Private Profit and the Public's Health: Which is More Important?

Health care is pretty complicated, and insurance coverage is even harder to understand.This is the message that comes through clearly from the interviews being done by Dr. Paul Gordon and recorded on his blog, https://bikelisteningtour.wordpress.com. Dr. Gordon is taking a unique sabbatical, riding his bicycle across the country from Washington (DC) to Washington (state), interviewing regular people, mostly in cafés and such, about their take on Obamacare. 

The economic status of these people varies from poor to pretty well-off (but none really wealthy), from well insured to uninsured. Their political perspectives range from “everyone should be covered” to “benefits just make people lazy”. Three recent quotes: ‘People use Medicaid as a crutch’, ‘You can’t penalize someone for not having health insurance when it’s so expensive and the economy is doing so poorly’, ‘Here’s my take on it – everyone should have insurance’. What they share with each other, and with most of us, is a general lack of understanding of how Obamacare works (or doesn’t) and why. The flaws in Obamacare are the result of the political tradeoffs that allowed insurance companies to continue to have control and make huge profits, but this is often not clear to most people.

Here is something that is easy to understand, however: when you call “911” as you have been trained to do in an emergency, and they don’t come. Or they don’t come for a long time. Or they come with inadequate supplies. Who do you get angry with when you, or your loved one, dies? The government? They are surely in part at fault, even though they probably contracted the service out, to save money, probably because voters want to pay less tax. But there is another reason, explained in an excellent special article in the New York Times, “When you dial 911 and Wall St. answers” (June 26, 2016). The piece, by Danielle Ivory, Ben Protess, and Kitty Bennett, details how many city services, including ambulance services, are provided by companies that are owned by “private equity firms”. These are companies whose investment capital comes from wealthy individuals and particularly from pension funds, unlike banks whose money comes from depositors. They are even less regulated than banks, and thus more able to pursue their core mission, making profit:

Unlike other for-profit companies, which often have years of experience making a product or offering a service, private equity is primarily skilled in making money. And in many of these businesses, The Times found, private equity firms applied a sophisticated moneymaking playbook: a mix of cost cuts, price increases, lobbying and litigation.

Whoa. This is starting to get complicated again. Banks vs. “private equity” vs. just plain old for-profit businesses? They are really just different forms of for-profit, and provide a stepwise progression, from public services operated by government for the benefit of the people, to private companies that are contracted by government to do a service but might care about doing it well, to having those companies owned by banks who really just want to make a profit, to having them owned by private equity companies who care about nothing but making a profit. The photo accompanying the Times article is of Lynn Tilton, owner of Patriarch Partners (an ironic name, given that she is a woman), which owned the emergency services company TransCare that served many East Coast communities. TransCare went bankrupt, leaving those communities without emergency medical services. Ms. Tilton’s picture is accompanied by the quote from her reality television stint “It’s only men I strip and flip.” As a poster child, she could become the Martin Shkreli of ripping off necessary public services the way he was of ripping off consumers of life-saving drugs.

“The business of America,” Calvin Coolidge is often paraphrased as saying, “is business.” This perspective, that it is not about doing things that are best for the American people, is based in a belief that capitalism – “business” – will, through the magic of the market, eventually meet those needs. OK, maybe not those of people at the margins, people too poor to buy, so maybe we need a safety net. But most people. A similar statement appeared today in the print edition of the Kansas City Star from KC Mayor Sly James, discussing the controversy over replacing the terminals at Kansas City International Airport with one big, new terminal. Surveys consistently show that the large majority of Kansas Citians (84% in this article, “Regarding KCI’s future, city ponders a new flight path”) like the current arrangement, with short security lines and easy access in and out from one story terminals, but the airlines and big businesses do not. In the large-type quote accompanying his picture in the print edition (but, along with the photo, left out of the online edition), Mayor James said “The people of this city need to be convinced of what I believe is a basic reality, that this airport is about a lot more than ‘how fast can you get out of your car and get to your gate?’” Right. Business interests first. Take that, 84% of Kansas Citians!

Because they most obviously involve life and death, emergency medical services and firefighting (yes, firefighting too has been contracted out to companies owned by private equity firms!) get the greatest play in the Times article, but many other services (like water!) are in the same situation: controlled by companies whose goal is to make a profit rather than to provide effective service for people. This is what happens when municipalities are starved of funds because people vote to cut taxes.

Whether it is health insurance or emergency medical services or municipal water, the system becomes very complicated and hard to understand when it is trying to meet conflicting agendas. When the need for people to receive critical, health-producing service (fire and police protection, clean water, garbage collection, ambulances) is compromised by provisions built into contracts (or the law) for companies (insurance companies, banks, private equity firms) to make profit. I guess it is fine if these services can be effectively and reliably provided by for-profit companies, but when their pursuit of profit through “a mix of cost cuts, price increases, lobbying and litigation” conflict with actually providing services, there is a big problem. In the case of emergency medical services, the problem was that “…many newly insured Americans turned out to be on Medicaid, according to the Kaiser Family Foundation. Medicaid restricts some of the most aggressive billing tactics.”

A variety of other difficult to understand strategies are also employed at the macro level to place the interests of wealthy corporations above those of the people. These include the unlimited political contributions permitted by the Supreme Court’s Citizen’s United decision, incredible gerrymandering of congressional districts so that we have states where the majority of voters vote for Democrats but most districts are solidly Republican (see the New York Times Book Review “Where votes go to die”, June 26, 2016), and the provisions of the Trans-Pacific Partnership (TPP) that prevent national governments from regulating multi-national corporations.

We could solve this if there was a single, over-arching principle, always codified into law, that the interests of the people as a whole always trumps the profit potential of corporations. I vote for that.

Serving others or self-serving? All generations have both kinds of people

The current generation of young adults, commonly called “millennials”, is often criticized for being self-centered, “spoiled”, the product of “helicopter parents”, showing the signs of having grown up in a culture where “everyone was a winner”. On the other hand, studies also show them to be the most socially conscious, idealistic, and optimistic generation in a long time (despite the evidence that things are not going so well for them, and little reason to think they’ll improve soon). They, as a group, have become politically involved, shocking the established political order with their enthusiasm for the presidential candidacy of an old Jewish socialist from New York City via Vermont, making Sen. Sanders a viable contender

This generation includes most medical students, as well as most residents, so I get to see them a lot. I can say that there are many in this group who are committed, hard-working, idealistic and self-sacrificing. And there are a lot who are not. In short, they are people. Yes, there are those who, for whatever reasons in their personality or upbringing, are “all about me”, argue their grades, have no time for giving to others, seem to have no sense of the collective good, and sometimes make me wonder why they want to be doctors. But you know what? We had those people back in my generation. I was in college in the 1960s, and not pre-med, and there were pre-meds around who had the reputation as narrow, grade-grubbing, and not socially involved. There were also pre-meds who were very involved in the major struggles of the day, anti-war, civil rights, racism. I was in a post-baccalaureate premedical program in the early 1970s, when the Vietnam War, with its extension into Cambodia, was peaking. Many of my fellow students, going to night classes after working all day, could not be seen as privileged, but many, including veterans, were active in those movements. And many were not.

I was in medical school in the mid-1970s, and there were many who were all about themselves and their futures. And many whose futures turned out to be very distinguished and productive. There was also a lot of social involvement. Chicago had a number of medical schools, and students knew each other across schools, even sometimes roomed together. When a physician researcher at one school was discovered to be doing research that targeted poor black women, students there protested; when he planned to leave for a job at another school, students there made an issue of it. I was involved in some of these struggles, and some in medical school. When, at a forum of the whole school to discuss the impact of our 3-year curriculum, the Chairman of Surgery announced he thought our 3^rd-year medical students were ill-prepared because he had heard some of them asking nurses for advice on skills such as starting an IV (“in my day, we would never have asked nurses for advice!”), I stood up and spoke on how we were glad to not be like that, that we wanted to be able to learn from anyone. Maybe not my smartest hour (the chair of another department tried to get my year-old grade in his clerkship changed), but I bring it up because there appeared to be generational differences then, as now. I am not an expert on generational trends (for this I recommend the outstanding book by Paul Taylor, “The Next America”[1]), but looking back I also remember senior faculty who were very supportive of progressive efforts; I think that then, as now, it is people who are different, not really generations.

Our current and recent medical students at KU created and continue to staff and work hard for the Jaydoc Student-run Free Clinic, which provides care for folks with little or no money or insurance in the evenings; succeeding classes, if not generations, have expanded the scope and impact of the clinic. Students frequently volunteer for, and self-fund, trips to provide care in poorer countries – and even sometimes in our own, for those left out of our non-system of health care. (These trips are generically called “mission trips” even when there is no explicit evangelical religious component; however, many are indeed organized by religious organizations, and personed by students, doctors and others motivated by their religious beliefs. I may not be a big fan of religious evangelism, but I am a big fan of people doing good work!) Many of our students are active in the community, in local as well as national programs. They regularly volunteer for the school-based health clinic at a local high school, named the Bulldoc for the school’s teams, the Bulldogs, by the high school’s students (post-milennials?). The clinic itself was created by a collaboration between the school, school district, community groups (particularly pastors), medical school faculty, and students – in particular one medical student, without whose efforts it would never have come to pass.

When I was young, and even in earlier generations, many students, like other people, worked for the interests of others as well as themselves. Many do so now. Others, it is sad (to me) to say, are indeed self-absorbed, and all about themselves. Like other people, like doctors – and nurses and accountants and steelworkers and retail clerks and unemployed people. We can only laud those whose work demonstrates the “better angels” of human nature, and hope that narrow, selfish behaviors will extinguish.

To those who are in medical school, I want to say “No, it is not about you. It is about the people for whom you will be caring. And let’s not forget what ‘caring’ means.” Sometimes I actually do. Maybe we should all say, or at least think, that more often.

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[1] Taylor, P and the Pew Research Center, “The Next America: Boomers, Millennials, and the Looming Generational Showdown”, 2014.