The Great Lie in the U.S. Health Care Debate

I want to talk about something a little different today. If you're an American with bad knees, yes, it affects you – but it also touches the lives of many millions more than than that.

I want to talk about the great lie in the debate about U.S. health care.

First, this isn’t about Democrats, Republicans, Democans, Republicrats, whatever. Personally, I’m an Independent. I think both parties have become corrupted by money, but that’s a subject for another day, and another blog.

The great risible lie is this: U.S. health care is a free market that people choose or choose not to be part of, and like other free markets, the solution to our current woes – millions of uninsured, soaring drug prices, unaffordable insurance, etc. – can be found simply by unshackling market forces.

This is ludicrous.

Look, if I walk into a Honda dealership, and demand an Accord for free, the salesman (if he’s not laughing too hard) will point me to the door and tell me to get lost.

Sales of autos operate well within the free market model. There are competing dealerships; comparison-shopping isn’t hard to do; a Honda Accord buyer who doesn’t find the deal he wants can substitute a like product (a secondhand Accord, or another model from a different carmaker) to satisfy his need for private transportation. Also, we all agree no one has a “right” to a car.

But if I walk into a hospital emergency room, staggering and vomiting blood and without a penny to my name, the nurse on duty won’t point me to the door and tell me to get lost. That hospital has a legal obligation under the Emergency Medical and Treatment Labor Act (passed by Congress in 1986) to care for me. If I don’t have insurance, it doesn’t matter. What’s more, the law doesn’t let doctors half-treat me or dump me on another hospital for failure to pay.

And, at some point, most everyone will wind up in an emergency room. It happens, even to people who eat their kale every day and exercise vigorously and do a hundred other things right. We’re all going to need a health care “product” at some point – and we’ll need it for much more than emergency room visits -- whether we can pay or not. If we can’t pay, everyone else gets to pay for us that day when we land in the ER (see Note #6 below).

The alternative is stark: All those people without insurance, and without a means to pay, we let die.

Who wants that? Who thinks that even makes sense in the richest nation on earth, which spends so much on health care?

I know there are a lot of ideas on fixing the U.S. health care system: offering insurance across state lines (which will do very little), tort reform (which will do a little, but not nearly enough). But the first thing we have to face: every American is in this system together. We need a proposal that starts with that as the first principle. Everyone gets covered. Maybe that leads to single payer. Maybe that leads to Medicare for all. Or maybe there’s a different way.

But let’s be honest about who’s in the U.S. health care system.

We all are.

Some additional notes:

1. The U.S. pays two to three times as much per person as most other industrialized countries on health care. Despite this, the quality of our health care is ranked only 28th worldwide, below Slovenia’s. The U.K., which is ranked fifth, spends less than half what we do per capita. So it’s like we order filet mignon at Le Cirque, and in return get a turdburger in a styrofoam clamshell. Why isn’t everyone incensed about this? This isn’t a Republican issue, or a Democrat issue. It’s a people-opposed-to-stupid-spending issue.

2. On free-market “comparison shopping” for medical services: It’s practically impossible. Don’t believe me? Read this. The author says he should have been the perfect shopper for medical care: (1) he lives in Massachusetts, a state that passed price transparency laws to help patients shop for care (2) he’s a physician (3) the surgery at issue was minor and not urgent, giving him plenty of time to shop around (4) his research focuses on consumerism and price transparency. So it’s like the author of the Kelley Blue Book shopping for a used car. And how did the process go? Terribly. How’s this an efficient free market when price discovery is a nightmare?

3. Did you hear the story about Fin Mox? It’s an antibiotic for fish. But people were buying it for their loved ones – er, loved “fish” – because they couldn’t afford regular antibiotics. I’d link you to the Amazon page, with the hilarious comments from people whose “fish” didn’t have health insurance, and for whom Fin Mox was a blessing – but Amazon took the page down. The richest country in the world has poor people buying antibiotics for fish to get the medicine they need? That’s a disgrace.

4. Read this from emergency room physician Farzon Nahvi. He treated people – including a man with a brain bleed, whose life he saved – who later said, “Thanks, but I wish you hadn’t done that.” Because they didn’t have the money to pay the staggering emergency-room bills. Nahvi quotes Paul Ryan on health care: “You get it if you want it. That’s freedom.” Nahvi observes “Being given services without your consent, and then getting saddled with the cost, is nothing like freedom.” No, and let me complete the thought: it becomes closer to indentured servitude – or actually slavery, since indentured servants at least have to sign a contract.

5. One thing that puzzles me: if you believe in a free market in labor, you should definitely hate the current health care system. A full 56 percent of Americans get their health care through their employer. Many people are shackled to jobs at large companies, resistant to changing, because they don’t want to lose that precious insurance benefit. So think of all the people who could be innovators, or who could switch to a more productive job at a smaller company, benefiting the economy, but don’t because they need their gold-plated health insurance plan. So we squander the potential in our labor force. Why aren’t more conservatives upset about this?

6. A report last year showed one of five Americans visit the emergency room at least once a year. Separately, a study showed that a whopping 71 percent of these visits were either unnecessary or avoidable. Emergency room care is very expensive treatment, so this indicates a lot of waste. People lacking health insurance sometimes wind up in an emergency room because they can’t afford regular doctors.

The Second Edition of Saving My Knees Is Out!

Here it is, with a new cover, new preface and five additional short chapters. Putting it together was more of an effort than I expected. Pardon me while I take a victory lap!

The first time, I formatted the book myself. It’s definitely doable, but tedious. I wrote out the steps last time, and on reviewing the process, I thought, “Eh, I’d rather skip this if I can find someone to do it for a good price.”

Did I ever. One of my luckier moments this summer was finding Allen of eB Format. He was responsive, intelligent, reasonably priced (less than $100) and did a nice job. He improved a few things without my asking. I said I’d mention his fine work on the blog, and his website’s here if anyone’s interested.

Now on to the book:

In the second edition, at the end I tried to answer a few criticisms that have surfaced – not that I’m really thin-skinned or anything, but for instance, when someone reads your book and likes it but can’t tell what you did to heal – well, that’s probably a failure of the writing or organization. By the way, if it’s unclear to anyone reading right now, I healed with high-repetition, low-load exercise, which for me was a very structured program of walking.

No fancy stretches, no miracle shoes, etc. Walking your way to health sounds simple, but there was a lot more to my story than that, which is what led to an entire book. I wanted to tell a story: of what happened to my knees, and how I got through it.

Which brings me to a second criticism: It would be a fine book, some readers have opined, if you could skip over the non-knee bits here and there, such as when, during my summer devoted to recovery, everything started going wrong, including my discovery of mold on my camera lenses. I completely understand this. Most people with knee pain just want answers. What do I do, what works, what doesn’t?

I conceived of this book as something different though: a story, with a central character (me) and a progression through the stages of knee pain, the experiments with things that didn’t work, and then the discoveries that led to healing.

Also, I thought it was useful to give readers an idea of what kind of person I am (competitive, type A, active, with a relatively injury-free history). That does figure into how I got into such a mess, and was related to the challenges of getting out. And the camera lens mold turned out to be part of a larger crapfest of a summer, and that turned out to be important too, because you will go through times like that when you have knee pain – every little bad thing that happens will seem like more grief dumped on you, and you’ll think that nothing will ever get better.

So there you have it. I also did the update because I wanted to include a chapter on Scott Dye and his “envelope of function” framework. I knew a little about Dye while writing the original book, but there was much, much more I only found out about later. I wish he could’ve been part of the first edition.

For first-time visitors wondering whether it’s worth their time and money: check out the blog. Poke around some. All the content here is free. If you like what you find, and want to find out the full story – well, Saving My Knees is it.

Cheers!

Update: I want to be clear that, if you bought the first edition, I'm not trying to suggest you buy the second too! That seems absurd. What's in the additional chapters (which are generally short) can be found around the blog (just do a search for "Scott Dye" for example; I talk about him in one of the add-on chapters). I will ask Amazon if people who bought the first can be automatically upgraded to the second, but I'm not optimistic Amazon will be able to do this.

Second Update: I reached out to Amazon. I was told that readers who bought the first edition could contact Kindle customer care, and someone there could help them download the latest version. A reader below in the comment section reports that this did work. Here are the url's Amazon gave me:
www.amazon.com/clicktocall
www.amazon.com/clicktochat