health care

How Doctors Broke Health Care

And politicians made things even worse

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This article is part of a feature package on how the American Dream became unaffordable for millions of working-class and middle-class Americans. For more on Reason's autopsy of how things veered off track, read "How the American Dream Became Unaffordable" or the other two features in the package, "Student Loans Aren't Working" and "Can't Afford Your Rent? Blame Herbert Hoover."

If there's one thing that almost everyone in America can agree on, it's that the health care system is broken.

Nearly 18 percent of America's economy is devoted to spending on health care, far more than the share in any comparable country. And although the U.S. medical system provides some of the best health care in the world, it does so only for those who can afford it. Moreover, fragmented service delivery undercuts overall quality. A decade after passage of the Affordable Care Act (ACA), health care spending is still eating up government and household budgets, nearly 28 million Americans remain uninsured, and costs continue bounding upward.

It's no wonder that health care was the top priority for voters in the 2018 elections or that debates over how to fix it dominated the 2020 Democratic primaries. On one side of those debates were candidates such as former Vice President Joe Biden and former South Bend, Indiana, Mayor Pete Buttigieg, who want to alter the ACA by adding a public option. On the other side were candidates such as Sens. Bernie Sanders (I–Vt.) and Elizabeth Warren (D–Mass.), who favor scrapping the current system and replacing it with a single, government-run program they call Medicare for All. Meanwhile, the Trump administration has declined to defend the 2010 health care law in court and promised to replace it (though the president won't say with what).

These proposals misdiagnose what ails the U.S. health care system because they ignore its history. Too many of today's policy "solutions" build upon the faulty insurance company model that currently organizes U.S. health care—a model that was concocted by the American Medical Association (AMA) in the 1930s as a way to protect the professional status and earning power of its members. It resulted in care that is expensive, bureaucratic, and frustrating for both patients and caregivers.

Some versions of Medicare for All would eliminate private insurers. However, the resulting program, though free from corporate power, would retain the same organizational model, with a government agency assuming the role previously played by insurance companies. Bad institutional incentives would largely remain intact.

The history of health care—both before and after the introduction of the insurance company model—shows how aligning the economic incentives of doctors with the needs of patients can deliver health care that is cost-effective, widely available, and humane.

The health insurance model we know today came about after physicians' professional stature began to rise at the end of the 19th century.

With the discovery of germ theory, medicine and medical procedures such as surgeries became safer and more effective. Innovative treatments proliferated. Doctors capitalized on their enhanced cultural standing to convince state legislatures to either pass or strengthen licensing laws. Along with AMA-backed reforms that helped reduce the number of medical schools, licensing laws significantly limited the quantity of practicing doctors. Women, African Americans, and the working class were disproportionately excluded from the doctoring profession and consigned to lower-level medical positions, such as nursing.

With the supply of doctors restricted and the demand for increasingly effective medical services growing, health care prices rose. During the 1920s, an ailment that required a hospital stay could easily consume 10 percent of a family's annual income. Increasing prices only lightly constrained demand, since patients highly valued services that could either improve their quality of life or determine whether or not they lived. Still, families found it difficult to budget for health care because of the unpredictable nature of illness, both in occurrence and cost.

These developments inspired a variety of groups to come up with new ways to organize health care. For example, during the first decades of the 20th century, the nation had thousands of mutual aid societies, also known as lodges or fraternal orders. While some lodges—like the Order of Elks—originally restricted membership to native-born white males, immigrants and African Americans established their own societies. Immigrant organizations ranged from the Venetian Fraternal Union (serving Italian Americans) and the Independent Order of Vikings (serving Swedish Americans) to the First Serbian Benevolent Society and the Chinese Consolidated Benevolent Association. They functioned as social clubs, usually with distinctive uniforms and regalia. At the local lodge, bar, or church where they met, immigrants could speak their native language and share food from their home country. Fraternal orders also offered members, in return for regular dues payments, financial security products. Most supplied life insurance. Many contracted with physicians and hospitals to provide medical care.

African Americans created a massive network of these associations, some of which evolved into black-owned insurance companies and banks. One such society in Mississippi—the Order of Twelve Knights and Daughters of Tabor—constructed a hospital. Dues-paying members received burial insurance and up to 31 days of medical and surgical care.

Labor unions also furnished health care for members. In 1913, the International Ladies' Garment Workers' Union (ILGWU) founded a clinic in New York City. In exchange for a small fee, members—who also helped run the clinic—could access both medical and dental services. During the 1930s, the Transport Workers Union contracted with more than 50 doctors, including specialists, to provide members with care both in the doctor's office and in the hospital.

Businesses experimented with medical care provision as well. While factories hired doctors to run on-site clinics, "industrial medicine" flourished as a specialty. To stave off bad publicity for their employers, industrial physicians monitored the workplace for ways to prevent injury and disease. They also weeded out the chronically ill from job applicant pools. Some businesses contracted with outside medical providers. During the 1920s, the Endicott Johnson Corporation, a shoe manufacturer in upstate New York, spent about $22 annually for each worker and his or her family to access physician, hospital, and dental services.

Consumer cooperatives were another vehicle of delivery. In 1931, Dr. Michael Shadid established such an organization in Elk City, Oklahoma. For an initiation fee and annual payment, patients could access both physician and hospital services. Subscribers also elected a board of directors to operate the plan. During the Great Depression, Farm Security Administration officials helped farmers' organizations establish similar cooperatives around the country.

Nor were doctors passive participants in the health care sector's wave of organizational innovation. By the early 1930s, they had founded hundreds of prepaid physician groups, which delivered high-quality care in a cost-effective manner. Two features distinguished them from today's physician groups.

First, they were multispecialty. This format offered patients "one-stop shopping" for comprehensive care, ranging from general practice and surgical to obstetric and ophthalmological services. But integrated care offered more than convenience—it improved service quality. In today's health care system, patients with multiple conditions or difficult-to-diagnose illnesses often consult a variety of physician specialists in separate practices. Although general practitioners theoretically coordinate the patient's overall care, in reality, most physicians lack the time to confer regularly with colleagues outside their practice. In contrast, early prepaid groups had responsibility for the patient's entire health profile. These group doctors met regularly to discuss how to treat difficult cases. Patients received holistic care, while physicians had more opportunities for creative problem solving and for learning across medical specialties.

The second distinctive feature of these doctor groups was that they were "prepaid." In the early 20th century, prepaid care was synonymous with health insurance. Accordingly, the prepaid doctor group acted as its own financing or insurance unit. Individuals and families paid a set monthly fee in exchange for unlimited services. Physicians who worked for prepaid groups typically earned a salary plus a portion of the group's quarterly profits. These financing arrangements motivated physicians to both hold down costs and provide high-caliber care.

Examining how present-day financing systems incentivize physicians to behave illuminates the elegance of prepaid group arrangements. Rather than directly financing care themselves, today's doctors are usually compensated by third parties, either governments or outside insurers.

In health care systems around the world, one of two problems almost always occurs: Either medical providers ration care, or they practice "overutilization," a fancy term for the delivery of unnecessary and wasteful services and procedures.

Where physicians earn a set salary—as do British doctors or American physicians who work for closed-panel HMOs like Kaiser Permanente—a primary patient complaint is that care can be difficult to obtain. Doctors seem reluctant to greenlight treatments, because their employers encourage them to ration care and because more services and procedures mean more work without additional pay. Moreover, these arrangements often produce lower-quality care, though the degree of this problem depends on additional economic conditions, such as whether the financier is a government monopoly or a firm competing against other insurance companies. (Similar complaints arise when doctors receive set per-patient "capitation" fees.)

With fee-for-service systems, in which each discrete treatment or action results in a payment from the insurer to the doctor, overutilization and rising costs are always among the drawbacks. Currently in the U.S., most insurance companies reimburse doctors on this basis, thereby encouraging them to oversupply care. It's not that physicians are particularly malevolent. It's that they respond to financial incentives just as carpenters, mechanics, lawyers, and, yes, even professors and journalists do.

Imagine renting an office, purchasing equipment, hiring a bevy of administrators to keep up with mountains of government and insurance company paperwork, and working 10- to 12-hour days knowing you'll be paid only if you bring in enough money to cover both overhead expenses and your salary. If Medicare and insurance company reimbursements (less than half of doctors accept Medicaid patients) were not enough, might you be tempted to find additional revenues not by "running up the bill," as we might see it, but by "providing my patients with the same gold standard treatment that I'd want my own family members to receive"? Perhaps?

In contrast to current financing arrangements, prepaid physician groups aligned the doctor's pecuniary self-interest with the patient's desire for quality care. They carefully balanced resource expenditures between rationing and overutilization. Remember: Group physicians collectively assumed the financial risks associated with insuring patients against the costs of illness, and group doctor compensation derived from a portion of the organization's total profits. On one hand, if group doctors delivered poor-quality care or rationed services, they earned less. Patients who became sicker would consume additional resources, and dissatisfied customers would discourage new subscribers from joining. On the other hand, if group physicians supplied unnecessary services and procedures, they reduced their pay by frittering away group resources.

Because they offered reasonably priced insurance and excellent care, prepaid physician groups were popular with consumers. In 1929, Drs. Donald Ross and Clifford Loos started just such a group in Los Angeles. Members paid a monthly fee plus a small deductible at the time of service. Benefits were generous. The Ross-Loos plan offered prenatal and delivery care well before insurance companies would even consider covering such high-cost benefits. Within six years of its founding and during the Great Depression, the Ross-Loos practice grew to staff 50 doctors and serve approximately 40,000 patients. Most prepaid groups contracted with hospitals for admitting privileges. Because of its size, the Ross-Loos practice had its own pharmacy, laboratory, medical library, and ambulatory surgery facility.

Progressive political thought burgeoned at the end of the 19th century and continued to influence policy makers through the New Deal era—and progressive reformers admired prepaid doctor groups. Progressives not only had respect for but were practically obsessed with expertise, scholarly studies, statistics, and facts piled high. The Committee on the Costs of Medical Care (CCMC), which operated during the late 1920s and early 1930s, embodied this impulse. Academics, leading physicians, public health officials, political reformers, and scholars associated with nonprofit foundations studied a variety of health care models, ultimately recommending the propagation of prepaid doctor groups. Progressive CCMC members recognized the model's organizational efficiency and wished to position it at the core of a government-financed health care system.

Today's progressives might protest, asserting that they too believe in expertise; after all, most academics stand among their ranks. But today's health care debates, rather than addressing fundamental economic and organizational issues, unfold largely as morality tales, pitting "good guys" against "bad guys." (Note that the "bad guys" in this telling—policy makers who either oppose reform or are proposing minor repairs—also fail to recognize the health care system's structural frailties.) Some contemporary reformers underscore the administrative savings they believe will result from the centralized management of health care. Others offer budget forecasts that, like the Knights of the Round Table, are notoriously fictitious. But what's missing are discussions of how to configure institutions and structure provider and patient incentives to ensure accessibility, quality, and cost-effectiveness.

So what happened to prepaid doctor groups and the health care models sponsored by mutual aid societies, unions, businesses, and consumer cooperatives? In sum, AMA leaders captured and reconfigured the market to serve their own ends.

Through the first decades of the 20th century, the American Medical Association marshaled its considerable power to shut down and halt the spread of "alternative" health care organizations. Physician leaders believed they threatened their professional autonomy and pay. Worried about interference in "their" sphere of medicine, AMA officials even opposed health insurance because it allowed groups external to the doctor-patient relationship to finance care. They also feared that physician groups would develop into corporations that would commercialize health care and produce "supermarket medicine."

Accordingly, AMA leaders waged war against physicians who contracted with or worked for "third parties," whether mutual aid societies or doctor groups. Since AMA members controlled state licensing boards during this period, they could revoke the medical licenses of transgressing doctors. For example, AMA officials warned physicians that working for Shadid's cooperative would jeopardize their medical licenses. Organized physicians also exercised a great deal of control over hospitals, and they frequently persuaded administrators to rescind the admitting privileges of doctors who ran afoul of AMA preferences.

Additionally, medical societies often expelled members who worked with third parties. The L.A. County Medical Association, a constituent AMA society, dismissed Drs. Ross and Loos. Physicians who lacked medical society membership had difficulty obtaining malpractice insurance, ostensibly because they lacked colleagues to testify on their behalf.

Although AMA leaders had great success suppressing the health care market's organizational evolution, their feat only amplified calls for government funding to increase access to services. As policy makers experimented with programs to improve economic conditions during the Great Depression, health care was a leading reform target. Committee on Economic Security (CES) members, who laid the cornerstone of the American welfare state with the 1935 Social Security Act, initially hoped to include government-financed medical care in the legislation. President Franklin Roosevelt—savvy politician that he was—rejected their plan, understanding that hundreds of AMA medical societies could lobby congressional members to sink the entire bill. But his administration continued to eye health care reform, and at the end of the decade it held a national conference to spotlight the issue.

Unable to fight a two-front conflict—on one side against competitive markets, and on the other side against government-financed medicine—AMA leaders concocted a new strategy. In 1938, they finally endorsed health insurance. Yet they continued battling the insurance models that the market had already produced, such as prepaid benefits delivered through consumer cooperatives and doctor groups. Instead, AMA leaders designed their own, very particular insurance model. They then promoted their specific model under the banner of the "voluntary" market—that is, the alternative to government programming, which they cast as communism.

The AMA's brainchild—the insurance company model that organizes our health care system today—permitted only one type of third party to finance medical services: insurance companies, not mutual aid societies, unions, or even doctor groups. The association's leaders instructed insurance companies to fund individual physicians rather than group practices and to reimburse physicians on a fee-for-service basis—a payment method that, as discussed, guaranteed overutilization and escalating costs. (Initially, physicians even set their own compensation fees, until insurers implemented standardized fee schedules between the 1950s and 1970s.) AMA parameters also required complete physician autonomy, free from insurer supervision.

Recognizing that it would drive up health care prices, insurance executives were wary of the AMA's proposed model. Insurers had little desire to finance services if they could not control, supervise, or even forecast the supply of those services. But they gave in to AMA wishes because they wanted to combat nationalized medicine and because their business clients—to whom they sold life insurance and pension products for workers—had been clamoring for employee health insurance. Federal tax guidelines granted employers a hefty tax break for providing workers with fringe benefits beyond monetary compensation. Plus, employer-provided health insurance weakened labor organizing by making businesses, not unions, the stewards of workers' financial security.

Though mistrustful of one another, physicians and insurers joined together to hurriedly develop the health care sector around the insurance company model. AMA officials and insurance executives continually and forcefully argued that government provision of health care was unnecessary because the "voluntary" insurance sector was thriving. Quite remarkably, they grew coverage quickly enough not only to rebuff Harry Truman's plan for universal health care but also to defeat moderate reform proposals proffered by President Dwight Eisenhower and a variety of bipartisan congressional alliances. Between 1945 and 1965, the share of the populace covered by health insurance increased from approximately one-quarter to 80 percent.

Predictably, under the insurance company model, health care costs shot upward in tandem with expanding coverage rates. Physicians and insurers responded by building institutions to manage their financing relationship.

Although physicians adamantly resisted insurance company regulation, AMA officials begrudgingly relented in response to the negative publicity surrounding medical costs. A 1950s Blue Cross study revealed that approximately 30 percent of hospital admissions were unwarranted. Hospitalization allowed doctors to deliver patients more tests and procedures than were available in a physician's office. During the same decade, the press uncovered a trend of unnecessary surgeries. Pathologists discovered, for example, that in some hospitals more than half the appendectomies performed were unneeded. Although overt fraud was worrisome, insurers were more concerned with small accretions of overutilization, both inside and outside the hospital. Such services were difficult to detect but, when aggregated, pushed insurance prices significantly higher.

Insurers responded by instituting cost containment measures. Gradually, over the course of decades, they gained the power to supervise doctors and influence how medicine is practiced. During the 1950s, they began carefully monitoring physician services through medical forms. By the 1960s, physicians often needed to obtain insurance company permission to admit patients to hospitals. Insurers also worked with medical societies and hospitals to establish utilization review committees, which examined whether physician services properly matched the patient's diagnosis. Insurers collected data from these committees to create standardized treatment blueprints: In return for compensation, doctors had to accept insurance company instructions on patient care. Despite these cost-containment efforts, health care expenditures, as a percentage of our nation's GDP, have grown each decade since the 1950s.

Though health care reformers had long attempted to dislodge the insurance company model, they surrendered that fight by the 1960s. As Social Security Administration officials and their allies developed a plan for government-provided retiree health care, they realized that they had to construct the program around the institutions that were already being used to manage service financing and delivery. They therefore designed Medicare to incorporate the insurance company model. Policy makers also appointed insurance companies to administer Medicare by acting as intermediaries between federal officials and service providers—doctors and hospitals.

The ACA also adopted the insurance company model. Although progressive legislators attempted to subvert the model with the "public option"—a government-run insurance plan that would operate alongside today's private insurance—that provision was ultimately defeated. And the public option, as proposed in today's health care debates, is unlikely to undermine the insurance company model to the same degree as initially projected, because state exchanges have not appropriated as much of the health care system as policy makers and analysts originally planned.

This checkered history helps explain the frustrating state of the U.S. health care system today. It shows why care is fragmented and costs are high—the highest in the world as a percentage of GDP. And it demonstrates that the country's health care system, including the so-called "private sector," is not based on the evolution of competitive markets. Instead, the model sprang from the minds of physician leaders seeking to safeguard their professional status and earning power. Ironically, the arrangements they designed have developed in a way that undermines those very goals. Today's system is largely controlled, in a top-down manner, by insurance companies.

Finally, this account reveals how our current health care debates are neglecting the most vital aspects of reform. To fix our system—that is, to provide better care while getting rid of unending and unsustainable cost increases—we must consider how to structure institutions to operate effectively without Washington bureaucrats supervising and controlling medical care. Insurers can tell them that such an approach to cost containment is futile. And cost control purely through budget constraints, without attention to institutional incentives, will only lead to rationing.

Direct Primary Care (DPC) physicians are beginning to reclaim their heritage by approximating the prepaid doctor groups of the early 20th century. Seen as a low-cost alternative to concierge care, DPC groups accept monthly membership fees in lieu of insurance. In return, they provide patients with extended physician visits, lab and diagnostic tests, and—in states where doctor groups are permitted to purchase drugs at wholesale costs—reduced-priced prescription medications. They have had excellent success in terms of cost containment and care advancements, such as increased doctor-patient communication through phone and email conversations.

DPC promoters often speak of physicians' desire to escape the "eight-minute consultation" and the burdensome volume of insurance regulations and paperwork. The American Academy of Family Physicians even sells a "DPC Toolkit."

However, these groups are single-specialty, revolving around general practitioners. If they do develop into multispecialty practices that deliver comprehensive care, they'll have to negotiate with hospitals for patient admissions and facility usage. And that process will take some time to evolve.

One can envision the innovations that might ensue under such a system. Imagine doctor groups catering to elderly patients with appointment pickup vans or offering free nutrition classes for diabetic and overweight patients.

DPC is neither a silver bullet nor the only way to reform health care. But the model does demonstrate that reformers must look at the health care system's economic structure to understand how all actors—physicians, hospital administrators, patients, and third-party financiers—are incentivized to behave.

In many ways, that would represent a return to traditional progressive ideals, from the institutional efficiency that reformers promoted in the early 1900s to the participatory democracy—or empowering of local communities—they advocated in the 1960s. As we debate how to make health care more accessible and affordable, we should emphasize institutions that can evolve on the ground, in response not to special interest groups or to federal officials but to the unique needs of patients. From the elderly Latino couple in San Antonio dealing with the effects of aging to the young black woman suffering from breast cancer in New York City, it's the patients with the least economic and political power who will bear the brunt of our health care system's failings—whether their care be costly and difficult to afford or inexpensive but rationed.

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  1. “spent about $22 annually for each worker and his or her family to access physician, hospital, and dental services”

    After selling our souls to the [WE] foundation (because you don’t own you [WE] do); that bill is now at least $8400!!!!

    The inflation calculator says $22 in 1920 is $284 today.. So the obsessive [WE] progressive plans tacked on $8,116 or 28-TIMES the price it could be!!!

    “But if we just add on a more progressive plan it’ll all be okay”, they keep spouting endlessly….

    1. “The inflation calculator says $22 in 1920 is $284 today.”

      That’s a little bit more than I spend per year, and I am uninsured

  2. Direct Primary Care (DPC) physicians are beginning to reclaim their heritage by approximating the prepaid doctor groups of the early 20th century. Seen as a low-cost alternative to concierge care, DPC groups accept monthly membership fees in lieu of insurance. In return, they provide patients with extended physician visits, lab and diagnostic tests, and—in states where doctor groups are permitted to purchase drugs at wholesale costs—reduced-priced prescription medications. They have had excellent success in terms of cost containment and care advancements, such as increased doctor-patient communication through phone and email conversations.

    Isn’t this really an argument for the Kaiser Permanente model?

    1. This article is very confused on that point. It lauds pre-paid as providing “unlimited” services, then says Kaiser rations health care.

      As far as patients are concerned, all insurance-coverage is prepaid. The minor co-pays are too small to matter.

      1. The article is confused on a lot of points. The idea that prepaid plans magically “aligned the doctor’s pecuniary self-interest with the patient’s desire for quality care” is counterintuitive and uncited. And although it’s anecdotal, I’ve been with Kaiser for 10 years, and a number of my friends have been there longer, through a myriad of ailments both big and small. and we’ve never had an issue with rationing.

      2. You are misunderstanding the article. While it’s true that from the patient’s perspective, insurance coverage is the same as prepaid, from the doctor’s perspective, it is not. Prepaid gives the doctor an incentive to control costs. Insurance gives the doctor an incentive to “bill to the limits” and see what happens.

        The other point, which I concede the article does not make clearly, is that insurance creates an incentive to consolidation to a single standard of care. (Personally, I think Medicare/Medicaid drove that standardization but the how is not important here.) The prepaid programs were more diverse so customers did have an incentive to control their own costs as they were choosing which prepaid program to sign up for. Would they stay diverse? I don’t know. I’d like to give it a try.

        1. ” Prepaid gives the doctor an incentive to control costs. Insurance gives the doctor an incentive to “bill to the limits” and see what happens.”

          Precisely. Search for DPC on youtube or go to https://d4pcfoundation.org and read up on Direct Primary Care. Doctors love it because it gives them a steady income and patients love it because they know exactly what they are going to get for a fixed monthly fee. Costs are down considerably. I have heard 15-30% because the doctor no longer needs staff to process Medicare or private insurance claims. He gets more time with patients and offers patients at-cost lab tests and sometimes medication. All in all it seems to be working except for where the government is trying to restrict DPC from Health Care Savings plans and more.

  3. If doctors broke health care, it must be because too many doctors were born in the country in which they practice. The Koch / Reason solution, of course, is to allow an unlimited number of immigrant doctors to relocate to the US.

    #ImmigrationAboveAll
    #OpenBordersWillFixEverything

    1. C-

    2. Wait, you are actually opposed to bringing more doctors into this country? The fuck?

      1. yeah i dunno if you realized but the weirdo who religiously posts xenophobic, stupid bullshit in every single article’s comment section is a huge dumb racist. i can’t believe it either

    3. Nice shoehorn.

  4. Individuals and families paid a set monthly fee in exchange for unlimited services.

    A little hyperbole never hurt. In reality, reality did provide both hard limits (medicine was pretty primitive back then) and soft limits (I doubt any of these services included long long hospital stays which, say, Rockefeller would have gotten). Just as this later quote shows:

    Doctors seem reluctant to greenlight treatments, because their employers encourage them to ration care and because more services and procedures mean more work without additional pay.

    That whole section is pretty bizarre. On the one hand, it thinks the early mutual aid and other pre-paid health services were great ways to provide good cheap medical care because the doctors all had plenty of time to hobnob and talk with each other about ongoing concerns; on the other hand, it thinks Kaiser and other pre-paid plans (“Where physicians earn a set salary”) ration medical care too severely. Earning a salary is pretty much the definition of pre-paid.

    And then again later, we get this:

    In contrast to current financing arrangements, prepaid physician groups aligned the doctor’s pecuniary self-interest with the patient’s desire for quality care. They carefully balanced resource expenditures between rationing and overutilization. Remember: Group physicians collectively assumed the financial risks associated with insuring patients against the costs of illness, and group doctor compensation derived from a portion of the organization’s total profits.

    Which is Kaiser — prepaid!

    It then complains that post-paid insurance plans encourage too much service because doctors work long days to generate enough income, as if all these doctors do is pile on treatments to get more reimbursement, as if the insurance companies are blind idiots who pay anything. And then says that people these patients complain of too much rationing!

    Conflating way too many things in way too many ways. I’m not at all sure what the point is for all this.

    1. The association’s leaders instructed insurance companies to fund individual physicians rather than group practices and to reimburse physicians on a fee-for-service basis—a payment method that, as discussed, guaranteed overutilization and escalating costs.

      This just gets sillier and sillier. Just about all other market transactions are fee-for-service. You buy groceries this way, clothes, all your retail needs. No one has a contract with Target to pre-pay once a year for everything you might want in the coming year.

      He’s right about the AMA and government fucking things up, but his reasons are complete bullshit. What makes medical care expensive is the same thing that makes NYC apartments expensive — price controls. Whether they be AMA with government backing, or directly from the government, there is your root cause. Occupational licensing by the AMA and government is just another form of price control.

      Everything scarce is rationed, whether it’s prepaid and rationed after payment, or rationed directly by price before service. That’s the first rule of economics. The AMA and government’s first rule is to ignore economics.

      1. This guy gets it.

    2. Note in particular that all his complaints about the AMA neglect to mention that all this AMA monopolization was only possible with the connivance of government. The AMA did not restrict doctors; governments did, in the usual crony fashion — in cahoots with the AMA.

      This article is really confused. The history is nice and matches everything else I have read on mutual aid societies, doctors’ groups, etc. But he goes off into the weeds all over, and it really shows when he can’t figure out that Kaiser is a pre-paid service just like the mutual aid societies, and when he thinks mutual aid society health care was “unlimited”.

      1. And it’s not just the AMA – every professional standards-setting organization acts as a guild to limit competition with a government-granted monopoly to set the standards. It’s been interesting to watch the legal fights over the copyright issue in the laws – most states, for example, incorporate-by-mention the National Electric Code but good luck demanding your right to know what the law is when the NFPA holds the copyright, charges $195 per copy, and makes sure it “updates” the thing every damn year so you’re going to have to pay them every year to know what the new law is. Basically, you’ve got private organizations of “experts” creating the laws “for the public good” and their interests are directly contrary to the public’s.

      2. It is my understanding that the majority of Medical Doctors do NOT belong to the AMA — that the AMA gets its money (and power) from the copyrighted list of billing codes which all MDs must use in order to bill Medicare.

        I think that’s an important point to make on both levels — not only is the government in cahoots with the AMA, but the AMA only has political power because of it’s monopoly on something that ought to be in the public domain.

        1. The AIA does the same thing.

          Lots of banks and lending firms require owners to use the AIA contract documents. Even if the owner and architect or owner and contractor agree on a mutually beneficial self written contract.

          None of the architects I know are members and just pay for the contracts piece meal.

    3. In terms of salaried doctors rationing care: I would have argued more directly that it’s a lot easier to ration care in a public system because putting the government in between doctors and patients insulates the doctors from the patients.

      Indirectly: a doctor in a mutual aid society doesn’t earn a salary, but whatever is left after expenses, so they directly balance consumer satisfaction with earnings. Medicare for All doctors can essentially unionize to do as little work as possible with an employer that has historically low employee termination rate and low expectations of functional employees to begin with. The results seem predictable.

      1. Medicare, medicaid, regulation of med students, doctors and hospitals have all directly led to less doctors in the USA.

        There is no reason that we could not have enough doctors to one in every Walmart and able to make a business with house calls.

    4. “Conflating way too many things in way too many ways. I’m not at all sure what the point is for all this.”

      The point is to distract you from your natural urge to look at every other first-world country in the world which has the Big Bad Government handle healthcare and see how they achieve the same or better results as us while spending 20% of the money. Anything but Single Payer.

      It requires a lot of verbal jujitsu and intellectual dishonesty, but why else do you read Reason???

  5. A free market can’t work in healthcare because everyone needs medicine and you can’t shop doctors and prices in the back of an ambulance.

    When was the last time you shopped for a medical professional? Yeah, didn’t think so.

    1. Idiot.

      A free market can’t work in car care because everyone needs repairs and you can’t shop shops and prices in the back of a tow truck.

      When was the last time you shopped for an emergency tow after a fender bender? Yeah, didn’t think so.

      1. You’re the idiot. If free market healthcare is so great, then why isn’t healthcare the best in Somalia?

        1. If free market consumer goods are so great, why are there so few Walmarts in Somalia?

          If there were a free market in medical care, you’d be able to get your healthcare at Walmart. The reason you’re not comparison-shopping from the back of an ambulance is because there’s a good chance your only option for healthcare is take it or leave it because there’s only one monopoly hospital in the area and if your insurance company is covering the cost who gives a shit what it costs? If your insurance covered the cost of food, would you give a shit about the price of ribeye steaks? ?

        2. What he said.

          You aren’t differentiating planned and unplanned procedures. You buy car insurance for unplanned problems — like tows after a fender bender. You buy health insurance for unplanned problems — like an ambulance ride. In a freed market, if you pay a doctor for an annual physical and he says you need a blood test, you are free to shop around. If the blood test suggests further testing is needed, you shop around. If you need an operation and have time, you shop around. If it’s an emergency and you are unconscious, you have insurance.

          1. Golly. And that model is exactly why the US is a clusterfuck in an epidemic like this. You can’t have a public health system where there is direct billing/payment precisely because you can’t then trace and test contacts of positives. And you can’t do preventive either because the ‘systemic rewards’ of preventive are many years down the road and direct pay means limiting access to precisely that care on the basis of out-of-pocket.

            ‘Libertarians’ are utterly useless in understanding medical care. No it ain’t like tummy tucks. And no it ain’t like fucking car insurance

            1. Honest question – what does method of billing/payment have to do with contract tracing? And why couldn’t you have preventative care if there was demand for it from patients/consumers?

              1. Because there’s a big difference between someone knocking on your door saying:

                Person X you know tested positive for some dread disease. They told us they recently met with you. Would you like to be tested to see if you have this disease too?

                vs same plus – it will cost you a few hundred dollars. Oh – and if your positive you will have to pay for your own quarantine too. Oh – you don’t have paid sick leave – well tough shit for that too.

                The latter immediately makes one wonder if the whole thing is a scam to sell something. Of course there is going to be resistance – which means tracing is quite pointless.

                Preventive only works with direct billing if the person themselves actually saves money on that future ill-health. Even then, not very well because people aren’t very good at comparing a current cost and a future probability of saving money. But those future events are precisely the sorts of expenses that are insured not direct paid. So there is no future saving to the person – only a cost today. Other than that – what the upper income is really buying with preventive is social acceptance not disease prevention. Their peer group doesn’t smoke anymore so they need to stop smoking or they wont get invited to the right parties at the right homes anymore. Can you help me doc?

                Preventive has a second serious problem in the US since everything is year-by-year here rather than any remote ‘lifecycle’ cost at all. But that technically is a different problem.

                1. “Preventive only works with direct billing if the person themselves actually saves money on that future ill-health.”
                  “Testing” is not “preventive care”, so quit conflating the two. And yes, any supposed savings from “preventive care” are the fantasies of lefty ‘free-shit’ idiots. It has NEVER been shown to reduce medical care costs in general.

                  “Preventive has a second serious problem in the US since everything is year-by-year here rather than any remote ‘lifecycle’ cost at all. But that technically is a different problem”
                  WIH is that supposed to mean?

                2. Why are you assuming that testing for a rare but deadly disease would not be covered under insurance? My insurance company is already waiving fees for a lot of COVID-related services. And what quarantine costs are there? You are staying home. Yeah, there is opportunity cost if you don’t have sick leave or vacation time, but that’s not a health insurance problem, so don’t conflate them.

                  If you really are convinced that a free market in healthcare can’t work in a disease pandemic, then propose government solutions to deal with that once a few decades occurrence. Leave the market to handle the 99% of things that it can.

            2. So much bullshit packed in such a short post:

              “Golly. And that model is exactly why the US is a clusterfuck in an epidemic like this. You can’t have a public health system where there is direct billing/payment precisely because you can’t then trace and test contacts of positives. And you can’t do preventive either because the ‘systemic rewards’ of preventive are many years down the road and direct pay means limiting access to precisely that care on the basis of out-of-pocket.”
              So all those places with ‘free’ medical care are the models? Or are you just admitting that your fave solution cannot exist under any know financial arrangement?

              “‘Libertarians’ are utterly useless in understanding medical care. No it ain’t like tummy tucks. And no it ain’t like fucking car insurance.”
              Fucking lefty ignoramuses have proven them selves to be every bit as valuable as tits on a bull, fucking lefty ignoramus.

            3. If the U.S. is a clusterfuck in the WuFlu situation, what do you call Spain (with socialized medicine)?

        3. Maybe Somalia does have those things. Go there and report back on what the state of the free market is.

          Nothing like Somalia being a failed Socialist state.

        4. Did you really attempt that analogy? Healthcare in Somalia might be hampered a bit by the lack of a functioning society, and massive poverty compounded by marauding violent warlords.

          FFS……….

        5. Hahaha, damn that is an oldie but a goodie. I haven’t seen a Somalia post since the last time I bothered reading anything on Reddit.

          Thanks for the laugh.

          1. You know, you guys could at least check some facts about the healthcare in Somalia, before just assuming it is in dismal shape because there is no central government. From wiki:

            Maternal mortality per 100,000 births fell from 1,600 in the pre-war 1985–1990 half-decade to 850 in the 2015.[10][17][18] The number of physicians per 100,000 people also rose from 3.4 to 4 over the same timeframe,[10][14] as did the percentage of the population with access to sanitation services, which increased from 18% to 26%

            Yeah, turns out they are doing all right.

            1. *compared to what they had with a central government

            2. “You know, you guys could at least check some facts about the healthcare in Somalia, before just assuming it is in dismal shape because there is no central government.”

              No one was assuming that; it was a sarcastic response to ANY “Somalia” reference.

              1. Look at Sevo with the John-like powers of knowing what everyone was thinking.

                1. Look at asshole making assumptions about what people are thinking and getting called on his bullshit.
                  I’m sure you ARE this dense.

                2. It’s called “reading”

    2. You contract with doctors and medical facilities based on your needs BEFORE you ever need them.

      I know which hospital that I am going to with an alternate, based on costs and services provided. I pay cash for most medical stuff and have catastrophic insurance for heart attacks and cancer and major stuff that can costs hundreds of thousands.

      Dont ever let Lefties try to force government medical just because many Americans were never taught about history where Americans paid cash for medical services.

      1. We can’t tell poor people and people with pre-e siting conditions to just go ahead and die, you asshole.

        1. No one here is suggesting that. Only 2% of healthcare spending is on ER visits. We are taking snot bringing down the cost of the remaining 98%. You may very well need a different solution for some emergency situations (but that doesn’t mean it has to be a government solution).

          https://www.politifact.com/factchecks/2013/oct/28/nick-gillespie/does-emergency-care-account-just-2-percent-all-hea/

          That number might be a little dated but the point stands.

          1. It’s been suggested here. The Man up, and die crowd is still around. You can google it.

            1. They are out there. And when you look at what corona virus is doing: more people have it here than anywhere else in the world, especially countries that have socialized medicine, like Europe.

              They literally want people to die in pandemics just for insurance executive profits.

              1. This is so stupid, I don’t even know where to start.

              2. Just an FYI, the US has more ICU/CCU beds and ventilators than almost any other country in the world (ventilator count depends on whether you consider those currently in service or include those that are a bit older but could be brought into service in ~a week).

                https://en.m.wikipedia.org/wiki/List_of_countries_by_hospital_beds

                Look at the columns for ICU/CCU beds and ventilators. The US is much farther down the list in terms of total hospital beds per capita.

                There could be many reasons for this. But it definitely is *not* true that having some element of profit in our system (distorted as it may be) has left us with fewer critical care resources than other developed countries with even more government involvement in their health care systems.

                1. Sorry, I should have made clear that we have more *per capita*. Raw numbers are not that enlightening here.

                2. Our large number of ICU beds is significantly because of pediatric/neonatal. Those are 30% of the total ICU beds here. We have a uniquely ‘heroic’ mindset re neonatal in particular. It’s one reason our infant mortality rates are high – where other countries have higher ‘stillborn’ rates. We put those deaths in a different pigeonhole.

                  That said – yeah even with that downward adjustment – that particular element of our system will put us in better shape than most countries. OTOH, the money that was spent on that was also part of the spending on other big ticket equipment (like MRI/etc) where there is no surge (or even capacity – outside the few really cheap bureaucratic oddballs like UK) issue. The decision here has always been framed as spend/reinvest profits v reserve profits. Our system always tilts to spend because there is no benefit to reserving profits to lower costs of care next year.

                  Except for adult ICU and ventilators, most of the other capital equipment is near useless for this epidemic – but it will still be added to the costs. And the money that could have been reserved to pay for say PPE is not available cuz it was already used to pay for the now empty photon radiation center.

                  1. Except for adult ICU and ventilators, most of the other capital equipment is near useless for this epidemic

                    And that’s totally ok. It’s not like our entire healthcare system should be geared towards being able to respond to a once every few decades respiratory disease pandemic.

                    I don’t say that to defend the existing system or overall response to COVID. It’s just a fact that no feasible system is going to just carry around the spare capacity to handle what are seeing now. The best system would be able to produce the extra equipment on relatively short notice when it’s needed.

                    1. Agree that the capacity for everything already in place is a waste. That sort of excess capacity is eg one reason why MRI’s are so expensive in the US. Have to spread the fixed capital costs over fewer uses per machine per year.

                      But there is a point in reserving rather than investing. We used to call it saving for a rainy day – and it used to provide flexibility rather than institutional brittleness

                    2. “Agree that the capacity for everything already in place is a waste. That sort of excess capacity is eg one reason why MRI’s are so expensive in the US. Have to spread the fixed capital costs over fewer uses per machine per year.”
                      So an increase in the supply of a good means the cost of using that good is increased?
                      There are times you post such crap I actually believe I must be missing the point, but every time your steaming pile of shit gets parsed, well, it turns out to be a steaming pile of shit.

                      “But there is a point in reserving rather than investing. We used to call it saving for a rainy day – and it used to provide flexibility rather than institutional brittleness.”
                      Concern troll spreading more bullshit.

                    3. Your point is illustrated by the video going around of Bill Gates five years ago warning us to start preparing for a pandemic. Everyone’s saying “If only we had listened.” But if you focus on the four things he said we should do, only one – spend a lot on R&D for treatments and vaccines – would be useful today (and we’ve done a lot of spending on this, in the private sector). But nowhere in his recommendations was there a call for massive spending on a stockpile of health facilities and equipment. It’s really difficult to know how to prepare for such rarities.

                    4. Nor is there a reason to do so because a well-off retiree or a lame lefty piece of shit suggests we do so.
                      Yes, if you live in tornado country, you have a cellar. In earthquake country, you have water.
                      We’re all to do what, EXACTLY, as preparation for what, EXACTLY?
                      They both are nothing other than chicken littles with nothing to offer to protect us from that falling sky.
                      Just ‘we should do something!!!’.

                  2. “OTOH, the money that was spent on that was also part of the spending on other big ticket equipment (like MRI/etc) where there is no surge (or even capacity – outside the few really cheap bureaucratic oddballs like UK) issue. The decision here has always been framed as spend/reinvest profits v reserve profits. Our system always tilts to spend because there is no benefit to reserving profits to lower costs of care next year.”

                    Were you born this ignorant of business finance, or did it take long years of practice?
                    Hint: There never is a benefit to ‘reserving profits to lower customer costs next year’. Never and nowhere.

                    1. Congrats you have just explained why both ‘non-profit’ hospitals and universities respond to stable revenue streams by simply jacking up prices more. And though I’m sure you didn’t intend to – why American companies are up shit’s creek now with a recession. They’ve been issuing debt in order to buy back stock for a long time – and now, they can’t lower prices in the face of what will certainly be changing consumer demand. But hey – you’re an R so of course you are all over their ability to get a taxpayer bailout now.

                    2. “Congrats you have just explained why both ‘non-profit’ hospitals and universities respond to stable revenue streams by simply jacking up prices more.”
                      Congrats. You have just proven to add yet more bullshit; your cite demonstrating your claim is missing. And will continue to be; your claim is a steaming pile of shit.

                      “And though I’m sure you didn’t intend to – why American companies are up shit’s creek now with a recession. They’ve been issuing debt in order to buy back stock for a long time – and now, they can’t lower prices in the face of what will certainly be changing consumer demand. But hey – you’re an R so of course you are all over their ability to get a taxpayer bailout now.”
                      That is among the most idiotic statements in a long line of the same from you.
                      NO company presumes to save for a government takeover, and if they did, the stockholders would have them in court in a New York minute.
                      You are amazingly stupid and similarly, amazingly proud to brag about it.
                      Now, got ahead and add to your record of stupidity: Tell us which country’s companies are better and why. I’m more than happy to continue ripping you another asshole.

              3. And yet the mortality rate here is so much lower than in countries with government medicine, where they stop treating anyone over 59 because health care is a right, or something. Or maybe it’s because socialist medicine is so compassionate and brother-loving. It’s hard to keep track of all the lying-ballsack rationalizations for the policy of letting people die in corridors.

              4. “They literally want people to die in pandemics just for insurance executive profits.”

                You want people to die as a result of poverty because you’re an adolescent whiny brat.
                First, the ‘executives’ don’t get the profits; the owners do. And if you ever grow up and have a retirement plan, that’ll be you.
                Now, I’m sure it’s your mommy and daddy who fixed up the basement so you can brag to the world what a fuckibng lefty ignoramus you are.

              5. No you leftist piece of shit, I want the ability to feed my kids and you have no right to tell me I can’t because 97% of people who get this disease will survive.

              6. Democrats want people to die so they can blame Trump. What you said was bullshit though.

            2. It’s evident here that lefty ignoramuses are willing to cripple the entire economy for fear of catching a cold, you cowardly piece of lefty shit.

              1. They’re dong it to get rid of Trump. They don’t care how many die.

                It’s the progressive way.

            3. “You can google it.”

              Can’t help but notice you could have too but didnt.

        2. Earnesto Concernada
          April.5.2020 at 10:22 am
          “We can’t tell poor people and people with pre-e siting conditions to just go ahead and die, you asshole.”

          You’ve come here to prove how stupid lefties are, right?

          1. If it saves just one life!

            1. Stay home and chat with sexy ladies on adultclassifieds – best web platform

              1. The true heroes in these dark times

        3. We do it with food, don’t we? Instead of common-sense bread lines, in this country the rich get all the food and poor people starve to death.

        4. Yeah, you’re too busy telling them to go starve to death.

          Fuck off, slaver.

      2. Poor new sock troll asshole. He cannot read. I said BEFORE you have medical problems.

        And YES you can tell Americans to be responsible for their own actions. Governments never really solve any of their problems. Government just makes most of the worse.

    3. When was the last time you shopped for a medical professional? Yeah, didn’t think so.

      Three times in the last couple of months.

      I need to get braces again (ugh). I visited three different orthodontists to compare prices and treatment plans.

      I need to get shoulder surgery. I looked into a surgery center that offers flat rate pricing and doesn’t take insurance. It would have been more expensive than my yearly deductible so I’m staying in network.

      Just this morning I woke up with a likely case of pink eye. I looked into Medexpress but my insurance offers a les expensive and faster telemedicine option, which I took. Got diagnosed and Rx was called in within 20 minutes of logging on to the website.

      1. Luckily for me there have been some incredible advances in topical creams in the last few years.

        1. We can put a stop to that right quick if we cap the profits those evil executives make!

    4. About 95% of medical care is non-emergency care. Why can’t you shop around for that again?

      1. +100000

      2. Lefty Religion 101:
        “Why can’t you shop around for that again?”

        … religious principle #1…
        “Because irresponsible and/or lazy people are *special* and we have a human ‘RIGHT’ to join the gang of mobsters that will will elect Bernie to come steal anything you have worked hard to earned and/or create.”

        … reason for principle #1…
        “Someone somewhere is going to DIE because you think stealing your car from you is a crime!!!!! You greedy pig!!!”

        … logical foundation for principle #1…
        MOBSTER VOTING -> GUN-ENFORCED THEFT = WEALTH instead of
        VALUE = WEALTH

      3. You can not shop around because in many cases you can not get price information. When you can get the information it is distorted because of insurance company and government programs. When I went looking for prices on a drug my child takes the pharmacies would not give me a straight up answer because the price depended on your insurance. What if went to the store and the clerk told you they could not tell you the price of a can of beans. That the price depended on your insurance company.

        1. “You can not shop around because in many cases you can not get price information.”

          Bullshit. Ask the cash price of the procedure.

        2. This is a good point. You need transparent pricing for a functioning market.

    5. A free market can’t work in healthcare because everyone needs medicine and you can’t shop doctors and prices in the back of an ambulance.

      Actually, you can — and people once did.

      Look at how Massachusetts General Hospital was founded — it was a subscription hospital (similar to fire companies at the time) where you paid a certain amount of money and if you were sick their ambulance (or boat) would come pick you up and take you to MGH for care.

      Look at all the hospitals that the religious orders set up, particularly the Catholics but various Protestant and Jewish denominations did as well. This legacy remains in the names of some of our large hospitals today.

      And then for childbirth, there were specific childbirth hospitals as late as the 1970’s, places where women planned to have their child, and where they went for prenatal care.

    6. Imagine being so stupid you think the only time people look for a doctor is when they have an emergency.

      1. Progtards always find a way to be that stupid.

  6. Ms. Chapman wants to blame doctors and the AMA for breaking health care. While she (or perhaps the Reason editor who may have written the headline) points out government made things worse, it’s really the government who gave the AMA a monopoly on licensing doctors and facilitated the institutional structures that’s led to less competition and service and lack of a free market.

    It’s also worth pointing out that David Goldberg’s book “How American Heath Care Killed My Father” (reviewed in Reason years ago) he points out that people getting their “free” Medicare actually pay a greater share of their income on health care than seniors did before Medicare existed! That fact suggests seniors would be better off abolishing Medicare. That’s how much the government’s messed up the market for health care.

    1. Health care is expensive because government has restricted it, just like rent control, land zoning, and building codes make housing expensive. But that message is way too simple and this article would have been much shorter if all it had done was say that, even with the useful history thrown in.

    2. Seniors who had paid into a private medical insurance plan for decades would have better return and you can sue private companies to get them to fix bad practices. The government medical under medicare and medicaid rarely allow the injured parties to sue.

      1. While I detest the Medicare model, it is not a medical insurance plan. What you pay in is totally unrelated to what you get out, and always has been. In fact, you’re in even if you never paid a dime in Medicare taxes. Medicare is simply a government entitlement based on age, paid for (for awhile anyway) by a payroll tax. We should have never called it a Medicare tax, since it confuses people into thinking it’s a contribution into some sort of individualized plan.

    3. Monopolizing the AMA (giving it legal weight) – just one of the many…
      https://mises.org/wire/how-government-regulations-made-healthcare-so-expensive

  7. I don’t see why the cost of healthcare should be a concern – once the Democrats get back in power it’s all going to be free.

    Of course, I’m not stupid enough to believe it’s going to be unlimited free healthcare, everybody is going to get the same 8 hours per year allocation. Fingers crossed you don’t need complicated surgery and post-operative care, kidney transplant procedures don’t work as well when they’re done in stages over a period of years.

    1. Democrats will never be back in power. They know this which is why this KungFlu hysteria is their last big ditch effort to destroy the USA before its too late for them.

      1. Just like you predicted a Republican landslide in the House last election?

        1. But for voter fraud, there would have been a Republican landslide.

      2. Poor alphabet sock troll. DINOs in the House doing what Trump wants is a republican majority.

        1. Riiiiight, that’s what you predicted, silly me.

          Along with you voluntarily paying taxes, and tariffs are not taxes. I suppose you don’t voluntarily pay tariffs in that case.

          1. Poor Alphabet troll.

            He gives the federal government interest free loans each year, thinks he pay “taxes” on products he doesnt buy, and is forced by someone to pay tariffs on US products.

      3. For their sake, they better not take power. If they push their current agenda, the public may respond with torches and pitchforks.

  8. You will never see something so expensive as that which is “free”.

    1. +100000000000000000

  9. Politicians certainly are making things worse:
    Gov. Newsom held a press conference yesterday, telling his subjects that we must re-double our efforts since the number of case “grew by double digits” yesterday, and we could ‘do the math’ as a result.
    Yes, I can ‘do the math’, and it means that the chicken littles are wrong

      1. And maybe, just maybe, the votes will go to the polls in November with figurative “Pitchforks & Torches.”

        Figurative, I pray….

        1. Literal ones if the democrats push their bullshit.

  10. We need a robust retail medical system with catastrophic insurance plans similar to auto insurance plans.

    We do not need any more of the collectivism that has cased this entire issue.

    Because collectivism, as with all things, is the problem here.

    From the collective mutual aid societies to the collective AMA ideas, to the collective government insurance push.

    Our costs are high because besides the doctor, there are armies of people managing the various collectives attached to medicine that all need to get paid.

    The focus in medicine should be towards eliminating the need to go to the doctor. NOT for making the doctor more affordable by finding innovative ways to disguise useless costs.

    1. Bingo

      Also, medical “insurance” becoming employer-provided as the standard has removed healthcare from all normal consumer control factors (not like you can shop blue cross vs Aetna when your employer has already chosen) and allowed medical coverage to become a pre-payment plan instead of actual insurance.

      All the ACA did is drive small, independent practices into submission to working for industry mega-corps.
      Thus goes progressivism and Reason style “libertarianism”

      1. And remember that employer-provided health insurance was just a way to raise wages (to recruit employees) during WW-II when there were wage freezes in effect.

        So we can blame the government for this as well…

    2. As always, the only journalism that occurs at Reason is in the Comments Section.

      Also, the only libertarianism.

      “The focus in medicine should be towards eliminating the need to go to the doctor.”

      Close.

      The focus should be on our freedom to purchase medicine and medical care *from whom we please*, without having to submit to the government enforced rent seeking of the medical mafia.

      The article didn’t contain a reference to freedom, liberty, or choice. Those get in the way of corporate profits. The policy choice offered by Reason is which type of medical mafia should be extracting pounds of flesh from us.

      Another of Reason’s “Libertarian” Moments.

  11. This article is a couple weeks late, but was worth it. What better time to show the dangers of central planning reducing the capacity of the system than when we have to stop everything we’re doing to not overload the system.

  12. Another excellent Reason article devoid of reason.
    Every thing she attributes to “the doctors” was done by government action. At the behest of some doctors, but by the government.
    Just to be clear, an insurance policy is a contract between an individual and an insurance company. It is intended to take a financial risk that is too great for one person, and spread the risk over a large enough population so that the expense is acceptable.
    In our current economy, only those with what is (erroneously) referred to as ‘a catastrophic policy’ actually has health insurance. The rest of have a hybrid product combining prepaid heath care with insurance. And the health care is restricted by contract to providers selected by the insurance company, not the consumer.
    That the prepaid component contains too many government mandated components is the reason the “insurance” cost is so high. Single men and older couples past child bearing age are required to carry maternity coverage they cannot possibly use. Women are compelled to have coverage for prostate care. And of course the costs of the unnecessary but required coverage is the excuse for fascism in the health component of the economy.
    There is no way to force price competition on health insurance because it is not purchased by individuals, but by corporations whose main criteria is tax avoidance. There is no way to force price competition on health care providers because the insurance companies mandate which providers are ‘allowed’.
    Until health insurance is only purchased by individuals, and pays benefits only to the policy holder who selects their own providers, we have suspended market reality, and will face the higher costs that involves.

    1. Exactly.

      CON laws are another way the government has fucked up medical care. All the screaming going on now about the lack of beds is pretty rich, since it’s coming from the same assholes who jump in the sack with hospitals to limit and prevent new hospital builds.

    2. If auto insurance was like health insurance, my insurance policy would pay for oil changes. Except that I’d have to go to the insurance company’s garage, at their quite inconvenient schedule, and spend all day waiting for them to do it.

      Instead, I can go out and do it myself this afternoon — much better.
      And considerably cheaper….

      1. Not just oil changes;
        The following for safety reasons; wiper blades, brakes, and newly defined inspections.
        The oil changes would be intended to keep your car “clean and green”, as would air filter changes and tune ups.
        And of course, since you would not be able to afford your policy after all this, a huge new federal bureaucracy (I mean jobs program) to administer a program of assistance, complete with preferred (politically connected) providers and all that jazz.

    3. I would ask why we have per state insurance regulators. All we need is a place on the web where consumers can rate insurance companies much like products are rated on Amazon. Get rid of insurance commissioners and get rid of idiotic restrictions about buying insurance across state lines.

  13. Two major problems with the current system are price opacity and price discrimination. For any given health care provider, it is nearly impossible to know ahead of time what will be charged for any given procedure, or what extra charges will be larded onto any given bill. Likewise, there is no uniformity across the descriptions of procedures or services provided, so it is not possible to shop across providers for the best price on, for example, a hip replacement. Even if prices were posted, and were uniform across providers, a private patient will still be charged more than a Medicare patient because Medicare refuses to pay the higher rate.
    This makes it impractical not to buy health insurance directly or indirectly (through an employer who provides insurance financed by lower wages than otherwise) to take advantage of an insurer’s market power in pricing. This in turn makes it less practical to shop for doctors or hospitals, because not all will be “in network” or otherwise approved by the insurer. SImilarly, you can’t go in to an orthopod and say “My ankle hurts, and I’m confident it isn’t broken, so please perform an MRI with no x-ray.” The insurer and hence the doctor will insist on the x-ray, increasing cost and exposure to radiation.
    Since insurance becomes a practical necessity for almost everybody, it becomes more plausible to argue that it should be available to all, or even that “health care is a human right”.
    If the market provided transparent and competitive pricing, showing how much each service cost, and who was charged which rates, we could all shop around, and ask for “most favored patient” pricing; and providers would have to compete for business. They could also fire all of the people they employ to be expert in “coding” procedures in order to milk the most out of the existing system.

    1. There was a recent episode of EconTalk with a guy that started a surgery center that touched on a lot of this. Can’t vouch for everything he said (I did try to verify some things but there is not a ton of information readily available), but it is worth a listen.

      https://www.econtalk.org/keith-smith-on-free-market-health-care/

    2. “Two major problems with the current system are price opacity and price discrimination.”

      Thank you FDR for fixing wages and Truman for keeping them fixed.

    3. “Similarly, you can’t go in to an orthopod and say “My ankle hurts, and I’m confident it isn’t broken, so please perform an MRI with no x-ray.” The insurer and hence the doctor will insist on the x-ray, increasing cost and exposure to radiation.”

      Because you have no idea how to put together physical findings, x ray and MRI into a diagnosis and plan for management of your ankle injury.

      Not a box of cornflakes. Orthopedic surgery is by far one of the most competitive residency slots and toughest programs. Then spend another 5 or so years after boards. Then we talk.

      There is an old aphorism. “Physician heal thyself”. It means that even those well trained and experienced are mostly terrible at self diagnostics.

      The amount you actually pay to the doctor is a fraction of the total cost. The amount the doctor collects is a fraction of billed.

      Most of them really are cost blinded. That is intentional. The medicos mostly do not want to think about that. Not allergic to money but no time for business. Best to pay other people for that. It is not what they signed up and trained for.

  14. And although the U.S. medical system provides some of the best health care in the world, it does so only for those who can afford it.

    So all those immigrants with their children who use the emergency room as their family’s primary health care providers are being mistreated?

    Nonsense. #1, it’s liberal bullshit propaganda that mindlessly gets repeated like a mantra, and #2, it’s a real fucking insult to all the doctors, nurses, orderlies, and others who work their asses off in our hospitals. You lefties really have no idea how offensive you can be sometimes.

    Look, America has 330 million people, it’s simply not possible for every one of us to get treated by the best doctor in the entire country. Maybe that could happen in a tiny backwater country like Iceland or something, but here it’s impossible. Most of us have to make do with the 2nd, 3rd, or 1000th best. Fucking deal with it.

  15. It can be good to look to the past to find proven solutions or good starting points. Here, it makes a difference how far back you look.

    In this article Christy Ford Chapin, author of Ensuring America’s Health: The Public Creation of the Corporate Health Care System, provided a summary historical narrative that offers a partial understanding of what can go wrong. She closed by suggesting that a good way forward could start from Direct Primary Care physician prepaid practices and, with evolution, reassemble the prepaid doctor groups of the early 20th century.

    Dr. Chapin is likely right that the early doctor groups’ partnership model has advantages for service delivery. Partnerships, like in many past medical practices and in many current legal practices, internally promote efficiency and excellence. Typically they focus on delivering either efficient commodity service or the highest expertise. The organizational model works well to provide whichever type of service is focused upon because the professionals who are most successful at providing the service end up being the most persuasive in managing the organization, and therefore in shaping its ongoing improvement.

    Dr. Chapin is wrong that the vertically-integrated prepaid services model of the early doctor groups would improve healthcare. This model would favor aggregating individual doctors into a few large groups which would be local oligopolies. This would work to squeeze out genuine catastrophic insurance, would limit competition for services, and would take hiring and firing decisions out of the hands of ruthless consumers and put them into the hands of squishier group managers.

    The right analysis needs to start with understanding that the doctors and hospitals didn’t have the power to limit competition, the state and national government people did. If we want better price, quantity, quality, and selection, we need to exclude all government abetting of socialization, including the government favors that restricted the supply of doctors, facilitating the doctors’ consolidation into the early prepaid doctor groups, which were excessively socialized internally and were anticompetitive externally.

    Eliminate all government control actions and substitute customers’ buying decisions, and everything develops in the ways that best add value.

    1. “Eliminate all government control actions and substitute customers’ buying decisions, and everything develops in the ways that best add value.”

      And makes the Bernies of the world quake in their boots!

      1. Actual consumer freedom to buy medicine and medical care from whom we please is mentioned in the Comments Section at Reason.

        “Libertarian” magazine.

    2. Do not forgot all those other little things that government does for us. GPOs are a good case in point. These allow for government approved kickbacks and general raise prices and reduce availability of medical supplies.

  16. Finally – a history of the medical system that actually gets most things right from actual history. Except that it entirely misses – hospitals – and their role in jacking up costs and reducing access separate from doctors.

    Along with AMA-backed reforms that helped reduce the number of medical schools, licensing laws significantly limited the quantity of practicing doctors.

    Should really read – the Flexner Report of 1910. That is what eliminated 50% of medical schools and consolidated the remainder along the lines of the Johns Hopkins model. Hugely incentivizing specialists and disincentivizing GP and ‘family doctors’. But that report was commissioned by Carnegie – and made effective via the newly tax-deductible donations of Carnegie, Rockefeller, and the other Gilded Age barons who by this time were retirement age and thus interested in ‘health care’. The changes served their interests – which they made stick via med school and hospital funding. The AMA was just the ‘survivor’s’ guild of specialists – the tail not the dog. Decades later when med schools had churned out specialists and ceased turning out as many GP’s, they were the ‘special interest advocates’ who ensured that hospitals used their non-profit status to invest in capital equipment (to attract specialists) rather than to reserve profits to pay for care (along the lines of the previous ‘mutual’ type model).

    Technically, that whole model proved its flaws just a few years after the Flexner Report during the 1918 flu. When many contagious people were simply not admitted to hospital. People paying for surgery did not want contagious quarantine next to them. Which is when muni hospitals (and yes – that is the 20th century equivalent of the older ‘mutual’ model) started to get built. That muni hospital was then much later undermined by Medicare and ERISA – which favored national provision rather than local provision. Problem is – the whole muni/mutual model didn’t have a moneybags behind them to write a ‘reform report’ recommending restructure- and federal level stuff has never been ‘friendly’ to local/muni governance.

    Where physicians earn a set salary—as do British doctors or American physicians who work for closed-panel HMOs like Kaiser Permanente—a primary patient complaint is that care can be difficult to obtain.

    That’s only partially true. Yes at the patient front-end, it requires the GP to be a utilization gatekeeper/intermediary. Which only works if they are a)paid for that functional value rather than just for time and b)if there are enough GP’s so patients are not limited in finding a GP they can build a relationship of trust with. Both of which fail in our system.

    At the tertiary care back-end, a salaried system of specialists can also work. Mayo Clinic being the obvious example. But that too works mainly under a capitated system or a system where it is hospitals (not patients) that buy re-insurance for their tertiary needs. The current fee-for-service system hugely disincentives a Mayo type tertiary care system by instead overencouraging the big ticket capital fixed-expenditures for ‘community’ type hospitals.

    The main reason other countries ‘public’ medical systems worked is because they used the implementation to rethink what a ‘public’ medical system should look like from first principles. Ours has failed because we simply viewed the implementation as a way to avoid thinking about anything from scratch and simply subsidized the loudest existing special interests.

    1. Stay home in pandemic times and go on casual sex sydney for your own sexy chat experience

    2. Good job.

      Yet again, the best journalism at Reason occurs in the Comments Section.

  17. “Decades later when med schools had churned out specialists and ceased turning out as many GP’s, they were the ‘special interest advocates’ who ensured that hospitals used their non-profit status to invest in capital equipment (to attract specialists) rather than to reserve profits to pay for care (along the lines of the previous ‘mutual’ type model).“

    You are asking government policy to determine how many primary care docs are needed vs how many interventional cardiologists.

    It will not work. It was tried and failed. I was there. One thing that has happened is that PAs and Nurse Practitioners have become more a part of the medical team. That is a good thing.

    1. You are asking government policy to determine how many primary care docs are needed vs how many interventional cardiologists.

      Not overall. But certainly for the patients that government pays for. Govt is not an intermediary. It is a fiduciary too.

      Best example of our failure is Medicare and geriatricians (who are effectively GP’s for the older population). Medicare covers 100% of that patient population. There is no other ‘market’ force. Boomers getting older and eventually going on Medicare is about the most predictable and projectable event in history. Geriatricians save a ton of money on overaggressive care and specialist overhype for that age group and specialize precisely in the longer visits that GP’s now refuse Medicare patients because of the way that’s paid for. Instead of just paying for the education of geriatricians to meet that known aging, Medicare did nothing. Waited for some non-existent market solution. The result is we have fewer geriatricians than Denmark (pop 6 million) – the number is declining here – and their practice here is mostly limited to Alzheimers patients who are no longer competent to make decisions themselves.

      What a horrible waste of both money and the skill set of those who pursue that.

      Likewise, for the poor who are always going to be priced out of most medical. GP’s are the only care they need for most of their life. But there have to be enough of them so patients don’t have to make appts months in advance, so they can find one to build trust/relationship with, and they have to be paid so a GP can make a living without needing a 2000 patient base. It’s no accident that countries with enough GP’s so that everyone can go to them far more often than we see them have better health AND lower medical spending.

      Carnegie and Rockefeller needed ONE GP each – and dozens of specialists competing and practicing on rats/peasants to see which one was ‘best’. Regular folks need kind of the opposite – a choice of GP’s to pick the one they can trust – because they ain’t gonna be able to ‘choose’ their specialist in any real sense.

      1. “Not overall. But certainly for the patients that government pays for. Govt is not an intermediary. It is a fiduciary too.”

        That’s flat out bullshit.
        It is impossible for the government to determine how many GPs and how many specialists by focusing on those paid for by the government.
        You’re hoping to let the camel into the tent, claiming ‘It was only meant to be the toe!’
        Go back to waving your worn-out PANIC!! flag and quit lying; we are not nearly stupid enough to buy your bullshit.

      2. There is near no such thing as GP in modern medicine.

        Geriatrics requires at least four years post graduate and board certification in Internal Medicine and then some additional training.

        1. There is near no such thing as GP in modern medicine.

          Sure – in the US. I think its about 10% of total practicing physicians here. Probably a lot less for younger doctors choosing how they are going to enter the profession.

          But that’s not the case everywhere – eg in Europe, those first two columns – generalist and misc generalist (maybe even generalist pediatrician) – account for much higher % of the total. Only Greece and Poland have a similar structure as us – where it is far easier to get an appointment with a specialist than with a GP.

          I know geriatrics (and generalist pediatrics) are specialties by training. But by patient orientation, they are generalists. Relationship oriented rather than body-parts or disease oriented. And no I don’t think PA’s or NP’s are a healthcare solution. They are a solution to the existing way we PAY GP’s and are cheaper ways of servicing the hamsters patients in their 30-minutes round the wheel.

          1. Well, how much more manure has JFree provided?

            “Sure – in the US. I think its about 10% of total practicing physicians here. Probably a lot less for younger doctors choosing how they are going to enter the profession.”
            Cite missing.

            “But that’s not the case everywhere – eg in Europe, those first two columns – generalist and misc generalist (maybe even generalist pediatrician) – account for much higher % of the total. Only Greece and Poland have a similar structure as us – where it is far easier to get an appointment with a specialist than with a GP.”
            Cites missing and I’m sure will be.

            “I know geriatrics (and generalist pediatrics) are specialties by training. But by patient orientation, they are generalists. Relationship oriented rather than body-parts or disease oriented.”
            So we’re riding the ‘holistic’ horse here, or simply more bullshit?

            “And no I don’t think PA’s or NP’s are a healthcare solution. They are a solution to the existing way we PAY GP’s and are cheaper ways of servicing the hamsters patients in their 30-minutes round the wheel.”
            So you really have nothing realistic to offer, just some fantasy you imagine.

            1. Let’s revisit this pile of shit on the base assumption:

              “But that’s not the case everywhere – eg in Europe, those first two columns – generalist and misc generalist (maybe even generalist pediatrician) – account for much higher % of the total. Only Greece and Poland have a similar structure as us – where it is far easier to get an appointment with a specialist than with a GP.”

              You failed to cite why your fantasy solutions are preferred, and I’m sure you can’t. And you also failed to suggest how those solutions came about.
              Can we assume, as a lefty, you are happy that those solutions which you have yet to show are better, are a result of government coercion?
              Just guessing, lefty ignoramus…

  18. Company towns are much derided in today’s society (and there is good reason to at times) but I remember reading about rh Coeur d’Alene mining wars in the 1890s. The mining companies provides hospitals and doctors for their employees. They also provided grocery stores, housing, saloons, brothels etc. While they charged outrageous amounts, the unions didn’t try to end these situations just tried to reduce the costs while improving wages and to end company enforced monopolies on these services to allow workers choices.

  19. And speaking of government screwing up medicine, Cuba, again and still, exporting educated slaves, taking any wages:

    “Doctors From Cuba Are Traveling The World To Help Cities Affected By Coronavirus”
    […]
    “Cuba’s largest export as a country isn’t what you think it is. While most people might guess products like tobacco or sugar, the communist-run country’s largest export is actually medical professionals — a service much of the world is desperately in need of right now. Since the 1959 revolution, Cuba has sent its “armies of white robes” to disaster-stricken countries around the world in the name of medical diplomacy….”
    https://www.refinery29.com/en-us/2020/03/9602651/cuba-doctors-abroad-help-coronavirus-viral-video

    1. It’s amazing what a small poor country subject to sanctions by a superpower can still afford to export its medical professionals and technology.

      While Cuba exports its doctors and medical tech, the US exports its B-52s and cluster bombs. Which one is worthy of emulation, I wonder.

      1. It’s amazing that lefty scumbags will continue to make excuses for the worst sort of hell-holes the world has ever seen.

        No, shitbag, Cuba exports slaves.

      2. What an idiotic statement. No wonder you were dumb enough to lose your house to foreclosure.

      3. Name me one country that we’ve exported B-52s to? Just one. Or any country since 2003 we’ve exported cluster bombs too?

        1. I’ll bet commie kid can’t even name the countries to which the Castros have exported mercenaries.
          He’s sort of stupid that way and many others.

    2. Cuba’s largest export used to be armed revolutionaries until the rubles ran out.
      I guess no one is beating their way in to take advantage of that superior Havana healthcare so Mohammed must go to the mountain.

  20. Its not really good to say anything about doctors. Because they are the person who are risking their life only for us. It looks like as they are providing water purifier for us. https://www.internetically9.com/best-water-purifier-in-india

  21. Speaking of health care…

    Boris Johnson hospitalized

    Gee… I thought all these right-wing assholes we’re immune to COVID. What’s going on?

    1. It’s thanks for again proving that lefty asshole scumbags are absolutely immune to intelligence.

    2. Your comments are going nowhere. I suggest suicide.

    3. Please try to make sense.

  22. “[the insurance model] was not based on the evolution of competitive markets. Instead, the model sprang from the minds of physician leaders seeking to safeguard their professional status and earning power.”
    Great article, but there in a nutshell is the idiocy of libertarian thought. Why would powerful, high status actors NOT try to become rent seekers? And without a powerful, independent state what can stop them?

    1. “Great article, but there in a nutshell is the idiocy of libertarian thought.”

      There, in one short sentence is the demonstrated idiocy of fucking lefty ignoramuses.
      Hint, fucking lefty ignoramus, those ‘high powered’ people, who hide under your bed every night, could do nothing absent the coercive power of the government. Yes, that self-same government which imbecilic assholes like you propose as the solution to every problem that government has already caused.
      Please, slaver, STFU, fuck off and die. The world will thank your memory for doing so.

      1. Lol. Thanks for answering the point so eloquently. Some states in history have indeed been able to purge rent seekers, others haven’t and have instead abetted them. But given that powerful and wealthy individuals will always form organizations to ensure easy rents, one has to hope that a state independent of and above those individuals exists (probably based on military or traditional aristocratic power) to curb them. Classic examples might be South Korea in the 1960’s or Meiji Japan.

        Does it occur to you that reality isn’t black and white? And I’m not a leftist in any sense btw, just a realist.

        1. “…Thanks for answering the point so eloquently….
          You’re welcome.

          “…And I’m not a leftist in any sense btw, just a realist.””
          We get that lie on a regular basis.

    2. “Why would powerful, high status actors NOT try to become rent seekers?”

      Ya know – in free markets there still has to be a *need* for it. Why would anyone pay rent if they can just buy??? If you want to pretend the whole market is trying to rent instead of sell out of greed then what is stopping you from selling? As long as the free-will option exists their is no legitimacy to be complaining about what the “buyers” have chosen to purchase.

      1. Those who think they are but helpless lambs at the mercy of Mr. Corporation have been brainwashed by lefty propaganda. The only entity that over-rides free-will is government law.

        Corporations exist there because of your own free-will. If any of you don’t think what they do is earn, do, or provide is right; you have the free-will to not buy there at all, start your own service and or do it right…. EVERYONE HAS THAT ABILITY until government law starts to dictate….

  23. I can’t stay away from the trainwreck that is the left shrieking about hydroxychloroquine on twitter.

    To sum up: No one should use it for COVID because they are STEALING IT from all of the numerous patients who use it for some other condition, but it won’t even work because TRUMP is a SNAKE OIL SALESMAN

    I guess they didn’t have time after Trump’s latest statements to make sure the talking points didn’t contradict each other

    1. Nor will any one of the idiots ever admit it when it is pointed out.
      This is a sad commentary on humanity; TDS is sufficiently virulent that assholes like JFre and Hihn can wave their PANIC!! flags in spite of all evidence, the grease-ball Newsom can lock-down people in 500-person towns since somewhere between 10 and 99 new cases were confirmed in the state of CA on Friday…….
      If the damage weren’t so great, I’d suggest we’ll all laugh about it in a couple of months.
      Unfortunately, and for the same reason, we’ll be cleaning up like the West Germans did after the wreck of communism there.
      Commies NEVER clean up after them selves; they think their remaining shit is just a result of no one doing “real” commie.
      Right, commie kid? JFree? Hihn?

  24. In the “prepaid subscription model”, what happens when they realize that the overweight chain-smoker is needing a lot more medical attention even though he is paying the same membership fee as everyone else?

  25. My real time work with facebook Im making over Many Buck a month operating low maintenance. I continued hearing distinctive people divulge to me how an lousy lot cash they can make on line so I selected to research it……Details Here

  26. I always thought it ironic that AMA also stands for “Against Medical Advice.”

  27. Direct Primary Care shows that costs can be reduced when physicians do not have to interact with government or private insurance. We need more of it.

    One area the author could have covered that is also lowering costs is cash-only surgical centers where procedure prices are on a websites. These center do not need hospitals which is a second level of cost reduction, they have their own surgical center(s).

    We need more experimentation along these lines. My money says we can beat single payer by miles with lower costs and higher quality if we had these kinds of institutions and price transparency too.

  28. You did not mention the model used in my county. We have a countywide Health care District gets its funds from a tax on real estate. They use this money to build a five Hospital and one surgery center world class network. I am a salaried physician employee and my patients get excellent care. Patients are free to go to the local private for profit hospitals, but I believe they get just as good, if not better care with us.
    We are in no danger of running out of supplies, as our five hospital network buys entire factory’s worth of production and stock piles it.
    We consider cost in our medical decision making, but can do as we see fit in the best interest of the patient.
    The rest of the country would do well to adopt our system

  29. Great article that reinforces the point about how there is almost lack of market competition for medical services providers REGARDLESS of HOW or WHO pays – hence the current rationing and unaffordability.

    While much of American labor faces competition from third world labor resulting in stagnant wages, the same cannot be said largely for health care providers. Its socialism for the providers and capitalism for the patients!

  30. Physicians are not the problem – hospitals are.
    There are 3 components to any type of risk-sharing arrangement. They are claims, reserves (required by regulators in any type of scheme), and administrative expenses. Claims are what they are. Face it – The world is wealthier than ever and we’re fatter than ever. 40% of cancers are caused by obesity. The Trifecta is diabetes, hypertension, and hyperlipidemia. Add obesity to the Trifecta and you have the Four Horsemen of the Apocalypse. Add atherosclerosis, carotid artery disease, and a number of other chronic diseases and you have a train wreck. Claims will never go down unless there is significant rationing of care. 93% of paid claims are less than $5,000 USD and the last statistics I saw, accounted for roughly 50% of cost. That means, 7% of the population, the unhealthy portion, spend roughly 50% of the money. When this problem is fixed; when the average American woman doesn’t weigh 165 lbs; the average child isn’t 90 lbs; and the average man weighs less than 215, we may be getting somewhere. It’s probably fairyland!

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