The scale of the coming health reformation in America may approach the scale of theProtestant Reformation, which was an earth-shaking event in the 16th century.

Our health care system is way broke. We receive good health by some measures,high-tech measures mainly, but the truth is, we are not doing all that well.Cost effectively, we’re the worst of the west. We spend the most per capita ofany nation, yet we are the sole western nation which has no universal coverage.You all know the details: about 50 million out of our 300 million citizens haveno health insurance. Altogether, the completely uninsured and the inadequatelyinsured are estimated to be about 1/3th of the population, as many as 90million people. When they do obtain care, it is usually emergency care in ER’s,generating higher costs that are shifted to other payers or absorbed byproviders as losses.

The result of all this is truly pathetic. We, as a nation, the self-proclaimedgreatest country the world has ever seen, are 28th in the world rate oflow-birth-weight infants, behind Costa Rica. We are 15th in maternal mortality,behind Greece. We are 9th in life expectancy, behind Japan and Spain. We becomeless competitive in the global economy as the health of the Mass Workerdeteriorates.

We are approaching the '08 elections, and we have a financial crisis in thissystem and in the whole economy. This may be a good thing for the systemeventually, after we get through the drama of the trauma. It is primarily dueto the largest generation reaching an age where the burden of social securityand health care falls upon a diminishing share of workers paying in to thesystem. 77 million of us baby boomers are aging, the first one collectingsocial security this year, causing the dramatic inverse ratio to the number ofwage earners paying taxes. The fiscal gap between what is being paid in (taxes)to what is being paid out (the budget), they say now, is almost a quarter mil(+$240,000) per citizen, and rising fast. Yikes!

There is no point in debating the merits of "socialized medicine", which ismerely a nebulous euphymism, although not as severe as "high minded goodgovernment". It is not the same as the one–payer system used in the UK.The US has an inefficient system of many private insurance companies, directdescendents of the protection money racket of the Mafia, where almost a thirdof our worker-citizens don't or can't participate, almost 50 million turn toemergency rooms for routine and stop-gap care at 5 times the usual cost,creating such chaos that it affects all other sectors of the system. Thesecompeting insurance companies are in the business of making money, with half ofall the costs going to administration, and routinely manage their own risk andprofits by turning away or denying care to the sicker clients/patients, whichcreates more non-participaters. Serious competition among these insurers, thebig gobbling up the little, happened during the catastrophic deregulation inthe Reagan Administration, the Decade of Greed. That failed to even remotelycontain health care costs, as well as banking, airlines, and other industries.The resulting shake-out allowed for the big to get bigger, and the emergence ofa few strong players. The federal government's part of the business of healthinsurance, Medicare, insurance for the retirees, and Medicaid, insurance forthe jobless and indigent, is going broke fast, due to the simple math explainedabove.

Medicare started up in 1966. Until then, large numbers of elderly patients with chronicintractable diseases lived in their homes or in the homes of close relatives,occasionally seeing doctors. The doctors, if wise, left these people to theirown and their families’ devices, monitoring only for life-threatening surgicalor medical problems. The greatest advances in public health essentiallyhappened decades before, with the control of the old communicable scourges bydevelopments in simple sanitation. The doctor was still a respected member ofthe community, and the patient could live and die with dignity. Along cameMedicare, making all medical care for the elderly ‘free’. Until that time,hospitalizations were relatively rare events for most people. But for better orfor worse, medicare primed the pumps of technology, the mega-hospital, newprocedures, new drugs, then the mega-insurance companies, sending costs out ofsight. It was the gilded age of medicine, when doctors and hospitals got rich,and some became greedy. It began an age in medical science during whichnon-invasive methods were developed for investigating people’s, pardon me,orifices. Simplistically, anything that could be seen by some sort of scope ordetected by laboratory methods was potentially abnormal; anything that couldnot be seen pretty much did not exist, for insurance purposes. While medicaladvances for the most part have been real, soon it became impossible to benonspecifically sick; now one had to be specifically labeled, for reimbursementby insurance. There are over 470 diagnostic category codes used to classifyhospital discharges alone. Just wait until the coming genetic medicinerevolution, which promises individualized cures, when the insurance companiesget ahold of our DNA records. Former head of the Centers for Disease Control,Dr Bernadine Healy, recently said: "...the strategy to offer individualpersonalized medicine has a big cloud over its horizon".

Our employment-based system begain in WWII, when companies ramping up for warproduction competed for needed workers, a big part of them females for thefirst time (i.e., Rosie the Riveter, incidentally starting up large-scale daycare for the keikis also for the first time), when all the males were made intosoldiers for 5 years. This offering of health coverage to workers was also aslick way to get around the war-time mandated wage-controls. The employercontribution was made tax deductible at a bigger deduction. It wasn't (andstill isn't) taxed the way wages are. If you have to buy your own insurance, itis not tax deductible (yet). If you pay your doctor directly, you pay taxes onthat as well.

Everything we hate about the health care system results from this tax break for employercoverage. That's how we ended up with the health insurance system we have now,based on employers. (And, to hear Michael Moore in "Sicko" tell it,that's why we are all afraid to lose/change jobs, why we are all 'kept inline', fired 'for or not for cause', subjected to indignities such as observedurine testing, etc.) But it also makes health care costs rise, since people areless careful and less inclined to be preventive when they are not paying out ofpocket. It also means people often lose their insurance when they switch jobs.

The root of the problem is not insurance. The main issue is trying to capitalizesomething which is not capitalizable. Some things, like K-12 education, must beseparate from the marketplace. We humans have taken ourselves out of the realmof capital for the last time in the Western Hemisphere in 1888, concluding thatslavery was morally wrong after many historical spasms over the ages. Not sovery long ago.

Health care can't be delivered in the free market. It really isn’t inthe free market now. Providing health care to all entails fulfilling a commitmentto linking all citizens as prospective patients to a relatively small cadre ofphysicians, In this critical function, the market cannot be relied upon toperform effectively, and it hasn’t. That small cadre of physicians consitutes amonopoly.

The science of economics is complex. Economics and psychology have similar andequally complex principles. Economic systems in particular are infinitely complex. Centralplanning, no matter how brilliant or creative, has trouble approaching theefficiency of the free market. Pretty much the rest of the world seems to havecome to the same conclusion, whatever your concept of efficiency. Americaneconomists are, by definition, marketeers. If they’ve made it in our system,they can’t remove the blinders. The social health care programs of othercountries, particularly of Northern Europe, which work, just aren't on theirradar screens.

The “invisible hand” of Adam Smith’s free market capitalism has not been applied tomedicine since the 1910 Flexner Report. This “invisible hand”, refers toSmith’s 1776 pamphlet called, “The Wealth of Nations”. He expounded upon thenatural ability of the free enterprise system to regulate itself, not only withregard to the distribution of resources, but also the fair and reasonablesetting of prices for each service and commodity. This has never been allowedto work in medicine. The Flexner Report was a major governmental policy change,which cleaned up medicine by regulating medical training and establishinglicensure. It also got rid of snake-oil salesmen, took the cocaine out ofcoca-cola, made certain drugs under the pervue of the DEA. BigPharm did therest, by taking ethnobotany out of the people's hands for profit. The otherconsequence of the Flexner Report was to de-legitimizing homeopaths, chineseherbalists, and naturopaths, even midwives, while making medicine astate-sponsored monopoly. Osteopathy was accepted into the club only a coupleof decades ago. One of the problems with capitalism is monopolies, and that’swhy there are laws in a capitalist society on the books which areanti-monopoly. The tendency of the rich is to get richer, the math of compoundinterest. Monopolies really compound that interest. Monopoly is the onephenomenon that paralyzes the “invisible hand” of free enterprise, and that iswhy so many anti-trust laws were passed after the Depression. Medicine is amonopoly, and to pretend that Adam Smith’s hand touches it is ludicrous.

A typical crime against women in those days was simply denying midwifery. Indenying midwifery, the mostly male medical establishment fostered the thinkingthat for something as routine as most childbirths, you can’t do it withoutsophisticated medical help. Europeans say that the high rate of sociopathicviolence in America may have its roots in the rapid separation of newborns fromtheir mothers over the past few decades of hospitalized birth. We’ve correctedat least this aggregious error in recent years by encouraging midwifery andfamily births again.

Beyond the monopoly, more fundamentally, taking care of patients to make money doesn’twork. Health care is not delivered in an assembly line fashion, as much asinsurance companies and industry want it to be. Furthermore, people do not buyhealth care on the basis of price alone. When sickness strikes, the price ofgetting well usually doesn’t enter into it. The process of real doctors takingcare of real patients does not, never has, and never will, fit well into anindustrial mode of organization. Medical care simply cannot be given when thatadvice is clouded by the profit motive.Because the doctors are at the interface with patients and not theinsurance carriers, this forces us into a love-hate relationship. Doctorsbasically have two choices: 1) give up the monopoly, allow complete acceptanceof herbalists, naturopaths, accupuncturists, colonic therapists, health careweb sites, alternative, complementary, and integrative modalities, with basiclicensing requirements like Germany, which would most likely be completelykapakahi for a few dozen years, but would effectively tier the system more inline with expectations; or 2) work to remove health care from the market byadopting single-payer. This is the core of the problem, resurfacing again foreach election year.

Sadly, the current health-care debate ignores what doctors think; the core issues ofmonopoly and whether or not health care is marketable are not on the table. Thebig debate is the decades-old battle over a distribution ethic for Americanhealth care. It goes right to the core of capitalism as we know it. It's calledeconomic rationing. The case for the current system of economic rationing ofhealth care was made during Hillary’s first foray into the health care debatein '93-'94. The argument boiled down to a mandate on employers to provide theiremployees with health insurance. Different states have tried/are trying this;Hawaii did this 15 years ago and was allowed to fail (after a loopholemandating employer-based coverage for all employers was closed). Economichealth care rationing boils down to this: should the child of a waitress or gasstation attendant have the same chance of avoiding a given illness and, ifafflicted by it, of surviving and fully recovering from it, as, say, the childof a corporate executive?

Evidently,the dominant decision makers in this nation have concluded that our healthsystem can properly offer the corporate executive’s child a higher probabilityof avoiding the illness, and fully recuperating from it, that it offers theother child--- that our health system can be properly tiered by income class.This was sold to the public by cloaking this distributional ethic in jargon,without proper warnings to the public. They sold it by arguing for a“market-based” health system in which individuals are granted “responsibility”for their own health care (and their own health status), in which individualpatients are “consumers” who exercise “free choice”. They argued that it wouldbe more “efficient”, and hence “better”, than the alternative, that it wouldobviate the need for rationing health care. The intention, which really wasn’tthe intention at all, to produce an “optimal mix of price, quality, andvariety”, failed miserably. The old “bait and switch” scam; we were bated withjargon and then the deal was altered.

To that uninsured single mother of several possibly sickly children, possiblyaffected by the endocrine disrupters in the environment proffered by the samecorporations that provide her medication at a 600% mark-up, to tell her thatshe is henceforth empowered to exercize free choice in health care on hermeager budget is not a form of liberation, nor is it efficient in anymeaningful sense of the word. It is rationing by income class.

To sum up the party differences, as the elections are fast approaching, theGOP'ers want to make insurance mandatory, portable, and tax-deductible for theinsured, which means cheap insurance would be covering major expenses, much thesame as homeowners' insurance, and leaving routine and predictable care to bepaid out of pocket; cost-conscious private payers for routine care would drivedown the cost of routine health care. The Dems want to find new ways to bolsterthe employee based system and fill in the gaps. Both parties want to shift theresponsibility for health coverage away from business. The main difference iswhether government or we ourselves would get control of the money businessesnow spend on health care. Business wins, no matter who gets elected. Thefundamental change in the health care system that is necessary may well be putoff for the next election. The major issues of the physician monopoly andhealth care as commodity versus utility will be ignored once again.

We physicians, as sanctioned humanists since the Therapeudiceae of Essene days,whose symbol of the Caduceus we adopt, must give up the priesthood willinglywhile we campaign for single-payer and work with and legitimize complementarybranches of healing which would enrich all of our lives, and cut costs.

The chicken always comes home to roost, and the traditional practice of medicine isnow on the verge of destruction by the backlash of its own efforts to preserveits monopoly. What we lose in sharing care with other integrative modalities,like in Germany, and what we lose in clinical freedom by the adoption ofpractice protocols, long the almost sacred right of the practitioner, inexchange for single efficient payer, like in Canada, will be made up in savingsto the public and improved quality of care, and, yes, more freedom and an easeof pressure in the long run for doctors. Setting standards and prioritiesshould lead to a more rational allocation of our finite resources, rationalrationing.

By appealing to the basic fundamental good that originally attracted us tomedicine as a service profession, we can continue toself-govern, self-determine, and self-police. We must ensureaccess to care of acceptable quality for all, practice economic soundness,balance health fairly against all other societal needs, emphasize goodcommunication, encourage prevention, and most of all, require and demonstrategood will toward all people. We can in this way hope to preserve ourprofession, share care with other members of the health community, and defendit against the pressures of the marketplace.

We must embrace the ultimate mission of our chosen profession while we make someconcessions for the sake of decreasing societal chaos, for the sake ofuniversal access to health and information about health. It is your doctor, when every otherentity in the marketplace relates to Mass Man or Mass Woman as Consumer, it isyour doctor who gets up in the middle of the night to see his or her patient.