Why comparing healthcare access to food is a false analogy

When I was in training as a resident and a fellow, I remember taking only a couple of sick days over the entire 6-year period.

And I had to stay home because I could not stop praying to the porcelain Goddess during a bout of a particularly nasty flu, despite a vaccination. I actually took pride in my health record, and attributed it directly to being rather sickly as a child. Well, not really sickly; I just contracted all of the childhood illnesses that prevailed at the time in my geography.

Yes, I spent my childhood in Odessa, Ukraine, where I got vaccinated against polio and smallpox, but not against measles, mumps, rubella, chicken pox, whooping cough or any other diseases that our children in the West will never contract. So, every couple of months I would succumb and have to stay home with a fever and a rash, and my mother would call my pediatrician who would come and visit me in our home promptly to examine me and, most of the time, reassure my mother that I would likely survive this time. And then, at the end, I was promptly seen at the clinic to be sure that I had recovered completely.

This is why James Gaulte’s entry on KevinMD.com got me thinking. I know that we have a hard time seeing shades of gray, but see them we must. Even if something seems bad to its core, some things about it may not be horrible. For example, we can argue whether home visits are the most efficient way to practice medicine, but we cannot argue the fact that healthcare in the USSR afforded me access to this primary care service. As it afforded it to every citizen, child or adult. Yes, I am thankful that I did not require any serious life-saving interventions, as those would surely have been either unavailable or substandard.

But then again, why should the need for heroics be the rule and not the exception in a relatively healthy population? Should we not instead throw our energies into addressing common things? My point is that, despite its many undisputed flaws, the socialized medicine in the USSR provided access to a healthcare system when it was needed, albeit not one that I would want if I required some state-of-the-art intervention. But again, the vast majority of a reasonably healthy population should not routinely require high technology medicine. So, a modicum of access to a reasonable system is not something to sneeze at. Take it from someone who lived it and did a lot of sneezing. And lest I be misquoted, I want to be very clear that I am not in any way advocating emulation of the Soviet style system, but merely pointing out that some things about it were not all bad. Just as some things about our catastrophe-focused system are not all bad. What is needed, as always, is some middle way.

Another point — comparing healthcare access to food? As already pointed out by a commenter, our food system is far from an example of free market success, as it is heavily subsidized by our tax dollars. Of course, one can argue that this centralization of food production has been a huge environmental and health disaster for our nation. So, this would appear to be an argument for decentralizing everything. If only healthcare were as simple as food…

Food happens to be a very bad analogy for our healthcare system, and here is why. Although we now indulge in high-technology food engineering, the reality is that food is a simple enterprise. If one has access to even a small plot of land, virtually anyone can produce their own food. As an example, people in cities and suburbs are beginning to raise their own back-yard chickens, and community gardens are springing up in large urban centers. If one cannot grow his/her own food, farmers’ markets are making a big comeback, and not just in rural areas. These locally grown healthy alternatives to mass-produced E. coli and salmonella-contaminated products are inexpensive, and many farmers are willing to barter their wares for services and products that customers can offer. So, food, while necessary for survival, is fundamentally a low-tech enterprise.

Along these lines, one could compare food to medicine, but the medicine prior to the Industrial era, when technology was non-existent and our doctors and farmers had far more similar business models. A doctor was a part of the community, there were no $10,000-a-week treatments, and bartering was acceptable in the doctor’s office. Today’s impersonal behemoth healthcare system with its fancy shiny and expensive gadgets, coupled with reimbursement rates in direct proportion to higher technology utilization, can hardly be compared to authentic food production. Simply put, while almost anyone in theory is able to access good food cheaply (the fact that we choose not to does not impact this point), no such possibility exists in the current healthcare system in the US.

Well, time to summarize.

Point #1: Not everything in an evil system is evil. It is useful to recognize paradoxically good points and see whether and how we can apply them to our situation.

Point #2: Comparing access to healthcare to access to food is perpetuating a false analogy.

Point #3: Can it be that Roemer’s rule is at play in our entire healthcare system? That is, since we have built a system for catastrophic health crises, now catastrophic health crises must be the rule and not the exception?

Think about it. Tell me if you think I am correct or completely out in left field.

Marya Zilberberg is founder and CEO of EviMed Research Group and blogs at Healthcare, etc., where this post originally appeared.

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  • http://fertilityfile.com IVF-MD

    I agree that in our world, it is physically possible to shift all our resources as to provide the maximal (or at least optimal) amount of food to every man, woman and child, while it’s not possible to do this with respect to healthcare. Two reasons are 1: Healthcare has no upper limit. 2. Providing healthcare can be way more resource-consuming than providing food.

    We have a RIGHT to pursue our own healthcare. We don’t have a right to force other people to sacrifice their time, energy and effort to provide us healthcare for nothing in return.

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

    I like the honest thoughtfulness of your post, but I don’t agree with much of it.

    There are reasonable analogies between food production and health care. But only in some countries can you try to point out the folly of a ‘right’ to health care by pointing out that we don’t have a ‘right’ to food. In communist countries, you cannot point out the absurdity in this way, because there it is believed we have a right to food as well!

    In any case, I think you underestimate the amount of technology, thought, and special knowledge that goes into creating and preserving the food of 1st world nations. I little pondering though will allow you to realize the vast resources that are brought to bear on this project (transportation methods, packaging, cleanliness, listing of ingredients and nutritional information). There is fast food, frozen food, and the nicest meals available at fine restaurants. There is a big difference between this and tomatoes I can grow in my back yard! There are vast and efficient resources at play here. In first world countries – food can be what you want it to be – quick, nutritious, cheap, or even work of art.

    I’m glad that you enjoyed some medicine provided by the state. I’m not sure you realized the cost you were paying for it, though. The cost of that modicum of ‘free’ health care was a decrepit overall system where, even you admit, you wouldn’t want to be exposed to if you had a more serious illness. A better system would allow everyone to have a career and make a profit in health care – thus giving rise to a vibrant industry that you would want to take advantage of, should the need arise.

    There are problems with the US health care system – but they stem from serious interference in the natural market due to innumerable forces – most of them originating from the premise that health care is a right and something that should be controlled by the state.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      Unfortunately, this vibrant market-driven system is barring most people who are involved in making your food “what you want it to be” from obtaining the same food you do, let alone the “work of art” portions of it.

      And the same “better system” is prohibiting those food creators (small farmers, cooks, dish washers, servers, truck drivers, packaging workers, migrant workers, need I go on?) from access to a system where other, more fortunate people “make a profit in health care”.

      I am not at all advocating the Soviet system and I don’t think the author does either, but there has got to be a better, more humane and more equitable way…..

      • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

        I’m all ears.

        • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

          I am not naive enough to presume that I have a perfect solution. There are multiple universal health experiments around the world, none perfect and all experiencing financial stress. This is most definitely a challenge, but since when do we shrink from a challenge? What is preventing us from looking around, learning from other people’s efforts, and mistakes, and then coming up with a uniquely American and better solution?
          Sadly, I think that we simply have no desire to provide adequate health care to all, or perhaps we reached a point where we cannot be bothered with tough challenges anymore.

          • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

            That uniquely American solution is actually called freedom and markets. If you review the ideas of the Austrian economists, they note that markets work far better and more mysteriously than economists or the smartest government planner can fathom. They naturally self-organize. Through the billions of decisions of producers and reactions to prices, you get a very efficient system that is continually improving itself. All the government needs to do is enforce individual rights, including property rights, and settle legitimate conflicts. For the rest, they simply need to step out of the way.

            If you observe one of the less regulated areas of our system (computers and software) you will note that innovation and excellent technology are continually being brought forth.

            So, is the government stepping out of the way, when it comes to health care? Far from it. Health care is one of the most regulated industries that exists. It is regulated at every level – hospitals are regulated by states and at the federal level. You cannot even open a hospital or free-standing ER without a ‘certificate of need’ from the local community (talk about anti-competition). Currently the US government spends 50% of all health care dollars in this country – driving prices up by doing so. There has historically been a massive push for health insurance to cover everything (wage/price controls historically led to this) – thus leading to a third-party payer system for everything, including routine outpatient visits – again driving up prices for things that should be much cheaper. Medicare and Medicaid have set that expectation in concrete. Doctors cannot practice without a license, and in many hospitals – without becoming board certified – leading to a shortage of physicians or an inflation in their charges (depending on how they are paid). Drug development is immensely expensive because of the requirements of the FDA. The FDA can also suddenly eliminate your drug from the market, or, make it an over the counter drug anytime after it has been approved! EMTALA laws, Stark laws, irrational lawsuits, lack of portability of insurance (due to tax laws), state requirements for certain types of coverage [making health insurance more expensive], massive bureaucracy and red tape that controls health insurance companies.

            I have been attempting to innovate in the medical field for at least 10 years. Nearly every time I came up with a new idea, I would have to run it by our practice manager who would then point out all the regulations, laws, and concerns that made it either impossible or potentially risky for our practice. While it is not impossible to innovate in medicine, it is certainly far harder than most other industries.

            So, you see, it is actually the liberal notion (and actions taken based on that notion) that health care is so important that it cannot be left to the markets that has gradually undercut the market’s ability to provide health care. Not completely (as the US still has one of the best systems in the world) but certainly to a great extent.

            There is nothing to prevent a truly free market from providing low cost catastrophic health insurance to most anyone. There is no reason why a true market would not provide low cost basic health care to almost anyone with a modicum of income.

          • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

            Dr. Allen,
            I do not oppose capitalism and free markets. However free markets are by definition regulated to prevent harming the citizenry. This is the role of government in the food industry, transportation, electronics, and you name it. When it comes to health care, I believe the FDA concept is as needed for drugs as it is for food, if not more. I don’t know what to say about board certification for physicians, but I find hard to believe that you would be satisfied with barbers doing surgery in unsanitary conditions in Times Square. Government has a pivotal role in free markets and there are no free markets where Government is not existent or not stable enough to support them.

            Your comparison to the computer & software market is very tempting until you realize that computers and software and technology in general are not accessible or even available to all citizens. There is a rather significant digital divide between the haves and have nots. Survey after survey shows that the poor, the elderly and minorities are lacking computers and broadband and are basically not with us here on this blog. This is a natural result of a free market and for technology, it is perhaps acceptable. After all, nobody died for lack of access to Facebook.

            Health care is different. People do die for lack of health care. Health care is also different because there is no cheap alternatives to most procedures. To go back to food for a moment, you can live a happy productive life on $5 worth of food per day, or $500 for the same. This range does not currently exist for, say, cancer treatment or liver transplants.
            If the free market is allowed to run unfettered here, you will probably see a decrease in some consumer prices and most folks will be able to afford some sort of “coverage”, while the usual suspects will have none.
            The quality, and extent, of care one receives would be directly proportional to their net worth and this may be fine for a purely capitalist view of the world, but it is not a sustainable method for maintaining freedom and democracy without which capitalism cannot thrive either.

          • ninguem

            Yes, try any other country’s system. As long as that system does not consider use of high-deductible health plans and Health Savings Accounts. You want to consider anything, except a system with demonstrated popularity and a track record of keeping costs down. Putting control of the healthcare dollar back in the hands of the middle class is an existential threat to the left.

          • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

            “However free markets are by definition regulated to prevent harming the citizenry.”

            No, not really. And certainly not by definition. Certainly regulators would have you believe their regulations are helpful – but truly it is the market that is helping people, with the regulators always a step behind and taking advantage of a ‘standard’ which has already been established by the market.

            Regarding your support of the FDA, you must understand that the FDA has a one size fits all approach to drugs. It should be an individual’s choice, with the advice of his doctor [if he chooses that] to take or not take a particular drug. People own their own lives and not the government. If you really want an FDA, then allow it to advise people about what to take, but not allow it to control drugs. This puts the locus of control in the patient’s hands. There are numerous examples of the folly of the FDA, but suffice it to say that the person who has terminal cancer has every right to consult his/her doctor and try a new (but as yet unproven, per the FDA) drug in order to attempt to preserve his life.

            Regarding your ‘digital divide’, you are performing a static analysis. Every 5 years or so, computers get faster, the internet gets better, cell phones get cheaper, etc., etc.. Will there always be some people who can afford better stuff than others? Of course. But if you project yourself back 50 years – you will get the proper perspective that EVERYONE is getting better access to technology. (To put it more bluntly, there wouldn’t BE a digital divide, until the capitalists created the digital.)

            “I don’t know what to say about board certification for physicians, but I find hard to believe that you would be satisfied with barbers doing surgery in unsanitary conditions in Times Square.”

            Is that what you think the market would provide? First of all, let me point out that there are many physicians who practice today, legally, who do not hold board certification – and who are excellent physicians. Do you think the ‘market’ though would eliminate board certification? I don’t. I think certifications for car mechanics, plumbers, doctors and yes, even barbers, will always have their place – as an indication (but not a guarantee) of quality. All of that changes once you have had some experience with the person in question – in which case you begin to make up your own mind. By the way, you will find many people are perfectly happy to see a nurse practitioner or a physician’s assistant for some problems. They’ll even go to a nurse who works at a Minute Clinic. They factor in the seriousness of the situation, the speed and access, and the costs. People are perfectly capable of using their own minds to decide what to do with their own health. If they want it, they are perfectly capable of using rating services and board certification to demand higher quality.

            I think part of your thinking stems from a misunderstanding of why things improved. It is not that physicians had low standards, and the government came in to clean everything up and demanded higher standards. Rather, it is that the market slowly improved – improving standards and treatments with the government trailing along behind, stating, in effect “OK, now this should be the new standard.”

            “If the free market is allowed to run unfettered here, you will probably see a decrease in some consumer prices and most folks will be able to afford some sort of “coverage”, while the usual suspects will have none.”

            You are basically conceding here. Now it us up to charities (to you and me and anyone else who wants to be involved) to help those deserving folks who are so poor that they cannot afford health care or catastrophic health insurance. Welcome aboard the freedom train.

          • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

            I do understand the power of markets. However unregulated markets translate into collusion, monopolies and a variety of schemes that work to the disadvantage of common folks. Even Adam Smith recognized this simple truth. The question is not whether markets need to be regulated, but to what extent they need to be regulated. I assume we differ on this point.

            As to the FDA, if you note the verbiage in my previous comment, you will see that I spoke of the “FDA concept”, not the FDA per se. I am aware of the shortcomings, but at the same time I prefer a vendor neutral regulatory body to keep the snake oil (and worse) peddlers out of the market. I’m sure we could let the market decide this one too, and after people were harmed and died in droves, the offenders will eventually be ejected, but it may take many decades and much suffering.

            And this last point is also why we cannot just leave health care to market forces. I do concede the theoretical possibility that the invisible hand may fix health care eventually, but just like technology, it could take 50 years or 100 years of incremental change. And while we wait, we will lose all semblance of humanity, assuming it will be even possible to wait.
            People in general are accepting of the notion that some folks have less, others have more and a few have a lot more wealth, based on luck, hard work and genetics. They will not be accepting this rationale for distributing life expectancy. If they did, we would not be having this discussion right now.

          • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

            The progression of our discussion is interesting – as it is taking very traditional turns.

            Now we are to: “Yes capitalism is good, so far as it goes, but due to evil people within it and their tendencies, it must be regulated.” This of course, depends on what type of regulation you are talking about. The issue is only the preservation of individual rights – that is – the protection of freedom of action of the individual and of property rights. There are all sorts of special circumstances which might require special laws, but that is the principle issue. You must certainly outlaw the use of force or fraud in the marketplace.

            Monopolies, unless established by the government, simply don’t exist under well-developed capitalism. I would say that they might be possible, temporarily, in an extremely remote area of the world – in which, so far, only one company has access. If you examine history (Robber Barons and the like) in this country, you will find that some of the worst examples of behavior were due either to government granted monopolies or due to an overall lack of competition (remote areas).

            WRT to your ‘FDA-like’ concept – again I would offer you a government body which studies the issues and makes recommendations – but which has no control over the drugs. This preserves everyone’s freedom. You would be able to consult that government body to decide which drugs you think you should or shouldn’t take. Other people would decide in a manner they were comfortable with. Everyone is free and happy.

            “it could take 50 years or 100 years of incremental change”

            Hardly. In one sense, there is no time horizon, since the job of the markets is never done – they are always striving to make a higher profit, which means striving to make their products better and better – and often cheaper and cheaper. But if we could somehow wave a magic wand and eliminate vast amounts of regulation and government interference in the markets – it would probably take no more than 10 years to establish a very fine system. After all, we have the very good beginnings of that system in place.

            Of course, we cannot wave that magic wand, because it would take a lot of hard work to reverse of the damaging regulations that are already in place. It also would not be fair to those who are ready to retire to eliminate their Medicare (that they have been counting on) just before the age of 65. I’m in favor of a slow phase out of Medicare.

            “They will not be accepting this rationale for distributing life expectancy. If they did, we would not be having this discussion right now.”

            I’m not sure what you are referring to – a revolution? Based on lack of heath insurance? If that is the case, why didn’t we have that revolution prior to 1900 when no one had health insurance? Why don’t we have that revolution on the part of the poor in general, who have a lower life expectancy. (http://www.google.com/imgres?imgurl=http://www.bmj.com/content/320/7243/1200/F1.large.jpg&imgrefurl=http://www.bmj.com/content/320/7243/1200.full&usg=__aFw3tx-qUQsMIhylmcRLii6YLRw=&h=906&w=1280&sz=138&hl=en&start=0&sig2=vrBEzg_f0SReJxDlaUTVFA&zoom=1&tbnid=ZRipiRB4-XcknM:&tbnh=125&tbnw=177&ei=hAvxTLHUEMKB8gbdtdi0Cg&prev=/images%3Fq%3Dus%2Blife%2Bexpectancy%2Bvs%2Bincome%26um%3D1%26hl%3Den%26client%3Dfirefox-a%26hs%3DyWg%26rls%3Dorg.mozilla:en-US:official%26biw%3D1920%26bih%3D854%26tbs%3Disch:1&um=1&itbs=1&iact=hc&vpx=455&vpy=226&dur=9256&hovh=189&hovw=267&tx=120&ty=125&oei=hAvxTLHUEMKB8gbdtdi0Cg&esq=1&page=1&ndsp=50&ved=1t:429,r:12,s:0)

          • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

            Capitalism in its pure theoretical form is as likely to be successful as communism was in its equally pure and theoretical form. Both sound enticing and both are doomed to failure not because people are evil, but because humanity does not exist in a pure and theoretical format.

            Communism failed because it failed to recognize this simple truth. Capitalism, as it is practiced in this country, has been rather successful precisely because it was flexible enough to adapt to human nature and perhaps also because it is more cognizant of said nature.

            Health care in the 1900s had very little to offer to quality of life for any given individual. As time progressed and medicine advanced, health care has become a life necessity, or at least it is perceived now as a life necessity in developed countries. [As an aside, it is interesting to note that freedom was not considered a life necessity until a certain point in time, but when it acquired that status, capitalism had to adapt and ensure that freedom was given to all in equal amounts, at least on paper. It took a war to accomplish that. Communism while paying lip service to the notion of personal freedom, failed to put this simple truth into actual practice.]

            Other things have also gained the status of life necessities in developed countries. Clean water, electricity, education and sanitation. For all of these Government took an active role in ensuring equitable availability to all citizens regardless of ability to pay, since no one individual of average means can provide them for himself. We may debate the level of success the Government had in these endeavors, but Capitalism did not seem to be harmed in the process and perhaps the opposite is true. Uneducated people living in filth are not conducive to good business.

            When light and warmth were provided by means of candles and sticks, they were within most people’s reach. As technology advanced and it now requires turbines and miles of cabling and great infrastructure to shine a light, Government had to intervene and regulate.
            Although health care is more complex and not binary (on/off) like electricity, we have reached the point where individuals with average means cannot provide health care for themselves any longer and Government is obliged to intervene, and sooner or later it will do so to greater extent.

            Capitalism, I believe, will adjust and embrace the change even though one industry may cease to exist in its current format (Adam Smith’s candle-maker is gone as well). I guess I trust our form of Capitalism to see that as uneducated people living in unsanitary conditions are bad for business, sick people are just as bad.
            [Another aside note: If you look at what large employers are doing regarding health care and wellness of their workforce, you would be led to conclude that most pillars of Capitalism have already realized that.]

          • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

            At some point, I guess we’ll have to call it quits, but among other things you said: “When light and warmth were provided by means of candles and sticks, they were within most people’s reach. As technology advanced and it now requires turbines and miles of cabling and great infrastructure to shine a light, Government had to intervene and regulate.”

            This simply doesn’t follow. Does the complexity of the industry, or buy-in price of entering the field, have anything to do with a reason for government interference? I would rather argue the opposite. The government is notoriously behind the curve when it comes to the application of technology to the job of living – and so serves only as an impediment to progress. Furthermore, the customer doesn’t have to invest in all this technology. That is the beauty of capitalism – those who are involved in the field are the one’s who must understand it the most – the others just flip on their light switch. Neither must they invest in the infrastructure. If they don’t want to buy electricity – they go back to their candles, or buy a generator – or whatever they believe is in their own interests.

            “Although health care is more complex and not binary (on/off) like electricity, we have reached the point where individuals with average means cannot provide health care for themselves any longer and Government is obliged to intervene, and sooner or later it will do so to greater extent.”

            Again, there is no logical argument ‘from complexity’ that makes sense here. Again, only the specialists need understand things to a great level of detail and only those who are providing the products need to invest long-term in them.

            “Capitalism, I believe, will adjust and embrace the change even though one industry may cease to exist in its current format”

            Capitalism is that system that arises when you protect individual rights and property. At a certain point, I believe you will no longer know what you mean by capitalism – as you want it to embrace its antithesis.

          • http://www.twitter.com/alicearobertson Alice

            Margalit Gur-Arie says:
            Dr. Allen,
            I do not oppose capitalism and free markets. However free markets are by definition regulated to prevent harming the citizenry. [end quote]
            Then Margalit Gur-Arie says:
            Capitalism in its pure theoretical form is as likely to be successful as communism was in its equally pure and theoretical form. Both sound enticing and both are doomed to failure not because people are evil, but because humanity does not exist in a pure and theoretical format.
            [end quote]

            Alice responds: If you are a purist then nothing is going to work. Ayn Rand was a purist, the walking example of the greed of capitalism, yet her ideas of how to make a profit were on the purist level and they do work. Yet, Teddy Roosevelt said sometimes the capitalists need policing…and he was a capitalist….not a purist…..a realist…..which most capitalists are. But we fear the purist form of those who say the free market doesn’t work. If we look to Europe (particularly Russia right now where they are blackmailing and falsely arresting businessmen for money and driving them out of the country) we see the government cannot be sustained without a free market. We need to encourage it…it provides jobs, innovations that save lives, and important tax money….yet the government wants the tax money and they want to run the market (on an aside it’s interesting that Obama and his cabinet are all vested in the stock market, so they have a personal interest in making sure it works…..keeping profitability in their own pocket. Hmmm…….a little selfishness going on with the government and the liberals too).

            Look at Cuba…..the land of Michael Moore’s fantasy (ever see those youtube videos taken secretly…..where people risk their lives to use their cellphones and tape the truth of what a Cuban hospital looks like?). The land Michael Moore doesn’t want to live in, nor get medical care for him or his family? Castro made a call to an American economist to come down to Cuba and help him out of the socialistic mess…..it just doesn’t work. Capitalism does……even with it’s flaws.

            Margalit….I am having trouble figuring out where you stand. I imagine we all have the same objective. We do want to help people……but looking to the government to solve everything ultimately isn’t the answer…..we need to encourage the free market…and yeah, some skepticism is fine with the markets……but hugely desired with the government.

          • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

            I agree with you that we probably reached the point where we should call it quits.

            We could take a large detour into the meaning of individual rights and the definition of property as they evolved since Capitalism was first defined, but this is probably better left to another day and another KevinMD post.

            It has been a pleasure “talking” to you and I am thankful for the fact that we do not agree on this issue. It makes conversation so much more interesting…. :-)
            Thank you.

  • ninguem

    “…….the socialized medicine in the USSR provided access to a healthcare system when it was needed…….”

    Must have been pretty easy to do, between Stalin and Lysenko, there weren’t nearly as many Ukranians left to need healthcare.

  • http://evimedgroup.blogspot.com Marya Zilberberg

    Thanks for your comments, everyone. I am always struck by how easy it is to take a few statements out of context and run with them in the direction we want to go, without paying any mind to all the surrounding commentary.

    David, your “Dagney Taggart” view of the world is not a way I wish to live. I see myself as a part of communities where money is not the sole driver of relationships. Equity and social justice need to be factored into the equation. Food production in the “developed” world is an issue that we can spend years discussing. I will simply say that I agree with Margalit’s remarks and stop there.

    ninguem, did you read the rest of the post?

    • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

      I welcome your right to your world view. I applaud your seeing yourself as part of communities with things other than money being more fundamental to the relationship. (Indeed, I share that notion). Things only get sticky when you (and others) attempt to take my (and others) money to pursue ‘equity’ and ‘social justice’.

  • jenga

    I prefer to live with David’s “Dagney Taggart” worldview. I will say I agree with David and stop there as well. Sometimes there is no middle ground.

  • Alice

    What a nice article…..a bit of romantic era nostalgia? Although, the doctor patient relationship may have been one to desire…….no way would I want treated bedside with just a black suitcase as the doctor’s arsenal (or the food back then before refrigeration). Reality and romanticism often collide……but the dream and the desires of your heart can be used for good in today’s complicated system.

  • Marc Gorayeb, MD

    Socialized systems are great at providing basic health care services, because they are cheap and don’t depend on intellectual innovation. I for one will take great catastrophic care over great basic care any day.

    I perceive an attempt to exploit rhetorically the difference between “access” to something and the “right” to something. Allow me to re-direct the discussion to the philosophical conception of social rights, and the prioritization of rights. Taking the perspective of a socialist humanist (for the moment), it seems to me that a right to shelter and food should take precedence over a right to health care. So I concur with your opinion without joining it; the right to food cannot be compared with the right to health care. In my utopia, food rights win.
    Now consider a non-utopian perspective: the idea that everyone should have an economic safety net. If the need for food, shelter or health care threatens to impoverish someone, our social system should provide support. Not otherwise.

    • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

      The problem with safety nets is that they work really well when there are relatively few people that need them.
      I am afraid that we reached a point in this country where a majority of people need support, which cannot be provided equitably or efficiently by the safety net mechanism any longer.

  • Alice

    Marc…I tend to agree……but the word “provide” is up for grabs. I think people are lacking in understanding on the word “rights”. We have natural rights, legal rights, etc. and a study of the Constitution would help the liberal mindset that wants a type of class warfare that will lead us right back to where we are now as we realize (as the European model shows)…..socialism doesn’t work on the grand scale…someone has to pay for all these gifts…..um supposed rights.

  • ninguem

    Yes, I read the rest of the post.

    The cost of that primary care was freedom. The cost of that primary care was bribery to get hospital care. The cost of that primary care was millions of Ukranian dead, killed by a regime with more blood on it’s hands than the Third Reich. That’s quite an accomplishment, and no, it’s not an exaggeration. See Black Book of Communism, Soviet Story, or similar.

    Primary care is cheap. Specialty care is expensive.

    So those lives were lost, the freedom was lost, for a mess of pottage. Not that they had a choice.

    And you didn’t even get good health statistics from that. I know what the Soviets said their health statistics were, and I also remember analysts at the time, contrasting what the government said, compared to records of shipments of small coffins, buried in an obscure report where they thought no one would notice. Because those vaccines often didn’t work. Like so much else in the USSR.

  • http://evimedgroup.blogspot.com Marya Zilberberg

    ninguem, do you see me advocating for the Soviet system? I am merely pointing out that it is not a bad thing to have access to primary care. And yes, primary care is cheaper than catastrophic care. It is also more cost-effective than catastrophic care. Should we not make sure that we have universal access to routine stuff for all before we agree to provide access to a treatment that costs $2.5 million for an extra year of life for an individual?
    Some may say that inability to afford healthcare is a personal problem. But when 50 million people out of 300,000 cannot afford care, does it not become a societal problem? I think so.

    • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

      I have often wondered about the statement that primary care is cheaper than catastrophic care. Is it true? Is there some data to back up this idea?

      You might say, well of course it is true, paying for a year’s supply of diabetes medications is highly likely to cost less than a hospitalization for a myocardial infarction, including an angioplasty! But is that really what you should be comparing? Shouldn’t you be comparing the cost of the number needed to treat (let’s say, 25 people – I don’t know the real number) to prevent one hospitalization? And if this analysis does yield a positive (in support of preventative care) result, then wouldn’t those who are paying this bill (the insurance companies) have an incentive to offer their medications free (or at much reduced costs) just to achieve this end?

      And looked at over a lifetime, haven’t you just delayed a hospitalization that you might have to pay for eventually anyway? After all, the same person may get that heart attack the following year – despite all the money that has been spent. From the insurance companie’s perspective – maybe it is best that they take your money, you take no medications, and then you suddenly die one day – never making it to the hospital!

      And perhaps the non-portability of health insurance is having an effect here. Because insurance companies don’t necessarily keep their clients for life – there is an underemphasis on long-term goals – since the ‘benefits’ may accrue to another insurance company. It is interesting, in any case, to think about how easily we all just accept certain notions.

      Now for diseases like cancer, it would seem sensible that preventative care would be much cheaper – but again – there is certainly debate on that issue – just look at the controversy regarding mammograms.

      • ninguem

        “…….I have often wondered about the statement that primary care is cheaper than catastrophic care. Is it true? Is there some data to back up this idea?……”

        Depends on how you’re looking at it, I suppose. Example that comes to mind. I have this patient, a small businessman. Came to me for the first time, known diabetes, sugar 300 or some such unacceptably high number, can’t recall. Blood pressure 160/100, high cholesterol, you know the drill.

        No surprise, times are hard, he lost insurance, or should say, couldn’t afford it. “Can’t see a doctor because I don’t have insurance.” I gave him the “insurance does not equal healthcare story”, which in his case worked, as he was in business. Metformin and glimiperide controlled his sugar when he had insurance. I pointed out the drugs he needed were ten dollars quarterly at most any pharmacy these days. My office fee a few times a year, and lab tests in-office. I have a cash pay schedule for all that, the usual prompt pay discounts, it was a few hundred dollars total, in a year, for all of it.

        “I don’t claim to know your personal financial situation, but was it that bad?” Bad, but not that bad, when he thought about it.

        He went out and got his high-deductible health plan and opened a HSA, which he’ll contribute to when he can. Yes, even with diabetes and HTN, not impossible. He saw the light.

        Cheaper than ER visits for him.

        Long run, another matter. I’m sure out-of-control diabetes and HTN, with a sudden-death MI is cheaper than primary care leaving him with diffuse coronary disease in older age.

        • ninguem

          Does the University of Massachusetts still have it’s annual symposium on Marxist economics? They founded the journal “Rethinking Marxism” in 1988, right before the Soviet Union collapsed. And no, they’re not “rethinking marxism” as in “we were wrong”, it’s the tired old “it wasn’t done right”.

          UMass has been particularly infamous for a Marxist economics deprtment. I mean holding regular meetings on the subject, symposia, publications, for decades.
          I suppose someone has to do it.

  • ninguem

    “……I am merely pointing out that it is not a bad thing to have access to primary care…..”

    You pointed out that under Communism, you had access to free smallpox vaccine, polio vaccine……and nothing else. You had access to clinic visits to tell you, after the fact, that the illness was recovered. Inability to get specialty care in the Soviet system is well documented, requiring bribes and political connections.

    So under the USSR, by your own description, you got inadequate vaccinations, clinic visits to tell you what you already knew, and a good thing that, because if you really did get sick, there would be no specialty care available to you.

    • Alice

      I read at times there are needle shortages in the USSR. There’s a cost saving method we should think about here. They run out of anesthetic too (the lucky ones get Vodka).

      Read the UK newspapers…..dirty sheets and some pretty awful stuff going on in the land Dr. Berwick loves. Romantic notions feed our emotional side, but when it comes to the physical side….I’ll take the good ole’ USA above any other nation on earth.

  • Muddy Waters

    Believe it or not, in the late 90′s, I actually visited a friend in a hospital in Estonia (part of the former USSR). Honestly, it was like walking into a history book. Even the waiting room chairs looked like fossils (and there was dried blood on them to boot). And, this was AFTER democracy had prevailed. Scary.

  • Jenga

    The truth that alot of patients need us to get better less than we would care to admit. Health of a population has far less to do with specialty and primary care and far more to do with lifestyle and environmental factors. Look at how much Albania spends per person on healthcare and their life expectancy. They spend less than 800 bucks per person have a piss poor primary and specialty care system but live longer. They also don’t have rampant smoking, don’t drive alot of cars and have 1/3 of their population being obese.

  • Dr. Kene Mezue

    It’s very sad that a first world nation like America does not extend health care to all it’s citizens…It is depressing to note that even with the “religious” nature of the Right and the “cerebral evolution” of the Left, there is no consensus to help the helpless.

    Working in the third world, I saw how people died simply because they couldn’t afford antibiotics to fight off an infection, or because they couldn’t get blood for post-partum hemorrhage. It’s sad that those same conditions exist in the US.

    Inequality in Access to Health Care on its own can affect the health status of a nation…one doesn’t need a stretch of the imagination to see how and why that is possible.

    Finally, hear Prof. Michael Marmot talk about this issue and why there must be political commitment to reducing the inequality.


    • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

      I must say, Prof. Michael Marmot is very silly. He feels the western countries simply ‘found’ all those billions of dollars? They borrowed them! Is this his solution for the slums of the world?

      Does Professor Marmot ever ask himself why there are so many slums in the world? Does he really think throwing money at the problem is the answer? He needs to understand that people’s fundamental ideas as well as the types of governments they suffer from either eliminate or cause slums. Liberals are bold to point out inequalities between one nation and another, but not the things (dictatorships, lack of freedom, poor monetary policy) that give rise to those inequalities. Incredibly, we are asked to ignore all of that and just borrow money and give it to other countries. The professor is the ultimate example of ‘counting other people’s money’.

      The professor then demonstrates sheer stupidity when he claims the current western systems are examples of unfettered capitalism (building ‘corporate’ and ‘individual wealth’). No, thanks to people of his ilk, we are far from any such thing. The western world’s markets are highly regulated, highly interfered with, and highly susceptible to government manipulation of the money supply. Where has he been to even utter such non-sense?!

      Finally, he tries to tie this in to man-made global warming. Global warming due to man’s activities is an unproven hypothesis. Only the left, who want it to be the case, push so hard on this issue. It gives them a chance to fight against their real enemy, capitalism and industry.

      Make no mistake about it – capitalism, where it HAS been practiced (historically and currently) has, and always will, lead to a higher standard of living for those who are lucky enough to experience it. If suddenly the middle east, Africa, and Latin America – could be transformed into free-market zones – the world would be much better for it and the people in those countries – rather than needing ‘bail out’ money borrowed by other governments – would be producing their own food, medicine, and trading with other countries. The Left cannot continue to ignore the great productive benefits of capitalism and the improvement it leads to in people’s lives. If they do, people will start to wonder at their real motives in advocating against it.

      • gzuckier

        Time to propose a new variant on Godwin’s Law; all on-line discussions will eventually reach the point where one participant will make his case using the axiom that the hypothesis of anthropogenic climate change is a fabrication and a plot by leftists to bring down capitalism/industry/America/freedom/the Second Amendment/the third world.

        Much as I learned so long ago: Under Communism, Man exploits his fellow Man; but under Capitalism, it’s the other way around.

    • ninguem


      People in the USA do not die for inability to get antibiotics and blood transfusions.

      It’s a fair bet, any American who has seen medicine in a Third World country would prefer the care access of a typical poor American to the access of an average African. I know I would. I’ve seen both, practiced medicine in both.

      American healthcare has it’s problems, but what you describe is not one of them.

  • Jenga

    Those conditions don’t exist both examples you gave, if life threatening, would be treated in any ER in any city in the country.

  • Alice

    Dr. Mezue…..the religious right is often out volunteering and I tend to fear your argument is bit of a straw man. How many Americans died from no medical care last year? And can I ask how many hours a month you volunteer giving care to those who need it for free? I agree helping those with true needs who have exhausted the roads available need help…I have seen no one advocate what you laid out. But it is vital you understand the liberal ideology is not sustainable. Have you studied the budget cuts in countries like France and the UK. You offer band aid solutions while conservatives offer more realism. Hopefully, accountability and better use of resources instead of huge waste while beating a help the poor mantra on the taxpayers breaking back.

  • Dr. Kene Mezue

    @Jenga and ninguem…I beg to differ with you. Watching “Sicko” left a bitter taste in my mouth about the American health care industry that leaves close to 50 million people without access to the care they need. Cancer patients without access to life saving drugs, coronary heart disease patients without access to timely life saving procedures…it doesn’t get uglier than that in Africa. It’s sad that the medical establishment in the US have connived with big business to make loads of money, and they try to ignore the fact that the system is too expensive and does not reach the people that need the care. I hope the next generation of health care professionals will be more altruistic.

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

    50 million is an exaggeration. But if you want to fix the system, allow health care plans to offer simple catastrophic insurance (which most states do not allow to be sold). Even so, most anyone gets some form of treatment in this country simply by showing up to an ER. For other ideas on reducing costs, read Mackey’s points:


  • http://Www.twitter.com/alicearobertson Alice

    Sicko? Oh my…..that film had so many falsehoods. It is an untrue documentary…….sigh! Do you want the links with the real facts?

  • ninguem

    CMU = “Couverture Maladie Universelle” = French Medicaid.


    - «Non, je ne prends pas les CMU. Je ne peux pas vous parler, je suis en consultation.» Et le praticien raccroche. -

    I actually take my state’s Medicaid in my own practice. I don’t hang up on the callers, as in the above quote.

    Here’s Médecins Sans Frontières running safety net projects in France because of the gaps in their system. The poor, the welfare recipients, the illegal immigrants.


    Because the gaps…….big gaps…….persist, even in the so-called “best” systems. The problem with looking at other systems is the left has blinders to this. Or were these problems mentioned in “Sicko”?

  • ninguem

    Anyone using the Michael Moore movie “Sicko” to illustrate a point about healthcare, loses all credibility. The movie is nothing but a string of……..as Alice diplomatically puts it……..falsehoods.

  • ninguem

    “…….Think about it. Tell me if you think I am correct or completely out in left field……..”

    You’re in Boston, looking at Fenway Park’s Green Monster from the Lansdowne Street side.

    • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

      This is a nice gem from Milton Friedman:


      • ninguem

        Thanks. Here’s another Nobel Prize Winner, Amartya Sen.

        Mr Sen is the winner of the 1998 Nobel Memorial Prize in Economic Science, This was attributed to him, I believe in his book “Democracy as Freedom”

        “No famine has ever taken place in the history of the world in a functioning democracy,”

  • Dr. Kene Mezue

    “Anyone using the Michael Moore movie “Sicko” to illustrate a point about healthcare, loses all credibility”

    Anyone using Milton Friedman’s arguments to illustrate a point about healthcare, loses all credibility….ha ha ha. (especially given the recent crashes on Wall Street, the recession and the $2.5 trillion debt that greedy bankers have cost the world that the people now bear).

    Dr. Allen and Ninguem, I hope you take out some time to watch this movie…

  • http://Www.twitter.com/alicearobertson Alice

    Dr. Mezue…you are again using straw men…..Milton Friedman won the Nobel Prize, so he is at least worthy of consideration….hmmm….thinking though…so did Al Gore….um…er…. Can I ask you what it is specifically you do not agree with Friedman on (and if like, I can talk all day about my problems with Al Gore:)

    So if you do not like Wall Street nor Main Street and can’t see the correlation of the free market on the medical spectrum….what do you believe in? The government? Does not Wall Street and Main Street fuel the economy? Less tax dollars means less healthcare, less social programs, etc. No fuel for the socialistic fire.

  • http://blog.headache-treatment-options.com/appliedobjectivism/ David Allen, MD

    Dr. Mezue,
    OK, I’m halfway through your Yes Men movie – regarding the Union Carbide industrial disaster (among other things) – but I’m not sure I can take anymore. The movie suffers from all the trappings of propaganda. There is no attempt to provide context or to present even a modicum of an alternative view. It is highly selective, focusing clearly on the worst moments of the people interviewed. It treats those interviewed as jokes – never intending to present them in a neutral light. (It may also represent criminal activity – I don’t think that you should be able to give press conferences and make announcements impersonating another person or company!)

    Art (including movies) or documentaries are all about what you choose to include and not include. By focusing on one of the worst industrial disasters – the focus is all on the negative aspects of capitalism. There is no mention of the positives (at least not so far). Also, why not interview the representatives of Dow Chemical to find out their position? Does a company which buys another company years later accept responsibility for what was done in the past? The company where the disaster occurred was nearly 50% owned by the Indian government. Do they accept any responsibility for what happened?

    Is man-made global warming a proven theory? The movie certainly intends for you to think so. There is no mention of the legitimate controversy regarding it – and so the context for branding certain organizations as evil for opposing the Kyoto protocols is only asserted, not proven. The movie implies that people who oppose global warming legislation do so from narrow concerns about their companies (big oil and the like) instead of giving them credit for having an actual well thought out point of view. It even implies that they wouldn’t care about the death of others – and would be willing to use their bodies as fuel! This demonification of the opposition, attributing the most nefarious motivations to them, is classic propaganda. If used often enough, people can eventually not view the opposition as even human – and so lynching them or destroying them physically won’t have the usual negative psychological repercussions. I’m sure we could find similar twisted films about the Jews in Nazi Germany – leading up to the holocaust!

    So the problems with this movie so far are legion. Only committed leftists would feel comfortable watching it and laughing along, giving each other occasional high fives at key moments. Yuck!

  • http://fertilityfile.com IVF-MD

    Those who support socialism want to force everyone to do things their way, but not so for those who want capitalism.

    Those who support true capitalism respect the freedom of other individuals to choose their own preference. They are fine with letting other be free to play by the rules of socialism as long as they themselves and other like-minded individuals are allowed the freedom to play by the rules of capitalism.

    How could we logistically make the division? Simple. Shift the tax burden. Lower the FEDERAL tax level to the bare minimum (just enough to cover military spending). Everything else would be run at the state or even local level as high or as low as each state/locality chooses. States that are low tax, low government, low entitlement would tend to attract people who want to work hard and expect almost nothing from the government. States that are high tax, high government, high entitlement would attract the people who want to pay more so that the government can give them more government handouts and government services. To each his own.

    Therein lies the true litmus test of a the morality of a system. If supporters of capitalism force OTHER people to live under a system of capitalism, that would be as immoral as supporters of socialism forcing OTHER PEOPLE to live under a system of socialism. The only fair way is for each person to be allowed the naturally-given human freedom of choosing for himself.

    • http://www.twitter.com/alicearobertson Alice

      Is man-made global warming a proven theory? The movie certainly intends for you to think so. There is no mention of the legitimate controversy regarding it – [end quote]

      Sometimes we have to decide if we want the truth or our own way supported with false facts. I just can’t resist this global warming topic…….and the false facts of Al Gore….for those interested check out the owner of The Weather Channel who has devoted millions to exposing the truth…..and the truth is the same “facts” Al Gore presents would never stand up in a court of law. But our society wants to believe him…..whether he is wrong or right. Same with Michael Moore. Who cares if it’s the truth…..it’s convenient.

    • http://www.twitter.com/alicearobertson Alice

      Therein lies the true litmus test of a the morality of a system. If supporters of capitalism force OTHER people to live under a system of capitalism, that would be as immoral as supporters of socialism forcing OTHER PEOPLE to live under a system of socialism. The only fair way is for each person to be allowed the naturally-given human freedom of choosing for himself. [end quote]

      Your post was very good until I hit this part. Thinking……surely voting responsibly for our representatives is another alternative? In my dreams I think Americans will vote for those who understand the Constitution…….but you hit upon a truth……at the next election (unlike this one) we will have a segment of society that runs out to vote to keep their government checks and goodies rolling in. That’s fine to help the truly needy, but when a populace votes completely on what they can take and we have huge numbers dependent upon the government…..Houston we got a problem!:)

      I do not find capitalism immoral……maybe the way some people would run their businesses may be, but the system works. But you are right each system has it’s difficulties…….I find socialism a romantic notion where facts don’t matter…it just feels good to say you support it…..and socialism comes before communism. Capitalism does mean a certain segment will have more….so what…..at least we have the opportunity to succeed……which means I don’t find it immoral.

    • ninguem

      Amartya Sen once wrote: “No famine has ever taken place in the history of the world in a functioning democracy,”

  • Dr. Kene Mezue

    I saw this article on the Salud Movie website and it makes solid points…(besides, you might want to watch the movie – SALUD…) Health care is a basic human right…it is not a luxury but a necessity.


    Sick Care vs Health Care:
    The Crisis in US Health

    Increasingly, the United States is challenging conventional wisdom that wealth = health. Current estimates put US health care spending at approximately 15% of gross domestic product (GDP), the highest in the world[1], but the health system fails to deliver efficient, effective, and equitable health services. Overall, there is a systemic problem: a huge gap between the care that everyone should receive, and what they actually receive – if they receive any at all.

    Underlying the crisis in US health is the system itself, where 45 million people are uninsured (over 8 million of them children)[3], forcing large swaths of the population to rely on high cost, stop-gap emergency services that causes an estimated 18,000 deaths annually.[4] When those emergency rooms and clinics shut down unexpectedly, as happened during Hurricane Katrina, the health of communities is plunged headlong into chaos, causing deepening illness, suffering, and in some cases, death.

  • Alice

    Dr. Mezue…you are confusing the label “uninsured” to mean no care. That is false, just as a few other presumptions and sources you provide.

  • Dr. Kene Mezue


    I seriously don’t understand why healthcare in a developed, first world nation should be delivered on an ability to pay for it…it really baffles me…

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