HOW TO GET THINGS WRONG
I thought I understood Atul Gawande. I’ve read his books. They give me hope the medical culture of doctors and particularly of surgeons in the United States had changed. Dr. Gawande writes with clinical clarity, beauty, empathy and frustration about work inside the dysfunctional American health care system. Nothing escapes his surgically trained eyes inside the operating room or out: nosocomial infections, medication errors, aging in America, military casualties. Gawande is obsessed with how to get things right so patients aren’t harmed or killed. He’s the kind of man who has the honesty, the humility and the cajones to apologize to a patient for almost killing him. And then calls the guy a few months later to see how he’s doing.
Gawande’s new book, The Checklist Manifesto: How to Get Things Right, makes the case for cooperation not competition, more democracy in medicine, the centrality of teamwork and the importance of respect and dignity for all health care providers and patients. As a medical social worker on the frontlines of the health care crisis for 15 years, I share Dr. Gawande’s values.
So I don’t understand why in his article in the New Yorker on April 5th titled “WHAT NOW?” Gawande not only supports the Democrat’s health care bill, he defends the most coercive and punitive aspect of the bill: the individual mandate. He isn’t concerned the legislation doesn’t “get things right,” that it doesn’t reform the health care system based on the cooperative, democratic ideas and values he so passionately espouses.
Gawande believes the bill “could prove as momentous as Medicare.” It will not. The core ideology of Medicare is the belief health care is an entitlement, a guaranteed right. It was a government takeover of health care for the elderly supported by the majority of Americans. Single-payer for sixty-five and older.
Gawande’s article outlines the opposition to Medicare by the American Medical Association (AMA) and the entrenched racism in the south during the year it took to enact the program. He explains President Johnson’s role in implementing Medicare but far more important and instructive is the role of grassroots activists, hundreds of thousands of seniors and union members, who fought to win Medicare. In Jill Quadagno’s book, “One Nation Uninsured – Why the U.S. Has No National Health Insurance,” she uncovers this hidden, ordinary people’s history as opposed to “Great Presidents/White Men make history.” The AFL-CIO created the National Council of Senior Citizens (NCSC.) Blue Cartenson, a lead organizer, explained, “We had to make it a cause and we made it a cause… We charged the atmosphere like a campaign… We were a little bitty outfit that was tackling the whole AMA in a little apartment on Capitol Hill….” The movement understood it had to confront the doctor’s lies and attacked their positions relentlessly. They published a pamphlet entitled, “Operation Negative” that sought to “discredit the AMA on the basis of their record.” Busloads of seniors crisscrossed the country advocating for the passage of Medicare at meetings and rallies. Imagine angry and activist seniors rallying for a government takeover of their health care. Once Medicare was established, the formerly and vociferously opposed physicians set about gouging the government. One doctor confessed, “No health care program has ever strained the ethics of the medical profession as Medicare is doing… I’ll admit that I try to take as much Medicare money from Uncle Sam as I possibly can…” Physician avarice led to fraud, abuse and later to implementation of a series of cost control measures doctors complain about to this day.
The civil rights movement set the stage for the integration of hospitals and clinics. Public protests to integrate hospitals and all-white medical societies began after the passage of Brown v. Board of Education in 1954. Activists organized pickets and protests at the headquarters of white medical societies and hospitals. In 1960, four students sat down at a Woolworth’s lunch counter in Greensborough North Carolina and unleashed the struggle to smash Jim Crow and desegregate every institution in society. There were “kneel-ins” in churches, “sleep-ins” in motel lobbies and “watch-ins” in movie theaters.
To be sure, the intervention of the federal government was important, but the highly charged political atmosphere created by the civil rights movement that demanded equality in southern states was crucial to the enactment of Medicare.
In the New Yorker article Gawande posits,“The medical world will wage no civil resistance.” He’s right. The most powerful resistance is being waged by the health insurance industry both privately and publicly. Did it not give Gawande pause when just days after the health care bill passed in March the insurance industry disputed President Obama’s claim that within six months children with pre-existing conditions would be covered? Insurers insisted they had until 2014. Children, sick, disabled and dying children…. And what did Dr. Gawande think in April when insurance companies in the state he practices medicine in, Massachusetts, tried to raise rates up to 34 percent? Insurance regulators said “no” to the insurers for the first time in 33 years! That didn’t stop the greedy bastards though; they filed a lawsuit against the state agency to reverse the decision.
In an interview on Democracy Now!, Dr. Gawande said Massachusetts had near- universal coverage and, “It’s like many European countries now.” Massachusetts has the most expensive premiums in the country, 300,000 are uninsured and there are four levels of coverage: gold, silver, bronze and young adult. Not like Europe at all, actually. I lived, studied and worked in Spain for almost two years – no one is uninsured, everyone receives the same coverage, including the undocumented. The word “uninsured” isn’t in the Spanish medical lexicon.
It’s in insurance company DNA D for denial, N for NASDAQ and A for avoidance of the sick to eliminate or blunt regulation that threatens profit margins. There is an escape hatch for insurers and a trapdoor for patients just below each proffered reform. Facts: no regulation of premiums; age-rating insurers can charge up to three times more for the “near elderly” (a designation I despise); companies can charge as much as 50 percent more for people who engage in “unhealthy behaviors” (the two new words for pre-existing condition); gender-rated premiums in businesses employing over 100 employees.
Starting in 2011, companies will be required to spend 80 to 85 cents out of every premium dollar on health care. Insurers loathe this new regulation and so the gaming has begun to ensure a medical loss ratio favorable to Wall Street investors. Why pay out more for health care if you don’t have to? The trick is to reclassify administrative expenses as medical expenses. WellPoint has already “reclassified” more than half a billion dollars of administrative expenses as medical expenses.
Gawande lets the predatory insurance companies off the hook when he argues the success of health care reform is the responsibility of providers and local communities and declares, “We are the ones to determine whether costs are controlled and health care improves…”
The “historic” legislation Gawande hails just forces millions to buy steerage berths on the Titanic. The ship will sink. It is a mathematical certainty.
Perhaps most disquieting is what Dr. Gawande writes toward the end of WHAT NOW?, “The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn’t pretend to have the answers.” Huh? For over a year the Democratic Party carried out an internecine battle full of rancor, high drama and daily, dire declarations of doom and then threw women, labor and the undocumented overboard to pass a bill that doesn’t have an answer to end the health care crisis? Absolutely unacceptable. Unacceptable when 45,000 human beings die every year because they lack access to health care. Unacceptable when nearly 25 million are underinsured and medical debt is the leading cause of bankruptcy. Unacceptable when racial and ethnic disparities in health care persist.
The enormity of all the unnecessary pain, suffering and death begs the question history books in the future will attempt to answer: Why didn’t we end it sooner? Why didn’t we eliminate the Jim Crow insurance industry instead of giving them more power and profits and enact a government-run, single-payer system based on the notion that health care is a human right and on the values of social solidarity, equality and freedom?
And how is it Atul Gawande the researcher and physician who believes in science, well-controlled studies, statistics, possesses a profound respect for human life and desperately wants to get it right in order to save lives who held a dying patient’s bleeding heart between his fingers and compressed the cardiac muscle until it started beating again supports a bill that in 2019 still leaves 23 million people uninsured and therefore at higher risk of death?
Gawande has got things wrong.