Ricochet is the best place on the internet to discuss the issues of the day, either through commenting on posts or writing your own for our active and dynamic community in a fully moderated environment. In addition, the Ricochet Audio Network offers over 50 original podcasts with new episodes released every day.
Will Concierge Medicine Remain Legal?
GrannyDude had an outstanding comment on another thread which read:
I should think that when the government is in charge of healthcare, there are strong incentives to discourage any “extra” medical attention, because it will raise expectations in the client class. The National Health in Britain didn’t want to pony up for little Alfie because then all sorts of parents might expect their very-sick-child to receive potentially lifesaving care. Alfie couldn’t go outside the system (e.g. to the US) because then British parents might reasonably ask “if American babies can get that treatment, why can’t British babies?
Granny brings up a question that has crossed my mind, from time to time. As you might imagine.
There are several countries around the world with significant governmental control of medicine which do allow people to pay for better care if they want to. Those systems inevitably result in a two-tier medical system – a private system for those with some means, and a public system for those who don’t have such means. And if you get sick, you don’t want to be in the public system, as you might imagine. Canada takes a different approach. Concierge and other models, which provide better care for more money, are illegal. To get better care, you have to leave Canada. (Ever wonder why Mayo is in Rochester, Minnesota?) This is not as restrictive as it seems, because around 90 percent of the Canadian population lives within 100 miles of the US border. But the underlying point is important: The system is fair only if everyone is forced to comply with it. But you can understand my curiosity – this is what I do for a living.
I practice concierge medicine in Hilton Head. I’m good at what I do, and I earn a very good living by providing a service which is not readily available through conventional means. Which bring up Granny’s question which is of such intense interest to me:
As our government gains more and more control of healthcare, will it remain legal to seek better care outside the system?
With the remarkable failures of socialized medicine around the world, nearly the only feature that can garner support is that it is fair. So allowing people to work around it, is certain to erode much-needed support. So our legislators must vote to make concierge care illegal. It must be fair.
But then again, it’s not that simple. There are a few problems here, but this one is not insignificant:
All of our legislators are members of concierge medical practices. Along with the generous donors who don’t mind dumping a million dollars into a political campaign via systems of varying legality. Do you really think that when those people get sick, they sit in plastic chairs in a Medicaid clinic somewhere?
Of course not – these are important people. So our legislators must vote to make concierge care legal. Socialized medicine is for those people over there. It makes sense only if I can continue to get good care when I get sick. After all, I’m a very important person. A two-tier system makes sense.
It’s easy to criticize our legislators. But which would you choose? Elections are complicated. Tough call.
I’m not interested in ethics here – this is about my ability to earn a living. So what do you think is likely to happen?
What do you think? As our government gains more and more control over medicine, will higher-level care become illegal? Or just part of the system?
I value your opinion. And I don’t want to move to Costa Rica.
Thanks in advance for your advice. I really don’t know how to plan for all this….
Will my job become illegal in two years? Or will our progressive leaders build a new system which openly allows for important people like themselves to seek better care than is available to, well, to those people over there?
My wife likes our nice house. She looks forward to your reply. Is my job sustainable? What do you think?
I thank you in advance for your input.
Published in General
It’s possible that most know what “concierge” medicine is, but maybe not. I dislike the term because I regard it as a euphemism based on my understanding, but I’m reluctant as a lay person to step in here with a definition.
In any event, I’m not sure that “two-tiered’ is the correct categorization because concierge (I prefer retainer medicine a la attorneys), to me, is actually a third or maybe fourth tier.
And, in answer to the question, I believe that it will remain legal since the most likely reforms will be at the lower end, with the higher end of treatment left alone. I’m a “concierge member” in Virginia, one of the prime states for such practices.
Congress kept itself apart from the Affordable Care Act, so you can safely assume Congress will make sure there’s some upper tier health care option for themselves and the donor class, even if they have to twist the law into a pretzel to define the exclusive tier system so it resembles something like the prohibition speakeasy system of nightclubs for the well-to-do (Canada could play the upstanding “equality for everybody” card, specifically because they know better care is available just across the border — if they passed a law saying anyone with a serious medical condition had to surrender their passport so they had rely only on their own medical system, a lot of upper-income and well-connected would junk Canada’s reputation for niceness and start acting like English soccer hooligans after a bad loss for their team).
Well Dr. with all due respect (after all I am a capitalist)
I don’t give a rat’s behind about your lucrative business model if I get stuck in one of those plastic chairs in the clinic.
I hope you understand.
People whine about income inequality, so I would expect the same type of hissy fits over healthcare inequality. And the easiest way to make things equal is to make things equally lousy for all.
Perhaps some system where everyone can get a base level of services and people are free to pay for extra on their own could work, but it wouldn’t “feel right” to those with socialist leanings so I don’t imagine such a system coming into play in our current political environment.
I see constant Facebook posts from my friends in the small Canadian town I grew up In complaining about the impossibility of finding a doctor there. Basically a new person in town has to go to the ER to be able to see a doctor – regardless of the severity of their illness.
So if the concierge medicine thing gets outlawed you can always move up to the Canadian Rockies and make a living. Sort of.
Understood, but I’m reluctant to underestimate the ability of our elected representatives to cater to what works best for themselves. I’m assuming that some type of upper level, “enhanced” care does that. I also don’t believe that they’ll be able to skate by with some kind of higher end congressional system while tinkering with the upper level in the private sector.
I wonder how many Canucks are looking askance at the chance of a Bernie or Warren taking away their ability to escape to a better level of health care?
If exclusive, concierge medicine is good enough for Fidel and Hugo, then by damn it’s good enough for America’s socialist leaders!
Somehow I’m pretty sure the anointed will have a workaround to all that fairness.
I don’t think Trudeau has to wait a couple of months for his MRI…..
For the leaders, sure. But the little people won’t be able to buy into that, no matter how much money they have.
As always with legislation the devil will be in the details. I foresee a monster bill of 50ooo pages that overtly institutes “medicaid” for all, banning private insurance and payment outside of the system for the ever illusive “fairness”, while having layer after layer of exceptions buried in the text. Like Obamacare. Favored Unions will be exempted. Congress and federal employees exempted. State and local government employees exempted. The anointed will always be able to circumvent the laws they write for the plebs.
I suspect you will find Dr B and myself in that case on the links or at the beach. Homey ain’t gonna play.
I ran to Saudi for 2 years and made a nice pile of cash working for ARAMCO to escape Obamacare when it rolled out.
Concierge medicine will be legal for a certain class of people. For the masses? No, it will be eliminated.
I have a friend who used to do short term Christian missions work in Cuba for years. The only thing that got him arrested was passing out food to poor people in the country. This was a big no-no since it was someone other than the government acting as their sustainer. I believe the same principle applies to medicine. Can’t have anyone getting goodies that the government isn’t handing out to everyone. Even our friends, the Brits, have run into this mindset as mentioned in the OP. If single-payer health care gains the upper hand, concierge medicine will be regulated out of existence. (Except for the most well-connected to the PTB.)
Which works because only a certain class of people can afford it anyway.
I don’t think the American people will stand for a government medical system that doesn’t have a bypass mechanism (whether you call it “concierge” or “supplemental” or whatever). But that won’t necessarily stop the politicians from trying to pass a government medical system that does not have a bypass. The politicians do not need to put a bypass for themselves into the law, as there will be a bypass invisible to the rest of us (see @kozak comment #11. I have heard that it is generally assumed that in the Canadian system there is a secret bypass for politicians.
I too have wondered about that. The US medical system provides so much pressure relief value to the Canadian system, particularly for diagnostics, that Canadians may find themselves with some additional problems if the US adopts a similar government run medical system. Medical facilities in Buffalo, NY also provide a lot of medical services to Canadians.
One of the key features of HillaryCare (1993) was a prohibition on medical care outside the government system. It was presented not so much as a “fairness” issue, but as a necessary element to keep wealthy people in the system. If too many wealthy people use a bypass system, the government system loses the support of those wealthy people for a generous government system, and the government system risks becoming even more substandard than we would normally predict.
If the quality of medical advances depends upon the possibility for lots of docs to make lots of money with their medical inventiveness, which I suspect that it does (but you would know, Dr. Bastiat) then the anointed would be very foolish to shrink the size of concierge medicine. Seems obvious to me that they would want more than a few outstanding docs and hospitals from which to choose. (One might also argue that medical advances can also come in situations of scarcity when one has to be more clever with the tools one has.)
This is one of the most critical issues facing Americans today, in my opinion. There’s an easy fix: we have to insist on an opt-out option in all government healthcare plans. We cannot assume that it will be included automatically. In fact, we should assume it won’t be.
The government is looking at compulsory Medicare as a model program. That is dangerous for all of us. It is a system that controls doctors and patients.
We need to protect concierge medical practices because it is too easy to harass them out of business. Where they connect to hospitals and labs and other specialties are points of vulnerability.
A great book on how we got here and what we need to do to fix this system is Regina Herzlinger’s Who Killed Healthcare? It was published in 2007, just ahead of the passage of the 2010 Affordable Care Act. In her book she predicted the entire rollout of that bill and its constricting effects on healthcare, innovation, and competition. (This is a recent Wall Street Journal op-ed piece she wrote on this subject. Professor Herzlinger is also a very active contributor and member of the American Enterprise Institute.)
In any proposed healthcare laws, we need to insist on an opt-out option. School choice has done more to help public school students than anything else ever has.
The anointed don’t care about the quality (or quantity) of medical advances. They don’t care about patients. Therefore, a reduction in the pace of medical innovations are irrelevant to them. In the unlikely event that some of them might care, they are ignorant enough to have convinced themselves that government sponsored research on whatever topic politically powerful interests are focused on will solve whatever is before them.
They might, however, care about themselves, and if they are using concierge care, which is rampant in Washington, they might want to keep it.
Australia has a public health system and a private health system which coexist more or less without difficulty.
The public health system is funded by taxes/levies and is available to all citizens/permanent residents in Australia.
If you want to buy private health insurance in addition to that you’re welcome to do so.
Public health care is rationed by urgency of need – so you might end up waiting for an operation or a specialist and your situation isn’t life threatening. Otoh you’re in a hospital pronto if you have something like a stroke. All Emergency Rooms are in public hospitals. Treatment at public hospitals is free, and you get a rebate to cover part of your GP visit costs. Some GPs only charge this rebate, essentially functioning as an extension of the public system, although they are private businesses. Other GPs do not do this.
Private health insurance, and the private system, allows you more choice about doctors, timing your operation to suit you, and quicker access to some specialists. Because everybody pays into the public system, the Government provides a means tested rebate for people who buy private insurance, and medicare will reimburse private providers 75% of the cost of that care in the public system. This means that people buy insurance to cover the portion that isn’t reimbursed.
This Government rebate to providers acts as a brake on cost in the private system, as does competition with the universally available public system.
Many people who have private insurance use it sparingly – going public when they aren’t in a hurry, but using their private cover when they are in a rush but are not in urgent need (as compared to everybody else). It’s possible to mix and match to suit your circumstances.
https://beta.health.gov.au/about-us/the-australian-health-system
https://www.privatehealth.gov.au/health_insurance/what_is_covered/index.htm
I suppose the next question would be where the best doctors go within the system, and the public/private compensation rates for physicians.
The issue is, what is thought through well enough for a given country? Not very many of them got it right. Singapore and France, maybe.
We should have wiped out employer-based insurance the second World War II was over. We’ve done one dumb thing after another ever since. Then the GOP wasn’t ready for 2016. Venal, self-dealing liars.
The term “Concierge Medicine” makes we miss @docjay. Just sayin’ …
And I favor your freedom to run a legitimate medical practice similar to the old days. Government should not be able to “outlaw” a business practice. That is restraint of trade. I think your greater challenges in the future lie with the costs of malpractice insurance rather than the government legislation/regulation.
https://beta.health.gov.au/about-us/the-australian-health-system
https://www.privatehealth.gov.au/health_insurance/what_is_covered/index.htm
Just about all GPs work out of private businesses. Paid by a combination of Government rebates and patient contribution per visit.
Salaries are higher for physicians and technicians in private hospitals, but public hospitals can offer more secure employment and a broader range of experience. (Most teaching hospitals are public.)
Often surgeons will work in both systems. In fact quite often hospitals will have a public and a private section – which are right next to each other and connected.
When my mother went to the Emergency room (public) she was asked whether she would agree to be checked into public or whether she wanted private. There was a corridor going to each place, it was physically easy to go to either. The two systems are pretty intertwined.
This stuff gets really complicated, but based on what I know right now, I would have outlawed any kind of insurance except simple catastrophic indemnity. That would force everything else you do to be more economic and transparent.
***edit***
I mean in 1946.
In the long term, no, unless you become a supplier to the political class. When we get to that point, doctors who provide high quality service to the elite will be located in facilities similar to what you see if you take one of the tours of the Cuban health care system which are so popular with the media. The clinics are great, the medical care is great, and for some reason, there is fence around each one with concertina wire on top, and there are soldiers with automatic weapons all around it, all pointed outward.
How long is your job safe?
No one knows. Not even the leadership of the progressive movement. Ultimately all open (non-black market) independent suppliers of care will need to be eradicated in mop-up operations, or the progressive movement will have been halted short of total victory across the entire front of the economy and the society.
The existence of alternatives to state-controlled supply is everywhere and always anathema to statism.
Statists do allow them, but only as a temporizing move, where they are forced to do so. There is always a long-term plan to abolish any such freedom.
A majoritarian society where collectivism
is in a dangerously unstable state, from the view of the ruling class.
As long as this condition lasts, the State is exposed to public exposure of its lies, and is at risk of an electoral or violent counter-revolution.
The propaganda efforts of socialists in Canada are made far more expensive and ineffective by the embarrassment of Canadians seeking good medical care by slipping through their joke of a Berlin Wall. They are forced to divert efforts which could be used to capture other industries and democratic institutions.
It is remarkable that they’ve succeeded in holding their line so far. They were expecting help to have arrived from their comrades in the US in 2016. They’re hoping to hold it till 2022.
The Canadian example is perfect: You can have socialized medical care when there’s an escape valve in the form of a rich neighboring country with a system that isn’t socialist (or at least, not completely so.)
In the conversation Dr. Bastiat cited, I was pointing out that Medicare, for all its undoubted virtues, is having the unanticipated effect of reducing the number of geriatric specialists not just for Medicare-dependent majority but for the elites as well. It doesn’t matter if you can pay big bucks for specialized care if there is no one around to provide it.
I was reading about a new in-utero, less-invasive surgical technique for treating children with even the most severe forms of spina bifida. Such surgeries have been developed in the U.S., but this particular advance came out of Brazil, a country that is leading the way on fetal surgery. Why Brazil? Because abortion is illegal there.
If most women are encouraged to respond to a catastrophic birth defect diagnosis by having an abortion, there are few incentives or opportunities for surgeons to develop and perfect treatments for medically vulnerable babies. This is not, in itself, an argument against abortion, only a recognition of the unintended consequences of public policy, especially those that have been set in “constitutional” stone.
Just as I imagine pregnant Icelandic women making decisions within a landscape with no services for Down’s Syndrome children but plenty of abortion providers, America could become (is becoming?) a place with no geriatricians and no breakthroughs in the management of aging but plenty of Death with Dignity clinics.