As outlined previously, I began my search to understand Health Care from a primitive prospective.  No matter how advanced we become we will never overcome our primal selves, nor should we try.  It is our primal self that rose from the great contest and became a man, the steward of all creation.

Yesterday I posted my belief that the market is the superior form of rationing, not only because it efficiently distributes scarce resources, but it does not deny people the opportunity to preserve themselves.

Before I post the skeleton of my ideas for fixing the inequities of our health care system, I must first state that the problems of health care in the United States are grossly overstated.  As pointed out by Mr. Ridley in his interview by Reason in the Friedman library, we are living 30% longer and are 3 times wealthier then we were 50 years ago.  This is significant for two reasons: modern medicine as we understand it has only existed since the development of penicillin, and people are in the prime of their productive lives longer.  There can be little doubt that much of humanities gains in science, technology, and even the understanding of ourselves can be directly attributed to medical advancement.  We will never know the full impact of our collective prosperity in the free markets of the free world.  How brief would the history of time had been if Hawking was cut down in his youth?  How far have we come standing on the shoulders of people who just fifty years ago would never had lived.

Major breakthroughs in the care premature birth including the development of artificial lung surfactant happened just months prior to my birth.  Without those advancements I would not be here today.  Without those advancements the work of my life would not be done.  Without those advancements I would not be married, nor would I have a pregnant wife.In any other country I would not have survived.  I was 27 weeks, 3lbs 10oz, and born with collapsed lungs and a heart that had failed to start.  Without the artificial surfactant my lungs would have stuck together.   I was given open heart surgery and granted a reprieve from The Reapers Scythe.  Within hours of my surgery I experienced severe cranial swelling and over the next few days dozens of cc’s of spinal fluid were drained from my tiny body.  For two month I lived in an incubator in intensive care.  I was baby Neo, still plugged into the Matrix.  When released from the hospital, I could still fit in one hand and slept in a blanket lined shoebox.

Today over 27 and 1/2 years later I am almost 100 times my birth weight (yes for those good with number that’s a very unhealthy 350lbs give or take a cheeseburger or two).  I am over six feet tall, have not noticeable defects, and suffer only from mild allergies to pet dander and some pollens and a stigmatism.  For all intents and purposes I am a perfectly normal American male.  None of this would have been possible without the health care system we are now debating so desperately on how to “fix”.

We should take note that because of doctors we live longer and more productive lives with a much higher standard of living.  That standard of living comes at a price.  What price is too much to live an extra 25 years?  I may sound disingenuous, but 1 out 5 dollars is a small price to pay for an extra 30%.  20% for 30% ?  Not bad!

But the counter argument is of course: but what if I can’t pay the extra 20%?   Work harder.  Sacrifice possessions and experiences for care and safety.  There aren’t many who truly can not afford coverage, and charity and the dole exist for those who do.  If we work harder on access and cost, fewer people will slip the cracks.

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Facet Number 1: Remove employer benefit tax benefit and transfer tax break to employee, or alternatively banish income and corporate tax all together with implementation of a national Fair Tax.  Currently the difference between individual plans and corporate collective bargaining is not as great as the public is lead to believe.  What is not understood is that employers pay 80% of the cost of the workers benefit plans.  Once this cost is known to the worker, the worker will naturally work to reduce these costs.

Facet Number 2: Transparency in provider pricing.  Doctors should be required to a) post costs for common procedures, including the medicare rates, and b) required to give a quote prior to any work being done.  Quotes should be simple to understand and communicate so that patients can easily compare with competitors.  True transparency in pricing will keep billing honest and prices lean.

Facet Number 3: Remove FDA emphasis on drug safety, renew FDA emphasis on drug approval.  This can be done by shortening and reducing drug trials to bring new drugs to market, and reducing the cost of such testing.  Also not-for-profit drug research and development may be spurred by removing trial cost for these organizations and extending patient life for these organizations with agree upon profit limits for subsequent manufacturers.  Current drug approvals and patent law are a mess.  The research costs are too high and the recovery periods are too short.  Time magazine publishes an article and has copyright for as long as 120 years.  Pfizer cures cancer and gets copyright on the drug for as little as 7 years.  Neither makes sense when the cost to create and purpose of protection are taken into consideration.  The FDA is barrier to new drug manufacturers entering the marketplace and a barrier to new drugs being introduced.  The Harry Browne argument that will always hold true is this: if a drug saves 10,000 lives a year and the government delays its introduction by 7 years, didn’t the government just kill 70,000 people?

Facet Number 4: Remove barriers to streamlining administrative process, including the claim by doctors and hospitals that a patients records are not his or her property.  All patients have a right to their medical histories.   Additionally providing protects against medical discrimination and providing for a paperless transition is essential.  The process of billing months after the fact should not be allowed to continue.  Transparency in pricing, simplification of tax code, and the other improvements should make this a simpler task.

Facet Number 5: Remove barriers to entry for doctors and allow and wider variety of practitioners.  Supply and demand dictates the desire for more professionals of all kinds, especially doctors.  Supplementing the supply of doctors with more specialists and care providers will improve the overall level of care and reduce cost.  Simply put, the government control over medical practitioners generates artificial scarcity.

Facet Number 6: Remove “standard of care” minimums on insurance plans.  If a young person wishes only to have catastrophic care, allow them too.   Allowing people more freedom in how they tailor their health care plans is essential to the system effectively managing cost.   If people want to pay out of pocket for maintenance drugs and only have insurance in case that once in a lifetime million dollar bill comes along, people should have every right to do so.

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I would like to debate these facets with people and see if they can tweek them more or less.  One thing about government is that they have no interest in solving a problem if the solution lessons government power in any fashion.  We lovers of liberty should be ever vigilant against government power grabs in whatever form the Trojan Horse is presented.

If someone makes a statement that Government should provide Health Care to its citizens, kindly remind them that if the government can giveth; the government can taketh away.  Ask them quietly if they would support government denying treatment to their family or them personally.  If they insist that the g-men would never do such a thing, inform that whenever they have had the ability to do so they always have done so.

If someone is ever bold enough to say that you are somehow being racist by not wanting “Obamacare”: frown at them, try not to cry, and tell them that it is because of what the government did to the Black men of Tuskegee that you are so adamantly against it.

Whenever scarcity of an item and demand for that item coexist a market is created for that item.   Few things in the world do not have scarcity of some degree.  The items that don’t have scarcity (or functionly no scarcity) have no market in normal time.  Air is plentiful, so no one pays for it.  Pure Oxygen is scarcer (it must be harvested) so people actually pay for it.   Medical care items (be they objects or services) are scarce (arguably more scarce then need be) and thus a market exists for these items.

A market is rationing.  This must be agreed upon before a conversation on why the market form of rationing is superior to centralized rationing.

Glenn Beck in his impassioned remarks on eugenics and his daughters story as referenced by Ganelon is a great starter for the reason why the market is superior to central planning in distributing the scarce resources of health care.

This is a deep arguement that spans generations, so I can not hope to even provide a primer for it here.  The question a person supporting a centrally planned system has to ask is this: if someone else decides you don’t deserve treatment, would you still support it?

Willing to sacrifice yourself for the greater good you say?  Ok, what about your parents?  What about your children?  What about that sweet old lady down the street?  What about the cute little boy next door?

Is it in anyway justifiable to deny a person the right to attempt to protect themselves?  No.  Never.  It is never proper to deny a person the right to attempt to protect themselves.  (I can hear you dissenters now: murders? rapists? really really bad baddies?  They have a right to attempt to protect themselves.  They don’t have to be successful, but they can certainly make the attempt.)  The right to attempt to preserve your life (in its three forms: your possessions, your person, and your freedom) is inalienable.  You can no server this right from a human being.   No matter who that human being is.  This point must be agreed upon before any further discussion of health care can occur.

So once it is agreed that rationing will occur in any system and that a human being can not be denied the attempt at preservation of life, the next question will be raised (quietly at first but louder as scarcity increases) what is a human being?

What is a human being?  This question comes in many forms.  Are brain dead people no longer human?  Are children who have no concept of the future human?  Are deformed or diseased people less human?  Are some ages of people less valuable as humans?  Etc.   (And the hotly argued “When does life begin?”/”Is abortion murder?” debate.  A debate that Peter Singer answers with 2 years old.)

I myself have posited the question in a different way: does a person who is unproductive (or even negative to production) deserve the same care as a person who is even only minimally productive?  The answer to the question as established above is yes, they have the right to attempt to preserve their life.  The question has to be asked because of the answer to its companion question that is never asked: does another person have a right to my (or anyone’s) life to preserve (that’s preserve not protect) their own?  The answer is of course: No. Never.

Because a person has no right to another persons life, they can not use another persons life to preserve their own.

Something must be traded from one party to the other to compensate for life spent in the service of others.

We must never get the fundamental philosophy of liberty, without it all is lost.   You own your life in al of its forms, your possessions (the embodiment of your past), your person (the vessel of your present), and your freedom (the ability to secure your person and possessions in the future).  Because you own your life, there are only two ways in which your life can be voluntarily interacted with others: trade and donation.  People often donate of themselves, this is the spirit of generosity that keeps the human family connected.  People instinctively trade with each other, this is the foundation of all prosperity.

So if medical care (the service or resources used to provide it) is not equally traded for or donated freely it is stolen.

When you steal possessions it is the theft of a persons past.  When you steal a persons services it is the enslavement of that persons life.

Think hard about stolen or reproportioned property.   Does a stolen or coerced item have the same value as its purchased or donated counterpart?  Would health care be any different?

So back to the title question: to ration or not to ration?  There is no choice, there must be rationing.  The question should be: to steal or not to steal?

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I have formulated a basis for health care reform and I will write about it soon.

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For a long time I have taken a very primitive view of health care and tried to apply it to the modern condition.  I reasoned that until very recently in our collective history people worked and played in very consistent groups.  These groups had three types of people: harvesters, traders, and servicers.  The harvesters were the people who farmed or mined.  They- like their modern counterparts in Eve, WoW, or LOTRO- brought forth the raw materials from the Earth.  Tradesmen bartered for these raw materials with refined items their talents had created.  Industrialists of all kinds are the modern equivalent.  Whether a person is making the widget or selling it, they are a tradesman.   The servicers didn’t manipulate the Earth or materials directly, they provided a secure and stable environment for these more basic market activities to occur.  Servicers included everyone from chieftain and shamans, priests and pastors, police and firemen, entertainers and scholars, garbage men and doctors.

While the primitive world may have had chieftain farming crops in addition to being old school community organizers, the larger the community became the less time the chief had for farming.  The modern world has brought us the double edged sword of being so specialized that we forget our basic nature; and people in service forget the meaning of service.

It is decidedly unfair to say that servicers are a drain, because the market tells us otherwise.  But there is something easily forgotten: overspecialization leads to inefficiency and waste.  One does not have to think too hard about bureaucracy to see this is true.  Image your daily life where perhaps you can do something yourself in half an hour at a cost to you of $50 or you can give it to another person to do in an hour at a cost of $40.   While you have lost time in the transaction you have gained capital, but what happens if the second person take two hours and costs you $80?   This is a very oversimplified example of problems we face in the real world everyday.  Given the example above, you would not have the second person do the task, unless you had a guarantee that the work would take less then an hour and fifteen minutes.  But in the modern world, the reality is seldom that transparent.

In the primitive times, the tribe toiled long to rip life from the earth.  Few people specialized, and fewer still invested in the service of others.  Instead of standing police forces or armies, civilizations had wartime conscription and militia.  Instead of large universities with medical centers, the tribe had an elderly shaman and a few amateur star gazers.

But through the history of man we developed.  We specialized.  We entered the market of ideas, saw a need and filled it.  Advances in technology skyrocketed the quality of life and standard of living around the globe.  Humanity proved again and again that a net positive interaction is possible.

But we are increasingly furthering ourselves from the tribe of the past.  One thing the small tribe had, was a sense of community.  The tribe had its servicers, its tradesmen, and its harvesters and each knew their part.  Dunbar’s number insured that the small tribe knew who to go to for every vital service and material need.

Only in the last hundred years has the service of medicine come to be thought of as a trade.  And it is hard not to blame the profession for falling victim to that mistaken identity.  So many advances in the material dimension of the profession were made that these service providers actually started to believe they were tradesmen.   And to compound the problem, modern technology shifted the balance of tradesmen away from production of items to support of those items.  But material support and communal service are not the same thing.

Doctors are not businessmen anymore then politicians, soldiers, firemen, police, or census takers are businessmen.  Anyone who goes into the “business” of medicine is not a doctor.  They are pharmaceutical researchers, cancer researchers, scientists, and inventors.  But they are not doctors.  The lines are blurry, but they do exist.

Do doctors make money?  Yes.  But that money is a reward for the place they hold in society.  Reward for the special service they provide.  Should doctors make money?  Yes.  Just as anyone who becomes specialized and fills a highly demanded need should be.

When asked how to reduce the percentage of harvested resources devoted to health, the question of efficiency is rarely talked about in basic terms.  If we do not talk in basic terms we can never identify the systemic problems.

What is a doctor?  A doctor is the member of the tribe whose purpose is to provide services designed to prolong the health of fellow tribesmen.  Why is the doctor important?  Because prolonging the life of fellow tribesmen increases their overall productivity both in quality (average output) and quantity (lifespan).  Because of the complexity that doctors deal with they must be highly trained.  This is a significant investment that needs to be recovered by the investor.  It is also a generator of scarcity.  While a nurse or a medic may be 95% as good as a doctor and keep you alive in the vast majority of cases, the diminishing returns in education versus application required to achieve that last 5% are significant.  The threats faced by doctors also represent a further divide in knowledge, while 4 of that last 5%  will be generally known, that last percentage point makes all the difference.  This is an incentive for doctors to specialize.

But these leaves us with some interesting questions.  If a Nurse is say half  (or 3/4 or 90%) as good as a doctor, wouldn’t it make sense to have more nurses?  Or more medics?  Or more general practitioners?  Yes, that is probably true, but unfortunately there are artificial barriers that keep this from happening.  The same systems of certification that make the medical service professionals so good also hamstring their dissemination among the general population.

Cuba is lauded for having 1 doctor per every 30 citizens.  But how good is that doctor, or better yet, how good is that doctors material support?

The increase of the medical trade has allowed for great increases to the outcomes of the medical industry in practice.  But the tribe is now spending more on the doctors tools then the doctor.  This creates a shortage of actual doctors, and leaves those unable to trade for that service without supply.  The demand goes unsatisfied.

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This relates to the average worker, and how health care usage naturally follows a production bais; those who don’t produce, don’t get service that enables their continued production.  But this is a broader topic for another time.  How does the tribe act to differentiate between need and greed, productivity and sloth?

It is fair to say that we should all be equal before the doctor as we are before the law.  That even though one person may produce more (and thereby help the tribe more), that a persons lesser production is not viewed as a barrier towards continued ability to produce.  The far more difficult question to answer is what about the person who does not produce?  Does the tribe have a responsibility to see that they continue not to produce?

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Gnite.