Pay primary care more: Kennedy may be getting this one right!

I have recently written strong criticisms of Secretary of Health and Human Services Robert F. Kennedy, Jr. and his positions on a number of issues, including most importantly vaccines (see RFK, Jr.: The Secretary of Health and Human Services is Dangerous to Your Health!). Not only is he wrong about vaccines being dangerous, he is in fact creating major danger by discouraging their use. The polio vaccine essentially eliminated a disease that was a major scourge in the US as well as the rest of the world, as did the measles vaccine. Many other vaccines protect our children – and adults – from other serious viral diseases like influenza, COVID, mumps, chicken pox, rubella, shingles, and human papillomavirus (HPV) which causes cervical cancer, as well as bacterial diseases including diphtheria, tetanus, pertussis, and Hemophilus influenza b. The last is something most people have not heard of, but early in my career was a major cause of morbidity and death in infants and young children from meningitis, pneumonia, and epiglottitis, which caused their throats to swell rapidly and choke off their breathing. Many others have articulately expressed this concern, including the pediatrician Perri Klass in the New York Times. While these diseases affected people of all social classes, they were more prevalent among the poor and minority groups such as the people I cared for at Chicago’s Cook County Hospital. Indeed, research has demonstrated tremendous benefits from vaccines on the health of children and other populations that go far beyond just the decrease in the specific diseases that they target to decreasing all-cause mortality!

Kennedy is wrong about many other things, if not all of as of such immediate potential danger as urging people to not get vaccinated. These include nonsense like suggesting that people who eat right and exercise won’t get disease, that raw (unpasteurized) milk is better for you, and that “natural” is always better (which, even if we could agree on a definition of “natural”, it isn’t). One recent example is his arguing for Coke to use “natural” cane sugar rather that high-fructose corn syrup, both of which are sugar and have calories and in large amounts are bad for you.

But there turns out to be one area where Kennedy and I seem to agree, which is the need to take concrete action to increase the number of primary care physicians. Lots of people, including politicians, healthcare providers, and health policy experts, express concern about the shortage of primary care, but have done nothing to address the real cause of this problem – that primary care physicians (and the nurse practitioners and physician’s assistants working with them) get paid a lot less than do physicians in other specialties. Kennedy appears to be doing something other than wringing his hands. On several occasions I have written about the RUC, the AMA committee that decides how to divide up the pie of Medicare dollars among specialists by deciding how much each thing doctors do is worth relative to other things that they do. (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid? July 21, 2013, Doctors' incomes and patient coverage: both need to be more equal July 26, 2014, and most recently, Not enough primary physicians OR Nurse Practitioners: It's the money, stupid!, June 27, 2024).

Not to get too technical, there is a set amount of Medicare dollars and the RUC decides (or recommends to CMS, which almost always accepts those recommendations) how many physical exams, say, are equivalent to one gall bladder surgery, considering (theoretically) both difficulty and time. This makes a tremendous difference in physician income and, I would argue, specialty choice by medical students. And, over the years, the amount of time it takes for doctors to do some things, particularly procedures, changes. Colonoscopies used to be estimated to take an hour and a quarter, but now are routinely done in 30 minutes. Cataract surgeries take a fraction of the time that they once did. This can result in physicians billing for more procedures than the model assesses as possible in a day. In contrast, the time it takes for a physical exam, or to listen to an interpret a person’s story, hasn’t changed significantly. The composition of the RUC, according to the AMA, represents all specialties, but its membership has a low proportion of primary care doctors – five of the 32 seats. Unsurprisingly, then, specialist-performed procedures are valued more highly than cognitive work. And, very important, these rates (relative value units) do not affect only Medicare payments – virtually all insurers pay based upon Medicare rates, so it is the whole health system! Prior to this new regulation, alternative models for allocating payment have been developed, such as this 2025 publication from the National Academies of Science, Engineering, and Medicine (NASEM).

So, now, maybe, a change. The NY Times reports that, buried in an 1800-page HHS regulation, are proposed changes in the RUC methodology that would benefit primary care. This would be real action! In addition to reassessing these relative values, the action would also look at the current practice of reimbursing more for the same procedures done in a hospital than in a doctor’s office, a major way that hospitals make money. And, for those who think “of course it costs more to do something in a hospital”, this is a technicality; it simply means that the hospital owns the practice or clinic. So two, say, skin biopsies performed in similar doctor’s offices across the street from each other are now reimbursed at very different rates if one is owned by a hospital. This is absurd and inequitable, and getting rid of it makes terrific sense!

The diffusion of medical services to people and communities is primarily driven not by the health needs of the populations in different areas but by the potential to make the most money for health care providers. These are largely, and increasingly, hospitals and health systems, as well as enormous insurance-company and private-equity owned practices rather than individual or small group physician-owned practices. So, we get enormous hospital campuses and medical facilities in major cities and wealthy suburbs and little or nothing in poor neighborhoods and rural areas. This should change. The only reason for decisions about what healthcare services to provide and where to provide them should be the health needs of people, and not on how much profit can be made.

The new HHS regulation will be a big step in this direction if it redirects Medicare (and thus all insurer) funds to primary care, and does not preferentially favor hospital-owned practices. To the extent that he is responsible for it, Kennedy should be congratulated. However, while it is a big step, it is not a solution. The next, necessary, step is a universal health insurance program where every single person is covered and covered by the same system, and where establishment (and closure) of health facilities, and the services that they provide or do not, is entirely based on the health needs of the people. Of course, there will be a lot of resistance – highly paid specialists will resist the proposed HHS reimbursement changes, and the institutionalized powerful insurance companies and other big players who are making lots of money from “healthcare” will oppose more comprehensive changes. Indeed, they already are, with highly funded social media campaigns against universal health care.

We are glad for this first step, but we need to keep fighting to get a comprehensive health program – like those of every other wealthy country!

Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!

The things to remember about “Medicare Advantage” plans is that 1) they are not Medicare, and 2) they may offer little or no advantage. They are a form of private insurance, cost Medicare a lot of money, and in some situations (especially when you are sick) can indeed hurt you.

Let’s get to the first. Medicare was created in 1965 to provide universal health care to senior and disabled people. It was a tremendous victory for those who had fought for decades to have a universal health insurance system in the US. It was also strongly opposed by those who thought their pocketbooks might be hurt, specifically the AMA, as well as other right-wing forces that just opposed everything that might actually help most people (and thus most Great Society, and even New Deal, programs). The supporters never envisioned that Medicare would be the end of the road, especially when, in the same year, Congress passed Medicaid, a federal-state collaborative program that was aimed at helping the poor access health care. They assumed that it would be expanded to finally include all Americans.

Of course, many of the opponents of Medicare didn’t give up either. The AMA, while never contrite, shut up about it after it became clear that rather than hurting physicians’ incomes, Medicare was a bonanza for them, ensuring payment for services had often previously been unable to collect for. Those who hate programs that benefit people, of course, are still around. But the most insidious and dangerous threat is from those who see any government program as a way to make lots of money, especially if it can be privatized without much risk to the private sector investors. This is really how Medicare (and many other public programs) have been most insidiously and effectively attacked -- by privatizing its programs to guarantee lots of money for the profit of the private companies, and largely insulate them from risk.

Enter Medicare Advantage (MA).  MA plans are largely run by insurance companies (and sometimes by venture capital groups) and are called “Part C” of the Medicare program, but they essentially take people out of Medicare and put them in a private managed care program. These companies then get the money that would have gone to the Medicare program (we’ll call it Traditional Medicare, or TM) for you. Plus they get extra money. Why do private companies caring for you under MA get more money than TM allocates for you? Because they do, right. Because the pro-for-profit “caucus” (PFPC) of the Congress, from both parties, wanted to increase the portion of people in Medicare entering MA. So these companies could make more money. And contribute more to the members of the PFPC.

Remember the old phrase “feeding at the government trough”? That is what these companies do, very well. Virtually no public function that is privatized becomes more effective at delivering service, since the amount of profit generated is increased by providing less service. To the extent that it sometimes seems to look better, it is almost always because of 2 things: that the public services were starved for funding in the first place, making them look bad and justifying the call to privatize them, and that private companies’ inefficiency, corruption, and overall bad acting is harder to ferret out than government agencies’.

How do MA plans make more money? In the traditional HMO manner, they limit access to a “panel” of doctors and hospitals. These are not necessarily the worst ones in your area, but they are the ones that the plans have negotiated the best deals with, for which they pay the least. They attract members with some perks like vision care, hearing care, etc., which can be useful if one is generally healthy. And of course, MA plans vary in quality and in performance; some of those covering state employees by contract have performed better possibly because of having a more educated, informed, and influential client base. But this is not always the case; see the example of city workers’ resistance to Mayor Eric Adams of NYC trying to push retirees into MA.  

And do not consider for a moment that the goal of any of these programs is to provide excellent health care: it is to make money. And that they make money is demonstrated by the aggressive marketing that Medicare-eligible people get from these companies, not to mention television advertising. The Commonwealth Fund recently published a piece called “The Role of Marketing in Medicare Beneficiaries’ Coverage Choices”, which describes this in detail. ‘Soaring private plan enrollment has led to a sharp increase in marketing and sales efforts, some misleading and inaccurate.’ It goes on to explain in how MA works and how they market. It also notes that about 1/3 of Medicare beneficiaries used an insurance broker; a boon to that private sector industry as well. MA plans can keep 15% of the money they get for profit and overhead, having to spend only 85% on actually delivering care (which they call the “medical loss ratio”!)

The way that MA plans make money is enrolling lots of people, many of whom are healthy (Wow! Free gym membership!) and don’t cost them much, and then submitting bills that make their patients look like they are as sick as possible thus inflating their bills (called “upcoding”). At best this an effort to maximize revenue from Medicare, which there is no incentive to do in TM. Plus, if they can get certain poor people enrolled, they can collect an additional $350 for each one regardless of whether they actually provide any care! This was implemented with the theoretical idea of increasing equity by incenting the enrollment of poor people, but really has the opposite effect since those folks now have their care restricted when they are sick by the private insurance company, while under TM it would not be. And, of course, they make money by fraudulently overbilling Medicare for billions of dollars, winning the Lown Institute’s 2022 “Shkreli Award” for bad behavior by corporations!

 

MA is not the only way Medicare is being privatized. As I have written before ("Private Equity": Profiteers in nursing homes, Medicare Advantage, DCEs, and all of healthcare, Sept 16, 2022; Direct Contracting Entities: Scamming Medicare and you and bad for your health!, Feb 7, 2022), the Center for Medicare and Medicaid Services Innovation Center (CMMI) implemented Direct-Contracting Entities (DCE), which was renamed REACH as of January 2023 (without any other significant change). REACH has allowed the creation of mostly investor-owned companies that contract with primary care practices (often already owned by corporations, not owned by the doctors) and voilà, all of those doctors' patients are in their REACH group, which then gets the money that Medicare would have paid for you. What is really tricky is that, unlike MA, you didn’t have to choose it; they choose for you by contracting with the group (often corporate) that owns your primary care practice! And your doctor may not even know that s/he is in one! You can only get out if you can find another doctor who is not in one – particularly difficult in rural or urban underserved areas where even finding a doctor is hard. Not to mention that REACH is even more lucrative than MA, as it allows the private company to keep 40% of its take as profit and overhead, spending only 60% on patient care!

The effort to privatize Medicare is absolutely the wrong way to go. The way to go is to keep the structure of Traditional Medicare, where anyone can use any doctor or hospital, where there is no profit taken out, and overhead is about 2%. And then increasing its benefits so that it covers 100% (not 80%) of approved charges so people don’t have to get a Supplement Plan, as well as cover dental, vision, hearing, etc. This is affordable, since it could be funded by money now used to generate huge profits for private investors, but could actually be used to improve our healthcare. While we still need to address access in terms of geography and specialty distribution, eliminating the profit motive will make major steps toward access and improved quality.

Then we can have Healthcare for All.

 

Kickbacks, corruption, and graft are not models for efficiency in health care

‘The Trump administration has labored zealously to cut federal regulations, but its latest move has still astonished some experts on health care: It has asked for recommendations to relax rules that prohibit kickbacks and other payments intended to influence care for people on Medicare or Medicaid.’

So begins the article ‘Trump Administration Invites Health Care Industry to Help Rewrite Ban on Kickbacks’ by Robert Pear in the NY Times, November 24, 2018. The next sentence provides the ostensible motivation for the rule change: ‘The goal is to open pathways for doctors and hospitals to work together to improve care and save money,’ but the sentence immediately after goes to the meat of the issue: ‘The challenge will be to accomplish that without also increasing the risk of fraud.’

The reason that there are anti-kickback laws in any industry is, of course, to prevent fraud. It is bad enough when we discover that a supposed impartial reviewer of a film or a book, or an item we may want to purchase like a car or a computer, is in fact being paid by one manufacturer to recommend their product. It is even worse if it turns out that the product that they are recommending is us, and that someone that we have trusted with our lives and our health, like a doctor, is being paid to send us to a particular lab or x-ray facility or hospital or specialist. Maybe the one we are being referred to is the best one, but it is hard to trust that if we discover that the doctor has a financial interest in that facility, or is receiving a kickback for those referrals. Most people are afraid of this and thus support anti-kickback laws; the exception is always those within the industry who stand to benefit. Surprise! And, it should be noted, it seems to be a core part of the business model of the Trump Organization.

But what about that middle sentence? The one that says that ‘the goal is to open pathways for doctors and hospitals to work together to improve care and save money’? Isn’t that a worthwhile goal? And both the American Medical Association (AMA) and American Hospital Association (AHA) are supporting the proposals. Am I saying that they are crooks or corrupt? Doesn’t it make sense that there can be not only savings but enhanced quality from the efficiencies that can come from such arrangements? How can we realize the efficiencies if doctors and hospitals are prevented from coordination of care?

The answer, as I see it, is “yes, but..”. There should not be unreasonable restrictions to care coordination, provided that they are upfront and obvious to the consumers (patients) such as in health maintenance organizations (HMOs) and the like which use limited panels of doctors, or public hospitals where care is often provided by employed physicians. The core issue, in health care, is to ensure that these arrangements are truly for the benefit of the health of patients, and not mainly to make more money for the providers. When your physician, Dr. Smith, refers you to a particular specialist (Dr. Jones) because they know them and think they are smart, competent and do good work even though another physician across town may have better results by some measures, it may be good or bad but it is honestly being done by Dr. Smith for your benefit. But if you discover that Dr. Jones is paying Dr. Smith for referrals, you might well be chary of the motivation.

There are several important things to remember in this discussion:

1.     Not everyone is, or is likely to become, a crook. There are many, maybe most, individual health care providers (like doctors) who actually care more about people’s heath than profit. There are even some institutional health care providers, hospitals and health systems, that may.

2.     There will always be people and institutions who “push the envelope”, and game the system. They will do everything that is legal, even if it violates the spirit and intent of the law, if it makes them more money. “Give them an inch and they’ll take a mile”.

3.     The looser the rules, the more these people and institutions will game it. There is no reason to suspect that money-grubbing cheaters will be satisfied if given a little more. Think about those (maybe me and you) who routinely feel ok about driving 5-10 MPH above the speed limit on a highway. If the speed limit is 65, we may drive 70 or 75. But if it is 75, we drive 80 or more. Raising the limit on what constitutes corruption will not obviate it.

4.     Carrots don’t work very well to change such behavior, although sticks might work a little better.

Don McCanne recently discussed a study from RAND called ‘Effects of Health Care Payment Models on Physician Practice in the United States’ which described the many different models being employed by various health systems and physician groups in the US, but alertly appened a reference to a NY Times article on October 27, 2018 by Alfie Kohn titled ‘Science Confirms It: People Are Not Pets: Research on the efficacy of rewards tells us that we can’t bribe others into doing what we want’. It reviews the psychological science that there is a difference ‘between intrinsic motivation (wanting to do something for its own sake) and extrinsic motivation (for example, doing something in order to snag a goody). The first is the best predictor of high-quality achievement, and it can actually be undermined by the second. Moreover, when you promise people a reward, they often perform more poorly as a result.’ Indeed, Kohn shows that sticks are not that effective either at changing behavior; I advocate them to some degree because at least they can put the biggest violators in jail!

The Pear article on kickbacks, trying to describe what its supporters see as the good side of loosening restrictions on them, says: ‘‘Federal law generally prevents insurers and health care providers from offering free or discounted goods and services to Medicare and Medicaid patients if the gifts are likely to influence a patient’s choice of a particular provider. Hospital executives say the law creates potential problems when they want to offer social services, free meals, transportation vouchers or housing assistance to patients in the community. Likewise, drug companies say they want to provide financial assistance to Medicare patients who cannot afford their share of the bill for expensive medicines.’ First of all, this is not “likewise”; drug companies who want new customers (and fend off efforts to regulate prices) are different from a hospital or provider offering free or discounted services; extra benefits to attract patients (as opposed to, say, free lunches to attact doctors) are quite different,  provided that these are really free, and the cost is not passed on to Medicare or Medicaid!

There is, in fact, a difference between ‘coordinated care’ and ‘graft’.

Pear also writes ‘‘The Justice Department in April accused Insys Therapeutics of paying kickbacks to induce doctors to prescribe its powerful opioid painkiller for their patients. The company said in August that it had reached an agreement in principle to settle the case by paying the government $150 million. The line between patient assistance and marketing tactics is sometimes vague.’

Vague? This is not vague at all. Creating efficiencies to improve care to patients, and reduce costs, especially to patients, is fine. Kickbacks and graft are not.

Doctors and health reform: maybe they do stand for health!

The new GOP health plan, the American Health Care Act (AHCA), aka “Trumpcare”, has crashed to defeat. The President, who pushed hard for it, looks like his greatest nightmare, a “loser”. It is worth thinking, however, about who opposed it. In Congress it was Democrats and (the few) moderate Republicans and very right-wing Republicans are against it, for different reasons. From outside government the response was pretty negative, with a 17% approval rating (amazing they could still think they could pass it!). Far-right “conservatives” thought that AHCA was too much like Obamacare in that it actually provides some federal support for some people, and  they don’t believe in the government ever helping anyone, except maybe themselves and their friends. (Oh, yes, and fabulously rich people. They deserve a lot of help.) The criticism from most of the rest of the universe (to say “the left” would be inaccurate, since it includes many quite a bit right of center, since, in fact, “Obamacare” started life as a Republican plan) was mostly because it would be a disaster for health coverage for Americans. Projections by the Congressional Budget Office (CBO) were that 24 million people would lose their health insurance, that access to care would be more and more limited, especially for the middle class and poor, and that costs would rise for patients exponentially. Also that the public health and preventive health infrastructure would be gutted and many of our advances in those areas lost.

The main “positive” in the CBO’s projection was that it would reduce the federal deficit by $337 billion over 10 years. This was only because it shifted costs to others, to states and employers and individuals. Those who could not pay with money would pay with their health and sometimes their lives. While, as I have pointed out (‘We have a bill! The GOP's plan to cut taxes on the rich and health care for the rest of us, March 16, 2017) many would have lost their insurance because of cuts in subsidies through the exchanges, the biggest impact would have been through the loss of Medicaid. This is clearly explained by Dr. Daniel Derksen, a family physician and director of the University of Arizona’s Office of Rural Health in a video on MedPage Today.

Among the many groups criticizing the draconian cuts in health care (as well as taxes on the rich) are almost all of the major hospital associations (including the American Hospital Association, the Catholic Hospital Association, and others), and physicians’ groups, most notably the American Medical Association (AMA) as well as most specialty societies including the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), as well as many others. They have been joined by the major nursing organizations and by patient advocacy groups. It should not be surprising, I suppose, that most of these groups would be critical of such a devastating attack on health care for Americans, but if it isn’t, it is at least a relief. The AMA is important in part because of its major role in opposing most historical expansions of health care access by the government, including President Truman’s attempt to get a national health insurance program (where they were successful) and President Johnson’s creation of Medicare and Medicaid (where they were not).

Of course, not all health providers and certainly not all physicians opposed the AHCA’s changes. MedPage Today published quotes from a number of physicians, and some were quite supportive; Darrell S. Rigel, a dermatologist at NYU, for example, said “It looks like it is a significant improvement over the ACA [the Affordable Care Act, aka Obamacare].” The most noteworthy physician advocate for the AHCA and Trumpcare was naturally Tom Price, MD, the Secretary of Health and Human services. As I discussed before his appointment (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters, December 3, 2016), Secretary Price, as a congressman from Georgia was a leader in the Tea Party caucus and an opponent of ACA or any other program to expand health coverage to Americans. Another recent voice to both support AHCA and channel the administration and GOP’s contempt for regular people is Rep. Roger Marshall, an obstetrician from Great Bend, KS who is the Representative from Kansas’ “Big First” district. Dr. Marshall told the Washington Post that “the poor just don’t want health care”. He kind of walked back those remarks later, but his analysis is telling:

“Just like Jesus said, ‘The poor will always be with us,’ ” Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. “There is a group of people that just don’t want health care and aren’t going to take care of themselves.” He added that “morally, spiritually, socially,” the poor, including the homeless, “just don’t want health care….The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,” he told STAT, a website focused on health-care coverage. “So there’s a group of people that even with unlimited access to health care are only going to use the emergency room when their arm is chopped off or when their pneumonia is so bad they get brought [to] the ER.”

I may not be the best person to comment on his bizarre interpretation of the Gospel, but I can say that for many of us the challenges that poor people face in just getting through their lives are reasons why we need to make health care accessible, not reasons to just write them off. I also wish that I could say that, in my experience, physicians with attitudes like those of Price and Marshall are rare, but sadly they are not. To some degree, there are differences by specialty, with primary care physicians and psychiatrists more likely to support government-involved health care and even single payer plans than surgeons (including orthopedists). I am sure that at least in part this difference is driven by income; while all physicians have relatively high incomes compared to most Americans (top 10%), some specialties, including orthopedics (at the top), radiology, cardiology, surgery, and dermatology make much more; the mean reported income for orthopedists, about $467K (which seems low to me based on those I know) is about the cutoff for the top 1%. When a friend of mine (who later became a surgeon) was on his surgical rotation in medical school, he was impressed by all the talk in the surgeon’s lounge about the “Big Board” – until he found out they meant the stock market, not the board listing upcoming surgeries! And primary care doctors are not immune; when I lived in Texas one family physician regularly railed against the liberal government spending our money. One day, however, his attacks were on delays in payments to doctors from Medicare. Umm…

Doctors are, of course, like other people. Their perspectives vary widely, with most being caring and some caring mostly for themselves. My family physician colleague’s self-centered view is not so different from that of those Trump voters who are now against the AHCA because they see that their benefits are being cut; see “Trump budget cuts put struggling Americans on edge”, NY Times March 18, 2017. The authors cite a retired nurse with lung cancer whose heat was cut off in the middle of the winter; she was rescued by a heating subsidy funded by the federal government and likely to be cut. “I understand what he’s trying to do, but I think he’s just not stopping to think that there are people caught in the middle he is really going to hurt,” she said. Somehow, I suppose, she thought that the cuts would only be to other people…

So, while it is true that doctors, like others, often share the perspectives of their class, and callously disregard or rationalize opposition to ensuring health care for everyone, they often do understand the situations their patients are in and serve as advocates for them. In 2001, the AMA passed its “Declaration of Professional Responsibility: Medicine’s Contract with Humanity”.  It includes the following “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”  The AMA was on the right side of the AHCA fight. I hope that most doctors agree with, and even practice, that principle.

I hope Tom Price and Roger Marshall are aberrant exceptions.

Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters

The election of Donald Trump as President continues to be extensively analyzed. It demonstrates major divisions among our populace. One of those that has been discussed a lot is that the “white working class” that voted for him by a 2:1 margin will suffer a lot from the policies likely to be implemented by his administration. Not more, and probably less, than minority people, but a lot.

Healthcare and health insurance is one of those areas, as discussed by me in several recent posts and by Paul Krugman in the New York Times, December 2, 2016, “Seduced and betrayed by Donald Trump”. He notes that anger about their health care coverage, and in particular the dramatic increases in premiums under the ACA exchanges, drove many people to choose Mr. Trump’s promise to replace it with “something terrific”. Of course, he never specified what that would be, for the same reason that the Republicans in Congress have never been specific, which is that any replacement plan that does not move “left” toward a more universal coverage plan such as the single-payer advocated by Senator Bernie Sanders (and me) will be much worse for most people, including most Trump voters, who will either lose or have to pay a lot more (if they can!) for their health insurance coverage. Repealing Obamacare means that many of the 13 million newly insured (a majority white, for the record) who received insurance under the exchange will not get rate cuts, but rather they will get no coverage. Certainly not those who need the insurance most, because they have pre-existing conditions that insurance companies were mandated by ACA to cover. As Krugman puts it, “we’re probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.” This is made clear in the Times article on December 3, 2016 “GOP plans immediate repeal of health law, then a delay” by Robert Pear, Jennifer Steinhauer and Thomas Kaplan. The reason is because the only plan they have will yank health insurance coverage for so many people, and despite their vociferous opposition and multiple votes to repeal ACA, they do not want to do that, at least right away.

The best evidence for their long term plan to, basically, remove health insurance coverage from many Americans including their base of support is the appointment of Rep. Tom Price (R, GA) as HHS Secretary. Mr. Price has been a leader of the Tea Party movement and a major Congressional figure calling for the repeal of Obamacare. His solution is not completely fleshed out, but does include eliminating guaranteed issue, community rating, and federal support for the exchanges. He is a fan of vouchers, an idea advocated for decades by conservative think tanks, and which, I guarantee (and this is far more of a certainty than Mr. Trump’s promises), can NEVER work, especially over the long term. Vouchers will never cover the cost of a decent insurance policy; people with health problems will naturally be the first to seek coverage, and faced by the adverse selection insurers will raise the premiums, co-pays, and deductibles for them. If there are problems with this under Obamacare, vouchers will make those look pale by comparison. And by getting out of the running-the-infrastructure business, the government will ensure that it never gets better.

Price, a wealthy orthopedist from suburban Atlanta, does not really care. He represents rich doctors who want to be able to charge whatever they want to be able to charge, and care only for the people who have insurance good enough to pay it. Sorry, Trump voters with not much money, chronic disease, and difficulty paying even ACA premiums, that isn’t you. And when you get to an age that you can get Medicare, finally having federally-supported coverage, Mr. Price has another answer for you – privatize Medicare! Make it subject to the same market forces that have made health care and health insurance so unaffordable and unavailable to younger folks affect the elderly too! The ACA has modified the egregiously negative impact of private sector health insurance for the under-65 group; the crumbum Price wants to both reverse that benefit and extend the damage to seniors too.

When Lyndon Johnson signed the Medicare law at the Truman Library in 1965, presenting Harry and Bess Truman with cards #1 and #2, he quoted the former President from nearly 20 years earlier: "Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection." LBJ then added that “There are more than 18 million Americans [in 1965; way more now] over the age of 65. Most of them have low incomes. Most of them are threatened by illness and medical expenses that they cannot afford. And through this new law, Mr. President [referring to Mr. Truman], every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”

This is what Tom Price and his colleagues want to reverse. The AMA, with its shameful history of actually having blocked Truman’s health plan, and unsuccessful opposition to Medicare, is endorsing him. The Association of American Medical Colleges (AAMC) is endorsing him as well. The American Academy of Family Physicians (AAFP) more tepidly expresses optimism. Presumably these are political decisions, to maintain access. After all, in the ongoing battles between insurers and providers (patients are rarely a real player), at least he is a provider. But many others, including Physicians for a National Health Program (PNHP) and Common Dreams, as well as the medical students of Future Docs, have appropriately condemned Price and these organizations endorsing him.

Mr. Price will be joined by Seema Verma, who will head the Center for Medicare and Medicaid Services (CMS). Verma helped Mike Pence design the Indiana version of Medicaid expansion. On the plus side, that state did expand Medicaid, helping people more than those states that did not. On the minus side, the requirement that everyone covered has to pay meant at least 1/3 of those who would have been eligible did not sign up. I guess she is the moderate!

Mr. Trump’s cabinet picks are, so far, a panoply of people who are either right-wing ideologues who wish to destroy everything that has been done to help the American people at least back to the Great Society and maybe to the New Deal, or are billionaires who speak for the corporate financial ruling class that he attacked so effectively during his campaign, or both. An example of the latter is anti-public education billionaire Betsy DeVos to head the Department of Education. Myron Ebell, a noted climate-change denier, will head EPA. Steven Mnuchin, a leading Goldman Sachs banker, will be Treasury Secretary. Senator Jeff Sessions (R, AL), denied a judgeship because of his racist beliefs and practices will be Attorney General. Trump's nominee for Commerce Secretary, Wilbur Ross, according to Money, alone has 10 times the net worth of the entire cabinet of President George W. Bush. Talk about foxes guarding the henhouse! Compared to these folks, naming El Chapo to head the DEA, as suggested in a New Yorker satire by Andy Borowitz, would be a moderate pick.

The future of not only public health, but also your individual private health, now and when you get to retirement age, is in great jeopardy. But, then, so is everything else that helps people. Not to mention the earth, since global warming is likely to accelerate during a Trump administration. There is an endless string of battles before us.

And we must join every one.

Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?

On February 2, 2011, I posted a piece titled Outing the RUC: Medicare reimbursement and Primary Care, describing the activities of this group, officially the “Specialty Society Relative Value Scale Update Committee” but known as the RUC, which is convened annually by the American Medical Association (AMA) to set the relative value of different kinds of work done by doctors. I included the accompanying graph, from the Robert Graham Policy Research Center of the American Academy of Family Physicians (AAFP). It shows the relative income of different specialists over time (FPs are the line at the bottom) and suggested that this might well impact specialty choice by students. I noted that the reason for the income disparities was the different weight given the work done by different specialists, and that the RUC was dominated by subspecialty societies. I pointed out that the real problem is that this encourages expensive procedures (by making them expensive) and that this skews the entire health care system.

I did not, however, call the RUC “The shadowy cartel that controls Medicare”. No, that is the title of a lengthy recent investigative piece in the Washington Monthly by Haley Sweetland Edwards that documents, in detail, the creation, formation, function, and results of the RUC’s activities that justifies this sobriquet. The problems documented are profound. Medicare has to pay for the work that doctors do, and it is pretty obvious that performing heart surgery should be paid more than freezing a wart. But how much more? And how does that relate to your doctor’s office visit or doing and interpreting a CT scan? And that doctor’s visit; is it for a cold or to manage 5 different chronic diseases? It’s complicated stuff. So the Center for Medicare and Medicaid Services (CMS) relies (90% of the time or more) on the recommendations of the AMA-convened RUC.

Note, above, that in the full name of the RUC the term “specialty society” is included; the members of the RUC are appointed by medical specialty societies, but are then told to then be completely objective and not look out for the interests of those societies, the specialists, or themselves! “Put your RUC hat on,” Edwards describes the chair of the committee telling its members, But even if you believe that this is possible, the outcome of RUC decisions would demonstrate that it is not in fact the case (“…in talking to a half-dozen current and former RUC members, including both generalists and specialists, the image of the committee that emerges is less a gathering of angels, cloaked by some Rawlsian Veil of Ignorance, and more akin to a health care-themed Game of Thrones.”) While the RUC only makes recommendations for Medicare, because all other payers base their payment rates upon Medicare, it is essentially controlling the cost of the entire health care system.

Medicare spending is like a pie, a fixed amount of dollars divided up based upon RUC recommendations. The original basis for this division, the Resource Based Relative Value Scale (RBRVS), developed by William Hsiao, may not have been equitable for primary care, but the modifications since then have been a disaster. When the first Bush administration gave the task of making these decisions to the AMA, “…the most powerful interest group in the industry,” Hsaio says “…that was the point where I knew the system had been co-opted….It had become a political process, not a scientific process.”

Edwards goes on, in great detail, to show the ways that the AMA maintains power – and makes lots of money – by controlling the RUC and the charge codes that are associated with it. And also describes, in detail, how it has a negative impact on primary care (“These manipulated prices are also a major reason why specialists are in oversupply in many parts of the country, while a worsening shortage of primary care providers threatens the whole health care delivery system. It’s precisely because the RUC has overvalued certain procedures and undervalued others that radiologists now make twice what primary care docs do in a year—that’s an average of $1.5 million more in a lifetime”) and why (“While the primary care docs make up roughly 40 percent of physicians nationwide, they have only 14 percent of the votes on the RUC.”). I would argue with the math, though; over a 30-year career every $100,000 of additional annual income results in an additional $3 million in lifetime income, and many sub-specialists earn several times $100,000 more than primary care doctors.

The idea of having independent, non-governmental, groups advise on policy is not necessarily a bad one. An excellent example of this is the US Preventive Services Task Force (USPSTF), which makes recommendations, based on the scientific evidence, about which preventive tests are effective and which are not. In Guidelines, bias, and your health, June 30, 2013, I cite an article by 2 USPSTF members who are concerned that by tying payment for services to positive recommendations by USPSTF, the Affordable Care Act (ACA, “Obamacare”) could politicize their work. The RUC has no such compunctions. While USPSTF is intentionally composed mostly of primary care physicians and examines only the scientific evidence, the RUC is dominated by specialists, who are appointed by specialty societies, who have a great financial stake in its decisions. And if the cartoons attached depict the doctors as poker players, the AMA is the “house”, which not only takes a cut of all decisions, but owns them and sells them back to anyone who wants to use them.

Edwards’ article is full of quotes from important – especially those who were formerly important in public life, both Republican (e.g., Gail Wilensky and Thomas Scully, heads of CMS during the GHW Bush and GW Bush administrations respectively) and Democratic (e.g., Bruce Vladeck, who headed CMS under Clinton), who are extremely critical of the entire process behind the RUC, see it as corrupt, and see it as a major contributor to a US health system that spends incredible amounts of money in a wrong-headed, upside-down way to reach mediocre health outcomes. Unfortunately, none of them changed it when they had government power (if they even tried to).

I would like to add two notes:

1. All specialists are not paid the same. Some (e.g, psychiatrists, some subspecialty pediatricians, some neurologists) are earn much the same as primary care doctors. Some (e.g., radiologists, orthopedic surgeons, neurosurgeons, anesthesiologists) earn several times more. Much of this is built into the RBRVS, which vastly overvalues procedures compared to cognitive care, and exacerbated by the RUC.
2. The last time I wrote about the RUC, I received a response from the AMA (AMA response to "Outing the RUC", February 5, 2011). It said "The entire premise of this column is false.” If you wish, you can read my reply in that blog piece. Nice to know they read it.

In summary, the flaw is not just the RUC, but the entire nonsensical non-system of medical care we have in the US. Medical care should be paid for by a single payer, and rates determined by an independent body without a financial stake in the outcome. Health care should be a lot more than simply medical care. And the health of our people will be most impacted by investment in the core functions of society: housing, food, education and jobs.