21 July 2007

What Ails US Health Care?

I went to a movie yesterday. It was "Once," a lovely bittersweet romance set in Dublin, with a scene or two where the protagonists explore the Irish countryside on the back of a motorcycle. As my friend and I entered the cinema, a man at a table implored us to sign a petition for single-payer health insurance. This was my first clue that "Sicko" by Micheal Moore was also playing there. I declined to lend my name to his list.

We saw Once, not Sicko, and I didn't see him again on the way out. Still, the incidnt confirmed me in what had been my wavering resolution to say something about the health care market here. For it seems to me that this is one instance out of many where government, as the supposed agent of a sovereign, poses as the solution to a problem of which it is the cause. The better solution is to remove that cause. How would that work, in the health-care context?

I'll explain by treating the matter historically, mostly perhaps because I read The Microbe Hunters (1940) by the great science-history popularizer Paul de Kruif about 20 times when I was a child, until the binding fell apart. So I'm going to answer Moore in Dekruifean style.

A one-paragraph clue to where I'm heading. It is inappropriate to say that a freemarket system for the provision of and financing of modern scientific medicine (MSM) has been tried and found wanting. The fact is, it has never been tried at all. To show this, we have to go into the 19th century development of MSM.

The American Medical Association was founded in 1847, to promote what its members already considered an orthodox or conventional model of medicine against challenges from homeopaths and mesmerists. (There were no Christian Scientists yet.) This is a curiosity itself. What did "orthodox medicine" mean in 1847? This was before Pasteur's discoveries had secured the germ theory of disease. Surgeons weren't physicians of any sort, they were still anybody skilled with a blade.

The defining characteristic of a physician, in the AMA/orthodox sense, in 1847 was the administration of "allopathic" drugs. Medicines that didn't resemble the suspected disease or poison. Allopathy -- "other than the disease." Obviously, this leaves possibilities wide open, and the particular drugs that would be administered to a patient by an allopathic doc in 1847 were those that had been selected by centuries of trial and error. The gastly connotations of that expression in this context are entirely fitting.

I think it is unlikely that any school of healing in 1847 was more likely to prolong your life than to shorten it. Or that any of the three contenders I've mentioned had a much better record than the other two. But the AMA's members were placing a sort of bet -- the homeopaths and mesmerists/mind-healers were placing contrary bets -- as to what would eventually prove to be the best approach to curing.

In 1855, the AMA put into effect what was called the “consultation clause” in its code of ethics. This clause meant that an orthodox practitioner risked expulsion (which at this point didn’t have the force of law, but we can think of it as a form of ‘shunning’ by one’s peers – in some contexts an effective psychological threat) if he so much as consulted with an unorthodox practitioner, i.e. a homeopath. This, you might say, was an effort at private-sector cartelization.

Lots of exciting stuff happened in the 1860s. In the United States, a civil war gave a lot of men opportunities to hone their skills as surgeons. They gained practical skill that the AMA would co-opt after the war, allying itself with surgery at last.

Meanwhile, in Europe, Louis Pasteur and Robert Koch put the "germ theory of disease" on a sound scientific basis in the 1860s. This also gave a foundation to the idea of allopathic medicine. If each disease has its own distinctive germ than the thing to do is to inoculate or immunize against that germ, or to find an agent that will kill off that germ without killing the
surrounding tissue.

Another development of the 1860s, this time in the British isles. Joseph Lister became the great proponent of an antiseptic surgical environment, specifically popularizing carbolic acid in this connection. The germ theory was an influence upon Lister, as one might expect. And his work helped undergird the alliance between physicians and surgeons.

So (returning to the US): after Appomattox, the AMA finally had something to sell. It was no longer just making a bet on something that might work, it had some science behind it. It was becoming an organization of entrepreneurs selling MSM.

It didn't take long thereafter, though, for the AMA to decide that private-sector cartelization, via such means as shunning, wasn't going to be enough to allow them to make the kind of profits for which they lusted. They started lobbying for licensure rules, essentially criminalizing the practices of their foes, and giving themselves control of entry into non-criminal healing.

Most of the states of the US have medical licensing laws that date to the quarter century 1875 - 1900.

So, to American's who can't get the insurance they need and/or the health care they need,and who are leaving the country to seek it elsewhere, what do I as an anarcho-capitalist have to say? To begin: God's speed. I wish you the best. Second, though, I should say that such anecdotes don't and shouldn't guide us as to the proper direction of reform. The proper direction would be, at last, to give a try to something that doesn't seem ever to have been seriously attempted, the de-licensing of modern scientific medicine, a true post-Pasteur privatization of the field.

Will Wilkinson, of The Fly Bottle, has expounded upon this a bit. Here's the money quote:

"There ought to be a guy, Manny, say, who does stitches. You cut your arm and you go to Manny’s stitches joint, which flourishes because Manny is the best at stitches. Manny leaves no scar! Ever! Moreover, he’s cheaper that some guy who spend years learning about the biochemistry of the human body. What does that have to do with stitches!? Why isn’t there a Manny’s Stitches Joint! You should be able to get a degree from the University of Phoenix in knee replacements. Just knee replacements! Why can’t you?! Because the AMA is evil. M.D.s are monopolists and welfare queens, and preventing a huge infusion of high-quality low-cost health care providers from coming to market."

Here's more on Wilkinson's tack, from his blog. http://www.willwilkinson.net/flybottle/2006/03/19/health-care-fantasia/

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Knowledge is warranted belief -- it is the body of belief that we build up because, while living in this world, we've developed good reasons for believing it. What we know, then, is what works -- and it is, necessarily, what has worked for us, each of us individually, as a first approximation. For my other blog, on the struggles for control in the corporate suites, see www.proxypartisans.blogspot.com.