by Rand Paul
I felt privileged to be with Dr. Crandall and his team, who had organized and completed more than sixty medical missions. His wife, Julie, was an integral part of the leadership that made the examination, measurement, and surgery of over two hundred patients go like clockwork.
I was grateful to be able to put on my scrubs, peer into the oculars of the microscope, and focus on the task at hand. I was excited to be back in my element. Since being sworn in to the Senate in 2011, I have operated on uninsured patients throughout Kentucky, but those occasions are limited to one day at a time. In Guatemala I was able to do what I love for several days in a row.
Familiar Faces
My connection to Guatemala goes back nearly fifteen years. When the idea of going on a medical mission during the August recess first occurred to me, Guatemala was my first choice, mostly because of my memories of children I had operated on in Bowling Green many years before. In the late 1990s, I’d treated the Hernandez brothers, Juan and Andres, and Juli Estrada. They were children when I saw them then: Juan was eight, Andres was fourteen, and Juli was ten or eleven.
I met them because of the humanitarian work of Bill and Judy Schwank. Bill was born in Guatemala and came to the United States to practice neurosurgery. As I’ve mentioned, Judy is an advocate for adoption.
The Hernandez brothers are from Jalapa, a tiny town in the mountains of Guatemala. Judy Schwank tells me it’s beautiful, with a view of the lush green valleys below. Once when she went to visit them she saw a quetzal, the national bird of Guatemala. The quetzal is red and aqua green, with long green tail feathers that follow the bird like the tail of a kite. Sightings are rare. Judy has been going to Guatemala for many years and lives there part-time, and it was the first time she saw one. It’s said that they die in captivity. They need to be free to live.
I admire the bird’s values along with its beauty.
Though the setting is breathtaking, the boys’ house is primitive, literally a stick shack with dirt floors and no electricity. When they arrived in Bowling Green, both the Hernandez boys had mature cataracts. Juan could see only hand motion, and Andres just light perception. Judy told me that Juan and Andres would hold hands and count the number of steps to a river that was eight city blocks away. There they would fill a bucket for their family and then count the steps back to their house. The story of the water buckets has stayed in my memory all these years not only because of its poignancy but because the boys caused something of a mini disaster for the foster family they stayed with in Bowling Green. The boys had never seen running water before, and somehow they stopped the drain in the upstairs bathroom and left the water running. The family realized it when they saw the water pouring through the downstairs ceiling.
Technically, the cataract surgery on the Hernandez boys was not that different from what we normally do for adults. The difference is in the expectations. In children, if vision is not normal in the first seven years of life, the vision center of the brain doesn’t develop. Since the Hernandez boys were beyond age seven, I couldn’t know in advance how much their vision center had developed or if removing their cataracts would restore much or any vision.
After the surgery we waited anxiously. As the patches were removed, big smiles beamed from each boy. I had a bowl of fruit in the office, and the sight of the bananas and oranges fascinated them. Outside, they were astounded to discover the color of the sky. Though their vision wasn’t perfect because the vision center in their brains hadn’t fully developed, the surgery did achieve what we call ambulatory vision. The boys could identify objects and find their way around their village. They would no longer have to hold hands and count steps to the river.
When they left, I didn’t think I would ever see them again.
But here in Salamá, courtesy of Judy Schwank again, Andres and Juan stood in front of me.
“Hola, Dr. Pablo!” they said in unison. The trip had taken them almost twelve hours, stopping first at Bill and Judy Schwank’s home on the other side of Guatemala City.
“Mire la luz,” I said to Juan as I pointed my pencil light into his eye.
Juli Estrada also came to the clinic in Salamá. When she came to see me in Bowling Green, her eyes were crossed inward, what we refer to as esotropia. As with the Hernandez boys, the vision center of her brain did not develop properly, and we could not restore the vision in the unused eye. But I was able to straighten her eyes and give her a normal appearance, and she’d grown into a beautiful young woman. The vision in her good eye could, however, be improved with glasses, which we were able to provide.
Fashion Statements
The trip went by quickly. There were some disappointments. Though the Hernandez brothers had desperately hoped for something that would further improve their vision, there was nothing more that could be done.
But there was laughter, too. The humanitarian organization the Hope Alliance brought suitcases filled with eyeglasses that had been collected by Lions Clubs, Rotary Clubs, and other organizations from across the United States, but especially from Utah. In total there were about eleven thousand pairs, with most coming from various lost-and-found boxes. Sorted and categorized according to power, they were piled on tables. By midmorning, elderly Guatemalan women were sorting through the stacks of eyeglasses, throwing back unwanted pairs, and looking for styles that suited them. Some things are universal.
Heading Home
My eighteen-year-old son, Duncan, also came on the trip, as did my niece Lisa Paul and her fiancé, Wes Kimbell. Lisa, a newly minted physician, was about to begin her training to become a pathologist, so the journey was of particular interest to her. While the medical team operated, Duncan, Wes, and my friend Rob Porter helped install a water purification system for a local school. One of the surgeons from Utah, Jeffrey Pettey, brought soccer balls to give out, and Duncan gave some of the soccer balls to kids at the school, which made him something of a hero.
We drove through the jungle toward Guatemala City and our flight home. Though the murder rate in Guatemala has dropped over the past three years, it can still be a very dangerous place. In the 2013 crime and safety report, the State Department’s Bureau of Diplomatic Security calls the violent crime rate in Guatemala “critical.”1 The president of Guatemala, Otto Pérez Molina, was nice enough to loan us part of his security team.
As we wound through the mountains on the way back to Guatemala City, our security team proudly kept us safe from harm. Axel, a strong, quiet man, did his job professionally and without obvious emotion, but as he bid farewell to us in the airport, I think I saw a tear well up in his eye. He then sincerely thanked us for what we had done for his fellow countrymen.
“De nada,” I responded, but it wasn’t just nothing—the smiles on the faces of previously blind patients is a priceless reward that I will never forget.
A New Way to Look at America’s Health Care
During the 111th Congress, the Congress passed and President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), commonly known as Obamacare. I was not a member of the United States Senate during the 111th Congress, but had I been, I would have voted against Obamacare. The law expands government, inhibits the free market, and shuns individual responsibility. It also costs our economy 2.5 million jobs by forcing employers to take money from payroll to buy insurance.
Since the passage of Obamacare, states, businesses, and other institutions have filed constitutional challenges to many of the burdensome provisions of the law. While the Supreme Court has ruled on the provision of Obamacare that requires individuals to purchase approved health insurance or pay a penalty, dozens of lawsuits remain pending on various aspects of the law.
As a doctor, I have had firsthand experience with the vast problems of the health-care system in the United States. As in other areas of the economy in which the federal government wields its heavy hand, health care is overregulated and in need of serious market reforms.
Many years ago when my father first entered
politics he wrote an essay on kwashiorkor. Caused by a lack of protein, the disorder creates the swollen bellies of starvation. I’m sure you’ve seen photos of African children with the disease.
As a medical student, my father dreamed of a cure for kwashiorkor. But the more he got to know about the disease, the more he realized that the answer was economic, not medical; it was more related to diet and poverty. In Guatemala, Alan Crandall gave me a book that explored the same theme as my father’s essay.
The book, Second Suns: Two Doctors and Their Amazing Quest to Restore Sight and Save Lives, by David Oliver Relin, tells the story of two remarkable ophthalmologists and their ambitious goal of eliminating preventable blindness worldwide. One of the ophthalmologists is Dr. Sanduk Ruit, who was born in a poor village in Nepal. Three of his siblings died of diseases that are curable in the West. It was those sad events that convinced him to go into medicine. From the beginning of his schooling he showed brilliance. He could have practiced medicine anywhere in the world but decided to stay where he was needed the most—at home.
His partner has quite a different story. Dr. Geoffrey Tabin was a world-class mountain climber and repeatedly dropped out of Harvard Medical School to follow his passion of climbing the Earth’s tallest peaks. Very few people drop out of Harvard Medical and are allowed back in, but Tabin was one. After becoming an ophthalmologist, he read of Dr. Ruit’s work and traveled to Kathmandu to meet him.
By then, Dr. Ruit had discovered a surgical technique for cataracts that took about four minutes to perform at a cost of about $20. The procedure consisted of a small incision that didn’t require sutures. The diseased lens of the eye was then removed, but the elastic capsule that covers the lens was left partially intact to allow an artificial or intraocular lens (IOL) to be implanted.
Though his medical accomplishment was substantial, the fact that he could manufacture intraocular lenses cheaply and locally in Nepal made his discovery a medical breakthrough with global ramifications. These types of lenses cost $150 or more in the West. In Nepal, they were making them for $4.
In all, Ruit’s cataract surgery produced results similar to those in America at a tenth of the cost. Ruit and Tabin, who are not only brilliant surgeons but also business dynamos, built cataract surgical clinics in seven countries and have trained thousands of doctors in the Ruit technique.
Ruit estimates his surgery has now been performed on over 3 million people.2
Though the debate over Obamacare may appear, at times, to be a debate over health care, it really should be a debate over what type of economic system distributes goods the most efficiently.
Since the collapse of the Soviet Union, most economists have acknowledged that only when the marketplace determines the price of goods and services can the goods and services be distributed efficiently.
What does that mean?
It means that the Soviet Union failed because a central planner, an office in the government, set the prices of goods. The Soviet Union failed because that office couldn’t determine the price of bread. If it set the price too low, bread would fly from the shelves, and there would be shortages and scarcity. If it set the prices too high, the bread would spoil on the shelves, and again there would be a shortage.
Only in democratic capitalism, where millions of consumers vote daily, can the correct price of goods be determined. By definition, that price would afford the most goods to the most amount of people.
There is no moral price. There is no correct price that any one individual, or government, can discover and set for the rest of us. This has been true since the first item was sold. The eighteenth-century philosopher and economist Adam Smith coined the phrase “fatal conceit.” In his book Wealth of Nations he wrote: “every individual, it is evident, can in his local situation judge much better than any statesman or lawgiver can do for him.” A couple of centuries later Friedrich Hayek, the Nobel Prize–winning economist, titled a book The Fatal Conceit and wrote that individuals would be presumptuous to believe they had sufficient knowledge to discover a correct price for the marketplace.
The same can be said for the current governmental control of health care. Every time a Washington bureaucrat sets a price the consumer suffers.
“But health care is too precious to let consumers decide,” the handwringers cry.
Health care is precious, but if you insist that it is somehow different from all other goods and services, you will suffer the consequences of economic fallacy. Our health-care situation is not a medical issue, it’s an economic one, and only when we approach it as such can a fix be found.
For example: beginning in the 1990s, a trend of hospital mergers developed and, not surprisingly, patient costs began to rise because of the lack of competition. Hospitals have merged at an exploding rate over the past five years. According to a report in Washington Monthly, in 2009 there were fifty-two hospital mergers. In 2011 there were ninety. In 2012 there were 105. A report written by James C. Robinson, a health-care economist and professor at Berkeley, exposes the huge disparity in the prices these megahospitals charge compared to hospitals in competitive markets. For instance, a knee replacement in a competitive market will cost you or your insurance company a little over $18,000. In a market where hospitals have merged, the same procedure costs almost $27,000. In a competitive market, an angioplasty costs about $21,600; in a consolidated market, the cost balloons to around $32,400. In a competitive market, a pacemaker costs a little over $30,000, whereas a megahospital will charge you $47,500.3 You get the idea.
I’ll give you another example from my own experience. In the late 1990s, LASIK surgery experienced a price war. The cost of the eye surgery, which had been as high as $2,500 and more for one eye, dropped to as low as $500 because of chain competition and advertising. It was not at all uncommon to see “Introductory Offers!” and “Holiday Sale!” boldly displayed in the ads for the surgery.4 Advertising a medical procedure was a relatively new phenomenon. Up until 1982, when the Supreme Court struck down the prohibition, the American Medical Association had banned the practice. Though some of the ads were cheesy, they were an indication of the free market at work.
There were those who railed at the idea of the market setting the price of eye surgery. In December 2000, Dr. David Kessler, former dean of the Yale Medical School and the former commissioner of the Food and Drug Administration, told the New York Times the trend was the “corporatization of medicine in the most extreme form.”5 Dr. Sandra Belmont, who served as the founding director of the laser vision center at Weill Cornell Medical Center in New York and a spokeswoman for the American Academy of Ophthalmology, said: “Patients should not choose their doctor based on price.”
Yet look at what happened in both the LASIK marketplace and the contact lens marketplace. Prices fell and remained lower. Contact lenses, which were $15 or so when I started in practice, are now less than $3 and are available in abundance.
The problem with Obamacare, and even with the old system, is that when insurance or government pays for the first dollar of health care, the consumer doesn’t care about the price and neither does the physician. Without a market, the price goes up. LASIK surgery is not covered by insurance. The average person will call multiple doctors to compare prices. I’ve never had one Medicaid patient call and ask about price. If you’ve got great Blue Cross with a $20 deductible are you going to call around and compare prices? I don’t think so. If you don’t shop for prices, you don’t force prices down.
But emotions run high when we talk of health care. Only the government can distribute it fairly, some say. But that is the same thought process that caused Soviet shelves to be bereft of bread. Rationing either by mandate or by waiting in line is an inevitable side effect of government distribution of goods.
There is a better option than what we now have. Free up prices. Legalize and expand tax-free health savings accounts. Allow a marketplace of freely fluctuating prices for everyone. The consequences will startle you. The beauty of capi
talism is that it distributes the greatest amount of goods at the cheapest price. Instead of socializing medicine, why not let the engine of capitalism distribute health care—it’s what we do best. It’s what made America great in the first place.
The economist Joseph Schumpeter once remarked, “The capitalist achievement does not typically consist in providing more silk stockings for queens but in bringing them within the reach of factory girls in return for steadily decreasing amounts of effort…”
But wouldn’t capitalism leave some people behind?
Yes, but so does Obamacare, and so would any health-care system. If we put in place a structure that works efficiently for the vast majority, then it will be easier to address the needs of those left behind. Can we promise that every person in America will receive the best and most timely health care? Perhaps not, though that is always the goal.
When the indigent and uninsured are the exception and not the rule, it will be much easier for the government and charities to take care of those still in need. In the private sector, this happens all the time. The idea that the poor would not be taken care of discounts the elemental nature of doctors and others in the medical profession, and it discounts a fundamental character trait of Americans. Think back to this country’s response to disasters both here and abroad.
Take the example of Dr. Barbara Bowers from Paducah, Kentucky. Dr. Bowers has been a practicing ophthalmologist for twenty years and has always donated part of her time for surgery on people without insurance. I’ve been teaming up with her on my time off from the Senate. Working with Dr. Bowers gives me a chance to keep my skills sharp, so to speak, and updated on the latest equipment. Last year, Dr. Bowers introduced me to a LenSx® femtosecond laser, an amazing machine that emulsifies a cataract without a blade and makes the aspiration of it much easier.