G. Keith Smith, M.D.

After giving a talk to a group of students recently, during which the long waiting lines for surgery and medical care in Canada were discussed, one of the students defended the Canadian system, saying that Canadians received the same care as we did here- just after longer waits.  I encouraged her to rethink her discounting of the time during which much pain and suffering occurs during these “waits.” I told her how eye-opening it has been to meet many of these Canadian patients who have been told that they or their children must wait 2-3 years for life-changing, pain-eliminating procedures.  What the student then said is the genesis of this blog:  ”These individual cases should be considered in the aggregate, though.”

In medical school I was taught that a certain number of unnecessary appendectomies, for instance, was a good thing, as the surgeon who was never taking out a normal appendix was missing some of the diseased appendices that presented more subtly.  This made sense to me then and now, as the risk for missing a needed appendectomy far outweighed the risk of undergoing this procedure unnecessarily.  Each and every one of these patients presents themselves differently and the decision to operate or not is an individual one, one which includes the patient’s assessment and acceptance of the risk/benefit picture.

As my dad once told me, “whatever the percentage of folks in the population get cancer, it’s 100% for those who do.”  His insight makes things clear, doesn’t it?  Neglecting individual suffering for the aggregate, greater good, doesn’t feel statistically justified by the victims of this type of thinking.  Which brings me to my point.

Thousands of people are wearing the pink ribbons these days to raise awareness of breast cancer, many of them women, many of these women supporters of the man in the white house and his health care plan.  Part of Pharaohbamacare is an emphasis on “wellness,” with mandatory suspension of copays and deductibles for many preventative health procedures like colonoscopies and mammograms.  Sounds great, doesn’t it?  Maybe- until you realize that “scientists” employed by the government are declaring in their “studies” that too many mammograms are being done, resulting in unnecessary breast biopsies.  Just as with appendectomies, some normal breast tissue should be removed to insure that the fewest number of cancers are missed.  The recent recommendation by “The U.S. Preventive Services Task Force” and “The National Cancer Institute” (both federally funded) serves to undermine Obamacare’s wellness promise.  To believe that there isn’t intense pressure on these “scientists” to find what their boss wants them to find, is naive.    

“Official” discounting of the importance of mammograms also demonstrates the true intent of “evidence-based medicine:” a rationing tool.  After all, if “studies show” that mammograms should be done less often, government and other third party payers will balk at payment for these “unnecessary” diagnostic studies.  More cancer for you, but less strain on the budget!  Still thrilled that the government is getting more involved with health care?

Female supporters of Obamacare should be protesting this obvious attempt to ration care for breast cancer.  I’m surprised that women aren’t burning their bras in mass riots, insisting that any of these government “scientists” and those in the political machine who control them be barred from wearing the pink ribbons on their lapels.

G. Keith Smith, M.D. 

I thought some of you might like to read the remarks I delivered last night at the AAPS regional meeting in Austin, Texas.

Almost 16 years ago now, Dr. Steve Lantier and I left the operating rooms of the big hospitals and began our practice in operating rooms that we owned.  Looking back on our decision to leave our very busy hospital practices behind and take this risk, I now realize that we did this in spite of all of the information we had, in spite of all that we had been told by those involved in health care.  Our distrust of hospital administrators and the corporate medical world had become so complete that what I now understand to be an entrepreneur’s business calculation was made assuming that all we had been told was false.  This, it turns out, was good judgment on our part.

At a recent conference conducted by the Mises Institute in Houston, one which seemed to focus on the difficulty entrepreneurs have in the current business environment, I came to the conclusion that we started our surgery center not based on a typical business pro forma type of plan, but based on the belief that everything we were hearing from hospital administrators about the business of health care was untrue, propaganda meant to discourage physicians from doing what we were setting out to achieve.  The anxiety we endured in pursuing this venture was mitigated by how troubled the hospital administrators were by our even considering making this move.

Indeed, we had been told numerous times that the operating room staff needed to be down-sized, because the hospital simply couldn’t make ends meet, the revenue generated by surgical cases inadequate to pay sufficient staff.  Large and unacceptable patient to nurse ratios in postoperative surgical areas were justified with the same lies.  The lack of proper equipment and supplies necessary to perform certain surgeries and a lengthy committee process for acquiring any new supplies were the order of the day, rather than the exception. 

Dr. Lantier and I were convinced that something about this didn’t add up.  We knew for certain who we were dealing with when after the Murrah bombing one hospital administrator in Oklahoma City publicly complained that his hospital hadn’t received their fair share of the victims.  We opened The Surgery Center of Oklahoma in May of 1997 and knew within 2 months that the highest quality of care with a full staff was not only possible, but could be accomplished profitably for about a tenth of what these so-called “not for profit” hospitals were charging patients.

The hospital lies and propaganda have continued for many years, culminating in the one great lie that led so many to naively embrace Obamacare:  that hospitals were struggling financially due to all of the uninsured folks utilizing their emergency rooms, leading to what we all know as “cost-shifting.”  I have written about this lie extensively and we all now know that the hospitals get paid even when they don’t get paid, in fact, to the extent that they claim they don’t get paid, they are paid more.  This is the uncompensated care system they don’t want anyone to talk about, a gift from Uncle Sam and one which happens to be one of the engines for giant hospital bill creation. 

I would never have understood the various lies conjured up by hospitals to maintain the fiction of their “not for profit” status had I not owned and operated a medical facility.  One of the first clues that something was wrong was that most insurance companies, in spite of our quality and pricing, avoided dealing with us.  The answer to “why wouldn’t an insurance company like better and cheaper” although a mystery then, is apparent to us now.  A look at the diagram located in this prior blog (“Anatomy of a Cartel”) will help you understand this seeming paradox.  

The only way to shine a light on this price-fixing cartel was to post prices online for all to see, a move we made 4 years ago next month.  Incredibly, the first patients to take advantage of our pricing were Canadians, followed by patients from those parts of the country where the tight grip of the cartel and the subsequent lack of any semblance of market competition has rendered the high prices you would predict from such an arrangement.

Our facility is now frequented by people from all over the country and outside, patients with high deductibles, patients waiting in lines, patients with no insurance whatsoever, and increasingly, patients whose care is paid for directly by the companies for which they work, the “self insured.”  You can imagine the conversations that I’ve had with the CEO’s of large companies who have been paying $30,000 for operations that they now see could have been obtained for $3500 at our facility.  You can also imagine the conversations they have had with their insurance brokers who have known about our facility and pricing and have nevertheless failed to alert their client of our existence. 

Our price-posting has had another effect.  Rather than travel to Oklahoma City, more and more patients are using our pricing to leverage rational fees at facilities in their hometowns.  Just last month, a Georgia patient whose primary care doctor was aware of our website pricing, was quoted $40,000 for a trans-urethral resection of his prostate, whereupon he informed his urologist he was headed to Oklahoma City, where we would do this for $3600.  Overhearing the disgruntled urologist’s reaction to losing his patient to Oklahoma City, the hospital CFO asked for details.  The $40,000 quote was reduced to $4000.  I think it is fascinating that our pricing saved this patient $36000….and we didn’t even do the case. 

Before you give the hospital CFO too much credit, though, remember the shell game.  You see, he will simply claim that he lost $36000, to bolster his “not for profit” fiction, plug that into his uncompensated care calculation and collect a portion of this “loss” from the taxpayers.  Everyone, including this patient, as taxpayers, would have been therefore better off if the Georgia patient had come to our facility, after all.

The big hospitals’ nightmare of price transparency has arrived.  This Georgia hospital and any others encountering patients familiar with our pricing have been thrust into a market economy whether they like it or not.  Having eliminated potential competitors with certificate of need laws all over the country, these corporate hospitals must now contend with our facility’s and others’ fair and rational pricing, just a short plane ride away.  That other facilities are doing this with more on the horizon removes several teeth from protectionist legislation like certificates of need, I think.

The medical price deflation resulting from a new competitive healthcare market,  poses an incredible threat to the central planners who are counting on the runaway pricing and market chaos resulting from Obamacare, that price “crisis” intentionally created to usher in the sequel to their plan:  single payer.  As physicians who are paving the way for many to pursue third-party-free practices, AAPS members’ contribution to this deflationary obstacle to Obamacare’s ultimate design may have, in an effort to save themselves and their patients, discovered the soft underbelly of this latest attempt by government to crush the private practice of medicine.  The deflationary effect of shunning third parties, will, I think, when we look back years from now represent the undoing of this horrible and deadly law.

G. Keith Smith, M.D.

Another great article from “Vermonters for Health Care Freedom.”  Healthcare in Vermont will look like the service received at the department of motor vehicles very soon.  Check out Vermonter’s for Health Care Freedom on Facebook.  Great updates on the healthcare central planner’s Nirvana there regularly.

G. Keith Smith, M.D.

What will single payer health care look like?  There are so many places to look it’s a little confusing.  Here’s a partial list.

Canada

I pick on Canada a lot.  Why?  Lots of Canadians come to our facility for their health care.  Do I really need to say anything else?  These are people who have been told to wait for years before they can see a specialist (because there are budget “caps”).  When the money is gone, the doctor’s office is closed.  Surgeons are limited on the amount of operating room time they can have in a month.  When they have used up their time, they can do no more surgery.  Rather than have the market determine the allocation of resources, a Canadian bureaucrat creates a budget and that’s that.  Presto!  This is how the “right” to health care is born.  Doesn’t feel like a right to health care for those who come to the states for their care, though.  Probably doesn’t feel like that to the patients who die waiting in line for care, I’ll bet.  Imagine that the government guaranteed a “right” to blankets.  They then dictated how long the blanket makers could stay open manufacturing blankets.  Is it really that surprising that this approach would lead to lots of shivering blanket-less people waiting in line for their ration?  

Great Britain

I like to pick on the Brits because they harbor such nationalistic pride in regards to their health care system, even though it is based on the same faulty economic premise as their Canadian brethren.   I like to pick on the Brits because they not only euthanize their sick citizens to free up scarce hospital beds (duh…wonder how this shortage of beds came about?) they are proud of this and have even given this highway to the cemetery  a fancy name:  The Liverpool Care Pathway.  British patients that become extremely ill have a better chance of survival at home, surrounded by family and friends, as no one stands a chance once on the Pathway.  Recovery from severe illness can occur without the help of modern medicine, but recovery of the very sick isn’t likely when the hospital staff is actively murdering them.  

But there is no need to go outside of the U.S. to see the wonders of socialism in medicine.  The VA hospitals and the Indian hospitals provide examples of the wonders of efficiency brought to us in medicine from government bureaucrats.  

Our local paper’s lead article today informed us that the Department of Public Safety (office administering driver’s tests) was closing their offices for the day to participate in training their employees on how to be more efficient and friendly.  Zeke Campfield of “The Oklahoman” writes that the “operator of a local Chick-fil-A restaurant will teach examiners how to be patient and courteous.”  Wow.  That can be taught?  And in one day?  

What would happen to an employee at Chick-fil-A that was not patient with and courteous to customers?  What would a patron of Chick-fil-A do if they were not treated in a timely manner and with respect?  What would happen to Chick-fil-A if this treatment of customers were widespread?  

Campfield’s article also talks about a mother getting in to line outside of the testing center at 4:15 am, only to be turned away at the end of the day because there were simply not enough examiners to get to her son.  Three mornings in a row.  The spokesman for the Department of Public Safety muttered something about budget cuts so I’m guessing we’ll see government’s usual response, that of throwing even more money at failure.  

Try to imagine the Department of Public Safety in charge of your medical care.  Rude and inefficient staff.  No competitive fears.  Hospitals working together to institutionalize mediocrity so no one stands out as better, eliminating troublesome comparisons.  Long waiting lines.  Always blaming the lack of funding or budget caps.  

The efficiencies and quality of the private sector cannot be superimposed on government agencies for one simple reason:  without competitors, government doesn’t have to care.  Ever.  Our state government wants to introduce private sector ideas into a failed government organization.  Ironic, isn’t it, that nationally, health care bureaucrats are increasingly embracing the business plan of the Department of Public Safety (DPS), even as the DPS is looking for private sector answers?  At least the DPS hasn’t started euthanizing applicants waiting in line to free up examination spots.  

G. Keith Smith, M.D.

My mother called me this morning to tell me that a 76 year old friend of hers had gone to her doctor to get a B 12 shot.  She was told her insurance (Medicare) didn’t cover that any more.  Her friend was incensed and left without getting the shot.

What are the lessons here?  First, my mother’s friend doesn’t understand what incredibly great news this is.  She will understand soon enough that the only care available to her might be only those things that Medicare doesn’t cover.  Care subject to price controls will be…ok..if you said “scarce” you get a gold star.  Care outside of the “system” will be controlled somewhat by market forces, with prices free to adjust and send appropriate scarcity signals to producers who then rationally respond.  If my mother’s friend really needs her B 12 (as opposed to those patients that obtain this injection simply because it is free or priced below its value) it will be available. 

But here’s the rub.  She will have to pay for her B 12.  All of it. So many people are conditioned to follow the “orders” of the third parties, including government payers. 

“The pharmacist will only fill 30 days at a time of my medicine because that’s all Medicare will pay for.”  I don’t know how many times I have heard that. 

“How much would it be for you to pay for a 6 month supply out of your pocket,” I ask? 

“Didn’t think about asking.” 

Did my mother’s friend have difficulty thinking outside of her usual box or did she not really need the injection?  I don’t know.  Maybe a little of both. 

What has happened to the price of Lasik surgery and plastic surgery over the years?  What has happened to the quality?  Poor results in this field are simply not tolerated.  Too high a price?  That surgeon’s waiting room is empty.  Why would anyone think that the rest of health care is any different?  Indeed, what is it about the medical economics of Lasik surgery and plastic surgery that results in reasonable pricing and great results?  Could it be the absence of the distorting influence of third parties?  Could it be the market at work?  What do you think will happen to the price and availability of B 12 shots once “insurance” is no longer part of the picture?  What will happen to the demand of the unnecessary B 12 shots?  What will happen to the incidence of B 12 shots reported given that were never given but billed for? 

How long will it take for patients to learn to pay for their hernia repair out of their pocket rather than wait years in a line like the Canadians have been trained to do?  Will people in the U.S. be intolerant of this treatment?  We’ll see.

I always learn something when I talk to my mom.

G. Keith Smith, M.D.

Today I anesthetized a Canadian woman who had waited two years to have a hip operation and had three more years of waiting to go.  No one argued in Canada that she needed surgery, they just weren’t going to do it for five years.  Her condition was one that left untreated, would result in the complete destruction of the articular surface of her hip joint, a situation then treatable only with a hip replacement.  

She found a hospital in Montreal that agreed to do her surgery as a “private” patient for $20,000.  She didn’t have $20,000.  Then she found us.  We did her surgery today for $5500.  She will do well and will be spared a total hip replacement. 

What are the lessons here?  

1)Canadian health care stinks.  Actually, any health care system combined with a governmental role stinks.  The current occupant of the white house believes that more government is the answer in the U.S.  This Canadian woman would disagree.

2)”Private” health care in Canada suffers from a lack of competition.  If a real market were active in Canada, the price would more closely resemble ours.  The Montreal facility charges $20,000, because they can get it.  We are going to assist this facility in discovering a more patient-friendly market clearing price.  Remember the market clearing price is the one at which no surpluses or shortages exist, one where the buyer and the seller exist in perfect equilibrium.

3)Rationing of early care leads to more expensive later care.  DUH.  We have seen this with hernia surgery too, where routine herniorraphy is delayed only to become a life-threatening bowel obstruction.  Routine knee arthroscopy to remove or repair a torn meniscus, delayed long enough, results in a knee treatable only with a total joint replacement.  Lumbar spine surgery delayed long enough results in irreversible nerve damage to the lower extremities or worse.  You get the idea.

4)The “right to health care” in Canada is a myth.  Canadians have a right to a place in line.  They have a right to hope for care.  They have a right to die in line.  That is it.  The “right” to health care is a lie, one that has enjoyed one of the most successful propaganda campaigns ever.  No right can exist, the exercise of which violates the property rights of another.  

5)The Surgery Center of Oklahoma’s fondness of free market principles resulted in this woman’s affordable and high quality surgical experience.  She is not alone.  We have more Canadians on our future surgical schedule now than ever before.  

6) This woman didn’t go to the “not show a profit,” charity, “critical access,” hospital across town.  Enough said.

7) The difference between what we charged ($5500) and what she would have paid in Montreal ($20,000) will be put to unknown use, but would never have the opportunity to be put to use had it not been for the competitive pricing at our facility.  Remember Bastiat’s “What is not seen.”  

8) A pricing system free of interference from the government results in prices that are affordable and quality that is actually better.  Yet the U.S. government has assumed a more active role in health care than ever!

9) This woman’s surgery was cheaper for her than for an American with insurance!  Due to the cartel-like arrangement between hospitals and insurers in the U.S., this procedure would have cost a U.S. citizen significantly more than this Canadian paid at our facility, had it been done at a “not show a profit” facility.

10) Those who continue to deny the facts and embrace a “universal care” model, one like the Canadians and the British and others have endorsed and endured are living in a dreamworld.  That Canadians are coming to our facility is all the evidence one should need to suspect that a government system is a failure.  Period.

11) A physician-owned facility (ours) gave this woman the best pricing she could find anywhere in the world.  Greedy doctors!

I’m sure there are other “lessons.”  I would happily entertain any additions to what I have listed above.

G. Keith Smith, M.D.

News flash.  You couldn’t make this stuff up if you had to.

Toronto——-“Canada’s justice minister says the federal government will appeal a British Columbia Supreme Court ruling saying that federal laws banning doctor-assisted suicide are unconstitutional.  A British Columbia Supreme Court justice ruled last month that laws banning assisted suicide are invalid because they discriminate against severely ill patients.  The justice suspended her ruling for one  year to give Canada’s federal Parliament time to draft new legislation.”

Wow.  And we thought Justice Roberts was unreasonable.  Can’t deny these severely ill patients suicide, now can we?     Oh well.  The Parliament will figure out a way around allowing these severely ill patients getting in the way of everyone else’s free health care.    And I guess they won’t be charged for getting killed.  What a model to copy.

G. Keith Smith, M.D.

If you are paying $1000/mo in health insurance premiums now, that number will soon be much higher as a result of today’s court decision.  Premiums will increase because of the definition of “insurance” in this law.  The benefits that are mandated (breast cancer and pregnancy coverage for all, including males!) will result in these higher premiums, as none of these goodies will be free.  Mandated screening for bureaucrat approved procedures and other jewels will drive up the cost of insurance.  All of this is according to plan, as the statists know that unaffordable private insurance will necessarily usher in a single payer plan, their ultimate goal.  Once this goal has been attained, Uncle Sam will collect the money (on behalf of the 3 or 4 insurance companies that remain) and pay very little of it out, as care is denied on a widespread basis and profits of these companies go through the roof.  

Look for more and more physicians and medical facilities to post their prices.  As fewer and fewer deal with Medicare and Medicaid (due the price controls and costs and hassles of data reporting and electronic medical record keeping), this posting of prices will be less problematic and therefore more prevalent.  The low prices of care at physician-owned facilities will render the prospect of going without insurance much less scary, and will make payment of the FINE/TAX/WHATEVER? make more financial sense.  Patients who value their privacy, who don’t want every detail of their life sent electronically to Washington bureaucrats, will increasingly turn to these physicians and facilities that have shunned federal money.

Whatever you do, don’t count on the Republicans to overturn this any time soon.  Remember we got the Medicare, Part D legislation from the GOP when they were in control, the greatest gift to big pharma in history until the Unaffordable Care Act.  The insurance, pharmaceutical and big hospital lobbies will have even more profits to spread around Capitol Hill, making tough talking legislators, soft actors.  Also keep in mind that the GOP is hoping you’ll count on them to fight this rather than hold them accountable.  July 11th’s symbolic vote to repeal the Unaffordable Care Act is an attempt to prevent consequences from raining down on incumbent Republicans.  I predict that pleas for campaign contributions will be like never before the next several months.  If placed in power they probably won’t deal with this right away as removing a crisis deflates the pressure to send them more money.  

The free market will continue to work in medicine.  You will find it in the office of a physician who belongs to the Association of American Physicians and Surgeons.  You will find it in the office of a physician who has opted out of Medicare, providing care to the elderly but unwilling to deal with their government-issued insurance.  You will find it at surgery centers like ours and at physician-owned specialty hospitals, increasingly transparent with their pricing and unsurpassed in quality and patient satisfaction.  You will be able to find all of this but you will have to look a little harder after today.  Many of those who count today’s court ruling a victory will soon have a worthless insurance card in their pocket, one which certifies them as “insured,” but one which will gain them no access to a physician’s office.  They will, like the Canadians, have a right to hope for health care.  Solutions to the allocation of scarce resources never make sense or work unless they come from the unfettered and free market.  Some semblance of it will continue to operate and function, and will be responsible for the provision of the only care worth having.

G. Keith Smith, M.D.

You know that a statist and critic of liberty has drawn their last breath in an argument when they invoke the plight of “the children.”  “What about the poor children?”  The statist or socialist demands guarantees that the poor and unfortunate (particularly “the children”) will be cared for by the state, as a free society left to its own devices provides no such guarantees. 

Check out this article sent to me by a Canadian friend.  This is what happens to “the children” protected by the state’s brand of guarantee.  The parents have paid cash for this child’s vision to be restored (by an ophthalmologist in Michigan) and are continuing to wait for their “right” to health care in Canada to rescue them from bankruptcy.  Soon-to-be blind children (standing in the line of medical neglect) are not alone in Canada.  They are shoulder to shoulder with hearing-impaired (soon to be deaf) children, as well, the state not offering timely hearing-saving procedures.  These state guarantees are nothing more than permission to hope for care.  I wonder if the health bureaucrats in Canada would wrap themselves in the Canadian health care flag and proclaim the wonders of a Canadian’s “right” to health care if this was their child?  Actually, many government officials in Canada don’t wait for care…they come to the U.S. for it at the Canadian taxpayer’s expense!  Maybe what the apparatchiks of the Canadian state mean is that while everyone there has a “right” to health care, only the government officials have true access. 

Also interesting in the article is the fact that the surgery tried by the Canadian ophthalmologist on the child was unsuccessful, while the surgery done in the U.S. by the pediatric retinal specialist was.  Is this pride?  Could the credibility of the Canadian government’s health care scheme possibly trump the importance of this child’s sight-saving eye care?  Do Canadians have a “right” to health care only as long as it doesn’t embarrass their government?  While the government promises health care, it seems they primarily deliver obstacles and constraints to care, as the doc for the job was right across the border.

In a traditional patient doctor relationship, the focus is on the patient, not on national budgets, yet that is exactly the system in Canada, and the one so many collectivists would impose on us here, a system that leaves scores, even the children, in the lurch.  The good of the many outweighs the sight of this child, no?  Stay with me and we’ll take this a step further.  A free market health care system actually creates a market and a demand for charitable organizations to fill in the gaps of care (particularly for the children here in the U.S.) where they occur.  Paradoxically, the very lack of a state guarantee creates the demand for this type of organization whose sole purpose is to fill in the gaps.  State guarantees suppress the normal inclination of the market mechanism to bring these types of charities into existence, organizations whose focus and mission isn’t clouded by political concerns and national budgets.  Indeed, where were the Canadian children’s vision charities on this one?

There are no guarantees.  Those who believe there are need counseling.  Those who believe that the state provides for a more efficient allocation of scarce resources than the free market are poor students of history, at best, vicious tyrant wannabes, at worst.  The only guarantee the state provides is their iron fist, one which blinds and bludgeons the children as well as adults.

G. Keith Smith, M.D.

A parent repeatedly tells a child at the supermarket “No,” as the small child continues to ask and beg for this and that.  Pouting and temper tantrums follow.  Spankings in the grocery store don’t seem to make much difference.  The next time the child asks again and again for this or that, the parent gets an idea.  Instead of “No,” she says, “Not now.” While this doesn’t solve this child’s disciplinary issues, introducing the variable of time (not now) softens the answer in a way that introduces hope, although probably a false hope.  The “time” variable has muddied things for the child, buying some time for the frustrated parent.

I often think about how the introduction of the element of time as a variable, can completely change the context of a discussion or contract.  Take health care for instance.  “Health care is a right,” many say!  What the government in Canada or Great Britain means when they say that health care is a right, is really this:  health care is a right…just not now.  Having waited three years for a hysterectomy or an incontinence procedure drives this home, doesn’t it?  How about watching your child struggle to breathe knowing he must wait three years to have his tonsils removed?  How about watching a loved one die of their heart disease, waiting in line for a life-saving bypass procedure?  Can the Canadian government honestly say this now-deceased cardiac patient has a “right” to health care?  They do, and they do it with a straight face, even though they have contaminated the entire context with the variable of time. 

We have operated on many Canadians whose government, having declared their health care to be a “right,” has failed to deliver on this promise.  Picture a Canadian saying, “I have a right to the free surgery on my brain to remove this tumor.  Just not now.”  Introduction of the variable of time has been useful in Canada (and in all “free” health care countries) to hide the bankruptcy of this health care plan, as any individual refusing to meet financial obligations (for years!) would be declared bankrupt by any definition.  Resources are limited, not infinite.  Lowering the perceived price to zero (free health care) will empty the shelves and result in shortages.  Lines will form for health care just as they did at the gas pump during the Jimmy Carter days.  Health care may be delivered, but only after waiting a few years and by then, the government hopes (for the sake of its own bankrupt balance sheet) it is too late. 

A cardiac bypass surgery is worth more to a patient with chest pain now, than three years from now. The dilution of the value of health care caused by this delay, is the same deceptive technique employed by governments destroying a currency with inflation.  This allows politicians to extract what they want now, leaving future taxpayers to pay for their current promises.  This is how politicians use the element of time to buy votes.  Inflation of currencies (printing money or creating credit out of thin air) results in a reduced purchasing power and a lower standard of living in the future.  Delaying medical care is essentially inflation of medical care, diluting its value, as well.  I believe this is a variation of the economic concept of “marginal utility.”  Simply, the first drink of water delivered to a man dying in the desert is worth more to him now than later, and worth more to him than any subsequent drink of water. A dying man needing a drink of water or heart surgery now, finds little value in the promise of these at a later time, just as a future dollar bill will likely hold even less value than one today.

“You can have your surgery.  We’re not saying ‘no.’  We’re just saying, not now.”  One consequence of “not now,” is that hernia surgery, for instance, if performed early on, is almost certainly uneventful.  But if this surgery is delayed long enough, an “incarceration” can occur. This complication can involve a bowel obstruction, sepsis (generalized infection) and death.  What would have been a routine hernia surgery has now become a life saving emergency procedure.  Surgeons busy with incarceration emergencies have less time to deal with the routine hernias and the initial delay snowballs, the lines for all becoming longer.  Almost any surgical disease if neglected long enough will degenerate into a similar emergent picture, the complications of which can be life altering if not fatal.

Modifying currencies and debts with the element of time results in higher prices and different amortization schedules.  Modifying health care with the element of time results in misery or death as “not now” becomes “never,” as governments, unable to pay their bills and deliver on this “health-care-as-a-right promise,” string out their obligations further and further.

G. Keith Smith, M.D.