Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people

 I -- and many others -- have written (frequently and recently) about the abuses of for-profit companies, and especially private equity companies, and “non-profits” that act like for-profits in health care (Private equity, private profit, Medicare and your health: They are incompatible, May 11, 2023; Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!, Jan 20, 2023; "Private Equity": Profiteers in nursing homes, Medicare Advantage, DCEs, and all of healthcare, Sept 16, 2022). But despite our efforts, it doesn’t get any better. Indeed it gets worse.

Drs. David Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, and John Geyman, have been leaders in the campaign for a national health insurance plan (e.g., Medicare for All), published an article 18 months ago in ‘The Nation’ (March 31, 2022) titled ‘Medicare for All is Not Enough’. They go through the ways in which the ownership of our health system has changed, particularly over the last decade, to focus on profit for the private owners rather than “health care”. That is to say, while a single-payer Medicare for All program would be a great thing and would limit the negative impact that for-profit insurance companies wreak on our collective health – which is considerable – as long as for-profit companies continue to own, and to increase their share of, our actual health delivery systems (hospitals, nursing homes, pharmacies, and physician practices) there will be terrible consequences, with those single-payer dollars flooding into investors’ pockets rather than patient care.

Insurance companies like United Health and giant pharmacy firms like CVS own large portions of our practice and health delivery sector. And the role of private equity companies and investors, with their “buy ‘em and burn ‘em” approach to acquisition and profit, in taking over our delivery system is at least as terrifying. As the authors state:

At least UnitedHealth and CVS plan to stay in business for the foreseeable future, and may be constrained by the worry that substandard care will damage their reputation. Private equity companies face no such constraints. They promise investors quick profits, and often sell off the businesses they’ve bought within five years, often after stripping their assets and loading them with debts that hobble future operations.

On top of who will own our care provision, there also is the issue of who will provide the care. Most developed countries, with more rational health delivery systems, rely on primary care physicians and other clinicians far more than the US does. In those other countries primary care is at least 30-40% of the physician workforce, while here it is closer to 20% and dropping, an issue I have written about often (see, for example, What is the problem with Primary Care? The US health system!, March 22, 2022).  Primary care clinicians – family physicians, pediatricians, and general internists, and the NPs and PAs who work with them – can provide not only cost-effective care but care that is comprehensive, continuous, and reassuring to people and families because they know the person who is providing it and have a relationship with them. And the cost-effectiveness is not (only) about the fact that they earn less money (see below) but because they are in a position, as a result of taking care of the “whole person” and having a long term relationship, to more wisely utilize resources when necessary. Nonetheless, there is a definite shortage of primary care clinicians, as anyone who has tried to find one recently, because they moved, or their physicians retired or had their practice bought out by a large company like Optum (a subsidiary of United Health Care, which has become UHC’s major profit center as documented by former insurance executive Wendell Potter in his “Health Care Un-covered” substack) or, sometimes in response, went into a “concierge” or “boutique” practice, can testify. Elisabeth Rosenthal, editor of Kaiser Health News, documents this in a recent piece in the Washington Post, “The Shrinking Number of Primary Care Physicians is Reaching a Tipping Point”. She notes that “fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.” And she makes the important point that

One explanation for the disappearing primary-care doctor is financial. The payment structure in the U.S. health system has long rewarded surgeries and procedures while shortchanging the diagnostic, prescriptive and preventive work that is the province of primary care.

Don’t forget that one. Rosenthal discusses the terrible experience of colleague Bob Morrow, MD, who, under financial pressure, finally had to sell his decades-old practice, and then, watching how the new owner ran it (suffice it to say, not in the best interests of the patients), leave medicine. Morrow is not a depressed person, but reading about what has happened to him and thousand of other primary care doctors is enough to make you depressed.

In a data-driven “Report Card” on primary care in the US, the Milbank Memorial Fund ranks it poorly on all front, although not on the quality of the physicians:

This first national primary care scorecard finds a chronic lack of adequate support for the implementation of high-quality primary care in the United States across all measures, although performance varies across states. The scorecard finds:

1.      Financing: The United States is systemically underinvesting in primary care.

2.      Workforce: The primary care physician workforce is shrinking and gaps in access to care appear to be growing.

3.      Access: The percentage of adults reporting they do not have a usual source of care is increasing.

4.      Training: Too few physicians are being trained in community settings, where most primary care takes place.

5.      Research: There is almost no federal funding available for primary care research.

The  report card, created for Milbank by the Robert Graham Center (the policy arm of the American Academy of Family Physicians, AAFP), not only identifies these deficits, but also the importance of solving them for the health of the American people. 100,000,000 people without a primary care doctor, only able to see a physician (if they can see any physician) who has a narrowly focused, disease-based practice is a real problem. We need those specialists for when we are diagnosed with a particular condition that requires their expertise, but they are often not knowledgeable about conditions outside it. Moreover, the primary care clinician does not only care for many conditions; much more important is that they care for the person who has those conditions.

The report also endorses the conclusions from the National Academy of Science, Engineering, and Medicine (NASEM) from 2021, recommending that the US:

1. Pay for primary care teams to care for people, not doctors to deliver services.
2. Ensure that high-quality primary care is available to every individual and family in every community.
3. Train primary care teams where people live and work.
4. Design information technology that serves the patient, family, and interprofessional care team.
5. Ensure that high-quality primary care is implemented in the United States.

Finally, for the moment, an effort is actually being made in Congress to try to increase the number of primary care clinicians.  In an uncommon bipartisan effort, the bill is cosponsored by Bernie Sanders (I, VT), chair of the Senate HELP Committee and Roger Marshall, MD, an OB/GYN and conservative Republican from Kansas, as reported by Jake Johnson in Common Dreams, Sept 14, 2023. It’s a good thing to have bipartisan support, but it is, sadly, unlikely to have a major effect on increasing the primary care physician supply. Funding in the bill – about $6 billion -- goes mainly to Community Health Centers (CHCs), especially Federally-Qualified Health Centers (FQHCs). These centers can be, and usually are, good. They provide care to lower-income people and communities where access to other clinicians is difficult. Republicans like them because they are not actually “government” programs, but responsible only to their boards of directors. But, while they often rely heavily on primary care, and expanding them will increase the number of jobs for primary care clinicians, it does nothing to increase the supply of those clinicians, to convince medical students to enter family medicine, pediatrics, and general internal medicine instead of much higher-paying subspecialties.

I mention money, the Milbank report mentions money. It is a lot about money. It is increasingly difficult to convince students to enter fields where their income is likely to be a fraction of that of subspecialists (even if much better than that of most Americans), especially in the context of huge educational debt (frequently over $250K), and the lack of respect given by the medical profession and often the society at large to primary care. And, not at all to be minimized, the takeover of so many practices by for-profit corporations and private equity, with situations like Dr. Morrow’s becoming the norm rather than the exception. Some subspecialties make 2-3 or more times that of primary care doctors, which makes it increasingly difficult for students to decide to enter primary care. And while some of these subspecialties have grueling work hours (e.g., general surgery) others have much more circumscribed work hours, often shift work and little call.

There IS certainly something the federal government could do. The Center for Medicare and Medicaid Services (CMS) sets the relative reimbursement for physician services (office visits, procedures, etc.) and virtually all private insurance companies reimburse based on multiples of the Medicare rate (traditionally more, but now often less). So all CMS has to do is to revise its fee schedule, increasing the relative value of primary care visits relative to procedures. Of course, there will be great opposition from other specialists; indeed the “RUC”, a non-government committee that advises CMS on this ratio is completely dominated by subspecialists (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013). CMS is not required to follow the recommendations of the RUC although it usually does; CMS could ignore or adjust what the RUC recommends, or reconstitute the membership of the RUC to have more primary care doctors. Primary care physicians do not need to make as much as the highest-paid subspecialists (indeed neither do those subspecialists!) but the difference needs to be decreased. Studies have indicated that if primary care doctors earned 70% of what subspecialists do, income would no longer be a significant factor in specialty choice.

Addressing this income gap is critical for increasing the number of primary care clinicians. Then there is a lot else to do, like getting for-profit corporations and private equity out of healthcare altogether.

 

For a “humorous” depiction of the takeover of primary care by for-profit companies like Optum, check out this short piece by the brilliant Dr. Glaucomflecken: https://twitter.com/i/status/1706339952857149895

Incremental change will not cure our health care system

Earlier this year I discussed (The denominator matters: we only have a quality health care system if everyone can access it!, February 16, 2020) an article from the New York Times by Elisabeth Rosenthal, the editor of the Kaiser Health News and an emergency physician, called “Where the frauds are all legal.” One of those “frauds” I focused on was “surprise” medical bills. “Even though you went to a hospital that was in your insurance network and saw a surgeon who was in your network,” I wrote, “it turns out that the ER group or the anesthesiology group contracted by the hospital, or the assistant surgeon your surgeon picked, is not in network. Boom! $10,000, $100,000 bills! No one is “satisfied” by this.”

In fact, this is not entirely correct. Yes, your insurance company is not happy about this if they have to pay the bill. Yes, you, the patient, are certainly not happy about it if the insurance company doesn’t pay the bill, or only pays a part of it, and you are stuck with the rest. Very likely, the hospital itself doesn’t like this if they themselves are indeed in your network, because it makes them look bad, and they know that you, and your insurance company, are going to hold them in large part responsible. So who likes it? Well, as you might guess, those doctors who are getting the big payments. In fact, probably even if the hospital tried to hire its own, say, anesthesiologists or emergency physicians, they’d have a hard time paying as much as those independent groups do.

But the other stakeholders who are happy with this arrangement are the owners of these physician practices, who are not always the physicians themselves but increasingly private equity funds, which have been buying out physician groups for a few years (‘Specialty physician groups attracting private equity investment’, Modern Healthcare, August 31, 2019). Expanding upon a “research letter” published in JAMA, JM Zhu from the Leonard Davis Institute of Health Economics at the University of Pennsylvania writes:

Of approximately 18,000 group medical practices, we found 355 physician practice acquisitions across a number of specialties, most commonly anesthesiology (19.4%), multi-specialty (19.4%), emergency medicine (12.1%), family practice (11.1%), and dermatology (9.9%). From 2015 to 2016, there was also an increase in the number of acquired cardiology, ophthalmology, radiology, and obstetrics/gynecology practices. Acquired practices had an average of 16.3 physicians, 4 sites, and 6.2 physicians affiliated with each site. About 44% of acquired practices were in the South. (‘Private Equity Investment in Physician Practices’, February 18, 2020).

Of course, it doesn’t take great acumen to realize that the reason that private equity investors are attracted to buy these practices is exactly the opportunity to profit handsomely from this “loophole”, by what Rosenthal calls “legal fraud”.  In essentially all areas, the whole strategy of private equity funds is exactly this sort of “gaming the system”, finding the margin where the income far exceeds the cost because of some loophole in the law.

This demonstrates several flaws in our current healthcare “system”. The most obvious is the specific problem created by “surprise” bills, one that has been even recognized (although not addressed) by Congress. For example, HR 3502, “Protecting people from surprise medical bills”, introduced in this congress by Rep. Raul Ruiz (D-CA). It could pass the House, and if both the Senate and White House flip, it could even become law. Of course, it would have considerable opposition from the very equity firms that are making money from the current situation. This is the second flaw – legislation to regulate the system often fails because those who make big money from the very problems such regulation is intended to correct have – big money. They can give contributions to legislators.

Every inequity in health care, every exploitation of the system, results in (and usually from) someone making money, and those “someones” are very interested in preventing the issue from being corrected. This holds true, as I have previously discussed, for hospitals (“health systems”), long term care companies, pharmaceutical and device companies, and insurance companies, as well as equity-owned physician groups. Kansas Congressman and GOP Senate candidate Roger Marshall, according to a recent article in the Kansas City Star by Shorman and Lowry, pushed for aid to physician-owned hospitals (ones not yet bought up by for-profit equity companies) while his wife, as a partner in real estate ventures that owned the land that they were on, profited greatly! In this case it didn’t even require contributions to politicians; the politician was in it for himself.  You can be sure that if there is a buck to be made, someone will be making it. You can just be certain that it isn’t you, the patient, particularly if you are uninsured, poorly insured, or poor. Of course, if you are, you’ve probably figured out by now that the system overall is not designed for you!

The design of the capitalist US, particularly so in this age of corporate “gangster” capitalism is to make money for the wealthiest and everyone else be damned. The only question that might still be open to discussion is whether people’s health, and health care, should be subjected to the same rules of that system as consumer goods. After all, it is your health, your life! Your family’s health and life! The same could, and should, be said for other basic necessities such as food, shelter, and education, but health has special resonance such that every survey of the American people finds overwhelming support for the idea that everyone should be able to get adequate healthcare, and agreement that profiteers such as insurance companies and pharmaceutical companies are bad guys (there is less awareness of the role of hospital systems, still less of the private-equity-owned physician groups discussed here).

The third key aspect (I keep wanting to say “flaw” until I realize there are strong advocates for these policies) that this illustrates is the fatuousness of trying to solve the problems of our health care system and its exploitation by profiteers one issue at a time. Each scam that has been exposed and addressed by regulations or legislation (more rarely) has generated another; each loophole that is supposedly “closed” contains exceptions. The problem isn’t “bad apples” (although there are many), it is the whole system and the powerful forces that wish to continue it.

While Republicans policies are often targeted at eliminating any regulation, and indeed encouraging overt corruption and exploitation, “mainstream” Democratic policies are about putting in occasional patches, and then saying “there!” until another scam pops up. The Democratic Party, like the GOP, is beholden to rich donors, and a high percentage of theirs are financiers. Their mantra, clearly articulated by Joe Biden, is that we need to keep the private (read: profit-making) sector, and not change everything. Unfortunately, if the goal is actual to make the health system more equitable and increase the nation’s health, it cannot work.  It certainly cannot contain costs; the very profit that these companies make IS the cost!

The only solution is a comprehensive change to our entire health system, one that eliminates the incentive for profit-making altogether. This will work, is a good idea, and is what we should do, starting with Medicare for All.

Contraception, women's health and dignity, teens, and stupid legislators

A bill before the Maine legislature would allow women to obtain a year’s worth of oral contraceptives at a time, rather than the previous 3-month limit. This is a good thing, as argued by its sponsors and supporters. Women typically take oral contraceptives for long periods of time, and the requirement that they return to refill their prescriptions every 3 months is at best an inconvenience and at worst a burden. It is a burden women should not have. Indeed, there is no good reason to require a prescription for oral contraceptives at all.

This does not mean that there are no reasons put forward by opponents; if there were none, there would be no opponents. Overall, the opposing arguments fall into 3 categories: money, control, and wacko paranoia. If women only have to fill prescriptions once a year there will be fewer prescriptions being filled, which could be a small hit to pharmacies. The bigger objection is from insurers, as addressed in an article in the Portland Press-Herald of April 19, who worry that it could become a “mandate” for coverage with no cost share for other contraceptives, particularly those that are more expensive for insurers.

Control is a big and insidious issue. The idea that women are incapable of making their own decisions, particularly with regard to their reproductive systems, is as outrageous as it is persistent. For generations women have fought and often won struggles to be considered legally as “people” (implicit definition: men); to have the vote, to own property, to divorce. But no area has been as fraught with (yes, “fraught” requires a preposition!) opposition as the entire area of women’s reproduction. From before the time of Margaret Sanger, every source of pressure – religious, economic, and legal – has been brought to bear against the idea that women should have control of their own bodies and particularly their reproduction. The struggle continues; abortion rights are the most vulnerable today, but as the opposition to the Maine bill illustrates, contraceptive rights are scarcely secure.

Even among the biggest supporters of contraception, there can be poor decisions. Nearly 20 years ago I sat on a Planned Parenthood advisory board, and many of its members were surprised that I strongly opposed a requirement that women have a Pap smear before receiving a contraceptive prescription. The logic of those who supported it was that the inducement of receiving contraceptives would encourage women to get their Pap, which was then recommended. My position was that the negative incentive of the Pap (and associated pelvic examination, see below) would keep women, especially young women and teens, from getting their contraceptives, and thus likely increase unwanted pregnancies. I am sure that that Planned Parenthood, and other contraceptive providers, no longer have such a requirement. Indeed, we no longer recommend Pap smears for women under the age of 21, and for others, they are recommended only every 3 years. Regarding the screening pelvic examination, it simply violates the first criterion for a screening test – there must be condition that can be screened for in an asymptomatic person. This has led the American College of Physicians, having reviewed the evidence, to recommend against it, while the US Preventive Services Task Force (USPSTF) somewhat incomprehensibly, gives it an “I” (evidence is insufficient to recommend for or against) recommendation. This is summarized in a recent review from the Agency for Health Research and Quality (AHRQ). The American College of Obstetricians and Gynecologists still basically advocates it, although it suggests the decision be made individually between the woman and her doctor, no real change from when I discussed it on July 3, 2014 (”The screening pelvic examination: not annual, not ever”).

Being a major provider of contraception does not save PP from the wrath of Congressional Republicans; indeed, while abortion is the flaming tip of the spear of conservative opposition, the right’s opposition to PP is also against those that do not do abortions, but mainly provide contraception and other women’s health services. The good news is that the GOP may be unable to attach defunding PP to the “health” bill (Obamacare repeal) because it is being done at a budget resolution. You might think that providing contraception would be seen as a good thing, since fewer unwanted pregnancies would lead to fewer abortions, but this is not their logic. [I think that they are, basically, anti-sex, at least that practiced by others, as demonstrated by all the patently false claims we hear constantly in school-based clinics that prescribing contraception will “encourage” sex.]

Of course, it does not. Hormones encourage sex, yes. Social pressure encourages sex, for sure. But not contraceptives; what they do is prevent pregnancy. Amazing. And if the whole campaign against PP, as well as opposition to allowing a year’s worth of OCPs, is grounded in a mindset that wants to control women, the issue for young women (and their partners) is far worse. They are seen as not only women, but immature and incapable of making wise decisions. There is some basis for the idea that they are immature, as parents know; the brain is not fully developed until at least the mid-20s and the last part to develop is the ability to make “executive decisions” – taking the information that you have, looking at it completely and objectively, and making a smart choice.  This is why teens and young adults make poor decisions in driving and, conversely, make the best soldiers.

But this is not a justification for restricting access to contraceptives, condoms, or other health services that might prevent bad outcomes. Because teens make not make the most mature decisions, and often regret them later, it doesn’t mean that they won’t make them. So we need to make it as easy as possible for them to not have long-lasting negative consequences, like STIs and unintended pregnancy. There need to be as few barriers as possible for young people to not get (or make another) pregnant, to not get preventable sexually-transmitted infections (STIs). These would include making oral contraceptives over the counter, making condoms in front of the counter, and preferably free. Should a young woman (or man) come to a clinic for care, invite them in, see them quickly, meet their needs. For goodness sake, don’t make it hard, don’t send them somewhere else to register as they’ll walk out the door!

The editorial in the New York Times, May 13, 2017, “The health care bill’s insults to women”, documents the degree to which women in rural and underserved areas, where more than half of PP’s clinics are, will lose if Medicaid doesn’t cover services at PP. It notes that in 105 counties, PP is the only provider of reproductive health services. The editorial starts with insensitive “sophomoric” quotes from several congressmen and senators, including one from Kansas Sen. Pat Roberts that “I wouldn’t want to lose my mammograms!”. Sen. Roberts would be well advised to identify which of the areas in Kansas, particularly in the very rural “Big First” district he once represented as a congressman, would be among those losing services. A lot, actually, especially since one OB/Gyn from Great Bend is now busy representing the district in Congress. Of course, Dr. Roger “the poor just don’t want health care” Marshall probably didn’t take care of many underserved folks.

This is not the way to go. Our goal must be to increase health as much as possible, not to create obstacles to it.

Trump's "bad doctors": mostly greedy and bad for the public's health

My recent post, Doctors and health reform: maybe they do stand for health!, March 25, 2017, lauded the positions of many medical organizations, including the American Medical Association (AMA) for their positions in opposition to the American Health Care Act (AHCA), the Trump-Ryan bill that never even got to a vote, and apparently was never even available to House members to read before the vote was scheduled.  But I also pointed out some “bad” doctors, defined as those who advocate policies that are bad for the health of the American people. They argue that they are really for health, but this means mostly health care, especially medical care, for those who can afford it. There is no small tinge of racism as well as classism in these positions, because poor people and minorities are those most likely to be left out, and because, well, these perpetrators don’t care.

The prime example I cited was Secretary of Health and Human Services Tom Price, who, as a representative from a wealthy suburban Atlanta House district, continuously railed against the Affordable Care Act (ACA), as well as, in fact, Medicare. Dr. Price is an orthopedic surgeon, and my essay noted that this specialty is over-represented in the cohort of opponents of expansion of access, possibly because their high average income puts them in an elite economic group, and many are more concerned with their self-interest than the health of the overall population. Price was not the only bad doctor I mentioned; I also cited the “tone-deaf” comments of Rep. Roger Marshall of Kansas, an obstetrician-gynecologist. “Tone deaf”, of course, is a mild and polite term for his racist, classist comments, summarized as “the poor just don’t want health care”. Tone deaf, by the way, is also the term commonly used to describe the demeaning commercialization of the Black Lives Matter protest movement evident in Pepsi’s commercial featuring Kendall Jenner, now mercifully withdrawn. That was a result of the strong and sustained protest of a large number of people, especially on social media.

Price and Marshall are abetted by the non-physician politicians in Congress and the administration who also would deny health care to a lot of people, and even, through changes in Medicare and Medicaid, make the coverage of many people who now feel moderately secure in their insurance status greatly at risk and much more expensive. Speaker of the House Paul Ryan and Vice President Mike Pence met with the “Freedom” Caucus of the House to discuss just how regressive a health care bill would have to be to get their support. Pretty bad, it turns out. Its chairman, Rep. Mark Meadows of NC, is quoted by the NY Times as saying “Lower premiums have to be our first and only priority. By repealing community rating and the essential health benefits, it allows for lower premiums across the board.” Well, lower premiums are something everyone wants (except probably insurance companies) but there are different ways to get there. “Repealing community rating” means that insurers would no longer have to cover people who have chronic disease and are often older (and, ironically, often Trump and Freedom Caucus voters) at the same rates as less sick people. Those people would not have lower premiums; their premiums would either be fantastically higher, as they were before the ACA passed (and when many of them were without coverage) or be altogether unavailable. This is not something that the vast majority of Americans want. Similarly, “essential health benefits” are, well, essential. Like, for example, maternity care, and preventive health care. The fact that Rep. Meadows used that word and didn’t replace it with some euphemism, illustrates how tone-deaf he is.

But not all doctors who I would characterize as “bad” are reactionaries who are trying to figure out how to deny health care to the American people. Some are just traditionally greedy, seeking to fill their own pockets with as much money as possible. This is not a problem limited to the right; even folks who are progressive on social policies can be guilty of “going where the money is”. An excellent example is Trump’s nominee to head the FDA, Dr. Scott Gottlieb. Gottlieb, like many researchers, has been highly paid (at least on the order of hundreds of thousands of dollars) by drug manufacturers. Gottlieb assures us that this will not affect his decision making at FDA, and that he can be trusted, as in the title of the NY Times article of April 5, 2017, in which he “deflected” criticism. While some Democrats, like Sen. Patty Murray of Washington, noted that he had ‘“unprecedented financial entanglements with the industries he would regulate,”’ Republicans like Lamar Alexander of Tennessee agreed with Dr. Gottlieb that “his experience with the pharmaceutical industry would be an asset in regulating it.” This is terrific tortured fox-guarding-the-henhouse logic, like having Goldman Sachs financiers regulating Wall Street, or petroleum company flaks running EPA (which we, in fact, have). This concept worked fine on “It Takes a Thief”, but not so much in real life.

Taking huge amounts of money from drug companies may be morally reprehensible (or not, depending on your view; in mine it is), but more concerning are the positions that Gottlieb has taken. While he is open (he says now) to lowering drug prices by importing drugs from Canada, something Trump has occasionally voiced support for, he has previously written against it (when he was in the pay of the drug companies). The issue is what the policies pursued by the FDA, HHS, CMS, and the overall Trump administration and Congress regarding the people’s health will be. Disrespect for preventive care (“essential services”) and environmental pollution bodes very poorly for public health, as the core principle of “cut benefits” does for medical care. And, as always, the most vulnerable – from poverty, age, illness, geographic region – will suffer the most.  It would be really good if we could count on doctors like Price, Marshall and Gottlieb to protect the health of the people, but don’t count on it. We are going to need huge public protest, at least as big as those that ending up canceling the Pepsi commercial.

Well, it could be worse. Another physician, Dr. Bashar al-Assad, is gassing his own people with chemical weapons. And there was also Dr. Josef Mengele. So far, none of Trump’s nominees are in that league.

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.