This is a commentary written in response to an article published in Surgical Neurology International and penned by the retiring neurosurgeon Dr. Clinton Frederick Miller that was highly critical of American medicine. He opines that a major overhaul, or rather overturn, of the American health care is necessary to correct the myriad of alleged abuses he perceives in the system. In his quest for reform, Dr. Miller also made a pitch toward supporting ObamaCare as a stepping stone in the implementation of socialized medicine in the US.
My friend and colleague Dr. Russell L. Blaylock has already written an excellent rebuttal as far as moral and political implications in Dr. Miller’s treatise to the effect “While some of the observations in the article may be correct, the type of liberal/left proposals to solve the problems are harmful.” Dr. Miller argues several points that are misleading and tendentious. Thus, I agree with Dr. Blaylock’s statement. Moreover, when Dr. Miller blames the free market for the problems in the US medical care system, I would argue that the reality is quite the opposite. A two‑level cervical fusion may cost $11000, but if the free market was fully allowed to work, the price would be far less because of unfettered competition, as occurs with the services in other professions and trades. The same would happen with the stereotactic biopsies at $4000–8000. Price would come down if the free market was allowed to work. For this to happen, though, patients and their families would need to be educated to become prudent consumers of medical care and shop around for quality as well as the most affordable medical care—same as they do with other services and purchases of household items as well as homes and automobiles.[7,8] Dr. Miller himself has pointed out that 96% of illnesses are not serious. I agree; this means that in most situations patients could act as prudent consumers and with freedom of choice in seeking medical care. This is what should be happening, but as we all know, it is not. If we truly had an unfettered free‑market in medical care, medical care would be competitive, more efficient, cheaper, and still humanitarian, as has been the case from time immemorial for the medical profession.[7,8,16] This is no longer happening to a significant degree because of the strain of modern living, the high cost of and depersonalizing influence of advanced technology, and more apropos in our discussion because of the distortions in the medical marketplace—namely the third‑party payer system and the antipathy of the government and insurance companies to allow for patient empowerment via medical savings accounts (MSAs) or health savings accounts (HSAs).[7,8] One only has to compare the price of dental care where the free market is less restricted to medical care (where third party payers and the government are involved) to immediately recognize the distortion of the fee‑for‑service US medical care system. Despite the misconception of the US having an unrestrained, laissez faire free market in medical care, the reality is quite the opposite—i.e., already more than halfof the system is socialized and the rest is under managed care, a highly regulated system in which cost‑containment is the raison d’être and the managed care entities and insurance companies work hand in glove with the government, which is a collectivist and corporativist partnership.[12,13]
Third party payers (insurance companies as well as the government) are problems because the system is perceived and, in fact, mishandled as if somebody else other than the patient is paying the medical bills. In other words, patients act as if they are spending somebody else’s money when they seek medical care. This also makes the system terribly expensive. In the present milieu in the US health care system, the invisible hand of the free market is hampered. I need not mention the cost of defensive medicine because of the adversarial litigious climate in which physicians practice. The system is abused on all sides and these abuses escalate unchecked. Insurance companies are stuck with huge medical and hospital bills, and they are able to pass the costs to the enrolees, ultimately the patients. This is a problem that, like the other shortcomings mentioned above, needs addressing. Reform is needed, but with ObamaCare, US medical care will be further disrupted and what is left of the free market will be further distorted. Dr. Miller warns us about the healthcare‑industrial complex and likens it unfavorably to General Dwight Eisenhower’s military–industrial complex, but the fact is we should be much more concerned when government enters the equation in these corporativist partnerships, as in ObamaCare, which is a more advanced level of corporate socialized medicine, a higher degree of collusion of government, managed care networks, and big businesses—threatening more regimentation, more socialization, and less freedom.[2,3,11]
As to the specifics, Dr. Miller alludes to over‑diagnosis and over‑treatment of breast and prostate cancer, and goes to mention that 85% of men over the age of 60 at autopsy harbored microscopic evidence of in situ prostate cancer, suggesting that this is a benign condition requiring no treatment. Let me just state that a dead octogenarian at autopsy is one thing; it is another for a symptomatic but very active octogenarian to be refused treatment simply because of his age with the medical pretext that his prostate cancer or her breast cancer is deemed probably not serious, probably not invasive, and ignored because of age discrimination, a tenet of population‑based utilitarian bioethics and not the individual‑based, traditional medical ethics.[6,9,15,16]
Dr. Miller then goes on to lambast over‑treatment in neurosurgery, and opines, based on a 2007 New England Journal of Medicine study, that conservative treatment of lumbar radiculopathy is as good as surgical treatment with microdiscectomy. That may be true in the long run in some patients but not in others, and he glosses over the fact that patients experience less pain and recover faster with microdiscectomy. He then impugns venal motives to his colleagues for advising surgery when medical treatment is supposedly just as good, claiming, “experienced spine surgeons have known this all along” but because of “selfish motives” fail to disclose this to the patients. Not necessarily so because the art and science of medicine and neurosurgery is imprecise and different surgeons have better or worse results with one method or the other. Patients (and surgeons) are unique individuals, not statistics. Despite the efforts of socialists to collectivize, one size does not fit all! Then, Dr. Miller accuses others colleagues equally of mercenary motives for criticizing the design and results of the study. He writes, “certain vocal elements within the spine surgery community” contended the results of the study because “obvious selfish intent to protect a ‘bread and butter’ source of income.” That may be so for some, but not for other honest critics, and as Dr. Miller himself had to admit, there were shortcomings in the study, as well as qualitative differences in the results.
Returning to more general concerns, Dr. Miller mentions Hippocrates and the Oath, and I am happy that he does. But it is not socialized medicine, not even managed care, that upholds the tenets of the Hippocratic Oath, but the individual‑based (not government‑based), patient‑oriented, free market medical care.[14‑16] It is of interest that Dr. Miller is supposedly concerned with the trend that physicians are “not fulfilling a physician’s sacred first duty to engage in responsible and humanistic collaboration with the patients we are privileged to serve.” Here, I tend to agree to some extent, but then I wonder if the word “humanistic” was chosen with an oblique purpose in mind, or whether he meant “humanitarian” or “compassionate.” The term “humanistic” has today, even as Wikipedia notes, so many meanings from “man‑centered” to “humanitarian,” that it is difficult to discern which one is meant within the context of his narrative. I suppose Dr. Miller meant “humanitarian.” If he meant “humanistic” with alternative meanings, the term is incorrect at best or disingenuous at worse.[14‑16]
Over‑treatment and alleged unnecessary medical care, too much surgery, heroic care, all of this happens—but they do not all mean greed and the implied (immoral) profit motive, as ascribed by Dr. Miller, but also the penchant of Americans to live longer sometimes without considering quality of life—after all, somebody else (government or insurance companies) is paying the medical bills! It is not always the doctors’ fault, but the imprecisions of the art and science of medicine and our way of life and our way of thinking. And the American way is not always wrong.[1,6,9,16,18] We need education and information, and how to take care of ourselves, but we in the US do not need further regimentation and collectivization.[2,3,7,8,16] Some of the problems enumerated by Dr. Miller do exist as noted, but some of the proposed solutions, such as full implementation of socialized medicine, are far worse.[1,7,18] Moreover, some of the accusations heaped on the American medical care system is based on alleged inequalities in access for the poor, the elderly, and the indigent or disabled. These are outright false accusations perpetuated by the misinformed, and the drama of Hollywood movies and the popular culture. The poor, indigent, and disabled are covered by Medicaid, a nationwide State program; the elderly by Medicare, funded by the Federal government. In some cases, individuals and families are covered by both. Furthermore, it is illegal by Federal law to turn away anyone in the emergency room under any circumstances. Everyone gets medical care in the US in one form or another, or eventually in the emergency room. The shortfall in funding is paid by the working middle and upper classes in Federal and state taxes. Paradoxically, it is these same entrepreneurial groups, including individuals, small and family businesses and the self‑employed, in the middle class that face problems with access to medical care because insurance premiums are so high, and now with ObamaCare must pay fines if they chose to remain uninsured and self‑pay. It is the American middle class that carries the burden, pulling the wagon in which everyone else rides! And, for the record, despite the demagogic allegations of some American politicians (Democrats), no one falls through the cracks in America. The poor in the US are on welfare and served by an alphabet soup variety of government programs, entitlements, and benefits (e.g., WIC [Women, Infants, and Children], EBT card for SNAP [food stamps], Medicaid, free cell phones, free or subsidized housing, etc.) tending to their every need and that of their families—subsidized again by the American middle class. Americans, as you can see, are very compassionate and generous people.
Modern liberals, who frequently prefer to call themselves progressives (and in the US usually resent the term socialists with the notable exception of Democrat Presidential candidate Senator Bernie Sanders), have also a predilection to compare the US with other industrialized nations when it is deemed politically convenient. Immediately, two items come to mind: The purported statistics of health care and gun violence. Let me state from the outset that selection bias has no place in scientific methodology, and the usage of numbers that usually accompany these discussions brings in a method of science, statistics, that abhors biases. Second, why should the rest of the world be ignored as if they were no part of the community of nations, nations made up of human beings with aspirations, yearning to live in peace, and with the same natural rights as anybody else? I have already discussed the issue of guns and freedom in terms of the history and culture of America and the rest of the world.[4,5] I will thus continue with a similar comparison of the US and the Europe in terms of health care.
I do not wish to offend our European friends and colleagues. After all, the US is only the culmination of European (Western) civilization. But Western Europe has a largely stagnant, and in some countries, an aging population that has difficulty sustaining itself. Until recently, Europeans have been able to ration health care very efficiently with socialized medicine because of the much more homogenous population and culture it serves. This situation would be very difficult to accomplish in America without establishing an authoritarian government, curtailing freedom, regimenting, and changing the American way of life—very likely for the worse. Scandinavia has had a long tradition of socialistic Nordic tribal welfare that is time‑honored, and thus, frequently not abused, serving its temporary purposes (e.g., socioeconomic and moral support) until the afflicted persons get back on their feet. In the US, welfare services are abused as they are largely politically motivated, rather than time‑honored social and traditional mores.
In Spain, Greece, France, and the rest, the economies are sinking because of their uncontrolled spending in social (including medical) services they can no longer afford.[1,7,18] I recommend the papers by Drs. James I. Ausman and David C. Stolinsky comparing health statistics between the US and the rest of the world.[1,18] Collectivism has been a failure wherever it has been established, and socialized medicine, in particular, has been the key arch of that socialization, an essential component of collectivism used by demagoguing politicians to seduce the people, making it easier for them to accept tyranny. Europe has been free to pursue their pacifism and social safety net, including socialized medicine, in large part from the goodwill of the US with liberation in World War II, the enactment of the generous post‑war Marshall Plan, and the protection that America (and her gun culture) provided during the cold war. But what worked for Europe may not work for the US. Collectivism, in any of its incarnations, socialism, fascism (National Socialism), communism, and even corporativism (the unholy partnership of big business and government as in corporate socialized medicine) is supported by a faulty, if not an unnatural and evil ideology. Humanity has paid the price in lives (i.e., 100 million lives in the 20th century alone) for the evils of collectivism! For all the criticism, capitalism, even “crony capitalism,” at its worst, may deal with greed and profits, but not with the taking of lives and the support of tyranny.[13,14]
It is worth reiterating that despite the shortcomings, drawbacks, and alleged abuses of the American medical care system, that fee‑for‑service American medicine is still the best in the world. This is particularly true given our uniquecultural situation, the growing and heterogenous population that it serves, rampant immigration, popular expectations, and other political and cultural considerations.
The pharmaceutical industry has also been attacked elsewhere and not always unjustifiably so. The abusive high‑price of US drugs has also been cited as a shortcoming of the American “free‑market” medical care. But pharmaceutical companies will gradually be paying the price in lost market share, as many Americans who pay for their own medications will buy them abroad via the internet at a fraction of the cost. Further competition from abroad with the development and mass production of high quality, generic drugs will become a pharmaceutical bonanza for patients. People paying for medical care (fee‑for‑service) and medications from their own pockets will shop for the best prices, which is the free market at work, but education and freedom of choice are essential for the free market to function.[8,11]
Third party payers, as mentioned, are a major problem and my concerns are worth repeating: The system is perceived as if somebody else other than the patient is paying the medical bills; thus the free market is hampered. It is abused on all sides and these abuses escalate. Even insurance companies are getting ripped off, but they easily pass the costs to the enrollees, ultimately the patients. This is a problem that, like the other shortcomings mentioned, needs addressing. But ObamaCare is not the answer.[11‑13] With the implementation of ObamaCare, the US health care medical system will be further distorted placing an undue burden on the American middle class and small businesses. And unlike any other health care proposal implemented in the U.S., ObamaCare is compulsory and those who choose not to participate are fined by the government. So, when ObamaCare fails to deliver all that it promises, it will be the same progressive politicians who will clamor for more socialization and more compulsion.
Socialized medicine in other countries is frequently lauded even by citizens, as in Canada and Great Britain. Why? Because it has become, for many, a national symbol of pride as well as a false measure of security. Only 4% of people are sick enough to need the system at any one time, and when they do they find queues to see specialists, waiting lists for radiographic studies, and surgery, restrictions of services, and various forms of rationing.[1,6,7,18] In some cases, pets can obtain tests faster than human patients because veterinary care is fee‑for‑service, whereas medical care is socialized! ObamaCare in the US will be a more advanced level of medical corporativism, another step toward fully socialized medicine with further regimentation and less freedom. I have provided supportive articles (which themselves contain useful references from various sources including other countries) that I hope are helpful to the uninitiated and to those who are researching the subject, and simply those who may want to learn a bit more about the U.S. medical care system—the good, and the supposed bad and the ugly.
1. Ausman JI. Perinatal mortality, free care, and other misconceptions — Socialized medicine vis-à-vis American medicine. HaciendaPublishing.com, November 27, 2012. Available from: https://www.haciendapublishing.com/articles/perinatal-mortality-free-care-and-other-misconceptions-%E2%80%94-socialized-medicine-vis-%C3%A0-vis-amer [Last accessed on 2016 Jan 29].
2. Blaylock RL. Regimentation in medicine and the death of creativity (Part 1). HaciendaPublishing.com, March 14, 2015. Available from: http://www.haciendapub.com/articles/regimentation-medicine-and-death-cre… [Last accessed on 2016 Jan 29].
3. Blaylock RL. Regimentation in medicine and its human price (Part 2). HaciendaPublishing.com, March 20, 2015. Available from: http://www.haciendapub.com/articles/regimentation-medicine-and-its-human-price-part-2-russell-l-blaylock-md-ccn [Last accessed on 2016 Jan 29].
4. Faria MA: America, guns and freedom: Part I — A recapitulation of liberty. Surg Neurol Int 2012;3:133. Available from: http://www.haciendapub.com/articles/america-guns-and-freedom-part-i-recapitulation-liberty [Last accessed on 2016 Jan 29].
5. Faria MA: America, guns and freedom: Part II — An international perspective. Surg Neurol Int 2012;3:135. Available from: http://www.haciendapub.com/articles/america-guns-and-freedom-part-ii-%E2%80%94-international-perspective [Last accessed on 2016 Jan 29].
6. Faria MA. Bioethics and why I hope to live beyond age 75 attaining wisdom!: A rebuttal to Dr. Ezekiel Emanuel’s 75 age limit. Surg Neurol Int 05-Mar-2015;6:35. Available from: http://surgicalneurologyint.com/surgicalint_articles/bioethics-and-why-i-hope-to-live-beyond-age-75-attaining-wisdom-a-rebuttal-to-dr-ezekiel-emanuels-75-age-limit/ [Last accessed on 2016 Jan 29].
7. Faria MA. Enhancing access via medical freedom — Call it MSA empowerment. Medical Sentinel 2000;5(4):123-127. Available from: http://haciendapub.com/medicalsentinel/enhancing-access-medical-freedom-call-it-msa-empowerment [Last accessed on 2016 Jan 29].
8. Faria MA. Enhancing medical care in the U.S. via health savings accounts (HSAs). Surgical Neurol, 2005 Sep;64(3):276-7. Available from: http://haciendapub.com/articles/enhancing-medical-care-us-health-savings-accounts-hsas [Last accessed on 2016 Jan 29].
9. Faria MA. Longevity and compression of morbidity from a neuroscience perspective: Do we have a duty to die by a certain age? Surg Neurol Int 2015;6:49. Available from: http://surgicalneurologyint.com/surgicalint_articles/longevity-and-compr… [Last accessed on 2016 Jan 29].
10. Faria MA. Medical liability tort reform: a neurosurgeon’s perspective. Surgical Neurology 2004;61(3):304-307. Available from: http://www.haciendapub.com/articles/medical-liability-tort-reform-neurosurgeons-perspective [Last accessed on 2016 Jan 29].
11. Faria MA. ObamaCare — Toward free market or socialized medicine? HaciendaPublishing.com, September 26, 2011. Available from: http://haciendapub.com/articles/faria-Obamacare-%E2%80%94-toward-free-market-or-socialized-medicine [Last accessed on 2016 Jan 29].
12. Faria MA. ObamaCare — Another step toward corporate socialized medicine in the U.S. Surgical Neurology International 2012;3:71. Available from: http://surgicalneurologyint.com/surgicalint_articles/Obamacare-another-step-toward-corporate-socialized-medicine-in-the-us/ [Last accessed on 2016 Jan 29].
13. Faria MA. Rationing irrationality in anticipation of ObamaCare. HaciendaPublishing.com, October 4, 2013. Available from: http://haciendapub.com/articles/faria-rationing-irrationally-anticipation-Obamacare [Last accessed on 2016 Jan 29].
14. Faria MA. Religious morality (and secular humanism) in Western civilization as precursors to medical ethics: A historic perspective. Surg Neurol Int 16-Jun-2015;6:105. Available from: http://surgicalneurologyint.com/surgicalint_articles/religious-morality-and-secular-humanism-in-western-civilization-as-precursors-to-medical-ethics-a-historic-perspective/ [Last accessed on 2016 Jan 29].
15. Faria MA. The road being paved to neuroethics: A path leading to bioethics or to neuroscience medical ethics? Surg Neurol Int 2014;5(1):146. Available from: http://surgicalneurologyint.com/surgicalint_articles/the-road-being-paved-to-neuroethics-a-path-leading-to-bioethics-or-to-neuroscience-medical-ethics/ [Last accessed on 2016 Jan 29].
16. Faria MA. Vandals at the Gates of Medicine — Historic Perspectives on the Battle Over Health Care Reform. 1995. Macon, GA: Hacienda Publishing, Inc. Review available from: http://surgicalneurologyint.com/surgicalint_articles/a-critique-of-dr-miguel-farias-book-vandals-at-the-gates-of-medicine/ [Last accessed on 2016 Jan 29].
17. Miller CF. Why I am concerned about the future of medicine. Surgical Neurol Int 2014. Available from: http://surgicalneurologyint.com/surgicalint_articles/why-i-am-concerned-about-the-future-of-medicine/ [Last accessed on 2016 Jan 29].
18. Stolinsky, David C. Is our health-care system “broken”? HaciendaPublishing.com, November 1, 2015. Available from: https://www.haciendapublishing.com/articles/our-health-care-system-%E2%80%9Cbroken%E2%80%9D-david-c-stolinsky-md [Last accessed on 2016 Jan 29].
Written by Dr. Miguel Faria
Miguel A. Faria, Jr., M.D. is an Associate Editor in Chief and World Affairs Editor of Surgical Neurology International (SNI). He is Clinical Professor of Surgery (Neurosurgery, ret.) and Adjunct Professor of Medical History (ret.), Mercer University School of Medicine. Dr. Faria was a member of the Injury Research Grant Review Committee of the Centers for Disease Control and Prevention (CDC; 2002-05). He is the author of Vandals at the Gates of Medicine (1995); Medical Warrior: Fighting Corporate Socialized Medicine (1997); and Cuba in Revolution — Escape From a Lost Paradise (2002). His website is https://haciendapublishing.com
This article may be cited as: Faria MA. Free market or socialized medicine for the future of US health care? Surg Neurol Int 23-Jun-2016;7:68. Available from: https://haciendapublishing.com/free-market-or-socialized-medicine-for-the-future-of-us-health-care/
Copyright ©2016 Miguel A. Faria, Jr., M.D.