The following article first appeared in the Maryland Medical Journal (MMJ) Vol 44 No.4 on April 1, 1995. TMP is republishing it in 2001 because of its timeliness. Human folly is nowhere better illustrated than in the human penchant for gambling or in the disastrous methods being used to regulate health care. The American Psychiatric Association has reported an alarming increase in on-line gambling during the past few years (since this story first appeared). The Baltimore Sun has reported that influential members of the Maryland State legislature have prepared a bill to legalize slot machines in Maryland, with the expectation that full scale casino gambling will follow soon after. We are told that legalized gambling will help the economy and raise funds to pay for schools and ironically, for addiction counseling and support. If necessary, legislators are prepared to rewrite the State constitution to permit this goal to be achieved. Sorry to say, this is not an April fool joke. Absurd as it is, the legislative proposal is all too real.

April 1, 2001. The health care crisis is finally over. It ended when Donald Trump and the gambling industry took control of health care from the Insurance Industry. Health care is now available to anyone who wants it, and it's free as long as you play. For those who have not kept up with the rapid changes in health care, a short review of developments over the past few years may be helpful.

The crisis was not really due to a shortage of health services or that health care cost too much. It was mostly over the amount of money that could be made and about who was going to get it. Nearly everyone agreed that doctors did not understand money and did not deserve to have it or even handle it. The public understood money even less and needed someone to manage it for them.

Politicians fought with the insurance industry for control and insurance companies battled with each other for market shares. It was like a bunch of dogs fighting over a bone. Some observers believed that a genuine health care crisis was actually created as the health care system was torn apart by this struggle. Everyone agreed that health care would never be the same.

Insurance executives say that they did a lot of good. Others aren't so sure. It is true that discipline was imposed on the system. Health care rationing was made less offensive to the public by giving it different names such as: Managed Care, Health Maintenance (as in (HMO’s), Capitation, and Free Choice. Other names were changed too. There were no more doctors or patients. They were relabeled providers and consumers. Doctors, nurses, social workers, technicians, and all other health care workers were lumped together as providers. This made them interchangeable and saved a lot of money that could go into profits for the insurance companies. As consumers, patients were empowered to make choices between health care "packages" without knowing the contents.

Health insurance companies' profits skyrocketed, while physicians’ incomes plummeted. Doctors burned out, patients burned up, and hospitals closed down. When patients were displeased with empty health care packages they took out their anger on doctors for lack of more accessible targets. Insurance companies used patient dissatisfaction as an excuse to further reduce doctors’ fees, thus creating even more profits for shareholders.

Health care evolution did not end with insurance companies and HMOs any more than biological evolution ended with Tyrannosaurus Rex. These business organizations dominated the landscape for a while, but they made some fundamental blunders, which set the stage for their demise. Their biggest mistake was in ignoring, or not knowing, TRUMP'S RULES, which are as follows:

1. DON'T TELL PEOPLE WHAT THEY NEED, GIVE 'EM WHAT THEY WANT.

2. MAKE EVERYONE FEEL LIKE A WINNER.

The insurance companies and HMOs gave no one what they wanted, and made everyone feel like losers.

Trump saw his chance and moved in. His thinking on the subject is described in his recent best selling book "You Bet Your Life", Trump reminds us that everything in life is a gamble, starting with which sperm will reach the egg. Taking chances is unavoidable, and we take them with every move we make. The best we can do is to play the odds. Humans have adapted to this uncertainty in life in various ways and have even learned to enjoy it by making bets. People like excitement and thrills, even to flirt with danger, but they also want security.

As Trump's argument goes: Although insurance is advertised as a way of buying security, it is in fact a form of gambling, in which security is often only an illusion. In insurance as in casinos, the player bets against the house. In life insurance for example, the policyholder is betting that he will expire before his policy does, while the company (the house) bets that he won't. In health insurance, the policyholder bets that he will need medical care costing more than his premiums. The insurance company bets that he won't need it or that, at least, they can avoid paying for it. The insurance industry is, in effect, a large gambling enterprise that represents itself as a quasi public utility. The industry has been successful because of a combination of actuarial, financial, marketing, and political skills.

According to Trump, these capabilities, though impressive, are no match for those of the gaming industry. The gaming industry has a far better understanding of human motivations and behavior than the insurance industry (or the medical profession, for that matter). Both the insurance industry and the medical profession attempt to tell people what they need. Trump knows what people want Trump knows that people want excitement. They want to take chances, but to feel safe while doing so. He also knows that people want to live recklessly while having the safety net of free health care. He will give them what they want. No one should complain if he enriches himself and his partners while doing so.

Trump's health care financing plan took the country by storm. Adding to his gambling establishment, he established the "Taj Majal Health and Gaming Resort", with headquarters in Atlantic City. He made health coverage automatic for anyone who plays, and for as long as they play. One can play roulette, blackjack, slot machines, craps or any other game in the house. It's all the same. Win or lose, coverage is in proportion to amounts wagered. (A small percentage of sums wagered goes into the health care account.) As long as you play you can never lose your health coverage. And you still have a chance to win the jackpot. Trump promotes his painless method of financing health care with such slogans as: DON'T GET SICK - GET LUCKY!

After Trump added his health care package to the Taj Majal operation, a revolution in health care financing took place almost overnight. Vast numbers of people from surrounding areas dropped their health insurance and headed for Atlantic City. Gambling facilities strained under the onslaught, but were rapidly expanded.

As other gaming organizations followed Trump's example, new facilities were established in Atlantic City and Las Vegas, on riverboats, ships at sea, and in States throughout the nation. Whatever your favorite game of chance, you can now play it and get free health coverage.

Home shopping networks have joined in by adding gambling channels. For those who are housebound, or prefer to stay at home for any reason, it is now easy to play on interactive television, 24 hours a day, seven days a week, and gain health coverage while doing so.

Indian Reservations, some of which already had legalized gambling, expanded their facilities and now offer free alternative medicine, Native American style, for everyone who plays.

Casinos overcame people's moral objections to gambling by donating some of the profits to charity or to other good causes. One week would be Cancer Week, in which a fraction of each dollar wagered would go for cancer research; another week would be for AIDs research, or for the homeless and so on. These charitable contributions are highly advertised and enable people to feel virtuous as they play.

Doctors rushed to join the system. There was no red tape and no paper work. In order to be "providers", they merely had to play at the gambling tables. A remark by a well-known medical leader is often quoted "Even if health care these days is just a crap shoot, now at least there's a chance of winning something." Your best chance of finding a doctor now is at a casino.

Medical school courses on "Managed Health Care" have been replaced by courses on "Gambling and Health Care". These are the only classes in which students always stay awake.

As the gaming industry took over health care, the health insurance industry collapsed. Victims of their own misjudgment of human nature, they quickly lost their contracts and went into the red. Down but not out, health insurance companies and HMOs had huge cash reserves gained during the preceding years. With these resources they bought into the gaming industry, and in the process drove the prices of shares through the ceiling. Wall Street went wild.

Trump cites recent studies conducted by the Taj Majal Institute for Medical Research, showing clinics and hospitals to be half empty. This is seen as proof that most doctors and patients think their time is better spent at the gaming tables. Ever since Managed Care set the standard by allowing a maximum of twenty minutes for any type of surgery, from ingrown toenails to kidney transplants, many people believe that their chances at the gambling table are better than they are on the operating table.

Members of Congress visited Las Vegas and Atlantic City in expense paid junkets to study the Gambling-Health Care System. Its superiority over other health-care systems was easily appreciated. This led to a bipartisan decision to dump managed care and turn Medicare and Medicaid over to the Gambling-Health Care industry for management and financing. The resulting Play And Pay As You Go Plan removed the immense financial burden of these programs from the taxpayer while providing daily gambling recreation for the aged and the poor. Most Medicare and Medicaid beneficiaries claim to be happier and healthier than under the old systems. A popular slogan is Live for today and forget about tomorrow!

Every advance in human society has its opponents. There are some voices from the medical field and elsewhere that denounce Trump's system as corrupt and evil. They say that we are rapidly going to Hell. Trump reminds us that under Managed Care, we were heading for Hell anyway. Under his system, at least we can enjoy the trip.

Perhaps things could be done in better ways. Perhaps the time will come when human affairs are governed by benevolence and wisdom rather than by greed and folly. Perhaps. But don't bet on it.