Pay, Pride, and Public Purpose: Why America's Doctors Should Support Universal Healthcare

Posted 02/28/2007

Laura K. Altom, BS, MSIII; Larry R. Churchill, PhD
Author Information

Abstract

Discussion of universal healthcare is nothing new for US politicians or among reform advocates, policy experts, or the general public. Physicians, however, have been minor voices in the discussion. Their relative silence has been detrimental both to the public and to physicians themselves. We pose 3 arguments as to why physicians should support universal access grounded in medicine's own self-interest, arguments that are largely ignored in the current debate. These are: (1) the need for paying patients, (2) the need for a sense of self-esteem rooted in professionalism rather than commercialism, and (3) the urgency to affirm a public purpose for medicine by promoting the nation's health through universal care.

Who has a stake in universal healthcare? Some groups, such as those lacking insurance, are obviously at risk and have a keen interest. Others, such as insured workers, have a less obvious but demonstrable concern. Arguments that urge adoption of an inclusive system typically focus on "healthcare horror stories" designed to evoke sympathy for the unfortunate persons whose lives are forever changed by unmet health needs or unpaid health bills.^[1] Our focus is different. We ask, regarding universal healthcare, "What's in it for physicians?" While the active support of doctors may not be a sufficient force to change the US system, it is probably a necessary one. At a minimum, universal coverage will be far less likely if physicians are opposed to it. Our aim here is to explore and discuss some of the reasons that should motivate active physician involvement in a more just and equitable system. We will discuss 3 reasons in particular. They are: (1) the need for paying patients; (2) the need to take pride in what one does -- that is, the need to be nurtured by recognition of skillful professional performance in medical work, and not just rewarded monetarily; and (3) the importance of embracing a public purpose for medicine and thus engaging the trust and esteem of the population. We will examine each of these in turn, but first we will discuss briefly the other constituencies for universal coverage, since their reasons for supporting an inclusive system are often shared by doctors.

Readers are encouraged to respond to the author at larry.churchill@vanderbilt.edu or to Paul Blumenthal, MD, Deputy Editor of MedGenMed, for the editor's eyes only or for possible publication via email: pblumen@stanford.edu

The Obvious, and Less Obvious, Public Constituencies for Universal Coverage

Perhaps everyone would agree that the uninsured have a vested interest in expanded access to healthcare. The uninsured are growing by about 1 million per year, and the current estimate is 46 million, or roughly 16% of the population.^[2] Their interest in being covered is powerfully punctuated by the fact that lack of insurance is a predictor of inferior care and shortened life expectancy. Those lacking insurance received only 50%-60% of the services offered to insured patients, both in terms of ambulatory visits and within hospitals.^[3] Among groups of uninsured, children are often the most vulnerable to inadequate care. A recent study by The Commonwealth Fund indicates that lacking health insurance for any period threatens access to care, so that even those currently insured who were uninsured in the past may not fill prescriptions when needed, and may delay doctor visits or otherwise forgo needed medical attention.^[4] In fact, passing in and out of insurance status may be nearly as bad as being uninsured for long stretches of time.

Yet the uninsured are not the only natural constituency for an inclusive system. Over the past decade there has been a growing awareness that those with reasonably good insurance coverage also have a vital stake in a universal system. The reason is that few workers and their families can be confident that their current access to affordable care is not vulnerable to sudden change. Since health insurance in the United States is largely provided as an employee benefit, most of us would risk medical impoverishment if we were to be fired or laid off. Many of those who lose employment can continue their coverage through COBRA or seek to purchase individual insurance policies, although both options entail large increases in premiums. Our friends and family members who have experienced this misfortune have only been able to find high-priced insurance, with low benefits, severe limitations, and extensive preexisting condition clauses, so that their most frequently anticipated and most extensive health needs would still have to be paid out-of-pocket. But being laid off is not the only vulnerability.

Even if one's own health security seems intact, the exclusion of members of one's family can be a vexing problem. One of us (LRC) has children who have passed in and out of coverage over the past 2 decades due to factors such as age, full-time student status, and employment status (ie, whether they could find jobs that provided coverage).^[5] This necessitated the purchase of additional policies with high premiums, hefty co-insurance requirements, and no out-of-hospital benefits to save them from being turned away from the hospital door and to protect the family from financial catastrophe. LKA has parents with chronic medical problems and has seen them struggle with the difficulty of exclusion from the system as well. Her father was left untreated for 2 years while he transitioned to a new job and waited to become eligible for insurance through his new company. Her mother was just starting to undergo a treatment that her insurance company had approved, but the insurance company reversed its decision and excluded coverage after receiving the first bill. There is no law against these arbitrary and pernicious insurance practices. A few years ago a friend (of LRC) called to say that his son, working away from home and without insurance, had been diagnosed with a cancer, but that the surgeon would not schedule the needed surgery without a cashier's check in hand for his fee. It would be comforting to think that these are isolated and unusual events. They are not. Even not-for-profit hospitals routinely use collection agencies, sue patients, and seize people's homes and other assets to collect unpaid medical bills.

But even being retained in the work force by a company that provides health benefits is not a shield against medical impoverishment. Many who in the past considered themselves "well insured" now recognize the inadequacy of their coverage and appropriately consider themselves "underinsured." What this means is that increasing deductibles, co-insurance requirements, and low lifetime maximum benefits could still bankrupt families who experience a major illness, even if they retain their current coverage.

Underinsurance has its roots in issues of cost. Employers are increasingly faced with escalating costs in providing health benefits to workers. While some employers drop health coverage entirely, those who continue to provide insurance are shifting costs to employees in the form of premium increases, or increased deductibles and co-insurance. The New York Times reported recently that the average cost of a family insurance plan rose 8% this year, to $11,500, having doubled since 1999.^[6] Perhaps most surprising, the majority of those who declared bankruptcy for medical reasons were insured at the time they received physician and hospital services. Even people who today enjoy ease of access to high-quality healthcare have little or no assurance that it will continue -- and this obviously includes a considerable number of physicians, their families, and their employees.

To these obvious, and less than obvious but demonstrable, constituencies for universal coverage, physicians should be added, and not simply because of the vulnerability they share with many others. It is to these distinctive reasons for physician support for universal coverage that we now turn, asking, "What's in it for doctors?"

Paying Patients

Even those who entered medicine for altruistic reasons and continue to be sustained by that motivation need to be compensated for their work. So one obvious answer to the question "What's in it for doctors?" is that they will have patients who have an assured way to deal with the bill. Whatever else their motivation, physicians have a powerful self-interest in being paid for the care they provide. Only the very wealthy can afford to routinely see physicians if they are uninsured.

Yet this reason may not be widely recognized or appreciated among physicians themselves. Here American history provides an exemplary tale. In 1965, the Medicare program was created, providing health benefits for all citizens aged 65 and over. The impact on the health of the elderly, and on their social status, was dramatic. Prior to the advent of Medicare, 35% of the elderly lived in poverty; in 2003 that number was at 9%.^[7] Medicare is also credited with desegregating US hospitals, being the largest funder of graduate medical education and creating the field of geriatrics. But for our purposes here, the critical change was creating millions of newly insured patients. In spite of the potential boon to physician incomes, organized medicine strenuously opposed Medicare, a situation in which a misidentified fear of socialism triumphed over common sense and economic self-interest.

The American Medical Association (AMA)'s well-organized campaign of lobbying and advertising against Medicare was dubbed "Operation Coffee Cup." The name bespeaks a strategy of building grass-roots opposition, and one feature of the campaign involved sending physicians' wives anti-Medicare phonograph records and tapes to play for their neighbors. One of the speeches on the records and tapes was given by Ronald Reagan and intoned that Medicare would mean that one day "we will awake to find we have socialism."^[8] The socialism charge was nothing new at the time, and has remained a staple ingredient of opposition to reform, including the defeat of Clinton's Health Security Act in 1994. Medicare was passed in spite of organized medicine's massive campaign of opposition. Yet our main point is less about the erroneous ideological charges that fueled the opposition of the AMA in 1965, and more about the great irony of organized medicine lobbying fiercely against the economic self-interest of its members. In retrospect, it is clear that Medicare has had a profound, beneficial effect on physician incomes, as well as on the health status of the elderly.

It could be objected that some of the government regulations that were feared by the AMA during Medicare's passage have come to pass, such that reimbursements are currently below what many physicians believe is appropriate. There is no question that regulatory changes since 1965, such as the introduction of the Resource Based Relative Value Scale (RBRVS) in 1989 and other adjustments in rates, have diminished the dollar value of Medicare reimbursements. Yet it remains clear that Medicare as a whole has been and remains an important component of medicine's economic well-being.

Imagine if the 46 million currently uninsured were provided with the insurance coverage similar to that provided by Medicare, as advocated by one of the most frequently proposed reforms. The reduction of costs involved in record keeping, filing, and negotiating claims would be substantial and immediate. Perhaps equally important, the vexing issue of finding a sustainable mix of insured-to-uninsured patients would be greatly lessened or eliminated. Because medical practices must now be run as small businesses, physicians are distracted from clinical care by worries about costs and profit margins, either their own or those of the health maintenance organizations (HMOs) for which they work. So long as reimbursements for the newly insured were adequate, physicians could spend more time actually doing what they were trained to do, rather than functioning as business managers or chafing under the control of MBAs.

Professional Pride: Commercialism and the Erosion of Physician Self-Esteem

A second answer to the question of why physicians should support universal coverage is to reduce commercialism in healthcare and the damaging effects of commercial forces on professional self-esteem.

Several years ago, one of us (LRC) was talking to a surgeon who was host for a visiting lecture at his institution. Arriving in the early afternoon for an after-dinner talk, we went to the construction site of his new home and we walked together through the emerging shell of beams and girders. It was to be a grand house, roughly 15,000 square feet, with rooms for every possible activity, multiple garages, and every amenity imaginable for a private residence -- and all for 2 people. Clearly it represented the fulfillment of his and his wife's aspirations. His comment about the opulent new residence, half in apology, was: "It gives me a reason to keep working."

We tell this story not because we begrudge physicians, or anyone for that matter, wealth or fulfillment of their material aspirations. Rather, what was striking was that "conspicuous consumption" had become the rationale for continuing a medical practice beyond the point of engagement for intrinsic rewards.^[9] Such values might not be worrisome in a corporate CEO or an NBA star, but they are in a physician. They signal the usurpation of the altruistic rewards of medicine by monetary gain. We are not concerned with whether this physician and his spouse should have settled for less opulence, but with how professionalism could be maintained when the motivation that impels the scalpel is the price of the procedure.

Commercial forces have always been a force in medicine, but it is only recently that they have come to dominate. While physicians have consistently sought to portray themselves as purveyors of a social service, until recently in the United States they have functioned as small-business owners. For the greater part of the 20th century, American medicine was a cottage industry with a professional service ethos, populated by solo or group practices, run on fee-for-service, indemnity insurance or out-of-pocket patient financing, providing adequate to good returns for most generalists and handsome pecuniary rewards for specialists. Those who received care were largely those who could pay, either through insurance or out-of-pocket, while the uninsured were the sporadic recipients of charity. So the conduct of medical practice as a business and the use of market forces as the chief mechanism for the distribution of medical goods and services are nothing new in the United States.

What is new is the pervasive presence of large corporations as owners and providers of health services, and the loss of physician autonomy in decision-making that goes with that change. While there were some healthcare corporations in the past, they were typically businesses owned by medical groups or nonprofit organizations that were governed by boards of local citizens and were community oriented. While not always altruistic in their aims, these organizations were often responsive to local needs. The new healthcare corporation has a Wall Street orientation and is responsive to markets and mergers. The new corporate providers are also far more skilled than the cottage industry entrepreneurs at advertising and selling their services, cutting costs, and shaping the way their customers think not only about the services they offer but also about the economic arrangements that undergird their profitability. The healthcare insurance industry's derailing of the Clinton healthcare reforms in 1994 is vivid testimony to their power.

The muscle of the new corporate health entrepreneurs can be documented by looking at the portion of healthcare services they now control, but our interest here is less in the size of their market share and more in the subtle but pervasive ways we have all been encouraged to talk and think about healthcare as a marketable product. For example, physicians are now "providers," while patients have become "consumers." The logic of these terminology changes is reinforced by the methods managed care organizations (MCOs) use to assure their members that quality is being maintained or enhanced -- through "consumer satisfaction surveys." The idea that consumer satisfaction is a good measure of quality means that patients now have the role of customers who, to be effective in this exchange, must be knowledgeable and shrewd in comparisons of price and quality. Health services are now "commodities," in which the cardinal defect is the absence of choice. The absence of choice prohibits the chief means of consumer assurances of value, viz., comparison shopping. In brief, commercialism means that going to see a doctor is increasingly portrayed as purchasing a product or claiming a service -- largely prepaid if one is insured -- rather than seeking help from a trusted professional.

Within the logic of the market, the goal of commercializing health services is to capture a market niche, to enlarge it, and to maximize profits. This, too, is reflected in changes in the idioms that describe the activity. Services to patients by physicians are registered in accountants' ledgers as "medical losses," precisely because these services reduce the fraction of income that can be counted as profit. Advertising is undertaken to attract and sustain the loyalty of carefully selected, low-risk groups, known as "revenue bodies," to whom the cheaper premiums are offered. Most physicians currently function under a variety of incentive systems designed to reduce utilization -- and thus costs -- in keeping with the aims of corporate profitability. If efficiency targets are not met, whatever portion of physicians' incomes that are "at risk" is lost. Thus, clinical choices about how much time to spend with a patient, or what services to provide or recommend, have substantial implications for physicians' incomes. Just how direct and severe these implications are depends on the model being used, and they range from those that simply produce a prudent cost-consciousness to those that are morally perverse because they create a conflict of interest for the physician.

The impact of corporate commercialization of medicine on physicians would be hard to overestimate. The literature of the past 15 years has been filled with carping, complaints, and other signs of demoralization. And this is entirely understandable. The experience of many practitioners has changed from patient care to patient and revenue management. Time spent in clinical activities is routinely cut short by conversations with benefit managers to gain approval for recommended diagnostic procedures or therapies, and the burdens of documentation are far greater as the consequences of nonconformity to insurance guidelines increase. The application of industrial, assembly-line management techniques to medical care has done perhaps more than anything else to reduce the self-esteem of physicians. Seeing more patients for shorter periods of time to meet a managerial quota has led, predictably, to less satisfying relationships for both physicians and patients.

Although we are painting a sobering picture, it is not a surprising one. It would be very strange if the logic of commercialism so pervasive in the rest of society had not invaded the medical sensibility. Physicians are subject to the same pressures as all Americans, increasingly measuring in dollars how they rank as good professionals, good family providers, and more generally as successful persons. In American society, these indices of merit and honor are all thought to be related, directly or indirectly, to the monetary resources one can muster. The result is that physicians are systematically encouraged to think about their most basic stewardship as one of protecting investor resources -- rather than, or at best in addition to, their stewardship of patients. But beyond patient vulnerability, management's claim to physician loyalty marks a profound shift in the sources of professional pride and self-esteem. In the past, this sense of worth was more firmly anchored in helping people, in developing and sustaining therapeutic relationships, and in a general altruism of purpose. The industrial-managerial model of care makes these sources of reward secondary and less available.

We are painting a portrait here of professionalism under siege, not to decry the evils of money or markets, but to note with some concern the diminishment of the traditional sources of professional self-esteem -- patient devotion and pride in skillful practice. What is so troubling about the waning of professional pride in the face of commercial forces is the way that physicians are cut off from the sustaining motivations that make the hard work of medical care rewarding, and sometimes just bearable. The cruelty in this waning of professionalism lies in the way money overpowers all other values and thereby uproots physicians from the deep rewards of recognizing themselves as part of a healing process. Money (and the considerable list of things it can buy) becomes the chief standard against which doctors are encouraged to judge themselves and to be judged. But for professionals, the only god worthy of solemn devotion is signified in the etymology of 'profession,' viz., an avowal of service beyond self.^[10] Without this piety technical proficiency may remain intact, and financial rewards may remain plentiful, but professional identity cannot be sustained. As Arthur Okun has remarked, "everybody (but an economist) knows that that money shouldn't buy some things."^[11] Yet to be accurate we need to go beyond the moral realm indicated by "should." One of the things money can't buy is a professional identity; this means that every encroachment of commercialism into medicine makes professionalism more fragile.

Would coverage for all Americans eliminate commercial forces from medical practice? That outcome, however desirable, seems unlikely. But it is reasonable to assume that commercial forces would be substantially reduced. No conceivable system of inclusive care could exist with the pervasive commercialism that now characterizes US healthcare. Commercialism exists at all because there are profits to be made, because there are corporate and individual bottom lines to be protected, because physicians must be financially disciplined against their instincts to provide more patient time and more complete care, and because persons with complex and expensive health problems represent financial liabilities to insurers in a system fragmented by health status and money. Universal care would eliminate most or all of these commercializing forces since it would require a clear and vigorous regulatory framework to be feasible. Commercial insurers in medicine make much of their money by shifting costs to others. In any well-conceived and well-managed universal system, such cost shifting would not be possible. Universal systems do not risk-rate insurance premiums, do not contain preexisting condition clauses, do not permit providers and insurers to enroll only the healthiest and lowest-cost patient groups. And universal systems, eschewing profitability and industrial models of physician work and rewards, together with accountability to the public for quality, lessen the tendency to tie physician compensation to denials of needed care. The availability of medical services in a universal system is a policy issue, not an individual decision made at the bedside by a provider with a conflict of interest.

Whatever else it brings, universal access, even in a system with multiple tiers, is a great equalizing force. Commercialism plays upon, and profits from, disparities in health status and income, and as noted above, makes physicians active players in that collusion against the poor and the sick. It is very likely that any system of universal care, whatever the organization and delivery mechanisms, will promote an environment in which physicians can again take pride in recognizing the skillful execution of their unique abilities in serving, healing, and alleviating suffering. For most doctors, a rise in professional self-esteem will be the result.

Public Purpose

William Sullivan has asserted: "It is hard to see how medicine can resolve its crisis of legitimacy without simultaneously seeking to redefine its identity around a public mission."^[12] We concur with this assessment. Our stress in the previous section was on how commercialism threatens the traditional professional self-definition and erodes the intrinsic rewards of medical work. Our focus in this section -- our third reason why physicians should support universal coverage -- is that it would clearly and forcefully unite physicians with the larger population in a fundamental concern for the nation's health.

Whatever else can be said about the virtues of physicians -- and a great deal can be said about individual physicians' commitments to their patients' well-being -- organized medicine in the United States rarely embraces a larger social purpose for itself as a professional body. For example, one would look in vain for anything resembling a public commitment in most of medicine's ethical codes and principles. An examination of the major ethical obligations of medical professional associations published in 2004 indicated that while there is often a robust and well-defined set of obligations toward individual patients, little is said about medicine's role in promoting the public good. Advocacy for the uninsured, or for vulnerable populations of patients, or even for public health more generally, were mentioned in only 11% of the medical codes examined, and in almost all these cases, it amounted to no more than a mention, not a developed or fully articulated commitment.^[13]

It might be argued that medicine should only be concerned with the way individual doctors relate to individual patients, and not with health policy, financing, and the larger questions of the health of society. But such an argument would be deleterious, both to the profession and to society. Physicians are among those best equipped to speak about matters of public health, and to be absent from policy making and political participation about health matters will only make the valuable expertise and experience of physicians irrelevant. More important, there is a long but largely unrecognized tradition of social activism and public purpose in medicine that serves as a model for an expanded professional identity in early 21st century America.

The idea that medicine takes its identity less from its scientific prowess or its professional sovereignty and more from a commitment to the public good was definitively articulated in the modern period by Jules Guerin.^[14] Guerin was a French physician-journalist who practiced and wrote during the time revolutionary urban changes were sweeping Europe in the mid-19th century. Guerin and other politically active leaders expressed both a hope and an expectation that medicine would be a force for social justice and rapid social improvement. This meant applying medicine's knowledge and skills to address the problems of growing urban industrialization and the many health problems it created: long hours in unsanitary working conditions, child labor, poor worker housing, and the general environmental filth of crowded, ill-managed factory life. The better-known contemporary of Guerin, Rudolph Virchow, put it this way: "Only an intimate knowledge of individual living conditions and the life of the people can transform the laws of medicine. . . into general laws for the human race." He continued: "Certain it is that medicine will suffer no loss of dignity when it mingles with the people, for among the people it will find new strength."^[15] Or, more pointedly, "Doctors are the natural advocates of the poor and social problems are very largely within their jurisdiction."^[16] In sum, Virchow, Guerin, and other activist physicians of their time recognized that medicine has a clear public purpose, and that in embracing it, medicine will find new strength.

This is essentially our argument here. The issue in early 21st century US society that most calls for organized medicine's attention is the suffering and second-class medical treatment of the uninsured. Physicians as a group are intimately acquainted with the problems created by the increasingly fragmented and brutal system in which they practice. They are thereby, paraphrasing Virchow, natural advocates of the uninsured. The insistence of organized medicine for a change in policy to a universal system would be a powerful force, one that political leaders could ignore only at their peril. But more to the point, such advocacy would be a way for medicine to side with patients rather than profiteers and rise above the professional indifference and political passivity that have often characterized its recent past. What is at stake is the health of millions of Americans, but also medicine's soul.