Health Care Reform - Old School!

Donald J Palmisano was President of the AMA for the 2003-2004 term. You can jump to his bio at his company's website. Apparently he also sends out his opinions via an email newsletter which a friend forwards to me on occasion. Here is the newest one, and since I haven't responded line by line to the conservative arguments on health care reform in a while, I thought now would be a good time to do so. I'm in italics.

DJP Update 6-1-2009: Health System Reform & AMA - Additional Reflections; comments on recent AMA writings.

The advantages of being an American and living in the USA are many. One of the great liberties we enjoy is the First Amendment to the US Constitution (part of the Bill of Rights) : http://www.archives.gov/exhibits/charters/bill_of_rights_transcript.html
AMENDMENT I: Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.

I always find it ironic when conservatives quote the Constitution given the penchant for the authoritarian-submissive personality among them. If that seems gratuitous, sorry, but I am always irritated when conservatives quote the Constitution as if it's news to the rest of us.

Also, one of the advantages of being an AMA member and getting elected to be a delegate (or have the privilege, as I have, as a former AMA president) and to sit in the AMA House of Delegates is the right to discuss, debate, and yes, offer alternative views if one perceives the ship of state is heading in the wrong direction. That is part of leadership. Without the courage to enter the debate, one cannot earn the title of leader. Of course, one's view may be defeated but then you have the comfort of the wisdom of Kipling's poem "IF" and President Teddy Roosevelt's words in his famous speech at the Sorbonne in 1910. See page 56 of my book, "On Leadership..." or go to:http://www.kipling.org.uk/poems_if.htm and http://www.theodore-roosevelt.com/trsorbonnespeech.html

Interesting bit from the TR speech: "It is a mistake for any nation to merely copy another; but it is even a greater mistake, it is a proof of weakness in any nation, not to be anxious to learn from one another and willing and able to adapt that learning to the new national conditions and make it fruitful and productive therein."

This would, unfortunately, require us to look past the end of our noses for potential solutions and, as Churchill might say, "This is something up with which I will not put!"

Another bit, "The poorest way to face life is to face it with a sneer. There are many men who feel a kind of twister pride in cynicism; there are many who confine themselves to criticism of the way others do what they themselves dare not even attempt. There is no more unhealthy being, no man less worthy of respect, than he who either really holds, or feigns to hold, an attitude of sneering disbelief toward all that is great and lofty, whether in achievement or in that noble effort which, even if it fails, comes to second achievement."

This is always how I see the conservatives sneering at the idea of universal health care. To quote JFK, "We choose to go to the moon. We choose to go to the moon in this decade and do the other things, not because they are easy, but because they are hard, because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win, and the others, too."


Enough time spent laying the foundation for the following. Consider this note a part of a "disconfirming opinion" as taught by Dean Donald Jacobs at Northwestern. Plus some praise too! Why has our AMA not put forth in writing to the world, and to those in government we negotiate with, our AMA policy of "unwavering opposition against the encroachment of government in the practice of medicine..." "including the right of physicians and patients to contract privately for health care without government interference." Or "It is the policy of the AMA: (1) that any patient, regardless of age or health care insurance coverage, has both the right to privately contract with a physician for wanted or needed health services and to personally pay for those services; (2) to pursue appropriate legislative and legal means to permanently preserve the patient's basic right to privately contract with physicians for wanted or needed health care services; ..." See multiple AMA policies below and if you want more on the same topic, go to the PolicyFinder at the AMA Website: http://www.ama-assn.org/ama/no-index/about-ama/11760.shtml Is there something that is not clear about the wording in our policy? I conclude no. Hasn't it been repeated enough times in various policies? Certainly.

He is absolutely right here, and I have posted about these AMA policies and the one about single payer in the past, just to serve as a warning that, when it comes down to brass tacks (in the AMA's case, when it comes down to its' (our) House of Delegates), the AMA policy remains staunchly conservative.

Here is the problem. Our government controls our fees. That is a violation of our liberty.

Really? I see conservative physicians posting all the time about opting out of Medicare and other insurance plans precisely so that the government and insurers cannot control our fees. Virtually every nation (Canada a partial exception) allows physicians to practice outside or alongside the national system.

Property rights are an important component of our liberty. We have to recognize that government has the right to decide how much money to spend on some benefit, BUT government doesn't have the right to determine what we charge for a service. AMA leaders for years have advocated defined contribution approach by government with ownership by the patient, and an array of choice of insurance options. Read some of the speeches of Dr. Stormy Johnson, Dr. Nancy Dickey, and mine. And of course, read anything you can find from another AMA president, Dr. Ed Annis, the gold standard for liberty in medicine. Not a price-control system that ends up creating loss of access to care for patients because the fixed payment is below the cost of delivering the service. Throughout history, price-fixing equals loss of availability of the product or service.

Isn't it just hilarious that in a nation of nearly 50 million uninsured and another similar number underinsured, in a nation where we are all at risk of financial ruin due to health care catastrophes, that he expresses concern over "loss of access?" "Throughout history," etc. Again, one does have to look past the end of one's nose to see that this is wrong, wrong, wrong.


AMA has been "at the table" and we are told our policy is being advocated. Great. But has this policy been advocated? Certainly not in our AMA writings. The quest to end the SGR payment formula is good and AMA has advocated that. Unfortunately, we still granted the government the premise that it has the right to control our fees.

First, as noted, you can opt out. You can opt out of the Private Health Insurance market too, except, oh, yeah, unfettered markets have led to dominance by one or two insurers in virtually every large market in the country.

Secondly, this reminds me of President Eisenhower's comments to his brother, "Should any political party attempt to abolish social security, unemployment insurance and eliminate labor laws and farm programs, you would not hear of that party again in our political history. There is a tiny splinter group, of course, that believes that you can do these things. Among them are a few Texas oil millionaires, and an occasional politician or businessman from other areas. Their number is negligible and they are stupid ." This is true of Medicare as well.

In a recent message from AMA, we are advocating a MEI index approach in the negotiations. If one negotiates and allows the other side to set the framework of the debate, you will lose every time (See "On Leadership...). Why do we let government continue to set the paradigm that we don't have a right to set our fees? Note the RECURRENT policies that direct action about privately contracting. AND reaffirmed many times! This is not optional. This is the command of the AMA House of Delegates, the policy setting body of the AMA. AND note the policy about government medicine. Why are we not speaking out against the "public option"? Medicare is going bankrupt, restricting our liberty, and we are not opposing expansion of government medicine? Why not? This is not optional based on our clear AMA policy. Thus you can see I do not share the enthusiasm of my friend Dr. Joe Heyman, AMA Board Chair, in his AMA opinion column dated June 1, 2009, entitled "Health system reform is coming -- and you all helped". I hope AMA's help has not sanctioned a public system enlargement.

He is right about this. In spite of some of the AMA leadership's conciliatory remarks, speeches, etc., AMA policy stands directly opposed to significant reform. The AMA Annual meeting is coming up June 13-17. It'll be interesting to see how that goes.


However, what I do strongly agree with is the praise he gives to the Litigation Center of the AMA and State Medical Societies. I served on that committee when I was on the AMA Board and it does outstanding work. It fights the abuses of managed care, medical liability injustice, and much more. I wish every doctor in America knew of the great work it does. I also applaud our AMA putting in earlier writings that we need medical liability reform and antitrust relief for negotiating against the monopsony power some health insurers have. However, all of this will be wasted if physicians end up as captives of a government takeover of medicine. Hard to compete against government when it has unlimited taxpayer dollars and the power to punish by mandates and tax treatments. Before agreeing to a "better system" read the fine print carefully. One person's version (or the government's) of "better" may be entirely different than ours. Just like some caps on "non-economic" damages are great and others are worthless. Fine print!

Medical liability is still a hot issue for many physicians. In a recent survey by the California Medical Association, 40% still thought it was their number one concern. I do not know the political make up of the responders to that poll [though 67% were in practice more than 20 years - MY cohort!], nor of physicians in general [95% were CMA members], but my guess is that the 40% who still list that as their top concern are the older, whiter, male-r, and more conservative members of the profession.

We have to ask why membership continues to drop and what needs to be done to end the internecine battles among the various specialties. Why join AMA if my specialty does everything for me, including lobbying? Of course we know why everyone should be an AMA member and the Litigation Center is just one of many reasons. If everyone could balance-bill for the additional amount needed, there would be no need for different specialties to run to Congress and say, "Give me more of the Golden Apple as I am the fairest." Remember Paris, the golden apple, and the three goddesses, Hera, Athena and Aphrodite? To the fairest goes the golden apple. The story ended badly and so will the present course our medical ship is on.

I think the answer about AMA membership is clear, but it is not at all the same answer arrived at by Dr. P. There are a large number of physicians who focus primarily on income or revenue and see medical liability premiums as a scourge to their take-home pay, but for most, this is not the focus of their lives, professional or otherwise. I would like to see us continue to make inroads into medical liability reform, but not through caps, but through honesty, alternative dispute resolution, and taking responsibility, as a profession, for our colleagues who have fallen behind.

On D-Day all allied forces agreed to land on the same coast of France and worked together for a common goal. Perhaps all physicians and every American citizen should watch the HBO special on Winston Churchill that played last night entitled "Into the Storm". Read about it at:http://www.hbo.com/films/intothestorm/ Outstanding and a gold standard how to rally the nation against what appeared to be overwhelming force directed against Europe. No appeasement; no giving up; no "You don't understand". Instead, a fight to the end for important principles.

I am prone to hyperbole as well, so will let this pass...

But on the larger point, D-Day was about solidarity, exactly what we who are advocating for serious, comprehensive healthcare reform are promoting. We are in this community, this society, this national life, together. There is no religion, no school of thought (I always have to add, "except Ayn Rand's") whose central message is "every man for himself."

As Uwe Reinhardt says, "Go explain to God why you cannot do this. He will laugh at you."

Review the following AMA policies on privately contracting and unwavering opposition to government medicine. Trust but verify. Here is your chance to verify. [DJP here sites the policies I linked to earlier.]

In 1976 (yes, 1976) I testified before the U.S. House of Representatives' Ways & Means Committee opposing the government takeover of medicine and opposing a single-payer system. Representative Rostenkowski was the chair of the committee. Since that time, I have not found any evidence to change that view and I now have had the opportunity, thanks to AMA, to visit the Canadian Medical Association and the British Medical Association's annual meetings and learn directly from the doctors there about government promises and the failure to keep them. Check out one of my writings about this at: JAMA -- Proposals for US National Health Insurance, December 3, 2003, Palmisano 290 (21): 2797. It contains the following:-----In June 2003, the Chairman of the British Medical Association characterized his nation's single-payer health care system as "the stifling of innovation by excessive, intrusive audit . . . the shackling of doctors by prescribing guidelines, referral guidelines and protocols . . . the suffocation of professional responsibility by target-setting and production line values that leave little room for the professional judgment of individual doctors or the needs of individual patients."4 His strong words come from long experience with a single-payer health system.------I also witnessed how the government breached the promise in Section 1801 of the Medicare law, ("Prohibition Against Any Federal Interference"), not to interfere with the practice of medicine. See Notes section of my book, "On Leadership..." at pages 255-258.

Yes, if you ignore everything wrong in our system, every other system looks awful. If you ignore every good thing in every other system around the world, our system looks great. If you focus on Canada and Britain, the two countries that perform near the bottom in the world for health care system performance (you know, down there close to as poorly as we do), our system looks pretty good. On the other hand, if you look at the high performing systems with great outcomes, satisfied patients and physicians, great high tech medicine and great primary care and low cost, we don't look so hot.

This is the same ignorant line of reasoning promulgated by the Right Wing Noise Machine, Health Care Edition.

Most importantly, I have seen the sacrifice of the brave men and women who fight for our USA to preserve our liberty. I had the privilege during my tour of duty at the time of the Vietnam War to treat them at our airbase when they rotated back to the USA for 6 months. And I write about other military heroes in my book. Surely we cannot dishonor them by giving up our liberty. Sounds too strong? Have at it.

Oh, yeah, conservatives loves them some soldiers. That's why they're in our US Socialized Medicine system, the VA. You know this one. [In the interest of full disclosure, I have a friend whose son has PTSD, from Iraq, and the VA is failing him. We need to put pressure on our Congress to step up and make this right.]

Let me end this discussion by again recommending that everyone read "The Road to Serfdom".The author is F.A. Hayek, the co-winner of the Nobel Memorial Prize in Economics in 1974 and recipient of the Presidential Medal of Freedom in 1991.Here is what the back cover of the paperback edition (ISBN-13: 978-0-226-32055-7) of "The Road to Serfdom - The Definitive Edition", edited by Bruce Caldwell, says:"For F.A. Hayek, the collectivist idea of empowering government with increasing economic control would lead not to a utopia but to the horrors of Nazi Germany and fascist Italy."The original text was in the book was written in 1944. Think about it. At the start of Chapter Nine, he has two quotes: Here is one: In a country where the sole employer is the State, opposition means death by slow starvation. The old principle: who does not work shall not eat, has been replaced by a new one: who does not obey shall not eat. ---Leon Trotsky (1937) Think about how that applies to medicine. Would it not be better to bring about change in medicine by testing rather than just getting an idea and implementing it for the whole nation? Imagine if we gave patients new drugs without proper testing. I believe there would be many disasters. As Louis Pasteur said,"Imagination should give wings to our thoughts, but we always need decisive experimental proof. "The debate in our Land of Liberty is upon us. We may hear things that are not true. As scientist, it is our duty to insist on due diligence. As George Orwell said, "In a time of universal deceit, telling the truth becomes a revolutionary act." It doesn't have to be universal deceit, it can be universal failure to do the homework and testing and a rush to pass bills. It can be erroneous statistics with sampling errors and failure to compare apples vs apples. You get the idea. The quest for truth can be a lonely path. Leaders must courageously pursue it. Let's be a revolutionary for truth!--

One would think this is a satirical critique on the modern conservative-authoritarian movement, the failure of regulation of the marketplace, and the interjection of commercial interests into medical research, but sadly, no.

Liberals are anti-authoritarian, for goodness sake. You think Thomas Jefferson was a conservative authoritarian?!?

It's just not worth wasting the time on.
*sigh*


---I look forward to the debate at the June AMA House of Delegates in Chicago. Watch for "Resolution 203 - Right to Privately Contract" at AMA June Meeting in Reference Committee B. Resolve two of that resolution deals with the right to restore fairness to negotiations with the private health insurers and the government. There are at least 19 state and specialty co-sponsors. This resolution elevates the issue to highest priority. The people of America need to know what is at risk with their medical care. If we don't sound the alarm, I believe other grassroots groups will take the leadership for a clarion call to action and the world will wonder what happened to our AMA.

Well, I hope the HOD has the chutzpa to smack these people down once and for all, but I'm not counting on it.

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