Last night, searing pain woke me around 2am—my sixth night in a row without proper sleep. My sheet was soaked with sweat and my mouth was throbbing. The hole in my gums felt gritty. All this because I was too paranoid to listen to my dentist.
Our collective paranoia about the medical industry is both completely insane and totally justified. The vast majority of doctors and dentists are deeply good people, and are guided by the most transcendent tenets of morality. A minority, however, really are shysters. And a handful are much more evil than that.
But, despite the bad apples, our caution should not be pointed at doctors. If we dig towards the core of the contemporary medical establishment we find a rotten cavity. Our medical and education systems are quickly becoming the twin mascots for our rigged, broken economy. We can keep our suspicions, but let’s start directing them at the right people–those shifting the medical establishment from a pillar of care towards an engine of exploitation.
When I was twenty-three or so, a dentist with poor bedside manner told me that I needed to have all four wisdom teeth out. I resisted, assuming that wisdom tooth removal was a mostly unnecessary procedure urged on by anti-social, money-hungry dentists. I asked myself, what did people do for centuries before wisdom tooth removal became a norm? Surely they survived just fine. Surely it was a no more than a contemporary rite of passage, sort of like skull shaping amongst upper class Mayans. In a hundred years, I was certain we’d look at it as pure insanity.
My upper two came in just fine, so I wasn’t totally wrong, but mostly my paranoia was unjustified. The lower right tooth came in almost all the way, but a skin flap developed next to the bone, creating a hidden stowaway compartment in my gum. Small bits of food stowed away, and, after an exhausting five weeks of traveling and teaching, my immune system indulged an infection.
Imagine having an infected cut on your fingertip. Then imagine someone rips off the fingernail with pliers. That’s similar to what the emergency removal surgery entailed, except it all went down in my mouth. Even with local anesthetic it was one of my more painful experiences, and particularly bad because the pain sticks. I’ve been in various stages of agony for a week.
What a strange set of facts, if you think about them. To intentionally disregard the advice of a medical professional because you’re convinced he wants your money. Am I completely insane? Is this a new phenomenon? In ancient villages, did villagers suspect their medicine men of trying to exploit them? We know that shamans were paid–usually with food, hides, livestock–but was it such an adversarial relationship? Did some shamans cheat?
As it turns out, our medicine men do cheat, and in a major way. A year ago, the FBI charged 46 doctors and nurses with billing Medicare for $712 million in patient care that was not actually administered. Among the bad actors were psychologists in Miami who billed tens of millions of dollars for psychotherapy sessions that never happened. Another group sent $22 million in glucose monitors to patients who didn’t request them. Instances like these are more common than you would think, and seem to be a recurring annual problem. A 2016 justice department takedown arrested doctors responsible for over $900 million in Medicare fraud. One Texas doctor cleared millions by shooting up elderly and otherwise home-bound patients with intravenous drugs they didn’t need.
It gets darker. Last year, a Detroit-area oncologist named Farid Fata was sentenced to 45 years in prison for prescribing chemotherapy to patients who didn’t need it. He would diagnose healthy patients with myeloma (blood cancer) and receive kickbacks from Medicare and private insurance companies. He defrauded (and traumatized) 553 patients for $34 million. Many of the victims were permanently damaged and disfigured by the unnecessary treatments. Fata will likely serve a reduced sentence in a low-security prison, but if it were up to me he would be tortured until death by his own chemo drugs.
Chemotherapy is particularly controversial treatment and the source of a great deal of medical paranoia. Many naturalists accuse it of being almost entirely profit motivated. Conspiracy theorists’ favorite statistics say that chemo is only effective about 3% of the time, and that 80% of oncologists themselves decline chemo if they are diagnosed with cancer. The reason for its popularity, naturalists allege, is that chemo is one of the only drugs where doctors can get direct kickbacks from drug manufacturers for prescribing it. These statistics have been widely challenged, and I’m certainly not in any position to tell you what the truth is. The point is that we are often even more paranoid about our doctors than we are about our health.
Doctors are ancient and dentists are even more ancient. Practitioners of both still take an oath written in the Fifth Century BC. The modern version of this pledge, the Hippocratic Oath, was last modified in 1964. It is a common misconception that it contains the words “First do no harm,” but the older Latin version of the oath does say:
Also I will, according to my ability and judgment, prescribe a regimen for the health of the sick; but I will utterly reject harm and mischief…
The modern version strangely omits this line, but adds:
I will apply, for the benefit of the sick, all measures which are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
The doctors above brazenly violated these rules, but that does not mean we should be distrustful of the lot. In fact, most doctors do a lot more good than harm. Some may be egotistical, others may be terse, but they are buckled deeper into the fundamental definition of “good” than almost any other profession. What other industry still uses an oath from almost three thousand years ago? The act of healing another human may be the most basic moral act, which is why our inherent distrust of the medical profession is so disturbing.
While bad doctors are to blame for their own actions, doctors as a class are not responsible for the system of bizarre incentives that creates monsters like Dr. Farid. I’m close to more than a few doctors, and they all, without exception, admit that the medical system is broken, and severely so. So why do they participate? Because to do any good at all, they say, they simply must operate within it.
Who, then, is to blame?
In 2014, a Tennessee branch of the ambulance company Rural/Metro, which operates ambulances nationwide, had been ordered to slash costs so much that they were working with a skeleton crew. The inevitable happened. Somebody called for an ambulance, and there was no one there to respond immediately. An off-duty paramedic offered to help and Rural/Metro scrambled to assemble a larger crew. It took a lot of time, enough for the off-duty helper to smoke a cigarette. Finally, the haphazard crew got out to the patient, and the patient died.
This happened because in 2011 Rural/Metro was bought by a private equity group called Warburg Pincus. Private equity groups are private investment banks with the same purpose as all banks: to make and horde money. The private equity group, however, is particularly aggressive type of bank. They acquire flailing businesses and, through “a mix of cost cuts, price increases, lobbying and litigation,” they try to make those businesses profitable again. If they succeed, those profits go entirely (or almost entirely) back to private equity group, like the profits from the sale of a rehabbed car.
A private equity group differs from a car flipper, however, because cars are made of parts and businesses are made of people. Private equity doesn’t rearrange metal to make objects function well, it rearranges people to make businesses profitable. Rearranging, in this sense, almost always means laying off, cutting pay, or reducing hours on the employee side, and reducing functionality and customer service on the customer side. Want to know why the institutions you interact with on a daily basis treat you increasingly less like a human and more like a number? Private equity strategy has made that the norm. If you don’t have to treat customers well, you shouldn’t.
This isn’t a huge deal if the company in question produces a product we don’t absolutely need. Consumers can always seek other options, hopefully ones not owned by private equity. But what happens if the business produces something we absolutely need?
Private equity apparently asked itself the same question. A hot new trend in the private equity world is purchasing emergency services–ambulances, paramedic agencies, and the like. What could possibly be more profitable than a product that, in the moment of its need, consumers have no choice but to buy?
This leads to a moral problem. As The New York Times stated in a recent piece on the practice of banks buying emergency services, “In emergency care and firefighting, this approach creates a fundamental tension: the push to turn a profit while caring for people in their most vulnerable moments.”
The article is titled, “When You Dial 911 and Wall Street Answers.” It details many of the hideous absurdities that can result when a bank in New York handles local emergencies across the country. A baby born in a Rural/Metro ambulance received a personal letter from Warburg, threatening to ruin its nascent credit if it didn’t pay close to $800 for its own birth. Another company, TransCare, owned by another private equity group called Patriarch, cinched down so hard on costs for NYC paramedics that they were stealing the equipment necessary to conduct runs.
If you’ve ever taken an introductory economics class, you’ll remember elastic versus inelastic goods. An elastic good is something relatively unimportant to people, something easily replaceable. It is called “elastic” because, if the price of good changes, it will drastically affect people’s willingness to buy it (its buyability moving around in loose circles like an elastic band). Imagine your cheap headphones break and you walk into a gas station to buy a replacement. If the gas station is charging $60 for a new pair, there’s no way you will buy them. But if the gas station is charging $1/pair, you will probably buy several pairs.
An inelastic good is the opposite; something that is irreplaceable whose price will not effect your willingness to buy it. The example that always stuck with me from Econ 101 is diabetes medicine. It doesn’t matter how much a drug company wants to charge for patented diabetes medicine, you will buy it. Whether it’s $1 or $10,000, patients will still scramble to get it no matter what, because they need it to live. To use idioms, the ultimate elastic good would be fire in hell; the ultimate inelastic good would be water in the desert.
The creators of certain inelastic goods are certainly entitled to cash in on their products (nobody would deprive Steve Jobs of his wealth, for example), but when people’s health comes into play, you move into very dangerous territory. Profit is meant to be an incentive for people to create value; value being a function of people’s happiness and wellbeing. Capitalism organizes society by rewarding those who create value. That calculation becomes warped when profit becomes more important than value itself, and if that occurs the economy will ultimately break down. Even Adam Smith acknowledged that capitalism is an imperfect system at its extremes:
Consumption is the sole end and purpose of all production; and the interest of the producer ought to be attended to, only so far as it may be necessary for promoting that of the consumer. – Adam Smith
Thus, Smith believed that certain institutions, like police, should be run by the public, because things like health and safety are values in themselves. The Hippocratic Oath is still used for a reason, because health is so intrinsically valuable that no contemporary laws are needed to interpret it. If banks don’t take the oath, how can we trust them with medicine?
Another way of thinking about it is that capitalism, like any system, is not natural law. Its play we put on, a general agreement that only works insofar as its intent is respected. Jack Ma illustrates this perfectly in a recent viral video,
When you have one billion dollars, that’s not your money. That’s the trust society gives to you.
Private equity groups that invest in emergency services have found the ultimate inelastic good. Who is going to refuse help in a dire emergency? In those circumstances, a consumer isn’t faced with a rational supply and demand decision. It is the exploitation of a non-good—something beyond what the market has the capacity to accurately attribute value to.
Abusing such non-goods in a market-economy is, in my opinion, the very definition of evil. It is to operate as a predator stalking your fellow humans; it dehumanizes them completely, reducing them to nothing more than potential assets to draw resources from. My reaction is the inherent, natural reaction that most of us have. It is the reason we despise Martin Shkreli, the banker who raised the price of an AIDS drug by 4000% simply because he could. It is the reason that private prisons, private enforcement of petty laws like parking tickets, and private fire companies make us so sick to our stomachs. One group of people is harvesting the rest of us like crops.
There’s another, deeper issue at stake here besides the obvious moral repulsion, which is that private equity companies are disconnected from the communities they exploit. Efficiency-obsessed corporate raiders have already driven out mom and pop restaurants, mom and pop drug stores, and mom and pop groceries and replaced them with national chains centralized thousands of miles from where they operate. If we get to the point where even our doctors and police officers are receiving their orders from a banker in New York City, then our communities have all-but ceased to exist. When your shamans work for Blackstone, your culture is dead. Not only will it have it lost its individuality, it will have been have been gutted of all the glorious fat that made it yours. If we are serious about understanding the recent mass backlash against globalization, perhaps this is a good place to start.
Besides seething in our chairs, can we actually do anything about this? Yes. We can lobby for a legislation banning predatory investment in emergency services, utilities, law enforcement, and health services in general. As far as I can tell, no such law is in existence, or has ever been proposed.
More broadly, what we can do is direct all of the disparate fury we feel towards each based on our identities—our blackness, our whiteness, whatever—towards the true enemy. We could stop writing off doctors as arrogant and indicting patients as entitled. We could stop blaming the wrong people and start blaming the right ones. And we better do it soon, because the people exploiting us at our most sensitive moments just started buying up our water…