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COVID-19 Makes the Case for a National Health Care System

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By MIKE MAGEE, MD

Governors like Andrew Cuomo of New York have discovered the price for inefficiency and conflicts of interest in the face of the COVID-19 epidemic. As he said last week, “No one hospital has the resources to handle this. There has to be a totally different operating paradigm where all those different hospitals operate as one system.”

Our system is marked by extreme variability: a nation of health care haves and have-nots. Yet even when we Americans acknowledge the absurdity of our convoluted system of third-party payers and the pretzel positions our politicians weave in and out of as they try to justify it, reform it, then un-reform it, many still find solace in telling themselves, “Well, we still have the best health care in the world.”

This crisis in a matter of weeks has revealed the limitations of a conflicted network built on short-term profiteering and entrepreneurial adventurism. Here are a few early learnings:

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Advanced Professionalism and Fitzhugh Mullan

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By MIKE MAGEE, MD

As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today. 

Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.

Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:

“From my own perspective, I have no reservations about accepting any, or all of the foregoing articulations of various qualities, attitudes, and activities of the physician as legitimate representations of important attributes for the trustworthy professional. In fact, I find it difficult to choose one list over others, since they each in turn seem to refer largely to the same general set of admirable qualities. While we in medicine might see these as our lists of the desirable attributes of professionalism in the physician, as the father of an Eagle Scout I know that Boy Scout leaders use a very similar list to describe the important qualities of scouts: ‘A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, reverent (respecting everyone’s beliefs).’ I make this observation not to descend into parody, but to make a point. These various descriptions are so similar because when we examine the field of medicine as a profession, a field of work in which the workers must be implicitly trustworthy, we end by realizing and asserting that they must pursue their work as a virtuous activity, a moral undertaking.”

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Charting The Economic History of US Health Reform

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By MIKE MAGEE, MD

Adam Gaffney’s recent Boston Review article, “What the Health Care Debate Still Gets Wrong”, a landmark piece that deserves careful reading by all, reaches near perfection in diagnosing our health system malady.

Dr. Gaffney is president of Physicians for a National Health Program, and a co-chair of the Working Group on Single-Payer Program Design, which developed the “Physicians’ Proposal for Single-Payer Health Care Reform.”

A seasoned health policy expert, his article cross-references the opinions and work of a range of health commentators including Atul Gawande, Steven Brill, Sarah Kliff, Elizabeth Rosenthal, Zack Cooper, and Canadian health economist Robert Evans. But his major companion is Princeton health economist, Uwe Reinhardt, whose posthumous book, Priced Out: The Economic and Ethical Costs of American Health Care, was recently published by Princeton University Press.

Gaffney’s affection for Reinhardt is evident as he recounts his desperate upbringing in post-war Germany, challenged by poor living conditions, but made whole by access to health care.  Quoting a 1992 JAMA interview, Reinhardt states, “When we needed medical care, we got it at the local hospital, no questions asked. When you were sick, society was there for you.”

That acknowledgment is not only personal but historically significant, as I outline in my recent book, Code Blue: Inside the Medical Industrial Complex. The services Reinhardt received were part of a new national health care system funded fully by American taxpayers as part of the Marshall Plan. At the very same time, American citizens were denied a national health plan of their own as Truman was effectively branded a supporter of “socialized medicine” by the AMA and a cabal of corporate partners.

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The Efficiency Mandate: To Achieve Coverage, the U.S. Must Address Cost

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By MIKE MAGEE, MD

It is now well established that Americans, in large majorities, favor universal health coverage. As witnessed in the first two Democratic debates, how we get there (Single Payer vs. extension of Obamacare) is another matter altogether.

295 million Americans have some form of health coverage (though increasing numbers are under-insured and vulnerable to the crushing effects of medical debt). That leaves 28 million uninsured, an issue easily resolved, according to former Obama staffer, Ezekiel Emanuel MD, through auto-enrollment, that is changing some existing policies to “enable the government agencies, hospitals, insurers and other organizations to enroll people in health insurance automatically when they show up for care or other benefits like food stamps.”

If one accepts it’s as easy as that, does that really bring to heel a Medical-Industrial Complex that has systematically focused on profitability over planning, and cures over care, while expending twice as much as all other developed nations? In other words, can America successfully expand health care as a right to all of its citizens without focusing on cost efficiency? 

The simple answer is “no”, for two reasons. First, excess profitability = greed = waste = inequity = unacceptable variability and poor outcomes. Second, equitable expansion of universal, high quality access to care requires capturing and carefully reapplying existing resources.

 It is estimated that concrete policy changes could capture between $100 billion and $200 billion in waste in the short term primarily through three sources.

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Doctors Will Vote With Their Patients

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By MIKE MAGEE, MD

As Robert Muller’s testimony before Congress made clear, we owe President Trump a debt of gratitude on two counts. First, his unlawful and predatory actions have clearly exposed the fault lines in our still young Democracy. As the Founders well realized, the road would be rocky on our way to “a more perfect union”, and checks and balances would, sooner or later, be counter-checked and thrown out of balance.

On the second count, Trump has most effectively revealed weaknesses that are neither structural nor easily repaired with the wave of the wand. Those weaknesses are cultural and deeply embedded in a portion of our citizenry. The weakness he has so easily exposed is within us. It is reflected in our stubborn embrace of prejudice, our tolerance of family separations at the border, our penchant for violence and romanticism of firearms, our suspicion of “good government”, and –unlike any other developed nation – our historic desire to withhold access to health services to our fellow Americans.

In the dust-up that followed the New York Times publication of Ross Douthat’s May 16, 2017 article, “The 25th Amendment Solution for Removing Trump”, Dahlia Lithwick wrote in SLATE, “Donald Trump isn’t the disease that plagues modern America, he’s the symptom. Let’s stop calling it a disability and call it what it is: What we are now.”

Recently a long-time health advocate from California told me she did not believe that the majority of doctors would support a universal health care system in some form due to their conservative bend. I disagreed.

It is true that, to become a physician involves significant investment of time and effort, and deferring a decade worth of earnings to pursue a training program that, at times, resembles war-zone conditions can create an ultra-focus on future earnings. But it is also true that these individuals, increasingly salaried and employed within organizations struggling to improve their collective performance, deliver (most of the time) three critical virtues in our society.

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Is “Medicare For All (Who Want it)” Enough?

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By MIKE MAGEE

In the 2nd night of the Democratic Primary debate on June 27, 2019, Pete Buttigieg was asked whether he supported Medicare-For-All. He responded, “I support Medicare for all who want it.” 

In doing so, he side-stepped the controversial debate over shifts of power from states to the federal government, and trusted that logic would eventually prevail over a collusive Medical-Industrial Complex with an iron lock grip on a system that deals everyone imaginable in on the sickness profitability curve – except the patient.

On July 30, 1965, President Lyndon B. Johnson signed into law “Medicare,” a national insurance plan for all Americans over 65. He did so in front of former President Truman, who 20 years earlier had proposed a national health plan for all Americans, and for his trouble was labeled by the AMA as the future father of “socialized medicine.”

For Truman, there was a double irony that day in 1965. First of all, the signing was occurring at around the same time as our neighbor to the north was signing their own national health plan, also called “Medicare”, but their’s covered all Canadian citizens, not just the elderly.

The second incongruity was that Truman was fully aware that in 1945, as he was being tarred and feathered as unpatriotic by taxpayers for having the gall to suggest that health care was a human right, those very same citizens were unknowingly funding the creation of national health plans as democracy stabilizers in our two primary vanquished enemies – Germany and Japan – as part of the US taxpayer funded Marshall Plan.

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All for One, One For All

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By MIKE MAGEE MD

Within the ever-widening array of Democratic contenders for the Presidency, the “Medicare-for-all” debate continues to simmer. It was only six weeks ago that Kamala Harris’s vocal support drew fire from not one, but two billionaire political rivals. Michael Bloomberg, looking for support in New Hampshire declared, “I think we could never afford that. We are talking about trillions of dollars… [that] would bankrupt us for a long time.” Fellow billionaire candidate Howard Schultz added, “That’s not correct. That’s not American.”

Remarkably, neither man made the connection between large-scale health reform’s potential savings (pegged to save 15% of our $4 trillion annual spend according to health economists) and the thoughtful application of these newly captured resources to all U.S. citizens without discrimination. Bloomberg’s own 2017 Health System Efficiency Ratings listed the U.S. 50th out of 55, trailed only by Jordan, Columbia, Azerbaijan, Brazil, Russia. Yet he seemed unable to connect addressing waste with future affordability.

Schultz was similarly short sighted. While acknowledging that the manmade opioid epidemic, mental health crises, and income inequality are “systemic problems” and at levels “the likes of which we have not had in a long time”, he failed to connect the cause (a remarkable dysfunctional and inequitable health care system) with these effects.

As I outline in “Code Blue: Inside the Medical Industrial Complex” (Grove Atlantic/ June 4, 2019), today’s greatest risk to continued progress and movement toward universal coverage and rational health planning is sloppy nomenclature.  To avoid talking past each other, we need to define the terms of this debate while agreeing on common end points.

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