You are invited to read this extra commentary from the Free Enterprise Foundation. It will make you think!

First, Do No Harm!

By Robert E. Freer, Jr., President of The Free Enterprise Foundation

"The physician must...have two special objects in view with regard to disease, namely, to do good or to do no harm" (Bk. I, Sect. 5, trans. Adams, Greek: ἀσκέειν, περὶ τὰ νουσήματα, δύο, ὠφελέειν, ἢ μὴ βλάπτειν).” Wikipedia

“It sounds noble, but health care is in many ways a commodity that cannot be made more available, at a lower cost without someone picking up the tab. This is why so many are worried about the ultimate cost of this measure as it relates to the working taxpayer.” Rep Tom Price R. Ga.

The summer of '09 will forever be remembered for the great health care debate. Would that Congress in its labors remembers as its first goal the physician’s ancient oath to do no harm! America’s health care delivery system does not begin from a blank computer screen in a congressional aides’ office. It begins with the dedicated attention of our nation’s doctors and other health care professionals who care for 300 million Americans.

The annual cost for this care amounts to more than two trillion dollars and accounts for about 16.2 percent of our GNP. However, the revenues generated from these high healthcare costs have encouraged substantial investment in a health care delivery system. Wikipedia confirms the United States is the leader in biotechnology, spending three times more per-capita in research and development than its nearest competitor. In addition, the U.S. produces more new pharmaceuticals, medical devices, and affiliated biotechnology than any other country, and more than all Western European nations combined. This robust research environment pushing the frontier forward is part of the reason 68 percent of voters in the United States pronounce their health care coverage good or excellent.

There is a need for reform, however, and the left is approaching its legislative effort as if a single payer system, no matter what it looks like, is the Holy Grail. The right is opposing the left’s effort as if it is the Unholy Griffin. Neither side gives quarter, nor is anyone speaking up for the rest of us who have questions about the existing system but wish minimal change to a system we like.

Those who wish major change recognize that scarcely 15 months away, history supports the likelihood there will be significant drawdown on Democratic majorities in the election of 2010, and, in Rahm Emmanuel’s words, “You never want a serious crisis to go to waste.” For them the battle is to do it this year or face the likelihood that election year politics will defeat them. Those actively involved in this debate use their terminology inconsistently; tell only their part of the story and heap scorn on everyone else. It is not an atmosphere consistent with the thoughtful approach required for such an important subject.

The Health Care debate really proceeds on several levels generating more heat than light. The first area of debate is reform of the existing health care delivery system. Despite my laudatory comments above, our health care delivery system is stressed and for efficiency in patient care needs an overhaul. At a minimum Americans recognize that effectiveness and cost containment would be improved tremendously if health care delivery reduced paperwork and fully utilized electronic personal medical records in a safe manner for coordinated health maintenance. Our need goes beyond this; however, almost five years ago, the late Dr. Leigh Thompson, a Charlestonian, and former chief scientist of Eli Lily, pointedly swirled his ancestral Scottish Claymore to condemn what he referred to as feudal medicine’s archaic ways and urged a “fractal” revolution in med schools and delivery systems of patient care.

Dr. Thompson’s reform is not the “reform” requested by the collectivists among us, but should be our primary target. The existing delivery system is inefficiency incarnate. We worship feudal order and separation that walls off specialists from generalists, nurses and other health care professionals. We use outdated technology, but more importantly, do not require all parts of medicine to reorder itself into a coordinated whole. It is exceedingly wasteful and costs in Dr. Thompson’s estimate, 100,000 lives a year.

Imagine the savings we might have if the nurse practitioner and the internist operated as the quarterbacks who maintain an holistic view of the health of their patients and refer them for specialist treatment when advisable. Imagine them coordinating help early in treatment and imagine that a joint approach is further encouraged in medical school itself in an interdisciplinary approach to medical education so that at the threshold of their residency, doctors think holistically and are encouraged to reach out for the most effective health management approach.

Not very sexy, is it? While it will be affected by the current battle, it is also not the focus of our legislative concern. Money, who provides it and for what and for whom are at the nub of our legislative struggle. Despite a very strong presumption to the contrary, according to JAMA, “employers do not bear the cost of employment-based insurance; workers and households pay for health insurance through lower wages and higher prices. Moreover, government has no source of funds other than taxes or borrowing to pay for health care. Failure to understand that individuals and households actually foot the entire health care bill perpetuates the idea that people can get great health benefits paid for by someone else. It leads to perverse and counterproductive ideas regarding health care reform.”

Health care insurance is merely a vehicle of forced saving. It does provide fee based power price negotiation with delivery authorities that all, one way or another show up in the disposable income, or lack thereof of our citizens. Whatever we do, those of us who can afford to pay are going to pay for those who cannot in any system that assures at least a European or Canadian level of care for all.

For most of us, we are pleased with the superior level of care that is available in the U.S., would not like to see it reduced or to face a system in which anything other than medical necessity determines whether we get care. The issue of price is there, but it is a separate question. Any “cure” should assure the availability of that care will not be diminished. The idea that some bureaucrat in Washington together with other bureaucrats on an “advisory” committee could have any influence on whether we receive care is enough to drive us off the edge. To hear that receiving such care, whether insured or not, might be illegal makes us ready to man the barricades. While there isn’t at this point one consensus vehicle for reform, all of them subject the private sector plans to the control of the public sector advisory committees for pricing and terms of coverage as well as the availability for treatment on a non insured basis. They will drive the private sector regimes to the public model, seriously restricting care options.

No one really wants this to occur but have been told that it is the only way to develop a model that works. That is just not true. Runaway costs not connected with normal medical delivery questions and the nature of private insurance are at the heart of the dilemma and can be solved privately. To handle insurance availability, we must as citizens recognize that from youngest to oldest and weakest, sickest to healthiest and strongest, we have an obligation, just as we do when we slide into our automobiles, to have an adequate amount of healthcare medical coverage. Health care insurance providers should be limited to those companies that are willing to offer coverage without regard to age or preexisting conditions to all comers at the broadest universal community rating. Nothing less will work. I leave to professionals to figure out issues of deductibility, surtaxes for rich plans, co-pays and the mechanism to cover those who truly cannot afford coverage, but individual coverage responsibility and broadest insurance rating must be included in any solution. What also must be included is limitation on the “piñata” approach to medical mal practice awards and accident coverage.

We all feel the pain of those who suffer an accident or are the victim of medical errors, but do we really believe it is our obligation as premium payers to support those victims in a style that is well beyond what they might otherwise have expected? Could we also remove the bonanza returns for law firms by removing their cost from the system as well by an approach closer to workman’s compensation than the existing showdown at the OK corral of the courtroom? I believe we can and must to preserve what is best about our system. To adopt the one payer or even a heightened role for government is to forfeit the first role of medicine to do no harm.

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Robert E. Freer, Jr., is president of the Free Enterprise Foundation. He is also a professor at The Citadel and was selected in 2005 to be their first John S. Grinalds Leader in Residence. A regular contributor to the Mercury, Prof. Freer may be reached at Robert.freer@citadel.edu.

Copyright © 2009 by Robert E. Freer, Jr. All rights reserved

About the author: Robert E. Freer, Jr. is President of The Free Enterprise Foundation. He is a Visiting Professor, at The Citadel and elected in 2005 to be their first John S. Grinalds Leader in Residence. A regular contributor to the Mercury, He can be reached by E-mail at The Citadel . Copies of his earlier columns can be found The Free Enterprise Foundation.