There is trouble getting healthcare in America. 28 million lack coverage for healthcare and current pending legislation, that seems likely to pass (probably after some modifications) plans to add another 24 million to that. If you recognize this as a problem, the next step is to find a solution.
Some blame the government for being involved where the free market fails. Others blame the market for being involved where the government fails. It’s also easy to shake a stick and find people who blame insurance, or pharmaceutical companies, and other elements.
But you know who never gets blamed? The doctors. We can’t seem to find a solution so far, so let’s examine the one element always overlooked: the doctors themselves.
“But the doctors are the ones fixing things.” Depends on how you define fix. If you added more doctors to take care of shortages, then yes, that may mitigate and temporarily salve our predicament. Health professional shortage areas are defined as an area with at least 3,500 individuals in need of a primary care physician, and in 2014 there was a deficit of 8,200 primary care physicians across 6,100 shortage ageas. Similarly, a shortage area for mental health is defined as an area with at least 30,000 individuals in need of mental health care and in 2014 there was a deficit of 2,800 mental health providers across over 4,000 shortage areas. The extent of the problem is estimated to be a shortage of 45,000 primary care physicians by 2020 and a shortage of 130,000 by 2025. While there is currently a greater number of physicians graduating from newer medical schools, this will still ultimately be insufficient since it will lead to an increase of only 11% in the physician workforce by 2025. And while the number of residency positions have increased, the total number is still a decrease in comparison to the total population, viz. 15% and 6%.
So the shortages and failure to have sufficient practitioners are projected to persist for the foreseeable future. That’s because another word for “insufficient” is “lack of supply” in economics. That’s bad for the buyers of medical care, and good for the sellers, viz. physicians. Despite the fact that 52% of physicians over 50-years-old, which constitute one third of clinicians, plan to stop practicing within 5 years it is not in the interest of MD’s to see more enter their field.
It is in this respect I would say they “fix” the market. Physician advocacy groups have a long history of manipulating policies in their favor. For a comprehensive yet readable history of medicine in the US, one could do worse than Paul Starr. So let’s see what he says about the American Medical Association (AMA) and their like-minded peers:
- 1847-1901: The AMA develops as a body of physicians that had “the more decided views about the importance of diplomas.” In short, they wanted to raise standards for medical school admissions (ie. bottleneck inputs into the system) and they wanted to do it nationally because if it was implemented on just the state level then labor markets could move.
1904: The AMA establishes Council on Medical Education, calling for 4 years high school + 5 years medical training + 1 year internship + licensing. This means of the 160 existing medical schools examined, they approved of only 82 and claimed 32 were beyond repair. Many reports and investigations, some more famous than others, were launched after this. The results showed that if the AMA had their way 20 states would have been left without any medical schools. Local legislatures intervened at this point and maintained the current supply of medical schools.
1905: The AMA establishes Council on Pharmacy and Chemistry predicated on the logic of regulating the system in order to “withhold information from the consumers and re-channel drug purchasing through physicians.”
- 1907: Physician Economic Leagues propose that “restriction of the number of those who attend at our hospitals is the condition sine qua non of economic reform.”
1914: The AMA opposed mutual benefit societies for their “ruinous competition”
1921: The Cleveland Clinic was denounced by the AMA as “medical Soviets”
1929: The AMA called the Sheppard-Towner Act (which provided matching funds to states for prenatal and child health centers) an “imported socialist scheme” and has it repealed. This leads to righteous indignation on the part of some physicians who form the American Academy of Pediatrics in 1930.
1932: The Committee on the Costs of Medical Care finishes its report. It was started six years earlier by former AMA president Lyman Wilber, a fact which made it “ideally suited to make the committee respectable and newsworthy and to buffer it against criticism of possibly ‘socialistic’ tendencies.” However, “basing its judgments on the ‘reasonable standards’ of its medical experts, the committee found that nobody was getting enough medicine.” This naturally forced an editorial in the AMA’s Journal that described the report as “an incitement to revolution.”
- 1934: The AMA prohibits “direct profit” in medical care. By this, they meant that “there must be no capital formation in medical care other than what doctors accumulated…if medicine required any capital that doctors themselves could not provide, it would have to be contributed gratis by the community.”
1934: In the midst of the Great Depression, “the AMA’s response to the economic crisis emphasized restricting the supply of doctors rather than amplifying the demand for their services” as “Walter Bierring, the incoming president of the association, recommended eliminating half the medical schools in the country.”
1937: The AMA denounces the Committee of Physicians for the Improvement of Medicine (who advocated on behalf of the “medically indigent”) by “insinuating that they had obtained signatures by devious and deceptive means”. Too bad twitter wasn’t around back then.
- 1938: The AMA is indicted on charges of violating the Sherman Anti-Trust Act. Cheekily, “the AMA did not contest the salient facts of the case. When the indictment was handed down, Morris Fishbein, speaking for the AMA, pledged a legal effort to ‘establish the ultimate right of organizing medicine to use its discipline to oppose types of contract practice damaging to the health of the public.’ The AMA’s legal defense argued that medicine was a profession, not a trade, and that the antitrust laws consequently did not apply to it.”
- 1939: AMA statement in JAMA calls social security “a definite step toward either communism or totalitarianism”
- 1949: AMA sends a statement to every member of Congress a resolution which, among other things, says “social security is in fact a compulsory socialistic tax which…has served as the entering wedge for establishment of a socialistic form of governmental control over the lives and fortunes of the people.”
1950: Truman is re-elected to the presidency. His proposals include an economic bill of rights and a national healthcare program. Unsurprisingly, “the AMA said in an editorial that Truman’s health insurance plan would make doctors ‘slaves’” (Sound familiar?). In true panicked fashion, “[the AMA] assessed each of its members an additional $25 just to resist health insurance and hired…a public relations campaign that cost $1.5 million, at that time the most expensive lobbying effort in American history.” The pamphlets red-baited Truman and asked “would socialized medicine lead to socialization of other phases of American life?” The strategy worked as “three quarters of those who had heard of the plan knew of the AMA opposition.” Also, any bills favoring reform failed because “the annual budget of the Committee for the Nation’s Health was about $50,000; in 1950 it spent only $36,000. That same year, the AMA spent $2.25 million in its ‘national educational campaign’ against national health insurance. More than $1 million was spent in two weeks in October alone, just before the 1950 congressional elections.”
- 1958: “[Democratic Representative] Aime Forand introduced a new and extremely modest proposal covering only hospital costs for the aged on Social Security. Unsurprisingly, virtually the same political constellation appeared that had existed years earlier. As before, the AMA undertook a massive campaign to portray a government insurance plan as a threat to the doctor-patient relationship.”
- 1959: “The proportion of approved residencies in unaffiliated hospitals fell to less than 10% of all positions” because “medical school empires…held a powerful position in medical affairs: they could grant or withhold teaching positions, hospital privileges, and the assorted capital equipment and labor that hospitals provide”
- 1962: JFK tries to pass the King-Anderson bill but is defeated by the AMA and their Operation Coffee Cup.
1969: Nixon proposes “program review teams” for “utilization review” of healthcare services. “The AMA responded that the bill gave HEW [Department of Health, Education, and Welfare] too much power and that such review ought to be a responsibility of physicians alone. The next year the AMA suggested as an alternative that HEW contract with state medical societies to carry out peer review. This suggestion was taken up…in August 1970.” Ralph Nader and the Health Research Group rightly called this a case of “the fox guarding the hen-house”
1979: Congressional Office of Technology Assessment calculates, somehow, an estimated 185,000 surplus physicians by the year 1990. So, predictably, the answer was to place a moratorium on new medical schools, which has only recently been modified.
… I think you get the idea.
There were more failed attempts at healthcare reform to follow, and even now Trump is not immune to be obstructed. The AMA truly are bipartisan in their hatred. And not merely on ideological grounds: HMOs were considered “socialistic” when proposed by Nixon, and even the consideration of disability insurance in 1950 was called “another step toward wholesale nationalization of medical care and the socialization of the practice of medicine.” Basically, everything they don’t like is socialist, regardless of how free the market it is. Until it is THEIR market.
A good example of this is Leonard Peikoff making a slippery slope argument of barbers and regulations, which you can view here. By their actions, it’s clear that physicians are not opposed to regulation per se, they’re just opposed to regulations they don’t like. But if you watch the video, the mentality is such that you’ll notice the physicians clapping at the prospect of you not getting healthcare and somehow applauding against the same type of regulations that the AMA and similar groups have been implementing for them. I’ve talked about the denial of ideology before, but this is still an impressive moment to capture on video.
If physicians, and their lobbying associations, are creating the situations that underlie the current medical predicament then they can’t claim to be hapless victims. In approximately a century and a half they have constructed a system carefully designed to benefit exactly who you think it would instead of who you think it should.
“But healers are altruistic.” The system is not, and they’re in the system. No part of it is. The schools charge, the banks charge, the hospitals charge, the insurance companies charge, the pharmaceutical companies charge, the malpractice lawyers charge, the doctors charge. There’s no altruism found anywhere, it’s all transaction based. You’ve been misled by comparisons to other countries and the outlier noble practitioner. Take it from a physician:
“I once stood on a small hill and looked at an ER, and from what I could see with my B&L 10x binoculars, nothing that occurred there costed $1000. You might legitimately ask me who am I to judge what an ER visit costs; I’d submit that the only legitimate answer to what costs what is the market. But medicine isn’t a market, because two parties don’t agree to terms either by negotiation or by repeated bids and asks. One party makes up the terms, and the other party just pays it, or doesn’t. Period.”
“But they’re just looking out for their own self-interest.” Maybe, but that’s not what they signed up for. However much you want to plead the Yuppie Nuremberg Defense (“I don’t really want to make the money, paying off my loans forced me to…”), clinicians are entrusted with the health of their patients. They’re granted their status, and your tacit approval when you receive their services, on the predication that they are actually going to do right by you and your interests.
“Well, at least they provide a good service that helps one’s health and makes us feel better”. So do vendors of cheese and alcohol. If the best reasoning you have for the kindness of the medical profession is that “a service was provided,” go re-read your Fountainhead and call me in the morning. If we’re going so far as to reduce ethics to transactions and utility calculus, then we should also declare that all the good acts stem from professional assertiveness thus making them fall under circumstantial moral luck – this reduces their ethical standing to a nullity and they deserve no praise as they are part of a causal chain but have demonstrated no moral responsibility.
So I reiterate, why not blame doctors? What sainthood is granted by a white coat? I’m not the first person to say this. Fortune, 1970 said:
“The doctors created the system. They run it. And they are the most formidable obstacle to its improvement.”
Milton Friedman, an economist as far from a socialist as they come, said:
“Licensure has reduced both the quantity and quality of medical practice. It has retarded technological development both in medicine itself and in the organization of medical practice.”
If we get past the theoretical situations of how transactions should run, and instead look at how transactions are run, we’ll get a very different picture indeed. Those in the know think it’s worse than being morally lucky:
“A scientist is no better, and possibly worse, than the average person at deciding what is good and what is bad.” – Marvin Minsky
Will a doctor keep your information confidential? That’s what they say anyway. But the reality is that they have loose lips concerning patients who are drug seeking, when insurance or employer wants the records, when the law wants the records, or just when you are a patient that has a certain disease. How much trust does that warrant?
Are they knowledgeable and paying careful attention to your health? Well, look upon the error rate ye mighty and tremble:
We’ve already talked about the incessant need of medical societies to grow in power and avarice. The growth of wille-zur-macht makes it hard to make objective decisions, and subsequently makes for some very bad science. One example:
“The Hamilton Scale for depression contains no questions about sleeping excessively [as it only asks about insomnia] or eating too much [as it only asks about weight loss.] On a 17 question scale in which a reduction of 10 points is outstanding, a sedating side effect can be the difference between $4 billion per year in sales or wasted millions in R&D. Add 2 points for drugs that make you hungry and that’s the whole game. Some will counter that the Hamilton isn’t meant to be a screening tool, but in fact it’s used as a screening tool all the time in clinical trials. You have to meet a certain threshold to be enrolled in a trial, so you can see that a person with [atypical depression] will be excluded. So why isn’t Abilify (non-sedating) testing their drug on other kinds of depressed people? Because they can’t. The FDA wants the HAM-D or the MADRS (which is skewed the same). Abilify would have to convince the FDA that their drug worked AS WELL AS change the entire infrastructure of psychiatric drug approval.”
Similarly, FDA approval for the use of Paxil in pediatric populations was granted in 1992 based on Glaxo-Smith-Kline’s Study 329. When contradictory evidence came out, black box suicide warnings were added in 2004, and the company plead guilty and settled for $3 billion in fines to the New York Attorney General in 2012. Sadly, this type of “correlation” between positive findings and pharmaceutical research is fairly common:
This is not just found in psychiatry. A significant portion, 30%, of the most influential medical research is wrong. Only an average of 10-25% of medical studies are reproducible, with specific fields, such as cancer research, having as much as 89% of landmark research findings for drug targets being unreproducible. Also, the current research paradigm is such that the age of cited articles cluster around the past 10 months and reference rot means that 13-25% of hyperlinks cited are broken and therefore unusable. EVEN IF all these obstacles are surmounted, we’d still have to grapple with the fact that 85% of global research spending is wasted on poorly designed studies.
So I’m not going to count on them for research. Or to provide cures. To sum up:
“It is a little tiresome to hear from our professional publicists of medicine that only practitioners have any comprehension of the problems of medical care…They exploit scientific services to which they have contributed nothing.” – John Peters, 1938
Well, nothing may be a stretch. There has been some very notable research done by Max Clara, Friedrich Wegener, Claus Schilling, Josef Mengele, Herta Oberheuser…in concentration camps in Germany. Or by Shiro Ishii if you want to visit Japan instead. Or Henry Heimlich if you prefer China. Or Marko Turina in Switzerland. Then again, you needn’t leave the USA if so desired.
This is clearly more than just seeking to control one’s own practice, as much as some would like you to believe. Physicians have never had trouble cozying up to power. If we turn back to Paul Starr: “During World War II, the AMA and the specialty boards aided the military in identifying properly certified specialists, who promptly received higher rank.” This in turn shifted the status quo such that “after the war, the VA ruled that no doctor would be treated as a specialist without board certification.”
The combination of power seeking and high intelligence tends to bring about situations of arrogance and danger more so than we would like to admit. You don’t have to go as far as Michel Foucault or the anti-psychiatrists of Italy to see this. Look at physicians overseeing torture in Uruguay in the 1980s, or psychologists being complicit with CIA torture in Abu Ghraib.
You could also just directly murder people, if these other methods are too roundabout. You could be a psychiatrist like Nidal Hasan or Radovan Karadzic, a surgeon like Ayman al-Zawahiri, or an opthamologist like Bashar al-Assad. The specialties don’t discriminate.
“You’re just pointing to a few bad apples”, you may say. And you conspicuously forgot the rest of that phrase: “a few bad apples spoil the whole bunch.” What part of “first do no harm” doesn’t make sense to you? Didn’t I just mention how they’re not blameless above? Are we on repeat? Is the eternal recurrence here already?
The history of medicine in America extends back to brilliant minds like Benjamin Rush. In 1819, he said American physicians should reject the aristocratic tendencies of European physicians since “they are incompatible with the simplicity of science, and the real dignity of the physic”. This slowly degraded until 1974, when Russell Roth, president of the AMA declared: “Of the consumers’ role, passengers who insist on flying the airplane are called hijackers!” Your role as a patient has gone from deserving dignity to collusion with plane hijackers. Their words, not mine, just put on your glasses.
I know you want to think there are objective healers out there who are perfectly humanistic, ethical, and know it all. The idea that the people caring for your very life are going to be just as selfish and (almost) as ignorant as you is a terrifying prospect. But the vast majority, like in most things, are not the ideal. Hell, they’re probably not even good. They’re “human, all too human” as a famous German used to say.
If you’re rushing to defend your favorite health practitioner, or you’re in healthcare, then this is a warning sign that you should stop refusing to hear this. If you’re skeptical of all of this, that means you haven’t learned the lesson. If you remain skeptical, that means your impulse wasn’t to say “Am I/they doing this?” or “How should I/they act differently?”. Instead, your reaction was to rationalize as to why you/they are the exception, and in that case it most definitely applies. “Physician heal thyself” before you get defensive.
For those accepting my argument, there may linger the the perennial excuse of being “just one person” against “the system”. Fine, I’ll grant that it is a larger job than one person, but whose side are you on? Are you confronting or colluding with the system? Remember:
“We should recall that in some [Nazi concentration] camps uprisings did take place: in Treblinka, in Sobibor, and even in Birkenau, one of the sub-camps of Auschwitz…In all instances, they were planned and led by prisoners who were in some sense privileged, and so in better physical and spiritual condition than the ordinary prisoners. This should not be surprising; only at first glance does it seem paradoxical that the ones who revolt are those who suffer least.” – Primo Levi, 1976
The power players, those with privilege, those who control the levers determining distribution of healthcare, have a special role to play. Things likely won’t get better until the privileged in medicine decide to change. But before you can even contemplate change, the first step is to correctly recognize the problem.
Good luck with that.