The Coming Medical Ethics Crisis

How the government is putting the medical profession-and your health-at risk


For the past several years, the medical profession has been undergoing a disturbing transformation. The process was begun by the Centers for Medicare and Medicaid Services (CMS) in an effort to control exploding Medicare costs, and was accelerated by the passage of the Patient Protection and Affordable Care Act of 2010. As a surgeon in practice for over 30 years, I have witnessed this transformation firsthand. I fear that my profession will soon abandon its traditional code of ethics and adopt one more suited to veterinarians.

For centuries, my predecessors and I have been inculcated with what has come to be called the "Hippocratic Ethic." This tradition holds that I am ethically required to use the best of my knowledge to recommend to my patient what I consider to be in my patient's best interests—without regard to the interests of the third-party payer, or the government, or anyone else.

But gradually the medical profession has been forced to give up this approach for what I like to call a "veterinary ethic," one that places the interests of the payer (or owner) ahead of the patient. For example, when a pet owner is told by a veterinarian that the pet has a very serious medical condition requiring extremely costly surgery or other therapy, the veterinarian presents the pet's owner with one or more options—from attempt at cure, to palliation, to euthanasia—with the associated costs, and then follows the wishes of the owner.

Several factors in combination are bringing this ethical approach to my profession.

Since the mid-1980s, Medicare has imposed price controls on health care providers. Over the years, in order to accommodate increasing Medicare utilization, physician payments have steadily dropped.

Meanwhile, the regulatory burden on physicians has increased. In the last few years, CMS required all providers to adopt electronic health records or face economic sanctions from Medicare. It is the ultimate goal that every health care provider, including pharmacies, will have electronic databases that will be accessible to the U.S. Department of Health and Human Services (HHS).

In 2009, as part of the so-called stimulus bill, the Federal Commission for the Coordination of Comparative Effectiveness Research (FCCCER) was created. Its mission is to collect the data culled from all electronic health records and make recommendations regarding the comparative effectiveness of drugs, procedures, and therapies. In rendering advice, the FCCCER will essentially answer the following question: What is the most cost-effective way of allocating a fixed amount of resources among a population of roughly 310 million people?

With this same question in mind, the U.S. Preventive Services Task Force, a committee that reports to HHS, concluded in 2009 that mammogram screenings should not be recommended to women under age 50. This caused an uproar among both private health care providers and breast cancer advocacy groups, and the task force soon backed down. Similarly, in the fall of 2011, the task force recommended the abandonment of certain routine prostate cancer screenings. Once again, health care providers and cancer advocacy groups protested, and the task force rescinded its recommendation.

In 2010 the Patient Protection and Affordable Care Act established an Independent Payment Advisory Board (IPAB). Beginning in 2014, the 15 presidential appointees on this board will determine what therapies, procedures, tests, and medications will be covered by Medicare, using advice provided by the FCCCER. Such determinations will then be used to design the coverage packages for the non-Medicare insurance offered through the government–run exchanges. The decisions of the IPAB are not subject to Congressional oversight or judicial review.

Meanwhile, in an effort to control costs now, CMS has developed practice guidelines and protocols for physicians to follow. Committees of health care academics and statisticians developed these guidelines, using data from large population samples.

These protocols govern the therapeutic decisions made by the health care practitioner—right down to the pre-operative antibiotics a surgeon may order. Despite the fact that several recent peer-reviewed studies concluded that the protocols have had no positive effect—in fact, one study showed post-op skin infections increased since the protocols were instituted—CMS imposes financial penalties on hospitals that fail to get protocol compliance from their medical staff.

Medical students and residents are now being trained to follow federally-derived protocols and guidelines as a normal part of medical practice. As a result, this new generation of doctors will be less inclined to challenge the recommendations of federal task forces and agencies. Some academics also worry that "teaching to the protocol" might discourage independent thinking and the use of intuitive knowledge, two traits essential to the practice of good medicine.

In addition, decreased reimbursements and increased regulatory demands on physicians have led many to sell their practices to hospitals. The New England Journal of Medicine* estimates that 50 percent of the nation's doctors are now hospital employees. As private medical practice becomes more economically untenable, look for the overwhelming majority of doctors to become salaried hospital employees—many working in shifts—in the next few years. Virtually every doctor now graduating a residency program is taking a position as a salaried hospital employee.

Ten thousand people will turn 65 every day for the next 19 years, placing an even greater fiscal burden on the Medicare program.

One way CMS is trying to deal with this is by penalizing hospitals and doctors who treat patients with resistant problems. Effective this year, any patient readmitted to a hospital within 30 days of discharge for the same or a related problem will be treated by the hospital without compensation. The plan is to implement the same policy with respect to the original treating physician in the near future.

To help deal with this more definitively, an old concept with a new name is being promoted and encouraged by the Affordable Care Act: the Accountable Care Organization (ACO). The ACO harkens back to the infamous HMO capitation system of the early 1990s over which the population rebelled.

In a nutshell, hospitals, clinics, and health care providers have been given incentives to organize into teams that will get assigned groups of 5,000 or more Medicare patients. They will be expected to follow practice guidelines and protocols approved by Medicare. If they achieve certain goals established by Medicare with respect to cost, length of hospital stay, re-admissions, or other "core measures," they will get to share a portion of Medicare's savings. If the reverse happens, they will face economic penalties.

Private insurance companies are currently setting up the non-Medicare version of the ACO. These will be sold in the federally subsidized exchanges mandated by the Affordable Care Act. In this model, there are no fee-for-service payments to providers. Instead, an ACO is given a lump sum, or "bundled" payment for the entire care for a large group of insurance beneficiaries. The ACOs are expected to follow the same Medicare-approved practice protocols, but all of the financial risks are assumed by the ACOs. If the ACOs keep costs down, the team of providers and hospitals reap the financial reward: a surplus from the lump sum payment. If they lose money, the providers and hospitals eat the loss.

In both the Medicare and non-Medicare varieties of the ACO, cost control and compliance with centrally-planned practice guidelines are the primary goal. The hospital and provider networks will live or die by these objectives.

When almost all health care providers are salaried employees of hospitals, hospitals might then be able to get ACOs to work better than their ancestor HMOs. The hospital administrators will have more control over their medical staff. If doctors don't follow the protocols and guidelines, and desired outcomes are not reached, hospitals can replace the "problem" doctors.

So where does all this place the medical profession with respect to its ethical credo? In a few years, almost all doctors will be employees of hospitals and will be ordered to practice medicine according to federally prescribed guidelines—guidelines that put the best interests of the state ahead of the interests of individual patients.

When the physician's primary obligation is to satisfy the wishes of the payer—ultimately the wishes of the state—how can patients be truly confident in their doctors' decisions?

I submit that it all boils down to a question of professional ethics.

The medical profession must decide—and soon—which ethical doctrine to follow: Are doctors to be agents of their patients or agents of the state? All of us should dread the latter choice—because we will all be patients some day.

Jeffrey Singer practices general surgery in Phoenix, Arizona, writes for Arizona Medicine, the journal of the Arizona Medical Association, and is treasurer of the U.S. Health Freedom Coalition.

Editor's Note: This article originally misattributed an estimate on the number of employed physicians to the American Medical Association. The estimate came from The New England Journal of Medicine.

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  1. But. Health care will be free and we’ll all be happy as Cubans on Castro’s birthday!

    1. ? Universal KOCH Industries pollution is profitable.
      ? Universal asthma is your fault.
      ? Universal birth defects are funny.
      ? Universal health care for the victims is horribly bad. OMG!

      If you’re a KOCHsucker.

      1. Trashes Kochsuckers on their own board yet gives free pass to warmongering $oros/Clinton/Obama 2012 machine.

        1. sorry, KOCHsucker, all city-Statists get the same

          1. Your advocacy of Tax Collecting makes you and agent of the Murdering Washington Horde.

            1. Oh, no, can’t do that. What a scary thought.

              1. Oh, scary thought! City-Statist Randroid can’t think of that.

            2. Oh, you don’t want that, city-Statist aggressor?

        2. Not that the truth has any real value to a Fibertarian.

          1. Since when are WarState Tax-Collecting agents concerned with truth?

      2. Agent of the Tax-Extracting WarState.

        1. ? Is any white person‘s right an individual or collective right?
          ? Is the right to take a negative or positive right?

          “[The Native Americans] didn’t have any rights to the land … Any white person who brought the element of civilization had the right to take over this continent.” ~Ayn Rand, US Military Academy at West Point, March 6, 1974

          1. A minute’s thought about the concept of what rights are would tell you that there is no such thing as a “collective right.”

            1. So ANY WHITE PERSON’s (collectively) right to take is an individual right, eh, Bill.

              You might give a minutes thought to what that city-Statist whore said.

      3. And the thread goes from zero to stupid in two posts.

        1. This is true. It is a real dilemma.

          I like sites like this where you can just post your comment.

          But, here is a good example of why moderated comments are sometimes needed.

          I think the best thing to do is just ignore posts like this. Don’t feed the trolls. Especially when they are as off topic as these are.

          1. and i’d love to see Like/Dislike selectons or “Agree/Disagree” voting, too… let alone “flag this shit as worthless,” too…

        2. Yep. Sigh…

      4. Ya know, I used to send links of these articles to my friends thinking they would find them interesting. While reading this one, I thought I might do so again. Then I started reading the comments. Fuck that.

        Most people spend a bit of time reading the comments after interesting articles. Once this troll gets started, everyone who posts a reply helps to bury the most thought provoking comments farther down, and nobody is going to spend much time reading beyond the retards who are flinging shit up front.

        Oftentimes the people I send these links to are on the fence about an issue, or have a polar opposite view, or have a really bad impression of Libertarianism. Once they read this shit, there’s no way to convince them that we’re not all a bunch of retards.

        1. I know. It just takes one asshole.

      5. I like it when you use “Koch” in the first sentence so I know to ignore your comment and scroll down to the next thread.

      6. do the world a favor and die. but do it in an enviromentally proper way. you will do your part in reducing both carbon emissions and stupidty, a double win. now hurry up, the world can’t wait.

      7. How are the treatments for your paranoia going?

    2. Welcome to Canada my friends.

      We win!

      1. Yeah, but the difference is that Canada isn’t flushing most of their money down the fucking toilet trying to be the Roman Empire 2.0!

        We’ll get it right this time cause we now KNOW that Cesar was killed because he just didn’t regulate, tax, and SPEND enough!

        1. We have nothing to flush anyway!

          1. Wait. Does that mean Americans will be crossing the Limes into Canada?

            Shit. Better learn to play hockey and lacrosse boys. It’s how we roll.

        2. no, they just come to the us when the choice is between dying while waiting for elective care or coming here and getting asap.

  2. Is that the first death panel? I kinda thought they’d be wearing black robes.

    1. death panels?

      u mean like in AZ where the state panel kicks transplant patients off medicare?

      1. No, I was thinking more Carousel.

      2. You didn’t get the memo?
        We are calling them “Life Panels” now.
        They decide who gets to live – no deaths involved.

        1. I was calling them Dearth Panels in the beginning.

        2. They should be called “Choice Panels” since they get to make the choices.

          1. or cut to the chase and call them Anyone-who-isn’t-a-democrat-wants-women-to-suffer-and-die….because any argument with them involving “choice” boils down to whether you hate women or not.

      3. I’d be very surprised to learn that a state panel could kick someone off of Medicare, which is the federal program for old people.

  3. FCCCER – pronounced fucker??? Sounds like they are named correctly for their mission.

    1. Yeah, wanted to post the same…

    2. Dammit! I was thinking the same thing when I read that, but you beat me to it.

    3. Who comes up with these things? Does nobody vet the ideas? Are their subconscious minds somehow compelling them to tell the truth?

      1. “Are their subconscious minds somehow compelling them to tell the truth?”

        I actually do think that is what it is.

        The rationing board in England is called NICE (National Institute for Health and Clinical Excellence). I don’t know why they dropped the “H” but the jokes just write themselves.

      2. My theory is that we who love freedom have unrecognized friends in high places who do a little here, a little there, to undermine the Progressives. Obama’s obviously cut and pasted up long form birth certificate and selective service card are good examples of someone leaving a trail to the truth from behind the scenes. For now, anyway.

  4. Any reason those doctors are wearing their coats, were they about to begin doctoring or something ?

    1. Argument by authority by clothing.

      1. Same thing.

        1. I always laugh a little when I seem a National Guardsman shopping around the local mall on a Friday night.

        2. Don’t have one. I prefer tattoos.

          1. A tattoo of a tie?

      2. Milgram experiment bears this out.

    2. Looks better than police uniforms.

      1. That’s the next PR stunt. The doctors are the carrot, the nightstick the stick.

    3. They were being good doctors, doing what the administration told them.


  5. I hope the Court does the right thing and strikes down the mandate and maybe the rest of the stupid law. It would be nice to actually reform the legal and policy framework for medical services and health insurance. With more market, less government, and fewer regulations.

    1. You mean doubling down on all of the aspects of the current system that make it so crappy won’t help??

      1. I know it’s crazy, but yeah.

  6. The medical profession must decide?and soon?which ethical doctrine to follow: Are doctors to be agents of their patients or agents of the state?

    Does he even think that’s a real question, which way doctors will go? Hint: it won’t be the with the patients.

    1. ^^ THIS. It’s a done deal.

        1. i love that joke…

          1. but i thought it was ‘Harold be thy name’

    2. Well, they are already mostly agents of the insurance companies, so I suppose it is an easy next step.

      1. A rare few may take the express elevator, but most journeys into the darkness are on a spiraling staircase made of many tiny steps. That’s why most everyone is always so shocked when they finally stop to take a look around and realize that they’re in Hell.

        Going from Big Insurance to Big Brother is just taking that next step downward.

    3. Doctors, as a group, are not particularly ethical or particularly brave. When the going gets tough, they consistently do whatever the State tells them to do. Then they rewrite their ethical standards so their successors won’t feel guilty about it the next time. They’re very thoughtful like that.

  7. ” If they achieve certain goals established by Medicare with respect to cost, length of hospital stay, re-admissions, or other “core measures,” they will get to share a portion of Medicare’s savings. If the reverse happens, they will face economic penalties.”

    Are any of these measures, you know, health of the patient? Because I bet I can meet the three measures outlined here (cost, length of hospital stay, re-admissions) and rake in a boatload- just let the patient die.

    Also, watch as some of these ACOs are widely successful in meeting the measures and make a huge profit. There will be calls to tax or otherwise take back their ‘windfalls.’

    1. Are any of these measures, you know, health of the patient?

      Health of the patient? You should just be glad they haven’t fired up the Soylent Green factories – yet.

      1. “Let me be clear, petroleum from algae is just the first step.”

    2. 1st hip replacement 3 wks in rehab no t problems since, 2nd hip replacement 1 yr ago booted out of rehab in 8 days; Medicare said I was fine. The past year pain, pain, pain.

  8. Are doctors to be agents of their patients or agents of the state?

    More importantly, when will we treat these moneygrubbing monopolistic rent-seekers with the disdain they so richly deserve?

    Until we treat doctors more like plumbers than like high priests, we won’t “fix’ the health care system.

    1. To be fair, there are some doctors who would prefer to have their profession be treated more like plumbers. I personally know two doctors who wish they could simply be paid for doing the job they did and not have to cut through the bureaucratic government jungle, the one has left the profession, the other one is considering it.

    2. I would love to be able to do something like this in my future practice. There are urgent care and primary care docs who have set up cash businesses. A 15 minute visit costs say $50 and a 30 minute visit costs $100 (I made these numbers up). The docs are able to cut out all the complexities and waiting associated with current billing practices. The cool part is they make just as much and get to spend more time with each patient. Unfortunately, this model doesn’t really lend itself to procedural specialties like mine.

    3. Frankly the dentists did it right. No money, no goods and service.

      Of course, they are not forced by EMTALA to treat anyone who comes along.

    4. PBrooks : you are definitely one of the lower branches of human intellect. When did physicians become lowered to the status of high priests? They are gods among men – the top 1% of intellectuals in the world. Physicians should be held far above others just for their hard work and especially for their integrity – compare them to lawyers or politicians and it is easy to see that discrepancy.

    5. try that with a plumber and see how far you get. come to think of it your paycheck needs a big downward adjustment.. it isn’t as if you seem to provide a valuable and needed service.

  9. i have a problem with your statement that more physicians will sell their practices to hospitals, then it being followed up by 50% are now hospital employees… this bill has nothing to do with the 50% of doctors now employed by hospitals as much as much as the reforms by nixon and reagan.

    1. matt|3.15.12 @ 2:02PM|#
      “this bill has nothing to do with the 50% of doctors now employed by hospitals as much as much as the reforms by nixon and reagan.”


  10. Most docs I know are pretty decent humans. The AMA is who needs to treated with disdain. As long as they have a monopolistic hold on the number of doc slots at med schools, the cost will never come down. Supply/demand trumps all.

    1. I am a physician.

      Yes, the AMA is corrupt and doesn’t represent most physicians.

      Until free market reforms restore power and responsibility to the patient as the paying customer, costs will continue to rise and care will decline. Giving the patient control over their health care dollars is THE only way to ensure quality and ethics in health care.

      1. Then it would be appreciated if those doctors would do something about the AMA. Even something as simple as a poster in the waiting room would be helpful.

    2. My doctor talks wistfully about some of his colleagues operating on a cash-only basis–no insurance.

  11. I wonder why Obama’s standing in front of the flag of a foreign nation. Weird.

    1. Yah, why’s standing in front of an American flag? Isn’t this the USSR?

      1. It’s pretty heinous to have the two in the same mile, let alone the same fucking picture. It sure as shit isn’t the flag of the nation Obama’s been wielding and building.

        1. This is probably more like it (from Suki earlier today):

    2. Isn’t that other one the great seal?

      1. Jest.

        1. I thought so, but you never know.

  12. What is the most cost-effective way of allocating a fixed amount of resources among a population of roughly 310 million people?

    Perhaps the same way a fixed amount of food, shoes, and computer monitors is allocated to a population of roughly 310 million people?

    1. …of allocating asthma and birth defects among a population of roughly 310 million people breathing KOCH Idustries (etal) pollution?

      1. there are fewer birth defects today then ever so I guess KOCHindustires is working for us

        1. Yup. And the air is a lot cleaner than it has been for a long time too.

          1. yeah, remember the river that was so polluted it would burn?

      2. Of course it goes without saying that not all industry is owned by KOCH. But then, you knew that didn’t you? Shitstain.

      3. its rather obvious that you are congenitally stupid. time to cull the herd.

  13. For example, when a pet owner government bureaucrat is told by a veterinarian doctor that the pet citizen has a very serious medical condition requiring extremely costly surgery or other therapy, the veterinarian doctor presents the pet’s owner government bureaucrat with one or more options?from attempt at cure, to palliation, to euthanasia?with the associated costs, and then follows the wishes of the owner government bureaucrat owner.

    1. I think it’s also worth pointing out that the vast majority of the time euthanasia is the cheapest option for pet owners, so it likely will be the cheapest option for our government bureaucrats malevelent overlords as well.

      But never fear, Sarah Palin’s a nutcase and all that “death panel” stuff is just rightwing fear-mongering.

      1. ? Is any white person‘s right an individual or collective right?
        ? Is the right to take a negative or positive right?

        “[The Native Americans] didn’t have any rights to the land … Any white person who brought the element of civilization had the right to take over this continent.”

        ~Ayn Rand, US Military Academy at West Point, March 6, 1974

        1. repetitive nonsense from an agent of the anti-PRIVacy surveillance state.

          1. True, but I do it for the love I get from you.

        2. I’m surprised that Ayn Rand hadn’t learned the distinction between a “right” and “power.” But then she came of age in the Soviet Union, where that distinction was probably never even considered.

          1. And christianity and fibertarianism and all the other faiths of the world are there to justify the aggression.

            1. Would that include whatever nutjob religion your non-gamboling fat fuck self belongs to?

              1. I’m curious, where does the Aztecs fit into Honky Injun’s insane view of Native Americans and civilized society?

                ‘Cause the “noble savages” down in Latin and South America were up to some bug fuck crazy that even the SPANIARDS thought was insane!

                Remember what one of the greatest franchise capitalists of all time once said about their morals?

                No good. I’ve known too many Spaniards!

                1. What are you, a shit-for-brain Fibertard, or what?

                  1. I’m a shit-for-brain ANARCHIST, Honky Injun!

                    You should pay more attention, Mrs. TRIBALIST, guys like me just wanna burn the world clean of ALL humans and that especially includes dumb fucks who cry about how all their problems are the fault of everybody else!

        3. Heil Commander BushBamaClinton, I will withhold care from your political enemies. Yes I will turn over their “PRIVate” medical histories. Because nothing is PRIVate in the NWO.

          1. Not that the truth has any real value to a Fibertarian.

            1. Ok, I admit a mistake.

            2. psychic thrill more important than dollar$.

        4. You must be confused as to think we give a shit what Ayn Rand said.

          1. ? Atlas Shrugged Part Two To Start Filming In April, Brian Doherty, February 2, 2012
            ? Special Edition Reason Atlas Shrugged DVD Now Available for Order!, September 23, 2011
            ? All Your Atlas Shrugged, Part I Coverage Right Here!, Nick Gillespie, April 19, 2011

            And isn’t Reason part of the The Atlas Economic Research Foundation, also known as the Atlas Network?

            The denials are so funny.

            1. Well, there is a bit of a distinction between recognizing that she had a few things to say worth noting and a few others that were simply bat-shit crazy.

              1. It’s like with the Bible, the decent Christians I know try to focus on things like “do unto others” and ignore the crazy like with “bastards born out of wedlock are forever forbidden from the church” (Deuteronomy 23:2).

                Like how plenty of people ignores the fact that the favorite past time of many young Native American males was to go over to the next village and casually engage in kidnap and rape when there weren’t enough squaws back home!

                Dig deep enough and EVERYTHING you love is completely fucked up!

                1. because that’s the way it happened

                  capitalism is founded on initiation of violence

                  to say otherwise is whitewash

                  1. funny, last time i checked i could still exchange dollars for stuff at Home Depot…

                    1. funny, last time i checked you still drove publicly funded roads to Home Depot…

                  2. Tribalists are just as good at being assholes as any Statist.

                    To say otherwise is to redwash.

            2. Your examples are three posts about a movie? God you’re an insufferable twat.

      2. Yeah. Total fear mongering.

        As if these decisions will be up to committees. There will be too many decisions to make committees take too much time to come to a consensus.

        No, these decisions will be made by teams of individual bureaucrats, not panels.

        1. The goal is that the decisions will be made by the ACO cabal of the payor, hospital, and “providers.”

          The government will say you can give any treatment you want. In capitation, it just comes out of the caregiver’s pay.

          Good docs who do more for patients get financially punished. Scumbags who screw over patients and don’t even present the more expensive options get rich. And CMS saves money while shifting blame to the caregivers who have zero training in assessing or managing population risk.

          Oh and did I mention there is no tort reform?

  14. “Effective this year, any patient readmitted to a hospital within 30 days of discharge for the same or a related problem will be treated by the hospital without compensation.”

    I don’t suppose that CMS has given a millisecond’s thought to the kind of incentives a policy like that will create in health care agencies. “Without compensation” doesn’t mean “free” no matter how many times President Obama says it; somebody will pay this cost. If it’s not going to be the health care providers, then they will find a way not to provide the care.

    1. What, a lemon law?

    2. So they’ll just make the person wait in the emergency room an extra day, which will of course tie up more emergency room resources. For those who may not be aware being admitted to the emergency room is separate from being admitted to the hospital.Once you leave emergency care you are then admitted to the hospital.

    3. They will also probably try to predict which types of patients will be repeat customers (read: ones with difficult to treat diseases) and then try to keep them from coming to their hospital in the first place (read: stop offering procedures/treatments for the difficult to treat disease).

    4. My mother had two ischemic attacks within 30 days (actually, it might have been a few days over 30) back in 2009. How the hell could the hospital have known she was going to have the second?

  15. I wouldn’t worry about this unless you’re a baby boomer. Then you’re f**ked. But then again, you’ve f**ked the rest of us, so we’ll call it even.

    1. The younger generations are gonna have an atomic fuck town of stress dealing with the boomers getting older but I also wonder how many problems will get solved by them just simply retiring and then dying off?

  16. Glenn Greenwald today quoted the liberal blogger Digby, who said something that I have long thought:

    The fact is that deep down, many Americans really want to be subjects.

    This is nowhere more true than when “social justice” and related positive rights start getting discussed.

    1. Deep down you NEED me to rule you like a KING!

  17. At this point in history, I do think a single payer government system would be better than this overregulated piece of corporatist crap called ObamaCare.

    1. Thats the goal, screw the present system up enough that people will be screaming for a single payer government system. I think it was their goal when Ted Kennedy introduce the HMO system.

    2. wait until the doctors unionize and go on strike..

  18. I suspect that as the level of financial compensation and prestige decreases in the medical profession, we will get different types of people becoming doctors. Basically, they will be drawn from the pool of people who currently become teachers, social workers, and regulators. They will be unionized and will have, at best, a love-hate relationship with their patients.

    We’re being shaken down, basically. The US public spends allot of other people’s money on health care, yet is overall unhealthy. So we will get the kind of crappy-but-cheap health care we really deserve.

  19. “Ten thousand people will turn 65 every day for the next 19 years”

    Medicare is the same Ponzi scheme as Social Security. Everybody knows medical costs are “skyrocketing” – that’s because 20 years ago the Baby Boomers were in their 30’s and 40’s and paying into an insurance system they didn’t use much. Now that the Baby Boomers are in their 50’s and 60’s, they need that money to pay for their heart attacks, strokes and cancer treatments. But nobody calculated future costs accurately.

    Last year, my 62 year-old bro had a heart attack, cost about $65k. 40 years ago, my mom had a heart attack, cost about $3500. The difference – my bro got triple bypass surgery and a week in the hospital. My mom got a box and a hole in the ground.

    There’s your equation. It’s going to cost a shitload of money to keep you alive someday – do you trust the government to take care of the finances for you?

    1. Well put.

    2. “-do you trust the government to take care…of…you?”

  20. This is really inevitable though when you have someone else paying for your healthcare (particularly the government).

    And yet, it seems like this is very unlikely to change.

    I wonder if a free market could really work though for seniors. Who would want to insure them? Maybe if it was just catestrohpic, with a super high deductible.

    I did read a pretty good analysis in the book “American Gridlock” which made the following excellent point. The only way we can really solve the cost problem is that if the supply curve increases faster than the demand curve.

    Too bad none of the solutions out there is really focusing on that.

    1. Kroneborge|3.15.12 @ 6:55PM|#
      “I wonder if a free market could really work though for seniors. Who would want to insure them? Maybe if it was just catestrohpic, with a super high deductible.”

      As a ‘senior’, I’ve had pre-tax coverage from several employers and after-tax coverage (when I was freelancing) for many years. Note I didn’t say the pre-tax was ‘paid for’ by the employer.
      Same coverage, same provider, same co-pay (mostly-some adjustments).
      No, it isn’t from a truly freed market, but yes, you can buy health insurance like you do auto insurance. It’d e cheaper if it was from a freed market.

    2. One way the supply curve is being addressed is promoting midlevels such as nurses, PA’s, physical therapists, and pharmacists to the title of doctor. Many of them are now giving out doctoral degrees in their area so that the midlevel can call themselves “doctor” without medical school/residency/board certification/etc.

      They are sometimes called noctors = not doctors.

      Yes I know this brings up the rent seeking argument… I bring this up only in the context of how the country will respond to demand needs. You will be seeing noctors as your main caregivers if you are not already.

      1. Yeah, but some of the meeting of demand has been in redefining what medicine needs or doesn’t need a doctor. I remember reading an article a while back in which a number of states were letting nurses do more procedures (that were minor in nature) since the average nurse now is MUCH more trained then they were when the rules governing their duties were originally written.

        I don’t have any examples to give you, though. I hate to be cliche, but is the a doctor in the house (to answer my question)?

    3. “I wonder if a free market could really work though for seniors. Who would want to insure them?”

      Businesses make a fortune in high-volume/low-margin markets every day.

  21. I don’t know that there is anything that can be done now. Lots of older people = ungodly medical bills. If they don’t have a couple hundred thou to pay the inevitable medical bills that come in the last few months or weeks or days or hours of life, they are either going to have to just die (which seems unconscionable) or somebody else is going to have to cough up the bucks. Obamacare is a mix – enter “quality of life” decisions made by third parties that say let them die if it costs too much to keep them alive, force young healthy people who have little need of health insurance to buy it anyway, (which money will be used to pay present older folks bills and then where does the money come from to pay the bills for the younger folks 30 years down the road?), and the inevitable Nanny State strangulation which will make you wish you were dead anyway.

  22. Getting rid of the AMA and half the medical laws might be a start though – they artificially restrict the supply of doctors and nurses and healthcare facilities and healthcare providers.

    For a lot of routine stuff, why not a nurse practitioner at Wal-mart?

    1. please, do you really want to give the lefties another reason to HATE on Wal-Mart?

      1. Like Wal-Mart will still be around in twenty years!

        Remember Montgomery Ward, Service Merchandise, Circuit City, Burdines, Zayre, Ames, and soon Sears/Kmart along with the indoor shopping mall?

        I did, however, hear that those first two were resurrected as online retailers.

    2. Or the methods used in Asia. You can go into a drug store and say look at my infected eye. 0 minutes waiting time. The pharmacist says “You need this”. $2.00. Or you can say “Give me 10 500 mg amoxicillin”. Reply- “Okay, $6.00”. How about 20 5 mg Valium? “$2.00, please”.

  23. From the Declaration of Independence:
    “He has erected a multitude of new offices, and sent hither swarms of officers to harass our people, and eat out their substance.”

    From the article:
    “In 2009, as part of the so-called stimulus bill, the Federal Commission for the Coordination of Comparative Effectiveness Research (FCCCER) was created. Its mission is to collect the data culled from all electronic health records and make recommendations regarding the comparative effectiveness of drugs, procedures, and therapies.”

    America, meet the FCCCERs.

  24. In the 1990s, I was the employment sponsor of a software engineer for green card purposes. He had been trained as a physician in Australia, but over there, the “profession” was “just a job,” with bosses, 9-5 shifts (in his case, 9am to 5am), and all the evils that Singer fears in his article. I was beginning to recognize the trajectory of our own health care industry at the time, and could see it leading right to the outcome, from which this fellow was attempting to escape.

    1. In my next job, I worked as a technical writer in medical informatics, and became very familiar with the parade of legislation, to which Singer refers, beginning with the HMO Act of decades past and the more recent HIPAA. Regarding the latter, I was struck by how the legislation purported to guarantee patient privacy — even to the disadvantage of the patient — against all comers EXCEPT the government, which would in many cases no longer need warrants to go through medical records. Subsequent legislation accelerated this questionable development. The government’s slow-motion takeover of health care (happening much more quickly today) has been horrific, like a train wreck you can see coming long before it happens: you are powerless to do anything but watch.

  25. (NOTE TO Reason: Please increase your comment length limit. “Continued” comments are just hokey. A 900 character slot almost never provides enough space to post reasoned commentary. If you want threads full of yahoos and spam, make the limits even LOWER! If you want thoughtful commentary, you need to accommodate, in a single message, at least 200-300 words of more than one syllable. I’ve been posting here for years and am about to quit due to this “dumbing down” mechanism. It wastes my time. Anyone who wants to skip my material can scroll right on past.)

    1. Reason Magazine… yes, J.A.M. is right.

    2. Mr. Merritt, I agree with your suggestion re: comment length restrictions. But please don’t quit posting here. I appreciate your well written comments and I’m sure others do too.


  27. Can’t we just get Dr. Kevorkian on the advisory board and skip all the intermediary drama?

    This is where it’s headed, after all…

  28. One alternative would be to return to a system where e pay for our own routine medical care out of pocket and carry truly catastrophic insurance. I don’t know why this isn’t getting more of a look.

  29. As a doctor isn’t the solution to this simply to not accept Medicare/Medicaid?

  30. Jeff: Another well written and brilliant article. Fairtaxer dittos.

  31. The Doctors for Patients vs Doctors of the State dichotomy is a false one. It assumes that the Doctors act in a way that patients, rather than insurance companies, dictate.

    Sorry, with Obamacare, we just traded one unaccountable bureaucracy (the Health Insurance Plutopoly/cartel) for another (Federal/State governments). The difference is that the latter has been demonstrated to provide health insurance more efficiently (95% Loss ratio for Medicare versus approximately 83% for private insurance).

    Now, if we actually were to decentralize the insurance market and decouple insurance from employment, that would be a different story.

  32. Answer to Tom: As a doctor in a specialty that sees TONS of elderly patients, all of whom are on medicare, non-acceptance of medicare is simply not an option. If I did that I might as well retire, and since I suspect that the government is on the verge of severely degrading our currency, this is not an option. The answer that NO-ONE, not even libertarians talk about is getting rid of government licensing of health care workers. Get rid of licensing and all your problems disappear.

    1. Teapartydoc,

      Thanks for the reply. So is this more a problem for certain specialties than others? Could a family practice doc, for example, make a go of it by not accepting medicare/medicaid?

  33. Moreover, the government in large part controls the “science’ and the studies that lead to the evidence-based guidelines. So whatever guideline they want, they can get the evidence to support it. It used to be we were skeptical of studies done by drug companies. not nearly as skeptical as I am now of anything done by the government.

  34. If we got rid of the 20 million plus …illegal leeches in every entitlement program the entire country would be better off..but then the Democrats wouldn’t stand a chance at another (tryanny) I mean Presidency.

  35. Dr Singer is right on the mark. I’m a pediatric eye surgeon specializing in procedures to repair vision deficits in cerebral palsy, autism and Down syndrome. The payment board will in the future deny these as wasteful expenditures on the Untermenschen. Like the 1000 year Reich it will brainwash the populace and the new generation of doctors, with the Institute of Medicine panels hand chosen to confirm regime policy. Nonbelievers will be punished, relegated to whispering in the catacombs.

  36. Dr. Singer is right on the mark with his comments. From the beginning of the campaign for Obamacare, it was obvious that it would be a “Mother, may I?” medical system, where everybody would go hat in hand to some federal bureaucrat and ask for permission to be healed.

    This takeover or collectivization of our medical industry is just exactly like Stalin’s collectivization of agriculture in the U.S.S.R. It’s vicious and totalitarian, and the main object is just control.

    Of course, in the U.S.S.R., all medical workers were state employees. And Soviet doctors barely made a living. Unlike our own past history, where doctors became prosperous commensurate with their years of training and the important job they did, doctors as mere pawns or functionaries of the state live a hand-to-mouth existence. That too will please all the left-wing power-trippers and wealth-bashers.

  37. In the future, lots of people are going to be denied the best of medical care. The question is.. Who plays GOD and decides. My vote is for someone who does not want the job.

  38. I just read an article yesterday commenting on how Naturpathic Doctors know how to heal people, more than 99% of the M.D.s, that practice medicine in this country. Dr. Singer, since you have a voice and an apparent following, why don’t you do something great for yourself, your patients, and your country! Stop complaining about the insurance companies and all of the corruption that goes with them, and instead, change the way medicine is conducted. Make a statement, stop taking insurance! Charge cash! Use alternative medicine! How can you ignore the fact that 67% of the U.S. is using alternative medicine with fantastic results. The market has so far, reached 37 billion a year, and going up. Are you aware that a good 80% of wht sends people to the emergency room, could be eliminated by the use of alternative medicine? If you only knew what alternative medicine is capable of.

  39. I am old enough to remember the time before Medicare. People bought health insurance against catastrophic illness/accident, but paid for meds and office visits out of pocket. Not as many high cost tests back then, and docs seemed to rely more on their training and experience to diagnose. After Medicare, costs seemed to sky rocket, maybe due to govt deep pockets?

  40. This is idiocy

  41. Thought-provoking article. Although he implies this is coming about because of the Affordable Care Act, that is not true. Medicare and the Insurance Companies have been pushing us this way for several years. And the treatment we receive today has little to do with the “good of the patient”. It has much more to do with “How much money is the doctor going to make”.

    As far as ACO and HMO’s, Kaiser Permanente is a great example of how this model can work. I’ve had Kaiser for 35 years, and have received excellent care. The failure of other HMO’s in the 1990’s was because the physician and hospital groups didn’t know what they were doing or how to do it right.

    The state of our medical system has nothing to do with Obamacare. The system has been broken for much longer than that.

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