Doctors For National Health | Feature | Chicago Reader

Doctors For National Health 

Sick of the restraints and paperwork imposed on them by insurance companies and HMOs, a surprising number of American MDs have begun to prescribe the Canadian cure.

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Dr. Carrie Angus, a resident at Humana Hospital/Michael Reese:

"Working in my clinic is sometimes an awful headache. We need to get approval for everything beyond the most basic care. It's so much paperwork. Practicing doctors have secretaries who do all that, but as a resident without any secretarial help I feel that sometimes I'm spending half my time filling out forms. I literally spend at least four or five hours a week doing paperwork.

"In making medicine into a business and trying to cut costs, we've created this endless paperwork. It's as if someone up there doesn't trust your judgment, they have to approve it first. And of course, before anyone will do any kind of diagnostic test they have to make sure they're going to get paid for it. It's this money consciousness now. 'I'm not going to do anything for you until I see this piece of paper saying that I'm going to get paid.' With all this paperwork, I've never had a test refused. That's why it's such a headache. It's so useless. Maybe there are doctors out there who are ordering unnecessary tests, but I doubt it. The whole process causes waiting time, paperwork, it's all such a hassle, it's endless."

Dr. Claudia Regan, an internist in a group practice in Hyde Park:

"It's a continuous frustration to practice medicine today. I can name you a half-dozen patients who have come in just this week with their diabetes uncontrolled, or their blood pressure uncontrolled, who don't come in sooner because they have no insurance or not enough coverage. Today a patient called my nurse to see if he could get drug samples because he couldn't afford to buy his medications. My average patient over 65 spends about $l00 a month on medications. For many of them, that's cutting into their food bills. Here are patients who you want to provide care for and you know what it takes to give them proper care, but financial barriers don't permit you to give them what they need. I'm talking now about medicare patients who have no coverage for drugs and not complete coverage for medical bills.

"For people who have no insurance it's difficult to get them diagnostic studies or to get them to a specialist. I had a patient in the past week who I really needed to get a test for to decide what was going on with her. That test cost over $400. She was a freelance photographer. She couldn't afford that test. It took a lot of wrangling with the system to finally get that test done for her at Cook County. Which is not the way it should be. It impaired my ability to treat her in a very severe and dangerous way.

"If you have no insurance and you go to Cook County as a last resort, you wait for days in the emergency room. I had a patient who found a lump in her breast and went to County and requested a mammogram. That was April. She was given an appointment for a mammogram in June. She was given an appointment to get the results in July. In September they finally told her she had cancer and she was given another appointment for surgery. She walked out of there and said no way. She came to us, telling us how humiliating and frustrating it was. We got her cancer removed and she had radiation and chemotherapy, but if it hadn't taken so long, she probably wouldn't have needed such radical treatment.

"I do everything I can to take care of my patients. I look the other way on a charge, I try to get them free medication, free care. All doctors do that. But it's patchwork and piecemeal.

"And the insurance companies make life unbearable. You admit someone to the hospital for an emergency. Someone calls you from the insurance company to justify the admission, then afterwards someone will call you to see whether you're keeping that patient in the hospital too long. Are you doing excessive procedures? It's the insurance companies who are making these decisions for you, and more often than not the person you're speaking to in that insurance company is not your peer. You're speaking to someone who is not medically trained but simply has a series of criteria they're supposed to check off. They can't figure out what's going on, so they refer you to a nurse. And if you have a complicated case that they still can't understand, then they'll refer you to a doctor. And finally you may get someone who understands what's going on with this patient.

"So the time you spend on the phone is astronomical. And the forms you have to fill out! I have a form right now sitting in front of me. "Please send all the records, all the bills, and a narrative about what you feel this patient's prognosis is.' It's ludicrous. There are l,500 insurance companies in the U.S., and at any one time you can be dealing with a dozen of them, each one with different rules and regulations. You have to fill out a form for everything you do. It can drive you crazy.

"And even in the seven years that I've been practicing things have gotten worse because more and more people are going into insurance plans that are more and more limited, for financial reasons. Employers are trying to shift the risk and the cost to their employees and the employees can't afford to pay the costs so they opt for less coverage.

"The most frustrating thing is that we just aren't allowed to take care of our patients the way we need to. There are all these artificial barriers put up by the insurance companies. They don't seem to understand that good medical care is cost efficient. If they allowed us to give the best care at the beginning they would have to spend less at the end, when the patients become much sicker. That patient who had breast cancer would have been less costly if she had been treated early on, for example. If we provided mammograms to every woman who needs one, we would have a lot less breast cancer in the long run. If we do pap smears for all our patients, we can treat cervical cancer at a stage where it is curable and much less expensive to treat.

"So many insurance companies will not pay for a routine physical exam. You have to find something wrong before the insurance company will pay. If a patient comes in for a routine examination and you find that this patient is very overweight and subject to hypertension, you can advise him of that then. But the insurance company will only pay after you've got the hypertension. Patients have to pay for routine medicals and they decide that's one expense that's expendable. That's not the way I was taught to practice medicine. It's not the way I want to practice medicine. It's no way to practice medicine."

An internationally known specialist who prefers anonymity:

"To fill out all the massive number of forms required by the insurance companies, you have to hire secretaries just to do that, which means that you have to charge the patients more than you would otherwise have to charge them. And it is difficult to keep secretaries because that is the most boring work in the world, filling out forms all day long.

"For my field, which is still very young and not widely understood, I have to spend a significant amount of my time educating insurance company clerks. It always angers me. I waste a lot of time. I order the tests and then they refuse to pay and I call up and get them to reverse it. I'm usually successful because it is such a rare field that even the doctors don't know anything about it and they have to take my word for it."

Dr. Michael Preodor, an internist practicing on the northwest side:

"For primary-care physicians like I am, we have to work with HMOs if we want to have any young people in our practice. The standard insurance plans have simply priced themselves out of the market, especially for young people. Most employers, especially in manufacturing, have bought into HMOs. For my practice, which is in a solidly working-class neighborhood, I have to work with the HMOs, which contract out with private physicians to handle their patients. And it is a major hassle. Every patient service that I authorize--say I need to have a patient see a gastroenterologist--I must refer to one of the panel of doctors that the HMO has organized. I can't refer to any doctor outside this group, with some exceptions, of course. That may or may not work.

"Also, they have very tight control over what is called utilization review. That is, if I have a patient who has some right-sided weakness that came and went and a severe headache and I want to get a CAT scan, I can't order that without prior approval from the bureaucrats at the HMO. Many times they will say that patient has to have an appointment with a neurologist before they'll approve the CAT scan. In most situations, this is just an inordinate delay. It's an imposition not only on my time but on the neurologist's time too, because he knows full well what is needed without making his own examination. This sometimes seems to be a brutal and not very subtle attempt to make testing and referrals more difficult and time-consuming to the patient and the doctor's staff, thus hopefully inhibiting future referrals.

"My office staff has told me they will quit if I make any more HMO contracts. They can spend as much as six hours trying to straighten out the referral forms for just one patient. It gets to be just ungodly. I have a patient 25 years old with acute leukemia. He has to see an oncologist regularly. He has constantly to have tests and treatment. The HMO wants a damn referral form for every white blood cell we take. My staff is remarkably in tune with the patients. They work here because they like the patients. But they can't do that. They spend all their time on the phone and filling out forms, dealing with these hassles. I've had to hire additional staff just to meet the paper demand.

"The HMOs have all kinds of ways to save money. A lot of it is good. They have cut down, with the utilization review, on a lot of unnecessary tests, for instance. But they have other ways. One way is to offer bonuses to doctors. They say, 'Look, we'll give you a thousand patients, and if you take care of them without exceeding x amount of dollars we'll give you that in your pocket.' By limiting utilization, you can make more money and it can be a lot of money. There are probably too many cases where doctors underutilize services in order to put that money in their pockets."

These four doctors speak for a profession increasingly impeded and demoralized by efforts to control the spiraling costs of American medicine. In a 1990 survey by the American Medical Association of l009 doctors, 39 percent of the doctors said the main problem facing health care in the United States is cost-related and 69 percent said the quality of health care is being hurt by attempts to control rising costs. Thirty-three percent said the intrusion into their practices of third parties, bringing bureaucrats, paperwork, and the agonies of reimbursement, gave them the most difficult problems they faced in the day-to-day practice of medicine.

The 1990 AMA survey proposed, "All things considered, the high quality of health care in the United States justifies the high cost of health care [their emphasis]." A small majority of the doctors, 54 percent, agreed with this sentiment, while 41 percent disagreed. Nonmembers of the AMA (slightly more than half of American doctors do not belong) were more apt than members to disagree. More women doctors disagreed than agreed, a result also true of family practice physicians, the low doctors on the medical totem pole in terms of income and prestige.

The most dramatic figure in the 1990 survey was the 38 percent of the doctors responding no when asked if they'd recommend medicine as a career to a high school or college student. In 1989, doctors were asked whether they'd go to medical school if they had their lives to live over. Nearly 40 percent said no.

Forty-two percent of the doctors queried by the AMA in 1990 who said they could no longer recommend medicine as a career gave as their reason, "outside interference, regulation." Another fourth said that "the rewards are not great enough for the effort, time, and risks involved." Yet the average income of American physicians is $l60,000 a year.

The AMA did not conduct a survey in l991, and in l992 the questions were changed. Health care reform was the primary issued studied. Several questions concerned "organized medicine's role in health care reform," for which one can read the AMA's role. Amazingly, American physicians know very little about efforts to reform their profession. Asked if they could name any specific reform proposals, 65 percent said no. Although 40 percent of the respondents were members of the AMA, only 1 percent named Health Access America, the AMA's own proposal. Only l percent named the single-payer proposal of Physicians for a National Health Program. Both plans have been widely publicized in the medical press.

At the same time, only 34 percent believed that organized medicine "definitely" can have a significant impact on reform. Forty-one percent said "probably" and 20 percent said "probably not." And only 42 percent said that the AMA could best represent the profession's views and interests in the health-care debate.

A l973 study found that 56 percent of the doctors questioned wanted to see a national health care plan in the U.S., even though three-quarters of them believed most doctors they knew were opposed to "some form of national health insurance." Four-fifths of the doctors believed that some form of national health insurance was inevitable.

In light of the rising level of cost and paperwork over the past 20 years, one might assume that the number of doctors who support some form of national health insurance would have grown. Perhaps. The 1992 AMA survey found that only 14 percent of the doctors questioned supported a federally financed health plan, but 81 percent favored some combination of government and private programs. Only 3 percent thought that medical societies should resist any change.

Change is certainly on the horizon. Even the AMA has proposed its own reform program, although it's one that would not fundamentally change the nation's health care system. In scope, Health Access America falls far short of the programs of most of the other countries in the Western world and far short of many other programs being proposed for the U.S. At this point, the U.S. and South Africa are the only industrialized countries that do not provide national health care.

In the vanguard of those doctors who support some form of national health insurance is a tiny organization headquartered in Chicago, Physicians for a National Health Program (PNHP). It claims 5,000 members from among the nation's 550,000 doctors, including the four doctors quoted at the beginning of this article. PNHP is working to promote a tax-supported single-payer national health care program similar to the one in Canada, where most of the problems facing American medicine do not exist.

Until this spring, doctors David Himmelstein and Steffie Woolhandler, the young husband-and-wife medical team that founded PNHP, ran the organization out of their offices at Cambridge Hospital in Cambridge, Massachusetts. They'd begun it in 1986 with 40 like-minded friends and colleagues from around the country. Himmelstein, who also teaches at Harvard's medical school, talked to me recently while visiting Chicago for a national meeting of PNHP. A middle-size, compact, intense-looking man of 41, his long black hair tied into a ponytail and his feet in sandals, Himmelstein met me in the lobby of the Blackstone Hotel and eyed his watch as we talked.

PNHP has acquired enough status to see its representatives called regularly to testify before the various congressional committees considering medical reform--along with those of the AMA, the Health Insurance Association of America, and the American Hospital Association, the other major players. PNHP's health plan is a model for Marty Russo's House bill, which has collected about 75 cosponsors; in the Senate, Paul Simon and others are supporting a similar bill proposed by Bob Kerrey.

A version of a single-payer plan like PNHP's was endorsed recently by the powerful Teamsters Union, the nation's largest, after the union's board heard the testimony of Himmelstein and others. And although the American Association of Retired Persons, with 33 million members, isn't supporting a single-payer plan, six of its six state organizations, including Illinois', are.

Among physicians' organizations, only PNHP is proposing a single-payer plan. But the largest professional medical society, the American College of Physicians, is moving toward a plan that combines private insurance benefits with benefits from a greatly expanded public sector. As upset as doctors are by the effects of private insurance, they're reluctant to get rid of it. Himmelstein suggests that this reluctance probably reflects the basic conservatism of the medical profession.

"Back in the mid-80s," Himmelstein told me, "we and several other people felt that the liberal strategy of trying to defend medicare and medicaid against cutbacks by Reagan and the right was a losing proposition, that these were terrible programs and trying to defend them was trying to defend an indefensible position. Even if they were successfully defended, we wouldn't have very good programs.

"Steffie was teaching at Boston University in the School of Public Health. One of the courses they wanted her to teach was on comparative health care systems in other countries. So she did a crash study of other countries, including Canada, and that's where we began to learn about the alternatives available.

"For some years we had been doing some research that led us to believe that the problem couldn't be approached as many liberals and leftists had, by saying that we need to strengthen the public hospitals and public sector. In fact, there were plenty of health resources in the country already, but they weren't in the public sector. What we needed to do was have the whole system function as a single system. If that happened, the resources were there to do the job right.

"In the mid-80s, we began to think what was needed was to put out on the table a coherent program of how the health care system might be organized, to say how the problems could be solved. We thought physicians were in a particularly good position to get that debate going because the physicians' media was generally more open to these discussions than the general media. That would make it possible to get attention. It would be an oddity--here were a group of physicians advocating national health insurance. One journalist said, 'Physicians asking for national health insurance sounds a little like furriers for animal rights.'"

For two years Himmelstein and Woolhandler worked to build their group's membership and develop a health plan. In l988 they submitted an article to the world's most prestigious medical journal, the New England Journal of Medicine. A year passed before the article was published.

Himmelstein and Woolhandler opened it by saying, "Our health care system is failing. It denies access to many in need and is expensive, inefficient, and increasingly bureaucratic. The pressures of cost control, competition, and profit threaten the traditional tenets of medical practice. For patients, the misfortune of illness is often amplified by the fear of financial ruin. For physicians, the gratifications of healing often give way to anger and alienation. Patchwork reforms succeed only in exchanging old problems for new ones. It is time to change fundamentally the trajectory of American medicine--to develop a comprehensive national health program for the United States."

When the article appeared, medical writers at newspapers across the country wrote about it, although the Chicago papers seem not to have noticed. The Wall Street Journal commented, "Doctors and national health insurance have always mixed about as well as George Bush and new taxes. Until now." Most press reports were favorable. "We became a kind of hot commodity," says Himmelstein. Membership in PNHP grew from 400 to l,200 in eight weeks.

The plan outlined in the New England Journal of Medicine closely followed the Canadian model: the people would choose their doctors, doctors would choose the way they wanted to practice, the emphasis would be on preventive medicine, and the entire system--hospitals, clinics, private practices, laboratories, and so on--would be financed by federal taxes but administered at the state and local levels. In Canada, everybody gets a medical-program card that buys any health care except cosmetic surgery, private ambulances, and a few other elective services. Doctors fill out one form for services rendered, the form is submitted at the end of the month to the provincial government, and payment is made immediately. Fees are set by a provincial medical society that reevaluates them every two years, and hospitals are given an annual budget, based on past performance and projected plans, that covers all expenses save capital improvements.

Doctors make their own decisions about treatment. The only paperwork they face is the simple monthly billing for services. And everyone in the society is covered. There are occasional waits for nonemergency treatment, especially treatment that relies on high technology, which is not as widely available in Canada as it is in the United States. The U.S. has far more technology than it needs, many experts say, because there is so much of it in private hospitals that are competing for patients.

In an article in last November's issue of Archives of Internal Medicine, an Oregon psychiatrist who had practiced in Canada until l981 wrote: "I had heard I could practice there [in Oregon] with 'greater freedom.' I had a lot to learn. . . . Today, I fight off role confusion and at times wonder who I really am. Physician? Maybe a marketing expert. Potential malpractice defendant? How about a legal consultant? A paper-pushing cog in the gigantic, ratchety, amorphous machinery that is American health care delivery today. The confused, pressured, fragmented physician practices primarily south of the 49th Parallel today."

The psychiatrist reported, "A recent survey of l0 countries shows Canadians to be the most satisfied with their health care; Americans, the most dissatisfied. . . . If Canadian physicians have some concerns about their medical plan, the rest of the country is quite happy with its crown jewel. My experience there convinced me that Canadian society values its physicians with respect and appreciation."

In their dramatic 1989 article, Himmelstein and Woolhandler spelled out in detail how a national health program would solve the two problems that most vex the American public and its doctors: the system's failure to provide health care for a third of the population and its tendency to provide less and less care to many more, and the increasing intrusion of the insurance companies and the U.S. government into all aspects of medical practice. The article defended the Canadian model against familiar criticisms from the AMA and others--not that the criticism then stopped.

A recent, just slightly negative article in the Chicago Tribune Magazine on the Canadian system nevertheless met head-on some of the things said against it, among them the claim by former presidential contender Paul Tsongas that he might have died had he fought his bout with cancer in Canada. Correspondent Storer Rowley pointed out that some of the most advanced medical treatments and technology now in use in the U.S. were developed in Canada.

That first New England Journal article did not look at dollars. In a 1991 article in the same journal, Himmelstein and Woolhandler compared the costs of operating the American health care system and operating Canada's. A Washington Post headline succinctly announced their conclusion: "U.S. System of Health Care Wastes Vast Sums on Paperwork." While Canada spends 11 cents out of each health care dollar on administrative and billing costs, the United States spends 24 cents. "The proportion of health care spending consumed by administration is now at least ll7 percent higher in the United States than in Canada and accounts for about half the total difference in health care spending between the two nations. If health care administration in the United States had been as efficient as in Canada, $69.0 billion to $83.2 billion would have been saved in l987," Himmelstein and Woolhandler wrote. (Himmelstein told me that's more than enough money to provide health insurance to everyone without it.)

Most of the waste in administrative costs, Himmelstein and Woolhandler reported, could be laid to the nation's l,500 insurance companies. "The scale of waste among private carriers is illustrated by Blue Cross/Blue Shield of Massachusetts, which covers 2.7 million subscribers and employs 6682 workers--more than work for all of Canada's provincial health plans, which together cover more than 25 million people." The overhead costs of America's private insurers in 1987 came to ll.9 percent of premiums collected, said the article, while administrative costs of government health programs such as medicare and medicaid were 3.2 percent of total expenditures. Together, said Himmelstein and Woolhandler, "administration of private and public insurance programs consumed 5.l percent of the $500.3 billion spent for health care, or $l06 per capita."

By contrast, the cost of administering Canada's public health system came to just 0.9 percent of that system's expenditures. With the private insurance carriers that underwrite those services not covered by the national plan running up administrative costs equal to 10.9 percent of the premiums collected, the total administrative costs for public and private health insurance in Canada were 1.2 percent of the nation's health care costs, or $l7 per capita, Woolhandler and Himmelstein reported.

For doctors concerned that a national health program like Canada's would reduce their incomes, Himmelstein and Woolhandler provided some interesting statistics. In the U.S., they wrote, "clerical and managerial staff accounted for 59.5 percent of the nonphysician employees in doctor's offices in l988, and 74,700 more were added over the ensuing two years. . . . In l988, the staff in a typical U.S. physician's office spent about one hour on each Blue Shield or Medicare claim, at least 20 times more than in Ontario. In a typical practice in Canada, 'One person does all the billing, bookkeeping and typing . . . for 8 physicians.'"

The more a doctor spends on billing, bookkeeping, and typing, the less goes into the doctor's pockets, Himmelstein told me. While the actual fees for service in Canada are somewhat lower on average than in the U.S., the average Canadian physician's net income is about the same as the American's because the Canadian is able to take so much more income home. Only very rich surgeons and a few other American specialists earn more than Canadian doctors, he said.

Himmelstein went on, "The U.S. and Canada are actually hard to compare because there is a difference in the practice of medicine. Many more physicians in Canada are primary care physicians. There are a lot fewer specialists. For those primary care physicians, incomes in Canada and the U.S. are about the same. But of course, specialists earn more than primary care physicians, in the U.S. nearly twice as much. The fact that American medicine has so many specialists [80 percent of the doctors in the U.S., 50 percent in Canada] now means that the average income in the U.S. is higher. The huge gap between specialists and primary care physicians in the U.S. is not duplicated in Canada. Specialists in Canada earn as much as l0 to 20 percent less than American specialists."

But there is no reason to think that the higher earnings of American specialists would be greatly reduced under a Canadian-style plan. In an article last year in the Journal of the American Medical Association, Himmelstein, Woolhandler, and several colleagues observed, "We do not advocate cutting U.S. health spending to Canadian levels. Even with a slower rate of growth under the [national health care], U.S. health expenditures will remain well above those of any other nation. Deploying our greater resources with Canadian efficiency would permit increases in utilization and improvements in technology without skyrocketing costs."

This article described how its authors would fund a national health plan. Insurance companies would all but disappear. The money currently spent for insurance by employers and employees would be paid in taxes, though only 22 percent of the population would pay more than $200 extra in taxes. And the costs would end there. More importantly, everyone, regardless of income level, would be covered. Fees would be set by the local medical society, and the government could not question a doctor's medical decisions.

Citing Congressional Budget Office estimates, the JAMA article suggested that financing for national health care could come from "a payroll tax similar to current payroll expenses for Medicare and health insurance premiums, from small increases in existing federal, state, and local revenues, and from new, healthy federal tax revenues that would largely supplant current out-of-pocket expenditures." By "healthy" taxes, the authors meant steep cigarette and liquor taxes and a variety of taxes designed to promote environmental improvements--such as an energy tax that would encourage conservation measures.

The authors contended that the system they were proposing would check the inflation of health costs. "Whether in Canada or New Zealand, Sweden or Britain, single-payer systems have stabilized costs in the past decade, while U.S. health care inflation has been impervious to the most earnest attempts to control costs."

The insurance industry is generally hostile to a single-payer national health plan, but PNHP has established good relations with several large corporations. Himmelstein told me Fortune 500 corporations pay as much for health benefits as they report in profits. Most labor disputes of the last few years have centered on health benefits. Companies try to reduce what they pay in benefits, and workers, correctly equating cuts in benefits with cuts in pay, are fighting back. The recent Caterpillar strike turned primarily on health benefits.

Himmelstein has been asked to address the American automakers and other large industrial firms. He told me, "The thing that is striking is that the audience is usually surprised at how many of them are favorable. I often ask for a straw poll and people are surprised at how many hands go up among them. I think that's actually generally characteristic of businesspeople. They are very shy about being seen in public on this issue because they don't think many of the rest of them would be sympathetic. There are actually many out there. But they are still very cautious. One thing I've learned about businesspeople is that they are very cautious, careful people in general."

As one Western nation after another introduced a national health plan in the postwar era, American medicine bitterly fought the idea. Even when medical costs skyrocketed in the 70s, when access to medical care became a political football and insurance companies began intruding into the decisions of doctors, the medical mainstream kept up its stubborn opposition. Himmelstein suggests that doctors are simply too afraid of government interference. "That deep-seated, oft-repeated fear has been very difficult to overcome, especially because medicare and medicaid adopted the private insurance model in this country and have interfered in medical practice. So there is a reflexive tendency to say, 'More government involvement means more interference, not less.'

"And that, for us, has been one of the reasons why Canada has been extremely important to look at, to see that if one structures a program differently government financing need not mean the intervention of government in the details of practice. That Canadian experience has not been widely known among American physicians. The insurance industry and the AMA have spent huge sums describing how bad the Canadian plan is, distorting the reality, even lying. Because of that, American physicians have just not seen an alternative to private health insurance. So we have to get them to see real alternatives.

"The second reason is that the average physician in this country makes $l60,000 a year. He can put up with some intrusions for that. Physicians have been the highest-paid profession in the country and there's no place to go but down. I think that position breeds a certain conservatism about things. Now, what has happened is that, as the insurance hassling has become more and more extreme, more and more physicians are saying, 'You know, it ain't worth it. Even if my income went down 10 or 15 thousand dollars, it would be worth it to get these people off my back.' That's the change we're seeing. Polls indicate that 90 percent of American physicians would trade l0 percent of their income for a decrease in utilization review and all the paperwork."

Between l986 and l992, the membership of PNHP grew from 40 to 5,000. But it remained basically a mom-and-pop operation in the offices and home of Woolhandler and Himmelstein and their two children. They spent a quarter of their time practicing medicine and teaching and the rest of it doing research, writing articles, and running the organization.

They put out a substantial newsletter and created, among other things, a slide show and book of charts for members to use in talking to colleagues. Encouraged to seize every opportunity to proselytize, members speak at medical meetings of all kinds, to hospital staffs, and occasionally to the general public. Most of the 3l chapters in the 24 states where PNHP is now operating began with the energy and enthusiasm of a doctor or two. PNHP grew largely by word of mouth, spurred by the articles in professional journals.

By the beginning of this year, the organization had grown so big that Woolhandler and Himmelstein felt overwhelmed with the details of operating it. The research and writing that are the backbone of the movement were suffering. It was time to become more businesslike. It also seemed to be a good time to move to Chicago, where the headquarters of the AMA, the American Hospital Association, much of the medical media, and the majority of the professional medical societies are located. "We thought it made more sense for a national physicians' organization to be headquartered in Chicago than in Cambridge," said Himmelstein.

Another incentive to move here was the presence of the energetic, charismatic Dr. Quentin Young. Serving his second term as president of the PNHP, Young knew how to organize, and he offered a cadre of loyal doctors who would work with him to build the organization. As Himmelstein told me, "There are a lot of people who trained under Quentin, people who were his residents at Cook County when he was chief of medicine, people who worked with him in all the organizations he's founded here for medical reform."

PNHP's offices are located in space rented from the Community Renewal Society at 332 S. Michigan. The executive director is Ida Hellander, an MD from the University of Minnesota who decided on social action rather than a medical practice after graduation and went to work for Ralph Nader's Public Citizen Health Research Group in Washington. Hellander has an administrative assistant, a computer, and a group of volunteers who come and go. One of the volunteers is Dr. Ron Sable, another longtime activist, who is on staff at Cook County Hospital and whose specialty is AIDS. Sable is president of the Illinois chapter, which now has about 200 members. He puts in one full day a week at PNHP offices and a good deal of additional time trying to recruit new members.

Talking to Quentin Young is like wading into a sea of words. At 68 years of age, having practiced internal medicine in Hyde Park for about 40 years and labored as long at the forefront of medical reform, Young offers an endless stream of stories and ideas. When I made an early call to find out what PNHP was all about, he talked steadily for some two hours. Words flow from him like water rushing down a mountain.

Why is it, I asked Young, that PNHP has been able to attract mainstream doctors who a few years ago would never have associated themselves with such a radical organization? Explain to me, I said, the sea change that has occurred in medicine.

"Our main point in PNHP is the money that can be saved by a single-payer system," he began. "In one sense, the insurance companies are right when they cut off funds for some tests. For instance, I come from the age when tuberculosis was a mass disease. Chicago had l2,000 hospital beds, 4,000 of which were devoted to tuberculosis patients, not because there were so many sick people but because of the long hospital stays. Those of us who worked in those hospitals, as I did, just took X rays all the time because it was the only way we could follow progress. It got into my gestalt that an X ray on a new patient, certainly if they were over 40, was completely necessary and justified. All of us did it routinely for years. But then we learned from a lot of data that you really couldn't find symptoms of all those things we thought we were getting with the X rays. It was a waste. It was a costly item that, done on everybody, goes into the hundreds of millions. That's a simple and obvious example of what we've learned. Cutting out that routine X ray would save millions every year.

"The more we study the routine stuff, the less justification there appears for doing it. When you get into such things as the routine giving of the ECG [electrocardiogram] before surgery, you find that it, too, doesn't tell you anything about patients that don't have any symptoms. Even when there are cardiac problems, the ECG didn't help a bit to inform us about it. We need to carefully evaluate what we do to save some of the massive costs of medicine today.

"Of course, our favorite money-saving technique lies with the $80 billion the insurance companies take for mostly denying benefits. That's what they do most of the time. 'You didn't call in to check with us about this routine procedure. Denied.' 'You went to the emergency room and you didn't have your doctor call within 24 hours. Denied.' These denials become more than an annoyance. They confound the system. Current studies show that 20 percent of American workers either couldn't move or had to consider not moving to a better job because their insurance wouldn't follow. The wife had a bad back two years ago, the kid has a congenital defect that might cause trouble. The insurance companies just cut them out. I've come to describe the insurers as antiinsurance and the beneficiaries as victims. If we simply had that one change, from private insurers to a single-payer system, we could save that $80 billion a year.

"And this has been confirmed by the Government Accounting Office study which compared the Canadian system to ours. But it's not only the money, it's what all this is doing to American doctors. It's making doctors nuts.

"One of the goals of PNHP is to attend to the increasing demoralization of doctors. There's not a lot of sympathy among the public for doctors--the long hours, and the unswerving loyalty a lot of doctors have for their patients. In the last decade or two there has been a sharp decline in doctors' prestige, esteem, the public impression of them. The rise of malpractice suits and the amazing awards people get is a symptom of that disaffection. The polls show that this mood is reflected in doctors' morale. The fact that so many of them say they wouldn't go into it again or wouldn't want their children to become doctors says more than I could ever say.

"I have a diagnosis for this essentially psychologic state. I think doctors have become alienated from the object of their training--their patients. I would argue that, despite the fabulous incomes some of them make, there's a central issue that goes all the way back to the first witch doctor, and that is the bonding to one's patients. Our prestige among our peers is based on how well our patients do. If a lot of your patients die in surgery, for instance, you soon become very downgraded in the profession. So there's that ultimate goal--the patient wants good treatment and the doctor wants a good outcome. That's the way the game has been played since the beginning.

"There has always been a social contract between doctors and patients. Doctors guarantee a certain service in return for certain very special privileges. The social contract in this country gives the doctors very high incomes, but that's the lesser part--he has the right to do things that someone not so qualified could never do, from undressing them to cutting them open and a whole array of medical prerogatives. In exchange for those privileges that in another person would be assault or practicing without a license, the doctor makes a countercompact. They guarantee that they have all the proper education and training and are continuing to get educated and that they get evaluated by their peers and that there are penalties for making mistakes. That's the deal. When that social contract is in good working order, the system works fine. But that social contract is now coming apart and the doctor is in the process of losing some of those prerogatives and the patient is getting cheated.

"The interference from the health system, the high costs, the obstacles to care, the ever-larger number of people who can't even get into the system, the ever-larger number of people who are getting things they shouldn't get like measles and polio because they haven't been immunized, have changed that equation. Doctors are fast losing their prerogatives to practice medicine as they see fit as the insurance companies move in on them. As a consequence doctors are very demoralized, and at the same time patients don't like their doctors anymore, don't trust them, keep changing doctors, and so on. That sense of loss in doctors is making them morose, even morbid. They are deeply alienated from their patients.

"That's not only not good for doctors, it's not good for the society. A good health care system will have a happy profession at its core. If it doesn't, it will affect the system very adversely if the doctors are sullen, disaffected, angry, feeling poorly appreciated.

"It is that mood that PNHP is addressing, not in a psychologic way, but to point out in a clinical fashion what the source of his discontent is. Once it is pointed out, it makes them feel better. But more to the point, it makes them more clear-eyed about the necessity for systemic reform.

"To return for just a minute to those malpractice suits, for a number of reasons Canada has very few. For one thing, the Canadian patient does not feel adversarial toward the doctor. The relationship between doctors and patients there now is what it was for so long here, one of friendship and cooperation. For another thing, there is no need for such suits, except in most unusual situations, because if the doctor has really made a tragic mistake and, for instance, a child is left a paraplegic, the universal health care will take care of that person for life, he doesn't have to worry about the medical bills for the rest of his life as he does in the U.S. Here, the single largest cause of personal bankruptcy is medical bills.

"If we had a system like Canada's we would once again have doctors who can treat their patients in the way they think is best, not the way some insurance company tells them they have to. I have to tell you that doctors in Canada did not at first go for the system. [The Canadian system was instituted in l971.] They resisted it and they continue to resist about certain things. In the beginning, they struck, they actually struck, and British doctors came in and scabbed on them. The strike was ultimately broken because it was so unpopular. As a result, doctors had a terrible image that persisted for years.

"In l984 there was another strike when the government outlawed what is called balanced billing, in which the doctor bills the government a lower fee in exchange for being able to bill the patient for part of a fee that is higher than the government allowed. We do that uniformly here with Medicare. Well, the government soon realized that balanced billing was creating a two-tier system in which some patients who could afford to pay the fees might be getting special treatment. So they outlawed it and the doctors struck, but they lost again because of the public pressure. Now doctors have come to accept the system, and while they negotiate as hard as they can every two years for the greatest possible amount of money, they are by and large content with their lot."

I interrupted Young to ask whether some of the alienation of doctors from their patients might not result from the extraordinary reliance on technology that has come to dominate American medicine.

"Some years back, in an article I wrote for JAMA, I characterized specialization as a fear of knowledge, namely that doctors were brainwashed into feeling there was so much to know that nobody could be a generalist, that everybody had to be a specialist, the more specialized the better, which nostril will the ENT guy handle? And that increasing reliance on technology is the fear of patients. I deplore the fact that, when I make rounds at my wonderful hospital [Humana Hospital/Michael Reese], when I ask the house staff, the good house staff, "How's the patient?' they go to the computer and start punching up the labs. Now that's important, but that ain't the patient.

"That overreliance on technology is an emblem of what has happened. We constantly look to technology to get answers, and there's been a steady withering away of what any seasoned doctor would say is the crucial interaction with the patient. This patient's pain is hysterical, this one's is very significant. This patient's significant loss of weight is a sign of tension in the home, this one's is an early sign of cancer. That's what the machines won't tell. I'm going to say what is a heresy--we have too much technology here.

"I'll give you one example. Last year, in the New England Journal there was an article on mammography in the U.S. The findings were that there were ll,000 mammography centers in the U.S. The author observed that if they were perfectly distributed, 4,000 working full-time would be enough. [It's a commonly made observation that for reasons of profit and prestige hospitals, especially major urban ones, want to have at least one of everything.]

"But of course nothing is ever perfectly distributed, so we could have comfortably five to six thousand. Why ll,000? He points out--and this is particularly important for those yahoos who think the marketplace will be enough--that despite the fact that in some urban centers there are not only twice the number necessary but ten times the number, the average cost of a mammogram is $ll0. The author ciphered out that $55 would bring a good profit with all the attendant costs factored in. But there is, even with two or three times the number of needed resources, no price competition. Even with the great underutilization, there is no effort to cut prices.

"Having an excess of this equipment and CAT scans and MRIs and so forth leads to abuse. For instance, there is plenty of evidence to show that there is no reliable information to be gotten from a mammogram in a woman under 40. After 40, and some argue 50, regular mammograms will pick up early cancers faster than any way we know. And detection is the name of the game. But doctors are still prescribing them for those younger women. The same is true for CAT scans for headaches. Someone justifies a $5,000 procedure by saying, 'It might be a brain tumor.' Yes, it might, but that isn't the way you make medical judgments.

"So the doctor is alienated from the patient because he's looking at screens and numbers and pictures instead of talking to his patient, and the patient is alienated from the doctor by the sheer ride he gets, the cost, the discomfort, and so on. One of the criticisms that is always made of the Canadian system is that they don't have all the technology that we have. Well, the fact is, we're not going to burn all our MRIs under a single-payer plan. We'll use them and people who really need them will get them as opposed to all those who really don't. Today, it is not given very often when it is needed because a patient can't pay for it, and all too often it is given when it is not needed simply because so many doctors rely so fiercely on the technology to help them make diagnoses. That is confirmed in the literature.

"Another big problem we have in this country that they don't have in Canada, which contributes to the harmony of the Canadian system, is our phenomenal disregard for primary care physicians, who are really in the ghetto of medical care. It is that brainwashing that I mentioned that partly contributes to the fact that so many young doctors choose to specialize. But there is another very good reason. The young doctor comes out of medical school with a debt of about 80K. He's got to go where the money is and that's not in primary care. 'I gotta get me my radiology license and earn some real money,' he says. That's one thing we absolutely have to change. We have to start giving incentives and rewards to young doctors to go into primary care."

I asked Young to explain the persistent resistance to so-called socialized medicine in America.

"It's a little quaint of you to call it socialized medicine. Only the right wing uses that expression now and they tend to get laughed at. It's lost its bogeyman status. The resistance historically goes back to the fact that in the halcyon days of medicine, care was not bad. Costs were lower, people were insured against the big costs. And there was the spectacular program by the AMA against socialized medicine so that people were inured against it.

"It started even before Roosevelt. When he was at the peak of his popularity in l936, all his programs went through except packing the Supreme Court and national health insurance. Nothing happened until l966, until Lyndon Johnson was able to get medicare and medicaid passed. That was the first defeat the AMA suffered. All along the line they raised the specter of how you wouldn't have your own doctor, you'd have a faceless bureaucracy. And then later they started castigating the Canadian system. In the course of trying to build PNHP, I talk to some very well heeled people who are very well educated and knowledgeable. One of those people started his conversation with me by saying, 'I understand in Canada, you have a choice of three doctors.' Now this is a very well read person. In l992 he says this. In Canada they have much more freedom to choose a doctor than we do. We are increasingly restricted by HMOs, PPOs, not to mention the fiscal constraints. You can't just go to any doctor unless you have lots of money.

"The Canadians are very angry about these distortions. On my radio program I interviewed the Anglican archbishop of Canada, who said he was here just to correct those impressions. He said, 'We are tired of the misrepresentation of our system and we decided to take the time and energy to go to your country and tell the truth.' One of the interesting things he said was that polls showed that the Canadians rate their health system as the single most unifying element in their history. Imagine what Americans would say about their system.

"But the heart of the issue is the fact that our system has not historically been as dysfunctional as it has become. There was, from the 30s to the 60s, a long period when we began to learn how to do a lot to help people. Health insurance had expanded. There was a general optimism about the health system which was translated into high prestige for doctors. That wasn't because doctors were such models of social behavior. They were doing good things. 'That son of a bitch gave me a shot in my ass and my gonorrhea went away.' 'That appendicitis that killed my grandfather, I went to the hospital and I came out a week later and I was all well.' Those were the real-life experiences. People genuinely loved their health system. And when the caretakers, the AMA, said, 'You want to lose all that? You want those government bureaucrats to take over?' they believed them.

"That doesn't hold anymore. It's a different ball game now--now that system has become dysfunctional. It is doing all the antisocial things, all the antimedical things we've been talking about. We don't spread the costs. We have millions of people excluded from medical care. We don't do any prevention stuff. A hugely disproportionate amount of the $800 billion that is spent on medical care goes to the end-of-life treatment. Things we couldn't dream of doing before--keeping people alive after that second stroke or heart failure--we now turn on our machines and spend $50,000 on a three-week stay in nirvana, in a coma. Drug prices are absurdly expensive. The whole system is coming apart and everybody knows it.

"As a consequence of all this doctors are beginning to look to reform. The American College of Physicians has on the table a very progressive reform. Even the AMA has a reform, which is not very serious. They are for expanding medicaid. And of all the systems that haven't worked, medicaid is the worst. For one thing, 80 percent of doctors in Illinois won't take medicaid because medicaid pays $l0 per visit, which is not even the break-even point for any doctor. As if that weren't bad enough, the state, as a part of the solution to their financial problems, just says they won't pay for a while. You have to wait months for your money. If a doctor has any substantial medicaid practice, that means he goes the route of l5 or so hospitals in Chicago that just closed down. Cash flow isn't a mirage. It's a reality.

"The hospital closings are one of the strongest indictments of the system. The way it happened in Chicago was what I call social Darwinism. They didn't close because they had too many empty beds--they had a higher than average occupancy. Not because they were inefficient, because they weren't. Not because they were old--some were nearly brand-new, like Provident. They closed because they had a high rate of Medicaid patients and were getting paid 63 cents on the dollar. The hospitals in affluent neighborhoods, even when they were clustered together, weren't touched. It was those in poor neighborhoods where they were desperately needed because there were so few of them. Social Darwinism is what it is.

"Our plan is moving ahead quickly. There's no question; this is no hype. The pay-or-play support, even though it is the avowed preference of the Democratic leadership, that oxymoron, is collapsing. They can't get enough people to give a good show in a vote, while the number of people supporting our program is the largest in the House and it's growing in the Senate."

Pay-or-play, a form of which is supported by Bill Clinton, would require a business either to provide health insurance for its employees or pay into a federal health insurance fund.

Young's optimism about the success of a single-payer system in the U.S. is matched by Himmelstein's pessimism. He says that before PNHP's program becomes a reality there will be a period of tightening restrictions on doctors and diminishing choice for patients, as HMOs owned and operated by insurance companies become the mode of American medical practice. Doctors generally are pessimistic. Asked in the AMA's l992 survey what they expect to happen in health care in the next five years, 69 percent of the doctors who responded said it was "very likely" that they'd see "substantial restrictions on fees for physicians' services, for both public and private payers." At the same time, 37 percent said that it is "somewhat likely" that the U.S. will establish government-financed national health care.

Only after the complete breakdown of the American medical system does Himmelstein see the possibility of introducing a system like Canada's. Until then he believes the huge influence of the private insurance lobby and the continued resistance of the AMA will prevail. The next few years will tell us if Young's optimism or Himmelstein's pessimism more accurately gauges society's ability to reform health care.

Art accompanying story in printed newspaper (not available in this archive): illustration/Andrew Epstein.

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