To Your Health (why being pro-business and being pro-free market are not the same things)

WHILE PRESIDENTIAL POLITICIANS OFFER VARIOUS PLANS to improve American healthcare, it is already changing – and not in all ways for the better, as my wife Ellen painfully learned. Knowing what she experienced and learned might save your or a loved one’s life.

Nine months ago Ellen had surgery, but the feelings of sickness and pressure this procedure was supposed to remedy never went away. A few weeks ago I rushed her to the emergency room of that same hospital, where doctors were unable to transfuse her with blood fast enough to offset her internal bleeding. With her heart overworking to compensate for hemoglobin levels only half of normal, her likelihood of a heart attack according one doctor had jumped tenfold.

Risky emergency surgery was done the next morning to stop that bleeding. But Magnetic Resonance Imaging (MRI) done prior to her going under the knife detected something unexpected.

The M.D. radiologist who operated months earlier, relying on what he now calls a "fuzzy" previous MRI, had completely misdiagnosed what was wrong with her. The surgery he performed – an embolization to cut off blood feeding a growth inside her – failed to remedy the problem for a simple reason: no such growth was there. A correct diagnosis would have ruled out performing that surgery.

The new emergency surgery at first seemed successful. Her bleeding stopped. But nine nights later Ellen was back in the same emergency room, vomiting up stomach acid. The previous surgeon apparently had not closed an opening in her inner abdominal wall, I was told, and a length of her small intestine had worked its way into this opening, twisted, and become blocked like a crimped garden hose.

"It’s good you stopped treating this with antacids and rushed her to the hospital," the third surgeon told me after operating on her next morning. "A few more hours and her intestine would have started to die."

This hospital and its doctors are rated among the best in our nation. It is certainly possible, even with such odds in one’s favor, to throw fate’s dice and roll snake-eyes twice in a row, to get two life-endangering medical outcomes.

But what I witnessed during each of these crises was disturbing. Expecting the best medical care our free marketplace could provide, I saw instead the kinds of problems and mis-treatments we read about happening in the socialized health care systems of Great Britain or Canada…but at the sky-high price of modern American medical care.

To be fair, what Ellen and I witnessed was a strange hybrid of the latest high technology and too-low attention, great surgical skill and dropped stitches, caring nurses and apologies that budget cutting had stretched thin their ability to maintain an earlier standard of care.

The health care we experienced seemed like a safety net that was somehow fraying, strong in some ways but unpredictably, frighteningly unreliable in other ways. What is causing this deterioration in what we once believed, beyond question, was the best health care in the world?

The first thing asked of people entering hospital emergency rooms is proof of insurance. It fell to me to do the paperwork at an admissions desk. I presented my wife’s plastic card for Blue Cross, one of the old-line major health insurers in my state. But on the card’s back, mentioned in passing, was an unfamiliar name, WellPoint. What was it? I asked the person filling out Ellen’s computer form.

"They own Blue Cross," she replied matter-of-factly. They own far more than this, my research soon discovered. Originally "formed in 1992 to operate Blue Cross of California’s managed care business," WellPoint and Blue Cross in 1996 "merged into a single stockholder-owned company, WellPoint Health Networks Inc. (NYSE: WLP)."

Today this Thousand Oaks, California, company has grown to 80 offices and more than 16,500 "associates" around the country. It "serves the needs of more than 13 million medical members and over 49 million specialty members," having acquired along the way health insurers from Massachusetts to Georgia. It is creating one innovative non-government prototype for the future of American health care.

Behind WellPoint’s rapid growth is its ingenious Chairman and CEO Leonard D. Schaeffer. "At 30," wrote Business Week, "the Princeton economics grad rose to become budget director of Illinois. Schaeffer took an aggressive approach to controlling debt….’I cut all kinds of unnecessary crap – cars, airplanes. The State of Illinois had nearly as large an air force as Israel."

Schaeffer got to know Joseph Califano, Jr., the Secretary of Health, Education and Welfare in Democratic President Jimmy Carter’s Administration. Califano made him HEW’s Assistant Secretary for Management and Budget.

Schaeffer was put in charge of combining Medicare and Medicaid into one agency. Part of that job was persuading state officials to cut costs. One of Schaeffer’s money-saving innovations was cutting the days a mother on Medicaid could stay in the hospital after having a baby.

Schaeffer, who took the helm at Blue Cross of California in 1986, used his penny-pinching and management skills to turn a non-profit company losing $165 million yearly into for-profit WellPoint, which by 2002 had become America’s fourth biggest private health insurer with annual revenues of $17.3 billion and average annual growth exceeding 20 percent. Last April WellPoint announced quarterly profits 37 percent higher than the year before.

WellPoint has made big profits for investors and been healthy for their portfolios. It split its shares on March 15, 2002. It has also been profitable for Schaeffer, 57, whose annual compensation reportedly jumped 29 percent in 2002 to $16.3 million.

But these profits, say critics, have come at the expense of doctors, hospitals, pharmaceutical research, and the financial and physical health of patients who depend on WellPoint companies.

In August 2000 the California Medical Association (CMA) filed a RICO (Rackeeter Influenced and Corrupt Organizations Act) lawsuit against WellPoint/Blue Cross of California and two other for-profit health insurance companies. The lawsuit accuses these companies of using coercive, unfair and fraudulent means to dominate and control doctor-patient relationships for financial gain. The for-profit health plan companies deny these allegations.

"For years these profit-driven companies denied needed services, interfered with medical decisions, and valued dollars more than lives," said then-CMA President Marie Kuffner, a professor of anesthesiology at the University of California in Los Angeles. "We cannot continue to allow our patients’ health to be jeopardized."

The state medical associations of Texas and Georgia have joined CMA in this lawsuit. After much delay, it is scheduled to go to court in Florida this Monday, May 19.

WellPoint/Blue Cross of California has also been named defendant in a class-action lawsuit filed in March 2002 in Illinois by the American Dental Association. The ADA is seeking relief under the Employee Retirement Income Security Act (ERISA) for what it claims is breach of contract, and under state laws for what it alleges is interference with the dentist-patient relationship and trade libel.

Behind this wrestling match among insurers, physicians and lawyers lurks a secret that few patients understand.

State and federal government mandates have stretched health coverage and budgets to the breaking point. They have ordered hospital emergency rooms to treat poor people and illegal aliens whether these patients can pay or not, and the poor and illegal aliens know and take advantage of this. Governments have required doctors to accept Medicare and Medicaid reimbursement as "payment in full" for treating patients, even though such payments are typically only about 80 percent of established doctor fees.

To compensate for such losses, hospitals have for decades overcharged privately-insured patients in various ways, e.g., billing $6 for a single aspirin pill. Doctors are also tempted to run up charges on these profitable patients, rationalizing marginal tests and treatments as "defensive medicine" against ambulance-chasing lawyers who sue almost anytime a patient has less than a perfect medical outcome.

Thus have private insurance companies been maneuvered into paying not only for their own customers, but also for freeloaders and those whose bills government deliberately underpays. This has become, in effect, a huge invisible tax levied through government mandates upon hospitals, doctors, insurers, privately-insured patients and companies that provide medical insurance for employees.

This gigantic redistribution of wealth has depended upon private insurers who were willing to overpay for medical care so that governments could underpay. But now this Jerry-built system is unraveling, and WellPoint for this bears much responsibility.

Leonard Schaeffer comes from a background largely in state and federal government, not the free marketplace. Much of his success as head of WellPoint has come from using government-like tactics, and from having the clout of millions of customers, to make take-it-or-leave-it offers that hospitals and physicians could not refuse: that they accept less and less reimbursement for treating patients.

As a result, hospitals and doctors who used to be able to "rob Peter to pay Paul," to overbill some to offset government-required underbilling of others, now find themselves facing government backing Paul and a government-like insurance quasi-monopoly backing Peter. Both of these powers now insist that physicians and hospitals not receive a penny more than rock-bottom reimbursement for their services.

Doctors, also stretched by soaring costs for their own medical malpractice insurance, increasingly complain that they lose money by treating many of their patients. Some go on strike, as doctors did in early 2003 in New Jersey. Others retire or quit doing high-risk medicine. Many become salaried assembly line doctors in impersonal Health Maintenance Organizations (HMOs) that at least let them work regular hours and shield them from liability lawsuits. And many young people are shifting their career path from medical school to law school, deciding that a better living is to be had by suing doctors than by being one.

WellPoint would tell you that its customers benefit from its big-stick approach to forcing down medical costs, and in some ways this may be true.

But the biggest beneficiaries of such savings are WellPoint stockholders, not patients. A new CMA study released April 15 found that WellPoint/Blue Cross of California spent only 78.9 percent – less than $4 out of every $5 – of its revenue on patient care. This, reports CMA, was "much less than comparable health plans."

"Blue Cross had the worst reimbursement out of all the major managed care plans," says Ray Stricker, MD, a San Francisco hematologist. Many California physicians who share this perception of its low and slow reimbursement reportedly refer to Blue Cross as "the Blue Shaft."

While spending much less than comparable insurers on patient care, WellPoint according to the CMA, "saw its annual profits [nationally] soar 70 percent to $702.1 million in 2002, increasing from $414.7 million in profits the year before."

The savings WellPoint has achieved by squeezing hospitals and doctors, in other words, have not been passed on to customers through lower premiums. On the contrary, customers have also been squeezed to enrich WellPoint.

My wife Ellen’s policy used to require her to pay 25 percent as her "co-payment" share of medical costs, albeit at the lower prices for services contracted by WellPoint for its members. Last year she was suddenly informed – because WellPoint reserves its right to raise rates with only 60 days notice, not the year-long notice of many other insurers – that her required "co-pay" would soon rise to 30 percent.

WellPoint is at least as aggressive as other health insurers in telling doctors and patients what procedures, medications, and other treatments it will or will not reimburse in a particular case. It offers customers choice through an impressive variety of plans, several of which require prior authorization for many kinds of treatment. Physicians for a host of reasons can perceive this as interference in the doctor-patient relationship.

What WellPoint is willing to pay for often limits choices and directs the course of treatment. It can feel as if your health and well-being are in the hands not of an MD but an MBA, a penny-pinching bureaucrat for whom saving money is the main concern.

But WellPoint’s innovative audacity shocked even the jaded business and medical worlds in 2001. The insurer got a surprisingly friendly response from the federal Food & Drug Administration to its improbable three-year-old petition to change the prescription allergy medications Allegra, Zyrtec and Claritin to over-the-counter status. In 2002 WellPoint filed a similar petition to switch another allergy medicine, Clarinex, from a prescription drug to OTC status.

Prior to this, pharmaceutical companies filed such petitions for their own drugs, but usually only after many profitable years of demonstrating a drug’s safety and efficacy in millions of patients, each under a doctor’s observation and care. These years of heightened profits also help drug companies recoup costs that can exceed $350 million to research, develop and win FDA approval for a single new patented drug.

These allergy drugs were safe, argued WellPoint by pointing to their manufacturer’s own advertising claims. But as medicines requiring a doctor’s prescription, said Schaeffer, these drugs were "costing" WellPoint $90 million more each year than if his policyholders could buy them over the counter at the local drug store.

Conservative commentators such as Doug Bandow of the Cato Institute and Kerri Houston of CNSNews.com found both risky and cynical things in WellPoint’s gambit. The risk came in drugs tested in the marketplace for a relatively brief time such as Clarinex, to which some patients might have unexpected reactions.

The cynicism is because once such drugs were switched to over-the-counter status, WellPoint is no longer obligated to pay for them. This cost shifts from the insurer to the allergic customer, now stuck with the bill for drugs WellPoint previously covered. By persuading the FDA to change the status of these drugs, WellPoint and other health insurers could transfer virtually their entire cost to customers.

These customers presumably would pay less for over-the-counter versions than the $4.4 billion now spent each year on prescription allergy medications – but they would pay out of pocket much more than their old $10-$15 co-pay. And those customers must continue to pay at least the same high price for health insurance coverage despite what Bandow calls this "sub rosa" benefits cut.

(This is not unlike governments more and more making us pay twice for things, e.g., fees for admission to our national parks, once open for free and funded by the same taxes we still must pay.)

Aging Baby Boomers are again turning to drugs – not marijuana this time, but Metamucil. The cost of drugs is rising by almost 16 percent a year, recently starting to increase faster than any other major facet of medical care. WellPoint, in addition to urging pill-splitting and generics to reduce costs, has suggested that allergy drugs were its first of many targets, that this insurer will press to have other kinds of prescription drugs rushed into over-the-counter status.

This will prompt more Americans to play doctor – choosing their own non-prescription drugs to treat ills more, and being seen by their doctor less.

This will save WellPoint lots of money on both drugs and physician visits, but it will have costs, some of which may go unnoticed. People will be stuck paying for both their insurance and many medications that health insurance used to cover. People who misdiagnose themselves risk suffering more illnesses and premature deaths. Pharmaceutical companies will have less seed money and incentive to research and develop new medicines. Fewer people will go to medical school, reducing the number and quality of doctors needed by our growing, aging population.

Public debate to resolve the drug pricing issue will probably last five years, Schaeffer two years ago told a panel of healthcare executives and government officials in San Francisco. "No one wants to pay $63 for Claritin in the U.S. when they know it costs $14 for a prescription in Canada," he said. "Drug companies will have difficulty holding on to windfall profits when baby boomers are demanding access to more drugs."

In fact, we demand more of every kind of health care, preferring long life to the alternative. And Americans expect somebody, whether private insurer or government, to provide it. If healthcare equals life, we want as much as needed to stay alive and well when we are 50 or 90 or 150.

But this cannot be. We already run up the largest chunk of lifetime medical costs during the final six months of life, not on preventive care but to slow the Grim Reaper by using heroic measures such as machines that pump blood and do the breathing for terminal patients to keep them "alive" an extra few weeks or months.

If we provided every possible medical option to everybody, such as organ transplants for every failing 98-year-old, medical costs would soar towards infinity. Health care costs would become a black hole, sucking in and devouring private insurance companies, government budgets, and the entire Gross National Product itself.

"What most health policy scholars know, and what experts who advise Democrats and Republicans concede in private," wrote Georgetown/Johns Hopkins Universities health policy expert Gregg Bloche in Sunday’s Washington Post, "is that there can be no serious, long-term containment without a willingness to deny beneficial care."

Somebody – whether a private insurer or government bureaucrat – will have to ration care, to draw lines and to some desperate patients and their families say the dread and impolitic word "No." Private health care management may be able to do this better than government. This is one reason why every Democratic presidential candidate who in recent days has put forth a health plan – Rep. Richard Gephardt, Senator John Kerry, former Vermont Gov. Howard Dean, and nominally Senator Joseph Lieberman – is either inching or running away from socialized medicine and towards healthcare via private insurance.

But in seeking the best ways that the free market ways can improve American healthcare and escape the harm done to it thus far by government policies, some conservatives have begun to wonder whether WellPoint has gone too far in reaping windfall profits at the expense of private medicine’s lifesaving infrastructure of doctors, hospitals, pharmaceutical companies and its policyholders. This one private enterprise has thusfar gotten wealthy not only by efficiency and fat-cutting, but also by siphoning away the income margins others in private healthcare need to remain alive and well.

In March 2003, after WellPoint refused to provide requested pricing and underwriting information, Maryland insurance regulators blocked its proposed acquisition of Blue Cross-Blue Shield entities in that state. The deal reportedly would have increased WellPoint’s customers by 6 million and annual revenue by $4 billion. This would have made the company America’s third largest for-profit health insurer.

"The devil," says Schaeffer of proposals to reform Medicare, "is in the details."

It’s been said that when Fidel Castro imposed his Marxist dictatorship in Cuba, he had no need to collectivize agriculture. This had already been done by the sugar barons. If America ever moves to socialized medicine, will the same be said of the governmentality of Leonard Schaeffer and the controlling influence of WellPoint Health Networks, Inc.?

Ellen, I’m happy to report, after three unnecessary and life-endangering surgeries is making a rapid recovery and feeling better than she has in many moons.

"I’ve gotten along well with Blue Cross over many years," she says, "and I’m thankful to live in a time and place with modern medicine."

I've been thinking about Healthcare lately, especially since I've been getting deep into studying the FairTax. Wouldn't the best way to administer healthcare in this country is not tying it to employment (which stifles euntrepeneurialism and risk-taking), not through a sink or swim "pay it your damned self" mentality which stifles euntrepeneurialism and risk-taking), not through socialized medicine (which effectively ends cost-lowering competition), but through a combination of all three. The Federal Government spends roughly $850 Billion/year of HealthCare (not including R&D, the CDC, etc.). If you divide that between the 285 million americans, that equates to roughly $3,000 per year for every american. Buying an individual health plan is much cheaper than that. So, why shouldn't the government send every american a check for their share of the money we're spending on healthcare and send it to every american every month. People can spend it on their own plans and pocket the difference if they want, or they can pay out of pocket for all the bells and whistles. And we'll make it a law that every American at least has to buy insurance for "emergency-only" care, similar to the way that most states make you purchase at least basic, liability-only car insurance. That way nobody is uninsured (and passing on the bill to the insured at the hospital) and we'll have INCREASED competition. It'll also break up a lot of the quasi-monopolies, like Blue Shield, that are crippling the industry. This will all drive down costs, prevent gov't takeover of the healthcare system, and will adopt a pro-free market, as opposed to pro-business, approach to the industry. This will also reduce the burden on employers to provide health care plans and break the stranglehold unions and their healthcare plans have on tens of millions of Americans. I'm looking for a single counterpoint to this argument, besides the old adage that everybody should be paying 100% out of pocket anyway. How can any of us conservatives be opposed to this idea???

Most of what the Feds pay for healthcare goes to Medicare and the VHA. You can argue that that should be spread more broadly, but that won't solve the problem for Medicare recipients and Veterans who, mainly because of age, have higher needs than the average citizen.

It's taken generations for the healthcare system to get to its current unhealthy state. Because of all the existing commitments/entitlements, it's going to take generations to get out -- unless a true crisis occurs.

Healthcare is way more expensive than it should be, for a variety of reasons. First and foremost is that, as a nation, we're not as healthy as we could be. 70-75% of healthcare expenditures are for the treatment of chronic diseases, such as diabetes, asthma, heart disease, and so on. Not only do these diseases cost money on the treatment end, but they also result in significant costs due to absenteeism and lowered productivity. Most of the healthcare system is still oriented around the acute-care model: if you have a serious problem, you show up at the emergency room at get it fixed. Modern approaches to disease management, invoking the Chronic Care Model, along with sensible prevention, will keep people healthier and their healthcare costs must lower.

A second huge problem is administrative costs. The insurance industry -- and its slaves working in healthcare organizations across the country -- extract 15 to 20 cents out of every healthcare dollar. This is partly due to the healthcare payment model, but also due to paper-based inefficiency. Fortunately, technology will soon have a huge impact on the latter, reducing the cost of a financial transaction from $8-10 to a few cents. The third big problem is malpractice insurance costs. This is only partly due to legal greed. The main problem is that the quality of healthcare -- as this article points out -- is not nearly what it should be. It is common to invoke airline safety as a metaphor. It the airline industry routinely lost tens of thousands of passengers each year in accidents, they would be shut down. Medical errors have killed tens of thousands annually for decades, and hardly anybody even knew -- except perhaps the lawyers who were profiting from the relatively few examples that came to light. Healthcare quality is also starting to benefit both from technology and from process improvement supported by technology.

The continuing increase in healthcare costs is unsustainable, of course, hence it can't continue forever. Fortunately, we're seeing mechanisms -- including a greater emphasis on health rather than healthcare, a greater emphasis on quality, and a better use of technology -- that, in time, may provide significant relief.

Fine. Give Medicare and VHA (I'm an active duty member of the Air Force by the way, so I am looking at my future benefits) directly to the recipients and let them buy their own insurance. There will be a while lot competition for those hundreds of billions of dollars. What's more, if a retiree is in excellent health, he may not need all the bells and whistles that these plans cover. As a result, he can pocket the difference and spend it on the economy.

I agree with you on your analysis on the problems of the health care system (malpractice, too extensive of coverage, bureaucracy, etc.). However, you don't seem to feel as strongly about the need for competition as I do. The deal is politically unbeatable as well. Who can argue with "we're going to let YOU decide how much health care YOU want", other than Ted Kennedy and Nancy Pelosi?

A simple idea like this often gets overlooked. It works in other areas too. An interesting one I've heard came from Ann Coulter when she was on Fox news debating Urban Public housing. She said that we should just give the tenants the deeds to the property if we want to solve crime there. Why? People take care of their own property much better than other people's stuff. A home owner is much more likely to call the cops on drug dealers than somebody living scot-free on the government dole.

Going back to health Care... maybe it's time to repeal ERISA (employee retirement income security act), or at least the part of it that gives a tax break to corporations for providing health insurance. the federal government can use those tax savings to give it to every American for BASIC insurance (like emergency-only), and companies can pass the difference on to their employees in the form of a bigger paycheck. It has been proven (and eloquently pointed out in an article recently by grover nordquist) that while the overall cost of health care has experienced double digit rises in price, the cost on ELECTIVE surgeries like laser eye surgery, stomach staples, and cosmetic surgery have has double-digit REDUCTIONS in price. Why? Because the consumer is going to go to the lowest bidder. If we expand this to everybody, we will wee true efficiency gains in the health care industry.

Medical Savings Accounts are to healthcare what homeschooling is to education. They provide a means for individuals escape an unhealthy system and take charge of their own healthcare

Perhaps I don't understand how they work, but answer this for me. My mother-in-law has been hospitalized three times in the past year, at a total cost of about $120,000 (so far), paid for by the taxpayers (Medicare.)

That isn't the most expensive care by a long shot. To care for a premature baby in a neonatal intensive care unit can cost half a million dollars. How are people supposed to save that much, especially if they have multiple sick people in their family?

What do retirees do who are in poor health? As it stands now, they either can't buy private insurance at all, or only at very high prices ($30,000 or more per year.)

How does this apply to the old? My m-i-l (mentioned above) was relatively healthy until her late seventies, at which point she has had three hospitalizations. Her heart disease is not something that probably could have bene prevented forever (after all, she is pretty old, and has a long family history of heart disease.) That it's held off this long is amazing.

The very old (age 85 and above) have even more hospitalizations and more expensive treatments. They're not working; they're not privately insured, and the cost of their care is coming directly from the taxpayers. Where does this end?

Most programs with MSAs include catastrophic coverage, which is where insurance makes sense.

No offense to your mother-in-law or to premature babies, but having the government be the deep pocket for all conceivable medical interventions is not sustainable. Choices must be made, but as things stand they we will be made for us by the government rather than individually.

My wife's grandmother, in her '80s, had the choice of going on lifetime dialysis -- paid for by Medicare once her life savings were drained -- or providing an inheritance for her children and grandchildren. She decided she'd rather exercise her right to die.

If government will pay for anything and everything, then there's no end to the life-saving measures that can be attempted -- draining the savings of everyone in the country.

How are people supposed to save that much, especially if they have multiple sick people in their family?

Think of a medical IRA as a "high deductible" insurance policy. You pay all the out of pocket expenses for routine stuff, prescriptions, etc. Then your high deductible insurance kicks in for catastrophic illness.

I don't know what the situation is now, but in Masachusetts as of a few years ago you could not legally obtain one of these policies.

I have a family plan for my wife and my five-year old, which now costs us over $1,000 per month. That's over $12,000 per year. Our actual medical expenses have never been anywhere NEAR that much in any year (knock wood).

I would much rather put most of that $1,000 per month in a savings account, pay for my own presecriptions and doctor's visits, and then just pay a premium for catstrophic illness and hospitalization. IT would be a lot less expensive in the long run for my family.

Medical Savings Accounts are to healthcare what homeschooling is to education. They provide a means for individuals escape an unhealthy system and take charge of their own healthcare.

Not really. In most states, home schooling gives 100% freedom to educate. By contrast, Medical Savings Accounts only give a tiny increase in freedom. There are extremely few drugs and treatment that might be covered by a Medical Savings Account not covered by my HMO. Freedom to get any APPROVED drug? My doc can already do this if I am willing to pay a 40% higher co-pay to go non-formulary. No big deal. Freedom to see any specialist? Well, almost all the specialists in my area are on my HMO, and my doc is a nice guy we have gone to for 20 years who will give us whatever referrals we ask for and call the HMO for authorizations as needed. Freedom to try new treatments? There the barrier is lawsuits and the related need for the experimenter to get hospital approval. Read about the history of how cortisone was introduced, pre-FDA approval, and ask yourself whether that tremendous life-saver could, with its dangerous side-effects, ever get through the FDA today. The real lack of freedom in health care today is the lack of freedom to try (or not try) new treatments as you desire. The causes of the lack of freedom are lawsuits against doctors who, with patient permission, treat creatively, and the requirement of FDA approval. Medical Savings Accounts don't address my real lack of medical freedom, which is the lack of freedom to decide what treatment risks I wish to take.

Medical Savings Accounts only give a tiny increase in freedom.

Good point. The FDA is still a barrier, and medical savings accounts still won't pay for a rowing machine even if that might be the best may to maintain your health. But they do make it possible to budget for your health care, and they do give you an incentive to optimize for the long term, since you get to keep the money you save in 20 years by modifying your behavior now.

Furthermore, your medical savings account is tax deductible, unlike homeschooling.

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