Sunday, November 9, 2014

Uber, pricey doughnuts, and health care: serving the needs of the people or the interests of the rich and powerful?

Two articles in the Sunday Review of the New York Times on November 10, 2014 that are not explicitly about health care seem to me to be very much related to the health care system in the US. “Republicans and the puzzle of Uber”, by Josh Barro, discusses the conflicting interests that affect policy making, particularly at the state level, and create an ideological challenge for that party. On the one side, the libertarian wing of the party lauds “the smartphone based car service” Uber as a wonderful example of deregulation, of opening the market to new ideas that nimbly serve the consumer and meet a real need. On the other side are the existing large and small businesses whose owners not only vote Republican but contribute money to Republican coffers, who want to have their interests protected. In the case of Uber, it is licensed taxi owners, but as Mr. Barro makes clear, this extends to many other businesses where profit margins are protected by legal regulations.

Examples that Mr. Barro cites include everything from licensing of interior designers, auctioneers and ballroom dance studio owners in Florida (run by Republicans) to limiting the sale of coffins to funeral homes (in Oklahoma, also very “red”). He notes that this also occurs in the case of very large businesses at the federal level, citing the controversy about the Export-Import bank, which can protect big companies in the US, but is seen as anti-competitive by some in Congress. Other examples which he does not mention include opposition to the presence of food trucks by local restaurants and “blue laws” in some states requiring car dealerships to be closed on Sunday (hey, if it were legal someone would open and then I’d have to also to say competitive, and I don’t want to work Sunday!)

What does this have to do with the health system? A lot, in a lot of areas, but one that is of great interest to me is the recent initiative begun by a collaboration of all of the major family medicine organizations and newly including osteopathic groups called “Family Medicine for America’s Health”. This effort, with the tag line “Health is Primary”, is good and important, calling attention to the fact (and it is fact) that the creation of a cost-effective health system that delivers high-quality care depends upon a strong primary care base (discussed and with evidence presented many times in this blog). It also emphasizes that family doctors are the central specialty in primary care, given the near abandonment of general medicine by internal medicine graduates. The argument is articulately made in a recent article (ironically called, internally, the “├╝ber article” as it will be succeeded by other articles addressing components of the problem) in the Annals of Family Medicine, Health Is Primary: Family Medicine for America’s Health”.

However, there has been less-than-sweeping coverage in the media, and a less than enthusiastic reception by other groups in the medical establishment. A generally positive article in the Kaiser Health News by Lisa Gillespie on October 24, 2014, “Family doctors push for a bigger piece of the health care pie”, quotes Atul Grover MD, chief public policy officer of the Association of American Medical Colleges (AAMC), who says “while primary care is important, taking funding away from specialty training isn't necessarily a solution because an aging population will need more specialty care.” This may or may not be true – we need as much training in different specialties as we need, not more or less. It is almost certainly true that we need more in primary care and less in some others – but it reflects Grover’s (and AAMC’s) role in representing the interests of our academic health centers and all of its components even when this may not be in the best interests of the health of the American people. Just like the Republican party, AAMC has constituents that may reflect different interests.

Thus, there is some irony to another quotation from Grover, that “It’s always a question of what motivates groups to do these kind of campaigns — is it looking out for patients or your own interests, and generally it’s a combination of both,” because this is exactly the position the AAMC is in. However, it is a real caution for the family medicine organizations who are working on “Family Medicine for America’s Health”: to the extent that this campaign keeps to the high ground of America’s health (as it generally is, notably in the Annals article) it deserves strong support. To the extent that the self-interest of family doctors is, or is seen to be, the major driver of the campaign, we risk being lumped with other “special interests”: we could become the funeral homes in Oklahoma selling coffins, or at least the AAMC.

The other NY Times article on November 9, 2014, is from Margaret Sullivan, the Times’ “Public Editor”. “Pricey doughnuts, pricier homes, priced-out readers” addresses common complaints from readers that the Times, not only in its advertising but its articles, seems to be addressing an incredibly wealthy crowd. Anyone who reads the paper is impressed by the lack of accessibility of the homes featured often costing not just millions but tens of millions of dollars, the ubiquity of ads for $10,000+ watches, and articles as well as ads for the highest-end consumer items ($160 flashlights and doughnuts costing $20 for a half-dozen). Sullivan notes that these may seem “aimed at hedge fund managers, if not Russian oligarchs”. She quotes Times executive editor Dean Baquet who, adding insult to injury, says of Times readers “I think we have as many college professors as Wall St. bankers”. This is a double insult; first of all there are way more college professors than Wall St. bankers, and the idea that college professors are the economic “low end” is amazing.

Ms. Sullivan’s article cites mixed reviews of the extent to which the Times covers of poverty (the Pew Research Center says 1% of page 1 articles), but it is clear that appealing to the middle class is missing from the Times. Baquet talks about “balance” as if it were reasonable to balance coverage of issues relevant to the 0.01% with those of the 1% or even only the 10% wealthiest Americans, and only an occasional piece addressing the world of the rest of the nation lives in. This, of course, is what parallels the health care system.

Our hospitals seek to attract well-off and well-insured clients, “balancing” them with poor people. But there are way more poor people, and they tend to be sicker and need more care, so justice, equity, demands that there be much, much more care and attention allocated to them than to the wealthy. If the Times makes money from advertisers who want to reach the wealthiest customers, our hospitals are interested in pleasing their wealthiest customers (oh, I mean patients) in hopes of getting big donations. And those donations are almost never used to provide necessary health care for the sickest and poorest, but rather to open new units (adorned with the donors’ names) to recruit yet more well-off patients. Both our health care institutions and the NY Times are about augmenting their income rather than meeting people’s needs.

Ms. Sullivan ends with “In the end, the upscale doughnut and the penthouse apartment — lofty as they may be — have nothing to do with The Times’s highest purpose.”  Good for her. Maybe Mr. Baquet will get the message, but I doubt it. At bottom, however, if the “balance” of whose interests are addressed by New York Times articles seems off, or offends you, or doesn’t meet your needs, you can read your local paper.

If the balance of who our health care system cares for is way off, we have to work to change it.

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