We liked our doctor. A lot. We invested time and effort in finding him. He spent time getting to know his patients. And when our health insurance premiums skyrocketed not so long ago — and, yes, they soared — we told ourselves that at least, when we need medical care, we have a good doctor.
But here it is. A letter arrived. As the perspicacious predicted (though not as the American public was promised), we are losing our doctor. Oh, he is not yet entirely unavailable — there are physician’s assistants in his old office who may still be able to see us, for at least a little longer, and if necessary consult with him by phone. But he has moved to a different job, in which he may be better able to surmount the paperwork and continue to support his family.
No surprise. Apart from physicians who cater to Hollywood-celebrity levels of wealth or Washington-elite levels of power, how can any doctor with a private practice find time to deal with individual patients? The new prime imperative imposed by law requires that a doctor spend most of his or her time and energy toiling to comply with a regulatory burden so titanic that even those who issue it can’t keep track of it. I have no criticism of our (former) doctor, who invested years in mastering his profession, but has now been effectively commandeered as a serf of the federal bureaucracy. He is behaving pretty much the way Obamacare (dis)incentives would have him do.
It makes me sad. Not only because I really did like our doctor, and what clearly lies ahead is a path of rising costs, dwindling choice and lengthening queues. But because what lies ahead for this country is not good medical care for all, but gray standardization in which we are not only forced to pay for things we don’t need, but deprived in a crisis of the medical care that we really do need. Federal regulators, not doctors and patients, will make the decisions.
And somewhere in all the public debate — amid the gibberish about Websites and “mandates” — there is a basic idea that’s gone missing. When people are forcibly deprived of the opportunity to engage in voluntary transactions with each other — when you and your doctor are kept apart by a minefield of impassable regulation (dolled up under the ersatz label of a “marketplace”) — the result is the destruction of potential wealth. No, I am not talking solely about money, but about the many dimensions of health, wealth and satisfaction, as in, The Wealth of Nations; the inalienable right to life, liberty and the pursuit of happiness.
Economists have a term for this kind of destruction, now being visited on American medicine. They call it deadweight loss. The nullity, the non-creation of prosperity, the absence of mutual benefit, the empty triangle on the supply-demand chart, where a free market would have allowed gains from trade — from which both parties emerge better off than before. At the extremes, the Soviet Union with its repression and its warped and beggared economy was a colossal exercise in blocking markets and enforcing a nightmare of deadweight loss — to the huge detriment of all but the exempt elite. The United States, with its astounding prosperity, and its much-envied and innovative medical industry, was a testament to the power of markets. (No, the markets in medicine were not entirely free; there was a big regulatory web, there were huge legal tangles; but the choices, and freedom, were far greater than what’s happening now).
If the aim is to subsidize the poorest members of society, or ensure that no one need go without catastrophic coverage, it would be far cheaper and more effective to tax the working folks directly and forthrightly, and turn over the money to the neediest — and let them buy their own health insurance. If the government fear is that they would choose to spend the money on something else, then give them vouchers for medical care. But keep it simple. As an act of redistribution, that would at least have the virtue of being transparent, reasonably predictable and minimizing the cut for bureaucratic or politically well connected middlemen. By contrast, it is vastly more expensive, uncertain, corrosive to choice and destructive to freedom to embark on redistribution via a vast machinery of state planning and regulation. An analogy might be the old crony state of the Philippines under Ferdinand Marcos. Had Marcos run a free-market economy, levied reasonable taxes, and then helped himself to a multi-billion dollar presidential salary from the state coffers, he might have faced protest for his greed, but he would quite likely have avoided beggaring his country. Instead, he set up crony monopolies, vastly enriching himself and his pals by way of throttling business for the multitude. In the end, he was overthrown, but his country paid — and is still paying — an enormous price for the the system he set up. For every billion he squeezed out of his crony patronage system, the Philippines lost many times that in wealth foregone. Deadweight loss.
Another point, rarely mentioned in all the talk about rising healthcare costs in America over the past few decades, is what those dollars have actually been buying. It is not only the costs that were rising, but the benefits in terms of prolonging life and enhancing its quality. My grandmother died in 1965 at the age of 63, of pneumonia followed by a heart attack. These are things far more readily dealt with today. So are many cancers, chronic diseases, or sheer accidents. We now have scans, heart medicines, laparoscopic surgeries, highly tailored cancer drugs — a host of methods that a few decades back were science fiction. Surely the cost of medical care would have been lower had we skipped all those costly inventions, and stuck with aspirin, penicillin and the surgical procedures of 1952. For that matter, most Americans spend a lot more on computers these days than did their counterparts some 50 years ago — in that broad and misleading sense, computer costs have gone through the roof. But then let’s factor in what a dollar spent on computers will buy now, versus then. In medicine, the question is not solely the unit price of a given procedure, but the tradeoffs and potential benefits involved.
There are a lot of ways to keep costs down. Allowing real competition in a real marketplace is one way — and allows doctors and their patients to choose, thrive and adapt. Smothering medicine with state planning is another — fraught with deadweight loss.
And so, we are losing our doctor. I can’t blame him for backing away from the private practice that not so long ago he was working hard to build up. No longer is it enough that he mastered the art of medicine; to continue full-time in private practice he would have had to also master the Affordable Healthcare Act, and then master the ability to comply with it — or pay someone to handle these labors of Hercules for him. Not that I have had time to read the “Affordable Health Care” Act, either. It has been more a matter of paying the rising insurance premiums and losing access to a doctor we really liked, as we find out what’s in it. This is a document compared to which even the UN budget reads like Shakespeare’s sonnets. On the occasions I have tried sampling it, I have found it so full of impenetrable cross-references, opaque clauses and intricate bits of incoherent social engineering, there is simply nothing that, as an average citizen, you can do with it, except maybe weigh it — and the accompanying 10,000-or-whatever pages of regulations.
Here’s a random sample, below, plucked from page 1707. Seems to me the real message here is that it’s folly these days for anyone to go into medicine. Just go straight to law school. And hope you never get sick.
(i) INCREASED FUNDING TO FIGHT FRAUD AND ABUSE.—
(1) IN GENERAL. — Section 1817(k) of the Social Security Act (42 U.S.C. 1395i(k)) is amended—
(A) by adding at the end the following new paragraph:
‘‘(7) ADDITIONAL FUNDING. — In addition to the funds otherwise appropriated to the Account from the Trust Fund under paragraphs (3) and (4) and for purposes described in paragraphs (3)(C) and (4)(A), there are hereby appropriated an additional $10,000,000 to such Account from such Trust Fund for each of fiscal years 2011 through 2020. The funds appropriated under this paragraph shall be allocated in the same proportion as the total funding appropriated with respect to paragraphs (3)(A) and (4)(A) was allocated with respect to fiscal year 2010, and shall be available without further appropriation until expended.’’; and
(B) in paragraph (4)(A), by inserting ‘‘until expended’’ after ‘‘appropriation’’.