I’d like to welcome you to the 54th annual meeting of the Association of American Physicians and Surgeons and to set the stage for the presentations that you will hear.
I am not going to start by telling you of the glorious achievements of our Association. I cannot say that we are “taking care” of all the problems of American medicine so that you can just come to the meeting, have a jolly good time, and not worry as long as you send in your dues and say “Amen!” with one voice to the latest glossy 14- or 16-point proposal.
The Association was founded in 1943 to fight socialized medicine. We have hardly won that battle, and in my opinion, we have not yet begun to fight. The fight will not be easy or safe.
Throughout the next three days, I ask you to consider a question that was formally raised at the annual meeting several years ago. Drs. Dan Jordan and Mac McDowell headed a discussion on the question: At what point will you resist? Where do you draw the line, and what do you do when you have drawn it? We came to no conclusions.
What we have seen in the years since is an incremental advance of socialist tyranny. We protest at each new infringement, but each one in itself is not worth laying life, sacred honor, or even a small part of our fortune on the line.
I am going to explain to you why I think the time to act is now, and what I think we have to do. I am not going to ask for your agreement today. I simply ask that you hear me out and give my idea your consideration. Then you, as an individual, will have to decide what you are going to do.
Let us first pause for a moment and look at how far we have come, one step at a time.
Stop and think, for example, of how you got here. If you came on an airplane, you had to show a government-issued picture-ID and answer some questions declaring that you were not aiding and abetting terrorism. Do you remember when all you needed to get on an airplane was a boarding pass?
And think about how things are different in your office. A few years ago, you could concentrate on getting your patients better. Now, for each and every patient you see, or at least for every insured patient, you need to think about supplying sufficient documentation to prove that you have not committed a federal felony in billing for the service.
Many doctors now say we have come so far that resistance is futile. When you ask them to join AAPS, they may say, “You were right 30 years ago. We could have fought them back then, but we didn’t, and now it’s too late.”
Of course, Bad Guys always want you to believe that resistance is futile. Let’s not prove them to be right by giving up immediately.
I am not a fan of tilting at windmills. I think we have a chance. The prospects may look bleak, but the consequences of defeat are so disastrous that we must seize the best chance that we have.
In general, there are two essential requirements for any successful effort to reverse a powerful societal force: you have to be ready and committed, and you have to seize the moral high ground. Are we ready?
That question is usually asked in another context, meaning “are we ready for the next step down the slippery slope?” The presumption is that the possible answers are either “yes,” or “not yet,” rather like the achievement standards in “outcomes-based education.”
We may not be ready for a National ID card — yet — but we’re ready to accept enhanced “anti-terrorist” measures at the airport. We may not be ready — yet — for the total abolition of private property, but we do accept the right of the government to seize the property of real Bad Guys like accused drug dealers before they ever see the inside of a courtroom. In 1993, we weren’t ready for the Clinton Plan, but by 1996 we were ready for criminalization of medicine and by 1997 for KidCare.
The question can be asked in another sense. In 1775, Americans weren’t ready to declare independence, but in 1776 they did it.
What do you do to get ready?
We have a good idea of what it takes to get a population ready for totalitarian government, since we have seen a number of examples during this century, for example in National Socialist Germany and Fascist Italy. At least some aspects of these governments are much admired by many leaders of our time, including Ira Magaziner if not Bill Clinton himself.
The requirements are: a dependent population, control of the language, a network of spies and informers (especially children), a culture of deceit, nonaccountable government, and widespread denial.
Bismarck’s great inspiration was to get Germans dependent upon the Kaiser for their health insurance.
Germans spoke of “the final solution” — not even the National Socialists called openly for brutality and genocide. The Hitler Jugend took children away from their homes, put them in uniforms, and instilled loyalty to the state and the Fuehrer.
There was pervasive deceit, the Party and the Fuehrer were accountable to no one, and denial was the norm, inside Germany and even abroad. My friend Petr Beckmann, who was a Czech, drank beer in a German pub downwind from Dachau many years after the war. He asked the bartender about extermination camps, and the bartender denied their existence and complained of calumnies against the German people.
What about America?
Most Americans — including American physicians — are heavily dependent upon government insurance (or at least government-regulated insurance) for their medical care or their incomes.
The government has tremendous influence on the language: Note that we do not speak of the “further destruction of the private insurance market place and the criminalization of medicine” but of the “Health Insurance Portability and Accountability Act of 1996.”
Schools, even our most prestigious “private” colleges (which are heavily dependent on federal funds), are increasingly becoming indoctrination centers. Clinton wants school uniforms. And soon, if the government wants to know whether Daddy has a pistol in the nightstand or speaks ill of Hillary Clinton, it will simply need to do a computerized search of the medical records from school-based clinics.
The culture of deceit in America is exemplified in the Clinton Health Care Task Force (HCTF), whose work goes on. Eric Holder, then U.S. attorney, decided that Ira Magaziner, HCTF guru, did not need to be prosecuted for his false statements to the Court, and the sanctions promised by the Judge have yet to be imposed. If they are, the taxpayers will probably pay them.*
Many Americans like to point fingers at Germans, but in this electronic age, Americans have far less excuse for denial. Everybody should know that at Waco, Texas, about 80 women and children were burned alive after being gassed in an assault on their home by federal agents — United States federal agents — who were purportedly serving a search warrant concerning a technical firearms violation. Everybody should know that at Ruby Ridge, Idaho, an American woman had her brains blown out by a sniper — a sniper employed by the U.S. federal government — while she was in her own home nursing her baby. Her 14-year-old son was also killed by federal agents. The person who publicly claimed “full responsibility” for the Waco incident is still Attorney General — of these United States of America — and has gone on to deputize Inspectors General so that they can carry guns without the approval of Congress. We know that doctors’ offices are being invaded by SWAT teams, that patients and children may be held at gunpoint, and that at least one doctor is serving a lengthy sentence in federal prison for technical violations of rules that the prosecutor would not even produce in writing. This, too, is happening here and now, in these United States of America.
For you children of the 60s, “How many times can a man turn his back, pretending that he just doesn’t see?” These episodes are “anecdotal,” says the Arizona Medical Association, among others. How many anecdotes do we need? Note that the three American industries with the highest growth rates are: temporary help, gambling, and prison construction.
So what can we do and when should we do it?
Let us ask: “What should the Germans have done about the Gestapo, and when should they have done it?” The answer is obviously that they should have done it while they still could fight without risking instant execution.
We can and we should resist any and all efforts to get the population ready for the next step down the slope. But it is long past time to mount a counteroffensive.
Some things immediately come to mind. We can petition Congress. We can file lawsuits. And we intend to do that. I think these things are worthwhile, but mainly in buying time and in educating our colleagues and our patients. Ultimately, they will not be enough. Ultimately, physicians will either assert their rights, or they will lose.
The 105th Congress and the Clinton Administration have handed us a tremendous opportunity. I’m sure they have done so inadvertently. They cannot imagine that anyone would take advantage of it — and the conservatives at Human Events and the Cato Institute agree with them.
AAPS has been fighting for nearly a decade to establish unambiguously that patients and physicians have the right to contract privately outside the Medicare system, without foregoing their entitlements. We believe that this right does exist, but few physicians have been willing to risk asserting it in the face of threats from Medicare carriers. Therefore, we have been strongly supportive of the efforts of Senator Jon Kyl (R-AZ), since 1995, to enact a guarantee of this right into law.
But what happened to his plain and simple bill, in Conference Committee, turned it into something entirely different. This process happens with great frequency. Secret bits find their way into laws without the knowledge, much less the support, of the Congressmen who vote for them. This is, we believe, outrageous and unconstitutional. We intend to challenge it, both in Congress and in the Courts. But we’ve seen how unreliable Congress is. Court challenges, at best, take years, and they too can have unintended, surprising consequences.
Either Congress or the Courts could strike a powerful blow for freedom, with impact far beyond this particular bill. But let’s make the most likely assumption: they won’t, or they won’t do it soon enough.
We have been given a tiny wedge, and it’s up to us to open the doors to freedom with it. It may seem like a small and insignificant tool, but it could be remarkably powerful.
Make no mistake about it. The loss of your cooperation is their greatest fear. The ferocity of the opposition to private contracting, on the part of the Administration and its congressional allies, is a revealing sign of its importance.
The Herd Mentality of Physicians
The Department of Health, Education, and Welfare held its collective breath when Medicare first passed, fearing that physicians would not accept it. But of course the temptation of the government money was too great.(1) Some physicians capitulated immediately.
AAPS declared a policy of non-participation,(2) but did not even make adherence to it mandatory for membership, out of the very realistic concern that a large proportion of the members would bolt. I think that a golden opportunity was missed.
Once a certain number of physicians join a movement, the rest can say that they “have to do it” also — especially if no medical organization is even willing to call the idea by its real name and explain why collaboration is unethical.
We see a replay of the Medicare situation with managed care.
Now that so many doctors have collapsed like dominoes, first with Medicare participation (socialized medicine for the elderly) and later with managed care (corporate socialism), the practical questions have become very pressing: Why should a patient pay a doctor out of pocket, if he can get the same service elsewhere without having to pay? And how can a doctor continue to serve his patients if he is not paid for his work?
Many of our members have moral compunctions about accepting government money because it is the fruit of legal plunder. However, you can argue that you are not responsible for seizing money from an unwilling taxpayer, as the money would be seized whether or not you accepted it. You do, of course, have the right to be paid for your work. And if you are paid with taxpayer’s money, it is a better use for the money than many others that you can easily name. Furthermore, unless you accept assignment, you can argue that it is the patient who is the recipient of the ill-gotten loot.
The morality of accepting Medicare money, either directly or indirectly, is between you and your conscience. However, I think you will agree that if you turn down the money, you are on morally unassailable ground, especially if you offer charity to those who are unable to pay. Moreover, you have deprived the government of its most potent legal justification for dictating how you will practice.
A Moral Counterattack
To the prospect of giving up Medicare revenues entirely, many if not most of you will be inclined to say, “Impossible!”
Instead, I ask you to say, “Not yet!” In the meantime, you can give your support (even if only moral support) to those who do withdraw, and your support to AAPS efforts to expand the unambiguously legal scope of private contracting.
For some, giving up Medicare would not be extremely difficult. Older physicians may be thinking of retirement. Why not retire from Medicare first? That is now easier than before because you can continue to collect payments from those who are able to pay, and at the market rate.
Young physicians may be able to steer their career away from specialties that are highly dependent upon third-party revenues, especially from Medicare. They can avoid commitments that will demand a vast amount of revenue, such as a large staff for processing paperwork.
Physicians in mid-career may have enough financial security that they can survive a temporary drop in income. They can then develop aspects of their practice that can thrive without third-party funds. Others may have non-medical skills with which they can supplement their income. And some may be able to adopt a more austere lifestyle.
Old, young, and those in between can take prudent actions to get ready to take the plunge into independence. Some are on such a high diving board that the plunge would now require nothing short of moral heroism.
Decision time is soon. Not everyone will be ready to say that the system is evil and to refuse to cooperate with it. But everyone, ready or not, will have to make a choice about their own personal status. That choice is becoming ever clearer. Will you be a free man or woman or a slave?
One can argue that Americans are already half enslaved because government takes about half of their income. I would disagree. One can be oppressed, victimized, robbed, impoverished, or even beaten up, without becoming a slave. One truly becomes a slave in America today upon accepting government money. If you take their money, they own you.
To claim Medicare money, you must sign a form that effectively waives your rights. The bureaucracy now has the power to view any of your records that they think they need to process the claim. You have agreed to abide by all their rules and regulations. Because that is literally impossible, you are already an outlaw, and your own records could undoubtedly incriminate you. If they choose to target you, they can deploy the effectively limitless resources of the government to destroy you. All that will stand between you and the federal prison is a jury, and prosecutors have enormous influence over the proceedings. They can manipulate the jury, present perjured testimony, and severely inhibit your ability to mount an adequate defense. Remember, they are wearing the white hats, and doctors these days are wearing the black ones. The federal government can confiscate everything you own and leave you with a ruined reputation and a lifetime debt that you have no way to repay. But they do not need to go that far with very many doctors. As long as you live in fear of them, they may not have taken possession of your house — not yet — but they already own your soul.
From the standpoint of physical comforts, slavery is not necessarily the worst of all fates. But ask yourself, which would you choose: the life of the most privileged slave in ante-bellum days, or that of a poor Irish immigrant?
Suppose you were the favorite slave of the kindest master in the entire country. You could live in the big house, eat the same food as the master (even if not at his table), stay indoors during the heat of the day, enjoy an abundance of leisure time, and lord it over your fellow slaves. All your needs would be met, including your medical needs. Your particularly benevolent master has even assured that your children will be educated, free of charge, in everything they will need to know to succeed in their appropriate station in life. Even if you were demoted from your high position, you would still be protected against the most dangerous work because your master would have a financial stake in your safety.
On the other hand, if you were a poor Irish immigrant in 1850, your days would not be nearly so easy. You would be subject to insults and derision. (Even today, I think it is still okay to tell Irish jokes.) You would be the last hired and the first fired. You could not afford to send your children to school; in fact, they would probably have to do menial labor to help put bread on the table. You would live in substandard housing, perhaps as bad as the average slave quarters in the Old South. You would frequently suffer from hunger and cold, and if sick, you might have to do without medical care. Your wages would be low, and you would have to do the dirtiest, most unpleasant, and most dangerous kinds of work. Your chances of getting killed on the railroad, in the coalmines, or in the Union Army, would be very high.
Which would you choose?
And if you were born a privileged slave and had a chance to gain your freedom, but only by becoming a poor Irishman, what would you do?
You are or may be soon in a comparable predicament. It would not surprise me if most physicians choose to be privileged slaves, hoping to be one of the lucky ones who would not incur the master’s disfavor if they simply refrain from being “disruptive.”
Our forefathers risked all to choose freedom. Many signers of the Declaration of Independence died in penury and obscurity. Many Americans died in battle. And countless men and women throughout history have died for the cause of freedom in efforts that failed and were long ago forgotten.
Patrick Henry said, “I know not what course others may take, but as for me, give me liberty or give me death.” Others followed his lead of course, but it could have been otherwise; they might have hooted him out of the Assembly.
Any one of you who will take a stand for freedom must be prepared for the worst. And you must be prepared to stand alone. You might be surprised. In 1962, Dr. Henrikson of Mt. Pleasant, New Jersey, dictated a little resolution vowing non- participation in King-Anderson, a program proposed before Medicare. All the doctors in his hospital signed it, and the resolution helped delay the birth of socialized medicine for the elderly by a few years. Now, he may be remembered only in this little AAPS pamphlet.(3)
The chance of victory is higher if we stand together, but the risk is great, and each of you as an individual must make a decision about what action you will choose to take. Martin Luther, who is famous because the 95 theses he tacked onto the church door at Wittenberg did not, for some reason, end up in the fire said: Dort steh’ ich; ich kann nicht anders. (“Here I stand; I cannot do otherwise.”)
I will do what I must do. And you will do what you must do. Maybe you will conclude that the time is “not yet.” But we must remember the words of Winston Churchill, which came to my e-mail thanks to Dr. Robert Cihak:
If you will not fight for the right when you can easily win without bloodshed, if you will not fight when your victory will be sure and not so costly, you may come to the moment when you will have to fight with
all the odds against you and only a precarious chance for survival. There may be a worse case. You may have to fight when there is no chance of victory, because it is better to perish than to live as slaves.
1. Confessions of Madame Perkins: a Prelude to Medicare and the Clinton Health Care Task Force. Testimony before the U.S. Congress by Thomas G. Dorrity, M.D., President of AAPS, Congressional Record, November 11, 1971.
2. Principles of the Association of American Physicians and Surgeons, Pamphlet 1014, January 1991.
3. A 1965 Interview with J. Bruce Henriksen, MD: The Past Is Prologue, Pamphlet 1020, December 1991.
Dr. Orient practices internal medicine in Tucson, Arizona, and is the Executive Director of the AAPS. Her address is 1601 N. Tucson Blvd., Suite 9, Tucson, AZ 85716 This article is based on a speech given at the 54th Annual Meeting of the Association of American Physicians and Surgeons in Chicago, IL, September 18, 1997.
Originally published in the Medical Sentinel 1998;3(3):84-87. Copyright © 1998 Association of American Physicians and Surgeons (AAPS).