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John Livingston

Bigger is Not Always Better

Everything is getting bigger. In my profession, the doctor-patient relationship has been all but destroyed by “vertical and horizontal integration” with hospital systems buying up medical practices and then employing physicians and physician assistants and nurse practitioners. Then the hospital systems are bought up by insurance companies or vice versa, and then the mega company gets bought up by Amazon, Microsoft, or a venture capital company. Sixty-six percent of revenues come from government sources—Medicaid, Medicare, VA, Tri-Care or the Indian Health Services and medical decisions are made by “experts” from the National Institute of Health (NIH), the Centers for Disease Control (CDC), The Center for Medicare and Medicaid Services (CMS).

In the case of Medicaid, transfer payments to these large mega companies are distributed by state government agencies that are charged with regulating those companies. Is it any wonder that the system is ripe for corruption. Since The Affordable Care Act (ACA), physician productivity as measured by the American College of Surgeons (ACA) has decreased by 15%. Hospital administrator salaries have skyrocketed—we have recently had a hospital CEO retire after receiving $18million his last two years. According to IRS Form 990 filed by St. Luke’s. Patients are assigned to a “medical home”. Most of us don’t have a doctor, but a “team” as an entree to the health care system. Once in the hospital with a critical condition we are assigned a “hospitalist” or an “intensivist”, who works an 8–12-hour shift. Ask a hospital patient or their family who their doctor is, and they can’t tell you. Process has become more important than the relationship. Care and communication suffer when there is a loss of trust. WHO IS MY DOCTOR?

We saw what happened during the Covid pandemic when a socialized system of Command and control tried to direct patient care via “emergency orders” and algorithms designed by bureaucrats who had never attended to a patient at the bedside. People were informed more often by Rachel Maddow, than they were by their own physicians and nurses.

Money talks and our elected officials at the Federal and National levels are acting as agents for large businesses that are squeezing individual professionals. Try to find a local civil engineering firm—I can find three in Boise, a private CPA or lawyer practicing on their own, and local banks are being squeezed by regional banks and regional banks are being squeezed by National Banks and the Feds. All because Federal money is being used to capitalize “bigness”. Over 50% of money allocated (as opposed to being appropriated) by our state legislature comes from the Federal Government—over 70% for Medicaid. Maybe Idahoans should just have a referendum every year to decide what large CPA firm should funnel transfer payments to large hospitals, and businesses seeking government grants, and we won’t need a legislature. The Executive branch—Governor, decides everything about spending and the budget anyway. There would be no need for lobbyists. The Idaho Association of Commerce and Industry (IACI) and the Idaho Medical and Hospital Association) IMA/IHA—are they one already(?) could just have representatives sit on advisory boards and decide the people’s business—almost like what is being done today, but less costly.

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The Federal Reserve and The Federal Deposit Insurance Corporation has backstopped losses beyond the $250,000 requirement on deposits held by customers in the Signature Bank and The Silicon Valley bank. They have “socialized the risk and capitalized the return”, thus increasing the chance that bad decisions will be made when allocating scarce resources. “Uncle Joe” just wants to forgive student loans across the board.

We could just give money away to developers who are constantly trolling for HUD grants—did you see Representative Simpson’s announcement about a development grant for Boise this week? Developers will soon be working for the Feds just like doctors and hospital administrators are today.

When people say that our capitalistic system is failing, they are wrong. Very little about our system of commerce today is about free and unfettered markets between buyers and sellers. Incentives in all their many forms, regulation, collusion between the private sector and government agencies and politicians themselves—campaign contributions in exchange for supporting legislation or an application before the city fathers for a development, all reek of mercantilism and socialism. Corporatism like what existed in Germany and Italy before WWII has supplanted capitalism. It is the individual that has suffered the most.

Most of the time bigger is not better.

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