innovative thinking, as well as access to significant financial resources through their own holdings, or through their connections with rich benefactors from around the world. I am thinking of organizations like the Cleveland Clinic, the Mayo Clinic, or the Kaiser system.

For the sake of mankind, I offer these suggestions free and clear. They may be taken up, with my blessings, by any institution or organization that wishes to employ them, with no obligations or strings attached whatsoever.

1) Floating Off-Shore Medical Centers. In this scenario, the Cleveland Clinic (say), with the help of their friends in Abu Dhabi, buys or leases a mothballed former Soviet aircraft carrier (nuclear power preferred), and refurbishes it into a floating, world-class medical center. The ship will ply the international waters off the American coasts, providing regular helicopter transport to and from major cities. There’s a lot you could do with an aircraft carrier, of course, to make it an attractive destination aside from medical care, including (for instance) establishing a world class hotel, food services, casinos and other entertainments. But the chief attraction would be that Americans will be able to buy the best healthcare services in the world, without fear of being arrested.

The fact that this floating medical center will be based on a former warship may turn out to be an advantage. Obviously, it would be useful to maintain at least some weaponry on board, if only to repel “pirates.” But given the anger this ship will generate among American government officials, the Cleveland Clinic (or whoever) might be wise to remain intentionally ambiguous about just how much firepower the ship has retained.

2) Native American Medical Centers. There are two things about the current state of Native American culture which make this approach to black market healthcare at least feasible, if not compelling. First is the recognized “sovereign status” of Native American reservations, the same status which has allowed various tribes across the land to open gambling casinos, even in states which otherwise do not allow such establishments. If their sovereign status justifies casinos (establishments of mere entertainment, which, in fact, encourage bad behaviors of all sorts such as alcoholism, prostitution, smoking and – gasp!- obesity), then surely the same sovereign status would justify establishing advanced institutions of healing.

Second is the deep guilt that Americans rightly feel about the treatment Native Americans have suffered over the years, much of which was arranged by the US government. Note, in particular, that one of the ongoing claims which Native Americans have against the larger American culture is the chronically substandard state of the healthcare services they are provided. So, who will dare stand in the way of these oppressed peoples, when they propose to dedicate a portion of their pitiful remaining sovereign lands (with the help of, perhaps, the Mayo Clinic and its benefactors) to the development of world-class medical centers?

One advantage of the “Native American Strategy” for black market healthcare is that it would allow medical centers of various sizes and emphasis to be established in numerous convenient tribal locations around the U.S., as the need and logistics allow. Within a decade or two, if they play their cards right, Native American tribes may even find themselves controlling nearly 20% of the American economy – which would be ultimate justice at its finest.

3) Medical Centers Across the Mexican Border. There are several potential benefits to this suggestion. Converting Tijuana, Nogales, Laredo and Juarez from hotbeds of human and drug smuggling into hotbeds of illicit healthcare would probably be a boon to the local populations on both sides of the border. It would create tens of thousands of good jobs in Mexico, for Mexicans. The heavily-armed gangs of Mexican drug-runners along the border could be hired by the Cleveland Clinic Juarez, or the Mayo Clinic Nogales, as security guards, thus absorbing their “talents” into a more legitimate economy. (Being located so close to the border of a powerful nation which will badly want to terminate these medical centers would, one must understand, create a certain need for security.)

If nothing else, world-class medical centers just across the Mexican border would reverse the flow of illicit border crossings. Americans (and Canadians, who, bless them, would now have to travel much farther south for their healthcare) would suddenly be streaming across desert border crossings into Mexico in the dark of night – and Mexicans would be staying put. And its desperate need to get rid of black market healthcare would, at long last, give the US government a compelling reason to control the borders once and for all. We would suddenly see American troops all along the Mexican border, supported by such features as a “no-man’s land” seeded with land mines, and constant surveillance by drone aircraft armed with cluster bombs.

And before long, Californians wanting to go to the Kaiser Tijuana Medical Center would have to get there by way of Cuba.

A Healthcare Reformation

For individualized healthcare to take a firm foothold – a foothold which will inevitably wreck the Progressive model of healthcare – will not be easy. Powerful forces will be brought to bear to stop the creation of a patient-empowering healthcare marketplace, where citizens, direct-pay physicians, professional advocates, and entrepreneurs come together to enable self-directed, individualized healthcare. All the necessary players – those citizens, doctors, advocates and entrepreneurs – will need to persist in their efforts despite increasingly strident, desperate, and threatening attempts by Progressives to stop them, and to have them denounced as elitist, criminal, and immoral.

The Progressive healthcare establishment is at least as entrenched (and corrupt) as the early sixteenth-century Church; the notion of patients becoming self-empowered is at least as frightening as the notion of the teeming masses communicating directly with God; physicians answering only to their patients is at least as threatening as renegade priests answering to parishioners; and empowering technologies are at least as heretical as printing the Bible in the vernacular. The coming fight will resemble nothing, in terms of its intensity and potential for acrimony (and worse), so much as the Reformation.

Most of us “reformers” will enter the fray not in any attempt to become reformers, but rather in the simple attempt to protect ourselves, our families, our professional legitimacy, and our businesses from the perfidies of a broken healthcare system – that is, for ostensibly “selfish” reasons. To survive the vociferous attacks that will undoubtedly come our way, however, we will need to remind ourselves of the higher cause we are serving.

Is what we’re doing unfair? It is not. It would be difficult to imagine a healthcare system more fundamentally unfair and inequitable than the one Progressives have in store for us now; in which deceptions, half-truths, outright lies, and coercion are techniques routinely employed by the Central Authority which manages the healthcare system; in which the interests of doctors have been systematically divorced from the interests of their individual patients; and in which patients are left to fend for themselves, without their rightful advocates, at a time when they are least capable of doing so, within a confusing and dangerous healthcare system. What we are doing – learning to protect our own rights and welfare, and in the process exposing the truth of herd medicine, and establishing the systems and methods for others to follow – is restoring, not destroying, equity.

Is what we’re doing immoral? It is not. By insisting on our right to self-determination, we are reestablishing a foundational American principle that has eroded in recent years in large part because of Progressive healthcare. By taking the steps necessary to empower ourselves and to enable that same empowerment for others, we are simply asserting our right to self-determination in matters related to our own personal needs. It is an American birthright. Others are trying to take it away. We are stopping them.

If we allow this attack on our founding ideals to go unanswered, or if we fight back and lose, we will pay a much higher price than merely a bad healthcare system. This is why we owe it to ourselves and to future generations of Americans to vigorously take up the cause.
We need to recognize Obamacare for what it is. We need to shine a bright light into the dark corners where it lurks. We need to point to it, call it by its name, illuminate its methods and reveal its secret language. We need to show what it is afraid of – truth, equity, and the intrinsic worth of the individual.

The shrillness of the cries and the brazenness of the protests against our efforts at self-empowerment should be recognized for what they are – signs of just how far we’ve already fallen away from those founding ideals, and of how close the idea of individual empowerment strikes at the heart of Progressives. If anything, these protests should steel our resolve. We are fighting for our own rights and welfare, to be sure, but we are also fighting a battle to restore every American’s right to self-determination. It won’t be easy. But we are not sinners; we are holy warriors. Here we must stand, for we can do no other.