Iss Not Fair!


One of my favorite movies of all time is The Big Lebowski.   There are so many great lines in it but the one that comes to mind for this article is below when the group trying to extort the Big Lebowski realized they weren’t getting any money from anyone:

Nihilist #2: Iss not fair! 

In this Forbes article, here is what Congress is doing:

When the Patient Protection and Affordable Care Act (“Obamacare”) was being debated, proponents were accused of saddling Americans with inferior and expensive health care while keeping generous coverage for themselves at taxpayer expense. To rebut that allegation and build confidence in the bill, a provision was added mandating that members of Congress – and their staff members – get their coverage through the new exchange system the bill set up. Now that the time to sign up for exchange coverage is nearing, a Democratic member, Rep. John Larson (D., Conn.), is saying that “this is simply not fair” – as key staff members head for the exits to avoid Obamacare.Politico reports that “many on Capitol Hill fear it could lead to a brain drain” and notes that “[t]he problem is far more acute in the House, where lawmakers and aides are generally younger and less wealthy.”

All I can say is that they are double standard pricks.   Oh, and let me end with how Walter responds to the nihilists:



Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  8 comments for “Iss Not Fair!

  1. arf
    June 27, 2013 at 12:52 pm

    How can Congress have a brain drain when they’re starting at zero?

  2. Pat
    June 26, 2013 at 12:23 pm

    This model has been tried, repeatedly, in the United Kingdom, France, Germany, New Zealand, Cuba, and of course, the good ol’ Soviet Union. And the results were the same every damn time, a lowering of the general standard of medicine, with the good stuff reserved for the government insiders.

    C’mon all you Authentic Medicine readers who supported the ACA – I know you’re out there. Tell us now, why you were right and all this mess will turn out any better than those previously failed outings. Come on, man/woman up and tell us how putting government in charge is ANY better than putting bloated third party insurance companies in charge. Damn you AMA and your support for a “strong and sustainable” Medicare and an expanded Medicaid, tell us all how any of that made anything better in the long run, once the money ran out. Those of you who were smarter than the rest of us told us that this would work, that you knew people would behave in ways you predicted. Well, are they???

    • J. R. Johnson
      June 26, 2013 at 4:33 pm


      Certainly we can have a discussion on the merits or foibles of the ACA and any other issue here amongst our colleagues and peers without pejorative, ad hominem, rhetoric can’t we?

      I for one am a supporter of the ACA and have no problems having a substantive discussion on the issue.

      First, a few comments on your missive.
      1) UK, France, Germany, New Zealand, Cuba, and the USSR are hardly a monolithic group of government healthcare programs. Some of the examples you listed own the entire system including the doctors and hospitals and some of the examples just control the funding to private hospitals and physicians.

      2) The results were definitely not “the same every time” and the results also clearly don’t show universally “failed outings”. The U.S. is behind countries like Germany, Israel and France is both quality of care and cost effectiveness of care on most metrics.

      3) “…good stuff reserved for…. insiders”. Yes, that is true of every form of government and is also true in every private industry. That insiders get an unfair advantage is hardly news and I don’t see how that is germane to a discussion of the ACA. If anything, kudos go to the government this time for trying a bit to mitigate the insider advantage. The silly complaining of Senator Larson underscores that at least this time it is a bit different.

      Second, a few general comments about healthcare in the U.S.A.
      1) The U.S.A is the only industrialized westernized country in the world where a legal resident can go bankrupt due to illness. I think this is shameful. In my opinion, there is a moral obligation that our government has to see to it that all legal residents have access to basic affordable healthcare. I went to medical school so I could deliver healthcare to those who need it, not to deny healthcare to those who need it.
      2) If we are going to force hospitals to take care of everybody regardless of their ability to pay, it is more sensible and cost effective to have everyone insured rather than to have cost shifting.
      3) The presence of a third party payor (private or government) system causes a disconnect from normal market forces in regards to access and pricing. Profiteering including over-utilization becomes rampant and costs go up.
      4) If the third party payor system was only private and was not forced by law to be inclusive of all patients, than many legal residents would be denied health insurance and would be unable to afford their healthcare needs (pretty much the system we had prior to the ACA).
      5). The government is the only organization with enough clout to insure that all legal residents do have access to basic healthcare. Our governmental leaders have chosen to do this by regulation of health insurance. In other words, the ACA does NOT nationalize or socialize the U.S.A.’s healthcare industry.

      Thirdly, some quick specific comments about the ACA
      1) It bears repeating- The primary goal is to have affordable basic healthcare for all legal residents. In my opinion, that is the moral and right thing to do.
      2). The ACA tries to find a way to keep the benefits (competitive innovations and cost efficiencies) of private industry while achieving the primary goal.
      3) I think the ACA is a good start, but there are real concerns about ACA in regards to costs. In my opinion, the ACA did not go far enough in two places- cost controls and malpractice reform.

      Those are just some quick comments- after all, I am an underpaid, overworked PCP.
      I’ll be glad to continue the discussion, on or off the blog, in a professional manner, if you so choose.

      • Tad Hominem
        June 26, 2013 at 9:42 pm

        well said, my friend. ACA is not a complete cure (being the result of a political process) but a start on a problem that had long festered. I am tired of hearing of “medical bankruptcies” and seeing signs for “benefits” being held to rais $$ for medical expenses for terribly ill people.
        I wish the debate could be conducted like this by all sides.

      • Pat
        June 27, 2013 at 1:13 am

        JR, glad to speak with you. Far from being ad hominem or pejorative, I stand by my remarks, insofar as I truly believe that the ACA is the latest result of decades of arrogance on the part of a great many physicians, as well as nearly all of government. I neither called names nor leveled personal insult. Okay, I did say “damn”… And so, to your points:

        1. The UK and France have struggling economies, their health care expenses annually increase, and both have recently discussed austerity measures in same. That cannot represent success. New Zealand continues to suffer a shortage of specialists as well as generalists (I can put you in touch with a close friend who recently worked as a PCP there for a year, for confirmation). Cuba has for decades had horrible shortages in many basic medical supplies, as did the USSR, despite many friendly reports to the contrary. In none of these nations have I ever known it to be reported that their health care systems improved their economies.

        2. I don’t believe the acclaim for the western European metrics and quality has been at all universal, and as for cost effectiveness, I return to my previous point re: economies.
        3. The article to which we both respond is an example of the government doing precisely opposite of that which you claim. Why would anyone think that this government would be any more benevolent or trustworthy than the next? Not germane? If the government is in charge, then those with government preference will get an advantage. That is the history of every government that has ever been – why would you think this time around its different?

        To U.S. health care:

        1. The actuality you reference is a sad one, I do not disagree. But I charge that it is worse so precisely because of government involvement, going back to WWII. Like you, I trained as a PCP, so neither of us expected to get rich. But that does not give either of us an inherent right to demand that someone else pay for our livelihood, which I have to say, is the case made by the ACA (and any societal expectation that employers have an obligation to provide health care).
        2. Your point here is valid in the present context – given the power, I would end EMTALA immediately as (again) a gross overreach of federal power.
        3. Right on! If we don’t want to further trust private insurance corporations – and they have caused great harm, I agree – why would we trust Uncle Sam, the biggest third party payor of them all? And so…
        4. …the ACA is only a continuation of the system set in motion at least as far back as 1965, since when government has fueled price inflation, bankrupting many and setting up an economic collapse in the near future. And no, I don’t wear a tinfoil hat (at least not at work).
        5. The government “clout” is force – and it will, very soon, complete the nationalization process.

        To the ACA:
        I do not think it is moral for some to vote to force others over questions of goods or services. Neither is it practical, hence your legitimate fears over cost overruns. I do not think it possible to retain the benefits of private innovation, as mixed economies over time always trend toward more centralized – therefore more sclerotic – control. My objections to the ACA are both philosophical and practical. It rests ultimately on the use of force – why else would it involve the IRS? – and as a result, it will fail. Oh it will be a great success in driving us toward a Canadian system, but it will fail to retain the individual patient and physician as anything but commodities.

        I’m glad to join in the friendly joust, ever professionally – Cheers!

        • J. R. Johnson
          June 29, 2013 at 1:49 pm

          Pat, Challenging your readers to ” ….man/women up…”, damning them if they are supporters of the AMA, and mocking their intelligence if they support the ACA would qualify in my opinion as pejorative and unprofessional. I’m glad we can now leave that behind.

          Lest you mischaracterize me, you should know that I am not a fan of large organizations and I am not a member of the AMA. I worked as an employed physician for 15 years before I successfully opened a private solo office where I very much enjoy taking care of patients with the help of my hand picked employees. In retrospect, I wish I had gone private sooner.

          That being said, sometimes a large organization is required to get the job done. I am sure that there are many examples we could both come up with where a large organization (either private or government) does a better job than a small organization could. There are many people who do well as employees of these large organizations and I respect the work that they do, I just happen to prefer the smaller organization work environment.

          In the case of healthcare, there is no network of private organizations large or small that will insure the healthcare needs of all or our legal residents. If one believes that basic affordable healthcare is something that all legal residents should have access to, the unfortunate reality is that only the government has the ability to do the task. I would liken this situation to that of national defense.

          To your assertions about healthcare and economics:
          1) Healthcare is a huge economic engine here and abroad. Shrink healthcare in any country and many people will be standing in the unemployment line. However, the primary purpose of healthcare is to deliver healthcare, not to create meaningless jobs just for the sake of Orwellian economics. The challenge for governments is to find the right amount of healthcare needed and to balance revenues and spending. I think your comments regarding healthcare and national economies are somewhat backward. Case in point, it isn’t healthcare which is crippling the Cuban economy, it is the Cuban economy which is crippling their healthcare.
          2) At first you say, “…the results were the same every damn time, a lowering of the general standard of medicine…” but I pointed out that is not true so you then reply with, “I don’t believe the acclaim for the western European metrics and quality has been at all universal…”. So you have changed your opinion from universally poor results every time to the acclaim not being universal. I’ll call that progress.
          3) I made no claim about government being “trustworthy or benevolent” (your words, not mine). Quite the opposite, I readily agreed that insider advantages are the status quo in both government and private industry. Our founding fathers, knowing that all governments can go astray, put in an elaborate system of checks and balances including the ability to throw the bums out with elections. I did say that Senator Larson’s complaining was an indication that things may be a BIT better with the ACA- apparently you misunderstood that as some sort of sweeping endorsement of the entire government. Let me be clear, I think government is necessary for a civilized society and because government does have the potential to go astray, it requires constant tweaking and oversight. I also believe, as a physician, that the ACA is an example of the government being on the right track and it will require tweaking and oversight to keep it on the right track.

          To the points about U.S. Healthcare:
          1) Really? Go back to the way medicine was in 1946? I too would kinda like to see nurses wearing those interesting little hats, but I would not want to give up so many excellent medical advances since then. An “inherent right to demand that someone else pay for our livelihood”?- I am not sure what you are tilting at. Everybody makes their livelihood from other people’s money. In very simplistic terms, that is what economics is, somebody sells and someone else pays. The ACA doesn’t force patient to come to my office, therefore I am not guaranteed a livelihood by the ACA. If your statement is a broadside against the concept of insurance, I would agree that insurance unfortunately causes problems, but I also believe it to be necessary.
          2) Seriously? You are okay with kicking granny with a broken hip or a child who was born with a congenital heart defect or any other patient with critical medical needs to the curb? Just curious, do you also think President Lincoln’s emancipation proclamation (which was prior to the passage of the 13th amendment) was also a gross overreach of federal power? I don’t really care if it was or not, it was the right thing to do. Likewise, in my opinion, EMTALA and the ACA are the right things to do for “We the People”.
          3) “…trust Uncle Sam”? Once again, your words, not mine. Let me restate it this way- We empower Uncle Sam because we need to, we watch him closely because we don’t trust him.
          4)”…government has fueled price inflation, bankrupting many and setting up an economic collapse in the near future”. Are you referring to healthcare in particular or national economics in general? Either way I am curious why you chose to focus only on bankruptcy and not mention the great many healthcare workers (including you and I) who have made their livelihoods (and some fortunes) in the healthcare industry. Economic collapse?- yup, gotta get those revenues and spending columns to balance. I think adding cost controls to ACA is important on the spending side, and I also would support payroll taxes, as is done in Germany and Israel, to help on the revenue side.

          In regards to your contention: “I do not think it is moral for some to vote to force others over questions of goods or services.” Voting to force an issue is exactly what any democratic government does by design. As a citizen I am forced to pay my taxes, some of those taxes go to fund things that I disapprove of. I have chosen to accept this deal because I like it here. Those who don’t like that deal can try to immigrate to some place they like better. Somali currently has no government and I hear that seaside real estate there can be a real bargain.

          Best regards,

          • Pat
            June 30, 2013 at 2:21 am

            JR, it seems that in every instance you tend toward a reliance on government. Yes I too make money off of government, because that is the system left me by my forbears. Cost controls added to the ACA will worsen the shortages already coming to fruition; adding more taxes is merely more force. I disagree that choosing less government is tantamount to anarchy (Somalia, indeed!) and it is certainly the central planning of a Cuban economy that leads to shortages in sub-component industries such as health care, or toilet paper.

            Health care as delivered by government – with ICD and CPT codes, core measures, JCHAO and HIPAA delights, P4P, mandated EHR’s, a great portion of Medicaid-services, and the notion of “sustainable” Medicare, as examples – I believe to be systemically dishonest, insofar as it purports to be about the patient and physician in the Hippocratic tradition. I’m not tilting at windmills now, just suggesting we call it what it is: we’re another special interest group, vying for a spot at the trough.

            As for Lincoln – sigh – the “rightness” of the Emancipation Proclamation really didn’t matter. He had already grossly exceeded his offices by invading the South. So that was a precedent, for some, of the expediency of force, allowing these latest achievements. Any moral underpinning the North had was that of securing the liberty of the individual against an oppressive majority, something surely at odds with the structure and execution of the ACA.

  3. Chris Knox
    June 26, 2013 at 8:40 am

    The Dude: (Hey Congress) How about we just give you all the money we have on us?

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