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Will the AMA Support A Move Toward Single Payer Health Care?

By MIKE MAGEE

The Politico headline in 2019 declared dramatically, “The Most Powerful Activist in America is Dying.” This week, 4 1/2 years later, their prophecy came true, as activist Ady Barkan succumbed at age 39 to ALS leaving behind his vibrant wife, English professor, Rachael King, and two small children, Carl,7, and Willow,3.

His journey, as one of the nation’s leading activists for a single-payer health care system began, not coincidentally, began with his diagnosis of A.L.S. in 2016, 4 months after the birth of his first child. His speech at the Democratic National Convention fully exposed his condition to a national audience.

His mechanized words that day were direct, “Hello, America. My name is Ady Barkan, and I am speaking to you through this computer voice because I have been paralyzed by a mysterious illness called A.L.S. Like so many of you, I have experienced the ways our health care system is fundamentally broken: enormous costs, denied claims, dehumanizing treatment when we are most in need.”

Three years later, with remarkable self-awareness, he told New York Times reporter, Tim Arango,  “That’s the paradox of my situation. As my voice has gotten weaker, more people have heard my message. As I lost the ability to walk, more people have followed in my footsteps.”

His was a shared sacrifice, laced with stubborn and very public persistence, under the banner, “Be A Hero.” His passage on November 1, 2023, was bracketed that day by a piece by veteran Healthy Policy guru, and columnist for KFF Health News, Julie Rovner, that certainly would have made Ady smile. In the Washington Post newsletter, Health 202, it read, “The AMA flirts with a big change: Embracing single payer health care.” 

The commentary that follows includes this, “That leftward shift in political outlook is showing up not just in the AMA, but in medicine as a whole. As the physician population has become younger, more female and less White, doctors (and other college graduates in medicine) have moved from being a reliable Republican constituency to a more reliable Democratic one.”

Ironically, the AMA’s lead journal JAMA last week reinforced the need for simplification with an article by luminary KFF health policy pros, Larry Levitt and Drew Altman, titled “Complexity in the US Health Care System Is the Enemy of Access and Affordability.” They write, “Health care simplification does not necessarily resonate in the same way as rallying cries for universal coverage or lower health care prices, but simplifying the system would address a problem that is frustrating for patients and is a barrier to accessible and affordable care.”

My friend and colleague at THCB, Kim Bellard took off on the article, writing, “Health insurance is the target in this case, and it is a fair target, but I’d argue that you could pick almost any part of the healthcare system with similar results. Our healthcare system is perfect example of a Rube Goldberg machine, which Merriam Webster defines as ‘accomplishing by complex means what seemingly could be done simply.’ Boy howdy.”

A bit further on, Kim comments, “If we had a magic wand, we could remake our healthcare system into something much simpler, much more effective, and much less expensive. Unfortunately, we not only don’t have such a magic wand, we don’t even agree on what that system should look like. We’ve gotten so used to the complex that we can no longer see the simple.”

As Kim suggests, status quo is hard to crack. But change has been in the air for some time. A KFF supported 2017 survey of 1,033 US physicians by Merritt Hawkins revealed a plurality of physicians favored moving on to a single payer system. Why? The survey suggested four factors:

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Ecology Rescued the AMA and Medical Professionalism Beginning in 1870. Will technology and science rescue the profession once again?

BY MIKE MAGEE

Medicine does not exist in a vacuum. The trusting relationships that underpin it function within an ever-changing environment of shifting social determinants. This is not new, nor surprising.

Consider for example the results of their 1851 survey of 12,400 men from the eight leading U.S. colleges had to be shocking. The AMA was only four years old at the time and being forced to acknowledge a significant lack of public interest in a physician’s services. This in turn had caused the best and the brightest to choose other professions. There it was in black and white. Of those surveyed, 26% planned to pursue the clergy, 26% the law, and less than 8% medicine.

It wasn’t that doctors with training (roughly 10% of those calling themselves “doctor” at the time) lacked influence. They had been influential since the birth of the nation. Four signers of the Declaration of Independence were physicians – Benjamin Rush, Josiah Bartlett, Lyman Hall, and Mathew Thorton. Twenty-six others were attendees at the Continental Congress. But making a living as a physician, that was a different story.

During the first half of the 19th century, the market for doctoring went from bad to worse. Economic conditions throughout a largely rural nation encouraged independent self-reliance and self-help. The politics of the day were economically liberal and anti-elitist, which meant that state legislatures refused to impose regulations or grant licensing power to legitimate state medical societies. Absent these controls, proprietary “irregular medical schools” spawned all manner of “doctors” explaining why 40,000 individuals competed for patients by 1850 – up from 5000 (of which only 300 had degrees) in 1790.

The ecology of 1850’s medicine couldn’t be worse. The marketplace was a perfect storm – equal parts stubborn self-reliance, absence of licensure to promote professional standards, diploma mills that showed little interest in scientific advancement, and massive unimpeded entry of low quality competitors. 

The legitimate doctors in those early days saw 5 patients on a good day. Horse travel on poor roads, and the absence of remote systems for communication, meant doctors had to be summoned in person to attend a birth or injury. And patients lost a day’s work to travel all the way to town for a visit of questionable worth. The direct and indirect costs for both doctor and patient were unsustainable. As a result, most doctors had multiple careers to augment their income.

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“All Men Would Be Tyrants.” History Reverberates!

By MIKE MAGEE

“We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.”

This striking and sweeping statement of values, the Preamble to our Constitution, was anything but reassuring to the wives, mothers, sisters and daughters of the Founding Fathers. Abigail Adams well represented many of them in her letter to John Adams in March, 1776, when she wrote:

“Remember the Ladies, and be more generous and favorable to them than your ancestors. Do not put such unlimited power into the hands of the Husbands. Remember all Men would be tyrants if they could. If particular care and attention is not paid to the Ladies we are determined to foment a Rebellion and will not hold ourselves bound by any Laws in which we have no voice or Representation.”

Her concern and advocacy for “particular care and attention” reflected a sense of urgency and vulnerability that women faced, and in many respects continue to face until today, as a result of financial dependency, physical and mental abuse, and the complex health needs that accompany pregnancy, birth, and care of small infants.

The U.S. Constitution is anything but static. In some cases, the establishment of justice, or the unraveling of injustice may take more than a century. And as we learned in the recent Dobbs case, if the Supreme Court chooses, it may reverse long-standing precedents, and dial the legal clock back a century overnight.

Roe v. Wade was a judicious and medically sound solution to a complex problem. Perfection was not the goal. But in the end, most agreed that allowing women and their physicians to negotiate these highly personalized and individualized decisions by adjusting the state’s role to the reality of the 1st, 2nd, and 3rd trimester made good sense. But getting physicians to step forward and engage the issue was neither simple nor swift.

In July, 1933, McCall’s magazine published one of hundreds of ads that year for contraceptive products. This one was paid for by Lysol feminine hygiene. It pulled punches, using coded messages, and suggesting that the very next pregnancy might finally push a women over the edge, and that would indeed be a “travesty.”

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When Push Comes to Shove: The AMA v. Dobbs. Part 2.

BY MIKE MAGEE

On November 8, 2022, five days after the 2022 Midterm elections, the AMA raised its voice in opposition to Republican efforts to promote second class citizenship for women by exerting public control over them and their doctors intensely private reproductive decisions. At the same time they sprinkled candidates on both sides of the aisle with AMA PAC money, raising questions whether their love of women includes active engagement or just passive advocacy.

Trump and his now MAGAGA (“Make America Great and Glorious Again”) movement has now returned to center stage. With the help of Senate Majority leader McConnell, Christian Conservatives had packed the Supreme Court with Justices committed to over-turning Roe v. Wade. And they did just that.

On June 24, 2022, a Supreme Court, dominated by five conservative Catholic-born Justices, in what experts declared “a historic and far-reaching decision,” Dobbs v. Jackson Women’s Health Organization, scuttled the half-century old right to abortion law, Roe v. Wade, writing that it had been “egregiously wrong,” “exceptionally weak” and “an abuse of judicial authority.”

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When Push Comes to Shove: The AMA v. Dobbs. Part 1.

BY MIKE MAGEE

Should anyone present know of any reason that this couple should not be joined in holy matrimony, speak now or forever hold your peace.”     Book of Common Prayer, Church of England, 1549

Last evening Trump rose from the ashes and declared it was time to “Make America Great and Glorious Again” (MAGAGA).

This past week, five days after the Midterm elections, AMA President, Jack Resnick, Jr., MD, raised his voice from the podium at the AMA Interim Meeting in Hawaii with the AMA’s own version of a call to action:

“But make no mistake, when politicians insert themselves in our exam rooms to interfere with the patient-physician relationship, when they politicize deeply personal health decisions, or criminalize evidence-based care, we will not back down…I never imagined colleagues would find themselves tracking down hospital attorneys before performing urgent abortions, when minutes count … asking if a 30% chance of maternal death, or impending renal failure, meet the criteria for the state’s exemptions … or whether they must wait a while longer, until their pregnant patient gets even sicker…Enough is enough. We cannot allow physicians or our patients to become pawns in these lies.”

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Mike Magee’s Advice to the AMA on Reversal of Roe vs. Wade

BY MIKE MAGEE

Stable, civic societies are built upon human trust and confidence. If you were forced to rebuild a society, leveled by warfare and devastation, where would you begin? This is the question the U.S. Army faced at the close of WW II, specifically when it came to rebuilding Germany and Japan, hopefully into stable democracies. The Marshall Plan answered the question above, and its success in choosing health services as a starting point was well documented by many in the years to come, including the RAND Corporation. Their summary in 2007 said in part, “Nation-building efforts cannot be successful unless adequate attention is paid to the health of the population.” 

They began with services for women and children, the very location that a splinter of politicians and Supreme Court Justices has targeted, replacing entrusted doctors with partisan bureaucrats in an approach so obviously flawed that it forced a course correction a half-century ago in the form of Roe v. Wade.

The practice of Medicine is complex. Ideally it requires knowledge, skills, supportive infrastructure, proximity and presence. But most of all, it requires trust, especially in moments of urgency, with lives at stake, when an individual, and family, and community are all on high alert. When time is of the essence, and especially if one or more people are trying to make the right decision for two, rather than one life, decisions are impossibly personal and complex.

This was widely recognized by most physicians, including those most devout and conservative nationwide in the troubling years leading up to Roe v. Wade. As recently as 1968, the membership of the Christian Medical Society refused to endorse a proclamation that labeled abortion as sinful. In 1971, America’s leading conservative religious organization, the Southern Baptist Convention, went on record as encouraging its members “to work for legislation that would allow the possibility of abortion under such conditions as rape, incest, clear evidence of severe fetal deformity, and carefully ascertained evidence of the likelihood of damage to the emotional, mental, and physical health of the mother.” In 1973, both the Southern Baptist Convention and the Christian Medical Society chose not to actively oppose the Supreme Court ruling against a Texas law prohibiting abortion known as Roe v. Wade, and reaffirmed that position in 1974 and 1976.

What they recognized was that the nation’s social capital, its political stability and security, relied heavily on the compassion, understanding and partnership engendered in the patient-physician relationship. As most doctors saw it, what possible good could come from putting politicians in the middle of such complicated, emotion-ridden, and highly personal decisions?

The American Medical Association’s prepared reaction to the June 24, 2022, reversal to Roe v. Wade was direct and immediate. They labeled the decision “an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient-physician relationship…” Their president, Jack Resneck Jr. M.D. went further to say, “…the AMA condemns the high court’s interpretation in this case. We will always have physicians’ backs and defend the practice of medicine, we will fight to protect the patient-physician relationship..” But what exactly does that mean?

Approaching 75, and a lifelong member of the American Medical Association, I expect I know the AMA, its history as well as its strengths and weaknesses, as well as anyone. Aside from having deep personal relationships with many of the Board of Trustees over the years (some of whom quietly continue to contact me for advice), I have studied the evolution of the patient-physician relationship in six countries over a span of forty years.

Those who know me well, and who have pushed back against my critique of the organization, know that my intentions are honorable and that the alarms that I sound reflect my belief that, for our profession to survive as noble, self-governing, and committed above all to the patients who allow us to care for them, we must have a national organization with reach into every American town and city, and official representation in every state, and every specialty.

My concern today, despite the strong messaging from Chicago, is that the AMA and its members have not fully absorbed that this is a “mission-critical” moment in the organization’s history. It is also an opportunity to purposefully flex its muscles, expand its membership, and reinforce its priorities. The strong words, without actions to back them up, I believe, will permanently seal the AMA’s fate, and challenge Medicine’s status as a “profession.”

Here are five actions that I believe the AMA should take immediately to make it clear that physicians stand united with our patients, in partnership with nurses and other health professionals, and that the actions of last week can not and will not stand.

  1. The AMA should pull all financial support for all Republican candidates through the 2022 elections.
  2. The AMA should actively encourage physician “civil disobedience” where appropriate to protect the health and well being of all women, regardless of age, race, sexual identity, religion, or economic status.
  3. The AMA should convene, under the auspices of its’ General Counsel, Andra K. Heller, a formal strategy meeting with the legal counsels of all state and specialty medical societies to formulate an aggressive legal approach to minimize the damage of the recent Supreme Court action.
  4. The AMA should actively promote AMA volunteers to help provide a full range of women’s health care services at federal institutions and on federal land, and stand up information sites that coordinate travel and expenses should inter-state travel be required for care access.
  5. The AMA should immediately make clear that any restriction of prescribing authority of medications in support of women’s health care, including contraceptive medications and devices, and Plan B treatments will result in a coordinated nationwide disruption of health services.

Mike Magee MD is a Medical Historian and the author of “CODE BLUE: Inside the Medical-Industrial Complex.”

A Missed Opportunity for Universal Healthcare

Connie Chan
Phuoc Le

By PHUOC LE, MD and CONNIE CHAN

The United States is known for healthcare spending accounting for a large portion of its Gross Domestic Product (GDP) without yielding the corresponding health returns. According to the Center for Medicare and Medicaid Services (CMS), healthcare spending made up 17.7% ($3.6 trillion) of the GDP in the U.S. in 2018 – yet, poor health outcomes, including overall mortality, remain higher compared to other Organization for Economic Cooperation and Development (OECD) countries. According to The Lancet, enacting a single-payer UHC system would likely result in $450 billion in savings in national healthcare and save more than 68,000 lives.

Figure 1. Mortality rate in the US versus other OECD countries.

The expansion of Medicaid under the Patient Protection and Affordable Care Act (ACA or Obamacare) was not the first attempt the United States government made to increase the number of people with health insurance. In 1945, the Truman administration introduced a Universal Health Care (UHC) plan. Many Americans with insurance insecurity, most notably Black Americans and poor white Americans, would benefit from this healthcare plan. During this time, health insurance was only guaranteed for those with certain jobs, many of which Blacks and poor white Americans were unable to secure at the time, which resulted in them having to pay out-of-pocket for any wanted healthcare services. This reality pushed Truman to propose UHC within the United States because it would allow “all people and communities [to] use the promotive, preventative, curative, rehabilitative and palliative health services they need of sufficient quality…, while also ensuring that the use of these services does not expose the user to financial hardship.”

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The AMA’s Digital Health Investment Fund | Andrew Elkind & Stas Sokolin, Health2047

By JESSICA DAMASSA, WTF HEALTH

The American Medical Association (AMA) announced Health 2047, its accelerator and investment fund in 2018. A year later, Andrew Elkind and Stas Sokolin, both Principals at the fund, stop by to get us up-to-speed on the progress the AMA has made so far with its $45 million accelerator fund and $30 million investment fund. What kinds of health tech startups are piquing the attention of this physician-led fund? Get the details behind the Health 2047 investment thesis here!

THCB Spotlight: Jesse Ehrenfeld, AMA

By ZOYA KHAN

Today, we are featuring Dr. Jesse Ehrenfeld from the American Medical Association (AMA) on THCB Spotlight. Matthew Holt interviews Dr. Ehrenfeld, Chair-elect of the AMA Board of Trustees and an anesthesiologist with the Vanderbilt University School of Medicine. The AMA has recently released their Digital Health Implementation Playbook, which is a guide to adopting digital health solutions. They also launched a new online platform called the Physician Innovation Network to help connect physicians with entrepreneurs and developers. Watch the interview to find out more about how the AMA is supporting health innovation, as well as why the AMA thinks the CVS-Aetna merger is not a good idea and how the AMA views the role of AI in the future of health care.

Zoya Khan is the Editor-in-Chief of THCB as well as an Associate at SMACK.health, a health-tech advisory services for early-stage startups.

Health in 2 Point 00 Episode 55

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We missed our chance to do a Happy Hour Health in 2 Point 00 at Connected Health in Boston (but let’s be honest, those are usually not the most cogent pieces of information in health and technology). Join Jessica DaMassa as she gets my take on the conference starting with #S4PM’s event, where I met some incredible people, including Patty Brennan and Doug Lindsey, who spoke about their experiences with health care knowledge (deploying it and creating it!). Danny Sands and e-Patient Dave even had quite the musical performance there, singing about e-Patient blues. Susannah Fox, Don Berwick, Don Norman were at Connected Health 18, presenting their new initiative, L.A.U.N.C.H. I even interviewed Jesse Ehrenfeld, the chair elect of AMA, and his spoke to him about the digital health play book that the AMA just released. A company to take note of that wasn’t at #CHC is Devoted Health, who just raised $300m. Devoted is looking at building a better Medicare Advantage “payvider” for seniors. If you are interested in Guild Serendipity’s conference which empowers and engages female CEOs and Cofounders, come join us in San Francisco October 26-27, SMACK.health is sponsoring the women’s health houses – Matthew Holt