med27I write this blog for 3 audiences. Many of these posts are written for the lay audience. Someone will ask me while mowing the grass about ebola or chikungunya fever and I will provide my (not so) learned opinion in blog form. My friends then access my deep thoughts through Facebook so that at the next cocktail party the conversation goes like this:

Friend: I read your post about chikungunya fever

Me: Chick-a-what?

It seems I have a short memory.

Another audience I write for is folks who make policy. I have a small following of people who actually have some influence. When I write about access to care for Medicaid-gap Alabamians (my favorite subject), insurance monopolies, or the fact that a certain legislator is both against Medicaid expansion and for trying to insert a phrase into a law that takes money away from Medicaid and puts it into a client’s pocket that is the audience that I’m writing for. So, after writing a blog like that, a conversation might go:

Person in position of authority: Who is this Perkins character?

Person who actually knows me: Some commie, I suppose.

Lastly, I write for students of family medicine. In my day job, I run a department of family medicine. This means that I am involved with teaching medical students (most of whom will not go into family medicine) and resident physicians (almost all of whom will go into family medicine), seeing underserved patients (who likely do not know they are seeing a family physician), and supervising faculty physicians (ALL of whom know what they do and let me know about it ALL the time). This blog post is for this audience (but all of you others feel free to read as well).

This past week, the president of the American Academy of Family Medicine, Dr Robert Wergin, announced that Family Medicine 2.0 has arrived. Why the reset? As Don Berwick and T.R. Reid point out at the accompanying press conference, we in family medicine have been working on changing the way we do business since 2000. Meanwhile, the rest of the the medical-industrial complex, not so much. In the words of Dr Berwick, the time to change healthcare is NOW.

What we as a specialty have committed to  is this:

  • Give patients the care they need when they are most vulnerable
  • Care for patients regardless of age and health conditions, and work to sustain an enduring and trusting relationship with them
  • Be each patient’s first contact for health concerns. Address all their health concerns, and resolve most of them
  • Help patients with preventing, understanding, and managing illness
  • Navigate the health system with patients, including coordinating with specialists and staying connected with patients before, during, and after time spent in a hospital
  • Set health goals that adapt to each patient’s needs as defined by them
  • With the care team, use data and best science to prioritize and coordinate services most likely to benefit patients’ health
  • Use technology to maintain and enhance access, continuity, and relationships, and to optimize patients’ care and outcomes
So, medical students, you are on notice that you need to leave our rotation knowing that this is who we are. Residents and prospective residents, you will be held to this standard. Patients, this is our promise to you. Faculty, we have some work to do.

63514_cartoon_mainNews item: An airplane in Birmingham is detained because a passenger threw up (into a vomit bag, I hope) and, not being clearly Caucasian, concern was raised among the crew about EEEEE BBBBB OOOO LLLL AAAA. Two hours later, the fellow passengers were allowed to deplane and the poor, sick Jordanian (home to no Ebola) who had a layover in Turkey (also straddling two continents without Ebola) was allowed to go to his destination. I hope to take his Zofran and suffer in peace.

News item: A woman in Mobile, Alabama who has lived in this country for seven years BUT who had visitors from the Congo ( in east Africa, where no Ebola is but sure sounds like Ebola should be there) was transported via ambulance (with roads blocked off in case the Ebola jumped out, I suppose) to a local hospital where, upon taking an effective history, the patient’s lack of Ebola was confirmed. Who paid for the ambulance ride was not discussed.

It has been a long time since we have had a good pandemic scare in this country. A pandemic, typically caused by an infectious agent, is notable for  its ability to cross over country boundaries and in general wreak havoc.America tends to be protected because of our size, limited number of international boundaries, and  public health infrastructure. The last really good pandemic we had was the “Spanish” flu which was blamed for almost 700,000 deaths in the US. The stories from that era consistently identify the randomness of being stricken as a dominant feature (person gets on the streetcar healthy and at the end of the line is found dead). It is the randomness of being afflicted that seems to create havoc as much as anything else. When a pandemic comes, there are often voices prematurely calling for closing the borders and the schools. Way back in 2009-2010, the public health officials were able to resist such calls when swine flu came. They were able to vaccinate the population and keep public concern to a minimum through creative use of media. They were also fortunate in that the case mortality rate was 1:2000 (as compared to 1:40 for the Spanish Flu and an apparent 1:2 for Ebola).

American reaction to pandemic risk can be constructive. For example, it was a measles epidemic in 1989 to 1991 that led Congress to change the way vaccines were distributed, creating the Vaccines for Children program. Maybe some day we’ll look back and see improved infection control in our hospitals in response. For now, my current hope is that the media, medical establishment, and all branches of government will act responsibly.

Some facts about Ebola:

  • As of today, there are 0 deaths of American citizens from this virus.
  • It is only transmitted through blood and body fluids of a person with a significant infection. People who are contagious are REALLY SICK. Don’t be afraid of the not so sick ones. Casual contact with a person will not infect you if there is no blood or body fluid transmission. If someone looks sick and you happen to touch their skin, hand sanitizer is likely sufficient protection
  • It is found in the semen of people who have recovered for 3 months. It is wise to avoid sexual contact with men who have a questionable illness history (likely always wise).
  • Avoid eating bats and monkeys (especially ones found already dead)
  • Avoid hospitals in West Africa. They don’t have enough gloves. In fact, get a flu shot so you can potentially avoid health care workers completely

Interestingly, Shep Smith on Fox News makes the same points…go figure.

'When did you first notice your timbers were shivering?'I get the New England Journal of Medicine (NEJM) delivered to my home. I know, I know, it is so 1980s to read a journal in paper form (ok, even to read a journal) but I enjoy browsing the most current science and sometimes retain a factoid that later might be useful. I still remember the time I read the Clinical Pathological Conference about a person with confusion and thrombocytopenia (low platelets) where the diagnosis turned out to be thrombotic thrombocytopenic purpura (very rare) and darn if a person with that exact same presentation didn’t call me about a month later. I, the junior resident,  called the hematologist who was at a party and he said something to the effect of “Yeah, right, what do you know…” I elected not to say “I read the New England Journal of Medicine, sir.” Instead I cited all the evidence without mentioning the NEJM article and he agreed with my diagnosis and came in. The patient survived without knowing that her life was saved (or at least the diagnosis was made in a timely fashion) because I got a journal and actually read it.

Many of the diagnoses for those complex cases in the NEJM hinge on an unusual piece of history. Typically, that history is not in the story of the illness (in doctor lingo, the HPI). A fever that starts a week ago is pretty much the same whether it is the flu or malaria. Instead, the clue is in the family or social history. “The patient reports swimming in a waterfall pool in Hawaii” would make me think “leptospirosis” (an infection carried by rats and spread through their urine, typically in large concentrations in the stream above the waterfall…kind of makes you think twice about those movie love scenes, doesn’t it). Part of the job of the health care team is to gather the correct information and synthesize it, keeping the valuable information (swimming in a waterfall pool) and discarding the red herrings (wearing a blue bathing suit). Part of the fun of medicine is to put things together and make a diagnosis so as not to miss a NEJM moment.

Although the details are sketchy, apparently someone in Dallas missed their NEJM moment and is blaming the computer. If you have not heard, Thomas Eric Duncan, a Liberian national, got on an airplane feeling well in Monrovia. He then flew to Brussels, Washington DC, and ended up with family in Dallas. When he started to feel ill, he want to the Emergency Room. At the time (5 days before he got really sick) he had some fever, body aches, and in general wasn’t feeling well. This is where the facts become murky but clearly the moment was missed. Even a doctor, half paying attention (“Ok, so any travel? New pets?”) should raised an eyebrow when a person with an accent says “Well, I did just get in from Liberia.” Reading between the lines of the Slate article, the hospital apparently assigned someone to take a history and enter it into the electronic medical record (perhaps to save the clinician time). Thus, “travel to Liberia” was buried in the record.

Doctoring is very expensive and interpreting symptoms is often unrewarding. Of 1000 people with fever, 999 will have something self-limited. This is especially true in America, where many infectious diseases have been eliminated. There is something, however, to be said for inefficiency. Every now and again, what one person thinks is a red herring (just where is Liberia, anyway) another puts into a pattern and prevents an epidemic. Doctors have got to want a NEJM moment enough, though, to pay attention.

1_123125_123050_2279896_2300573_2302170_3_lineup.jpg.CROP.original-originalDoes the money to pay for this come from taxpayers held at gunpoint?

Comment on a forum about an upcoming meeting on the need for Medicaid expansion

Long answer: I am serving on a panel in Fairhope, Alabama to discuss the need for Alabama to accept the Medicaid expansion. Fairhope is a Victorian resort town on the bluff overlooking the Eastern Shore of Mobile Bay, about 30 miles from where I live. The town itself was first known as Alabama City but a group pf 28 folks from Des Moines, Iowa, purchased land in the area in 1894 and created a single tax colony:

The people who established Fairhope wanted to create a community that would, as best they could, implement the theories of economist and social activist Henry George. George wanted government to tax the full rental value of land, the value of which is created by community improvements and not by labor or invested capital. He felt that if the full rental value of land were taxed (including minerals under the land) that all other taxes could be abolished, thus becoming the single tax. Others termed his theories the Single Tax, and the name stuck.

The single tax corporation collects all taxes associated with property due to state and local governments and distributes them as well as administration and demonstration fees. These fees go to things that raise the value of the property for all. These projects include bayfront parks, a pier that goes a quarter mile out into the bay, the library, and many others. The Fairhopeans do indeed get value for their housing dollar. They also get waterfront parks.

The state share of Medicaid in Alabama is not paid for by a tax on property. In fact, very little of the tax dollars the state actually collects are used to pay for healthcare for the poor, as I have previously outlined. Though the people of Fairhope may want further the common good, averages Alabamian seems much more concerned about keeping their hard-earned in their own pocket. As such, they are seemingly willing to forgo 30,000 jobs and hundreds of millions of dollars of federal money to keep their own, personal, income taxes from going to someone who is undeserving. In the words of one commenter “Why should I work anymore if the government will give me everything I need?”

So, I will go and spread the word to the gentle socialists of Fairhope of the reality that corporations look for good community health when they relocate, along with the concern that, since the mechanism to fund poor people who become sick has changed, we are getting LESS federal dollars as a consequence. I feel certain that those in the room who are true Fairhopeans will see the need for them to look after their brother and, given that the federal dollars going into Medicaid ARE OURS ANYWAY, will nod their heads in agreement. I despair of convincing the people of the rest of Alabama that poor people are folks who get sick anyway, need care to prevent illness, and Medicaid is the only mechanism to provide that care. I can only hope they remember the wisdom of the Fram oil filter man, “You can pay me now, or, you can pay me later.”

cartoon9I have to remember that I’m an officer and when I give a Marine an order they will obey no matter what. When I use the tonometer and say “don’t blink” I had better remember to follow up with “blink” before they get dry eyes.

Conversation with a Navy Optometrist

I remember fondly my time being a doctor to the Marines. Wet behind the ears, eager to hone my craft, suddenly given superhuman abilities such that with only an internship I could function independently in a remote setting…oh, wait, that last part didn’t happen. Fortunately there was, on the base with me, a wizened old doc (I think his name was Wenzel) who had practiced in rural Kentucky prior to going back and studying pediatrics. His counsel was always wise and when distilled down often ended up being “When in doubt, turf it out.”

We were at a fairly busy ambulatory clinic and urgent care center in Kaneohe, Hawaii. All of us took call. I remember making multiple trips to the civilian hospitals to transport patients. The active duty dependent and military retiree patients had to pay quite a bit out-of-pocket if they used the civilian facilities without consulting us first. We used to get folks driving PAST the civilian hospital to come to our ambulatory dispensary having heart attacks (I can remember one dying on the H-3 while in the car, wife driving 80 miles an hour) and  respiratory arrests (one of the most harrowing ambulance rides of my life, ever) in addition to the assorted 21-year-old Marines who never failed to learn the lesson that alcohol renders no one invincible. The lessons I learned there about the limits of an ambulatory practice setting, the triage and transport of sick people, as well as the health risks folks will take as they try to save a buck,  have stayed with me for 25 years.

I also learned some very concrete lessons on practice organization and care delivery. First, we had a very robust quality assurance program and worked hard to create a culture of quality and safety before it was fashionable. Second, against the wishes of the base commanding officer who wanted to have “his own hospital,” any attempt to be who we were not (a small ambulatory presence designed to get folks the care they need when they need it) was resisted by folks above my pay grade. Third, the Navy was experimenting with nurses in charge of practices such as this and I was extremely fortunate to work with several very good Nurse Corps OICs and learned to work as a member of a care team.

The military is a unique practice environment. The emphasis on readiness as well as wellness provides lessons for all of us in healthcare. Unfortunately, military medicine may be in trouble. The remote locations, providers who may not be invested with tours of only 3 to 5 years, and inexperienced physicians who are moved rapidly up in rank based on medical training apparently has led to problems.  The New York Times has recently published a story highlighting the downside that is worth a read. I was most struck by the quality and safety problems highlighted in the article. Physicians are apparently being placed in small hospitals with skills ill-suited for the location and/or patient population and attempting to provide care comparable to what they learned in their training. In addition, data aggregation techniques now used in the civilian world to assess quality and improve care are not in common use in the military hospitals. Leadership positions are being given to physicians who have a high rank by virtue of their residency training but limited real world or even military experience. The military is not entirely to blame. When they try to consolidate hospitals or provide care in a different fashion they are obstructed by the community, who uses their congressperson to keep the jobs local.

Our troops and their families as well as those who have retired from active duty have the expectation of high quality and safe healthcare, as does the general public. We need to equip all physicians with the skills necessary to practice in the environment in which they find themselves. Surgeons in isolated areas need to focus on doing small procedures well and leave the complex cases for hospitals with teams to provide care, whether on a military base or in rural Alabama. We need to teach how to assess and incorporate meaningful quality and safety practices starting at day one of medical school and not assume competency by virtue of a residency training certificate. The Milestone project seems to be a good start at making sure this happens at the residency level. Lastly, we need to teach leadership. Physicians are expected to be leaders. It’s time we give them the tools to do it.

“And the illusion posted to the feds is that there is a range of options available. And it seems to me that BCBS is basically using the Obamacare turmoil as a cloak for forcing everyone into higher cost plans (and blaming it on the federal law). And, well you know all that. But still.” e-mail from Bill

The system I work for charges about $120 for an office visit to those who are uninsured (increasingly the poor in Alabama). I am an “in-network” provider for Blue Cross of Alabama as well as other insurance companies. This means that I have agreed to accept payment of less than $120 from patients (typically $60 for a routine visit)  in exchange for them referring people to me. The payment generally requires the patient to cough up about $25 up front and me submit a bill (costing my practice about $10) to collect the other $35. The difference between $60 and $120 I never see and is referred to in the office as an “adjustment.” Pre-ObamaCare, I could be fairly certain that if I submitted the bill to Blue Cross I would get the $35. In addition, as an in-network physician if I ordered x-rays or blood work it was paid for no matter where the patient went to get it. If I had a lab in my office I would get paid but, since I don’t, we have a LabCorp draw station in our building. The patient walks 50 feet and stick an arm out and I get the lab results in my electronic health record.

In the post-ObamaCare days, things are a little trickier.ObamaCare required  insurance companies tell tell us a little more about what we are paying for. Remember the list of essential services? When you pay your premium there are 10 things you are supposed to get. No fine print, no bull. One of the 10 things is Laboratory Services. My friend Bill, who is self-employed and purchased an individual Bronze Plan policy (low monthly, high deductible), had an illness. His policy was through Blue Cross of Alabama. He went to an in-network physician who took 50% of what the cash payment would have been (and paid $10 to get some of it from Blue Cross). In good faith he was sent down the hall to get labs (a covered service). He just got his lab bill for $200 which is the full freight, cash price. No adjustment, no Blue Cross portion. My friend Bill, we now know, is virtually uninsured for Labs (and a bunch of other stuff as well).

Here are the fun activities you get to learn about if you have a Blue Cross Bronze plan.  Your money no longer pays for someone to negotiate rates for your labs, x-rays, or surgeries. Better sharpen your negotiating skills.  For you Bronze plans holders, they’ve already negotiated an exclusive contract with Quest who will gladly schedule that stat CBC in Foley, 25 miles away, on Wednesday (true story). Want something a little more convenient, pay full freight. You need a little minor surgery or even major surgery?  My friend Bill will get to employ one of two strategies. The first is to do what he can to get the costs as low as possible. The second will be, rather than worry about the $5 aspirin,  to forfeit his $6000 deductible up front and ask for the single room and steak dinner, secure in the knowledge that they can’t hurt him more.

Turns out that Blue Cross Silver is the plan to get in Alabama, by design. For the extra $81 a  month you pay to Blue Cross, here is what you DON’T have to do. If you need an X-ray, CT, MRI or any other imaging, you DON”T have to negotiate the price yourself. You will pay only $300 a test, no matter how expensive the test is. If you need a lab, you DON’T need to drive over 25 miles to have it done. and then ask them to only process your blood in a single lab in the state. If your in-system doctor orders it, Blue Cross will negotiate for you to get the best price possible from LabCorp or whomever.  You need a little minor surgery or even major surgery? You Silver slackers DON’T need to negotiate the anesthesia fee, surgeon’s fee, or operating room costs.

This likely isn’t tomorrow’s problem. Even with the limited price pressures in the Silver plans (by far the most common), the prices in most states are less this year than they were last year. What this illuminates more than anything else is the crazy and perverse incentives that are currently incorporated in our health care system. We in health care set our prices crazy high and let Blue Cross or some other insurer reduce them arbitrarily. The bill for surgery includes $5 aspirin and $3000 MRIs, prices that no one is expected to pay. Look for the pricing structure to change dramatically in the next 5 years with many things getting bundled together and much greater transparency. Meanwhile, Bill, I understand Humana is looking to compete head to head with Blue Cross in Alabama. You may, however, want to find out which lab they use first before changing.

ÒDaddy, can I stop being worried now?ÓText from my daughter “Should I worry about Ebola”

Text back from me “Are you considering moving to west Africa?”

My first class in medical school was in our freshman auditorium. The Dean (or someone who looked old, must have been about 50) came up to the podium and said: “This is a great time to be a doctor. When I was sitting in your seat, the person at the podium had us look to our left and to our right and then said “Of the three of you, one will not be here by the end of the 4 years because of tuberculosis.” You, fortunately, do not have to worry about that.”

Tuberculosis, I thought. What the heck is that and of course I’m going to worry about it (I remain uninfected to date).

When I was a third year medical student, AIDS hit New Orleans. I remember being on an infectious disease rotation and going into the emergency room where an emaciated man with blue tumors (Kaposi’s sarcoma, I now know) all over his body was in “isolation.” The isolation, in this case, was no one placed in the bed next to him (it was an open bay ward) and yellow CAUTION tape placed across the entrance to the bay where he had been placed. My attending, who remains a role model to me, tore the tape down and said “Whatever you THINK you are doing with this tape it is accomplishing nothing except dehumanizing this person who is ill.” The patient died. None of us on the health care team became ill.

Ebola virus is the latest illness to capture the public’s attention. Confined to west Africa unless those ill are transported, it has claimed the lives of 1427 people, about 10% of whom are health workers. Apparently my daughter’s text was prompted by the news reports associated with the transport of the American physician to Atlanta. Spurred on by movies like “Outbreak” and breathless news reports from Dakar by Ofeibea Quist-Arcton (pronunciation found here), folks here are concerned WAY out of proportion to what they should be (unless their neighbors are west African health care workers who just got back and appear mighty sick). Americans should worry about a lot of things: their diet, their lack of physical activity, their use of tobacco and guns. “Ebola” should be appear on the list below “death from bee sting” (100 Americans annually)

Turns out that Ebola is big news because people tend to make many decisions based on feeling and belief rather than based on a calculated risk assessment.  Psychologists have coined the term “Dread Factor” for the combination of

  • perceived lack of control,
  • catastrophic potential,
  • fatal consequences, and
  • the inequitable distribution of risks and benefits.

Ebola (0 deaths in America) hits the sweet spot. We humans worry more about what we can’t control, especially if the long term consequences are unknown, the potential risk is believed to be high, and there is nothing we can do to mitigate it. In “Perception of Risk Posed by Extreme Events” Peter Slovic points out that, probably as a result of eons of programming, we worry excessively about things such as a satellite falling out of the sky and hitting us (0 human deaths so far) and worry very little about backyard swimming pools (10 Americans die A DAY). Makes setting public health policy difficult. If you don’t believe me, look at the backlash regarding Michelle Obama’s healthy children initiative to reduce obesity (1375 American deaths A DAY).

Fine, you say, I know that smoking is unhealthy. What I don’t want to do is die from Ebola.What can I do? Turns out, a lot.

As a health care consumer, make your concerns known. If not dying from Ebola is the most important thing to you, let your doctor know. He or she might suggest something simple, like avoiding travel to the remote villages of west Africa. Meanwhile, take some time to understand why worrying about other elements of your physical well-being might be more useful in the long run.

As a health care professional, don’t just dismiss your patients’ concerns. Listen to them and provide information about why these fears might be unfounded. By the same token, don’t take advantage of your patients’ irrational fears. Providing excessive testing is expensive and often is less helpful than a frank discussion on risks.

We humans react instinctively (on feelings) and intellectually (based on rules and empirical evidence). We often make decisions based on feelings (I am unsafe and need a gun) that run counter to evidence (a person with a gun is 22 times more likely to kill a family member than a bad guy).

As physicians, much of what we do (and don’t do) affects health in a limited fashion. Perhaps we need to get better at helping people to overcome their own barriers to achieving health instead of offering tests for scary things we know aren’t going to happen because “the patients want them.”

I am taking a summer away from some of my daily and weekly tasks to focus on other things. I am spending my time helping to redesign our healthcare system to prepare for the transformation of Alabama’s Medicaid into an Accountable Care Organization which is scheduled to occur in 2 years. This will take a lot of effort on the part of a lot of people to accomplish but in the end an effective Medicaid program is something that we in Alabama need.

I have written this blog, in part, so others will take up the cry for affordable, accessible health care for America. Although the ACA is not perfect, it is the law that we have. I am heartened to see others take up the mantle. In today’s newspaper, two UA-Birmingham medical students have written an essay asking the people of Alabama to see past their prejudices and support the expansion of Medicaid based on their experience volunteering in a free clinic.They use the case of Ms C, a woman who suffers from difficult to control blood pressure and no insurance, to illustrate the need and then close with:

As Alabama continues to refuse Medicaid expansion, we witness the fallout every Sunday. For all of us, it is frustrating to think about how a preventable illness such as Ms. C’s high blood pressure, can cost so much for our healthcare system and for an individual’s well-being because it went untreated.

As care providers at the free clinic, we must swallow the hard realities of the current healthcare environment and watch our patients do the same. As future physicians, we worry about practicing in a state where the most downtrodden among us are overlooked. And as your fellow Alabamians, we hope that this state will prove to be one that looks past ideology and supports our neighbors in their toughest times.

Rethink coverage. Expand Medicaid.

Have a productive summer.

News item:



On the NPR show “Wait, Wait, Don’t Tell Me” when this item came up one of the panelist suggested that this was an evidence-based decision. Perhaps a study of homeless people had been done and they had all sung the “Crayon Song” one too many times. Big audience laugh…

As a parent, we want a lot for our children. We want them to have a good life, to work hard but not too hard, to enjoy beauty and the company of others, and to have a family of their own to torture them like they tortured us. To this end, schools function to provide content that our children need to learn but also contribute to the rest of this as well. By ignoring any outcomes but college acceptance, we diminish the other aspects of education.

The two pillars that predict community success are educational and health care infrastructure. Measuring both has been fraught with peril.  Like Justice Stewart said about pornography, we know good schools and good healthcare when we see it. Unfortunately, that metric, like pornography, is difficult to quantify. In the Mobile   public schools that my children attended, there was a metric of “total scholarship money offered.” This was a particularly weird metric that encouraged the students to apply to colleges they had no intention of attending so they could receive a reportable scholarship offer. The healthcare metric, “Providence Hospital is MY hospital” is likewise not a good metric. If you go to the government’s hospital compare website (found here) you’ll swhat are good metrics.

Commonwealth has just come out with the latest report on the state of our county’s health (found here). We as a community once again fared poorly. Out of 306 health regions, we are listed at number 270. Of the 43 metrics that are used to assess our health system’s performance, we were excellent in one and very poor in 13. We were rock bottom in 3. What are we best in? Nurse response to call lights and home health wound healing. We are rock bottom in preventable mortality (people dying early) and people who have lost 6 or more teeth.

Mostly, it turns out that good schools reflect a critical mass of motivated parents who are willing to pay extra to attract good teachers and work harder to help their children achieve. When that happens, the halo effect tends to help others to achieve as well. Health care quality, it turns out, also is dependent on insurance status, educational attainment, regional income, and engagement of people in their own health. To improve education or health care delivery, it takes a village.

People want to live in areas with quality education and healthcare. I can only hope we can find a metric other than early ABCs to measure kindergarten quality with.  I also hope that our doctor governor accepts the health care metrics and charges us to work together to improve them, rather than force us to live in denial and in a broken system.


Libertarian-LifeguardsWhen I was a child there were only 3 channels on the television (and yet, folks found something to watch, go figure). One of the commercials that it turned out was foreshadowing for the loss of our textile industry to Chinese sweatshops was included a catchy song that went “Look to, the union label, when you are buying that coat, dress, or blouse.” We as kids would sing it as our mothers took us to the discount store to purchase knock-off tee-shirts for half the price of those high-falootin Jockey ones. Although they were clearly of poorer quality (and the tags itched) they did cost a lot less.

In America today, goods have become fungible. The source of origin is unclear, in part because Egyptian cotton might go to Bangladesh to create a tee that has an American rapper’s face on it. Since I work in a service industry with access limited by licensure, I don’t worry about outsourcing. Here in Alabama, though, there are a group of economists who want to change that.

Troy University’s Manuel H. Johnson Center for Political Economy, which I have written about before, has decided to take on Alabama’s licensing laws. Daniel Smith, professor of Economics, has published a “study” where he determined that 25% of Alabama workforce being required to have an occupational license is too many. Health professionals are one of the groups he singles out for his bureaucratic reduction act. In doing so, he cites a position paper from the libertarian leaning Cato Institute that argues 1) Defensive medicine is what protects you from incompetent physicians, not licensing; 2) Defense lawyers  are actually quality control monitors; 3) Specialty boards provide more quality control; and 4) People would pick quality over price if given enough information.

What bought the study to my attention was “Koch Brothers endowed professor” Scott Beaulier’s, editorial at It includes the circuitous argument that licensing limits the supply which limits access so more people get sick, and if only we could expand access by allowing unlicensed health workers there would be fewer sick people. Huh? He claims that once one person’s house wired by Bubba the shade tree electrician burns, others will shun Bubba and he’ll go out of business. Same thing for doctors, I guess.

In the 45 years since the commercial, unions have lost almost all of their sway. Americans demand clothes made so cheaply and with so little regard for those involved that when we find out 800 Bangladeshis are injured annually while making $7 tees we shrug and continue to seek out even cheaper options. I look forward to the Libertarian state of Alabama where we all get to be quality monitors. As they say on the Simpsons, “Hi Dr Nick…”




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