Liberty, population pressure and health care

While I try to figure out how to upload some medical slide shows to this blog I'll lend my opinion on how our heritage has gotten us into our health care mess. It seems time to acknowledge our libertarian good side but give into some communal living. I'm going to get into some history that may be skewed, so please cut me some slack. It is my blog you know. Dammit, I'm a doctor, not a historian.

Please don't read this if you don't like history or if you're tired of the health care debate, and who wouldn't be, so I guess I'll just write for myself.


The population of Europe was thinned by the bubonic plague in the 15th century. After that everyone got along and most had a job and the Church led peaceful, wonderful harmony within Europe (I made this up...). Then people started to read and trouble makers sent people's minds all akimbo. Luther, Knox and Calvin took the right flank and Hobbes, Locke, Kant, and all those other precommunists took the left flank. Governments churned and turned over. There developed a group of individually-minded people interested in liberty and the pursuit of happiness, no matter who suffered around them. They were particularly interested in themselves, perhaps more than their larger community, or the King, or the Church (this is understandable since the leaders here were pretty corrupt... maybe you're not supposed to have wives and vast quantities of gold when your a Pope, and the King should not drink so much or have more than three wives at the same time, and he should leave Celtic people alone (my rules)). The individualists answered to the Lord, their money belts, or to some voice in their head that no one else heard and they didn't feel like fighting in huge armies for no wages, moldy bread, and the privilege of sleeping in the same bed with six other men who smelled like wet horses.

Anyway a group of Puritans couldn't get comfortable in their own skin in England or the Netherlands so they moved to North America to bother the Indians, who themselves couldn't get along with their neighbors, but they lived in the woods and were, as the saying goes, "born in a barn". Others moved to America since business was good here for those that didn't go to Oxford, Cambridge, the Sorbonne, or the Prussian School for Fanatical Military Strength. It was hard to move up unless you were born to some Royal family where your parents were also your brother and sister,or vice versa, or you-know-what-I-mean (?), or unless you were a genius like Napoleon or the guy that created the slinky, later of course. I'm not saying that Napoleon played with a slinky, but I think he would have been good at that, and the hula-hoop ( and all Wham-O products for that matter) just like he was good at controlling most of Eurasia and the Middle East. Nerf basketball would have been hard for this short man though. OK, I was digressing...all those of Europe that didn't want to be bothered by the psycho, in-bred, warlike Europeans thought they could avoid taxes and hassle in the New World. Where it seemed like no one lived, emphasis on "seemed".

So people came in droves to North America, but they soon discovered that where there are other people there could be trouble. So they brought diseases like tuberculosis and small pox with them to act as infectious napalm. To clear the woods as it were. This wasn't their fault though since it was also clearing their own woods, and the European woods, as about 1 in 2 people that died in Europe died of some horrible disease. The others died sleeping with wet horses in fields festooned with uniforms taken from dead sheep. A more pleasant sight could be had by touring a coal mine in the English Midlands circa. the 18th century.

So the religious, the entrepreneurial and a 2:1 mix of sane and insane moved to America. They were looking for a better life understandably. Here the sane and the insane grew in similar numbers leaving the sane in much greater proportion than the insane. But the sane seemed to like their new digs where the insane still felt cramped. And while the population multiplied government grew, as Thomas Hobbes would argue to be a natural phenomenon, and taxes followed them from England. Americans didn't like taxation without representation, as a reasonable person would not, but I think there were some that just didn't like taxes at all, no matter who was imposing them. This was discovered when the new nation was developed. General Washington couldn't pay for the army and the Constitutional Congress couldn't meet without money. But they had trouble raising taxes to pay for these necessities. Revolts ensued and the Constitution become a tough sell. The Bill of Rights was soon developed because, despite the formation of the Constitution, this revolutionary document which codified new freedoms in the world's first representative democracy, there were still those that worried about an individuals freedom from the tyranny of the majority. Slaves were eventually given up but guns, states rights(i.e. local, not federal authority) and individualism became staples of our heritage.

This seems to be a consequence of population pressures, amongst other things. As population increases there seems to be more demand for protections from others and taxes to pay for these protections. The West is still less populated than the East in America, as the New America was less densely populated compared to Europe in the 17th and 18th centuries. Now there is a trend of communality in the Northeast and a persistent desire for individuality in the West (Democrat and liberal Republican v. Republican and conservative Democrat), perhaps because of population density, or a historical lack of it in the West. A common human trait may be for liberty but when one finds a nice place to live and others find it too, which is inevitable, perhaps it becomes more practical to make community compromises. Reasonable sharing is in every bodies interest when population density increases but the hard part comes in deciding how much to share and what's reasonable. Sharing becomes advantageous when everyone benefits. The West is in the grey zone with population, many are diffusing here, as has been happening since the 19th century and population pressure is making people crazy. There are many here that feel entitled to serenity when in fact they will not find serenity until they can deal with population pressure, other people will not go away, and the phrase, "My ancestors did not move here to have to deal with immigrants" won't wash. I "emigrated" to Washington State almost fifteen years ago. There is no where else for the Frontiers people to go except into the Pacific Ocean (call-back to the wet horses reference). A more conservative libertine of our country seems to emanate from the West. I admit that I enjoy living in the West and agree with some of a libertarian philosophy but I don't agree with the self-sustaining individual over health care.

In health care we are crawling all over each other with nontransparent fee structures, unequal distribution that costs everybody directly or indirectly, expenditures that are out of control without added benefit, and that's poor value, again for everybody, and a medico-legal system that seems wacky, and stacked against reasonable practice. The economy of medicine is a wreck that no one understands, and I believe no one! Not the eggheads in think tanks, the President, Glenn Beck or Hannity or your Grandfather who knows everything else. We need some system that will help everyone because this will help us all! We have reached a critical mass of population in this country. We can't be the libertarians that we pride ourselves to be on this issue, or many others, because it is limiting the enjoyment of our other libertarian institutions: enjoying life's tranquility, having our own businesses, and living the pleasant life without worry of health bills or taxes and premiums for taking care of people who have never had insurance, or those kicked off insurance for being too sick. It is making it hard to find serenity. The burden of being witness to many suffering (mentally, emotionally, physically) has become nearly unbearable, at least for me, and for many we read about in the press but some of us would like to put our head in the sand to make it go away. It won't. So let's deal with it, as a nation. Republicans and Democrats, and Libertarians. It's deal with it now or deal with it later.

Here's where I get to say, "If I were King... I would have three wives, drink too much and I would kick the Celts off my land." OK, that's a joke, I would not drink too much.

(As an aside, I think there has been little resolution on the issue because America doesn't know what it wants and it doesn't want to be led. What's new. We need a crafty leader. Obama seems to be more of a mediator than an advocate. Maybe we could do some dance with LBJs DNA to resurrect the King of the Legislature.)

But if I were King of health care I would:

Argue that the Constitution anoints the government to "promote the general welfare" of its people as stated in the preamble.

Argue that health coverage may arguably be a right but is more convincingly a part of our heritage in that it would level the playing field of opportunity for those who are sick.

Work to transfer responsibility of health insurance to the individual and remove the burden from employers.

Remove tax credits from employers, if they want to offer insurance as means of attracting employees they would shoulder that burden without tax credit.

Work to make fee schedules transparent and knowable by everyone who purchases health care. I would also work with experts to break into the black box that is hospitals negotiating fees with insurance companies and doctors and medical equipment reps, followed by how they decide what to charge to the consumer. If everyone was insured there may be less accounting wizardry that leaves one baffled.

Create health insurance exchanges but leave the government out of day-to-day coverage.

Require everyone to have catastrophic insurance (the original intent of "insurance") or task the federal government to catastrophic coverage. This would mirror the educational system where our kids are covered by public schools but if a parent wants to spend more for private school they can.

Leave entitlements where they are for the poor and elderly.

Make a consumer health oversight body, the Medical
Reserve, much like the Federal Reserve oversees the banking industry, current political position of the Federal Reserve notwithstanding. It's still a good idea. The intent would be to allow the patient from getting screwed as a consequence of transparency deficiency.

Work with professional medical societies, and the legislatures and courts, to create guidelines of care that are reasonable and more firm nationwide since this would alter a "Standard of Care" aspect of our medico-legal system. If avoiding an MRI for everyone who has a headache is considered reasonable, through the guidelines of the professional societies it should then be reasonable in a court of law, or vice versa. Chest pain in the ED? society needs to give some guidelines to those on the front lines. Yes, the one in a thousand missed heart attack is tragic, but is it malpractice? Or do we want to pay more for defensive testing? at least give the doctors a clue what you want America. This is the people's issue, not lawyers, or even doctors.

All right. I'm tired of this. I'm glad I'm not a politician.