Book Review

As Sick As It Gets: A Diagnosis and Treatment Plan

Rudolph Mueller, MD

(Olin, Frederick, New York, 2001, 228 pp.)


As might be expected from the rave reviews by Physicians for a National Health Plan, As Sick As It Gets offers a single diagnosis and a single prescription for whatever ails any non-rich American.

Why was the author's nephew killed in an automobile-equestrian accident? An alcoholic had failed to lock a gate: probably a "ripple effect" of lack of universal access to free substance-abuse treatment. Why do young persons turn to crime? Ditto. Why does an elderly man commit suicide? If he's a smoker bothered by respiratory symptoms, his early exit is another ripple from lack of free prevention or treatment of tobacco addiction.

Why did 82-year-old "Bill" have a stroke, or why did "Paul" die two days after a seven-hour operation for a ruptured aneurysm of the thoracic aorta? Obviously, it was because of lack of coverage of drugs more expensive than aspirin and lack of insurance, respectively. True, Paul "never got around to taking care of himself," even when he had insurance, and he quit going to the VA Hospital because it was too inconvenient --- although neither of those factors caused his aneurysm either.

Dr. Mueller has numerous poignant tales. There are elderly people who select an HMO that won't pay for their drugs if they spend more than three months of a year in Florida. There's a patient who would quit work if only the taxpayers would take care of her medical insurance. Then there's a woman who can't get an immediate divorce and still have a $30,000 operation paid for by her husband's insurer. The need to pay for your own medical care can really restrict your freedom.

The "market-driven system," Dr. Mueller opines, is responsible for the "inherent injustice" of "allowing 43 million Americans to live without health insurance" --- and allowing more than 200,000 Americans to die every year without having seen a doctor in the previous year. What we need, he thinks, is a system with "everybody in, nobody out."

Why would anybody want to be out of the utopian "single payer" system that he promotes? Perhaps patients would want a better standard of care. There are lines and rationing in all the "single-payer" systems that have been tried. Dr. Mueller admits that, but just rushes to say that some people have to wait in the United States also. What we need is equal misery:

What would happen if all the government officials, doctors, hospital and pharmaceutical company executives, the wealthy and their families had the same coverage and access to medical care as all other Americans? I believe these political, medical and economic leaders would make sure the system works and meets their individual and family's needs and all others too.

That's the Mueller trickle-up theory of economics, the heartfelt faith of all proponents of socialized medicine. If the "rich" can't get better medical care for their children without buying equally good care for everyone else in the world first, of course they will just empty their bank accounts and donate all their assets. The failure of this theory in Canada would probably be attributed to allowing the greedy rich to find treatment in places like Seattle, Rochester, or Detroit --- if Dr. Mueller were to admit to the existence of that vexing issue.

Why would doctors want to escape? Dr. Mueller can think of only one reason. He asserts that "it pays not to participate." Yet in his own state of New York, doctors who do not participate in Medicare are required by law to charge less than doctors who do. Some of the rare, courageous doctors who refuse to sign HMO contracts for ethical reasons --- such contracts put them in a conflict of interest with their patients --- risk serious financial losses. Some such doctors would clearly be better off financially as schoolteachers. Yet Dr. Mueller encourages people to shun independent doctors, without even bothering to find out the cost, and thus he contributes to the dominance of the HMOs he professes to deplore.

Fact checking is not Dr. Mueller's forte, and neither is statistics. Correlation proves cause and effect by his analysis --- as long the "cause" is lack of a "single payer," and the effect is a poorer health outcome. If Americans have a higher incidence of diabetes than nations with socialized medicine, it's because "obese patients' access to medical care can help them realize the importance of regular exercise and diet." If more American diabetics are on hemodialysis than Japanese, Germans, Norwegians, or Australians, it has more to do with medical financing than genetics. Blacks are five times more likely to end up with renal failure than whites (and America has more blacks) --- but Mueller simply assumes that the outcome is wholly due to underinsurance and resultant undertreatment, and that universal single payer would be better than the current single-payer Medicare and Medicaid. Universal coverage would, he baldly asserts, cut end-stage renal disease in half and save $6 billion per year. Actually, it could: by rationing hemodialysis.

Mueller's methodology could be used with equal validity to show that smoking prevents chronic obstructive pulmonary disease (COPD). The U.S. has a 10 percent higher death rate from COPD than selected other nations, but they have both socialized medicine and 34 percent more daily smoking (so much for the purported salubrious effect of socialized medicine on tobacco addiction). Which factor explains the difference in death rate --- or could it be something else altogether? (My guess is that more Germans, Frenchmen, Italians, and Japanese may die of cancer before they would have died of COPD.) Dr. Mueller's single focus prevents him from asking such questions.

In the afterword, Dr. Mueller seems to think of himself as a prophet, a "lone voice calling out in the desert wilderness," and quotes Isaiah 40:3-5. In a way, the book is a call to "prepare the way of the Lord." It is certainly based on ideology, not on science or sound economic analysis, and champions new overlords that will include HMOs (only "not-for-profits," of course), philosopher-king regulators of the health care utility, and tax collectors. No more voting with your feet or your own dollars ("pure market whims") will be allowed.

All that is needed is for the United States to follow the rest of the world down the socialist slope to perdition --- and for the not-so-lone voices of Dr. Mueller and his allies to drown out or smother the individual dissidents. Then there will be no escape.

So follow Dr. Mueller's links to the yellow brick road, such as

Reviewed by Jane M. Orient, MD, Tucson, AZ

Dr. Orient is an internist and the executive director of the Association of American Physicians and Surgeons (AAPS).

Originally published in the Medical Sentinel 2002;7(3):103-104. Copyright ©2002 Association of American Physicians and Surgeons (AAPS).