Legislative bodies are moving with unprecedented swiftness to ensure we lead healthier lives. From bans on soda to bans on fast food, from mandates on health insurance coverage to mandates on EMR use, from bans on trans fats to mandates on care delivery models, our governments (federal, state, and local) are supposedly helping us live well. But our current approach to health care is about as scientific as our approach to fashion — skinny jeans, bans, and mandates are in; bell-bottoms, freedom, and individual responsibility are out. Intrusive legislation and false moral imperatives abound despite being little more than blind stabs at improving health, one dim-witted buffoon at a time. But is that what Americans are? Are we all helpless buffoons?
The issue of freedom is a critical one in health care. After all, no individual liberty is more worthy of protection than the right to sovereignty over one’s own mind and body. When we ban something, then, it would be reasonable to assume that the evidence in favor of doing so is clear and irrefutable, that it is immutable. It would also seem logical that anything banned must, by definition, be more detrimental to human health than other things which are not banned. The same is true whenever we, in effect, mandate widespread adoption of a specific health care delivery model, digital technology, or administrative policy. The evidence supporting those mandates should be equally robust, and what is mandated should be decidedly better and more effective than all available alternatives.
The problem is that, in practice, bans and mandates are never applied in this well-reasoned, equitable fashion, and sustained good health will therefore never result from these authoritarian tactics. They generally do little more than limit choice, restrict individual freedom, and codify systemic injustices and inefficiencies that obstruct patient care and prove virtually impossible to reverse. Admittedly, there are indeed rare instances where implementing a ban or mandate is justified. But, too often, they are ineffective, costly, burdensome, and arbitrarily applied.
Mandates that favor particular care delivery models such as PCMHs, for example, are ill advised. A delivery model’s value lies solely in its proven utility to a specific group of patients and physicians. And in any given community, for any given disease, it is the freedom to innovate and creatively address patients’ unique needs that yields improved care and true health gains, gains that develop organically rather than in conference rooms full of bureaucrats far removed from the clinical processes they seek to control.
Another problem is that, in most cases, banning or mandating something is terribly ineffective at changing health behaviors or improving outcomes. Why? Because bans and mandates do nothing to increase someone’s knowledge of how best to sustain or improve health. If you ban one “unhealthy” substance, the food industry will simply develop another that increases flavor, extends shelf life, improves margins, or possesses chemical properties that induce addiction. Ban that new substance and another will arise. Without a primary focus on education, the public will consume each new substance voraciously because bans do nothing to promote real knowledge or a lasting culture of informed choice.
Yet another concern, one that highlights the prominent role of special interests in what should be an impartial process, is the arbitrary nature of what we choose to ban or mandate. For example, if improved health is the goal, should we ban or otherwise legislatively curtail cigarette smoking while simultaneously allowing recreational marijuana use? Should we ban trans fats while encouraging the widespread use of pharmaceutical drugs that have considerably more toxic effects on the human body? Does it make sense to ban large sodas at fast food restaurants while allowing the sale of jumbo-sized alcoholic beverages, ultra-caffeinated, sugar-packed soft drinks, and unregulated nutritional supplements at local convenience stores?
Similarly, is it wise or just to mandate health insurance coverage without restricting insurance industry profits or outlawing narrow networks? Why do we ban tests that allow individuals to better understand their own genetic composition while simultaneously encouraging mass use of mammography and colonoscopy, even though the data is clear that these tests also carry significant risks and provide no benefit for the majority of those screened? If patient safety, portability of health information, and enhanced inter-provider communication were major goals of the EMR mandate, why spend billions of dollars on software that can’t yet communicate across proprietary platforms?
The only way to truly improve our nation’s health is to unequivocally embrace two concepts: education and freedom. The problem, of course, is that both of these require patience and discipline. Letting education and freedom transform health behavior and care delivery, watching them work their irrefutably effective magic, is no more exciting than observing evolution in real time. But they have an unparalleled ability to improve outcomes while protecting the public’s right to self-determination. Over time, education inevitably impels most individuals to make better health decisions. Some, however, will continue to consume unhealthy foods, forego screening tests, and engage in unhealthy activities. But, as politically incorrect as it may be to say this, it is their right to do so in a free society.
One argument often used to justify bans and mandates, one consistently touted as incontrovertible, is that they prevent those that engage in unhealthy activities from unfairly burdening others with the health care costs they incur. But there is one fatal flaw in that argument. Namely, it is based on the false moral imperative that every citizen is responsible for every other citizen’s health care, that charity and compassion can be effectively legislated. These two highly desirable human qualities are critical to individual self-actualization and societal progress. But attempting to impose them through legislation often has precisely the opposite effect, transferring individual wealth not to fellow citizens in need but to insurance companies, health system administrators, and government bureaucracies.
Laws like EMTALA and PPACA do little to improve real health; they are successful only at redistributing resources in the most inefficient ways possible, providing only the illusion of security and choice. They also treat health care differently than the socioeconomic phenomena truly responsible for health status, things that include food, shelter, employment, and wages. We do not, for instance, guarantee employment, ensure a living wage, subsidize luxury housing, or provide lavish unemployment benefits, nor are food stamps redeemable at the best restaurants. And yet we expect anyone arriving at the ED to receive not only triage and basic care but also expensive imaging studies and procedures, the best available services from multiple specialists, for what are often chronic health problems. Why the lack of consistency and foresight? Why the legislative hypocrisy?
We need to focus on peeling back the layers of legislation and administration, on restraining our penchant for bans and mandates. We must allow physicians to embrace the care delivery models and technologies that best serve their particular patients, not those deemed best by bureaucrats. We need to compensate clinicians for the full scope of their professional services, services that include consistently communicating with and educating patients using all available modalities, not just for writing prescriptions, ordering diagnostic tests, performing procedures, and structuring care to comply with anunnecessarily complex and meaningless collection of codes.
Rather than limiting choice with authoritarian decrees, legislative efforts should focus on health promotion and education, on ensuring price transparency in health care, on demanding clear, accurate ingredient labeling from the food industry, on safeguarding the integrity of the research used by the biopharmaceutical industry to make health claims, on assuring unambiguous, easily accessible disclosures from insurance companies regarding scope of coverage. We also need to grant patients control over how their health care dollars are spent, not continue to transfer that authority to third-party payors or government officials.
In 1755 Benjamin Franklin famously said, “Those who would give up essential Liberty, to purchase a little temporary Safety, deserve neither Liberty nor Safety.” And the wisdom imparted therein is every bit as applicable in the realm of health care as it is in our fight against terrorism.
We want to improve health, so we mandate health insurance. We want to prevent disease, so we ban large sodas and trans fats. We want to control health care costs, so we favor one care delivery model above all others. All we accomplish, though, is less access to physicians (due to narrowing networks and greater administrative burden), increased health care expenditures (by increasing uncompensated ED visits and diverting scarce resources toward unproven delivery models), and diminished patient autonomy (with control increasingly transferred to insurance industry and government bureaucrats). We are relinquishing freedoms at an alarming rate and receiving virtually nothing in return.
These affronts to individual liberty, their inability to achieve tangible health gains, merit one final, equally applicable quote, one attributed to Patrick Henry: “Give me liberty, or give me death!” Sadly, if we continue on our current path, we may indeed be forced to choose between the two because, despite all claims to the contrary, the path to wellness does not reside in any legislative document, nor does compassion originate in the halls of Congress. In most cases, the potential for improved health resides exclusively in the minds of well-informed, free individuals, and true compassion can only be born of those same individuals’ hearts. Let’s educate, not mandate, and let’s allow freedom to guide our way, no matter how inconvenient that process may be to those occupying the halls of power.
Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.