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Dr. Bob’s RX for our Managed Care Mess

Published in Washington Law & Politics

I’ve reached a conclusion about my friend, Dr. Bob.

God made him without waiting for the environmental impact study.

Dr. Bob Cihak (pronounced Chee Hawk) grew up in South Dakota and claims he didn’t know “bohunk” was an insult until long after he got to Harvard. “I’ve always considered it a compliment,” he avows, and still occasionally wears his “Bohunk Is Better Than No Hunk” lapel button.

A diagnostic radiologist – “If there’s one thing I know about radiation, it’s that most people don’t get enough” – he took early retirement several years ago because he wouldn’t let the government, and the Managed Care Mafia generally, tell him how to practice. Indeed, so averse is he to the whole system that he carries no routine medical insurance and recently made (or ruined) another doctor’s day when he paid cash for some tests after negotiating a reasonable deal.

Since retiring, Dr. Bob has worked with and supported a variety of libertarian, conservative, and radical causes which have at their heart the advancement of human freedom. But medicine remains a primary concern. He and a colleague now write a nationally syndicated (Scripps-Howard News Service) medical issues column. And he’s president-elect of the Association of American Physicians and Surgeons (AAPS), a small but feisty alternative to the AMA colossus. Among the group’s accomplishments:

“We sued Hillary and won.”

Seems that back in 1994, during the Clinton administration’s attempt to take over one-seventh of the economy, Hillary’s task force violated the Federal Advisory Committees Act by holding secret meetings and not releasing documents. So AAPS went to court, required the government to follow its own laws and extracted large quantities of documents.

“Hillary is an amazing woman” says Dr. Bob. “Not only was she willing to listen only to advisers who stood to profit if the government snatched medicine. She was willing to devise an entire system without needing to write anything down on paper herself, judging from the absence of her signature on any of the hundreds of thousands of documents.”

In the end, she settled for second best and a piecemeal approach: a 1500 page plan that included, among other things, prison sentences for doctors who dared to treat anybody outside her system.

So what’s the problem with government medicine? Dr. Bob answers simply.

“If you pay the physician, the physician works for you, based on an oath that requires him or her to put your welfare first. If the government pays the physician, the physician works for the government and their oath is to buy votes today and pay for them with political IOUs. The government pretends it can meet all medical needs. But the politicians can’t fulfill their promises. For example, the bureaucrats interpret the 110,000 pages of Medicare laws and regulations to mean that the government provides all necessary medical services. By bureaucratic ju-jitsu, this gets turned upside down to mean that if the government doesn’t provide it, it’s not necessary, even if the patient and doctor disagree.

“Same thing if the doctor works for the insurance company, but at least there you’ll often have a dysfunctional kind of competition. In every market, there’s a buyer and a seller. In this case big employers are the buyers and big insurance companies or medical conglomerates are the sellers. Neither the patient or the doctor are in the marketplace. Neither the individual patient’s desire for independent medical judgment nor the doctor’s need to provide independent medical judgment are seen as important until it’s too late.

“If the physician is paid by the government . . . single-payer means single buyer. If you don’t like it, where do you go? As a patient or a doctor . . . what’s your choice?”

And yet, Dr. Bob feels that American medicine is not heading toward outright socialism. It’s actually becoming a corporative, i.e., fascist affair. In fascist economic systems, private property seems to remain. Ditto private profits. But the government tells you what to do. The solution, according to Dr. Bob, is not socialized medicine “If you think it’s expensive now, wait till the government makes it free.” Nor is the answer total return to a simple fee-for-service arrangement or an old outright indemnity insurance regime. Rather, he favors a lively mix of diverse approaches, everything from portable insurance and individual medical savings accounts to co-operatives and letting private physicians charge on a sliding scale, based on ability to pay. Even managed care would be acceptable — if available to and freely chosen as an option by both patient and physician.

In short, there is no reason why everybody can’t get the medical care they need. But one government-controlled system does not and cannot fit all.

“If thereĀ‚s no competition, there’s no need to respond to competitive forces. And, if you happen to be out of favor politically, you might also be out of favor medically.” Dr. Bob points to a nation with a medical system developed over several decades with minimal political interference, based on the advice of the best international experts. This country included medical care for all in its constitution. How did that system really work out? There were 2 medical systems, with an equally divided number of doctors between them. One system took care of 5% of the population, the Nomenklatura elite. The other handled the other 95%. Tilt. So much for Soviet medicine.

And medicine can be corrupted in more subtle ways. To minimize or deny the non-material side of medicine is to reduce human beings to machines – doctors as well as patients.

“Compassion,” says Dr. Bob, “means, literally, to suffer with. Just as conscience means, literally, to know with. Patients are free to regard their doctors as service providers. Doctors are free to see their patients as physical objects. I suspect that aggregate biological outcomes wouldn’t be that different. But the participation in the healing, of the practice, suffers. And life itself loses flavor and meaning without participation. One reason is that serious and terminal conditions make people think about a lot of non-physical things. We love to talk about self-esteem, but if you’re going under the knife or facing chemotherapy, knowing something higher, helps more medically as well as spiritually. If you’re going to die in six months, does it matter how you die? Yes, it does. How you die is also about how others see you die, help you die. What others learn about dying. The end of life is precious for what it teaches all of us. Life only makes sense in its perpetual face-off against death, as Plato knew.

“Another reason is that a lot of sickness is the result of people doing things they shouldn’t. At the physical level, they know they shouldn’t. Smoking or gluttony is bad for you. Just knowing that doesn’t change behavior. But when you add a spiritual dimension, when you see yourself as more than an isolated bit of matter, it helps. Look at the Seven Deadly Sins. Spiritual and medical, absolutely intertwined.

“And have you noticed,” he concludes, “how none of them really turn out to be fun — or even look like fun — for more than a very short time.”

Phillip Gold is a Senior Fellow of the Seattle-based Discovery Institute.