By Joan Brunwasser
OpEdNews, Nov. 18, 2014
My guest today is second-year medical student, Brad Zehr. Welcome to OpEdNews, Brad. Something very interesting happened at the AMA (American Medical Association) recently. What can you tell us about it?
BZ: The Medical Student Section of the AMA adopted a resolution at the Interim AMA meeting in Dallas expressing support for innovative state legislation to achieve universal health care, including but not limited to single-payer health insurance. The reason this policy item was particularly high-profile and groundbreaking was because it is the first instance of any section of the AMA adopting policy in support of single-payer health insurance. Although the Medical Student Section (MSS) is only one of ten sections of the AMA, and although this resolution pertains only to the MSS and not the full AMA, the resolution signals a generational shift in organized medicine’s approach to health care reform.
Historically, the AMA has explicitly opposed any forms of single-payer, including opposition to the creation of U.S. Medicare in 1965. The AMA House of Delegates (HOD), which is the highest policy-making body of the AMA and includes representation from all of the AMA sub-sections and from state medical societies and medical specialty societies, still has three policies stating express opposition to single-payer health insurance in the U.S. The MSS boldly voiced support for single-payer despite the HOD’s continued hypersensitivity to single-payer.
JB: How did this come about? I understand that you were one of the students responsible for writing the resolution. Was there a knock-down drag-out fight about this? What was the process like? Tell us more, please.
BZ: Several recent developments in U.S. health care contributed to our motivation to submit the single-payer resolution to the AMA-MSS at this particular time. First, the Affordable Care Act includes a lesser known component called “Sec. 1332: Waiver for State Innovation.” The section allows states to apply for an exemption from the federal ACA law beginning on January 1, 2017, to implement their own alternative, state-based health care law, given that their state law would cover at least as many people as the ACA would have, that the coverage would be as affordable to individuals and families as the ACA coverage would be, and that the state law would not increase the federal deficit.
Upon receiving approval from the U.S. Department of Health and Human Services and the U.S. Department of the Treasury, such innovative states would receive federal funds equivalent to what they would have received under the ACA in order to implement their alternative health care reform plan.
Vermont is the first, and so far only, state to commit to applying for a Section 1332 State Innovation Waiver. The state plans to establish a state-based single-payer health insurance system beginning in 2017. The program will be called Green Mountain Care and would be the first-ever example of a state-based single-payer system in the U.S. In addition to Vermont, at least half a dozen other states have active single-payer popular movements.
BZ: A second recent development that motivated our resolution was the Massachusetts gubernatorial candidacy of Dr. Don Berwick, an internationally recognized health policy scholar and former chief administrator of the U.S. Centers for Medicare and Medicaid Services. Berwick campaigned on a pledge to move Massachusetts toward a single-payer system. His campaign energized a vast progressive base in the state, and he earned endorsements from some of health care’s most celebrated thought-leaders, including Atul Gawande, Paul Farmer, and John McDonough. Berwick often noted on the campaign trail that Massachusetts has historically been a beacon of progress for the nation, including the passage of so-called “Romneycare” in 2006, which became the model upon which the ACA was based. Berwick’s inspiring vision was for Massachusetts to once again lead the nation in health policy reform. Although he lost the Democratic primary to Martha Coakley, he mobilized incredible stores of political energy in the state with his bold commitments.
Finally, we wrote the resolution because single-payer has been conspicuously absent from the health policy conversation at the AMA-MSS throughout this past 15 years of upheaval in U.S. health care. The last time medical students debated single-payer at the AMA was at the interim meeting in 1999. That resolution asked the AMA to study the advantages and disadvantages of a single-payer system, but the MSS did not adopt it.
We submitted a single-payer resolution to the Annual 2014 meeting this past June in Chicago. That resolution was strong: asking the AMA HOD to advocate for national single-payer health insurance. Sixty-one medical students from 18 medical schools co-authored that resolution. However, the MSS Reference Committee recommended the resolution not be adopted based on the argument that asking the AMA HOD to advocate for national single-payer in light of their continued opposition was politically futile and a waste of our limited MSS influence. Furthermore, many student delegates expressed support for single-payer, but said that it should be tried on a state-by-state basis, and that we should keep this policy within the MSS.
With the feedback of dozens of medical students from around the country, we crafted a compromised resolution for re-submission at the Interim meeting in November. This second version of the resolution was internal to the MSS, and asked for support for state-based single-payer. And rather than being co-authored by 61 individual students, it was co-authored by 4 delegations: Massachusetts, Wisconsin, University of Vermont College of Medicine, and SUNY-Downstate College of Medicine. During the MSS General Assembly, the Reference Committee recommended adoption after amending the resolution to be expanded to include other innovative state legislation to achieve universal health care, in order to garner broader support. The resolution was adopted by approximately a two-thirds majority, although only 51 percent was required for adoption.
JB: This is definitely encouraging, but what does it all mean? Vermont’s Green Mountain Care won’t even kick off until 2017 and it’ll take a while to assess its effectiveness. I’m intrigued with the sea-change among you future physicians. You’re clearly out of step with the AMA as a whole. How do you explain the gap? What about your own motivation?
BZ: We’ve asked ourselves these questions often throughout this resolution-writing process. I often return to the words of the immediate past president of the AMA, Dr. Ardis Dee Hoven. In May of this year, she visited some medical students in Detroit. She said, “Students are the lifeblood. They are the future. Medical students are so much better and so much smarter than I was as a student. They’re learning early. They’re learning the democratic process and the tools they need to make a difference. … The status quo is unacceptable. We have to move medicine ahead and it is our job to move this forward. You will be the leaders.”
From the highest levels of organized medicine, medical students hear that U.S. health care is not working and that we need to advocate for the system we want during our careers. This is exactly what we are trying to do with this resolution. We know that single-payer is one of the best ways to guarantee universal health care while controlling costs. The evidence to support this assertion is extensive, some of which we included in the Whereas clauses of our resolution. We think it is time to treat the AMA’s hypersensitivity to single-payer in the U.S. and have an evidence-based debate about the merits of such a system, especially in light of the fact that one state has already committed to it.
JB: You’re passionate about this. Have you always been? What drew you to medicine in the first place and do practicing medicine and activism go together well or does one get in the way of the other?
BZ: Single-payer health care reform was not on my radar going into medical school. Throughout college and grad school, I had followed the national health reform debate, from the 2008 presidential elections through the tumultuous rollout of healthcare.gov in October 2013. I learned about single-payer a year ago by attending the annual meeting of Physicians for a National Health Program, which happened to take place in Boston (10 minutes by bus from my medical school). David Himmelstein, MD, and Steffie Woolhandler, MD, the co-founders of PNHP, presented several hundred slides of data analyzing the poor performance of our current health care system — or “non-system” as they demonstrated. Medical students and physicians respond to evidence and data. The evidence presented at that meeting was so compelling that several classmates and I decided to start a PNHP chapter at our school and to study single-payer in between studying anatomy, physiology, biochemistry, and histology. What we discovered was an energized community of physicians whose priority is to create a health care system where everyone is in, nobody is out, and the profit motive is removed from health financing. I’ve made single-payer a major part of my medical education because I want to practice in a more sane, ethical, and sustainable system.
JB: What’s wrong with what we’ve got now? Aren’t we a lot better off with the Affordable Care Act? So many more people, millions more, are covered. Isn’t that what we’ve been aiming for?
BZ: The ACA will leave about 30 million uninsured and tens of million more underinsured. It is inadequate. Half the states are opting out of the Medicaid expansion. The most popular plans on the exchanges are silver and bronze, which are low cost up front but high cost out of pocket, exposing patients to extreme financial toxicity. Patient choice of doctor and hospital are limited by private insurance networks. The administrative overhead in the private health insurance system is 15 to 20 percent, whereas the overhead of single-payer Medicare is less than 2 percent. Our country spends twice as much per capita on health care as the other advanced nations yet we consistently achieve poorer health outcomes across the board and leave millions out. Physicians are tired of fighting with private health insurance plans to cover the care their patients need.
We need a modern, 21st-century health care system that includes every citizen automatically and simply. The ACA exacerbated the flaws of the pre-ACA system and further entrenched the private health insurance industry. It is a patchwork fix and will not suffice during my career. Millennials have a low tolerance for needless complexity and systemic inequality, and they demand simplicity and fairness. Millennial physicians will not tolerate a system that leaves out millions, outspends all other peer nations for poorer outcomes, and creates daily interferences with treating patients.
JB: Everything you say is true, Brad. I believe the U.S. is the only industrialized country without some form of universal health coverage. But, as you pointed out, the AMA opposed Medicare’s creation back in 1965. And the organization, your resolution notwithstanding, is still adamantly opposed to single payer. So, how realistic is it to think that a bunch of idealistic young’uns are going to turn things around any time soon? done
BZ: The AMA is struggling to maintain its position as the singular voice of American doctors. The percentage of U.S. physicians who are AMA members has declined for decades — from a peak of 75 percent in 1960, to 50 percent in 1973, to about 20 percent in 2008. These figures come directly from AMA CEO Dr. Michael Maves, who addressed the AMA House of Delegates at the 2008 Interim meeting in Orlando. He listed several reasons why the AMA struggles and said, “Perhaps most difficult of all, physicians don’t think that the AMA gets ‘it’ and gets ‘them’ and can act as an agent of positive change. ” When your colleagues back home no longer think of the AMA as ‘stuck in the past’ and see us as future-focused, you will know we are on the right track.”
Medical students participate in the AMA because we want to advocate for patients and for the future of the profession, not to subscribe to any particular political ideology. We study medical ethics in the first year of med school, and then steadily over the next years we observe in hospitals and clinics a fundamental disconnect between the Hippocratic Oath and the reality of American medicine. According to the Oath, the interests of patients trump the interests of physicians and all other interests, including those of profit-seeking health insurance companies. If taking the Hippocratic Oath seriously is perceived as foolish idealism by the system, then it is the system which requires correction.
When the AMA-MSS voiced support for innovative state legislation to achieve universal health care, including single-payer health insurance, it took one step toward treating the AMA’s historical hypersensitivity to single-payer. We invite the AMA to listen carefully to the voice of its youngest members and engage in an evidence-based discussion on single-payer. We hope the AMA takes this opportunity to evolve, keeping in mind its long-term membership goals.
JB: I couldn’t agree with you more. I’m buoyed by you passion for this topic and am consequently cautiously optimistic for the long run. Getting the insurance companies to surrender what has been a cash cow of gargantuan proportions will be another big fight. Any thoughts on that?
BZ: Polling shows a majority of Americans prefer national health insurance. Can you believe it? A 2009 CBS News / New York Times poll showed 59 percent of Americans favor government-run national health insurance.
BZ: Ultimately, voters will need to force their representatives to write and pass legislation that creates a more equitable health care system. Things might have to get worse, sadly. Right now, our national political discourse is in disarray. Few are optimistic about major national reform in any area of policy, let alone one as sensitive as health care. We will likely need campaign finance reform to get to a place politically where the will of the majority of Americans is prioritized over the will of the wealthiest donors and private health insurance lobbyists.
In the meantime, there are a handful of states where there are popular movements advocating for the creation of state-based single-payer health insurance — Vermont, New York, Massachusetts, Washington, Illinois, Pennsylvania, among others. We want to support those states that will move toward single-payer in the coming decade.
JB: Maybe after people see how well Vermont and any other forward-thinking states are doing with single-payer, it will catch on like wildfire. Anything you’d like to add before we wrap this up?
BZ: For anyone on the fence or skeptical about single-payer, I invite them to listen to a physician debate on single-payer in March 2014 at Albany Medical College.
Last, I want to share a story I recently discovered. In 2004, the Canadian Broadcasting Corporation ran a TV series called “The Greatest Canadian.” The show conducted national polling in the spirit of “American Idol” to identify who is the greatest Canadian in history. The winner was Tommy Douglas, who started Canada’s first province-based single-payer health care system in 1962 Saskatchewan. The system was later adopted nationally. By popular vote in 2004, Canadians deemed the father of their single-payer system their greatest citizen, beating such Canadian luminaries as Wayne Gretzky, Celine Dion, Mike Myers, Alexander Graham Bell, Frederick Banting (co-discoverer of insulin), Neil Young, Jim Carrey, Michael J. Fox, Tecumseh, and John Candy.
We will create a health care system for all Americans, eventually. Millennial medical students are moving us toward that goal with the adoption of the AMA-MSS resolution supporting state-based single-payer.
JB: This interview has been an eye-opener for me. I’m thrilled that our medical future will be guided by souls such as yourself so dedicated to the true spirit of the Hippocratic Oath. Thanks very much for talking with me, Brad. Good luck to you!
1) The PNHP press release on this resolution —
2) 2003 JAMA article, Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance — the foundational paper describing what single-payer in the U.S. would and would not be (note, the group is set to publish an updated version of the proposal in 2015, but the basic tenets of the proposal will be unchanged).
3) March 2014 Albany Medical College debate on single-payer, audio from which is posted on WAMC Northeast Public Radio website.
Joan Brunwasser is a co-founder of Citizens for Election Reform has been Election Integrity Editor for OpEdNews since December 2005. Her articles also appear at Huffington Post, RepublicMedia.TV and Scoop.co.nz.