StylesGrant Posted August 8, 2014 Posted August 8, 2014 Open-Source Healthcare By Kevin Carson / blog.p2pfoundation.net The healthcare industry is a textbook example of what Ivan Illich (in Tools for Conviviality) called a “radical monopoly.” The central function of the government’s “safety” and “consumer protection” regulations, in most cases, is either to exclude competing providers of a good or service from the market, to circumscribe the areas of competition between them, or to set a floor on the capitalization required for doing business and thus impose a mandatory minimum overhead. The overall effect, as Paul Goodman put it in People or Personnel, is to create a 300% or 400% markup in the cost of doing anything, and render us all dependent on institutional providers with bureaucratic cultures and high overhead costs. By mandating centralized, high-tech, and skill-intensive ways of doing things, the state makes it harder for ordinary people to translate their own skills and knowledge into use-value. Tollgates are erected between effort and consumption, so that it becomes harder to meet our subsistence needs through our own direct labor or through barter with other small producers outside the wage system. As a result, “decent poverty becomes impossible.” For example, schooling becomes something you can only get from somebody with a degree from a teacher’s college, according to a state-prescribed curriculum. According to Illich in Deschooling Society, the first thing students learn at school is to confuse process with substance, and to view almost every form of consumption good imaginable as something properly provided by a professionalized institution. Self-treatment, self-education, etc., are things that only dangerously irresponsible people do. Back in the 1920s and 1930s, public school Home Ec curricula threw their weight behind the creation of mass consumer society, teaching students that home-baked bread, home-canned vegetables, and home-sewn clothing (in fact, pretty much homemade anything) was old-fashioned and grounds for suspicion by right-thinking people. In the field of housing, around a third of which was still self-built in the U.S. as late as the 1940s, self-building is virtually illegal thanks to local housing codes set by licensed contractors and their lobbyists. This despite the fact that the available technology for self-building (modular houses, “cob” building, etc.) is far more user-friendly than it was sixty years ago. And in healthcare, state intervention artificially skews the model of service toward the most expensive kind of treatment. For example, the patent system encourages an R&D effort focused mainly on tweaking existing drugs just enough to claim that they’re “new,” and justify getting a new patent on them (the so-called “me too” drugs). Most medical research is carried out in prestigious med schools, clinics and research hospitals whose boards of directors are also senior managers or directors of drug companies. And the average GP’s knowledge of new drugs comes from the Pfizer or Merck rep who drops by now and then. The professional licensing cartels outlaw one of the most potent weapons against monopoly: product substitution. Right-wing libertarians are fond of using “food insurance” to illustrate the effect of third-party payment: if there were such a thing as grocery insurance, with low deductibles and a flat premium, people would be buying a lot more filet mignon and a lot less hamburger. The problem is that we’ve got a medical licensing system that criminalizes the sale of hamburger and mandates the sale of filet mignon. While healthcare consumers fall into many tiers of income, the state mandates only one tier of service regardless of ability to pay. Much of what an MD does doesn’t actually require an MD’s level of training. Unfortunately, no matter how simple or straightforward the specific procedure you need done, you have to pay for an MD’s level of training. The medical, dental and other lobbies make sure that legislation is in place prohibiting advance practice nurses or dental hygienists from performing even the most basic services without the “supervision” of an MD or DD. In an open-source healthcare system, someone might go to vocational school for accreditation as the equivalent of a Chinese “barefoot doctor.” He could set fractures and deal with other basic traumas, and diagnose the more obvious infectious diseases. He might listen to your cough, do a sputum culture and maybe a chest x-ray, and give you a round of zithro for your pneumonia. But you can’t purchase such services by themselves without paying the full cost of a college and med school education plus residency. The government having made some aspects of treatment artificially lucrative with its patent system and licensing cartel, the standards of practice naturally gravitate toward where the money is. The newly patented “me too” drugs crowd out drugs that are almost (if not entirely) as good, so that the cost of medicine is many times higher than necessary. The licensing cartel requires diagnosis and treatment by someone with an MD’s level of training, when something much less might be all that’s needed. Result: radical monopoly. The state-sponsored crowding-out makes other, cheaper (and often more appropriate) forms of treatment less usable, and renders cheaper (but adequate) treatments artificially scarce. I’m very big on the idea of reviving the mutuals or sick-benefit societies that working people organized for themselves, back in the days before the state and the capitalist insurance companies conspired to destroy them. One small-scale attempt at doing this sort of thing is the Ithaca Health Fund, created by the same people involved in Ithaca Hours. But such things alone are not enough. The problem with such systems is they handle only the financing end of things, while delivery of service is still under the control of the same old institutional culture. Any real solution will have to involve cooperative control over the provision of healthcare itself, as well. Imagine, for example, a cooperative clinic at the neighborhood level. It might be staffed mainly with nurse-practitioners or the sort of “barefoot doctors” mentioned above. They could treat most traumas and ordinary infectious diseases themselves, with several neighborhood clinics together having an MD on retainer (under the old “lodge practice” which the medical associations stamped out in the early 20th century) for more serious referrals. They could rely entirely on generic drugs, at least when they were virtually as good as the patented “me too” stuff; possibly with the option to buy more expensive, non-covered stuff with your own money. Their standard of practice would focus much more heavily on preventive medicine, nutrition, etc., which would be cheap for members of the cooperative who didn’t have to pay the cost of an expensive office visit to an MD for such service. Their service model might look much more like something designed by, say, Dr. Andrew Weil. One of the terms of membership at standard rates might be signing a waiver of most expensive, legally-driven CYA testing. For members of such a cooperative, the cost of medical treatment in real dollars might be as low as it was several decades ago. No doubt many upper middle class people might prefer a healthcare plan with more frills, catastrophic care, etc. But for the 40 million or so who are presently uninsured, it’d be a pretty damned good deal. Health Care: An Anarchist Approach By Gary Chartier / c4ss.org The current US debate about health-care funding can be understood as concerned with meeting the challenge of doing three things at once: (1) Ensuring that everyone can afford to buy ample medical services and (2) lowering the price of care while (3) not interfering with our choices. An Unnecessary Tension among Health Care Goals—Created by the State If you assume that most or all of the features of our current health care system should be treated as given, the trilemma really does seem irresolvable. Suppose everyone can afford ample medical care. We know what doctors charge. We know what hospitals charge. We know what drug manufacturers charge. We know what medical device manufacturers charge. And we know what insurers charge to, we’re told, make it all possible. And we know the charges are anything but insubstantial. So, given they way things work right now, if everyone can afford ample medical care, then everyone must be able to spend a lot of money. If the current pricing of medical care really reflects conditions in the current market, and there’s no reason to think it doesn’t, then there’s no way to lower the cost of care without, realistically, making fewer services, fewer drugs, fewer devices available, as long as current market conditions persist. And that means, of course, interfering with our choices, since it’s hard to choose an option that’s not on the table. With fewer services available, options have been reduced, and, assuming the real value to patients of some available procedures that would be less prevalent as a result of cost-control measures, the quality of services would be reduced. So Goal 1 doesn’t look too achievable. Of course, we could insist that Goal 1 be achieved no matter what, perhaps along with Goal 3. But then it’s hard to see how Goal 2 could be achieved. Or we could dramatically reduce choice, and perhaps, just perhaps, that might enable us to offer an ample supply of, well, some kind of care judged by someone to be of high quality, while controlling costs. Would the quality be adequate? Without choice, it would be hard to tell, and it would be hard to require quality, since that’s what unrestrained markets do, and since we wouldn’t have anything like an unrestrained market. So it might seem, at first glance, as if there were a real problem achieving all three goals. But there’s not, if you vary one assumption that isn’t being made explicit in most of the discussions being conducted on-line, on TV, and in the print media by Beltway insiders. That’s the assumption that we need to keep a whole range of monopolistic cartels intact, cartels established by the state at least in part precisely to keep costs up. A natural approach for anarchists to take is to challenge this assumption, while suggesting that, if it’s not endorsed, the three explicitly stated goals can all be achieved at the same time. One way to think about this is as an ongoing contribution to the debate about “socialism.” The Tuckerite claim (I’m not precisely a Tuckerite, but I like to think of myself as a fellow traveler) is, I take it, that “socialism” is best understood as naming a series of goals which can be achieved using the political means or the economic means. For the Tuckerite, the economic means turns out to achieve the desired set of goals more efficiently than the political means—and so without the aggression that’s definitionally part of the use of the political means. But what is achieved is still socialism. The Tuckerite socialist can achieve what the state socialist purports to want, but without many of the human and financial costs created by a state-based approach. What the State Does to Keep Health Care Costs High Consider the impact of the monopoly power drug companies and medical device exercise by retaining and enforcing patent rights arbitrarily conferred by the government. Or consider the effect on prices when licensing requirements limit who can be a doctor, how many doctors there can be, what kinds of procedures non-doctors can perform? Or the effect exerted by similar licensing requirements that dramatically reduce competition in other health-care professions. Or the effect of limiting the accreditation of hospitals—too frequently in light of the market conditions of the communities in which they wish to operate (so that there’s as little head-to-head competition as possible). And there’s more: what about the rules that provide tax incentives for employers to purchase health insurance for employees, thus taking responsibility out of the hands of employees with incentives to seek good individual deals? And what about state rules that make it harder, or impossible, for people to seek insurance from out-of-state carriers? Or ones that limit who can be an insurer (hint: not a physician who wants to offer her patients care on a flat-fee-per-year basis). These constraints create or promote monopolistic or quasi-monopolistic positions for many players in the health-insurance industry. The FDA approval process is also, of course, a state monopoly that drives up costs and lengthens the time-to-market of many products. It’s also one of the factors that helps to make health care unaffordable for many people. State subsidies to agriculture also contribute to health-care costs by encouraging the purchase of lots of low-nutrition foods. Purchasing these items simultaneously redirects resources that could be used to buy foods that made positive contributions to people’s health away from the purchase of such foods and encourages the purchase of items that may actually decrease health and thus boost health care costs. Finally: it’s not a monopoly, precisely, but it is a dubious legal privilege that also drives up costs. A punitive damage award can turn an individual person into scapegoats, someone to be “taught a lesson” on behalf of the entire class of victims of conduct like his or her own. Punitive damage awards drive up costs unnecessarily while forcing health-care professionals and hospitals to focus on defensive medicine. How the State Can Help to Make Health Care Accessible by Stopping Its War on Poor People Remember, the driving force behind so much of the debate about health care is accessibility. That’s a function of cost. But it’s also a function of the incomes of people who might want access to care but can’t afford it. The first step would be to lower taxes. The long-term goal must be to eliminate all the tribute people pay to the state at all levels, but legislators might start by dramatically increasing the standard deduction while , at the federal level, increasing the Earned Income Tax Credit. It’s worth asking, too, about the impact of multiple monopolies on the circumstances of poor people. The state does lots of things that make and keep people poor. Some kinds of jobs require business licenses, or other kinds of permissions from local actors to start up. Maybe the licenses require costly and dispensable equipment or unnecessary certification, or maybe they just involve prohibitive up-front costs. (Think about how much it costs to obtain a New York taxicab medallion.) Sometimes, they preclude people using the low-cost facilities that are their own homes for business purposes, imposing the heavy burden of working elsewhere. And sometimes—as when Tulare, California, officials recently shut down a little girl’s lemonade stand because it didn’t have a license—licensing requirements are just exercises in petty tyranny. Whatever their form or their motivation, the burdens created by licensing requirements fall hardest on poor people. Those same requirements impact where poor people can find housing: housing that doesn’t meet someone else’s standards of middle-class acceptability is denied to poor people who could pay for it, but might be able to pay for anything else. And the burden on the poor is only increased when certain kinds of jobs are denied to people at all—like selling medications that the government wants sold only by government approved pharmacists in government-approved pharmacies. Tariffs also hurt poor people by significantly increasing the costs they need to pay for imported goods (including, often enough, food that would be less expensive than domestic alternatives absent import duties). Often touted as propping up poor workers’ incomes, they serve primarily to boost the profits of poorly performing domestic producers at the expense of both domestic consumers (especially poor ones) and foreign producers. In a perfect or near-perfect market, it might make little difference whether or not everyone was unionized. But in today’s un-freed market, state-guaranteed privilege, rather than competitive excellence, is responsible for some corporate profits. In this kind of market, unionization can help to improve workers’ economic positions. State limitations on union activity can tend to reduce unions’ influence, and so to reduce the incomes of workers who might make more were they free to engage in more radical bargaining tactics. An Initial Anarchist Agenda Bottom line: arguably the most important thing government officials could do to reduce health care costs would be to get completely out of the way, to stop privileging favored elites and driving up prices. State functionaries could: Stop offering protection to patents and copyrights. Eliminate hospital accrediting and professional licensing rules, leaving a variety of flexible, competing market-based certification systems to do the job. Limit malpractice awards to actual damages plus the costs of recovery (including reasonable legal fees). Repeal regulations that prevent the sale of insurance across state lines and the prevent the operation of what amount to insurance schemes by health professionals. Alter the tax code to de-link employment and insurance. (This change would have the potential to boost net taxes, of course, if it weren’t made in tandem with the tax cuts for which I’ve argued.) Replace the FDA approval process with alternative, voluntary private certification systems. Eliminate agricultural subsidies. And government officials could also ensure that ordinary people had the resources needed to pay for (newly much less expensive) health care. They could: Eliminate licensing, zoning, and related restrictions that prevent people from starting small, low-capital businesses. Eliminate rules that prevent poor people from entering business regarded as off-limits (like selling non-approved pharmaceuticals—which could be certified by voluntary, non-state certification services). Eliminate rules that force poor people to choose between the kind of housing middle-class planners and neighborhood busybodies prefer—and no housing at all. Eliminate import duties. Slash the tax burden at the state and federal level as much as possible—sharply increasing the standard income tax deduction and the Earned Income Tax Credit—and make corresponding reductions in spending. Eliminate state limitations on collective bargaining, including compulsory arbitration requirements, prohibitions on secondary boycotts, back-to-work orders, and “all state Right-to-Work Laws which prohibit employers from making voluntary contracts with unions.” Notice how the Tuckerite socialist model would work. It would ensure that poor people had more money. By eliminating monopolies (and quasi-monopolistic market distortions like tax subsidies for particular insurance choices), it would also ensure that prices for health care services—whether purchased directly or provided via insurers—were lower. By keeping a competitive market in place, it would ensure that competitive market pressures would tend to elevate overall product and service quality. And because it wouldn’t involve the installation of yet another czar, or the equivalent, because it would leave people free to make their own health-care choices, it would preserve liberty rather than limiting it. It would achieve all three of the goals proponents of current health-care reform measures say they want. Putting it on the able could also provide an opportunity to link a variety of other pro-freedom legal changes with (radical) health-care reform. And it would force proponents of statist options to ask more clearly whether they value the goals they say they want to achieve more than they value the opportunity to give more power to technocrats. While a Tuckerite socialist plan would, indeed, provide a way of achieving state-socialist goals via the economic rather than the political means, such a plan would be anything but a continuation of the status quo. Indeed, it would be a dramatic attack on the status quo, one that redistributed wealth from privileged monopolists to ordinary people, and dramatically increased the likelihood of access to inexpensive, high-quality medical care for all Americans.
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