By Adam Gaffney, M.D., M.P.H.
The Baffler, February 19, 2020
“Compulsory Health Insurance is an Un-American, Unsafe, Uneconomic, Unscientific, Unfair and Unscrupulous type of Legislation [supported by] Paid Professional Philanthropists, busybody Social Workers, Misguided Clergymen and Hysterical Women.” So affirmed Dr. J. A. O’Reilly to the Kings County Medical Society of New York in the waning days of the nation’s first fight for a European-style health care reform, some hundred years ago.
If Dr. O’Reilly’s screed—which is quoted in Ronald L. Numbers’s 1978 chronicle of the saga, Almost Persuaded: American Physicians and Compulsory Health Insurance, 1912–1920—strikes modern readers as rather histrionic, it bears some resemblance to the position held by American Medical Association (AMA) ever since. As the title of Numbers’s book suggests, the AMA was at first tempted by arguments for what was then called “compulsory health insurance,” but eventually realized it despised it—and helped to scuttle it. This became part of a pattern: in the late 1940s, the AMA famously fought, and defeated, national health insurance legislation supported by President Harry S. Truman and backed by organized labor. It even opposed Medicare in the 1960s, enlisting Ronald Reagan to record a ridiculous LP wherein the actor and future president described health insurance for the elderly as the death knell of American freedom. “One of the traditional methods of imposing statism or socialism on a people,” Reagan sternly warned, “has been by way of medicine.”
But it was not just fear of the Reds or Hysterical Women. National health insurance was, some physicians felt, a threat to their livelihood as well as their autonomy—and to the sacrosanct doctor-patient relationship. “State medicine . . . means death of individualism, of humanitarianism, and of scientific practice,” Dr. Morris Fishbein, editor of the AMA’s medical journal and a leading opponent of national health insurance, contended in 1928. Yet though the AMA succeeded in its fight against national health insurance, it failed to protect the independence of physicians. Instead of “state medicine,” we have witnessed the “rise of corporate enterprise in health services,” as sociologist Paul Starr described it in his 1982 classic, The Social Transformation of American Medicine. This new corporate medical landscape seems to be making just about everyone miserable. So miserable, perhaps, that today doctors are coming to see national health insurance, now popularly referred to as “Medicare for All,” as less an existential threat and more a solution, both for their patients and their profession.
The shift is becoming obvious in the highest echelons of organized medicine. In January, the nation’s largest medical specialty society—the American College of Physicians (ACP), which represents internal medicine doctors—swung out in support of universal health care reform, explicitly endorsing single-payer Medicare for All alongside a universal “public choice” model. The announcement in the pages of the ACP’s official journal was followed a day later by an open letter, published as a full-page ad in the New York Times, signed by over two thousand physicians (including such prominent doctors as Partners-in-Health co-cofounder Paul Farmer and the developer of the defibrillator, Bernard Lown) “prescribing” Medicare for All to the nation—an effort organized by Physicians for a National Health Program (PNHP), for which I serve as president.
These widely reported events came on the heels of some remarkable developments within the AMA, in large part driven by medical student activism. In June, members of PNHP’s student wing organized a demonstration outside the AMA’s national convention in Chicago to protest the organization’s opposition to Medicare for All—and its support of the anti-single-payer, deep-pocketed, dark-money lobbying group, the Partnership for America’s Health Care Future (which you may know from its goofy multimillion dollar ad campaign attacking what it calls “one-size-fits-all” health care). Student members inside the AMA conference subsequently introduced a motion in its House of Delegates to end the group’s opposition to single-payer and were—startlingly—only narrowly defeated, by 47 percent to 53 percent. Then, in August, the AMA withdrew from the insurer- and pharmaceutical-led Partnership: a remarkable retreat.
These developments represent a dramatic, if incomplete, shift in the profession, although they are not without precedent. As Danielle Carr recently described in The Nation, a “rebellion” of more than four hundred well-known doctors endorsed national health care reform in the face of AMA opposition in 1937, an event that was covered on the front page of the New York Times. In subsequent decades, various physician groups—the radical Physicians Forum of the post-war decades, the Medical Committee for Human Rights in the civil rights era, and PNHP today—have helped keep the flame of the universal health care ideal alive in the face of institutional (and corporate) intransigence. Something new, however, is unfolding in the mainstream of the profession today.
Perhaps this is unsurprising, considering the hardship that physicians regularly see inflicted on their patients. As an intensive care unit physician, for instance, I have treated patients with “hypertensive emergencies”—high spiking blood pressure that can lead to swelling in the brain or a suffocating buildup of fluid in the lungs—because they were uninsured and went for years without care and medicine. Studies have found that patients in the throes of heart attacks are delaying coming to the hospital out of financial fears, and that women with breast cancer and high-deductible health care plans put off biopsies and even the initiation of chemotherapy due to costs.
There is more to it than being witness to suffering, however. The medical landscape of Dr. O’Reilly’s day—of black-bag toting independent practitioners beholden, they might contend, to nobody but their patients and professional creed—has ceased to exist. Consolidation and corporatization have led to a brave new world of giant insurance conglomerates and sprawling hospital systems. For doctors, this has been a mixed bag. On the one hand, physicians are still well remunerated—some particularly so, like those who join private-equity owned staffing organizations infamous for using “surprise billing” as a business tactic. On the other hand, physicians are unmistakably moving from the ranks of small businesspeople to those of employees. In 2016, Modern Healthcare reported that for the first time, less than half of physicians were owners of their medical practices. The new owners, increasingly, sit at the commanding heights of the American economy. A 2018 article in Bloomberg, for instance, described how the insurance giant UnitedHealth has built “an army of tens of thousands of physicians to fend off invaders” in the health care space. Dr. O’Reilly wouldn’t recognize this corporate-dominated medical landscape—and might not have liked it much more than “compulsory health insurance.”
Consider that this landscape is upending the work life of physicians with ever increasing requirements to bill, code, and document—and to sit on the phone and fight insurers for authorizations of care for their patients. One study found that nearly half of a physician’s working day now consists of time spent on the computer or doing desk work, double the proportion spent face-to-face with patients. Another study found that primary care doctors spend some four-and-a-half hours each workday glued to their computers—plus about another hour-and-a-half after they get home at night. Such a large administrative burden appears to be contributing to a rampant epidemic of physician burnout. In a 2019 Medscape poll of some 15,000 physicians, 44 percent reported experiencing burnout—and by far the leading contributing factor cited was “too many bureaucratic tasks (e.g. charting, paperwork).” Even putting professional satisfaction aside, it’s clear that our financing system generates enormous waste: in 2011, one study estimated that in the United States, we spend more than $80,000 on each physician annually merely to cover their costs of wrangling with insurers—nearly four-fold higher than in Canada. These costs are ultimately passed on to patients, but they can drain the joy out of medical practice, too.
Over the last century, our failure to achieve national health insurance—and the resultant rise of a corporate medical behemoth—has meant, far too often, the neglect of patients. Yet it also seems to be leading to a growing sense of alienation within the profession. And so, while previous generations of physicians felt they had much to lose from national health insurance, today physicians increasingly feel that they, like their patients, have much to gain from a universal system. As the political tides shift, Medicare for All will once again be within reach. This time around, rather than standing in its path, physicians may help to win it.
Dr. Adam Gaffney is a pulmonary and critical care physician and public health researcher at Harvard Medical School and the Cambridge Health Alliance, and serves as president of Physicians for a National Health Program. He writes about issues of health policy and politics and is the author of “To Heal Humankind: The Right to Health in History,” published by Routledge in 2017.