"Barefoot Doctors" in America?

We've had another reaction to our article claiming that there's really only one problem in health care - the issue of limiting demand.

With the development of so many extremely expensive medical procedures, there's no limit to the amount of health care a person can want; we've documented some of the economic effects of a system in which treating one illness can cost more than the patient can earn in his entire life.

An earlier reader objected that our depiction of the medical costs imposed on society by a friend who didn't pay for health care wasn't credible because it was hard to believe that we knew a welfare recipient well enough to comment on the welfare lifestyle.

The latest reaction pointed out that one datum does not a trend make and that just because we know a person who abuses the system didn't mean that such abuse is widespread.  In addition to pointing out flaws in our reasoning, this reader also outlined a conceptually simple approach to reducing the cost of medical care.

A Modest Proposal

This idea is a based on the well-known fact that the administrative expenses and paperwork required when a hospital bills an insurance company for medical procedures accounts for 30-35% of overall medical costs.  The reader pointed out that eliminating billing would reduce medical costs by 30% right off the top.  He suggested that emergency room care and walk-in care be provided free.

He responded to our incredulity by pointing out that there was a time when firefighters worked for for-profit companies, hence the origin of the term "fire company."  Households who wanted fires put out paid an annual fee.  If a fire company was called to a building which lacked the medallion which indicated that they'd paid, they'd watch the edifice burn to the ground while making sure that nearby buildings whose owners had paid weren't damaged.

Just as we no longer expect people to make individual arrangements with fire companies and pay for fire protection out of general tax revenue instead, my friend said, we ought no longer to expect people to make individual arrangements with providers of simple emergency medical care.

He wasn't advocating a full-scale single-payer system as in England and Canada, he was suggesting that only procedures that could be handled on a walk-in basis be provided free.  Everything else would remain with the current system.

If you could get to the emergency room and they didn't check you into the hospital, care would be free.  If they had to bring you in an ambulance or admit you to the hospital, they'd run the meter and bill you.

Handling Local Problems Locally

The more we thought about this, the more plausible it seemed, particularly if the municipalities which tried this adopted a page or two from the "Barefoot Doctor" program.  The Chinese "barefoot doctor" program was based on the realization that around 90% of the injuries and illnesses that were encountered in a community could be handled locally at low cost through minimal training.  The phrase "barefoot doctor" came from the fact that most rice farmers in southern China went barefoot in the paddy fields; the name indicated that a person need not own a pair of shoes to be eligible for medical training.

Barefoot doctor training lasted from six to 18 months and focused largely on preventive medicine and on the diseases and injuries which were common in the area.  Graduates were familiar with a small number of drugs and herbs that could deal with local conditions; many of them grew herbs and medicinal plants themselves.  A large part of their training dealt with recognizing when a disease or injury could not be treated locally so that the patient could be sent elsewhere.

One of the less frequently discussed reasons for the high cost of our medical system is that the various state and medical associations have used their political clout to make it illegal for anyone who's not an MD to prescribe any treatments, no matter how obvious.  This forces all medical incidents, no matter how trivial, to boost the income of the most expensive people in the system.  By recognizing that simple conditions could be dealt with by people with a whole lot less training than medical doctors receive, the Chinese system provided health care at much lower cost.

It's easy to forget that the laws of supply and demand apply not just to salable manufactured goods, but to services as well, and specifically to the providers of those services.  If there are more people able to provide medical services, but the demand remains the same, the cost will be driven down.  By restricting medical practices only to people who possess fantastically expensive and time-consuming medical degrees, the supply is restricted and the cost driven up.

Now, naturally, we don't want just anyone providing medical treatments.  The last thing we need is more quacks and phonies.  But it's proper to re-examine exactly what sort of treatments could be provided by a person with medical training, yes, but not a full MD.

Some medical practices are already attempting to take steps in this direction; many primary care offices now use nurse practitioners as front line medical staff.  If you really do need to see an MD, there's one available; but if all you have is the sniffles, the nurse practitioner is perfectly adequate and, being cheaper, will probably pay more attention to you than an MD would.

Carry this logic far enough and tremendous cost savings become apparent.  There are innumerable prescription drugs and a fully-trained MD needs to be familiar with most if not all of them; but there are relatively few drugs that are prescribed frequently for the most common conditions.  A doctors office staffed with, say, 12 nurses trained to identify and prescribe for the most common complaints, 3 nurse practitioners with more complex training, and one full-on MD would be able to take care of enormously more patients at far lower cost.

Not the Holy Grail

This idea isn't the answer to all the issues in our medical system. Given the fact that free services tend to be abused, it might be a good idea to have a nominal co-pay of $5 or $10 per adult visit, but that's a detail.  The overall concept of allowing simple conditions to be dealt with cheaply by a person with only enough training required to hit the most common complaints and the ability to refer patients on for more specialized care if required has a certain appeal.

But most of all, this underscores the real source of America's health-care woes, which is almost never discussed by politicians: not the lack of health insurance, nor the lack of access to care, but the egregious cost of medical care which is brought on by over-regulation.  Lower the costs and the other problems will take care of themselves.