Go Ahead, Make My Deductible

Early On in the orgy of lobbying and recrimination that is the debate on health care reform, I discovered who is really at fault for this mess.

I am.

Now before you rat on me to Hillary's health thugs, let me say there are good reasons why I ruined health care in America and personally flushed the economy down the crapper. Greed didn't make me do it. Indifference did. And that's the problem.

If somebody were looking for a culprit, I would have made the police lineup. I'm in my mid-30s, I make a good salary, my wife doesn't work professionally and I have two children. For the next 20 years, I will be the market for health care. Go ahead, make my deductible.

This culpability doesn't run in my family by the way. When my dad used to call Dr. Birney in the middle of the night to have him come to see me or one of my three brothers, it was a simple transaction. The doctor came, he worked out of his black bag and my dad paid. Those were the days.

The health equation has become a lot more complicated. In these unhappy times, there are at least four levels of bureaucracy between me and my many doctors (I have one, my boys have one and my wife has two). There is the personnel department where I work. There is the insurance behemoth that handles my employer's account. There are the government agencies (state and national) that regulate the insurance behemoth and my employer. And there are the lobbyists, professional associations, industry hacks and opportunists that buzz around this great stinking heap of a health care system.

Is it any wonder, then, that when I enter into what should be the most intimate of professional relationships--that between doctor and patient--I regard it with as much warmth as I would a trip to the post office? If Karl Marx were around today, he might say that I am alienated from the health care system.

Why? I'm not sure I need to go into this; we all have our reasons. But I will, anyway, because it feels so good to complain.

Three years ago I fell hard on my elbow while cross-country skiing. The next day I noticed some tingling and numbness in my hand so I went to see my doctor. Among the first words out of his mouth were, "It's probably a touch of neuralgia. Nerve damage. It'll go away in a couple of months." Then came the seven most expensive words in medicine: "But we better run a few tests."

What followed was a month of torture in various labs, capped off by the sine qua non of medicine gone awry, a ride on the thousand-dollar magnetic resonance imaging roller coaster. (At least, that's what I think MRI stands for; it could be money removal intensifier.) The result of $1800 of testing? The doctors found nothing, and my neuralgia healed itself in two months, just as my doctor (now my ex-doc) had predicted.

Jump forward a couple of years to the birth of my second son. As second babies will, Tyler arrived in a big hurry. The labor pains were marked by intense screaming from my wife and complete indifference from the hospital staff.

At one pivotal point we were being ignored by a nurse who was folding sheets in our room, so I had to run into the hallway and shout at the nurses and doctors in the lounge that my wife was having a baby and would they get their asses in there and help her? A few shrugged to their feet, mildly interested. Fifteen minutes later my boy was born, no thanks to the hospital staff.

The capper came two months later when the bill arrived, padded with hundreds of dollars of medical services--an IV drip, for instance--that were never provided because the labor was so rapid and because the staff had no evident desire to visit us in the birthing room.

This is where we get to my responsibility for the health care crisis. Presented with this bill, and still fuming over how we had been treated, I did absolutely nothing, and for an abominably good reason: I'd met my deductible--piling on the amniocentesis, the ultrasound tests, the genetic counseling--and my insurance was picking it up. So why waste my time rectifying a padded bill?

Therein lies the rub. Acting in my own interest, I spent a small amount of money to reach my out-of-pocket limit, and then I hit pay dirt--100 percent payback. That is precisely when the dollars ceased to be real. Somebody else was picking up the tab. When I pay for health care in fake dollars, I pay no attention to the charges.

My decision not to protest was, until recently, the national decision. Yeah, you guys are in this with me. How many times have you heard a co-worker say, "Well, I maxed out on my deductible, so I may as well have the surgery now." I've heard it plenty. Where there is no incentive to forbear, doctors will prescribe and people will spend.

One of the reasons why doctors over-prescribe expensive testing and unnecessary surgery is that they are covering their asses against malpractice suits. This is an area where the federal government could help out by limiting liability. But that doesn't excuse all of the high-tech tomfoolery.

If any single aspect of medical care has been overhyped, it is the saving graces of big machines. Most of that horrific, impersonal, dehumanizing technology is trotted out to torture failing bodies in their final months or days, and it robs people of their dignity and selfhood at a time when they need it most. Death by machine is the lowest circle of modern medical hell. If it weren't, Dr. Kevorkian wouldn't be devising suicide machines to save people from its clutches.

Until we reconnect the elemental relationship between doctor and patient--where the doctor has incentive to offer only the care that the patient needs, and the patient has incentive to buy only what is necessary--the upward spiral in health charges will continue unabated.

How to reconnect? I have a few ideas, none of which are my own. In the brilliantly argued treatise Patient Power, John C. Goodman and Gerald L. Musgrave do the impossible: They write clearly and engagingly about a murky problem. Their views run counter to the Washington health reform stampede, (concluded on page 146) Deductible (continued from page 70) which posits that new government bureaucracies can untangle the existing health bureaucracy. The authors call, instead, for a world in which patients, empowered for the first time in decades to make choices, take control of their own health care.

To pack their argument into a nutshell--where it doesn't belong--Goodman and Musgrave believe that the marketplace for medical services should operate the way other marketplaces do: The self-interest of buyers causes providers to offer the highest quality for the lowest cost. (In the main part of this playboy package on health care reform, the plan is disparagingly called "survival of the healthiest." Hey, I'm for survival. You can't fight evolution, baby.) To achieve this, they would transfer the power in the system--currently hogged by the insurers and the government--to the patients in the form of their health care payments.

In any transaction, sellers respond to the needs of the buyer. If the buyer is the government, the government's needs are met. If the buyer is an insurance company, the insurance company's needs are met. If the buyer is the patient, the patient's needs are met. By putting the transaction back in the hands of the patient, and by providing tax and other incentives to make sure people save for future health care purchases, the authors believe that the system will reform itself, lobbyists be damned.

If you are worried that patient power will come out of your paycheck and wallet, think again. There are incredible amounts of dough flying through this system, but you see hardly any of it. That's by design, of course. It costs a lot to feed bureaucracies, which are to American society what ticks are to dogs. The system now operates to fatten these parasites on cash, and it's cash that doesn't do a damn thing to make you feel healthier. Make the system more efficient--i.e., squish the ticks and put the money back in your pocket for you to use as you see fit--and the funding is there to make you healthier and wealthier.

The argument presented in Patient Power (get the book from the Cato Institute in Washington, D.C.; I really can't do it justice here) is so persuasive that it made my imagination wander a bit. Imagine the doctors' death grip on simple diagnosis and prescription being broken, with these responsibilities taken on by plentiful, inexpensive diagnostic nurses and doctors' aides. Imagine insurance companies returning to their original and useful role: spreading risk for truly catastrophic health emergencies. Imagine the dinosaurs of inefficient medicine--including that MRI team and the doctor who sent me to it--being replaced by fast-on-their-feet practitioners who concentrate on personal service and reasonable cost, not out of the goodness of their hearts but because they must do so to keep my business. In place of the legions of specialists whose piecework mentality rings up outrageous medical fees, imagine a prosperous tribe of general practitioners who pride themselves on treating the whole patient.

This is the part I like best: Doctors who live by machines should also die by them. Those who live by caring for and healing people--and that includes talking them out of horrific tests and pointless therapies--should be rewarded.

Maybe you are thinking, "Patient power is fine for him, he has money to pay for it. What about the poor?" A good question. There's a solution here, but first we'll have to deal with another problem I've helped cause: rich people hogging all the health dollars. The fact is, I'm overinsured. You probably are, too. Goodman and Musgrave point out that a huge number of Americans--one estimate puts the number at about 100 million--carry policies that are, in effect, prepayment for an unlimited list of outré health therapies that few people really need or want.

This sort of prepayment is the equivalent of going prix fixe to a five-star restaurant that has a 1000-page menu. By curtailing the choices, the cost can be contained as well. When you rein in the outlandish number of choices, and then rein in prepayments for those who can afford but don't need them, you might liberate a pile of cash for those uninsured who never got to see the menu in the first place.

Specific policy suggestions aside, one of the most appealing things about the Goodman-Musgrave school of health care reform is that it acknowledges a profound truth about current history: We, the people who share this planet, are moving away from collective forms of organizing societies--i.e., socialism--and toward individualist, democratic forms. Remember, if government is the buyer, government will be served. How ironic it would be if, at the very moment when individual freedom of choice is sweeping the world, the republic that started it all tried to solve its biggest problem by embracing what could become the world's biggest bureaucracy.

What about Canada? you hear people ask. Promoters of Big Health often cite our neighbors to the north and the excellence of their single-payer system, whereby the government pays all health bills and reduces costs and rations health care efficiently. To them I say: Canada, shmanada. The entire country--26 million souls--could fit on the pinkie toenail of the U.S. health giant.

And a giant it is. As the Lilliputians learned, to subdue something very large, you simply wait till it sleeps, then swarm over the inert body and restrain it. Each of us, acting to ensure our best interests, can conquer Gulliver. But first we have to knock him out. Bring on the anesthesiologist. It's time for major surgery.

"It costs a lot to feed bureaucracies, which are to American society what ticks are to dogs."