Government Versus Your Health

A new book by Dr. Jeffrey Singer proposes a simple idea: “Every human being of adult years and sound mind has the right to determine what shall be done with his own body.” You might think that principle is hard to argue with. Yet in Your Body, Your Health Care, Singer shows that government potentially interferes with just about every decision we make in health care.

Government regulations limit whom we can seek care from, what facilities we can seek care in, what drugs we can take and who can prescribe them. In fact, there is hardly any area of medicine where we are able to make unrestricted choices.

In Dallas, Texas, where I live, for example, I am not allowed to seek care from a nurse-practitioner in independent practice, even if the services she offers are services she has been trained to provide by government-sanctioned training programs. The only exception is for a nurse who pays a doctor an average of $50,000 a year to “supervise” her practice. Yet this supervision is perfunctory and has almost no real content. It is little more than an expensive bribe that nurses are required to pay doctors for the right to do what they have been trained to do. Both patients and nurses are paying the cost of that bribe.

You might think that restrictions like this one exist because of government’s concern that patients might make bad decisions that would be harmful to themselves. Yet in states where nurses are able to practice without paying doctors $50,000 (27 in all), there is no evidence of patient harm.

At times, Singer (who is himself a general surgeon) suggests that much government regulation of medical care is overzealous paternalism. But if that is what mainly motivates lawmakers, why are we allowed to make so many risky choices unimpeded by the state? For example:

• There is no law that prevents me from putting on a scuba tank and exploring an underwater cave. Yet in as many as 1 in every 3,000 cave dives, someone dies.
• No law prevents me from hang-gliding. Yet among those who engage in the sport, as many as 1 in 1,000 die every year.
• No law prevents me from mountain climbing – an even riskier sport. Yet one in every 80 people who attempt to climb Mt. Everest dies. Of those who reach the summit, one in 20 never makes it back down.

The most important reason for most medical interventions, as Singer acknowledges, is the financial self-interest of those who benefit from the regulations.

Beginning in the middle of the 19^th century, the Amercian Medical Association set out to make licensing of physicians a reality in every state. By the second decade of the 20^th century organized medicine had gained virtually complete control over the practice of medicine.

Like the medieval guilds of old, organized medicine has successfully sought to restrict supply in order to increase doctor incomes. Singer gives us a short review of that history, which I have explored in a full-length monograph for the Cato Institute (also the publisher of Singer’s book). He also brings us up to date on the many studies of the competency of nurses. If anything, nurses may be slightly better than doctors for those tasks they have been trained to do.

Right now, America is suffering from a doctor shortage. One way to solve that problem is to expand the number of providers and the scope of services they are allowed to provide. In addition to nurse practitioners, there are physician assistants, foreign-trained medical doctors and assistant physicians. None of these are being utilized to the full extent of what they have to offer.

And here is a fact some readers might find surprising. Most people know that after students complete medical school, they go through a complicated process of finding a residency program to complete before they can become full-fledged practicing doctors. But 7 percent of doctor-of-medicine graduates and 10 percent of doctor-of-osteopathy graduates never find a residency. These students fall into a sort of legal limbo – unable to use their skills to meet patient needs.

We could greatly expand the supply of medical care in this country if politicians would just step aside and let the market for professional services work.

Without regulation, what would keep patients from seeing providers who are untrained in the care they offer to deliver? Singer says the private sector already has tools that protect us against that eventuality. If Singer claims he has surgical skills that he never trained for (brain surgery, for example), no hospital would allow him to practice there; no health insurance company would pay for his services; and no malpractice insurer would cover him.

Space does not permit a full discussion of the many valuable contributions to health policy you will find in this book. But no reader should skip Singer’s excellent treatment of the “War on Drugs.”

Singer introduces us to the “iron law of prohibition,” which holds that as law enforcement of prohibited drugs becomes more intense, the potency of the prohibited drug increases. That’s partly because smaller packages of the drug make smuggling easier. The iron law explains why bootleggers smuggled whiskey instead of beer or wine during alcohol prohibition. The iron law explains why cannabis has become more potent, why crack cocaine replaced powdered [?] cocaine, why cracking down on black market prescription pain pills brought on heroin, and why cracking down on heroin brought on fentanyl.

For students of health policy, Singer’s new book is a must-read contribution.