Dr. John M. Livingston | Medical Policy Adviser

Last week, I took a trip back to my home state of Ohio. There I helped teach a group of military surgeons from all across the world at the National Center for Medical Readiness, at the Wright Patterson Air Force Base in Dayton. At the end of the course, the gathered medical professionals had several hours to talk about the state of medicine and public health—two different issues that are often times confused.

Most of the surgeons were American military physicians, but we also hosted students from Australia, South Korea, Japan, New Zealand, the Netherlands, Egypt, Canada, and the Philippines.

Very few of those countries have organized trauma systems that incorporate civilian institutions into their emergency disaster systems. New Zealand, for example, has no trauma system, and Australia has very limited public support for such costly trauma system development. Only one country besides the U.S.—Canada—has organized civilian trauma systems. Even these are not organized across the Canadian provinces, but are local pockets in mostly urban areas.

Throughout the course, in formal discussions and informal surveys, all the students (with the exception of those from Germany) would prefer that arising complex medical problems be taken care of in the United States, instead of their own countries. To clarify, complex problems include complicated neonatal care, cancer care, heart disease, and severe trauma. Their predilection for American trauma care did not surprise me.

What did surprise me was the students’ ambivalence about the state of primary and preventative care in their home countries. Many reported rationing of resources, in the form of prolonged waiting periods for care of everyday situations like diabetes, prostate and GI cancer surveillance, and follow-up care for heart disease.

This mirrors complaints of the terrible efficacy of government-run healthcare programs in America.

For example, I read a statement from one American physician who went to medical school on a public health services scholarship. She recently finished her five-year obligation to the Indian Health Services program, and was very negative about the quality of care available to Native Americans utilizing those facilities. According to her, the allocation of scarce human and physical resources was "uniformly disproportionate," resulting in routine delays in diagnoses and treatment.

This doctor’s comment could have been made by any number of physicians who have served in our military, Veteran Affairs, or Indian Health Services. Her experience (and those of others)

are anecdotal, but the practitioners all recommend controlled morbidity and mortality studies of healthcare provided by these government agencies. They believe such studies would shed light on the low quality of care available via single-payer systems (i.e. government-controlled healthcare). For example, many government-employed practitioners often cite the ongoing Oregon Medicaid study, which shows that (except in the areas of mental health and drug rehab),

Medicaid has had no impact on morbidity and mortality of patients or indigent populations.

These doctors’ criticism of government healthcare was an interesting insight to me because, in my experience, younger physicians—most of whom have been trained in large, urban-centered, publically supported medical schools—believe that government-run medicine is not such a bad idea.

What is the difference between these two groups of physicians? Those currently serving in the military or public health services have experienced the limitations and frustrations of working in a command-and-control, top-down economic system. In fact, these doctors often point out that they are working for the government, rather than for their patients. On the other hand, those younger physicians who favor single-payer healthcare often have no real experience working in such environments.  

It is not my purpose in this discussion to talk about the economic implications of socialized medicine, that is a topic for another article. What is pertinent to this discussion is the folly of the unintended consequences of government intervention in healthcare. As the old proverb famously states, "The road to hell is paved with good intentions."

So it is in Ohio, where lawmakers decided that access to the opioid Narcan should be universal, and would not require a prescription from a healthcare provider. Those who supported the legislation to allow such access believed they were being compassionate and caring, but the proof is really in the pudding.

The result was not anticipated. Sales of Narcan have almost tripled. And when addicts got easy access to Narcan, they were given a sense of false security. They have taken increased amounts of the opioid—synthetic or otherwise—which has resulted in a higher rate of opioid overdose admissions to ERs and opioid-related deaths. This is just one unintended consequence that resulted from a good intention.

Consider also Medicaid expansion in Ohio. Since expansion, twice as many people are on Medicaid as there were seven years ago. The cost of coverage for this new population has more than doubled, with increasing premium costs not only for the Medicaid program but for everyone across the board. Furthermore, an emergency room doctor, who is also a professor of emergency room medicine at Wright State University, told me that one in five emergency room visits in Ohio is for drug- and alcohol-related problems. Anyone who has read "Hillbilly Elegy" by J.D. Vance knows the story of the drug problem in Southeastern Ohio. My colleague pointed out that the situation became worse with Medicaid expansion. Bear in mind that the Medicaid population in Ohio is only eight percent of the total population. However, it is estimated that over 50 percent of drug-related ER admissions in Ohio are from the Medicaid population. Prior to Medicaid expansion, this number was only 25 percent.

This same physician related that he had been all-in for Ohio governor John Kasich’s Medicaid expansion, but over the last year has come to the conclusion that Medicaid has exacerbated Ohio’s drug problem, at great cost to the residents of Ohio.

This friend also runs a drug rehab center in Dayton. As expected, admissions to Ohio drug rehab centers have increased significantly since Medicaid expansion. On the surface, this should be good and anticipated, indicating increased care access. But it is not often reported that the recidivism rate of the Medicaid population is significantly greater than those paying for their own care, or who have rehab services covered by commercial insurance. The physician noted recidivism is much lower if families or employers pay for the services, instead of relying on government subsidies. Government-run healthcare may have compassionate intentions, but we must also look at the consequences.

So with regards to Idaho’s Medicaid expansion, I am reminded of a comment I overheard after my team was beaten in the Ohio state high school football championship in 1966. The coach that beat us shook the hand of my teams’ coach and said, "We look forward to beating you next year.” Our coach just replied, "We'll see."

I say the same to those who helped pass Medicaid expansion—congratulations. You ran a great campaign. Your win proved decisive.

But to your promise of improving healthcare for the people of Idaho, and improving access and cost and clinical outcomes, I have only one comment.

We'll see.

Beware of unintended consequences.

Finally, I want to incorporate a new term into general discussions about government healthcare.  The adjective my friend used to describe John Kasich seems appropriate: Governmentalist.

In my dictionary, "governmentalist" and "compassionate conservative" mean much the same thing.  In economics, the dilemma of the public good verses the motives of individuals and families acting in their own selfish interests is theoretically addressed by economic externalities. These do not take the form of increased taxes or regulations, but by the application of incentives which facilitates transactions that all parties have a vested interest in.  

In Idaho’s Medicaid expansion vote, what surprised me most was that Butch Otter, our governor—who, by example during his 40 years of public service, taught me several of the lessons I alluded to above—came out in favor of expansion. Maybe I was naive, or just unfamiliar with the political quid pro quo and the influence of money on the political process—but boy, was I surprised!

Butch says he is compassionate, but maybe after serving so long in government, he sees himself as an agent of government rather than of the people.

Agency and asymmetry. Maybe Butch should ask: Who do I work for? How much support to factions should I give? If the Idaho Hospital Association, Idaho Medical Association, Idaho Association of Commerce and Industry, and other large special interests are disproportionately represented, then who represents the people?

So now I ask: is Butch a conservative or governmentalist?

Maybe people like John Kasich should form a new party: the Governmentalist

Party. Hopefully, nobody from Idaho would join.

Hopefully, we will not be for sale to special interests ever again.