“Run for your life from any man who tells you that money is evil. That sentence is the leper’s bell of an approaching looter.” – Ayn Rand

“Do not muzzle an ox while it is treading out the grain.” – Deut 25:4

Part I: Laying the Groundwork
Part II: Principles and Strategic Choices
Part III: A Laffer Matter

[NOTE: This will likely be the most contentious article in this series, as there are no "good"/"painless" answers. Whether we suffer a gradual descent into madness via incremental socialism or whether we're able to accelerate the its catastrophic failure, people will be hurt - regardless. My contention is that fewer will be hurt by a catastrophic failure - if the recovery is to learn from the failure and to ditch socialist and semi-socialist policies - than by the steady decline inevitable in the existing and proposed Ponzi schemes of government-provided health-care. Most, if not all of my 'Galt-ish' suggestions are simply pushing trends faster in the direction they will already be going, for optimum "failure-potential".]

Assumptions

While no health-care “reform” bill has yet passed out of the House or Senate this year, it is probably a safe assumption that one will – in some form, popular opinion be damned – ultimately pass.  I’ve already written on the topic at least three times this year.

Within that plan, for the sake of this article, I will assume that there will be provisions that:

• Prevent health insurance companies from policy denial for pre-existing conditions (”Guaranteed Issue”) and from charging different rates to different customers, based on their risk potential (”Community Rating”).  What this means, if this were auto insurance, is that ACME Insurance would have to insure Lindsay Lohan, and they would have to insure her at the same rates as my father-in-law, who I’m not sure has received a ticket or been in an accident that was his fault in 50+ years of driving.
• Require individuals to carry health insurance or pay a fine (for which the fine would be significantly less money than the cost of insurance).   What this means, using the above example, is that Ms. Lohan is better off paying the fine for not having insurance until after she’s been in an accident.
• Pay doctors on a scale tied to the same scale as Medicare (which most often pays doctors less than their actual costs of providing care).

By the time the government system fails, the goal of “going Galt” should be making it obvious that the road to hell is truly paved with good intentions.

The Looming Tsunami

Currently, there are 267 doctors (without regard to specialty) per 100,000 residents in the USA – a downward trend since the high-water mark of 279/100K in 2000.   Even that mark was below the optimal mark – thought to be in the range of 325-350/100K – to support the medical system as it is used in America.  Even worse is the huge shortfall in Primary Care Physicians (PCP’s) – where the majority of PCP’s are within 10 years of retirement (right when the wave of Baby Boom retirements hit) and the supply of graduates is less than 50% the number of retirements.

To make matters worse, the trend-line in graduates is headed downward – dropping 50% between 1997 and 2006, and is only kept afloat by the increasing number of immigrant students, willing to help fill the ranks.   And it’s not just “about the money” (PCP’s earn 50+% less than most specialists), but also the work, itself – which has longer hours, a more demanding customer base, and lower reimbursement rates from payers.  With med-school bills of $300K+ and an ever-increasing risk/reward ratio, along with an explosion in defensive medicine, malpractice insurance and burdensome paperwork that consumes 10 minutes of work for every 1 minute with a patient, it’s no wonder medicine is not an attractive field to enter.

And let’s not even start with nurses – the numbers are even bleaker for nursing, where the shortage has hit much sooner, primarily due to the physical demands of the job that many older nurses cannot sustain for 40-60 hours/week, and that an incoming supply cannot keep up with.

Compounding these issues is the aging demographics of America.  With the first ‘Boomer turning 70 in 2016, the need for PCP’s and nurses is going to skyrocket in the next 10 years without any expansion in government-provided services, and shortages will reach crisis levels for adult patients.   One can only imagine the Class-5 catastrophe that will occur if 30-47 million more patients are added to the already overburdened and tightening system.

It is no wonder that two-thirds of physicians oppose ObamaCare, and 45% are considering retiring or cutting back if it passes!   Added patient-load (that won’t cover baseline costs) and increased risk (since the Dem’s are in the pockets of trial lawyers opposed to tort-reform) make O-Care a lose-lose proposition for anyone in a health-care role.

Carry Out the Threat

In a recent survey, 4 out of 9 doctors said they would curtail their practices or retire (see Part III of this series for more on this) if ObamaCare passes.  Carry out this threat!  If you’re a doctor late in your career, this may be the most logical and economic option.  If you’re early in your career,though,  it might not be a bad idea to move your practice to the suburbs, where private insurance will hold out the longest.

With the time take away form the US health-care system, consider keeping up your board certification(s) and volunteering your time through churches or out on the mission field (where  often baseline health-care and education are almost non-existent ) where your work will be far more rewarding than working as a contractor for the US government.  There’s lots less paperwork that route, as well!

The Union of the State

In high school, my US History teacher (may he rest in peace) wrote a phrase on the board.  If we wrote that phrase at the top of any test or homework assignment, he gave us 10% extra credit.  The phrase?

“Unions suck the life-blood out of America.”

Indeed they do!  While they once served a purpose, unions now create unsustainable wages (driving business overseas), support anti-competitive entitlement-driven environments, and bankrupt businesses and governments.

Buried in the 1200 pages of HR3200 is a payoff provision to government unions that will encourage state medical professionals to join public employee unions.  Such unions in California, New York and other states have broken budgets and created unsustainable cost conditions.  When catastrophe hits, expect government-worker union-busting to hit with a vengeance.  In referring to the current health-workers union in New York, the Weekly Standard notes:

The union-hospital alliance has been so successful in aligning itself with politicians, Democrat and Republican alike, that not only has 1199 been largely untouched by the downturn, but New York spends as much on Medicaid as California and Texas combined. And come boom or bust, hospital and health care employment in the state keeps growing.

Pushing unionizing to the budget-busting point – to where government-worker unions are crushed – may be an overall positive outcome, impossible to have achieved without O-Care.

The Twisted-Sister Approach

For as long as it is possible, probably the first thing to do after ObamaCare passes is to follow the lead of the Mayo Clinic (which earlier this year stopped taking new Medicare patients at some of its hospitals because it was losing so much money) and say “we’re not gonna take it anymore” for any form of ‘public plan’ insurance.   Currently, 40% of US physicians and clinics do not accept public insurance.  Flipping this number, overnight, to 60-70% will push the system toward failure even sooner.

For a short time, you can expect that those with pre-existing conditions will enter the private healthcare system and jack up the demand for services.  During this time, there will likely be little need to take anyone in a public program (be it the “public option” or the “public co-op”).

With the already limited and dwindling supply of doctors – particularly PCP’s (who are the ‘gateway’ to specialists) – you can expect that insurance rates and reimbursement rates will skyrocket much more quickly than government rates.  By keeping the supply-side pressure on, the crappiness of the public (or co-op) system – both in terms of wait-time and availability – will bottom out even sooner than it inevitably would otherwise.  While this will likely lead the government into short-term and ill-advised price controls, these will also quickly fail into free-fall.

The Reverse Fast-Pass

If the number of doctors is low enough (i.e. if it significantly accelerates beyond the without-Obamacare predictions), there will not be a shortage of patients with insurance, and the governmental solutions will focus on increasing the supply, rather than regulating the mix of patients.

If, however, the government passes regulations that prevent PCP’s taking new patients from turning away ‘public plan’ patients (or to carry a specific mix), institute a system similar to Disney’s Fastpass, but in reverse.  Using queuing theory, you create two virtual “lines” for patients, with the government minimum% hours for ‘public plan’ patients available on your calendar and the remaining hours on the calendar for private-plan patients.  This will quickly generate “waiting line” horror stories for the media, with which to beat the ‘public plan’ to death.

School is Cool

If you’re an undergrad college student considering med school, and you want to be able someday to both a) feed your family; and b) see them on occasion, your best option is to pick an undergrad major that is accepted by med schools, but can be marketable in industry, apart from getting a medical degree.  So – instead of majoring “pre-med”, consider Chemical Engineering, BioChem E, BioMed E, BioMed Tech, BioChemistry, Pharmacy, Genetics or some similar science major.  Then, if ObamaCare passes, use your undergrad degree rather than becoming a government contractor.

If you’re already a med student scheduled to graduate in 2010 or 2011, and O-Care passes, you might consider holding off – get into a research program or re-specialize in Primary Care.   The expected shortage in doctors will likely lead the government to offer med school loan-payoffs in return for a set period of working in rural or urban clinics that accept ‘public care’ patients.   Without the weight of the med school bills, choose rural areas near smaller cities/towns, as when the government systems break down, the inner city is far from where you want to be (and your not being there will help it break down faster).

Where is the Church?

Again, as I’ve noted in the other articles, the church needs to be there to help pick up the pieces where the systems start breaking down.   Look for retired nurses and doctors who would be willing to offer preventative care workshops and (depending on local laws/regulations) clinics.

When the healthcare system completely breaks down, it is likely that – even if only for government debt reasons – the only insurance available will be catastropic health insurance (like HSA’s) – rather than comprehensive insurance (like Medicare).  This is as it should be (does your automobile insurance pay for your oil changes and flat tires, or just for accidents?).  As such, the need for simple preventative care clinics will grow – because people will generally pay for these things out of pocket, which will drive down costs.  The poor will need options, though, and the church could provide such infrastructure as could care for them.

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[Again realize, this is all exploratory in nature, and that I am not necessarily advocating this course of action at this point in time. My hope is to gain the wisdom of other voices to see if this avenue is a) fruitful; b) possible; and c) a better way forward than passivity. Some folks may not wish to comment, but can send me feedback via my Facebook mail account.]