The Modern Health CareMaze : An Interdiscipinary Approach

The Modern Health Care Maze

The Modern Health CareMaze: An Interdiscipinary Approach Charles Kroncke, Ph.D.Dean of the Business DivisionCollege of Mount St. Joseph

Ronald F. White, Ph.D.Professor of PhilosophyCollege of Mount St. Joseph

1IntroductionThe current state of health care reform in the United States.Why does health care reform requires an interdisciplinary approach?What can philosophers and economists contribute to health care reform?

Last summer, Charles and I published an essay in the Independent Review titled the Modern Health Care Maze, where we argued that employment-based health insurance is the source of most of our health care woes. The systems growing dysfunctionality is evidenced by: a rising unemployment coupled with a growing number of Americans without health insurance, an escalating rate of inflation in the health care industry, and less than flattering comparisons with European health care systems. If the U.S. system is broken, then how do we proceed toward reform?

Today, Charles and I would like to suggest that one way to approach health care reform is through interdisciplinarity. In short, we think that an interdisciplinary approach can contribute significantly to the reform debate. Philosophers can help clarify our thinking about health care and economists can show us how to pay for it. So in the next hour, Charles and I will sketch in what might be called an interdisciplinary approach to health care reform. 2Current State: Cost Overall Costs Medicare and MedicaidEmployment-Based Health Insurance

COSTS ACCORDING TO THE NATIONAL COALITION ON HEALTH CARE (CHARLES)

OVERALL COSTS:1. National health spending is expected to reach $2.5 trillion in 2009, accounting for 17.6 percent of the gross domestic product (GDP). By 2018, national health care expenditures are expected to reach $4.4 trillionmore than double 2007 spending.

2. National health expenditures are expected to increase faster than the growth in GDP: between 2008 and 2018, the average increase in national health expenditures is expected to be 6.2 percent per year, while the GDP is expected to increase only 4.1 percent per year.

3. According to one study, of the $2.1 trillion the U.S. spent on health care in 2006, nearly $650 billion was above what we would expect to spend based on the level of U.S. wealth versus other nations. These additional costs are attributable to $436 billion outpatient care and another $186 billion of spending related to high administrative costs.

4. A recent study found that 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Of those who filed for bankruptcy, nearly 80 percent had health insurance.

GOVERNMENT ENTITLEMENTS: MEDICARE AND MEDICAID 5. In just three years, the Medicare and Medicaid programs will account for 50 percent of all national health spending. Medicare's Hospital Insurance (HI) Trust Fund is expected to pay out more in hospital benefits and other expenditures this year than it receives in taxes and other dedicated revenues. In addition, the Medicare Supplementary Medical Insurance (SMI) Trust Fund that pays for physician services and the prescription drug benefit will continue to require general revenue financing and charges on beneficiaries that will grow substantially faster than the economy and beneficiary incomes over time.

EMPLOYMENT-BASED HEALTH INSURANCE6. The average employer-sponsored premium for a family of four costs close to $13,400 a year, and the employee foots about 27 percent of this cost.4 Health insurance costs are the fastest growing expense for employers. Employer health insurance costs overtook profits in 2008, and the gap grows steadily.

7. Total health insurance costs for employers could reach nearly $850 billion by 2019. Individual and family spending will jump considerably from $326 billion in 2009 to $550 billion in 2019.6

8. Without health care reform, small businesses will pay nearly $2.4 trillion dollars over the next ten years in health care costs for their workers, 178,000 small business jobs will be lost by 2018 as a result of health care costs, $834 billion in small business wages will be lost due to high health care costs over the next ten years, small businesses will lose $52.1 billion in profits to high health care costs and 1.6 million small business workers will suffer job lock roughly one in 16 people currently insured by their employers.

9. The Congressional Budget Office has estimated that job-based health insurance could increase 100 percent over the next decade. Employer-based family insurance costs for a family of four will reach nearly $25,000 per year by 2018 absent health care reform. 3Chart 1: Percentage of GDP Spent on Health Care (From: CDC)

Current State: QualityAccording to the CIAInfant Mortality: 33rd (Out of 224)Life Expectancy: 50thPreventable Deaths: 19th (Among Industrialized Countries)Overall Ranking: 37th out of 191 Countries (WHO) 5Chart 2: Infant Mortality (CDC)

6Chart 3: Overall Satisfaction

Principal Stakeholders in Health Care Reform What is a Stakeholder?Most Visible StakeholdersFirst-Party Patients Individuals that want or need health care products or services from providers. Second-Party Providers (physicians, nurses, pharmaceutical companies, medical technology corporations) Third-Party Payers (government programs, private insurance companies) Fourth-Party Employers (large and small businesses )Least Visible StakeholdersPublic and Private Research Facilities (NIH, Merck)Teaching Institutions (Public and Private Colleges and Universities)Tuition-Lending Institutions (banks)Malpractice LawyersMalpractice Insurance ProvidersTechnology Manufacturers (GE)Government Employees (NSF, NIH, FDA etc.)Stockholders in the Health Care IndustriesInsurance Brokers hired by employers to purchase health insurance for employees. Given that health care reform will inevitably redistribute costs and benefits among stakeholders, lets take a quick snapshot of the principle stakeholders that stand to either reap benefits and/or pay the costs of health care reform.

MOST VISIBLE: Our health care system today, the status quo, is a four-party-system (which Charles will detail shortly). It involves first-party patients, second-party providers, third-party payers (insurance companies and government programs) and fourth-party employers that purchase our health insurance from third-party payers.

LEAST VISIBLE: But there are also many less visible stakeholders that seek to either maintain or upend the status quo. Social scientists that engage in descriptive inquiry tell us how our health care system works. Philosophers, theologians and other prescriptive inquirers tell us whether the status quo is good or not. 8What is Philosophy? Human InquiryDescriptive Inquiry: questions and answers about Truth or the way things are.Prescriptive Inquiry(questions and answers about Value, whats Good or the way things ought to be).Ethics: Good Human BehaviorDeontological Theories: Rights/Duty BasedTeleological Theories: Consequentially Based

Philosophers study human inquiry; that is the inter-generational process of questioning and answering. There are two basic lines of inquiry: descriptive inquiry (questioning and answering in pursuit of Truth) and prescriptive inquiry (questioning and answering in pursuit of Value, Good). Social scientists that engage in descriptive inquiry tell us how our health care system works. Philosophers, theologians, and other prescriptive inquirers tell us whether the status quo is good or not. Philosophers distinguish between three different kinds of moral theories: virtue-based theories (virtues and vices), rights-based theories (rights and duties), and consequential theories (costs and benefits). Most of the current debate over health care are over rights and consequences.

In terms of health care reform there are two lines of prescriptive inquiry. What IS good health care? And, how OUGHT good health care be distributed?

9What is Philosophy? Human InquiryDescriptive Inquiry: questions and answers about Truth or the way things are.Prescriptive Inquiry(questions and answers about Value, whats Good or the way things ought to be).Ethics: Good Human BehaviorDeontological Theories: Rights/Duty BasedTeleological Theories: Consequentially Based

Philosophers study human inquiry; that is the inter-generational process of questioning and answering. There are two basic lines of inquiry: descriptive inquiry (questioning and answering in pursuit of Truth) and prescriptive inquiry (questioning and answering in pursuit of Value, Good). Social scientists that engage in descriptive inquiry tell us how our health care system works. Philosophers, theologians, and other prescriptive inquirers tell us whether the status quo is good or not. Philosophers distinguish between three different kinds of moral theories: virtue-based theories (virtues and vices), rights-based theories (rights and duties), and consequential theories (costs and benefits). Most of the current debate over health care are over rights and consequences.

In terms of health care reform there are two lines of prescriptive inquiry. What IS good health care? And, how OUGHT good health care be distributed?

10Is there a Right to Health Care?Deontological ArgumentsWhat is a right?Relationship Between Rights and DutiesIndividual Rights/DutiesCollective Rights/DutiesTheoretical FoundationsNatural RightsMoral RightsLegal RightsLibertarian View of RightsPositive Duties and Positive Rights (entitlement: A has a duty to provide B health care)Negative Duties and Negative Rights (non-interferene) All rights are property rights).Is there a right to health care?Natural RightMoral Right Legal rightPositive or Negative RightWho has a duty to provide health care?What products and services are covered by the right to health care?Moral debates about the distribution of health care usually invoke a right to health care.

DEONTOLOGICAL MORAL THEORIES: Deontological moral theories view morality through the lens of interlocking rights and duties. So what do we mean when we claim that there is a right to health care? When you claim a right on behalf of yourself or others, you are saying that others have a duty to treat you in a certain way. Therefore, you have a right if and only if someone else has a duty to fill that right, and in fact fulfills that duty. Philosophers disagree over how rights and duties play out in the real world. Philosophers ground rights based on Human Nature, Morality, and/or Legality. NATURAL RIGHTS are rights that are deduced from the descriptive facts of human nature. Since the Enlightenment, most rights based theorists have argued that human beings are rational individuals that possess free will. If you treat humans otherwise, Mother Nature strikes back. Hence, Mother Nature enforces Natural Rights. MORAL RIGHTS are rights that are based mutually agreed upon moral principles. When we do our duty the moral community praises you, and when you fail to do your duty, they blame you. Most of the Enlightenment philosophers argued that universal moral rights are grounded in Nature. LEGAL RIGHTS are moral or natural rights that are also enforced by the coercive power of government. If you violate the rights of others (fail to do your duty), government will intervene and force you to rectify your that violation and force you to do your duty next time. Obviously, we have many legal rights and duties that are amoral and others that are immoral. And, there are many moral rights and duties that are not enforced by government. I you claim a right and by implication claim a duty on the part of others uphold that right, what might that entail? POSITIVE AND NEGATIVE RIGHTS: Deontological (right-based) libertarians distinguish between positive rights and negative rights. If you claim a positive right to health care you are saying that some individual or group is entitled to health care and that some individual or group has a corresponding positive duty to assist you in your pursuit it or even provide it. If you claim a negative right you are saying that other individuals or groups have a duty to not interfere or impede you in your pursuit of health care. Most libertarians argue that there are no positive rights apart from those that are covered by voluntary legal and/or moral contracts. Legal Contracts are enforced by the coercive power of government. Moral Contracts are backed up by public sentiment. If you violate a moral contract, your neighbors will hold you blameworthy. The debate over health care reform is about whether there is a positive moral right or a negative moral right to health care, and if so should either be construed as legal rights. And, if the government affirms a positive legal right to health care, then we must also decide if it is a universal human right. Does it apply to all Americans, or just a few specific groups: poor, elderly, children, or soldiers? If it is less than universal, then which individuals or groups have that positive right? And finally, if they have that positive right, what kinds of health care do these groups have a positive right to access? Libertarian-based health care reform would seek to eliminate laws that might impede patient access to health care. Reforms might include: reforming licensure requirements for providers and third-party payers, reforming patent laws for new drugs and devices, and eliminating all laws that skew competition in favor of providers and/or third party payers. In our essay, Charles and I argued that the current health care system is a primarily a system of corporate welfare. In sum, rights-based arguments about health care reform boil down to what we mean when we say that health care ought to be distributed equally. Positive rights usually imply equality in the ultimate distribution of health care or equality of results: negative rights usually imply equality of access to health care, or equality of opportunity.

11The Ideal Health Care SystemIf there is a positive legal right to health care, what would the ideal health care system look like? Universal Access Positive or negative right?Access to what?High QualityWhat is good health care?Measurements: Life Expectancy, Infant Mortality Rate, Avoidable Mortality Comprehensiveness Reasonable CostWho pays the cost? Who reaps the benefit?What is reasonable? So what is the ideal health care system? It is generally acknowledged that the ideal health care system entails universal access to high quality products and services, at a reasonable cost. Well, what would a philosopher say about all that? SurpriseIt depends on what you mean by vague terms such as access, quality, and reasonable cost.

UNIVERSAL ACCESS: What do we really mean by access? First of all, lets differentiate between access and possession? As Milton Friedman observed, in the real world, there is no free lunch. Therefore, access to anything good involves the expenditure of someones time, effort and resources. So if health care reform grants all Americans a universal positive legal right to health care, someone will have to pay for it. That entails the collection and expenditure of tax money. (See Cost Below). And finally, universal access to health care raises the question of access to which products and services? Realistically, can government provide comprehensive health care for all Americans, or just some products and services? What would that level of taxation would it take to provide access every product and service on the market? (See Costs Below)

HIGH QUALITY: What do we mean by high quality health care? What do we mean by a high quality health care system? First of all, how do we go about measuring quality? Unfortunately, whats high-quality health care for an individual does not always translate into collective high quality. Many critics of the U.S. health care equate systemic quality to collective measures such as infant mortality and life expectancy. Based on those measurements the U.S. system does not fare well in comparison to European countries. Other utility-minded critics argue that we sacrifice bang for the buck by spending too much on catastrophic treatment such as neonatal intensive care and cancer treatment. (Tell that to my wife who survived breast cancer thanks to state-of-the-art medical science!)

REASONABLE COST: What do we mean by reasonable cost? How much should we be spending on health care in comparison to food, clothing, shelter, or education? Who is better situated to make that determination, individuals or leaders of groups that are spending their own money or employers or governments that are spending other peoples money? Libertarians argue that within a free market individuals are best situated to decide reasonable costs. Unfortunately, our four party health care system is so far from a free market its difficult to apply that principle. On the other hand, that doesnt mean that government or employers can do a better job.

Although philosophers are skilled at probing how the meanings of words affect arguments about health care, they are not very good at figuring how to pay for it. Thats what economists are good at. Heres Charles12Free Market and Socialized MedicineWhy there is no free lunch.Two highly idealized views on how nations pay for health care Free Market Capitalism Individual Planning by Individual Buyers and SellersInformationFreedomCompetitionSocialism Collective Planning by Government Information: Perfect information means that prices and output levels are known by buyers and sellers and that competitors prices are known. While perfect information is unlikely in the real world it is a good goal to be moving toward. Currently, in the field of health care information price information is hard to come by. Prices of insurance plans, prices of doctors visits, prices of medical procedures, out of pocket expenses are all obscured and difficult to find. Recently, my wifes chiropractor recommended an MRI for some back pain. I had to make three phone calls and spend 30 minutes on the phone to find our out of pocket expense. I can find the price of a pair of shoes in less than a minute on-line.

Freedom: Free markets give individual the freedom of choices. Freedom is repressed in the field of health care. For example, state line rules impede freedom of choice.

Competition: Recently our college switched health insurance companies. We have 335 benefit eligible employees and only three companies sent bids back for our business. Two of the three were extremely high. While, the market is not monopolized, it also does not resemble free market competition.

Free market capitalism requires minimal government distortion of prices and products produced. While government does not set prices and production level it strongly influences them by regulations.

It cannot be expected that a health care market be characterized by perfect information, and complete freedom and competition, movement in that direction is desirable. 13Four National SystemsBeveridge Model (England)National Health Insurance Model (Canada)Bismarck Model (Germany)Out-of-Pocket Model

What is socialized medicine? This question has no distinct answer. Here are four national systems with different degrees of socialism. They are ordered in declining degrees of government control. In the next few slides we will see that all these systems exist in the United States. 14National Health Care System Model (Beveridge Model)William Beveridge (Great Britain)Great Britain, Italy, Spain, Scandinavia, Cuba, and Hong KongHealth Care financed and provided by government via taxationNo medical bills, public serviceMost doctors are government employeesMost doctors are private doctors collect fees from govt.U.S. Correlate: Military and Veterans, Indian Health ServiceProblems: High Taxation, Shortage of Specialists, Waiting Lines, Patients may not be treated if the doctor deems unimportant, Government (not price) rations health careThe basics of this plan government run hospitals Government paying the billGovernment is both provider and payer This is closest to pure socialized medicine Origins early 1940s. William Beveridge and Nye Bevan. Beveridge was on Churchills Social Insurance and Allied Services Committee. 1945 Nye Bevan a committed socialist was Minister of Health. Beveridge designed the plan, Bevan implemented it. 15National Health Insurance ModelCanadian SystemCanada, Taiwan, South KoreaSingle-Payer SystemPrinciples Governing Canadian SystemPublic AdministrationComprehensivenessUniversalityPortabilityAccessibilityU.S. Correlate: (Medicare) Individuals over 65Basic Problems: Waiting Lines, High Taxes

National Health Insurance Model

Basic concept Private sector doctors and hospitalsGovernment insurance plan Origins in Canada: Tommy Douglas child in Scotland who injured his knee before moving to Canada in the early 1900s. He received treatment only because he was selected to be the subject of a demonstration of surgical technique. He would later be elected Governor of Saskatchewan in 1944. He would then design and promote this single payer system that would cover everyone in the country by 1961.

16Bismarck ModelGermany, Japan, France, Belgium, Switzerland,Otto Von Bismarck (Germany)Universal CoverageProviders and Payers are Private Insurance Financed by Employers and EmployeesNon-Profit Sickness Insurance Funds300 in Germany (pay physicians via regional physician associations) Individual and Employer Mandates (payroll deduction 50/50)Unemployed paid for by benefits agency or government social fundPrice controls on medical services, premiums set at about 14% of incomePublic and Private HospitalsChoice of physicians U.S. Correlate: Four-Party System Most working individuals under 65Basic Problems:Sickness Funds run out of money Doctors not highly compensated UnemploymentPerverse Incentives: U.S. Job-Lock, Job-FlightSummary of Health Care Systems

The basics of this idea areUniversal CoveragePrivate providers (Unions)Private insurance Government regulates coverage and prices

Origins in Germany. Otto von Bismarck the Iron Chancellor unified the nation in the 1800s. January 1971 birth of the German Empire. He created his Sickness Insurance Laws in 1883. Why did he create these laws? Possibly benevolence. A program of applied Christianity. Possibly to undermine political support to left wing parties. Possibly to insure healthy young men for the military.

In Germany competition among the sickness funds and pressure from government have lowered the price of health care, but costs continue to increase. This puts a squeeze on doctors. Includes Dentistry

17Out-of-Pocket SystemCountries without any organized Health Care SystemSomalia, Afghanistan etc.Products and Services not covered by countries with Health Care Systems. Treatments that address wants (elective v. necessary treatments)Cosmetic surgery, Sex change, weight reduction surgery etc.Treatments with marginal cost-benefit ratiosJoint replacement surgery Dental care, psychiatric care, pharmaceuticalsIllegal Treatments on the black market (Rhino Horn etc.) The United States Unemployed or UnderemployedUninsured with pre-existing conditionsExceed Lifetime Insurance LimitsUnder-InsuredContractual ExclusionsProblems: Access to health care by the poor, inequality of quality (the rich get better care).

18Health Care Systems in the United StatesDecentralized Mixed System Based on Groups Four-Party System (workers) Bismarck Model Federal Employees Health Benefit Program (employees of government) Medicare (elderly)Beveridge ModelMedicaid (poor)National Health Insurance ModelVeterans Medicine (veterans)Beveridge ModelIndian Health Care (Native Americans)Beveridge Model State Childrens Health Insurance Program (SCHIP)National Health Insurance ModelReauthorized in 2009Cobra Consolidated Budget Reconciliation Act COBRA (unemployed)Since the early twentieth century, health care in the United States evolved based on governmental meddling with the free market by advancing the interests of various stakeholder groups at the expense of others. 19Does the Concept of Private Insurance Work for health Care?The Concept of InsuranceEconomic IncentivesCommunity Rating SystemsAdverse SelectionMoral HazardExperience Rating SystemsInformation AsymmetryFraudEnabling Legislation

Insurance provided by government of private companies has difficulties and may not be viable for health care.

The point of a private insurance company to make money. Potential government (or non-profit) insurance plans have to be concerned with cost.

Community rating system: all members of a specific group pay the same premium. Some high risk and some low risk buyers. However, these community rating systems have two big problems:

Adverse selection: Without coercion, healthy individuals may not sign up for health care and unhealthy individuals will sign up for plans with the highest level of coverage. Without low use consumers, insurance providers will not be able to balance the expenses of the high use consumers.

Moral Hazard: Once a consumer has coverage, they are more likely to visit the doctor for small problems.

Community rating systems respond to these problems by raising prices on all buyers. Thus, low risk buyers have an incentive to leave the pool. Deductibles, and co-payments are just two ways insurance companies deal with these problems.

Experience rating: Set premium to known risk exposure. High risk people pay more than low risk people. Unintended consequences: Information asymmetry and insurance fraud.

Enabling Legislation: The political process is used rather than a free market to enhance profits. 20Key Issues For Health Care ReformIs there a positive right to health care? If so, who has a duty to provide it?If there is a positive right to health care:which products and services ought to be included in this basic package, and which ought to be paid out of pocket? should there be one health care system to provide universal coverage or several systems covering different groups: elderly, poor, veterans, etc.? Which group gets the best and most?should there be one centralized (federal) system or should it be a decentralized system (regional, state, or local)?what role, if any, should private health insurance companies play in the distribution of products and services?what role, if any, should non-governmental , non-profit organizations ply in the distribution of products and services?what role, if any, should health care policy be subject to politics?

Free-Wheeling Small Group Philosophical DiscussionThis morning President Obama and Congress called you on the phone and asked you to serve on a Committee to redesign the U.S. health care system. You have absolute uncontested power to make all decisions related to health care, as long as you can all agree on the answers to the following philosophical and economic questions.

Break into groups of 4-5. 22Question #1Will any of the following groups will have a positive legal right to health care? Why or why not? Chronically Ill (All or some? How ill? Which diseases?)Poor (All or some? How poor?)Elderly (All or some? How old?)Children (All or some? How young?)Military Personnel (All or some? For how long?)Native Americans (All or some? Which tribes?)Institutionalized prisoners (All or some? Which crimes?)Employees of the Federal Government (All or some? Which employees)Citizens of the states of Massachusetts and HawaiiUrban Americans living in large cities (All or some, which cities?) Question #2Question #2 If any of these groups will have a positive legal right to health care?, which of the following products and or services will be included in this coverage? Explain why or why not?Catastrophic Treatment (trauma centers, ambulance service, helicopters, cancer centers) Preventative Care (vaccinations, annual physicals, mammograms, obesity surgery) Palliative Care (pain, hospice etc.) Reproductive Treatment (IVF, birth control, abortion, neonatal intensive care)Cosmetic Surgery (hair restoration, breast augmentation/reduction, weight reduction) Dental Treatment (annual exams, cleaning, simple extractions, root canals, braces)Vision Care: (Eye glasses, surgery, transplants) Psychiatric Care (drug therapy, counseling, suicide interdiction, ADD treatment, autism treatment)Mobility Treatment (artificial limbs, hip and joint replacement surgery, physical therapy, motorized wheel chairs) Substance Abuse Treatment (alcohol, drugs, tobacco, food)Gambling Abuse TreatmentHospice Treatment(food, shelter, nursing care, pain medication)Treatments of Unknown Safety and Effectiveness (experimental treatment, untested treatments Tested Treatments Known to be Unsafe or Ineffective (magic incantations, astrology, human sacrifice to all powerful Gods, etc.)Question #3If health care is a scare good, WHO ought to distribute (ration) it? Why?Physicians or physicians Unions, or Groups? Hospitals or hospital groups?Health care experts?Private Insurance companies or Sickness Funds?Government (President, House, Senate, Supreme Court)State or Local Government?Panels of experts hired by government?Lobbyists for the various health care industries?Individual patients ration their own health care based on quality and cost.Non-profit charitable organizations A combination of any the above?

Question #4If Health care is a scarce good, HOW should it be distributed (rationed)? Why?Lines: Whoever is willing (or able) to wait the longest in line gets the best/most.Location: Whoever lives near a provider gets the best/most.Favoritism: Whoever is friends with the distributers gets the most/best. Age: Adults, Elderly, or Children get the best/most.Employment Status: Whoever works gets the best/most? Health Status: Whoever is healthiest or sickest gets the best/most. Lottery: Whoever wins a state-run lottery gets the best/mostUtility: Whoever is more useful to society gets the best/mostPrice: Whoever is willing/able to pay for health care gets the best/most.

ConclusionsThere are no Health Care Systems that Approach the Ideal of Universal, Quality Health Care, at a Reasonable Cost. There is no rational way to distribute health care between competing groups.There are no pure free-market systemsThere are no pure socialized systems.There is no rational way to decide which products and services ought to be included in a national system.Substantial health care reform is unlikely.

27Toward Libertarian Health Care ReformBasic Principles and Specific ReformsINCREASE INFORMATIONIncrease Transparency of Contracts (Price and Quality)Eliminate the use of Private language in health insurance policies by codifying insurance language and coding. Limit or control price discrimination by providers and insurersINCREASE FREEDOMIncrease Personal Liberty to Choose Insurance End employer-based health InsuranceIncrease Personal Liberty to Choose ProvidersINCREASE COMPETITIONIncrease Competition Between Insurance Companies, and ProvidersEliminate legislative obstacles to the formation of larger interstate buyer groups and allow the purchase of health insurance across state lines.Enforce anti-trust laws to insurance companiesMinimize licensure requirements for providers. End the longstanding tradition of piecemeal health care reform based on political groupings: poor, elderly, children, tribe, military status, employment status, etc.

Practical suggestions:

end employer based health care provision Standardization and automation of medical records28Suggested ReadingDavid Boas, Libertarianism: A Primer (Free Press: 1997)Michael F. Cannon & Michael D. Tanner, Healthy Competition: Whats Holding Back Health Care and How to Free it (Cato: 2007) T.R. Reid, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (Penguin: 2009)Arnold Kling, Crisis of Abundance: Rethinking How We Pay for Health Care (Cato:2006)Charles Kroncke and Ronald F. White, The Modern Health Care Maze: Development and Effects of the Four-Party System Independent Review vol. 14, no.1 (Summer 2009) pp. 45-70 Leiyu Shi & Douglas A. Singh, Delivering Health Care in America: A Systems Approach (Jones and Bartlett: 2008)29Appendix 2: Cost of a Long Life

30Appendix 4: CT Scanners

Appendix 5: MRI Units

Appendix 5: Assorted Statistics Compiled by the CIAPopulationLife Expectancy at BirthInfant MortalityDeath RateHIV, AIDS Deaths