An equitable and effective healthcare system, then, one that supports basic American principles by straddling the upper quadrants of the healthcare landscape, is at least imaginable. Achieving such a system requires acknowledging limits to what our healthcare system can provide and then ensuring that those limits are distributed justly. By allowing the American spirit of individualism and innovation to guide our efforts, we can make this new system-even with the open rationing it will require-energizing instead of enervating to our society.

But how can we begin to make it real? Let's first look at the likely outcome if we do nothing.

Wonkonians ascendant

In the battle between Wonkonians and Gekkonians over whether our Quadrant III healthcare system will be controlled by the government or by business-like enterprises, the Wonkonians are on the ascent. Since the 1994 collapse of the Clintons' universal healthcare plan, Gekkonians have had their chance to show what they can do. They have had more than a decade to wield their mega-HMOs in an effort to control costs. But despite the inconveniences and dangers they have foisted on American patients, despite the intensity of their coercive efforts to force covert rationing, and despite the opportunities they have created for greater efficiency by promulgating massive consolidations of healthcare institutions, Gekkonians have proven failures at controlling the accelerating cost of healthcare. What's more, they have discharged their only weapons and they seem bereft of new ideas.  In truth, Gekkonians really had only one idea. They have had many years to try it. It hasn't worked.

Wonkonians, on the other hand, remain energized by their one big idea, the establishment of a fully centralized, government-controlled, top-down system of healthcare. The model they invoke most often is the Canadian healthcare system. Wonkonians, in addition to not being Gekkonians, are further advantaged by being single-minded about their plans for healthcare; they are politically savvy, well organized, and generally favored by the mass media. Their basic message-that their healthcare system will be fair-is attractive, especially in view of what we have today. And they have absolutely no trouble showcasing satisfied Canadian citizens (presumably from among the ninety percent who have not been seriously ill recently) who are happy to offer testimonials confirming Wonkonians' claims about this style of healthcare. Wonkonians have never stopped lobbying and working for their big idea, and it is likely that if the healthcare debate of 1994 were taken up again today, they would enjoy the support of a substantial proportion of the American public. Although I would find such a system extremely undesirable, I will stipulate that with some care it could be made more equitable-and ethically more acceptable-than the system we have now. (But then, it is difficult to imagine a healthcare system that would be more unfair and destructive than the one we have now.)

Politically, however, Wonkonians were damaged so badly by their prior ill-conceived attempt at a government-controlled healthcare system that they seem reluctant to push too hard or too soon this time. The disadvantages of a Canadian-style healthcare system remain all too visible-the long queues, the lack of real medical innovation (except via osmosis from the United States), and the dissatisfaction voiced by increasing numbers of Canadian citizens and doctors. These factors are keeping Wonkonians relatively cautious. But they can see that Gekkonians are failing badly; they can afford to wait.

Biding their time is a wise strategy. A centralized healthcare system that subjects Americans to centrally dictated, population-based, government-controlled decision trees would rub Americans the wrong way. That kind of system relies on a compliant, passive, fatalistic populace resigned to a much lower level of self-determination than Americans have traditionally enjoyed. Today, as in 1994, a majority of Americans would not fit this description.

But several more years of being subjected to Quadrant III healthcare may get us there. This is almost certainly what Wonkonians are relying on. Each day we remain under our present system of inefficiency and inequity, more Americans become completely fed up and resign themselves to the idea of a single-payer, government-controlled healthcare system. It seems to be the least bad of several very bad choices. All Wonkonians have to do is continue advancing the perfidies of our present system and wait. The people will come around.

It is a good strategy, and there is an excellent chance that it will work. Short of riding out our current piecemeal, largely Gekkonian system of covert rationing to the end, that is, until the fiscal time-bomb it is creating actually goes off and wrecks our society, most Americans would find it hard to imagine an alternative to the Wonkonian "solution."

Only one thing can steer us away from the Wonkonian solution - empowering patients to act on their own behalf. Patients with sufficient knowledge and the systems to apply that knowledge will not only wreck covert rationing (which relies on patients being complaisant) but will also make the Wonkonian healthcare solution of centralized governmental control completely unworkable. We will have to discover an alternative to both Gekkonians and Wonkonians; and patient empowerment will reveal to us what that alternative should look like.

Patient empowerment

Covert rationing depends on a credulous public, and on well-behaved patients. Maintaining Quadrant III healthcare requires the general public to ignore the necessity and the reality of rationing, and to believe that any apparent limits on healthcare result from corruption, waste, and inefficiency, which, thanks to the efforts of Wonkonians and Gekkonians, are being rooted out bit by bit. More important, when members of the general public become patients themselves, covert rationing requires them to rely on their doctors and their health plans to determine what's right for them.

This requirement is the Achilles' heel of covert rationing. For once you become a patient, behaving as you're supposed to produces an immediate threat to your own life and limb. In other words, continued covert rationing requires that patients continue to act in a manner that is against their own interests.

Patients who understand this-who understand that it is not in their interest to rely on the advice of their doctors and health plans-can take immediate steps to protect themselves. Instead of passively accepting the diagnoses and recommendations for treatment that are presented to them, these patients will check things out for themselves and seek independent confirmation that nothing is being overlooked or "forgotten." They can make it hard for the healthcare system to practice covert rationing against them.

If enough patients do this, the covert rationing of healthcare will no longer be possible. Covert rationing will collapse under its own weight, from within, because of the actions of tens of thousands of individuals acting independently in their own interest. Covert rationing simply will not work any more.

The collapse of our Quadrant III healthcare system will be painful. When it occurs, our healthcare system is likely to become even more chaotic for a time than it is today. Yet it is at this point that we will be forced to face the real limitations to what our healthcare system can provide. Americans will at last be ready to hear the truth. Some brave leader can show us what our real choices are, without being stoned, banished, or ignored. And finally we can begin constructing a new, rational, and equitable healthcare system.

At this moment, when Gekkonian covert rationing collapses under the weight of patients behaving badly (that is, autonomously), Wonkonians will immediately step forward with their solution-a centrally controlled Canadian-style healthcare system. But they will find that Americans are even less ready for such a system than they were in 1994.

Here's why: Covert rationing will not have failed because it wore everybody down to the point where anything seemed better. Instead, it will have failed because of a new multitude of self-empowered Americans. The American populace will fit even less than it does today the profile necessary to establish a paternalistic, top-down, government-run healthcare system. Whatever system we establish at that point to replace covert rationing, whether or not it resembles the system we discussed in the last chapters, it will have to honor the self-actualized, self-empowered, autonomous American patient.

The catalyst to a uniquely American solution to the problem of healthcare rationing, then, is the empowered patient. Americans-not all Americans, not necessarily a majority of Americans, but a critical mass of Americans-are going to have to begin taking their healthcare into their own hands. For this to become possible, a sufficient number of doctors have to recognize that empowered patients are their best hope for salvaging their profession, and they have to support those patients. And the American biomedical industry has to understand that their own survival depends on helping individual patients become self-empowered.

What patients need to do

When you interact with the healthcare system as a patient, your first concern is not reforming the system. Your concern should be getting what you need from a healthcare system that systematically subjects you to covert rationing. This means taking charge of your own healthcare and, by so doing, immunizing yourself against covert rationing.

This is not a trivial task. Having to resolve your own medical problems is frustrating. No matter how much time you spend searching the Internet, listening to the accumulated wisdom of your Great Aunt Hilda, or playing Twenty Questions with taciturn medical personnel, you can never be sure you have the right answer. The system today is not geared toward helping you; for it to work, you have to remain at least partially in the dark. That's what covert rationing is all about.

Still, there's a lot you can do to protect yourself within the healthcare system. You can empower yourself with knowledge. You can manage your relationship with your doctor so that, when it is time to covertly ration care, perhaps you will be the patient for whom he occasionally goes the extra mile. You can demonstrate a desire for-and show your willingness to pay for-the tools of empowerment. And when your ability and even your right to empower yourself are challenged, you can firmly stand your ground. The Surviving It section of this website provides more specific advice on self-empowerment.

What health professionals should do

Of the many negative ramifications to Quadrant III healthcare, only one directly affects all patients and all doctors all the time: the loss of the traditional doctor-patient relationship.

When we get sick, every aspect of the healthcare system we rely upon to restore our health is concerned mainly with not having to spend too much money on us. A concern about spending is to be expected-and it is necessary. We want regulators to be concerned about maximizing the benefits of healthcare for society. We want HMOs to be concerned about maximizing benefits for their subscribers. We want everybody to be concerned about spending our limited resources wisely.

But what we don't want is for our doctors-as they sit at our bedside and make decisions about our health-to be primarily concerned about the needs of society or about their continued ability to earn a living if they spend too much. We want them to be primarily concerned about our needs. Just like the citizen accused of a felony, we need that highly trained professional who takes up our cause and jealously protects our rights and welfare in the face of all opposition. For, as long as our doctors fail to assume their traditional roles as our personal advocates, we will be at the mercy of a healthcare system geared toward saving or making money. Thus, the deterioration of the doctor-patient relationship puts us in immediate peril.

The destruction of the doctor-patient relationship weighs on physicians more than on patients. While loss of this relationship may affect both doctors and patients all the time, few people are patients all the time, while doctors are always doctors. Doctors feel the loss every day of their lives. It is particularly frustrating to doctors that they have been coerced into becoming the engine of destruction of this relationship. Many of them understand, deep down and better than their patients, that without the classic doctor-patient relationship, their worth as professionals is fatally devalued; their profession is, in fact, ended.

Physician heal thyself

Is there anything doctors can do to heal themselves, other than leave practice and become florists, deep-sea fishermen, or authors? There is. They can find a way to create a demand for a restored doctor-patient relationship and then provide the means for achieving it.  The Surviving It section of this website gives some examples, and my book, Fixing American Healthcare, goes into some detail in describing how doctors can re-make themselves into facilitators of patient empowerment, instead of tools for covert rationing. 

What biomedical entrepreneurs should do

The classic Quadrant IV healthcare system was a boon to the biomedical industry; as long as its products promised some measurable (or perceived) benefit to patients, the Tooth Fairy would pay for them. This "if you build it, they will come" paradigm led to explosive growth within the biomedical industry in the decades following World War II and to remarkable progress in our understanding and management of a host of diseases. Unfortunately, it also led to one of the most convoluted business models that capitalism has ever produced.

A complicated business model

The biomedical industry  is unlike any other. To successfully sell a medical product in the American healthcare system, a business must: (a) invent, develop and build the product; (b) convince the FDA, often with evidence from randomized clinical trials (at a cost of $10-50 million and several years effort), that the product is safe and effective; (c) once FDA approval is gained, convince insurance carriers and Medicare that they ought to pay for it; and finally, (d) convince doctors to prescribe it.

Each of these steps is costly and complicated. Both the business risk and overhead expense of such a business model are massive; these costs guarantee that most products this industry sells, even if the unit cost of manufacturing an item is small, will be very expensive.

Nobody would design a business model like this on purpose. It evolved. But a few score of large biomedical companies have adapted to it, and over the decades successful companies have developed all the processes and subsystems necessary to function within this complex model. Companies that have learned to operate under this model are not anxious to change it, because it creates a huge barrier to entry for new competitors.

Threats to the biomedical industry

There are two major threats to the biomedical industry as it now exists. The first is that in a Quadrant III healthcare system, the built-in complexity of their business model, combined with their dependence on hostile third-party payers, makes biomedical companies vulnerable targets for covert rationing.  The second is that these businesses usually have little or no contact with those who benefit from their products,the patients. Their chief potential allies, therefore, are largely indifferent to them.

Biomedical companies often have trouble articulating who their customers are. This is because they have many customers-the FDA, Medicare, other federal agencies, insurance companies, HMOs, professional organizations and societies, and, especially, doctors. But patients have little to do with the decision to purchase the products of these companies. While these companies loftily proclaim that patients are their primary reason for existence, in general patients are no more the customers of the biomedical industry than poodles are of the companies that make doggie sweaters.

This leaves the biomedical industry vulnerable to demonization. Drug companies especially, but increasingly others as well, are no longer spoken of as good corporate citizens or as institutions whose dedicated efforts cure disease and alleviate suffering. Instead, they are painted as evil and corrupt, as willing to satisfy their greed through graft, double-dealing, animal abuse, and even manslaughter.

Wonkonians and Gekkonians want to demonize the biomedical industry. One of the key reasons for our exploding healthcare costs, they insist, is "too much expensive technology." Blaming the technology itself - which the public finds useful and wants more of-for the healthcare crisis is a tough sell; but accusing the capitalists who supply this technology of waste, fraud, corruption, price-gouging, etc. - well, that's an argument with legs. Wonkonians demonize the biomedical industry and the press abets them. This strategy has traction with the public, placing many Americans squarely in the Wonkonians' camp. Wonkonians would fix the problem with new laws and regulations to bring the out-of control biomedical industry to heel.

Most executives in targeted companies wonder why they, who consider themselves in the business of helping mankind, are under attack. But covert rationing requires the biomedical industry to be brought under control. Today's biomedical industry is not compatible with covert rationing, and it has to go.

Painting the industry as greedy and untrustworthy is a necessary strategy for Wonkonians and is a good strategy for Gekkonians, too. It creates the political mandate needed to regulate and prosecute the biomedical industry into submission.

Why the biomedical industry needs the support of patients

In the battle over its future, the biomedical industry has few allies. Many of its customers - especially the federal government and HMOs - are customers only reluctantly and resentfully and are among its demonizers. The industry's other main customers, the doctors, are engaged in a battle for survival themselves and are not likely to be effective or focused allies.

The industry's only natural allies in this fight are those who directly benefit from its products and who have good cause to defend it from destruction-the patients. Patients would be powerful allies if they rose up in the industry's defense. But the public in general and patients in particular do not usually have warm feelings for the industry and are all too happy to line up with its persecutors.
For the most part, the biomedical industry just doesn't get it yet. They don't realize that they are in a battle for survival, one that will determine whether they are to continue as innovators or instead as assembly lines churning out government-approved quotas of government-approved widgets and pills. While the industry continues playing under the old rules, keeping patients at arm's length, Wonkonians and Gekkonians and their allies are filling the public's head with horror stories, trying to work the public into a frenzied cry for those in the greedy and callous biomedical industry to be tossed to the lions.

Unless the biomedical industry wakes up and figures out how to get the public on its side, it faces ruin.

How can the biomedical industry recruit patients to its cause?

A multi-million dollar public relations campaign is not the way for the biomedical industry to get patients on its side. The public is already convinced that biomedical companies routinely engage in price gouging, in withholding vital information to keep their unsafe products on the market, in lying about the supposed benefits of their products, and in bribing doctors. The public is being fed this story every day in a hundred ways by prestigious newspapers, medical journals, politicians, medical experts, cable news channels, and talk show hosts. (By their actions companies often enough provide plenty of fodder for this story.) Against this unrelenting attack, even the slickest advertising campaign won't work. Battling the press in the press isn't a winning strategy.

A better way to win patients over would be to give them something they want and cannot easily get. That something is empowerment.

Empowering patients

Biomedical companies that want to assure their survival as independent and self-directed enterprises should partner with patients whose goal is to become self-empowered. Businesses that learn how to enable patient empowerment will be immunizing themselves against subjugation by Wonkonians. Empowered patients will not stand by and watch the destruction of the entities that make their empowerment possible.

Companies in the biomedical industry will find this hard to do. They don't sell products directly to patients or know how to interact with patients. They don't know what patients want. They are geared up for the much more complicated task of selling things to the healthcare system. They are intimidated by actual patients.

Even the remote contacts they do sometimes have with patients, such as producing educational materials or running TV commercials, are viewed as controversial or inappropriate (because doctors reserve the authority to determine what patients ought to know). Avoiding direct contact with patients is embedded in their corporate cultures, and many companies will find the idea of starting a patient empowerment business counter to their values.

Companies that want to remain successful over the long term have to find ways to work around this barrier. The demand for empowerment tools among the public is a massive business opportunity. Setting that aside, unless these companies develop a patient empowerment business model, they risk extinction.

Biomedical companies should not abandon their current businesses to concentrate on patient empowerment. But they should engage in patient empowerment so they can continue their core businesses. This might require establishing spin-off enterprises that can develop and market patient empowerment tools without contaminating the core business. But they should take this effort seriously, as if some day the patient empowerment side of the business might be their chief endeavor. Because some day it might.

What will patient empowerment look like?

Nobody knows what patient empowerment will actually look like, because it hasn't been invented yet. Like most entries into new markets, this one will probably begin with tentative and primitive forays into the landscape, seeing what patients will respond to and not respond to. When they recognize the possibilities, patients will begin asking for specific products, services, and features; that is, the customers will begin to better define the market. And, seeing the growing demand, more and more entrepreneurs will jump into the fray, testing an array of ideas. Sooner or later, there may come a killer app, a VisiCalc  of patient empowerment, that forever changes expectations and makes the empowered patient as common as the personal computer. If we reach this stage, covert rationing will be doomed.

We already know some of the things patients want. More than increased longevity, they want to remain healthy and independent into their old age. They want to avoid disability and institutionalization. The sandwich generation wants the tools to keep their aging parents out of institutions, without neglecting their own young families. Patients with chronic illnesses that need a lot of management-diabetes, heart failure, and difficult-to-control hypertension immediately come to mind-want the tools to do most of that management themselves. And those at high risk for treatable cardiovascular emergencies-heart attack and stroke-want to prevent these emergencies and, if they cannot be prevented, to immediately detect and treat them whenever and wherever they occur. These are among the things that many people will pay for themselves.

A lot of tools can be brought to bear to begin meeting these needs, including a multitude of technologies, sophisticated communication systems, and data management and decision support systems, all aimed at providing remote monitoring, self-monitoring, effective diagnostics, and novel therapies and services.  In Fixing American Healthcare I provide concrete illustrations as to how doctors, patients and biomedical entrepreneurs can evolve systems that empower patients, re-establish doctors' professional integrity, and remove the biomedical industry out from under the Wonkonians and Gekkonians. Here, I'll just assert that such things are imaginable and eminently possible - it's a largely a matter of realizing the potential, and just doing it.

A healthcare reformation

None of this will be easy. Powerful forces will align to stop the creation of a patient-empowering healthcare marketplace. All the necessary players-patients, doctors, and entrepreneurs-will need to persist in their efforts despite increasingly strident, desperate, and threatening attempts by Wonkonians and Gekkonians (but especially Wonkonians) to stop them and to denounce them as elitist, criminal, and immoral. The covert rationing establishment is at least as entrenched (and corrupt) as the early sixteenth-century Church; the notion of patients becoming self-empowered is at least as frightening as the notion of the teeming masses communicating directly with God; physicians answering only to their patients is at least as threatening as renegade priests answering to parishioners; and empowering technologies are at least as heretical as printing the Bible in the vernacular. The coming fight will resemble nothing, in terms of its intensity and potential for acrimony (and worse), so much as the Reformation.

Most of us will enter the fray not to become reformers but rather to protect ourselves, our families, our professional legitimacy, and our businesses from a broken healthcare system-that is, for ostensibly selfish reasons. To survive the attacks that will come our way, we need to remind ourselves of the higher cause we are serving.

Is what we're doing unfair? It is not. It would be difficult to imagine a healthcare system more unfair and inequitable than the one we have now, in which money is being taken from the paychecks of workers to pay for the healthcare of others, when they themselves have no health insurance; in which deceptions, half-truths, outright lies, and coercion are routinely employed by the central authorities entrusted with managing the healthcare system; in which the interests of doctors have been systematically divorced from the interests of their individual patients; and in which patients are left to fend for themselves, without their rightful advocates, at a time when they are least capable of doing so, within a confusing and dangerous healthcare system. What we are doing-learning to protect our own rights and welfare, in the process exposing the truth of covert rationing, and establishing the systems and methods for others to follow-is restoring, not destroying, equity.

Is what we're doing immoral? It is not. By insisting on our right to self-determination, we are reestablishing a foundational American principle that has eroded in recent years in part because of covert rationing. By taking the steps necessary to empower ourselves and to enable that same empowerment for others, we are asserting our right to self-determination in matters related to our own personal needs. It is an American birthright. Others are trying to take it away. We are stopping them.

If we allow this attack on our ideals to go unanswered or if we fight back and lose, we will pay a much higher price than a bad healthcare system. This is why we owe it to ourselves and to future generations of Americans to take up the cause.

We need to recognize covert rationing for what it is. We need to shine a bright light into the dark corners where it lurks. We need to point to it, call it by its name, illuminate its methods and reveal its secret language. We need to show what it is afraid of-truth, equity, and the intrinsic worth of the individual.

The shrillness of the cries and the brazenness of the protests against our efforts at self-empowerment should be recognized for what they are - signs of just how far we've already fallen away from those founding ideals and of how close the idea of individual empowerment strikes at the heart of the enemy. If anything, these protests should steel our resolve. We are fighting for our own rights and welfare, but we are also fighting a battle to restore every American's right to self-determination. It won't be easy. But we are not sinners; we are holy warriors.