Replace government healthcare with patient-controlled health care

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University of New Mexico, Albuquerque (the USA)

Replace government healthcare with patient-controlled health care

Deane Waldman



Abstract

The purpose of the article is to analyse the shortcomings of the state-run healthcare systems and to substantiate the need for and feasibility of transition to a patient-controlled model. It is shown that patient-controlled health care, free from centralised domination, can provide timely, high-quality, compassionate medical care at an affordable price for both individuals and the nation. It significantly expands the patient's rights and opportunities to choose a doctor according to their own preferences and financial capabilities. The patient pays for the medical service provided directly to the doctor, who no longer has restrictions on choice of treatment protocols or prescription of medicines. The analysis in the article is based mainly on the example of the United States, where federal control for residents is both direct (194 million Americans are covered by Medicaid, Medicare, Tricare or EMTALA) and indirect (138 Americans have private insurance). In addition, aspects of the article analysis also apply to single-payer countries (Canada, the United Kingdom, France and Spain). The article examines the shortcomings of the current US model of its healthcare system in terms of its compliance with the Constitution. It is noted that, according to the Tenth Amendment to the US Constitution, healthcare powers are not among the 18 powers delegated to the federal government. Also, noncompliance with the law is also observed: government control or administration of state Medicaid programmes is contrary to US law; medical autonomy as the patient's ability to make personal medical decisions without undue influence from the state. Another disadvantage of state-run healthcare system is that state-controlled healthcare payment structure violates the fiduciary relationship between doctor and patient, as doctors' authority to make medical decisions is limited. It also calls into question the observance in the United States of the citizen's “right” to receive medical care in its interpretation as a personal service of a professional caregiver when a patient can demand the desired care and the service provider cannot refuse. The article emphasises that state-run healthcare systems create a conflict between efficient use of financial resources and effective provision of medical care. This issue is considered through the prism of the interests of the main stakeholders: shareholders of companies operating in this area, politicians, patients, healthcare providers and administrators. As evidence of the inefficiency of the existing US healthcare system in comparison with other countries, comparative data for different countries on life expectancy and incidence rates of a number of diseases are provided. The author also discusses the problem of limiting access to medical care (rationing) for patients with public health insurance due to a shortage of healthcare professionals accepting new Medicaid patients. This is caused by low reimbursement rates, overly bureaucratic verification procedures for obtaining payment, overregulation of requirements for doctor-patient relations and procedures for reviewing medical errors, the need to comply with population-based clinical algorithms, etc. It leads to a decrease in the quality of medical care, an increase in patient deaths while waiting for medical care, the risk of disease complications due to delays in diagnosis and timely treatment, ignoring the needs of unique, individual patients, and an increase in the likelihood of medical errors. All of the above disadvantages of state-run healthcare are obviated when the patient is in charge, patient-controlled health care.

Keywords: medical care; access; affordability; central economic control; free market; death-by-queue; fiduciary; single payer; health insurance; health savings account.



Introduction

patient-controlled model health care

Top concerns in the U.S. as well as other nations include violence/crime, inflation, and especially, health care. People everywhere experience manifold failures of government healthcare.

As one word, “healthcare” refers to the system. As two words, “health care” means medical care service, the work product of a professional caregiver offered in exchange for a patient's money. State-run (government) healthcare is defined as any healthcare system where the government, rather than the patient, makes financial and medical decisions that impact patient care. In some single-payer countries like Canada, Great Britain, France, and Spain, such control is direct, total, and overt. In the U.S., federal control is direct for 194 million Americans covered by Medicaid, Medicare, Tricare, or EMTALA, and indirect for 138 Americans with private insurance.

Evidence proves that government healthcare is both unconstitutional and illegal in the U.S. Furthermore, all government healthcare systems - both the U.S. and single payers - are immoral, inefficient, and ineffective. They abrogate the fiduciary patient-doctor relationship. They are waste huge amounts of money paying for non-care related activities. Government healthcare systems are ineffective in delivering timely, quality medical care. They all suffer from shortages of providers, especially physicians; medically hazardous wait times for care; and the resulting death-by-queue. The U.S. experiences all these inadequacies plus an “unsustainable spending curve” on healthcare. Single payer systems avoid such unsustainable spending by strictly rationing medical care.

Patient-controlled health care is essentially a non-system: there is no government control. Patients (who are consumers) are also the payers out of pocket for care, or more likely out of a very large HSA. Patients shop for care and choose providers and facilities based on patients' - not federal - value calculation (price versus quality.) Providers (sellers) compete for patients' (buyers') dollars. For the rare, unexpected, expensive medical catastrophe, there is very high deductible health insurance.

Patient-controlled health care, freed from central domination, can achieve timely, quality, compassionate medical care at an affordable cost for both individuals and the nation.

Although this article focuses predominantly on the United States, the concepts and conclusions apply to all healthcare systems directed or regulated by the central government.



Evidence, analytics, theory, and conceptual framework

Government Healthcare: Illegal

Unconstitutional (U.S. only)

The Tenth Amendment to the U.S. Constitution reads as follows (Constitution of the U.S., 1789): “The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.” Such delegated “powers” - Washington's areas of authority - are specified in the Constitution.

The U.S. Constitution specifies a list of 18 powers delegated to the federal government (“the United States”) such as: establish post offices and post roads; coin and borrow money; constitute Tribunals inferior to Supreme Court; raise and support armies and a navy; and regulate commerce with foreign nations (Constitution of the U.S., Article I, Section 8, 1789). NOTE: Authority over health care was never delegated to Washington. Thus, by the Bill of Rights, the federal government is prohibited from having “power” - control - over healthcare, which is strictly “reserved to the states respectively, or to the people” (Constitution of the U.S., Tenth Amendment, 1789).

The charge of unconstitutionality applies to the United States but not to single-payer nations such as Spain, Great Britain, and Canada.

According to Article 43 of the Spanish Constitution of 1978, all Spaniards are entitled to “equal, efficient health care assistance of the highest possible quality” with the government responsible for providing such care (Pablo et al., 2017).

In both Great Britain and Canada, the government accepts primary responsibility for the health care of its citizens. Great Britain allows the private practice of medicine outside government control. Canada does not - it takes sole and exclusive control of health care services with prohibitive penalties for engaging in private practice.

Failure to follow the law (U.S. only)

At present, Washington controls the administrative, financial, and medical aspects of Medicaid, a system supposedly run by the states. The Medicaid law itself prohibits any federal involvement. Section 1801 (Public Law 89-97, 1963) reads as follows: “Nothing in this title shall be construed to authorise any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided, or over the selection, tenure, or compensation of any officer or employee of any institution, agency, or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person”.

When Washington supervises, controls, or administers state Medicaid programs, it does so illegally, in direct contravention of its own law.

Medical autonomy suppressed

In addition to federal and state levels, government healthcare is unlawful on the individual level. Washington - directly or indirectly through federal insurance benefits regulations - dictates the medical treatment of all Americans. Witness the mandates for mass vaccination against COVID-19 with an experimental, never-before-used genetic therapy (Waldman, 2022). This violates the principle of medical autonomy (Coggon & Miola, 2011).

Medical autonomy is generally defined as the patient's ability to make personal medical decisions without undue influence by a person, organisation, or government. In the U.S. by law, the final or ultimate decision maker is the competent, adult patient. Whereas in Great Britain, the High Court has established that a government medical panel can override patient's wishes. Thus, the government, not the patient, is the ultimate medical decision-maker (Waldman, 2018).

In theory, a case can be made that third parties only control payment and not the medical choice itself. However, in practical terms, with the impossibly expensive costs of medical care and since patients cannot decide how to spend their own health care dollars, third-party payment authorisation takes away patients' medical freedom (Waldman, 2023).

Government Healthcare: Immoral

Fiduciary no more (all nations)

The practice of medicine is based morally on a fiduciary relationship buttressed by a physician's ethical obligation to do everything possible for the health of the individual patient for whom he or she is responsible (Ludewigs et al., 2022; AMA Code of Medical Ethics, 2024; Barlow, 1999). Presumably, the patient has chosen a specific physician as his or her fiduciary, literally giving up (temporarily) the patient's freedom and personal agency to that physician, who in turn uses that agency for the patient's benefit. Of necessity, a fiduciary physician must be the decision maker in the patient's medical matters, since he or she is ultimately responsible. Such august responsibility requires requisite authority.

The current third-party payment structure of government-controlled health care supplants physicians as decision-makers and thereby nullifies the fiduciary relationship. The physician cannot (or should not) be held morally or legally responsible if government healthcare takes away the physician's ability to make decisions.

“Right” to health care

The right to health care is a hot-button item everywhere. In the U.S., it is legally and culturally disallowed. Elsewhere, things are different.

The United States was founded with its first and highest principle being liberty - personal freedom or independence from government control. The Bill of Rights (U.S. Constitution, 1789) is really a Bill of Restraints, a list of limitations on federal power. Free speech and assembly in the First Amendment are not rights per se: they are prohibitions so the federal government cannot stop your speech or prevent a gathering “to petition the government for a redress of grievances” (U.S. Constitution, First Amendment, 1789). The Bill of Rights (Restraints) was intended to protect one over-arching right: personal freedom.

Health care (two words, medical care) is a professional caregiver's personal service, his or her work product. If a patient had a “right” to such service, then the patient can demand the care he or she wants, when desired, where, for no compensation - one doesn't pay for the right to free speech or to assemble - and the provider would be unable to refuse (Barlow, 1999; Waldman, 2023).

Inexorably in the U.S., a right to health care would require a return to slavery, this time for care providers. Since slavery is immoral, so is any “right” to health care.

In countries such as Great Britain, France, Germany, and Spain, the issue of human rights is part of the social contract between the residents and the government to protect peace and personal property, members of society defer to the volonte generale (“general will”), which can supersede individual freedom (Encyclopaedia Brittannica, 2024). Societal good, not liberty, is the highest value. As such, there is an accepted “right” to health care (a professional's work product). The Spanish Constitution of 1978 literally says Spaniards have a “right to health protection and health care” (Congress of Deputies and the Senate, 1978).

Government Healthcare: Inefficient

Efficiency is defined as the “ratio of the useful work ... to the total energy expended” (Cambridge Dictionary, 2024). Practically, efficiency is resource husbandry: using the least to produce the most or best.

Efficiency, like beauty, is in the eye of the beholder. Consider the following beholders of health care efficiency: a healthcare stockholder, politician, patient, care provider, and administrator.

For stockholders of HCA (Hospital Corporation of America) or Pfizer Pharmaceuticals, profit is beautiful. What is efficient is what produces the greatest profit at the lowest cost. However, such profit-making, measured by growth in stock value, has been associated with reduced access to care for patients (Waldman, 2020).

For federal politicians, beauty is a successful re-election campaign. Efficiency would then be garnering the most votes using fewer resources, such as time and money. By creating administrative healthcare jobs, politicians can acquire grateful voters at taxpayers' expense, since average Americans, not politicians, pay the salaries of these positions. These non-clinical healthcare jobs can be abbreviated as BARRCOME - Bureaucrats, Administrators, Rule and Regulations writers, Compliance officers, Oversight agents, and Mandate Enforcers (Waldman, 2023).

Healthcare job growth reached a 32-year high in 2023 (Gooch, 2024). In addition to gaining grateful voters, generating more BARRCOME costs money. It is estimated that 31 percent to more than 50 percent of all U.S. healthcare spending goes to BARRCOME and thus produces no patient care (Woolhandler et al., 2003; Waldman, 2019).

What is efficient healthcare in politicians' eyes is very inefficient from patients' perspective. Those trillions of “healthcare” dollars used to generate insurance profit, pay for BARRCOME, and garner votes are dollars taken away from patient care (Reichard, 2012).

For patients, efficient healthcare means receiving the care they need from their preferred provider in a timely manner (not waiting four months for an appointment including adequate face time with that provider, at a price they can afford) (Merritt Hawkins, 2017).

Efficiency starts with resources used, especially money. For American taxpayers, both health care as well as the healthcare system are impossibly expensive. The U.S. spent $4.5 trillion just on healthcare. This amount is greater than the entire GDP of the fourth most productive nation on earth, Germany. In 2023, the average health care costs for a typical American family were $31,065 (Bell et al., 2023). In the same year, the average median household income was $67,521.

For patients, U.S. healthcare is highly inefficient both medically and financially.

For care providers, efficiency means being rewarded adequately and in a timely manner. For them, there are two rewards, with money being of lesser import. Of much greater value to providers is the psychic reward, what Maslow called self-actualisation (McLeod, 2024). A nurse described it best: “When my babies (her small, young patients) do well, it feeds my soul” (Waldman, 2019). From the providers' perspective, an efficient healthcare system would maximise the psychic reward. Instead, with third-party disruption of the fiduciary connection, the psychic reward is minimised or even eliminated (Waldman et al., 2003).

For the managers of healthcare, an efficient doctor sees the most patients per day and thus generates the largest number of Bills for Services Rendered. Obviously, this means spending the least time with each patient.

This author was a paediatric cardiologist (now retired). His efficiency benchmark was 4.2 established outpatients per hour, referring to patients he had seen previously and presumably diagnosed. That translates to 14 minutes to practice proper medicine: take a history, review past records, do a physical exam, study intervening test results, make a diagnosis, devise a therapeutic plan, write prescriptions, and explain everything to the parents.

Doing all that in 14 minutes was clearly impossible. The physician had to choose between being efficient or being effective. Incentives in government healthcare drive provider efficiency to the detriment of medical effectiveness.

The U.S. expends much more on its government-run healthcare system than nations with single-payer systems (Wager et al., 2024). In a comparison study long before the ACA increased administrative costs, Woolhandler et al. (2003) showed that Canada expended 16.7 percent of its healthcare spending on administration while the U.S. spent nearly double: 31 percent.

Lower costs are achieved through overt rationing of care. Some say that medical rationing is generally accepted by Britons as a necessary evil of modern health care (Klein, 2020). Rationing is also widely used in the U.S. but covertly, as Americans are repeatedly promised by their political leaders, they “will get all they deserve” (Obama, 2016).

While financially, single payers spend less and technically are more dollar efficient than the U.S., all government healthcare systems are medically inefficient, or more precisely, they are medically ineffective. They do not achieve timely quality care for their patients.

Government Healthcare: Ineffective

The purported goal of any healthcare system is the restoration and maintenance of good health for the residents of that country. Government healthcare systems in the U.S. and the United Kingdom - a paradigm single-payer system - are ineffective.

The Commonwealth Fund is a widely used source for data comparing the results of healthcare system in various nations. Of the high-income nations studied, the U.S. was labelled the worst, eleventh out of eleven (Schneider et al., 2021). Some of the reported U.S. system failures, such as access to care, were valid. However, other metrics were not appropriate indicators of system failure.

Japan has a greater life expectancy than the U.S. (86 years against 80.5 years) despite spending less than half ($4,150 against $9,451 per capita) on healthcare. However, longevity is determined more by genetics and lifestyle than by actions of a healthcare system.

As the U.S. has the highest obesity rate of any developed nation, it also has the largest number of people with type II diabetes with its myriad of health complications such as debilitating arthritis, blindness, cardiovascular disease, and kidney failure. The end-result is worse health outcomes blamed on the system but attributable to the American lifestyle and diet.

The U.S. has the highest usage of illegal drugs with all the negative health consequences (CBS News, 2008). Like diabetes, this driver of poor health also cannot be attributed to what physicians do.

Equity of health care outcomes is driven more by socioeconomic factors and educational status than anything physicians do. Infant mortality is reported differently by various countries. That is some nations consider neonates below 26 weeks as not viable and simply do not report them as mortalities while the U.S. includes all live births regardless of level of prematurity.

Above notwithstanding, there is substantial evidence of the ineffectiveness of government healthcare systems in both the U.S. and single payers (Schneider et al., 2021).

Access to care

The U.S. has a well-documented shortage of care givers - doctors, nurses, mental health professionals, even dentists (Perspectives of Change, 2007). Such shortages limit patients' access to care. Even before the Affordable Care Act (ACA), the average maximum wait time to see a primary care physician was medically dangerous at 99 days. After the implementation of the ACA, the wait time had increased to 122 days (Merritt Hawkins, 2017).

Access to care is particularly problematic for patients with government -supplied health insurance such as Medicaid and Tricare. The percentage of physicians who accept new Medicaid patients has been falling for years. In 2017, the national average acceptance rate was 54.9 percent, ranging (depending on the state) from 25 percent to 94 percent (Merritt Hawkins, 2017). Thus, as Medicaid enrolment grows and a number of doctors willing to care for Medicaid patients shrinks, Americans experience the “seesaw effect”. As the number of people with government-provided health insurance goes up, their access to care goes down (Waldman, 2023).

The shortage of care providers, especially physicians, resulting in inadequate access to care is due to several factors. Though the low reimbursement rates, sometimes below the cost of doing business, is a common complaint, the regulatory burden is more off-putting. Providers must traverse a confusing, constantly changing barrage of obstacles and flurry of forms before they can submit requests for payments. Then, they must participate in mind-numbing, frankly insulting review procedures, and wait months to years before the check arrives (McCloskey & Moffitt, 2023).

Even more than the low pay or oppressive regulatory burden, what is driving providers out of clinical care is the work environment. Imagine care givers as employees working for a company called “ Healthcare.” These workers trained extensively for years to do work that the customers, members of society, desperately need 84 and want. When these employees finish training and start to work, the company tells them what to do rather than allowing them to use their judgment and do what they were trained to do. Instead of facilitating employees' work activities, the company makes i t very difficult for them to do their jobs. When something goes wrong, the employees are automatically considered guilty even if they did nothing wrong. Several hours each day, employees must fill out forms and surveys that add no value to the customers. Workers must complete their assigned tasks within time benchmarks that are impossible to achieve. The salary they receive is not the salary they were promised. The psychic reward they expected to receive from doing their noble work never materialised (Waldman et al., 2003; Waldman, 2023). And finally, the hostile environment in which they work is coming not only from their managers and supervisors, but also from the customers who are literally attacking them (American Hospital Association, 2023; Sachin, 2023).

The above describes the work environment of medical care givers in the U.S. When viewed from their perspective, it is a wonder anyone still works for the company called Healthcare.

A shortage of physicians is not limited to the United States. The British National Health Service government system has the unenviable distinction of being the first nation to have physicians go out on strike (Associated Press, 2016). Limitations of both staff and facilities have forced the NHS to cancel thousands of surgeries (Donnelly, 2018). Recently, there has been an “exodus” of British senior physicians leading to a critical shortage (Gregory, 2023). This loss not only limits care to present patients. The lack of these doctors as teachers will limit the ability to produce future physicians.

Provider shortages lead to long, medically harmful delays in diagnosis and treatment. The end result is death-by-queue - people dying while waiting in line for technically possible care that is not provided in time to save their lives (Waldman, 2023).

Quality of care

The long delays or total inability to access medical care directly contributes to reduced quality of outcomes. “Even a four-week delay of cancer treatment is associated with increased mortality” (Timothy et al., 2020). Imagine the effect of a four-month delay before a cancer diagnosis is made (Merritt Hawkins, 2017).

As fewer and fewer physicians and dentists are willing to accept new Medicaid patients, there is an increase in death-by-queue (Waldman, 2023; KHN Staff Writer, 2012; Texas Medical Association, 2016; Horton, 2016; Otto, 2017).

There may be no greater condemnation of U.S. healthcare than how it treats its veterans, or actually doesn't treat them. According to an internal VA audit, “47,000 veterans may have died” waiting for authori sation for care (Veterans' Health Administration, 2016).

The U.S. problem of physicians refusing to accept government-insured patients is not a problem found in single-payer systems such as Great Britain and Canada as all individuals are listed on some doctor's panel. However, delayed access is at least as bad in those nations as in the U.S. (Donnelly, 2018). Just because a patient is on some physician's panel list does not mean the patient will receive timely care. In fact, the term death-by-queue was originally coined for Great Britain's National Health Service. (Waldman, 2023).

One advantage of government control of healthcare is the legal machinery to evaluate quality of services provided. The NHS has suffered several scandals of poor care prompting Blue Ribbon Panels. Each panel suggested both specific and system-wide improvements. The specific institutional recommendations were usually enacted, such as firing individuals, but the system remains unchanged (Blue Ribbon Panels, 2001; Gosport War Memorial Hospital, 2023).

In government healthcare systems, the practice of medicine is controlled largely by federal guidelines and insurance regulations. This is a one-size-fits-all approach that ignores the needs of unique, individual patients. Substituting a population-based clinical algorithm for a physician's knowledge of the specific patient and the doctor's best judgment based on training and experience produce s a less-than-optimal outcome for that patient. In fact, the probability of error or adverse outcome increases.

The U.S. medical malpractice system diminishes the quality of care by exacerbating the error rate. The Japanese call errors “little gems” because mistakes have great value as teaching tools. By emphasising confidentiality when settling lawsuits after adverse outcomes, the U.S. tort malpractice system prevents the wide exposure of what went wrong. This suppresses learning and increases the likelihood that the adverse patient outcome will recur (Waldman, 2014).

Theoretical Basis: Patient-Controlled Health Care

When faced with overwhelming evidence of health care system failures, most people would seek a government solution: allocate more money, policy change, new mandates, revised regulations, and of course, someone or some group to blame. Rarely do people recognise the common thread.

Government healthcare fails BECAUSE the government controls healthcare

Since the cause of healthcare system failure is government control, the solution is obvious: remove the government. Since centrally dominated systems constantly fail, a widely distributed system should work. This is analogous to the economic success of the free market in contrast to the failure of centrally controlled economies, viz., U.S. versus U.S.S.R.

Most people cannot imagine healthcare that is not government controlled. Yet before Medicaid and Medicare, prior to President Lyndon Johnson's Great Society, Americans got timely, quality care from a doctor of their choosing when they needed it without going broke. This author's wife was born in 1946. We found her hospital bill in her parents' attic. Her father paid the bill out of pocket: $19.50.

The mechanics of current government and third-party healthcare in contrast with patient-controlled health care are displayed in Figure 1.



Figure 1. Government-Controlled VS Patient-Controlled Health Care

Source: Prepared by the author specifically for this article

The patient is separated, “disconnected” in market terms (Waldman et al., 2003), from the provider by the federal government, which makes all decisions, both financial and medical.

With government healthcare, the patient (buyer) does not pay the doctor directly. The patient's money is taken by a third party that distributes the money as it sees fit, always paying itself first. What is left after paying for BARRCOME and generating middlemen profit is available to pay care providers.

The provider (seller) is not paid the charge (price) but rather a fraction of the charge that the third party chooses to pay - take it or leave it. The provider (seller) is not allowed to use the personal experience and knowledge of a particular patient to formulate a medical plan. Rather, the provider must follow Washington's one-size-fits-all advisories, algorithms, mandates, and prohibitions, which are effective commands. Keep in mind those doctors who wanted to use the well-established drug, ivermectin, for their COVID patients but who were prevented by FDA/CDC prohibition against the drug (Leake, 2023) and who were punished for not following medical dictates from Washington. (Louise, 2021; McGregor, 2023; Mercola, 2023).

With patient-controlled health care, the third party (government) no longer makes medical or financial decisions. The patient and physician are reconnected and can interact directly. The patient pays the doctor, probably out of a large family HSA. The doctor gives medical recommendations specific to that patient, since he or she knows the patient's medical history and idiosyncrasies.

Additional features of patient-controlled health care include revised HSA rules and state-based, not federal, medical safety nets. Note the absence of BARRCOME and its massive cost.

Allow large, no-limit (both time and contributions) family HSAs. Most can be funded by current employer insurance payments. Transfer the tax advantage from employer to employee. Federal restrictions on HSAs should be eliminated so individuals can contribute as much as they choose, such as the $32,065 average American families expended on healthcare last year (Bell et al, 2023). There should be no time limit on family HSA - no use-it-or-lose-it at year's end.

Pay out Medicare into senior HSAs before the program becomes insolvent (Ruger, 2022; CMS, 2023). Dismantle Medicaid and repeal the ACA as both are unnecessary regulatory over-reach. Allow states to design and operate their own medical safety nets. Effective, fiscally advantageous options of such safety nets are available (Waldman, 2019).



Conclusion and research potential

In contrast to government healthcare, patient-controlled health care would be:

Legal - it follows the law.

Moral - it is consistent with American values and the Hippocratic oath.

Efficient - it balances supply and demand.

Effective - it will provide the care that people need when they need it at a price they and the nation can afford.

Patient-controlled health care is, in a sense, a non-system: there is no single organizing principle (other than freedom), no central control, and essentially no bureaucracy. It would achieve legal, moral, efficient, and effective health (medical) care. Decision-making is widely distributed rather than centralized and health care would acquire all the advantages of a free market - the best and most of something to the greatest number at the lower cost. The cost to the nation would become nominal and sustainable as patient-controlled health care eliminates virtually all of government healthcare BARRCOME. For individuals, patient-controlled health care would produce timely, high-quality, affordable medical care.

In the landmark U.S. Supreme Court case, New State Ice Co. v. Liebmann (1932), Justice Louis Brandeis wrote the following in his dissenting opinion. “It is one of the happy incidents of the federal system, that a single courageous state may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country.” (Greve, 2001) His laboratory of democracy idea could be used for future research aimed at optimizing healthcare systems.

Research to prove or disprove the theory of patient-controlled health care could be done by applying Justice Brandeis' idea. In the book, “Curing the Cancer in U.S. Healthcare” (Waldman 2019), the subtitle - “StatesCare and Market-Based Medicine” - suggests that precise approach. StatesCare is a novel term for applying Justice Brandeis' “laboratory of democracy” concept to healthcare. If states were released from federal control, they could design their own healthcare systems specific to the needs and limitations of their state residents.

The U.S. states of Montana and Rhode Island have the same number of residents, approximately one million. Montana has 1100 physicians to cover 145,000 square miles with the nearest major trauma centre being 8 hours' drive away from the capitol, Helena, assuming the roads are passable. Rhode Island has 1212 square miles, 5500 physicians, and three world-class medical centres less than 45 minutes' drive from Providence, its capitol. To apply a one-size-fits-all healthcare system to these two states, as government-run healthcare does, is ludicrous.

If states were allowed to design and implement different healthcare systems, comparative research studies could show what works, where and why. For example, one state such as California (population = 39 million) might create its own single-payer system while a second state, say Texas (population = 30 million), might implement patient-controlled health care, and a third, viz., Illinois with 12 million residents, might keep the ACA and insurance-based healthcare in place. Let them function independently for five years or more and then evaluate the effects on access, cost, quality, and patient satisfaction.

Laboratories of democracy, indeed.



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