Howard Husock. “Project Phaseout.” City Journal. 20 September 2009. <http://www.city-journal.org/2009/nytom_project-phaseout.html>.

The Digest

Apparently, low initial estimates and out-of-control cost is not  confined to health care [1], but also in other areas various governments touch. This City Journal article, for example, high-lights New York’s public housing projects. The projects were also initially estimated to be self-sufficient, which did not prevent them from being a massive drain on public money year after year.

The article also high-lights the tremendous waste of the projects, of which as much as 22.8% is underoccupied. Sadly, such waste is permitted at the same time people who do not qualify for public housing, such as poor new immigrants, must double or triple up in inflated private apartments.

Next time when governments throw out catchy phrases like “help the poor”, “cut waste” or “pay for itself”, please ask yourself whether they are based on illusive pipe dreams or reality, since time and time again, reality has turned out much differently.

Notes and References

1. Arlanjio. “Article Digest.” Arlanjio Blog. 2009-08-27. <http://arlanjio.net/2009/08/27/articles-on-the-web-3/>.

Larry P. Arnn. “A Work of Recovery.” Imprimis 37.12 (December 2008).

The Digest

The Imprimis article written by the President of Hillsdale College is incredibly insightful, with insight built upon those of James Madison and other giants of American history. One thing that stands out the most is the inevitability of human nature.

It would be desirable to eliminate all human vices, such as greed, Arnn argues from the writings of Madison, but doing so necessarily also eliminate liberty, since the two are so intricately linked. Further, the very vices that people seek to contain through government also permeates government itself. It is consists of humans, after all. This is precisely why the Constitution sets up a powerful government while severely limiting it at the same time.

The art of governance, therefore, is not to devise rules and regulations to restrict liberty, but to promote free people to govern themselves. Arnn cites the Homestead Act signed by President Lincoln, which gave away federal land to people willing to live and work on it. Unlikely modern entitlement programs, this Act assists the poor while promoting hard work and personal responsibility, rather than repressing them. Unfortunately, this is an art long lost in our government.

Senator Sam Brownback. “Are Health Care Reform Cost Estimates Reliable?” Joint Economic Committee, U.S. Senate. July 31, 2009. <http://jec.senate.gov/republicans/public/_files/Are_Health_Care_Reform_Cost_Estimates_Reliable__July_31_2009.pdf>.

The Digest

I have written that cost for virtually every government run health care system always exceeds initial estimates. This report puts some figures behind this claim. Yes, it is written by a Republican Senator, but unless the numbers are made up, they speak for themselves.

Most notable is a quote from the Massachusetts Democratic State Senator Jamie Eldridge (D-Middlesex), which is repeated here:

The assumption was that, as more people—and, in particular, more young and relatively healthy people—joined the system, premiums would go down across the board. There was also the assumption that as more people became insured, the number of people going to the emergency room would drop dramatically, saving the Commonwealth money. Neither of those things happened—at least not enough to produce the cost savings we were told we would see. In fact, health care reform has cost the Commonwealth much more than expected.

These are exactly the same assumptions the President uses in selling his plan, which is strikingly similar to the Massachusetts version.

Read the full report here >>

Update 2009-08-30

Changed title from the original “Articles on the Web”, and added the “Reviews” category. Also, added the “The Article” and “The Digest” headings.

Lawsuits

Lawsuits account for a significant portion of America’s health care cost. Yet all proposed reform bills designed to combat that cost wittingly omit tort reform. How should Americans believe that these proposals are serious?

President Obama casually dismissed tort reform since it “can be unfair to people who’ve been wrongfully harmed” [2]. Interestingly, his administration promises to reduce so much waste in the health care system to deliver the same quality service to tens of millions of additional patients, but cannot reduce any waste in the tort system while guaranteeing fairness to the relatively few who are wrongfully harmed? This is some serious schizophrenia that needs treatment.

The better answer is that trial lawyers as a group is one of the top donors to the Democratic Party. To his credit, there is one Democrat, Bob Beckel, who favors universal health care but also advocates tort reform. If only it is done to shut up opponents and let ObamaCare regain momentum. After all, he argues, are the trial lawyers going to switch sides? [3]

Problem: Frivolous and Meritless Lawsuits Cost Money

Lawsuits are expensive and cost a tremendous amount of money. Rewards to plaintiffs judged “wrongfully harmed” are often huge, with trial lawyers benefiting handsomely. I have written about the ambulance chaser, John Edwards, who made a fortune suing doctors and hospitals for causing cerebral palsy based on fictional science [4].

It turns out that many of Edwards’ trial lawyer colleagues also find OB/GYNs easy targets. In some states, OB/GYNs pay over $200,000 per year for malpractice insurance [4,5]. This means that patients and their insurance companies pay almost twice the value of the services they receive just so that trial lawyers like Edwards can become wealthy.

Even studies that supposedly dismiss the problem of frivolous lawsuits demonstrate their prevalence. A study conducted by the Harvard School of Public Health in 2006, for example, examined 1,452 closed claims from malpractice insurance companies. It shows that more than 90% of their claims involved a physical injury, but 37% of these cases “lacked evidence of [medical] error”. [6]

Here is the math: 10% does not involve any physical injuries and 37% of the remaining 90% is about 33% of all claims. Therefore, fully 43% of all claims either do not involve any injuries or the injuries are not caused by medical errors. The study goes on to says that:

The costs of litigating claims, including defense costs and contingency fees paid to plaintiffs’ lawyers, averaged $52,521 per claim. Overall, these administrative costs amounted to 54% of the compensation paid to plaintiffs. [6]

So, fully a third of malpractice claims do not go to the injured parties. Here is an idea: Why not limit lawyer fees? In doing so, the greedy lawyers will refrain from filing too many frivolous cases, but the good ones who truly want to help injured patients will continue to do so. They will sacrifice for good causes, and over the long run, may even give their profession a good name.

Problem: Defensive Medicine Costs Money

As a result of Edwards’ phony charges, C-section deliveries increased from 4.5% in 1965 to 31% of all births today, while cerebral palsy rates remained about the same [2]. Naturally, the cost for delivery increases on average and directly for those who have C-sections unnecessarily. Not to mention the higher risks associated with this major surgery, which was found to increase the risk of cerebral palsy and even death [7].

OB/GYNs are not the only physicians who fear lawsuits. As Charles Krauthammer wrote in a recent column:

An authoritative Massachusetts Medical Society study found that five out of six doctors admitted they order tests, procedures and referrals — amounting to about 25 percent of the total — solely as protection from lawsuits. [8]

Overall, a 2006 PriceWaterhouseCoopers report estimates that 10% of all health care insurance premiums go into medical liability and the resulting widespread practice of defensive medicine. In contrast, profit for insurance companies was only about 3 cents on the dollar [9].

The Pacific Research Institute estimates the dollar amount to be $200 billion per year [8,10]. Half of that amounts to $1 trillion over 10 years, enough to cover the current CBO’s estimate of the President’s plan.

Problem: Lawsuits Reduce Goodwill

If the nation is serious about helping the poor, then it should logically treasure those who volunteer. It is therefore, unconscionable for doctors and hospitals that provide charity care in many states to face the same prospects of being sued [11]. Texas State Representative Dan Branch understood this:

Rep. Branch’s father, Dr. Charles L. Branch, Sr., a retired San Antonio neurosurgeon, travels to Nigeria on an annual medical mission. He is restricted from volunteering in his home state however due to the risk of nuisance lawsuits despite charitable immunity. Other retired providers are discouraged from volunteering because they are required to pay the same fees as active practitioners. [12]

Worse yet, doctors and hospitals forced by the Emergency Medical Treatment and Labor Act (EMTALA) to provide free health care also face the same prospects [13]. As Dr. Bliss, who volunteers at a charity clinic, learned from her defense lawyer, “[she] should now regard each patient as a potential enemy.” [11] Such is the result of supposedly compassionate policies.

Putting it together, it is easy to see how twisted the logic is: We will spend a tremendous amount of money to cover every person in the country, but will discourage doctors from providing services for free. There are always poor countries in Africa or Latin America where doctors can go for medical missions. Only the poor back home who will miss their services. [14]

Solutions

Naturally, the solution is tort reform. Many ideas have been proposed. Among the popular ones are:

1. Capping non-economic damages,
2. Loser pays,
3. Mandate cases to be reviewed or decided by people with medical expertise instead of lay juries, who are more easily influenced by emotional arguments rather than scientific evidences, and
4. Suspend or revoke an offending physician’s license instead of punitive rewards [8].

Item (1): Non-economic damages are not calculated from anything, they are compensation for such things as emotional damages, which are by definition arbitrary and can be astronomical. This instability is a strong factor causing many malpractice insurance companies to bail out and the remaining ones to increase their premiums.

Items (2) and (3) are designed to reduce frivolous lawsuits, leaving only the ones with strong merits to go through the system. As such, patients truly injured benefit, because their cases can go through the system more quickly and begin with stronger footings due to prior reviews.

Item (4) deserves a closer look, because a lawyer, Leo Boyle, while defending trial lawyers, points out the obvious: most doctors are decent and a few bad apples cause most of the medical damages. He cites two studies in support:

An investigation by the West Virginia Sunday Gazette-Mail revealed that just 40 doctors were responsible for more than one-fourth of the 2,300 cases of medical malpractice reported to the state’s Board of Medicine between 1993 and 2001. And a recent analysis of medical negligence records in Kentucky found that from 1992 to 2001, only 16 percent of the state’s doctors were responsible for 100 percent of the medical malpractice there.  [17]

Boyle went on to defend malpractice lawsuits despite demonstrating that they have been powerless against those bad apples. This is not difficult to understand. After all, what do punitive awards absorbed by malpractice insurances do to the offending parties? Nearly nothing. A more effective means of disciplining doctors who cause injuries is suspending their medical licenses temporarily, with the duration lengthened upon each repeated offense.

Instead of abolishing the medical tort system altogether, as Krauthammer advocates [8], I suggest that every malpractice lawsuit be split into two parts. The medical fact finding part is handled by the relevant medical board with independent medical experts. Direct disciplinary actions are also determined by the same board. Cases with merits then go on to trial to determine damages awarded to the injured party. Such damages will include economical and restricted non-economical damages, and will still come from doctors’ malpractice insurances.

Subsequently, details of those cases should be easily accessible by the public, so that future patients will be able to obtain the full history of the physicians they intend to hire before committing to one.

A Model to Follow

After Texas passed Proposition 12 in 2003, the state witnessed exactly what was expected: more physicians especially in traditionally underserved regions, lower malpractice insurance [18], and an increase of charity care by more than $600 million [19,20]. In the words of Joseph Nixon, the author of [20]: “The dominoes have fallen exactly as predicted.”

A separate study that evaluated tort reform and its effect on insurance coverage between 1981 and 2004 also validated what the Texans have experienced. The study concluded that:

…reform generally increased health insurance coverage for the most price-sensitive groups (the young, the self-employed, and the single). [21]

How about those who are injured? In Texas, claims and lawsuits have been cut in half following the reform [19]. This means that patients with strong cases are still filing lawsuits to get their compensation, but they do not need to wait nearly as long after the frivolous kinds. Moreover, disciplinary actions handed by the Texas Medical Board nearly tripled since 2001 [22]. It sure sounds like patients are still protected, since poor doctors are disciplined more harshly than merely filing a claim with their insurance companies. The trial lawyers, on the other hand, are an entirely different story that I did not bother to research.

Update 2009-08-29

Changed the title from it’s original: “How to Reduce Health Care Cost (Part 2)”.

Notes and References

1. Arlanjio. “How to Reduce Health Care Cost (Part 1).” Arlanjio Blog. August 14, 2009. <http://arlanjio.net/2009/08/14/how-to-reduce-health-care-cost-part-1/>.
2. “They’re Coming For Your Tonsils.” Investor’s Business Daily. July 29, 2009. <http://www.ibdeditorials.com/IBDArticles.aspx?id=333759404527100>.
3. Bob Beckel. “Dems’ Ace in the Hole on Health Care: Tort Reform.” RealClearPolitics. August 18, 2009. <http://www.realclearpolitics.com/articles/2009/08/18/dems_ace_in_the_hole_on_health_care_tort_reform_97919.html>.
4. Arlanjio. “Why Should Christians Oppose ObamaCare?”. Arlanjio Blog. July 22, 2009. <http://arlanjio.net/2009/07/22/why-should-christians-oppose-obamacare/>.
5. Katie Gazella. “High cost of malpractice insurance threatens supply of ob/gyns, especially in some urban areas.” University of Michigan Health System. June 1, 2005. <http://www.med.umich.edu/opm/newspage/2005/obgyn.htm>.
6. “Study Casts Doubt on Claims That the Medical Malpractice System Is Plagued By Frivolous Lawsuits.” Harvard School of Public Health. May 10, 2006. <http://www.hsph.harvard.edu/news/press-releases/2006-releases/press05102006.html>.
7. Michael Fumento. “John Edwards vs. Babies and Moms.” The American Spectator, March 21, 2007. <http://www.fumento.com/fumento/edwards2007.html>.
8. Charles Krauthammer. “Health Care Reform: A Better Plan.” Townhall.com. August 07, 2009. <http://townhall.com/columnists/CharlesKrauthammer/2009/08/07/health_care_reform_a_better_plan>.
9. The Factors Fueling Rising Healthcare Costs 2006. PriceWaterhouseCoopers, Prepared for America’s Health Insurance Plans. January 2006. <http://www.ahip.org/redirect/TheFactorsFuelingRisingHealthcareCosts2006.pdf>.
10. Andrew Foy and Brenton Stransky. “How to ‘bend the curve down’ in healthcare costs.” American Thinker. August 11, 2009. <http://www.americanthinker.com/2009/08/how_to_bend_the_curve_down_in.html>.
11. Dr. Joy Bliss. “What we learned this week in the charity clinic: Good deeds are often punished.” Maggie’s Farm. June 17. 2009. <http://maggiesfarm.anotherdotcom.com/archives/11737-What-we-learned-this-week-in-the-charity-clinic-Good-deeds-are-often-punished.html>.
12. Rep. Dan Branch’s Charity Health Care Bill Becomes Law. Texas House of Representatives. July 14, 2005. <http://www.house.state.tx.us/news/release.php?id=1398>.
13. Rep. John Shadegg (R-Ariz.). “Restrict lawsuits arising from free care at hospitals.” The Hill. February 25, 2004. <http://www.house.gov/hensarling/RSC/doc/Shadegg–EMTALA.pdf>.
14. Some will counter that the poor are now covered and therefore do not need charitable care. As I have written earlier, coverage does not mean health care. It merely means a promise to pay for care. [15,16] When there are no additional doctors and hospitals to provide the extra care, it simply means long lines and reduced quality.
15. Arlanjio. “Health Care Reform.” Arlanjio Blog. July 1, 2009. <http://arlanjio.wordpress.com/2009/07/01/health-care-reform/>.
16. Arlanjio. “The ‘Broken’ Health Care System.” Arlanjio Blog. August 4, 2009. <http://arlanjio.net/2009/08/04/the-broken-health-care-system/>.
17. Leo Boyle. “The Truth About Medical Malpractice.” Trial. April 2002. <http://www.vanosteen.com/news/medical-malpractice.asp>.
18. “Texas Liability Rates Dropping After Prop 12.” Texas Medical Association. 7/13/2009. <http://www.texmed.org/Template.aspx?id=3868>.
19. “Proposition 12 Produces Healthy Benefits.” Texas Medical Association. 2/9/2009. <http://www.texmed.org/Template.aspx?id=5238>.
20. Joseph M. Nixon. “Proposition 12 a Winner Five Years Later.” Martindale-Hubbell. November 3, 2008. <http://www.martindale.com/medical-malpractice-law/article_Beirne-Maynard-Parsons-L.L.P._539600.htm>.
21. Ronen Avraham, Max M. Schanzenbach. “Impact of Tort Reform on Private Health Insurance Coverage.” Northwestern Public Law Research Paper No. 07-16. December 17, 2007. <http://ssrn.com/abstract=995270>.
22. Don Brunell. “Texas economy shining brightly despite recession.” Washington View. August 10, 2009. <http://www.tortreform.com/node/537>.

A consumer-driven health care system actually exists in Switzerland, which could be a model for the United States, but the administration and Congressional Democrats haven’t looked at it.

Switzerland has an individual mandate requiring everyone to be covered by private insurance. There is no employer-provided or government-managed coverage, and poor people are subsidized to help them buy insurance.

Switzerland has health care outcomes comparable to the most affluent U.S. states, while its health costs per capita are 40 percent lower than in the U.S.

Read the full article >>

The government devises a system that promises to provide universal coverage while keeping the budget neutral from the “savings” the system will derive, mostly due to preventive care and cutting waste.

Then reality kicks in. Enrollment for the program exceeds initial estimates, and cost goes up. Many people who had private insurance coverage replace them with the heavily subsidized “public option”. Waste is not reduced but exacerbated, and as a result, cost runs out of control after a few short years. The government then scrambles to contain costs in various ways, which always defeat the intention behind the establishment of the system.

I cannot help but wonder why Albert Einstein’s famous quote about insanity keeps coming into my mind? “Insanity: doing the same thing over and over again and expecting different results.”

U. S. State Programs

Tennessee

The TennCare program started after the failed HillaryCare. After a few years, the state government proposed for the first time in history to levy a personal income tax, which was ultimately defeated. The program was a disaster.  In short, hospitals shut down, medical professionals left, and the state was driven nearly to bankruptcy. [1,2]

Massachusetts

Gov. Mitt Romney’s pet program started in 2006, and it did cover more people as a result. However, it has already needed a tax increase to keep up with the steadily rising cost [3]. The highly predictable problem also results: long lines [4]. Further, state legislators are already talking about excluding legal tax-paying residents [5]. I suppose the meaning of “universal” needs an update.

Hawaii

The island paradise dropped its universal coverage for children after only seven months [6]. I guess there is still no paradise on earth where laws of economics do not apply [7].

Oregon

This is the famous government program that refused to cover a cancer treatment but offered assisted suicide instead [8]. “Death panel”, anyone? Now, in order to enroll in the plan, you must first win a lottery [9]. How about calling it a “Lottery Health Plan”?

Maine

Yet another failed government experiment that required tax hikes to salvage and restrictions on enrollment. So much for “universal” coverage, again! [10]

Foreign Systems

These foreign systems do achieve “universal” coverage to some degree. However, “coverage” is the key word and not “care”. Unfortunately, coverage is not health care [7,11], and governments are not God. When they say “Let there be health care for everyone”, health care do not pop out of nowhere, they still need to be provided by doctors and hospitals and the laws of economics still apply.

This is not to say that we cannot learn from their experiences. I am sure each country have something valuable we can borrow, but universal “coverage” is not one of them.

Canada

Our northern neighbor’s health care system is so great that the system itself routinely sends patients it cannot handle to us [12]. Not to mentioned the long lines and denied coverage for specialized treatment [13,14,15]. If you are rich, you can still come down south for treatment, otherwise you are stuck waiting, even if the wait time is longer than the average life span for that particular illness.

United Kingdom

The UK gave its citizens an organization called NICE which devised a formula called QALY: quality-adjusted life years. This QALY is used to make decisions on what medical equipment to purchase and what treatment to cover in order to, you’ve probably guessed it, control cost [16]. It all sounds nice until you are hit with an illness that NICE determines unworthy of treating, such as those cancers patients whose lives may be prolonged by certain expensive cancer drugs [17].

France

To be honest, I don’t know too much about France’s system. From the limited material I have read, they have a mixture of private and public coverage options that may be better than the Canadian or British models. However, if we were to imitate the French, we may want to be prepared for heat waves [18], especially in light of the imminence of global warming disasters that the Prophet Al Gore predicted.

Update 2009-08-24

There is apparently not only a QALY formula in the United Kingdom, but also a “best interest” clause in the Mental Capacity Act of 2005. Basically, doctors must follow certain guidelines to act in the “best interest” for patients who cannot communicate.

In the case of Mrs. Ellen Westwood, doctors, following national guidelines, concluded that she was going to die. So, the “best interest” for her, despite objections from her family, was to remove food and water and to give her morphine instead. The story did have a happy ending because Westwood’s daughter fought hard for her. [19,20]

Again, so much for panels that devise life and death decision making guidelines based on averages and standard deviations.

Notes and References

1. Reps. Marsha Blackburn and Phil Roe. “Lessons For Health Care Reform.” RealClearPolitics. July 22, 2009. <http://www.realclearpolitics.com/articles/2009/07/22/tenncare_lessons_for_modern_health_care_reform_97570.html>.
2. Patrick Poole.  “Governor Schwarzenegger Should Go to Nashville.”  American Thinker.  <http://www.americanthinker.com/2007/01/governor_schwarzenegger_should.html>.
3. Michael D. Tanner. “How Not to Reform Health Care.” National Review (Online). June 9, 2009. <http://www.cato.org/pub_display.php?pub_id=10279>.
4. Kevin Sack. “In Massachusetts, Universal Coverage Strains Care.” The New York Times. April 5, 2008. <http://www.nytimes.com/2008/04/05/us/05doctors.html>.
5. Molly Line. “Massachusetts Universal Health Care Cuts.” Liveshots, Fox News. July 17, 2009. <http://liveshots.blogs.foxnews.com/2009/07/17/massachusetts-universal-health-care-cuts/>.
6. Paul Detrick. “CNN Glosses Over Failure of Universal Health Care.” NewsBusters. October 17, 2008. <http://newsbusters.org/blogs/paul-detrick/2008/10/17/cnn-glosses-over-failure-universal-health-care>.
7. Arlanjio. “Health Care Reform.” Arlanjio Blog. July 1, 2009. <http://arlanjio.wordpress.com/2009/07/01/health-care-reform/>.
8. “Oregon health plan covers assisted suicide, not drugs, for cancer patient.” Catholic News Agency. Jun 6, 2008. <http://www.catholicnewsagency.com/new.php?n=12857>.
9. “Oregon Health Plan.” Wikipedia. Last modified: 15 August 2009. <http://en.wikipedia.org/wiki/Oregon_Health_Plan>.
10. No Maine Miracle Cure. The Wall Street Journal, page A12. August 21, 2009. <http://online.wsj.com/article/SB10001424052970204619004574322401816501182.html?mod=djemEditorialPage>.
11. Arlanjio. “The ‘Broken’ Health Care System.” Arlanjio Blog. August 4, 2009. <http://arlanjio.wordpress.com/2009/08/04/the-broken-health-care-system/>.
12. Lisa Priest. “Critically ill patients rushed to U.S. for care.” Globe and Mail. Last updated Mar. 30, 2009. <http://www.theglobeandmail.com/life/article661794.ece>.
13. Thomas Lifson. “Canada’s ‘universal’ health care.” American Thinker. August 17, 2007. <http://www.americanthinker.com/blog/2007/08/canadas_universal_health_care.html>.
14. David Gratzer. “The Ugly Truth About Canadian Health Care.” City Journal. Summer 2007. <http://www.city-journal.org/html/17_3_canadian_healthcare.html>.
15. John Stossel. “’Better’ Health Care?” Townhall.com. July 01, 2009. <http://townhall.com/columnists/JohnStossel/2009/07/01/better_health_care>.
16. “Measuring effectiveness and cost effectiveness: the QALY.” National Institute for Health and Clinical Excellence. 2009. <http://www.nice.org.uk/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp>
17. “Life prolonging cancer drugs to be banned because they cost too much.” Daily Mail. 05th March 2009. <http://www.dailymail.co.uk/health/article-1159506/Life-prolonging-cancer-drugs-banned-cost-much.html>.
18. “France heat wave death toll set at 14,802.” USA Today. 9/25/2003. <http://www.usatoday.com/weather/news/2003-09-25-france-heat_x.htm>.
19. J. R. Dunn. “Palin v. ObamaCare.” American Thinker. August 20, 2009. <http://www.americanthinker.com/2009/08/palin_v_obamacare.html>.
20. “Hospital ‘starved’ elderly mother.” BBC. 2 July 2008. <http://news.bbc.co.uk/2/hi/uk_news/england/west_midlands/7486166.stm>.

I do not profess to be an expert in the health care industry, but these days, it is difficult not to come across many related writings. This article serves to summarize the many thoughtful ideas I have read, plus a few of my own. Admittedly, some of my ideas may be flawed and I may revise or even abandon them in the future. But who knows, may be some of them will stick.

Why Is It So Expensive?

There are many reasons American health care is expensive, and I do not pretend to have an exhaustive understanding. From what I have collected so far, they roughly fall into three categories.

1. Quality,
2. Law suits, and
3. The Wedge, as economists call it, between consumers and providers.

In each section below, I will examine various factors that contribute to the high health care cost and offer what I deem as practical and sensible solutions.

Quality

As I wrote in an earlier article, the quality of American health care is unparalleled, if you consider what it has delivered, such as cancer survival rate, instead of misleading metrics such as life expectancy and infant mortality rate [1]. Like it or not, quality always comes with a premium, here are just a few.

Problem: Equipment costs money

Patients in the United States enjoy nearly three times as many CT scanners and more than four times as many MRI machines on a per capita basis than those in Canada or the United Kingdom [4]. Unfortunately, these machines, along with many others that make American health care superior, cost money, and being relatively new technologies they are expensive.

The easy scape goat is the equipment designers and manufacturers. After all, why must “evil” capitalists make a profit on something as essential as medical equipment that saves lives? People who have such thoughts never ask themselves a simple question: Would I put my own money in an investment that promises no returns but a real risk of losing the principal? If not, who will? The inescapable reality is that there must be a cost for capital, or capital will not be freely available [5].

Without capital, who will set up factories to manufacture these machines? Who will pay the rent and buy the necessary tools? Who will pay the wages of the workers and contribute to their benefits? Who will fund all these before the first machine is built and the first payment received?

Surely, governments can do all these with money coerced from their citizens, but we have all seen their track records. When governments ran farms, millions of people died of starvation. When they produced cars, we got such beauties as the Yugo. In the place where that Sicko Michael Moore glorified as having a better health care system then ours, the government cannot even produce enough toilet paper for its meager 9 million citizens [6]. I am sure the Cubans are all entitled to affordable toilet paper, but getting it is another matter.

Solution

There is one area in this where governments have complete control: corporate taxes. Unfortunately, when “evil” corporations are levied heavy taxes, to the tone of 39% and the second highest among developed nations [7], they must pass them onto their customers in order to return a fair amount to their investors [8]. Otherwise, capital will diminish, because there are plenty of other investments, such as foreign corporations or commodities that are subject to lower or no taxes [9].

Problem: Research cost money

Private hospitals and corporations in America pour in a tremendous amount of resources into research and development of novel medical devices and drugs. “Fact No. 10” in [2] speaks for itself:

Fact No. 10: Americans are responsible for the vast majority of all health care innovations. The top five U.S. hospitals conduct more clinical trials than all the hospitals in any other single developed country. Since the mid-1970s, the Nobel Prize in medicine or physiology has gone to American residents more often than recipients from all other countries combined. In only five of the past 34 years did a scientist living in America not win or share in the prize. Most important recent medical innovations were developed in the United States.

In fact, American patients subsidize a significant portion of these R&D costs for most of the world by paying a premium on their fruits. This is not entirely unjustified, however.

One reason Americans pay more is simply that they can afford more, being wealthier than any other nation on earth. Businesses will price their products to maximize profit in each market, provided there is a reasonable separation between markets [10]. This is natural and reasonable, since living standards vary greatly. For example, Mexicans simply cannot afford as much on health care as Americans do. If drug companies were to offer them the same prices they do north of the border, then few Mexicans would be able to purchase those drugs and the drug companies could not make a meaningful profit. In the end, both sides suffer.

Another reason is government intervention. Since nations with heavily subsidized health care almost universally face the problem of runaway cost, their governments often implement price control measures. As a result, American patients, being in a system where prices are relatively flexible, inadvertently pick up a disproportional amount of the R&D cost.

A third reason and probably the predominant one why Americans pay more is law suits [10], which I will discuss later.

Solution

There need not be a solution for price discrimination. It is quite moral for the wealthier to pay a higher portion of something that benefits all. Ironically, out of self interest, businesses inadvertently adopt this progressive practice. The problem arises when states determine that the disparity set by the markets are still unfair, and impose further constraints.

This brings up the fundamental dispute between statists and free marketers on who should set prices. It is not a trivial matter and is beyond the scope of this article. As a free marketer, I personally think that the U. S. government should treat this as a trade issue and attempt to remove artificial price controls by foreign governments. There are good reasons to spare truly impoverished countries, but none for subsidizing wealthy nations such as Canada. If governments of wealthy nations wish to subsidize their citizens’ health care, they should do it from their own coffers and not ours.

Problem: Doctors cost money

Doctors cost money to train and require proper compensation for their valuable services. While hypocrites like Bill Maher call private health care providers “soulless vampires making money off human pain” [11], they never question why they themselves should be paid beyond what is enough to cover the basic necessities of life. Surely, HBO can benefit millions of people if it were free, but Maher would have to give up 95% of his salaries. Incidentally, that’s something he wishes doctors would do, but when it comes to his own profession, well, that must be different.

In the United States, a typical aspiring physician must first obtain an undergraduate degree before entering a medical school. After graduating from medical school, a few years of residency is required before he or she can officially practice medicine [12,13]. Due to the high cost of education, new physicians often carry a hefty student loan before seeing a single patient. Naturally, a significant higher commitment in both time and money commands a premium in compensation. Otherwise, the number of people attracted to the profession will dwindle, further straining the supply.

Solution

According to Wikipedia citing AAMC, nearly 40% of new medical students came from non-biology or non-health care related undergraduate programs [13]. This means doctors can be adequately trained with only four years relevant education. So, why waste the other four on such unrelated studies like English or History?

As many universities are already practicing [14], why not encourage more to combine four years of undergraduate study and four years of medical training into six years or even shorter? Of course, to ensure a high quality medical training, courses cut must come from non-related subjects such as English or History. This will make it easier to obtain a medical degree and reduce the tuition burden for that goal, and therefore, increase the supply of physicians and drive down their compensation.

I will even suggest that any reduction in the undergraduate studies be made up proportionally in residency. After all, physicians in training contribute to the supply of health care, albeit under supervision, and receive compensations. In contrast, aspiring doctors studying English or History contribute nothing.

Problem: Extra capacity costs money

The story of the Calgary woman carrying identical quadruplets in 2007 speaks volumes [15]. Apparently, not only the oil rich Calgary did not have four neonatal intensive care units, but neither did the entire country:

There was no room at any other Canadian neonatal intensive care unit, forcing CHR officials to look south of the border [15].

In contrast, the Canadian officials did not need to look far across the border. The first small American city down south, Great Falls, Montana, population 56,000 (in 2000) [16], had no problems supporting them.

Clearly, extra capacity costs money [17]. Sometimes equipment must sit idle while operators must standby. People who use the machines and the staff inevitably pay for the idle times as well. Understandably, though, this is one area where cost is justified, especially in a wealthy nation such as ours. After all, a low cost coverage is useless if the proper equipment and staffing are not available during a time of necessity.

To Be Continued

Seeing that this article is already so long, I will continue with the remaining topics in the next part.

Update 2008-08-29

Changed the title from the original: “How to Reduce Health Care Cost (Part 1)”.

Notes and References

1. Arlanjio. “The “Broken” Health Care System.” Arlanjio Blog. August 4, 2009. <http://arlanjio.wordpress.com/2009/08/04/the-broken-health-care-system/>.
2. David Gratzer. “The Ugly Truth About Canadian Health Care.” City Journal. Summer 2007. <http://www.city-journal.org/html/17_3_canadian_healthcare.html>.
3. David Gratzer. “Canadian Health Care We So Envy Lies In Ruins, Its Architect Admits.” IBD Editorials. June 25, 2008. <http://www.ibdeditorials.com/IBDArticles.aspx?id=299282509335931>.
4. Scott Atlas. “10 Surprising Facts about American Health Care.” National Center for Policy Analysis. March 24, 2009. <http://www.ncpa.org/pub/ba649>.
5. Arlanjio. “Exploitation (Part 1).” Arlanjio Blog. June 22, 2009. <http://arlanjio.wordpress.com/2009/06/22/exploitation-part-1/>.
6. “How End-Users Suffer Under Socialism.” Investor’s Business Daily. August 11, 2009. <http://ibdeditorials.com/IBDArticles.aspx?id=334882669428387>.
7. “Capital Drag.” Investor’s Business Daily. August 11, 2009. <http://ibdeditorials.com/IBDArticles.aspx?id=334883199202130>.
8. Since the term “fair” has been so misused by lefties to mean basically whatever they want to support their government mandates, I think it is necessary to clarify it here. What I mean by “fair” is simply a sufficient return to attract enough capital to fund the business operations. The return is only “fair” because it is determined by the market, or put more concretely, willing businesses and investors.
9. Do not confuse corporate tax with capital gain tax, which applies to other investments as well. Profits from corporations are essentially taxed twice, while other investments, such as in commodities, are only taxed ones. Then, there are foreign corporations which may enjoy much lower corporate taxes competing for the same investment money. Sure, investing in foreign countries is more difficult, but mutual funds have diminished this barrier greatly.
10. Brian Lee Crowley. “Why are Drugs Cheaper in Canada? A Revised Version of a Talk by AIMS President Brian Lee Crowley To the MPPI Conference ‘Drug Re-importation: Unintended Consequences.’” Atlantic Institute for Market Studies. September 16th, 2004. <http://www.aims.ca/library/MPPI_pharma-revised_.pdf>.
11. Bill Maher. “Health Care Problem Isn’t Socialism, It’s Capitalism.” Real Clear Politics. July 24, 2009. <http://www.realclearpolitics.com/articles/2009/07/24/health_care_problem_isnt_socialism_its_capitalism_97610.html>.
12. “Medical education in the United States.” Wikipedia. Last modified: 23 May 2009. <http://en.wikipedia.org/wiki/Medical_education_in_the_United_States>.
13. “Medical school in the United States.” Wikipedia. Last modified: 8 August 2009. <http://en.wikipedia.org/wiki/Medical_school_in_the_United_States>.
14. “Schools Offering Combined Degree Programs in BS/MD.” Association of American Medical Colleges. <http://services.aamc.org/currdir/section3/degree2.cfm?data=yes&program=bsmd>.
15. “Calgary’s quads: Born in the U.S.A.” The Calgary Herald. August 17, 2007. <http://www.canada.com/calgaryherald/story.html?id=41ccae74-8325-449a-b89f-e68957ca25ae&k=79546>.
16. “Great Falls, Montana.” Wikipedia. Last modified: 8 August 2009. <http://en.wikipedia.org/wiki/Great_Falls,_Montana>.
17. Thomas Lifson. “Canada’s ‘universal’ health care.” American Thinker. August 17, 2007. <http://www.americanthinker.com/blog/2007/08/canadas_universal_health_care.html>.

Economic Systems: If you ever wonder why we so resist socialism, consider the latest news out of that collectivist island paradise known as Cuba.

Central planners announced this week that they were fresh out of money to buy toilet paper — yes, toilet paper — for the island’s 9 million citizens. But not to worry. A nameless official for state-run monopoly Cimex and quoted by Reuters assured that “the corporation has taken all the steps so that at the end of the year there will be an important importation of toilet paper.”

Read the full article here >>

The same Congress and White House that ridiculed executives of automobile companies for flying in private jets to beg for bailout money, and the same people who is pushing the Cap-and-Trade legislation intended to reduce carbon emission, have just ordered three military jets for $200 million to spare the important members of the ruling class from flying first class commercial airlines [4].

These are also the same people who is actively trying to sell us the “cure-all-illness” government run “public option” health care coverage, but conveniently exempt themselves from subjugating to its limitations.

When Rep. John Fleming introduced House Resolution 615 to ask House members who would vote in favor of the public option to pledge to personally use it, guess who are the few co-sponsors? Later, when Rep. Dean Heller offered a similar amendment to H.R. 3200 in the House Ways and Means Committee, guess who are the ones voted in favor? Hint: None of them have the letter “D” in their titles [5]. The ones who are elevating government health care into a heavenly status is apparently unwilling to enjoy it. Snake oil, anyone?

How about the top salesman for the public option? When asked if he would seek outside help if the public option limits his options for treating a hypothetically serious illness of his wife or one of his daughters, predictably President Obama refuses to pledge to stick with the plan:

And, you’re absolutely right that if it’s my family member, if it’s my wife, if it’s my children, if it’s my grandmother, I always want them to get the very best care [5].

Well, please forgive me for wanting to do the same for my wife and my daughters, but I am not as wealthy as the Washington elites who can do so despite socialized medicine. So, please spare me the agony of suffering the high human cost of socialized medicine [6] that you are not willing to taste.

No wonder politicians feel the globe is warming up, there is just too much hot air around them.

Notes and References

1. Jack Kelly. “Gore’s Plan Just a Dream.” RealClearPolitics. July 22, 2008. <http://www.realclearpolitics.com/articles/2008/07/gores_plan_just_a_dream.html>.
2. “Al Gore ignores ‘Earth Hour’ Driveway to Nashville mansion flooded with electricity.” March 29, 2009. WorldNetDaily. <http://www.wnd.com/index.php?fa=PAGE.view&pageId=93315>.
3. There is no lack of defense for the Prophet from his lefty minions on sandy grounds such as he’s got a big house, he’s paying a premium for renewable energy, and he’s paying carbon credits. How convenient is it for the wealthy who can maintain his life style while offsetting his carbon footprint to dictate the same on those who cannot? No doubt, I will start reducing my carbon footprint once I can afford a house that big, have money to spare for those renewable energy, and own a carbon trading company that will pay for my carbon credits as benefits. In the mean time, I have plenty of catch-up to do.
4. Andrew Taylor. “House provides $200 million for gov’t VIP jets.” Townhall.com. August 06, 2009. <http://townhall.com/news/politics-elections/2009/08/06/house_provides_$200_million_for_govt_vip_jets>.
5. Chelsea Schilling. “Why won’t Congress enroll in gov’t health care?
   Democrats exempt themselves from own ‘reform’.” WorldNetDaily. July 23, 2009. <http://www.wnd.com/index.php?fa=PAGE.view&pageId=104716>.
6. Arlanjio. “The ‘Broken’ Health Care System.” Arlanjio Blog. August 4, 2009. <http://arlanjio.wordpress.com/2009/08/04/the-broken-health-care-system/>.

So much for a “broken” health care system, Americans enjoy much higher cancer survival rates and better access to certain treatment than people who receive free health care in Europe and Canada [1,2]. And these are merely a few benefits we often take for granted. The National Center for Policy Analysis (NCPA) lists quite a few more in a recent report [1].

Critics often cite such statistics as lower life expectancy and higher infant mortality to infer an inferior American system. As convincing as they may seem, these barometers always depend far more on other factors like genes, lifestyle, diet, sanitary conditions, etc. that have little to do with health care [3,4,5]. For example, Japanese Americans have similar life expectancies to native Japanese [4]. The “inferior” American system is apparently not a factor to them.

Indeed, if these measures are good indicators of the overall quality of a country’s health care system, then Americans, at least those living along the Canadian border, should be flocking up north to seek better treatment. In reality, we see the exact opposite. The Canadian system itself routinely sends patients across the border [6], and far more are those who come on their own. Ironically, our northern neighbor with lower infant mortality rate [7] had to send high-risk mothers down south because of its lack of advanced facilities to handle them [8].

How will the public option work?

Horror stories of universal health care abound [9,10], but little do we hear about them. Why? It is likely because to a left leaning media, the idea of “equal access” is so attractive that quality is of secondary concern. But what good is “equal access” if access is equally unavailable to those most in need [9,10,11]?

As I wrote in an earlier article, health care is a scarce resource that must obey the fundamental laws of economics [12]. No matter how compassionate a government is, it can no more wish or decree away these laws than it can with gravity. The high cost of health care in the United States notwithstanding, providing universal “access” or “coverage”, as the President and the Democratic Congress suggest, does not mitigate the true cost of health care.

The true cost of any scarce resource is not the money necessary to pay for it. Money is merely a measure of cost, much as a ruler provides a measure of an object. The underlying cost is the availability of resources to supply what is demanded, in competition with alternative uses of the same resources. Just as stretching a soft ruler merely makes the object it measures appear shorter, distorting the market artificially only masks the scarcity of those resources [12,13].

Two things are certain with the implantation of the proposed universal coverage, the so called “public option” that is essentially subsidized insurance coverage:

1. Demand for health care will increase because more people will take advantage of the low cost coverage, but
2. Supply will not, as nothing in the proposal seems to suggest anything to that effect.

The result is highly predictable, not only because the basic laws of economics never changes, but also because similar schemes have been tried before. Many more people than expected will find ways to qualify for the public option and cost will rise quickly. Private insurance companies will go out of business because they cannot compete with a tax-payer subsidized option. More people will join the public option, making it the de facto single payer before long. In attempt to lower cost, bureaucrats who run the public option must resort to rationing and limiting payments to service providers. Naturally, the former means long lines and the latter reduces supply and thus further exacerbates the problem.

Sadly, this is not just my wishful thinking. A similar public option has been tried in Tennessee, after the failure of the original HillaryCare [14]. Another one has been running in Massachusetts for a few years [15]. Legislators are already proposing cuts to legal tax paying immigrants in order to contain the much higher than initially expected cost  [15,16]. Then, there is Hawaii, which recently dropped its universal program for children after only seven months due to, you have probably guessed it, higher than expected enrollment and cost [17].

Rationing

Despite long lines, does government subsidized health care provide affordable access to every one? This question is not a difficult one, especially considering the economic corollary of the proposed public option. Can a scheme that spurs demand and maintains, if not reduces, supply make the system more affordable? It can, but only if you substitute monetary affordability with the high cost of human suffering and unnecessary deaths. Bureaucrats facing such economic realities necessarily resort to rationing, or let cost run amuck, which will eventually bankrupt the entire nation.

Already, President Obama has suggested employing a panel of “experts” to recommend coverage. Such recommendations will automatically become standards of the public option unless Congress acts to overrule it. This is classic central planning with its fundamental weakness faithfully inherited: A small number of people, no matter how smart and proficient in the subject matter, cannot possibly understand the intricacies of millions of slightly different situations and make appropriate decisions. Simply put, one size does not fit all.

John Stossel interviewed Shirley Healy in an ABC’s 20/20 episode [18], and subsequently wrote about it in a column [19]:

Shirley Healy, like many sick Canadians, came to America for surgery. Her doctor in British Columbia told her she had only a few weeks to live because a blocked artery kept her from digesting food. Yet Canadian officials called her surgery “elective.”

“The only thing elective about this surgery was I elected to live,” she said.

This example perfectly illustrates a fundamental flaw of “expert” defined rationing. Experts can only act on aggregate statistics like averages and standard deviations and recommend treatment accordingly. Even if we consider such statistics fairly accurate and reasonably represent the present, what if, like Shirley, a patient falls outside of the norm? The surgery she needed may in fact be “elective” in most cases, but in Shirley’s case, it was certainly not. Her life became disposable as a result of a government cost control measure.

Luckily for Shirley, she could simply drive across the border to get the treatment out of her own pocket. Luckily still for Canadians, private clinics and insurances have been blooming in recently year. However, the very problem that system originally intended to heal resurfaces, in that, the poor is still stuck waiting for health care. Accessibility is limited by long lines instead of cost.

Ask yourself a simple question: When you or a loved one becomes ill, would you like the continuation of your life be determined by a panel of “experts”, the political party happens to be in power, or even a national debate? If the obstacle is money, you can borrow, run it on credit cards, sell your house, or conduct a fund-raiser in your church or community. I will even support the government granting emergency loans to those in need, so long such loans carry a market interest rate and must be paid back. It may be a high price, but is any price too high to save a life?

A high price

Understandably, American health care carries a high price. Part of it is necessary to sustain a high quality system and part of it is due to the various government policies and regulations. In my next article, I will discuss these issues and explore practical ways to relieve the cost without harming the goose that is still laying the golden eggs.

Update 2009-08-05

I have just read an Investor’s Business Daily article that details how countries classify live babies and tally infant mortality rates differently [20]. Judge for yourself which system is more humane, one that treats and attempts to save any infant with any signs of life despite the cost, or one that determines certain infants not worth saving based on some arbitrary factor such as weight or length? The editors at IBD is absolutely right when they wrote:

It must be embarrassing to Canada that a G-7 economy and a country of 30 million people can’t offer the same level of health care as a town of just over 50,000 in rural Montana.

Yet, many today fancy a system just like that. Go figure!

Update 2009-10-01

It turns out that not only Japanese Americans do fairly well. Asian Americans in general, according to a USA Today article published in 2006, had an average life expectancy of 85 years [21]. This is longer than the longest life expectancy listed by country on the CIA’s World Factbook. That title currently belongs to Macau, with 84.36 years [22].

Is it because they are relatively wealthy? Maybe, but wealth in general is not an indicator of life expectancy. The same USA Today article cited the second longest living group turns out to be poor Whites living in Minnesota, the Dakotas, Iowa, Montana and Nebraska, which came out slightly ahead of average and wealthy Whites [21].

Notes & References

1. Scott Atlas. “10 Surprising Facts about American Health Care.” National Center for Policy Analysis. March 24, 2009. <http://www.ncpa.org/pub/ba649>.
2. Zosia Chustecka. “Cancer Survival Rates Improving Across Europe, But Still Lagging Behind United States.” Medscape Medical News. August 21, 2007. <http://www.medscape.com/viewarticle/561737>
3. David Hogberg, Ph.D. “Don’t Fall Prey to Propaganda: Life Expectancy and Infant Mortality are Unreliable Measures for Comparing the U.S. Health Care System to Others.” National Policy Analysis, July 2006. <http://www.nationalcenter.org/NPA547ComparativeHealth.html>.
4. “How Not To Judge Our Health Care System.” National Center for Policy Analysis. November 15, 1994. <http://www.ncpa.org/pub/ba141>.
5. Ronald Bailey. “Accidents, Murders, Preemies, Fat, and U.S. Life Expectancy.” Reason Magazine. June 17, 2008. <http://www.reason.com/news/show/127038.html>.
6. Lisa Priest. “Critically ill patients rushed to U.S. for care.” Globe and Mail. Last updated Mar. 30, 2009. <http://www.theglobeandmail.com/life/article661794.ece>.
7. “Country Comparison :: Infant mortality rate.” CIA: World Fact Book. July 2009. <https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html>.
8. Thomas Lifson. “Canada’s ‘universal’ health care.” American Thinker. August 17, 2007. <http://www.americanthinker.com/blog/2007/08/canadas_universal_health_care.html>.
9. Katharine DeBrecht. “Health Care: You May Get What You Don’t Pay For.” News Blaze.  July 20,2009. <http://newsblaze.com/story/20090720152302zzzz.nb/topstory.html>.
10. David Gratzer. “The Ugly Truth About Canadian Health Care.” City Journal. Summer 2007. <http://www.city-journal.org/html/17_3_canadian_healthcare.html>.
11. Arlanjio. “Why Should Christians Oppose ObamaCare?” Arlanjio Blog. July 22, 2009. <http://arlanjio.wordpress.com/2009/07/22/why-should-christians-oppose-obamacare/>.
12. Arlanjio. “Health Care Reform.” Arlanjio Blog. July 1, 2009. <http://arlanjio.wordpress.com/2009/07/01/health-care-reform/>.
13. Thomas Sowell’s excellent book, Basic Economics [20], is highly recommended for an introduction of fundamental economic principles to the laymen.
14. Patrick Poole. “Governor Schwarzenegger Should Go to Nashville.” American Thinker. January 17, 2007. <http://www.americanthinker.com/2007/01/governor_schwarzenegger_should.html>.
15. Michael D. Tanner. “How Not to Reform Health Care.” National Review (Online). June 9, 2009. <http://www.cato.org/pub_display.php?pub_id=10279>.
16. Molly Line. “Massachusetts Universal Health Care Cuts.” Fox News Liveshots. July 17, 2009. <http://liveshots.blogs.foxnews.com/2009/07/17/massachusetts-universal-health-care-cuts/>.
17. “Hawaii Ending Universal Child Health Care After 7 Mos.” FoxNews.com. October 17, 2008. <http://www.foxnews.com/story/0,2933,439607,00.html>.
18. John Stossel. “Sick in America: ‘Free’ Is Good?” ABC News. April 3, 2008. <http://abcnews.go.com/video/playerIndex?id=4578691>
19. John Stossel. “Better” Health Care? Townhall.com. July 01, 2009. <http://townhall.com/columnists/JohnStossel/2009/07/01/better_health_care?page=1>
20. “Canada’s Single-Prayer Health Care.” Investor’s Business Daily. June 30, 2009. <http://www.ibdeditorials.com/IBDArticles.aspx?id=331254362316405>.
21. Steve Sternberg. “How long you live depends on which USA you live in.” USA Today. 9/12/2006. <http://www.usatoday.com/news/health/2006-09-11-life-expectancy_x.htm>.
22. The World Factbook. Central Intelligence Agency. 2009-10-01. <https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html>.

Other References Not Cited

1. Thomas Sowell. Basic Economics: A Common Sense Guide to the Economy. 3rd ed. New York: Basic Books, 2007.
2. Simon Santow. “22yo dies after being denied liver transplant.” ABC News. Jul 22, 2009. <http://www.abc.net.au/news/stories/2009/07/22/2633055.htm>.
3. Philip Klein. “The Matter With Myths.” The American Spectator. July 2009 – August 2009. <http://spectator.org/archives/2009/07/21/the-matter-with-myths>.
4. John C. Goodman. “10 Steps to Free Our Health Care System.” National Center for Policy Analysis. July 30, 2009. <http://www.ncpa.org/pub/ba669>.