In one of Mark Twain’s masterpieces, Tom Sawyer and Becky Thatcher wandered deeper and deeper into a cavern, and got lost. It is much easier to penetrate deeply into such a labyrinth than it is to find the way out. Such appears to me to be the history of the plight of modern American medicine from about 1955 on.

By1955 wewere10yearspost-war,emerging from what seem now to be primitive medical practices. I would venture to say that most of what we know in science and medicine we have learned in the last 65 years or so. Our nation entered a long period of relative prosperity, and we far surpassed there’s to the world in medical and scientific research and practice.

But just as a stupid idea to enter a cavern with only a few candles can lead to disaster, so can a stupid or immoral idea in politics. Once we realize we are stuck in a figurative labyrinth, we are so lost that we do not even identify the decision(s) that led to it.

When “leaders” in prewar/wartime Germany came up with ideas for which they needed scientists, they used the scientists’ expertise to help them to destroy their nation, and to stain its name. The scientists became like zombies, acting in their own bodies, but controlled by outside, evil forces. The scientists abdicated their human responsibilities to these false leaders, and were complicit in their crimes.

Meanwhile in America, a disastrous immoral idea took hold. It shunted our founding principle aside in a malignantly insidious fashion. Our law contains no “duty to rescue” for a very good reason—it could and would totally drain citizens. If you see someone in need, and have something to give, you are perfectly free to give all you wish—but it is your decision, not a duty.

Until Franklin Delano Roosevelt, no American president dared to lay a claim on one citizen for some other favored citizen. A coup d’etat took place in the 1930s when the Constitution was traduced. Instead of the single category, “American citizen,” citizens were de facto divided into officially favored and disfavored groups. Some citizens were statutorily burdened with the duty to rescue others, not necessarily from disaster, but from responsibility for their own lives.

The Entitlement Labyrinth

Lyndon Baines Johnson went further down this path in 1965, when he bestowed Medicare/Medicaid on favored groups, thus relieving old people and poorer people from responsibility for their decisions about education, work, and health. Politicians who “give” things to citizen groups give other people’s things, not their own. With other people’s labor, and other people’s money, they give favors in exchange for votes. We live in a transfer society now, where government forcibly transfers some citizens’ property and the fruit of their labors to other people. Those other people are not necessarily even in need. Many of them are quite well off. To help the fleeced citizens accept this, politicians excite envy among groups.

Many of the politicians who currently practice the politics of envy are millionaires, but they engage in vilifying others who have done useful work, who created jobs and wealth, not to mention useful products and services, and who freely bestowed voluntary charity on others The politicians who do this may be trying to deflect envy, which they may fear might be directed toward themselves, onto the producers in the nation, such as . “corporations” and “doctors.”

When LBJ decided to make political hay by pretending to “save” the groups now called “seniors” and “the poor,” his chosen method enlisted physicians. Despite early resistance, due to recognition of the destruction socialized medicine would cause, physicians were nevertheless eventually seduced, just as scientists had been by other regimes. By the time many of us currently practicing medicine came of age, Medicare and Medicaid were firmly entrenched, and we were enrolled into them, barely knowing they existed, while we were in medical school.

The original Medicare/Medicaid legislation provided that there would never be interference in the practice of medicine. We were reassured that the programs would never cost more than $9billion a year, maximum. So much for predicting the future: the cost was up to $406billion in 2006. The sage, widely respected luminaries who came up with the $9 billion figure do not seem to have been acquainted with human nature.

In this process, true charity was greatly diminished. Why give to the needy when your labor and money are already being confiscated by government, which pretends to “take care of” so many needs and problems?

Wolf Crying

An interlocking chain of events ensued. As patients realized they could get medical care that was free to them, or almost free, they stepped up their use of the emergency room(ER), they went to physicians’ offices for ever slighter reasons, and they did such things as having their joints replaced not just to keep walking, but to keep playing tennis. All fine, except that the people burdened with the bills for their care might want time and money to play tennis and lead their own lives, with the money that they earned. It wasn’t just the spending. Once, if a person presented at the ER with, say, a headache, we could presume that there was a real problem: a headache out of the ordinary. No more. Since it costs many people little or nothing to come to the ER, they come in for the slightest of reasons. Maybe they could have taken some aspirin. But

maybe in the ER they can get Tylenol with codeine, which has a resale value, or maybe the headache is connected with family problems, and they can score some points against the other side by taking on the sick role.

Maybe they have just learned to be dependent. Maybe they don’t feel as important if they treat the headache themselves as they do if they “have to” go to the ER for it. So we are now faced with an influx of the mildly indisposed, “just wanted to be sure” people drowning out the truly sick, making decision-making much more complicated for the physician. There is a limit to how many people can get head CTs and MRIs. Also gone unremarked is the likelihood that physicians are not immune to the mindset induced by people crying “Wolf!” After a certain number of false-alarm headaches, the physician may be more likely to overlook, for example, a leaking berry aneurysm.

False Turns

Physicians, whose motto has been “First, do no harm,” at first resisted government interference in medicine, but eventually they saw no harm in making taxpayers pay the bills for the medical care their patients received. Naturally, the bills mounted.

As things got out of hand, the politicians got scared. Most of them are too cowardly to face reality. Instead of forthrightly stating that the Medicare/Medicaid system was out of control because there is no brake whatsoever on the medical desires of the population segments the system favors, they attacked the physicians and hospitals.

There was no appreciation of how much worse they could make the problem of giving people total personal discretion in spending their fellow taxpayers’ money by distorting medical care with perverse incentives.

The diagnosis-related group (DRG) system was imposed sometime in the 1980s to pay hospitals a flat rate per diagnosis, regardless of the actual cost of the care of the patient. It provided incentives to make hospital care more efficient—or at least speedier. Discharge planning became more important, with a kind of game to figure out the best (most remunerative) way of stating the diagnosis, and the quickest discharge, ready or not.

As John Goodman of the National Center for Policy Analysis has pointed out, there is a tuning fork-shaped graph that results from tracking all the fixes government has tried. Without radical surgery on the entitlement system that bestows favors on some at the expense of others, tinkering with it can reset the point on the graph showing what our present spending is, but it has no effect on the growth rate.

When DRGs did not work, a big “waste, fraud and abuse” hunt was launched, with Medicare patients told their physicians might be committing fraud, and to look over their “Medicare Beneficiary Notices.”

In order to recover some money, the government now employs “bounty hunters”—people who get part of the loot when they “find” overcharges. Unlike defense contractors, physicians have no big money sluice for sliding cash to politicians, so we mean nothing to them.

With the burdens mounting, and fewer willing to carry them, politicians have decided—again without clearly stating their aims—that we need a huge influx of foreigners to shoulder the burden. And to meet the demand for taxpayer-funded medical services, physicians began using “physician extenders” (sounds like “hamburger helper,” doesn’t it?). Nurse practitioners, a new category, got into the act, supposedly to take care of the less sick, the worried well, the slightly indisposed. Of course, sometimes things did not work out that way. Sometimes the truly sick ended up with a nurse practitioner unable to handle the problem.

An explosion of “initiatives” has been designed to corral people, force vaccinations on their children, monitor their prescriptions, visit their babies at home, and have them beg for permission to take drugs that the government does not approve of.

Instead of studying diseases and therapeutics, physicians waste time learning “correct coding.” Not for their patients, but for the bureaucrats. Some physicians have retired early. Others have fled to an area not “covered”—especially cosmetic surgery—where there is freedom, but which removes them from the heavy lifting in medical care. Some just game the system, meeting absurdity with dishonesty. Some over-treat the patients paid for by government in order to make more money. Now that there is such an outcry about spiraling costs, some under-treat patients, because government has made it a money-losing proposition to treat Medicare and Medicaid patients, by paying less and less for that care.

Very few people saw where this path was leading, as they voted for politicians who promised to give them money taken from their fellow citizens. It supposedly represents some kind of pact between the generations, except that members of the younger generation never gave their permission. But now the giant Ponzi scheme is unraveling, and the nation is going bankrupt.

There’s no guarantee at all that the U.S. will not end up like a Third-World nation. As long as we do not recognize that medical care is not, and never can be, free of charge, people will continue to respond to perverse incentives, and never recognize that third-party control is the whole problem with our medical care. Things can get a lot worse than they are now. To some, the house of medicine may look fine, but it is like a house riddled with termites.

Away Out

But there is good news. We could fix things overnight, by seceding, dropping out of the system. Tom and Becky survived being lost in the cave because they saw a gleam of light, and found a way out. We can do the same. No need to retrace our steps in this Byzantine labyrinth of “compliance” and control. At some point, Medicare and Medicaid will implode, just as the U.S.S.R. did. When it happens, people will still need medical care.

In the meantime, every physician should think about a fallback plan for an alternate livelihood. We should be ready to be independent. We can grow food, modify a house for passive solar heat, install windmills, save money, invest in some other thing to learn or do to support ourselves, and take care of our patients without Big Brother in the room with us.

©2024. Tamzin A. Rosenwasser, M.D. All rights reserved.