Quentin D. Young Festschrift

By John Geyman, M.D.
Northwestern Magazine, Summer 2016

Quentin Young ’48 MD was an eloquent and persistent voice and advocate for social justice in U.S. health care from the time he entered medicine more than 70 years ago until his last breath recently at age 92. He lived at least five lives in one, always in defense of health care as a human right. He was a consistent moral compass for the medical profession, always ready to defend medicine against the incursion of those who commercialize and exploit the system for their gain over the care of patients. He excelled all along the way as a clinician, teacher, administrator, and as a fierce advocate for health care reform in the public interest.

In this Festschrift we will look at the body of his work over his long and productive career, drawing partly from his 2013 book, Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause, ¹ and some of his other writings along the way. Because of his prodigious efforts over the years, it is only possible to touch on some of the highlights.

Early Years

Quentin was born in Chicago in 1923, the first-born of a Jewish couple who had moved there shortly before. His dad had graduated from Fordham University in pharmacology, wanted to go to medical school but could not afford it. His mother wanted to name her son after Quentin Roosevelt, the World I flyer killed over France in 1917, and was able to get permission to name him that instead of after a deceased relative. The family lived in a modest house just half a mile west from the University of Chicago.

As a youngster, Quentin read a lot, and was bumped up two grades at his elementary school. He had many friends, and was an active member of the Jack and Jill Players, a well-known children’s acting troupe that performed onstage and on the radio. That led in later years to a long association with the Chicago public radio station WBEZ, where he would host a show and appear frequently on others.

Entering high school at 16 in 1936, in the middle of the Great Depression, Quentin became fully aware of rampant unemployment and labor-management struggles as well as Hitler’s rise in Germany, Mussolini’s invasion of Ethiopia, and the Spanish civil war. He gave credit to his parents, as New Deal Democrats, for his social and political conscience, and soon became active in the American Student Union at Hyde Park High, an anti-Nazi, progressive group. He went on to the University of Chicago in 1940, attracted by the curriculum instituted by President Hutchins, the “Chicago Plan,” requiring all students to take two-year courses in the humanities, the natural sciences, the social sciences, and reading, writing and criticism.

Sometime during his first or second year in college, Quentin decided that he wanted to be a doctor, for these reasons:

Because medicine was the profession most in keeping with my system of beliefs. It was a livelihood that offered the opportunity to do good (not that every doctor takes up that offer). Yes, it was a relatively tough academic ride, but if you could make it to the end and get your license, you could earn a comfortable living. And, if you chose, you could go to work every day and be a decent, caring, supportive person practicing your profession. ²

Army experience

At the time of the Pearl Harbor attack on December 7, 1941, Quentin was 17, was anti-isolationist and wanting to join the military and fight, especially against Hitler. He was too young to enlist, and was pre-med. Two years later, at 19, though he could likely have secured a student deferment, he enlisted in the Army. His first choice was the infantry, but he was too nearsighted.  His second choice was the artillery, but he was assigned to the medical department, hoping to be trained as a medic on the front lines.  But the Army instead put him into the just established Army Specialized Training Program (ASTP). He was sent to Cornell University in Ithaca, New York, to complete pre-med studies, then back near home to medical school at Northwestern University, starting in 1944 and graduating in 1948, when he was a civilian again and married with two children.

Graduate medical education at Cook County Hospital 1948-53

There was no question about where he would take his graduate training. Cook County Hospital, with 3,400 beds, was with Los Angeles County and Bellevue in New York, among the largest and best teaching hospitals in the country. He had taken medical student rotations there during medical school, and liked the emphasis on service and seeing everything that happens in medicine. He wanted to become a general internist, and spent the next three years there after his two-year internship, plus a year in West Virginia in 1951, completing his residency training in 1953.

True to his nature throughout his medical school and residency years, Quentin spent time agitating for better conditions for both his colleagues and patients. He became active in the Association of Interns and Medical Students (AIMS), lobbying for the end to racial and gender discrimination in  medical schools, better policies to address unwanted pregnancies, other health issues, and national health insurance. AIMS ran counter to the AMA and more conservative deans of medical schools, with its sequel in 1952 becoming the less progressive American Medical Students Association (AMSA), as it is known to this day. In 1951, Quentin founded the Committee to End Discrimination in Chicago’s Medical Institutions (CEDCMI).

Quentin was inspired by Cook County Hospital, which he described as “like a loving mother with arms outstretched to embrace all who sought her care. Without barrier and with no exclusionary questions asked, County stood poised to help all comers and usually the care was very good.” And this is what he learned at County:

I am convinced that until we, as a nation, have a system of universal health care, including everyone—everybody in, nobody out—until we provide that, we as a society just provide care through a system like County. [In his 2013 book, he said]: Sadly, all these years later, this is still the case. ³

Practice years

Quentin hoped to set up practice in a neighborhood near the steel mills on Chicago’s far South Side and serve blue collar workers, but that plan was thwarted by potential landlords who wouldn’t rent him office space, fearing that the powers that be would not want a physician on the premises treating union men and women. So instead, he joined another physician in Hyde Park, where he already had many friends. He welcomed the socioeconomic and racial diversity of Hyde Park. He enjoyed being a generalist primary care physician in a way that he had seen modeled at Cook County. As he said, “My joy and comfort mostly lay in seeing all kinds of people with all kinds of illnesses.” ⁴

Civil Rights Activist

Taking time from his own practice, Quentin’s political activism increased even more when he met and marched with Dr. Martin Luther King, who had settled in Chicago’s ghetto on the West Side in 1966 in order to fight for open housing and an end to segregation in the public school system. They had first met in Mississippi during the Freedom Summer of 1964. Quentin had been an early organizer of a new group in Chicago, the Medical Committee for Human Rights (MCHR), that provided medical services that summer, during the march from Selma to Montgomery the next year, and at other later events to forward the cause of civil rights. MCHR, with its membership of physicians, dentists, nurses, and social workers, had responded to a call from organizers of the Mississippi Summer Project to join these marches, both to bear witness and provide services as needed. Quentin was just one or two people away from Dr. King on these marches, and was the first to treat him when he was hit in the head by a rock and sustained a large scalp laceration. Many of the marchers were jailed, often with wounds. MCHR physicians were generally well treated by the police, who let them accompany those arrested into jail cells to determine the extent of their injuries, if any. MCHR would loudly proclaim any who were uninjured, which helped to reduce possible jailhouse violence. ⁵ Quentin later served as national chairman for MCHR from 1967 to 1968 and from 1971 to 1973.

Chief of Medicine at the County 1972-1981

All was going well in his practice and political activist work until 1972, when Quentin was recruited to his old home, the County, to help fix desperate problems the hospital was having. The newly elected Republican Governor Richard Ogilvie, with the support of the state legislature, was planning to downsize the hospital to 500 beds, more as a community hospital with full-time staff, and with “links to neighborhood health centers.” That would eliminate County’s mission as a long-time teaching hospital, and where would all its patients go for care? This plan prompted a firestorm of protest from attending physicians, department chairs, and house staff as the politics became intense. The chairman of the Department of Medicine at County, Quentin’s medical school classmate, Dr. Rolf Gunnar resigned. That department alone had 450 beds, 70 interns, more than 200 residents, fellows in many other specialties, and many attending physicians.

Quentin agreed to take on this challenge, to save County as he had known it. Before accepting, he demanded that the hospital establish health care clinics in the neighborhoods, with resources for comprehensive care. His immediate challenge was to ward off mass resignations of house staff, which brought a strike in 1975. Under dire circumstances, he needed to settle the strike and continue to recruit the most competent house staff, attending physicians and departmental chairs to maintain the County’s teaching excellence. Despite having the strong support of senior physicians and the house staff as he dealt with these problems, he was fired twice (temporarily) by the commission and administrator that had been established by the Governor. Persisting through his ten years as Chief of Medicine at County, Quentin outlived the commission that had fired him, succeeded in averting any further strikes by the house staff, saved his Department as a leading teaching service, started a new program in occupational medicine, and established four vital community health centers in surrounding neighborhoods.

Despite these successes, County was still in big trouble. It was an old facility and in financial crisis, largely due to its serving a large working poor population without Medicaid (the cutoff then was $4,600 annual income for a family of four). In view of this crisis and seeing an inadequate political response to it, Quentin offered his resignation after ten years, citing underfunding, the threat of privatization, denial of unionization benefits to the County’s workforce, problems with the Jail Health Service, and mismanagement by the Hyatt Hospital Management Association. As he said at the time:

I have decided to resign because of a series of developments [above mentioned] have convinced me that unless there is new support and remedy of these situations, it would not be possible for this wonderful and historic institution to continue its mission, offering health care to the hundreds of thousands of sick poor in this area who depend on it. ⁶

Health and Medicine Research Policy Group

Based on his experience and beliefs, it was only natural that Quentin, soon after leaving County, established the Health and Medicine Research Policy Group (HMRPG), an “action think tank” with the goal to positively influence the health system in Chicago and Illinois. As he said at the time: “it would be independent of any institution, we would oppose the exploiters of the health system—specifically corporations—and the board would be a working board, not a membership one.” This group set about to “RESEARCH the major medical, political, and social determinants of illness…EDUCATE the public about the hazards inherent in the existing health care system…Analyze HEALTH POLICY decisions to identify and expose the corporate beneficiaries of the existing system. [Such work would serve as] “the foundation to advocate changes in the system…Quentin served as the chairman of the HMRPG board continuously since 1981 as it grew by 2013 to a board of thirty active members with an annual budget of more than $1 million and a staff of a dozen people. This is what he said after this 32-year experience with HMRPG:

We have accomplished what we have by joining with others who share our vision. Policy change is hard and can only be done by building coalitions, conducting solid research, and articulating a clear vision to the media, policy makers and the public. I never expected this group to accomplish so much and to be a leader in so many spheres. But it has, and I am proud that I have been the leader of such a robust action-think tank for these 32 years. ⁷

Here are two examples of Quentin’s prescient concerns in 1975 and 1984 about the threat of the growing for-profit private enterprise in U.S. health care, all of which has come to pass:

Since the sale of health services for profit is counterproductive, the major elements in the therapeutic system should be dealt with as public utilities with standards established nationally but control vested locally. Included in such a system would be production and distribution of drugs, hospitals, and nursing homes, physician and other professional services, laboratory services, and financing arrangements. ⁸

[Once for-profit providers have the stage], their monopoly behavior so odious to this nation could easily be the most serious new distortion of our vast health resources. The for-profit moves to add vertical consolidation (combining hospitals, psychiatric units, health maintenance organizations, home health care and even hospices) to the massive horizontal consolidation of the big chains are harbingers of a for-profit dominance in our system of health care from birth to grave. ⁹

Chicago Public Radio

Acting on his leadership role in education of the public, Quentin put on still another hat from 1983 to 2005 as Talk Show Host of WBEZ Radio’s “Speaking of Health and Medicine.” In these regular one-hour shows, as the program’s medical contributor, he would speak to issues of the day, interview policy makers, and take listeners’ phone calls on subjects ranging from immunizations to the segregated health system in Chicago. ¹⁰

American Public Health Association (APHA)

Quentin’s leadership extended way beyond Chicago and Illinois. He served as president of the American Public Health Association in 1988. Founded in 1872, this Washington, D.C. based organization has a membership of more than 25,000 health care workers with a mission to “protect all Americans and their communities from preventable, serious health threats and strive to assure that community-based health promotion and disease prevention activities and preventive health services are universally accessible in the United States.” ¹¹

Physicians for a National Health Program (PNHP)

As an early member of PNHP, formed by co-founders Drs. David Himmelstein and Steffie Woolhandler in 1988, Quentin rose to its presidency from 1991 to 1993 before serving as its National Coordinator for the next twenty-plus years. PNHP has endorsed single-payer national health insurance from its beginnings as an improved Medicare for All program. The 2010 Affordable Care Act has fallen far short of the nation’s needs. As Quentin said in 2013:

Conventional wisdom suggests we should wait and see how the Obama administration’s health law plays out. But we’ve seen how comparable reforms have fared on the state level: they’ve invariably failed, chiefly because they can’t control costs. Meanwhile, more millions suffer and tens of thousands die each year from lack of adequate coverage. Tragically, this picture will not be significantly improved by the new health law. But it’s never too late to do the right thing. ¹²

Quentin Young’s Legacy

After this long and productive career, we might wonder when and how his passion for leadership toward fairness and reform started. He answered this in his 2013 book:

I think that whatever organizational leadership I’ve demonstrated has its roots in my childhood. Recall, I was double promoted in grade school—a very bad thing. Getting out of grade school at age 12 and high school at age 16, I had to rely on something other than physical prowess and athletic skill to make my way in my peer group…When I went to University of Chicago, I was 16…If you were willing to give it the time, you could have a leadership role. That happened successfully as time went on…And there’s this: I always loved a battle. Still do. I’ve never tired of the good fight. ¹³

Over his entire career, Quentin naturally rose to leadership positions in most every effort he tackled. Table 1 lists just some of his top leadership positions over the years. He received widespread recognition and awards, including the Ethical Humanist Society’s Humanist of the Year award in 1976, the Doctor of Humane Letters at Columbia College in 1972 and at the University of Illinois in 1997, and Alumnus of the Year at Northwestern University in 2010.

Table 1

This is what Margie Schaps, Executive Director of HMPRG over many years, had to say after Quentin’s passing:

Quentin’s extraordinary intellect, his moral compass, combined with his total recall of history always led us to a clear path as we tried to solve the challenges in front of us. He taught me that the lessons of history should never be forgotten—that fighting for social justice, racial justice, for health justice is not new. We must learn from struggles that came before us, learn from the failures, and build upon the successes. Quentin taught me to always stand in solidarity with the struggles of working men and women, that no rally was too small to attend, that any opportunity to get our message across was worth taking, that every individual injustice is an injustice to all of us. In his words, you could get a lot accomplished if you didn’t have to take the credit and if you linked arms with others in struggle. ¹⁴

Drs. Mardge Cohen and Gordy Schiff trained with Quentin in the 1970s, then worked with him for many years afterwards at Cook County Hospital. Here’s how they describe his mentorship:

He always found time for us and everyone else, which is a model for us and we strive to be mentors for others. We would call him when we needed input into key professional, personal and political decisions. He listened, got it immediately and helped tremendously. From his witty and prescient metaphors to his lessons in talking truth to power and information sharing to his commitment to a doctor-patient partnership, Quentin taught/showed us what it really meant to listen, empower and partner with patients to make them better and to make a better world. ¹⁵

Here’s how Quentin ends his own 2013 book, words that are timeless as we face the future:

From my adolescent years to the present, I’ve never wavered in my belief in humanity’s ability—and our collective responsibility—to bring about a more just and equitable social order. I’ve always believed in humanity’s potential to create a more caring society…It’s been a lifelong, driving force to promote equality and the common good. I’ve spent a lifetime trying to help others—in my daily rounds, in my clinic, as a hospital administrator, at demonstrations, in my work with health advocacy groups—and it all adds up to a deeply rewarding career. Few people have such good fortune…I retain a terrible reputation for excessive optimism. The glories of humankind’s ingenuity and inventiveness have not yet been exhausted. The future can be bright, but only if we work to make it so. ¹⁶

Some of Quentin Young’s Leadership Positions

1955-1957, President, Southside Branch, Chicago Medical Society

1972-1981, Chairman, Department of Medicine, Cook County Hospital

1981-2016, Chairman of the Board, Health and Medicine Policy Research Group

1983-1984, President designate, Chicago Board of Health

1987-2016, Clinical Professor of Preventive Medicine, University of Illinois Medical Center

1989-1991, Chairman, Human Rights and Medical Practice Subcommittee, American College of Physicians

1991-1993, President, Physicians for a National Health Program

1993-2014, National Coordinator, Physicians for a National Health Program

1997-1998, President, American Public Health Association

References

1. Young, QD. Everybody In, Nobody Out: Memoirs of a Rebel Without a Pause. Friday Harbor, WA. Copernicus Healthcare, 2013, pp. 3-12.
2. Ibid # 1, p. 13.
3. Ibid # 1, p. 36.
4. Ibid # 1, 45, 124.
5. Ibid # 1, 55-65.
6. Ibid # 1, 179.
7. Ibid # 1, 182, 196.
8. Young, QD. Structural reforms in health-care delivery. Ann Intern Med 135: 909, 1975.
9. Young, QD. Impact of for-profit enterprise on health care. Journal of Public Health Policy 5 (4): 452, 1984.
10. Ibid # 1, 233-234.
11. Ibid # 1, 231.
12. Ibid # 1, 72.
13. Ibid # 1, 75.
14. Schaps, M. Remembering the extraordinary intellect and moral compass of Quentin Young. Health and Medicine Policy Research Group, March 10, 2016.
15. Ibid # 1, 178.
16. Ibid # 1, 239, 242.

John Geyman, M.D. is professor emeritus of family medicine at the University of Washington School of Medicine in Seattle, where he served as chairman of the Department of Family Medicine from 1976 to 1990.

http://www.northwestern.edu…

By Wendell Potter
The Huffington Post, Sept. 29, 2016

You undoubtedly have heard that some of the country’s biggest health insurers have decided to leave several Obamacare markets, which means that tens of thousands of us will be affected next year.

You probably haven’t heard — at least not lately — that some of the biggest health insurers are moving full steam ahead to merge with each other, which means that tens of millions of us — yes, millions — will be affected next year. And not in a good way. If the consolidation happens as planned, many of us will find ourselves in health plans with much worse patient satisfaction and customer complaint scores.

Here’s some context: Executives of UnitedHealthcare, Aetna and Humana made headlines this summer when they announced plans to quit selling policies on several Obamacare exchanges at the end of the year because they haven’t yet figured out how to turn a profit on that business. That means people enrolled in those companies’ Obamacare plans will have to pick a different insurer for 2017.

If That’s Not Bad Enough

That’s a big inconvenience for those folks, of course. But far more of us, including several million who are enrolled in employer-sponsored plans, will be more than inconvenienced if state and federal regulators approve the Anthem-Cigna and Aetna-Humana mergers.

Employers, consumer groups, the American Medical Association and many other organizations have told regulators they think those mega mergers are not in the public’s best interest. The U.S. Justice Department and several state officials agree. They filed a lawsuit in July to stop both of them. Nevertheless, the mergers are far from dead.

That should worry us. A lot. That’s because the acquiring companies, Anthem and Aetna — but Anthem especially — have higher customer complaint ratios and lower patient satisfaction scores than other companies, as recent reports by the state of California’s Office of the Patient Advocate (OPA) show. And if the Anthem-Cigna merger goes through, Anthem, with the worst scores overall, would become the nation’s biggest health insurer.

“Your Call Is Not Important To Us”

Take a look at OPA’s Annual Health Care Complaint Data Report, which provides a wealth of information about the complaints California regulators received in 2014, the most recent year for which data were available for analysis.

Anthem scored the worst by far of any of the other health plans operating in the state. Data provided to OPA by the Department of Managed Health Care, which has jurisdiction over most of the state’s HMOs, showed, for example, that Anthem had 12.28 complaints per 10,000 enrollees. Compare that with Kaiser Permanente, the nonprofit company that rivals Anthem in terms of enrollment in California. Kaiser had just 4.50 complaints per 10,000. In other words, Anthem had nearly three times as many complaints as Kaiser.

Anthem also led the pack in the ratio of complaints received by the California Department of Insurance. That department said Anthem had a whopping 47.64 complaints per 10,000. Cigna, the company Anthem is trying to buy, had just 2.69 complaints per 10,000.

And it’s not just in California that Anthem has generated an inordinate number of complaints about how it treats its customers. It appears to be nationwide. In fact, the Department of Justice cited Anthem’s less than stellar reputation in its lawsuit to block its takeover of Cigna. This is from a September 20 story in the Hartford Courant about the status of the proposed $54 billion deal:

The federal government claims that many large employers dislike Anthem and that doctors fear the company because its large customer base gives it leverage in negotiations.

The Department of Justice complaint says that although Cigna can’t get as low prices from hospital systems and doctors in some markets as Anthem does, “Cigna competes vigorously with Anthem for large groups by offering exceptional customer service, innovative wellness programs that lower its members’ utilization of health care, and provider-collaboration programs with hospitals and doctors. By contrast, many large-group employers believe that Anthem provides poor customer service and is far less innovative. Soon after the merger was announced, two prospective customers complained to Cigna: “We hate Anthem and you guys are about to become them.”

When it comes to how patients rate their experience with their HMOs, another report by the California Office of the Patient Advocate shows that the big for-profits involved in the proposed mergers also get much lower scores than their nonprofit competitors. Nonprofit Kaiser Permanente’s HMOs were the only ones rated “excellent.”

Earlier this month, a Harvard Law watchdog group filed complaints with the U.S. Department of Health and Human Services against seven big insurers — including Anthem, Cigna and Humana—alleging that they all were in violation of anti-discrimination laws pertaining to the coverage of HIV/AIDS treatments. The allegations involved refusing to cover vital medications that HIV/AIDS patients need and requiring high-cost sharing for other medications used to treat HIV/AIDS.

“When an insurer requires chronically ill patients to pay a disproportionate share of the cost of medication, it violates federal law,” said Robert Greenwald, clinical professor of law at Harvard Law School.

The American Medical Association has become one of the most vocal opponents of the mega-mergers, particularly the Anthem-Cigna deal. On September 21, the AMA released a report showing that Anthem’s “market power” would be significantly increased in several states and numerous metropolitan areas — especially in California — if the deal is approved.

Despite all of this, the mergers could still happen. A U.S. District Court has set a November 21 trial date for the lawsuit the Department of Justice has filed to stop the Anthem-Cigna merger. The Aetna-Humana trial is scheduled to start on December 5. Both trials likely will go on for several weeks. If the Department of Justice loses, millions of Americans will soon find themselves enrolled in health plans administered by companies with some of the industry’s worst quality and customer satisfaction scores. That’s something not only to worry about but also to try keep from happening. The last thing we need is for Anthem and Aetna to be more in control of our lives.

This has also been published by HEAL California.

http://www.huffingtonpost.com…

The Presidential Debate That Wasn’t

By Jeanne Lenzer
The BMJ, Sept. 27, 2016

The 90 minute presidential debate between Hillary Clinton and Donald Trump ended last night without a single word about healthcare. Yet two-thirds of voters said “the future of Medicare and access and affordability of healthcare are top priorities for the candidates to be talking about during the 2016 presidential campaign.”

Clinton, a Democrat, and Trump, a Republican, have both said they support “universal” healthcare and both rely on market forces and private insurers to provide coverage for healthcare. What follows is a summary of what is – and isn’t – known about the candidates’ positions on various healthcare issues, followed by comments from critics right and left.

full, with comments by Dr. Adam Gaffney of PNHP:
http://blogs.bmj.com/bmj/2016/09/27/jeanne-lenzer-clinton-and-trump-on-healthcare/

PNHP note: Physicians for a National Health Program is a nonpartisan educational organization. It neither supports nor opposes any candidate for public office.