SECTION II

CHAPTER 13  BLACKS ARE ALLOWED TO PARTICIPATE

During the last century and a half the right to receive state-of-the-art care was periodically granted to one group, then another. 

Black men and women were gradually and reluctantly allowed to fully participate. 

After the American Civil War ended the government faced a humanitarian crisis.  Four million former slaves were abruptly told you’re free to leave, but they had no resources and nowhere to go to-– no basic shelter.  Often cramped together in abandoned buildings, they couldn’t maintain basic hygiene, and many got sick.  Privately run institutions for the very poor existed, but there were no hospitals, and the private shelters wouldn’t accept the newly emancipated.  Former slaves died in large numbers.  In some places “their bodies were littering the streets.”  About that time there were 54,000 male and 300 female medical doctors in the U.S. and only a few were people of color.^41,42

Congress established the Freedman’s Bureau in the South.”  It “fed millions of former slaves and poor whites, built hospitals, and provided medical aid.  But its hospitals didn’t have enough beds, linens, quarantine facilities.  There were merely 120 doctors for the entire population.  And there was a smallpox outbreak.  In July of 1872, “responding to the continued hostility of white Southerners, Congress terminated the Freedman’s bureau.”

In the early post Civil war years the government founded a number of black schools and colleges.  In 1868, one of them, Howard University in Washington D.C., “became the first school to have a medical program for blacks.”².

The country’s first black surgeon, James McCune Smith, had to go abroad to get his medical degree.  He grew up in New York and had a white father and a black mother who had once been a slave. Educated in the city’s African Free School, he was denied entrance to an American University and went to college in Glasgow. In 1937 he graduated from a London medical school, returned to the U.S. and became a vocal abolitionist.  He wrote the introduction to the Frederick Douglass book “My bondage and my freedom,” and was practicing medicine in Brooklyn when the Civil War ended.⁴⁰ 

In 1864 Rebecca Lee Crumpler became the country’s first black “doctress” of medicine.  Born a “free” black in Delaware in 1831, she later wrote about her journey in the Book of Medical Discourses.  “Having been reared by a kind aunt in Pennsylvania, whose usefulness with the sick was continually sought, I early conceived a liking for, and sought every opportunity to relieve the sufferings of others.” The book was published in 1883. 

Between 1852 and 1860 Crumpler “served as a nurse under several doctors.  In 1860 she “was admitted to the New England Female Medical College, the first institution in the U.S. to train women in medicine.”  It merged with Boston University in 1873.⁴⁰ Students were “taught by rote–four lectures each day, often clocking in at eight hours total. A systematic course of study with nominal variation from college to college didn’t exist, and there were no “medical licenses” or exiting exams.” ⁴¹

Educated in the days before Pasteur and Koch discovered that bacteria—germs– cause infections, Crumpler explained that infectious diarrhea—she called it cholera infantum– was caused by “poor milk, bad air arising from old water-soaked cellars, or some atmospheric phenomena.”

I grew up in a suburb of St. Louis in a white man’s world and for much of my life had limited exposure to world and the struggles of the black men and women who lived so near yet so far.  My awareness went up a few notches after I entered Washington U medical school.  My 1958 freshman class contained 75 white men, 8 women and the school’s first black student.  His name was James Sweatt and for decades he “had the impression that it was routine for all the professors of the departments in the ­medical school to sit around and quiz applicants for ­admission.  At the 25th class reunion he found out that everyone else who was interviewed for medical school had been seen by one person and that was that.”

Dr. Sweatt grew up in Dallas, a town where, in the 1950s,”Whites Only” signs peppered the landscape.  Blacks were allowed to buy clothes in the town’s department stores, but they weren’t allowed to try them on.”  His mother was an 8^th grade teacher, his father a high school principle and he was educated in white schools and at a university where he was one of each institution’s 2- 3 black students. 

Officially desegregated in 1947, Washington U had only 2 black medical students during the subsequent decade. ³⁹

After Jim graduated from Medical School in 1962 he became a thoracic surgeon and practiced in Dallas. In 1995, he became the first African-American president of the Dallas County Medical Society.  

During the years when I was a student, St. Louis had an all black hospital.  Founded in 1937 after a political struggle, Homer G Phillips had 600 patient beds and was the primary source of health care for the area’s indigent blacks, and a major training center for young black doctors. It was also affiliated with the medical school.  White guys like me spent three of our med school weeks at the facility learning how to deliver babies.  During my time there the color of my skin was obvious but insignificant.  I was treated as just another no-nothing med student.

At the time black physicians, by and large, couldn’t get privileges to practice at hospitals dominated by whites.  Ninety six percent of the patient’s in New York’s for-profit hospitals were white and 97% of the people in the city’s private and semi-private not-for-profit hospitals were caucasian.²⁶” Throughout the American South and in many of the border states black physicians were denied membership in the local medical association, and non members could not get hospital admitting privileges.³⁷

As late as 1968, the AMA (American Medical Association) condemned racial discrimination, but allowed its member medical societies to refuse admission to black doctors.  Physicians who were not members of the AMA could not get admitting privileges to most U.S. hospitals.

Seemingly politically influential, the AMA is a national conglomeration of physician groups, and it has often been on the wrong side of history.  It opposed national health insurance and currently disapproves of the single payer option.  For years their journal, the JAMA ran cigarette advertisements that touted the health benefits of filtered cigarettes.  They didn’t consider smoking a health risk until 1963, the year before the U.S. surgeon general– on the basis of more than 7,000 medical articles that were available and that doctors should have read–“ concluded”:  Cigarettes cause lung cancer, laryngeal cancer, and chronic bronchitis³⁰. . 

Many primary care doctors had separate waiting rooms.  Black patients were seen after the white patients were seen. Some of the ill went to county hospitals—where they often sat for hours on wooden benches waiting to be called.  In white hospitals they were often bedded in the basement wards. 

Chapter 13  Medicare and Medicaid

It’s difficult to get a man to understand something when his salary depends on his not understanding it.  –Upton Sinclair. 

In 1940, after conquering most of Western Europe, Hitler mercilessly bombed British cities and tried to bring England to its knees.  18,000 tons of explosives over 8 months killed close to 40,000 people.¹⁶ 3 ½ million people were moved to the countryside and the Ministry of Health “built or expanded hundreds of hospitals”, updated laboratories, X-ray facilities.  The country began paying for ambulances and the care of civilians and combatants who suffered fractures, burns, and head injuries. The ill and injured were transferred to private suburban hospitals and “doctors received government salaries.” Unexpectedly amidst the death and destruction most Brits got healthier, and when the war ended the people didn’t want government care to end.  In 1948 parliament formally passed the National Health Service act and health care became a taxpayer funded right. ⁴

Postwar France was devastated.  “Seventy-five per cent of the population paid cash for private medical care.  Many people had become too destitute to afford heat, let alone medications or hospital visits.”  However, pre war, some manufacturers and unions had instituted a self imposed payroll tax. They now used the money for medical care.  As an outgrowth, the French government currently oversees an integrated network of hospitals and service providers that deliver health care with a small co-pay to all citizens.

In the U.S. president Franklin Roosevelt didn’t mention health care or use the word “rights” in his famous 1941 speech to congress.  The four freedoms he championed were speech and expression, “the freedom to worship God in a person’s own way, freedom from want and freedom from fear.” He had wanted federally sponsored health insurance to be part of the 1935 Social Security act, but “he allowed it to be thrown out in order to hurry the bill through Congress.²” 

Before health insurance was more than a concept, the military and VA were caring for the wounded. During the Second World War employers attracted workers by offering health insurance.  At the time the wages industry could offer were restricted as part of the 1942 Emergency Stabilization Act.  Our nation’s work related system created inequities and it helped foster the rugged individualistic belief that people don’t deserve health care.  They have to earn it.   

In 1947 health care costs were rising and it was too expensive for many. That January in his State of the Union address, President Truman said: “Of all our basic resources none is more valuable than the health of our people.” He proposed a plan that provided medical care to all who need it.  “A government funded health care program that everyone pays into and from which they can withdraw when they need it.  Not a charity, but (care) on the basis of payments made by the beneficiaries of the program.” 

Truman’s idea initially had widespread support. Then the powerful white male American Medical Association (AMA) launched a massive campaign:  Radio and newspaper ads. Pamphlets and mailers.  “Keep politics out of medicine.”  Truman was a Communist. (At the time Communism was a real scare.)  “His plan was socialized medicine.  Government officials will intervene in medical decisions and destroy the “sacred doctor patient relationship.”

Popular support plummeted and the bill failed to get through congress.⁶” Efforts by subsequent politicians to provide government sponsored health insurance was repeatedly opposed by the “influential” American Medical Association.

In the post war years Blue Cross and Blue Shield were started in one state, then another as public, tax-exempt corporations. By 1945 the “blues” were responsible for 2/3 of the nations’ hospital insurance, and by 1955, 60 percent of Americans had an insurance policy.¹

Aetna and Cigna began marketing medical policies in 1951.  They tended to target people who were healthy and unlikely to need expensive care. The IRS did not treat employer provided health care as part of a person’s taxable income and the Revenue Act of 1954 made it official.⁶

In 1960 John Kennedy, the son of a wealthy Irish immigrant became the nation’s youngest ever president. In 1959, the year before Kennedy was elected, Cuban revolutionaries ousted their ruler, a dictator named Batista, and Fidel Castro became the country’s leader. He was a communist and “Under communism, virtually everything belongs to the state.”  Large single owner farms were taken over by the government and “either redistributed to peasants or run as communes.” The U.S. and Russia were in the midst of a “cold war”, and the thought of a Soviet ally a mere 110 miles south of Florida troubled some of the nation’s leaders. In 1961 a group of Cubans, sponsored by the CIA invaded the island.  The U.S military didn’t get involved and the intruders were quickly defeated and captured.  After that the popularity of the U.S. president waned.⁹

At the time Kennedy was trying to change the system that prevented blacks in the South from voting.  His efforts went nowhere.  Nor was he able to convince Congress to pass legislation that provided medical care to our older citizens.

Then in the fall of 1963 Kennedy was assassinated.  The nation mourned, and Lyndon Johnson, former leader of the senate, became the nation’s president.  Under his direction Congress paid tribute to their slain leader. 

Congress passed and President Johnson signed a law that established a new “right” –and created two new programs:  Medicare and Medicaid.  The entities were funded by a payroll tax; an additional 2.9% of a person’s earnings were taken from each paycheck. 

• Medicare– paid for the hospital care and some home services for citizens over 65. 
• Medicaid covered the care of citizens who were “poor enough”–whose “resources were insufficient to pay for health care.²⁹”
• Medicaid also covers nursing home costs for people who meet the eligibility requirements.
• 50 to 75% of Medicaid’s costs were paid by the feds and each state paid the rest.   States with higher per capita income paid more.
• Every state got to limit the amount a family could earn before they no longer qualified.  Criteria for inclusion in the “program” have changed over time, so there are variations in Medicaid coverage across the country.¹
• Additionally—Medicare later established a hospice benefit.  Dying people now had help and many could and preferred to manage their pain and problems in their own homes. 
• As part of The Emergency Medical Treatment and Labor law, hospitals had to provide pregnant women “appropriate medical screenings and stabilizing treatments.
• Medicaid coverage for pregnant women and infants (up to 1 year of age) was established as a state option for people who earned up to 100% of the Federal Poverty Level (FPL).
• “In 1964, a year before it enacted Medicare, Congress passed the Civil Rights Act.  One of its provisions, Title VI, prohibited discrimination on the bases of race, color, or national origin in programs that received federal funding. 

The following year when Medicare was being debated there was no mention of Title VI.  It didn’t come up and nobody wanted to raise it. “The assumption was that some accommodation would be made that would allow segregation to continue on a separate but equal basis.” The nation’s response to the 1954 Brown v. Board of Education Supreme Court decision had shown that when it comes to race, changes don’t  happen very much or very fast.   The ruling ordered states to put a stop to segregation in schools with “all deliberate speed.”  But “The vagueness about how to enforce the ruling gave segregationists an opportunity to organize resistance.”

In 1956, two years after the Supreme Court decision, the University of Alabama enrolled the first black student, Autherine Lucy. Then “riots engulfed the campus and she was expelled for “her own safety”.  In 1962 demonstrations greeted James Meredith, the first black student to attend the University of Mississippi. (A veteran of 9 years in the U.S. Air Force and a man who felt it was important to make a statement, he was ready.)  My medical school, Washington U. in St. Louis, didn’t graduate its first black physician until 1962.  Berkeley California became the first sizable city that had a “substantial portion of black students” to voluntarily begin two way bussing.   Some white children were transported to schools in black neighborhoods and some black students were bused to schools that were largely white. Their program didn’t start until 12 years after the Supreme Court ruling. 

          “The Medicare law might carry the threat that federal funding could be withheld from any hospital that practiced racial discrimination.  That’s what Title VI of the Civil Rights Act “required.”   But the Office of Equal Health Opportunity was in charge of federal funding based on the presence or absence of discrimination, and it only had five employees. Swift action seemed unlikely.  “Hospitals might have to come up with a plan, but they could presumably proceed gradually and cautiously.  Ultimately racial changes wouldn’t get done; hospitals would operate on a business as usual basis.”

Then HEW (Health Education and Welfare) Secretary John Gardner, put out a quiet call for volunteers. More than 1,000 people from federal agencies offered to help, along with tens of thousands of Civil Rights organizers. Field inspectors fanned out to hospitals to make sure they were in compliance with the law and eligible for federal funds. As David Barton Smith explained in his book, “They wouldn’t let anybody off the hook,” “The reason they were so successful is that they had this secret army of local civil rights workers and local health workers making sure [the hospitals] complied. Hospitals quickly figured out that they couldn’t fake it.”²

CHAPTER 15—government grants right to renal failure

On Oct 30, 1972 The U.S. government chose a very expensive pre-existing condition (advanced renal –kidney failure) and made its care a “right.”  

Kidney failure wasn’t part of the bill the Senate debated during a rare Saturday morning session on September 30, 1972.  Nor was it part of the legislation passed earlier by the House of Representatives.  The amendment that added dialysis to the Medicare bill was introduced late that Saturday morning.  There was 30 minutes of debate before it was accepted by a 52 to 3 vote.  Weeks later a House, Senate Committee discussed the kidney amendment for 10 minutes, and left it in the bill.  Nixon, who was a pro health care president, signed the legislation with a flourish a week before he was re elected. 

Bodies have two kidneys.  They are located near the back of the upper abdomen on both sides of the spine.  They strain the blood and produce urine, fluid that is unneeded and unwanted.  The urine, in turn, is “flavored” by a number of soluble additives: debris, break down wastes, and proteins that in high concentrations are toxic.  After the blood is filtered the processed liquid is returned to the body.  A number of conditions and diseases can cause the kidneys to malfunction or fail.  

When I started medical school people with chronic renal failure died.  “In 1960, a group led by Dr. Belding Scribner, a man who called himself Scrib, used a Teflon catheter to connect the artery and vein on the under-surface of a person’s forearm.  The shunt allowed doctors to repeatedly draw blood from a body, cleanse it, and return it.  Located on the skin surface, and subject to infection, and displacement, the device needed a lot of care.  But it allowed physicians to start and keep people on intermittent hemodialysis.” The vision of the man who created the pivotal gadget had been threatened then preserved as a result of transplants of his cornea, the outer lens of his eye. Over time the transplants “became very scarred,” but he didn’t need to drive to work. He lived on a houseboat on a lake near the Seattle hospital where he practiced, and he rowed a canoe to work each day.³⁸

In 1963 “the Veterans Administration (VA) decided to “establish approximately 30 dialysis treatment units in VA hospitals across the country.”  In 1964 learning that “immunosuppressive drugs prevented the rejection of transplanted kidneys, the NIH established a program in transplant immunology.”

Over the subsequent 8 years “Programs sprang up across the country,” By 1972 10,000 Americans with renal failure were being dialyzed.  Funding was a problem and some people were left out.³

Once Medicare was paying the bill dialysis became a big business and a significant part of the program’s budget.  4000+ free-standing centers were established in hundreds of cities by corporations, not hospitals. Their number in the U.S. has increased 4% a year.  More than half are owned by Denver-based DaVita, a Fortune 500 company.  The other big player, Fresenius is a subsidiary of a German company that operates centers in 28 countries and also sells the machines and other supplies.    

Dialysis accounts for 6% of Medicare money.  In the first quarter of 2008 DaVita’s revenues were $1.45 billion, up more than 8% from the first quarter of 2008. Fresenius’ revenues from dialysis in North America were $1.57 billion.

The external shunt is no longer used.  Before hemodialysis is initiated an artery and a vein are sewed together to create a large blood vessel under the skin.  Then three times a week patients with end stage renal disease come to a center and sit in a lounge chair for a few hours.  A needle is inserted into the artery-vein, and blood is drawn into a machine.  It flows past the “cleansing” membrane.  The toxin level in the blood is lowered, the excess fluid is removed, and the blood is returned to the body via the same shunt.     

Some people opt for peritoneal dialysis, using the lining wall of the abdomen, the peritoneum, as the filter.  Initially a physician places a permanent catheter deep in the cavity.  Then, usually nightly in the person’s home, a patient pours a sterile solution (dialysate) into the peritoneal cavity. The membrane’s pores allow waste products like urea and creatinine to seep into the fluid. The liquid is left alone for a few hours, then it is drained.  Some studies suggest that people who use this approach do better the first year, and they are more independent. A year of hemodialysis can cost up to $88,000, while a year of peritoneal dialysis costs about $53,000, according to information from the U.S. Renal Data System.

People with very diseased kidneys are usually anemic. To stimulate the production of red cells people on dialysis are also commonly given injections of erythropoietin, a costly hormone, normally produced by healthy kidneys.

A fourth of the people who were being dialyzed died annually, and 80% who started live for less than 5 years.  That’s largely because more people starting dialysis were over 50.  The mortality rate in the older and sicker people was higher than it was in younger patients or individuals who had hereditary polycystic kidneys.  In 1972 high blood pressure was the leading cause of end stage renal disease. Today obesity and diabetes are keeping the dialysis machines whirring.  The annual death rate of Americans on dialysis (20.1 % in the U.S. in 2006) is higher than it is in France, 8%, or Japan, 7%.  Americans who started dialysis after they were confined to a nursing home did poorly. The first year 58% died and 29% were less functional.⁶   Nearly 20 percent of dialysis patients stop dialysis prior to death.⁹

That’s what happened to the famous humorist Art Buchwald.  In his later years he had diabetes and high blood pressure; when he was 74 he had a significant stroke.  6 years later a leg was amputated.  I don’t know when or if he started dialyzing his blood, but in 2006, when he was 80 he decided to stop and apparently described his decision as his last hurrah.  Contemplating death he wrote “the question isn’t where you are going, it’s what you are doing here in the first place.” Known in the hospice as the man who wouldn’t die, he once quipped:  “to land a big obituary in the New York Times you have to “make sure no head of state or Nobel Prize winner dies on the same day” and “Whether it’s the best of times or the worst of time it’s the only time we’ve got.  The best things in life aren’t things.” A year after he stopped dialysis his heart stopped beating. The cause of death was kidney failure.

Medicare also pays for kidney transplantation.  The procedure wasn’t very good until we had adequate immunosuppressive drugs, but by 1974 over 3000 kidneys were being transplanted annually in the U.S. The number tripled by 1986 and in 2016 reached 13,431.  5600 of the kidneys came from live donors. 

We were visiting an acquaintance who was in the hospital recovering from a transplant.  “So” she said, “things kept going wrong with my shunt and my dialysis and it seemed like I was always in the hospital on the phone complaining.  One day I was in the midst of a tirade and the friend I was talking to stopped me cold.  “Ok, ok” she said.  I’ll give you a kidney, and here I am.

Nine of ten transplanted kidneys were alive and working a year after they were implanted, and half lasted at least 10 years.   93,000 people in our country are currently on waiting lists.  The wait is longer, and the people are sicker in New York and California than they are in many other parts of the country. For transplant reasons, the nation was divided into 11 geographic regions; some cover large areas.  Committees establish recipient transplant criteria—how sick, how old, body mass index, drug addiction, alcoholism, HIV.  And “federal mandate prohibits the allocation of solid organs for transplantation based on “accidents of geography.”

The feds pay for most of the charges associated with a kidney transplantation and pay for the drugs that prevent the body from rejecting a kidney for the first three years post transplant.  After 36 months patients are expected to pay for their own medications. 

Liver, lung, and heart transplantation is also a “right” for those who “already have Medicare due to age or disability.”²⁸

41 years after the Medicare dialysis benefit was initiated the NIH reported that 63.7 percent of people with advanced renal disease were receiving hemodialysis, 6.8 percent were being treated with peritoneal dialysis, and 29.2 percent had a functioning kidney transplant.⁷

6000 undocumented Americans have end stage renal disease.  A few came to this country when they were young and never lived anywhere else.  They went to school, paid taxes, and worked until they got sick.  Unfortunately decades back, sometimes when they were children, they crossed the border illegally.

For context there are 11 million undocumented people in this country of which one in 1833 needs dialysis.  More than 400,000 documented Americans are dialyzed on a regular basis.

Federal funds can’t be used to dialyze undocumented individuals.  California and Massachusetts pay for the procedure with county taxes or state-allocated Medicaid funds.  Texas and most other states only detoxify the blood of people whose serum potassium is so high or whose build up of toxins is so extreme that death is imminent.  People have to wait until dialysis has literally become a matter of life and death. 

180 of the 6000 undocumented people with end stage kidney disease live semi-near the Texas Baylor Emergency room.  Each day many come to the E.R. and wait.  Their blood is drawn; EKG’s are obtained, and they are assessed.  The hospital has 12 dialysis chairs, and the people who occupy hospital beds are dialyzed first.  Then the sickest of the undocumented are served.⁸

In 1997 congress granted the “right” to health and preventative care to kids from very poor families who didn’t qualify for Medicaid. The program goes by the initials CHIP, is individually run by each state, and is funded by the Medicaid – state/federal formula.   It took years before most of the kids who are eligible signed up.  But the program was popular, and granted coverage in 2009. 

The program was partially paid for by raising the federal cigarette tax from 24-cents-a-pack to 67 cents.  That rangled some Republicans whose election campaigns were aided by the cigarette industry.  Their policy committee argued “the lost cigarette revenue would cost too much.  States and localities would lose $6.5 billion over five years.”  Orin Hatch, a Republican who supported the program found their argument “absolutely preposterous.  Does that mean that 419,000 Americans must die every year in order to preserve the state tobacco revenues? That’s like saying we should withhold life-saving treatment from senior citizens in order to save Medicare money.”³⁶

In 1976 the U.S. Supreme Court created a right for medical care to people who are incarcerated.  Eight of nine justices “acknowledged that the eight and fourteenth amendments required the Texas government to provide medical care for prisoners.¹⁰” The eighth amendment of the U.S. Constitution prohibits governments from imposing cruel and unusual punishments. When the Supreme Court rules that a practice is unconstitutional in one state it’s automatically unconstitutional in all states.

          To be meaningful, of course, rights need to lead to action. Each state deals with its inmates a little differently.  California, for example, has more than 150,000 prisoners.  In 2006, in response to a law suit, a federal judge learned that prison conditions were “disgraceful”, declared the health care the institutions provided was unconstitutional,”  and put the California State facilities into receivership.¹¹ 

San Quentin Prison sits on San Francisco Bay and houses over 5000 inmates.  Many have mental health problems. In 2009, as a result of a judge’s order, the facility opened a $136 million, 5 story hospital, and it was employing 10 full time psychiatrists.  Pay, according to one internet ad, started at $19,000 a month plus benefits.  According to Eric Monthei the chief psychologist, clinicians try to give care similar to that of their colleagues in the community. But they must deal with the prison environment, something we can’t begin to understand on a gut level.  The population contains a disproportionate number of people with personality disorders, depression, and substance abuse issues.  Psychiatrists see people for medication management if they have serious symptoms or if they wish to be seen.   If there is a psychiatric emergency, if someone who is incarcerated becomes suicidal or homicidal, there is a 7 bed psychiatric ward.  In the private world psychiatrists are responsible for hospitalized people and drugs.  In prison a psychologist works in the hospital. Some of the prisoners are “Axis one”.  They have major mental health disorders like Schizophrenia, bipolar or schizo- affective disease.  Some committed crimes under the influence of methamphetamine, alcohol or other drugs.  There are non violent offenders who have committed their third felony and are thus in prison for life because of the California three strike law.¹²

According to the psychiatrist I interviewed, when prisoners arrive they are screened by a psychologist and interviewed by a social worker.  They are assigned a case worker who is responsible for their medical care (with the exception of medication.)   Some people are already on drugs, so called “bus meds”, pharmaceuticals like the anti depressant Prozac.  They need to see a Psychiatrist for refills.  Prisoners who are “triple CMS”, those taking psychiatric drugs who have medical problems, are placed in single cells.            

When the MD psychiatrist arrived in the morning he or she was given a “docket”, a list of people he/she had to see that day.  There could be as few as 4 to 5 and as many as 14; visits commonly ran 30 to 45 minutes.  Inmates who were not administratively segregated or in protective custody came as a group and waited in a holding area. Others arrived one by one heavily guarded and shackled.  The “non dangerous” people were seen in an office.  The “dangerous” prisoners were seen while they sit in corrugated metal “cages.”  The interface between physician and inmate was like a heavy metal chain link fence.  There was a spit mask and the prisoners were tied.  The psychiatrist carried a fire arm and a whistle.  When the doctor spoke to the patient, the guard was usually outside the door, just out of ear shot.

The psychiatrist I interviewed worked at San Quentin, California’s oldest.  Located on 400 acres of prime real estate, it borders San Francisco Bay, and is largely sheltered from the fog and ocean breezes that batter some of the areas multimillion dollar houses. The home of some of the nation’s more significant criminals, it has a death row that houses 737 individuals. In the U.S., a nation of 76 million people, 2.3 million people were confined in March 2020; 450,000 people were locked  up for a non violent drug offense each day. Most of the crimes that lead to jail or prison time are non violent.   Many who are jailed will soon make bail or can’t afford it and plan to stand trial.

The nation has 1,833 state prisons, 110 federal prisons, 1,772 juvenile correctional facilities, 3,134 local jails, 218 immigration detention facilities, 80 Indian Country jails, and many more.  9% of the prisons are run by private for profit organizations.³⁴

In the spring of 2020, there was an outbreak of coronavirus at the state prison in Chino California and 121 untested inmates were transferred to San Quentin.  Within a month San Quentin was dealing with a major coronavirus outbreak.

“Incarcerated persons have high rates of communicable and chronic diseases, and though health care is a “right”, “the type and quality of the care depends to some extent on variations in policies, budgets, and staffing across federal, state, and local jurisdictions.”³²

Chapter 17 FEDERAL EMPLOYES ; NATIVE AMERICANS

Affordable quality health care became a “right” for federal employees in 1960 when “The government began to contribute 72% to 75% of the cost of the health care insurance premiums.” That brought the price of the policies way down. “At least 10 fee-for-service plans” compete in a special marketplace congress created.  Applicants don’t have to worry about their age or any pre existing conditions. More than 8 million people who work or have worked for the federal government—and their spouses, dependents, and retirees—and legislators and their families– were allowed to buy the insurance. About 90 percent of the employees of the federal government participate.  The FEHB, federal employees’ health benefit program, is administered by an agency of the government whose director is appointed by the president. The privilege/right is technically called a managed care scheme.   (when a righ is granted and funded by the government it exists.¹⁷) 

As part of the Affordable Care Act, members of congress and their staff members lost the ability to purchase insurance through the FEHB. To maintain their “right” to affordable, quality medical care they established a new way to buy highly subsidized care.  They are using the DC health care exchange, and the government still kicks in 72% of the cost of the premium—for those who chose a gold plan.  When and if one of them retires with five years of government service under their belt they can again be insured through the FEHB.¹⁹

          In 1993 children whose insurance didn’t cover the cost of 16 important vaccines were given the right to receive them free.  Congress created the Vaccines for Children Program, the CDC (center for disease control) managed it, and 40,000 doctors throughout the country administer the vaccines.

In 1811 federal legislators established and funded a home and medical clinic for military veterans. Fifty years later, after half a million fighting men died of wounds and illness in our destructive civil war (1860-64),the government created a number of veterans homes – that “incidentally” provided medical and hospital treatment.

50 years thereafter our nation entered the First World War (1917-18).  116,000 men lost their lives.  Many more were wounded and disabled–and a number of facilities were built.  After they were officially launched in 1921, the Veterans Administration started building hospitals. By 1948 there were 125, and the VA currently says they operate 1600 health care facilities.⁵ They once cared for all service men and women who had been on active duty, even briefly. 

After September 1980 the government began limiting the pool by requiring a “minimum length of service.”

Indian Health, while being a right, is also a small underfunded and significant part of the care supplied by the federal government.  In the centuries that followed Columbus first voyage, 95% of the continent’s indigenous people died.  The Europeans brought infectious illnesses with them that were unknown and had never been confronted by the immune systems of the people of the continent.³³ “Smallpox undoubtedly played a huge part in the fall of the Aztec Empire.” Early settlers alternatively courted and hunted the people of the land.  Some of our elders tried to integrate natives into our society.  Others gave them terrain which was “eternally theirs”, and still others reneged on one promise or another.   In 1830 President Andrew Jackson signed the law that officially required tribes living east of the Mississippi River to relocate on lands west of the waterway.  They moved only to later discover that many Americans believed the United States was “destined to expand across the North American continent, from the Atlantic seaboard to the Pacific Ocean.”   Over the centuries some natives came to our cities and many blended in.  (There are clinics for Native Americans in Oakland California and many other large towns.)  For others there were reservations, (areas of self government that are “managed” by the U.S. Bureau of Indian Affairs). 

The war department got involved in the health of the Native populations in the 1800s after they decided to vaccinate the indigenous people against Small pox to protect soldiers in remote forts.   In the 1880s the Department of the Interior constructed infirmaries and hospitals.   

The government’s involvement in any kind of health care was pretty limited until Congress passed the massive Public Health Service Act of 1944 and established the NIH (National Institute of Health) the CDC (Center for Disease Control), and the now defunct Public Health Service hospitals.  The Indian Health Service was created and added to the mix in 1955.  Serving half of the known Native Americans of the day, the VA like system covers the people who lived on the remote rural reservations, and they run urban clinics that do what they can for the indigent Native Americans in our cities.  Half the identified Indians try to maintain their distinctiveness.  The service is “culturally sensitive.”  Local beliefs and traditional practices are blended with the modern medical model.  The emphasis is on public health and community outreach activities.  In her book The Scalpel and the Silver Bear, Lori Alvord M.D. a Stanford educated, half Navajo, physician who practiced medicine at an Indian Hospital recalled how the chant of a medicine man gave emotional strength to a male with advanced cancer.  She had removed his tumor and he was receiving chemotherapy, but he was despondent and had lost hope before the “singer” arrived and performed a ceremony known as a Chantaway.  As she explained, different songs and ceremonies help different illnesses:  If an accident caused the disability, the Lifeaway ceremony was performed.  The Shooting way was chanted if an arrow or lightning was the source of the problem.²⁰  

The federal government spends $3.5 billion a year for a service that delivers health care to 1.9 million of the nation’s 3.3 million American and Alaska Natives.  The “system” is large and spread out.  By their count there are 31 hospitals, 63 health centers, and 30 health stations plus 34 urban Indian health projects.  They are staffed by 2,400 nurses, 800 physicians, 400 engineers, 500 pharmacists, 300 dentists, and 300 sanitarians. The patient pays nothing, not even a co pay, for testing, drugs, or hospitalization. Part of the funding for the Indian health service comes from other government programs.  If a patient was covered by Medicare, Medicaid, or had insurance through their work, the insurer could be billed, and the money could be used to help cover the costs of care. 

The facilities are up to snuff.   All 31 IHS-operated and all 14 of the tribally operated hospitals have been inspected and accredited.  

Despite this the Indian life expectancy (72.3 years) is still about 4.6 years less than that for the U.S. general population (76.9 years). Death rates for some conditions are significantly higher.  Tuberculosis is 750% more common, and there are elevated rates of alcoholism (550% higher), diabetes (190% higher), unintentional injuries (150% higher), homicide (100% higher), and suicide (70% higher).

Juliet told Romeo that a rose by any other name would smell as sweet.  In this country most have the right to affordable health care.  Many are left out.  We don’t call a spade a spade.  And many have lost their ability to smell.

Over the last 80 years one group of Americans then another has acquired the right or expectation that they will receive the health care they want or need.  At times their access is funded by the government through taxes.  On other occasions employees receive benefits in place of a good wage or the care is provided by employers who get tax breaks.  At the same time many people living in our country are excluded.

When asked if they thought health care was a right, people interviewed in Athens Ohio pointed to neighbors who were unwilling to work yet qualified for “Medicaid”, the taxpayer funded program for the very poor.  One of the people interviewed thought “People should contribute to the cost”.  Health care shouldn’t be free unless you’re really hard up.  At the same time, as one citizen explained, “You shouldn’t have to worry about medical care anymore than you worry about “the fire department, or the police…or the roads we travel on.”⁴³

CHAPTER 18  EMERGENCY CARE

In 1986 by passing the Emergency Medical treatment and Active Labor Act, (EMTALA) congress created an important right for everyone. 

• That includes –the insured and uninsured.
• Citizens, foreigners, and “illegals”. 
• Anyone who suffers an acute illness or injury;
• people who show up in the emergency room and
• those who call an ambulance.

They all have to be treated. Hospitals that take Medicare funds, in other word almost every hospital in the country, is required to provide emergency and necessary hospital care for: serious illnesses, injuries-for women in labor—the ill and injured.  The care must continue until they are “stable.¹³”   

Before the law was passed some hospitals wouldn’t care for you if you couldn’t pay.  Sick unstable uninsured people were “dumped”.  People were “transferred for financial reasons, from private to public hospitals without consideration of their medical condition or stability.” Some of them died.

After Congress passed the law one of the government agencies, the HCFA, (Health Care Finance Administration) held hearings and created a number of rules and regulations.  Their guidelines “have the force of law” and they apply to all of the 98% of U.S hospitals who participate in Medicare.  Hospitals are required to medically screen any person who comes to the hospital emergency room and asks to be checked out.  If the person has an “emergency” problem the hospital must stabilize the situation if they can. For example:  a person with a ruptured appendix must be treated medically and/or surgically before he or she is discharged. 

• A person with an acute myocardial infarction (if medically appropriate) must be catheterized, stented, and observed before he or she is released. 
• If the hospital doesn’t have the expertise or equipment to care for a person, they must transfer the patient to an appropriate hospital. 
• They are in violation of the law if they delay services “in order to inquire about the individual’s method of payment or insurance status”  
• The sick person doesn’t have to be in the emergency room.  They can be in almost “any area of the hospital “campus” including structures and all areas that are not strictly contiguous with the main building but are located within 250 yards of it –or of hospital owned and operated ambulances.

Doctors who are on call are also, often, on the hook.  In some states they must show up within 30 minutes of being notified.  There are rules, and physicians face fines if they violate them.  We’re talking up to $50,000, money that is not covered by malpractice insurance.  Transfers are possible with a patient’s consent, if they are “stable.¹⁴ “

          A friend awoke one night with chest pain.  He was sweating and dizzy, and his daughter called 911.  The ambulance arrived quickly.  The paramedic determined he was having an acute myocardial infarction.  He was rushed to the county hospital where a skilled cardiologist was ready to act.  Within minutes a tube was inserted into an artery in his leg and threaded up the aorta.  When it reached the heart it entered a coronary artery.  Injected dye revealed an important artery was obstructed.  The tube was removed and was replaced by a catheter and stent.  A balloon on the catheter opened the artery and the stent kept it open.  Blood flowed to the oxygen starved portion of the heart muscle, and it looked like the heart had escaped serious injury.  My friend lived from paycheck to paycheck, didn’t own a home, and had allowed his insurance to lapse.  He was observed for a day, went home, and was sent a bill. .

The Emergency Care Law (EMTALA) gave people having an acute medical problem the right to receive one of the benefits of modern life— but it was not funded.  The care is not free.

U.S. hospitals and doctors accept the amount paid by Medicare and Medicaid as payment in full. (That’s the law.) There’s a website that tells how much insurance companies really pay.  Called Healthcare Bluebook, it allows people to punch in their disease and zip code.  The program provides a dollar amount.  If the website is correct the bill my friend with a heart attack received was outrageous.

The “fair price” for a coronary angioplasty and three days in a hospital in his zip code (per the Bluebook) was $24, 853.  (That covers the cost of the catheterization room, the equipment, and the hospital bed.)

The “fair” physician remuneration for stenting a single vessel was $1105.   (Add 25% for additional arteries.) The “fair” anesthesiologist fee for close to three hours of work was $1325.¹⁸ 

My friend’s bill for his heart stent and two days in the hospital was in excess of $100,000. 

What will it cost if you’re appendix bursts or you have a severe asthma attack when you’re in Paris?  Not much.  Health Care is good in France; an emergency room visit costs about $120, and a doctor’s visit goes for less than $30. 

When someone is in the U.S. doesn’t have insurance and has an emergency, they get a bill.  When the hospital or physician that provided the care didn’t have a contract with the person’s insurance company, and the policy only covers in-network emergencies the bills for the service can be enormous. 

In San Francisco, as the local newspaper, the Chronicle put it, injured parties “can (now) rest easy,’ “If you’re hit by a car, shot, fall off a roof or suffer any other major injury, you can now receive top-notch medical care at the city’s only trauma center without risking bankruptcy.”³⁵

In early 2019, San Francisco General Hospital, the city’s trauma center, was under pressure for its unfair billing system.  The hospital had no contracts with insurance companies.  All the care it provided was out-of-network.  As a result the city could bill as much as their self-determined rates allowed.  Health Insurance companies would then kick in as little as their self-determined policies permit.  The difference, thousands of charged and unpaid dollars, became the burden of the ill and injured people who showed up in the facility’s emergency room. 

“Three simple appendectomies left stunned patients on the hook for bills ranging from “$54,000 to $92,000”.  Well meaning doctors, nurses, clerks, and ambulance drivers were treating people’s physical maladies and destroying their economic well being.  The city owned the hospital, and taxes paid for some of the care.  Then, in place of being fiscally “prudent”, the hospital did something that, best I can tell, was unprecedented.  They adopted a humane approach.  They stopped billing poor people.  And they charged a maximum of $4800 to people who earned $121,000 (single person) or $250,000 (family). The affect on the hospital’s income was a fifth of a percent. 

Insurance companies have long argued that “networks” allow them to control the cost of care. They meet with hospitals, agree on fees, and sign in-network agreements. New York and a number of other states have laws “that cap or limit charges for services that are delivered out-of-network, especially for emergency care.”²³  

“Between 2010 and 2016 the number of and price tag of the charges went up pretty dramatically.

(For readers who are into numbers:  Out of network bills rose from 32.3% to 42.8%; the number of inpatients who got an out of network bill for some of their care rose from 26.3% to 42%.  The cost of an ER visit, in that six year period increased, on average from $220 to $628 and hospitalization charges rose from $804 to $2,040.”  Fifteen percent of hospitals have out-of-network billing rates that are 80 percent above the standard rate.  Some of the physicians in one study charged over 600% of the Medicare rate.²³)

California AB 1611 would have limited the fees charged for people who have insurance, but have a medical emergency and are seen at a hospital that’s “out of network.”  As it was about to be presented to the state Senate health committee when the sponsoring legislator “pulled” it as a result of “insurmountable” opposition from lobbyists and CEOS for California hospitals”¹⁵  

10 percent of anesthesiologists, pathologists, and surgical assistants sent patients who have insurance a bill because their insurer refuses to pay or only pays a portion of the bill.

They call the process “balanced billing” and it’s no longer legal in California.  (In 2009 the California Supreme court ruled that the 1975 Knox-Keene act implicitly forbids “balanced billing” for certain but not all types of insurance.)   

It’s a big glitch in the system.  (At present, there are more than 4,500 emergency departments in the country, and they are staffed by about 40,000 physicians.  One investigator found that “65 percent of hospitals contract out their emergency providers.²⁴” Another that two large companies EmCare and TeamHealth control 30 percent of the physician market, establish fees, and send bills.  In Texas the three largest insurance companies “had no in-network emergency room doctors²⁴.”)

California bill AB72 limited the amount people pay when they get elective care at an “in network” facility but part of the care is provided by a physician who is “not in network.” Physicians can’t charge “more than the in-network cost-sharing amount.”

I’m a physician. 2 decades back an out-of-network physician operated on a disc in my neck. I asked him how much he would charge and he said he didn’t know.  Someone would send me a bill.  Our visit lasted half an hour in the office and Surgery may have taken two hours. He was great and the operation went well.  I spent the night in the hospital and didn’t need any post op pain medicine.  Just coffee. My bill for “his role” arrived in the mail.  $8000.    I saw him a few weeks later for my only post op visit and I handed him a check for $4000.  Is that O.K.?  He looked stunned.  I have no idea what he was thinking, but he took the money and when I left he shook my hand.   

Chapter 19 INSURERS MOVE IN

It’s difficult to get a man to understand something when his salary depends on his not understanding it.  –Upton Sinclair. 

In the post World War Two years Blue Cross and Blue Shield were started in one state, then another.  They were public, tax-exempt corporations. By 1945 the “blues” were responsible for 2/3 of the nations’ hospital insurance, and by 1955, 60 percent of Americans had an insurance policy.¹

Aetna and Cigna began marketing medical policies in 1951.  They tended to target people who were healthy and unlikely to need expensive care. The IRS did not treat employer provided health care as part of a person’s taxable income and the Revenue Act of 1954 made it official.⁶

During the subsequent decade medical care became more effective, technical, and hospital based.  Costs escalated.  In the early 1970s the political elite felt there was a “crisis”.  In 1973, during the Nixon presidency, the HMO: health maintenance organization–act was passed.  The idea was to get groups of doctors working together.  In addition to treating illnesses physicians were now being asked to keep people healthy.  Companies with more than 25 employees were required to offer this new entity as an option. 

Groups popped up all over the country, and they took customers away from the ‘indemnity” insurance companies.  In response traditional insurers started buying HMO’s and the new bosses put pressure doctors and hospitals.  They tried to modify the way medicine was practiced by enforcing “guidelines”, recommendations by authoritative medical committees that told doctors what tests to perform in certain situations.  Physicians were paid less.  Knowing they would only be compensated for a portion of their charges, doctors and hospitals raised the “list price” of their surgeries, visits, and procedures. 

At one time HMOs tried to kick women out of the hospital the day after they delivered a child or had a breast surgically removed.  Some of the patients were ready to go home, but others had medical or physical problems that created risks.  An outcry led to publicity and lobbying.  Laws were passed, and the practice ended. 

The law restricted the amount a sick person in an HMO had to pay in the form of co-pays and deductibles.  And it required HMOs to hold an annual open enrollment period.  During that time people with pre-existing conditions could become members.   HMOs were required to provide insurance “without regard to health status.”

For-profit companies could exclude high risk individuals.  A law passed in 1945, the McCarran-Ferguson Act, had “exempted the business of insurance from most federal regulation.”  For profit companies were able to cherry pick—to offer the young, healthy, and employed, low cost policies, and they were able to reject individuals with medical problems, people who needed health care.   An expectation—a de-facto right—was created for young, healthy, and employed and it was taken away from others.  HMO’s could not offer companies high deductible or low benefit policies, but for-profit insurers could and did. Employers and healthy individuals increasingly bought policies from for profit companies.

Over the years the high risk populations of HMOs like Kaiser of Northern California and the Blues grew. For the young and healthy the plans they offered were costlier than those offered by for- profit companies, and the young and healthy increasingly chose private insurers.  In time “the Blues were hemorrhaging money”. The HMO I worked for was in grave risk of failing.

          In 1993 Bill Clinton became president and he asked his wife, Hillary, to form a committee and come up with a bill that would do something about the rising cost of health insurance.  The premiums people paid were going up 8.5% a year; many Americans were dropping their coverage, and polls indicated the public would welcome controls.

At the time the government, under Medicare and Medicaid (and to a lesser extent the Public Health Service, the National Institutes of Health (NIH), Indian Health etc.) was on the hook for more than half of the nation’s health care costs. 

Blue Cross controlled a large part of the private insurance market.  The Blues weren’t a single large company.  They were a conglomeration of state by state plans that were non-profit and tax exempt.  Their boards and CEOs were very well (and sometimes quite richly) compensated, but they had no shareholders.  They didn’t need to earn money or pay dividends. 

When Bill Clinton entered the White House he decided to tackle the “health care crisis.”  He asked his wife Hillary to create and lead a task force and to take some of the heat.  And she accepted. 

As Hillary later put it “I wanted to try to make a difference in people’s lives.  What could be more important than solving our nation’s health care crisis?  She spoke to people who had been denied coverage and she publically unloaded on the industry:  “It’s almost like they decided we should just drop dead without ever going into the hospital.”

Her goal, she told Congress, was “guaranteed universal health coverage at an affordable cost for every American.  A comprehensive package of benefits.  Health care that can never be taken away.”

In 1990, while Hillary Clinton’s group was working on their bill, the CEOs of insurance companies pow-wowed with the people in charge of hospitals, and with drug and medical device manufacturers.  They formed a group called the HLC., the Health Care Leadership Council.

I suspect the Clintons thought their proposals would be popular. They were obviously not prepared for the HLC attack and spin that followed. 

The plan Hillary and her medical advisors (Atul Gawande was one of them) came up with sounds a lot like Bernie’s Medicare for all. It didn’t pass so it’s not really part of the “real history of medicine.” Many of the details are in the foot notes.¹¹

The proposed legislation would have required health plans to provide an all inclusive benefit package. It would have been regulated by a regional non-profit organization or an agency of the state. When people got their insurance from their jobs the employer had to pay 80 percent of the cost of the premiums.

AND, it WAS comprehensive.  Hospital, outpatient, drug, and dental care were part of the scheme.

To keep costs from going through the roof there was a regional money target.  If it was exceeded the payments to hospitals and doctors would drop. Out of network emergency charges couldn’t be inflated. Balanced billing–making the patient kick in when the insurance company refused, was prohibited. There were caps on premiums and drug prices would have been “reviewed.” A tax increase was not recommended.

Bill Frist, physician, senator, republican, and founder of a huge for-profit hospital chain said “Hillary Clinton was seen as more rigid, probably more principled.  She was out front on the issues that “maybe half the country didn’t think should go that far” so she was easy to demonize.  One of their ads talked about a whole bunch of guys who were in Hillary’s testicle lock box.  Bill was portrayed as Hillary’s poodle.  Rush Limbaugh pulled out a picture of her as an evil witch and showed photos of her daughter.

  The HLC claimed that if the proposals became law: Health care would be rationed. Patient’s rights would be compromised.  The Clinton plan “was formed by academic elites behind closed doors.”   

T.V. ads featured Harry and Louise, two fictional Americans who thought the suggestions would let “Washington bureaucrats decide how much care you and your family receive.”

Congressmen and women were lobbied.  There were letter writing campaigns.  The Medicare program was pronounced “dysfunctional”.

The effort to prevent health care reform cost $300 million.  Insurance companies argued that the “free market could work if government got out of the way. “

In the end the Clinton proposals were not accepted by Congress, and Clinton went on to fight other battles.

As I read about the political clout of the AMA, American Medical Association, I began wondering how doctors decades later allowed the for profit insurance companies to totally take over the entirety of health insurance.  Where were we?  Why didn’t we do or say something?

My answer:  Doctors in the 50s and 60s had feared and fought government involvement, but they found Medicare led to better care and higher salaries.  I think the experience lulled the profession and made us more trusting and complacent.  Big organizations, it turned out, weren’t bad after all. 

Insurance company representatives were smooth and seemed to be good guys.  A prominent Georgia doctor named Leaderman was convinced the companies would “respect physicians” and allow them to provide high quality, cost effective care.”

At the time that Clintons released their plan, Blue Cross and Blue Shield created obstacles to the for-profit companies.  They controlled a large part of the health care market.  The money they took in was actually used to pay for medical care.  Driven by “need” not “greed”, these companies only charged what they needed to cover their costs.  By so doing they established a de-facto price boundary, and it limited the amount the for-profits could charge for policies. 

But over many decades the Blues had gradually lost market share, and they were about to crack³.

Then, one day in 1994 I heard a group at the nurses’ station discussing an article in the local paper.  The board of directors of Blue Cross had resigned.  They formed a for-profit health care organization and took all the low risk policies with them. 

We now know⁷ that in 1994 the national Blue Cross and Blue Shields board of directors met in Washington D.C. and voted to allow its members to “operate as for profit companies.”  Blue Cross of California changed its name to WellPoint, took a bulk of the policies that insured low risk individuals, and they became a new, for-profit company.  They then bought the non- profit Blues plans in Missouri and Wisconsin.  Blue Cross of Indiana became Anthem, and merged with WellPoint.  By 1996 California, Colorado, Ohio, Virginia, Kansas, Maine, Missouri and Georgia had changed over.  There were few remaining not-for-profit insurance plans.  But the private companies were in charge and could now call the shots. 

The for-profits were not required to “provide affordable, accessible health care” to all the people of their state.  They could, instead, provide and/or charge for health care according to risk, and they could concentrate on making money for their stockholders. Kaiser, the group I worked for, modified its business model.

In 1987, the for-profit companies contended they were providing a service to the community and convinced the IRS to give them “special tax benefits.”

In 2008 a former insurance executive named Wendell Potter had enough, quit, and wrote an “expose”, a book titled Deadly Spin.  His revelations didn’t make headlines or shake events much.  But his story is similar in some ways to that of the man who exposed big tobacco.  Formerly one of the nation’s better PR people, he was a “spin” expert.  When the press came after his company for misdeeds, questions were not answered.  He taught his people to respond with talking points.  CEOs were trained. Potter attended interviews, and he limited the scope and duration of the sessions.

In his book he explained the “right way” to reply to questions about the 45 million Americans who didn’t have health insurance.  Spokesmen and women were taught to blame the victim:  40% of the uninsured were young adults, and company representatives explained that many of the uninsured believed the risk of injury or illness was too low to justify the cost of the premium.  35% earned $50,000 a year and should be able to afford insurance, so it was a question of choice.  20% were not citizens. 

Potter, a poor boy from the back country of Tennessee, was the first in his family to go to college.  His father served in Europe and North Africa during the Second World War, then came home, married, and opened a grocery store.  When the business lost money his dad got a job in a “brutally hot factory”, and toiled there until he retired. 

In and after college Potter was briefly a journalist.  Later he became a press secretary for a man who ran for governor and lost, and he next became a “spokesman for a failing banking empire.”  In time the health insurer Cigna hired him “to help boost awareness” of the company’s health care business.  He became a PR man extraordinaire and helped devise the messages of some of the nation’s leading insurance companies.  He participated in the demolition of Bill Clinton’s health bill.   Well paid, important, and at the top of his game, he paid a visit to his parents in July 2007.  While there he learned that John Edwards, the presidential candidate, was scheduled to talk about health care reform at a fair in nearby Wise County Virginia.  Wendell decided to attend and listen.  He was devising talking points for his company and was looking for inspiration.

The health fair was produced by an adventurer and T.V. personality named Stan Brock.  In 1985 Brock had founded a nonprofit organization called Remote Area Medical.  “Volunteer doctors, nurses, technicians, and veterinarians, at their own expense, were taken on expeditions where they treated hundreds of patients a day under some of the worst conditions.”  Crews worked in Katrina after the hurricane, Haiti after the earthquake, and held day long clinics in underserved areas in the U.S.  Wise County Virginia was one of those locations. 

Potter arrived early and parked in a jammed lot.  Some of the people who formed long lines had slept in their vehicles.  It had rained the night before and it was damp.   Inside the treatment area large numbers of people waited in lines that led to clinics.  Some people got their care in tents or animal stalls.  Dentists pulled teeth.  Nurses performed pap smears.  Potter recalled mammograms, sigmoidoscopies, and doctors cutting out skin tumors. 

He was troubled by what he saw.  This wasn’t happening in a third world country.  This was America, the land with the best health care in the world.  Two thirds of the people at the health fair had no insurance, but a third did.  Problem was many of their policies didn’t kick in until thousands of medical dollars were paid by the policy holder.  In some cases we’re talking about $15,000 each year.  In other cases the amount was $30,000.  The average income in the nearby counties was $23,000 to $26,000.  A “family health insurance” policy went for $13,375. 

62% of bankruptcy filings in 2007 were the result of healthcare costs.⁵

What Potter witnessed could have been spun. The young uninsured were risk takers.  People who earned $50,000 a year were shirking their responsibilities.  Non citizens would be lumped and denounced as illegal aliens, though many were students.  Other non citizens were in the country legally, and were performing jobs Americans couldn’t or wouldn’t do.  They didn’t have health care because they couldn’t afford it. 

Potter knew how to tell the story, but when he looked into the faces of the people standing in the line in the rain for hours to get care in animal stalls, Wendell saw folks who could have been his relatives or neighbors.  He didn’t know them, but they seemed so familiar.  They were like his dad and mother.  The army had sent Potter’s father to Europe and North Africa during World War Two.  When his dad returned, both parents dropped out of high school and worked.  “They sacrificed years to send Wendell to college.” The people Potter was being paid to vilify were no longer anonymous or faceless. 

A few days later Wendell was aboard a company jet.  When his food arrived on a gold trimmed plate, he thought about the people who days earlier were receiving medical care in animal stalls.  That’s when he decided to quit the spin game.  The contrast between the compensation executives exacted and the care they denied was something that Potter pointed out in his book.

When Edward Hanaway left Cigna in 2009 he wrote a book blaming the health care consumer for the rising cost of health care.  His retirement package was valued at $111 million.  In 2007 a top average Health Insurance CEO had a salary of over $11 million.  William McGuire of UnitedHealth backdated his stock options, was caught, and paid back $620 million dollars.  He then managed to survive on $530 million in non stock compensation plus an additional $800 million in stock options. 

In his book Potter documented, but avoided direct comments about the pay executives received, dollars that could have gone into providing better or more care (or even used as dividends for investors).⁴

Corporations in this country are strange inventions.  They are endowed with the same freedoms of speech the constitution gives to humans.  Some tend to only have the conscience and ethics needed to mollify the public and the government.  They make no bones about their purpose for being.  Their job is to make money, nothing more. 

Chapter 7 FDA AND THE RULES

The protection of a man’s person is more sacred than the protection of his property.  Thomas Paine.

If some critics were correct, if it once took too long for new drugs to be evaluated and approved, that’s no longer the case.  If anything, the FDA is tilted in the other direction: 

Drugs are often approved when their long term effect won’t be known for years. 

Cancer drugs that may or may not make people live longer are marketed. 

And physicians don’t have to wait for FDA approval before they prescribe an experimental medication.  There’s a mechanism that allows physicians to legally use a drug that is still being tested.  Called the IND, (Investigational New Drug) permit, the process has been around since 1987.  If a therapy is needed urgently and a manufacturer has an experimental product that might help, a doctor can apply.  The FDA received over 500 commercial, research, and emergency IND requests in 2018 and in 2019.¹

Using a different tool, 5 months into the coronavirus epidemic the Food and Drug Administration made the anti-viral drug remdesivir available under an “emergency-use authorization.”  A month long study of over 600 hospitalized patients with severe disease had shown that the median time for recovery in people NOT given the medication was 15 days.  For those who received Remdesivir intravenously daily for 10 days it was 11 days.²²

The TV is full of ads for diabetic drugs that lower the A1C.  That’s a marker of a diabetic’s average blood sugar.  Tight control may or may not lead to a better outcome.  When the average blood sugar is close to normal there’s less damage to the small blood vessels of the eyes and kidney.  But in a study of the frail elderly, an emphasis on keeping the average blood sugar low led to “increased mortality and did not significantly reduce major cardiovascular events.”  Hypoglycemia, a blood sugar that’s very low, can cause irrational behavior, falls, and even death.²

The FDA protects us from harm and misrepresentation.  That’s what it is there for.  And it likes to illustrate how important this can be by retelling the story of Thalidomide.

When it was introduced in 1958, the medication was hailed as the tranquilizer of the future.  It put you to sleep without the expectation of a hangover, could be used for “over tired” children, and wasn’t fatal, even in a massive overdose.  Chemie-Gruenthal, the manufacturer quickly found acceptance for its product thorough out the world.  Three countries held out against approval:  France cited “technical reasons”; Israel kept delaying without giving a reason.  And in the United States there was Frances Kelsey. 

Competent and a bit over educated for her FDA position, Frances had, as she put it, “entered college in the depth of the depression and graduated when there were absolutely no jobs.”  Deducing she could choose “either to do graduate studies or join the breadline,” she studied and acquired a Masters degree.  There still were no jobs so she earned a PhD.  In 1943 she was a biochemist at the University of Chicago and she met and married a fellow biochemist.  At the time “two members of the same family could not be employed in the same department”, so (she wrote) “needing all the help I could get to obtain a job I entered medical school.¹⁶”

She was hired to be a medical reviewer for the FDA at a time when the agency was required to pass on a drug within 60 days or it would automatically be approved.  By chance, Kelsey was assigned to the thalidomide case.  It would be marketed by Merrell under the name Kevadon.  As the sixty-day period came up Dr. Kelsey routinely rejected Merrell’s application as “incomplete.” 

She was dissatisfied with the quality of thalidomide application.  The submitted clinical reports were testimonials, not well-executed studies.  She learned that when the sedative was taken for a period of time it sometimes caused peripheral neuritis, a very painful tingling of the arms and feet. The effect had been recognized in Europe, and was the main reason the medication had lost its over-the-counter status in Germany.  About that time, the FDA was also an interested in the effects of drugs on the fetus. Embryos and newborns are unable to handle drugs in the same way that an adult can.  If a person taking the medication for three or four months could develop a severe neuropathy, how would it affect an infant that might be exposed to it for months?  “We were NOT thinking in terms of absent arms or legs, but just– if it did something to the adult over time, it might just as well have an adverse effect on the child.¹⁶“

Within a year of the introduction of Thalidomide a very rare deformity in newborn babies began to appear in Germany.  It was called phycomelia.  In the place of arms and legs babies were born with something like fins.  From 12 cases in 1959 the number grew to 83 in 1960 and 302 in 1961.  Near the end of 1961 a Hamburg pediatrician made a statistical connection between this ominous health problem and mothers who had taken Thalidomide while pregnant.  The manufacturer was sufficiently concerned, and withdrew the drug from the market just as Israel was about to approve it.  According to the FDA 10,000 people in 20 countries were victims of the simple sedative.³    

At the time Senator Estes Kefauver was investigating “the escalating expense of lifesaving prescription drugs.”  He openly berated pharmaceutical executives for profiteering.  Doctors were portrayed as dupes of the companies that produced our medications.¹⁹ A household name in the 1950s, the Tennessee Senator campaigned for office wearing the kind of coonskin cap David Crockett wore when, in 1836, he died defending the Alamo.  Kefauver’s committee had questioned mob leaders on live TV, and in 1956 he ran for Vice President of the U.S. and lost. 

The “endlessly polite Southern senator in horn-rimmed glasses” unsuccessfully attempted to require newly approved drugs to “generate competitive markets after 3 years” and he failed to eliminate the promotion of “me-too drugs” and “molecular modifications.^5,22”   

But, thanks to thalidomide, the Kefauver-Harris amendments to the Food, Drug, and Cosmetic act of 1938 became law in 1962.  Proving a drug was safe in mice and a rat was no longer enough.  A drug now had to be shown effective as well as relatively safe.

The drug companies fought back in the courts.  In 1974 the Supreme Court allowed the FDA to rule that drugs in use before 1962 were no longer protected by a “grandfather clause.” It gave the FDA full authority to demand double-blind studies.”

A federal agency with more than 22,000 employees, the modern FDA does much more than give marketing approval to drugs and monitors their side effects in humans.  Among other tasks, it ensures “the safety, efficacy, and security of human and veterinary drugs, biological products, and medical devices.” And, of course, it’s responsible for the safety of our food supply.

Its precursor was created in 1906 when Congress passed the original Pure Food and Drugs Act.   The law “prohibited misbranded and adulterated foods, drinks and drugs in interstate commerce.” After spending time as a subdivision of the department of agriculture, the FDA became an independent agency in 1930.

The FDA’s next boost in responsibility came after Bayer developed, but was unable to patent mankind’s first antibiotic, Sulfanilamide.  It was made and sold in pill form by manufacturers throughout the world, and it was widely used.  Then a company in Tennessee created an elixir.  Their chemist dissolved the medication in diethylene glycol, a compound normally used as antifreeze.  Flavored with raspberry extract, saccharin, and caramel it was a commercial success.²⁰ But it was also toxic and caused kidney failure and the death of over 107 men, women and children.  As a PhD student, Frances Kelsey had been part of the team that, after Sulfanilamide had been recalled, tried to understand what went wrong.  She gave the solvent to rats, and watched as their urine turned red and they died.  In its liquid form the antibiotic had never been tested in animals.  “It was just put right on the market and sold like wildfire.”

Following a public outcry about the “wonder drug”, Congress passed, and President Franklin Roosevelt signed the Federal Food, Drug, and Cosmetic (FD&C) Act of 1938.  “For the first time, manufacturers were required to show a drug was safe before it could be marketed³

In 1980 congress passed the Bayh-Dole act.  At the time research and discoveries that were paid for with government (tax payer) moneys were available to all comers.  They were in the “public domain.”  The legislation changed the rules.  After 1980 universities and the NIH were allowed to patent their discoveries, and they could sell licenses to drug companies.  With the license in hand the drug companies could use the “taxpayer funded research” as a basis for pharmaceuticals.

In India, the patent law of 1970 took a different approach.  New medications –the drugs themselves–could not be patented, but the process, the way it they were produced, could.  In 2005, as part of the international agreement–TRIPS (Trade-Related Aspects of Intellectual Property Rights)–product patents became available.¹⁴

In 1984 the Hatch-Waxman Act “created a period of exclusivity, an amount of time when a drug that was newly approved by the FDA was protected from competition.¹⁸ The law also made it easier for generic drugs to come to market.  Companies making these medications had been forced to repeat clinical controlled trials, to start from scratch even though the drugs had been used for years and were relatively safe.  The law ended that requirement and the market for copy cat drugs went wild. (See chapter on generic drugs.)  

After 1984, when a drug’s FDA granted monopoly ended, a generic company could ask for permission to produce the medicine.  The law gave the first appropriate applicant a 180 day restricted head start on the competition…unless the product was covered by a “valid patent”.  If the drug was “protected,” the original manufacturer could file suit and allege violations.  That was the loophole that lobbyists presumably inserted. 

Most drugs were initially covered by a patent whose 20 year life-span starts early in the research process.  Additional patents are typically filed at various stages of the medication’s development.  Many deal with non essential ingredients, like the color of a pill or the starches used as filler. When a drug’s years of private ownership ended, the additional patents were sometimes used by a company to sue alleging its product was “patent protected”.

When a very profitable drug’s “privilege” expired, they filed.  The legal allegations were often capricious.  But that didn’t matter.  The law said that once the suit was filed, the FDA had to automatically delay the approval of the generic drug for 30 months “to permit litigation.”

At this point both manufacturers knew the generic drug maker would probably win, but lawyers know how to drag things out.  Court battles are lengthy and expensive.  So lawyers got together.  The company that owned the revenue generating medicine typically paid millions of dollars a month, and the generic drug maker waited a bit before it produced and marketed their version.   There were 33 pay-for-delay settlements in 2010.  In 2013 the Supreme Court ruled the practice was subject to antitrust laws and in 2015 the generic drug company, Teva, settled a pay for delay lawsuit for $1.2 billion.  In 2012, 40 pay-for-delay law suits were filed.  The number dropped to 29 in 2013 and 21 in 2012.

In 1992, after Congress passed the Prescription Drug User Fee Act (PDUFA), Two thirds of drug approval expenses were paid by big Pharma.  The fox was paying the regulators who were guarding the hen house.

In 1997 drugs that had only been tested on adults were sometimes given to children and Congress passed a law.  It required medications that were prescribed for kids to be proven safe and effective IN KIDS, and it gave the manufacturers who got approval an additional 6 months of exclusivity.   

That, of course meant that when a drug that brought in more than a billion dollars a year was about to lose its monopoly, a company could give the medication to a few kids, write up a study, and shut generic drug makers out of the market for an additional 6 months.

The FDA uses a number of advisory boards, groups of physicians who are experts in the field.  The FDA officer makes the final decision, but, in tough situations, it must be nice and at the same time awful to have a group of M.D.’s who serve as a sounding board and buffer.

The 2007 their approach to Avandia (rosiglitazone)—a “glitazone” that is used to lower the blood sugar level in diabetes– is an example of how wrong these boards can be.  Made by SmithKline Beecham, Avandia had a side effect.  It raised the level of cholesterol in the blood.  You don’t have to be a doctor to know that a high serum cholesterol creates an additional risk for people with diabetes.  The condition increases the likelihood that they will have a heart attack or stroke. 

The other glitazone, (Actos),Pioglitazone didn’t worsen blood lipids.   

In 1999 the agency approved both rosiglitazone (Avandia) and pioglitazone (Actos)for use in people with diabetes.  Doctors could prescribe either, but the FDA wanted companies to monitor the drugs for problems.

By 2006 both drugs were grossing more than 1.5 billion dollars a year.

Actos did not increase the risk of coronary disease, but Avandia did.  It also, sometimes caused heart failure, fluid in the lungs and legs. FDA panels were convened.  The experts voted to keep Avandia on the market, but black box warnings were added to the packaging.  Physicians on the panels hoped doctors would read them and use the drug sparingly.

They didn’t, and a 2007 medical study convincingly showed that Avandia caused heart disease.  The drug’s sales dropped, but a million prescriptions a year were still being written.

The panels of experts convened by the FDA agreed that Avandia “posed significant cardiovascular risk”.  Then they voted.  Twelve of the 33 doctors thought the drug should be removed from the market.

The chairman and 9 others voted for much stricter controls.  The doctor in charge wrote that “several meta-analyses revealed a significant increase in the risk of myocardial ischemic events among patients taking rosiglitazone…  But a second analysis, failed to demonstrate a similar risk.”  Then he added a little gibberish:  “the results regarding the safety of rosiglitazone raised new questions about relative and absolute risks.^4”

In July 2010 the manufacturer of Avandia settled a lawsuit for the harm the medication did for $460 million.  Compared to revenue of $1.1 billion dollars the prior year and much more in the years before the 2007 hearings, the monies paid did relatively little harm to the company’s bottom line.  Pioglitazone– Actos, is still being widely used.

Then in the early morning hours of June 27, 2003 a controversial law was enacted.  A mere thirteen years had passed since Congress granted Medicaid “most-favored customer” status, and required drug manufacturers to sell their meds to Medicaid at the “best price” available to any other purchaser.  This time, however, congress passed a law that said pharmaceutical manufacturers can charge what they want to charge and the government can’t price negotiate.  The Secretary of HHS was prohibited from negotiating lower drug prices on behalf of Medicare Part D beneficiaries. When asked why he thought House leaders had scheduled the vote long after most Americans had gone to bed, Representative Dan Burton (R-IN) said “a lot of shenanigans were going on that night (that) they didn’t want on national television.”  According to Walter Jones, a disgusted North Carolina Republican who voted “no”, it was the “ugliest night” he had witnessed in more than two decades as a member of Congress.  “Pharmaceutical lobbyists wrote the bill;” ¹⁷ 

Touted as a means of providing cheap or free drugs for people on Medicare, the bill did not include any new taxes.  The entitlement was not funded, though part of the cost was paid by enrollees.  Seniors paid $265 to receive the benefit, and then kicked in $25 + a month.  When a person took and expensive drugs and the annual cost exceeded $2400 a year the government stopped paying for a while.  Enrollees had to shell out for the next $4000 worth.  If the annual drug cost exceeded $6400 a year, the government started paying again.  The $4000 was called the donut hole, and it was eliminated by Obamacare.

After the bill was passed the government accounting office claimed that American prescription drug prices rose 6.6% a year between 2006 and 2010.  By contrast the price of generic pharmaceuticals increased by 2.6 percent annually and overall medical costs rose 3.8% a year.

“Representative Billy Tauzin (R-La.),the “Cagey Cajun”–he came from a French Speaking Louisiana family–  coauthored the bill, then negotiated a $2-million-per-year job as a lobbyist for the drug industry’s trade organization.”  Thomas Scully, a Bush Medicare official who misstated the program’s cost, became a health industry lobbyist.”

During the following decades the FDA used a number of techniques to drugs that seemed promising to people who were willing guinea pigs.

(FOR THOSE INTERESTED IN THE DETAILS: At the height of the AIDs epidemic, activists protested the delay between a new drug’s submission and approval.   In response the agency created fast-track rules that sped up the development, assessment, and sales of new treatments– for life threatening conditions.  The FDA also made unapproved drugs available to people who had AIDS (and other serious conditions) who were unable to enroll in clinical trials.²³ 

In the 1980s it created “treatment INDs.”  To obtain a medication a provider has to submit a form that can usually be filled out in 45 minutes.  The agency then takes up to 4 days to process a non-emergency application; emergency requests are approved in less a day.  Between 2005 and 2014, 1200 forms were submitted each year; over 99% were approved.  Most were for a single patient and half were for an emergency.¹³ 

          In 1970 a strong demand for experimental cancer drugs led the FDA to adapt an early-access policy.   In 1992, the agency started allowing speedy approval on the basis of end points that were seen as “reasonably likely to predict patient benefit.”

During the 2014 African Ebola outbreak, acting on preliminary data, the FDA authorized the use of six tests that rapidly identified infected patients, and they reviewed IND applications for 2 investigational vaccines in less than a week.  Then they allowed developers to proceed with phase 1 clinical trials.⁷)

In 1992 Congress passed the prescription drug user act.  It authorized the FDA to collect money from pharmaceutical manufacturers, and told the FDA to review special drug applications within 6 months.  Ordinary applications had to be assessed within a year.

As therapies were developed and authorized more quickly, the FDA started “requesting” post approval studies. Under the 2007 FDA amendments act, congress allowed the FDA to “require” studies after a drug was approved. 

In spite of the law only half of the post approval studies were completed within 5 years.  “20% had not been started; and 25% were delayed or ongoing.”¹⁵ 

In 2012 the FDA didn’t approve Solanezumab. “The drug binds the amyloid-B peptides that form plaques in the brain”, that many believe are the cause of Alzheimer’s dementia.  They hoped the Solanezumab monoclonal antibody would help clear amyloid from the brain.  The company’s original placebo study, performed 4 years earlier, had shown Solanezumab didn’t work—“didn’t improve cognitive function in people with mild to moderate Alzheimer’s.”

At the same time “there appeared to be a statistically significant benefit for the subgroup of patients with mild dementia–a 34% reduction in cognitive deterioration” Maybe Lilly had something.  The company went to the FDA and sought tentative approval, and the FDA turned them down.  They demanded further testing.

In recent years, the FDA’s testing requirements have been under attack.  One section of a new law “allows the secretary of health and human services to rely more heavily on surrogate measures, or “drug development tools,”  Using these softer criteria, FDA leaders could theoretically have approved the drug.  It seemed safe enough.  The agency could have then required post marketing testing–studies that take years to perform.  But why would anyone with mild dementia risk getting a placebo rather than the real thing?

Lilly enrolled 2100 people with mild dementia and followed them for 18 months.  They learned their drug didn’t slow the disease. The money saved by waiting was substantial.  People are desperate for something that can stop, prevent, or reverse Alzheimer’s.  2.5 million Americans would have been able to access the medication.  Drugs like this almost always cost more than $10,000 per patient per year.  So, using surrogate criteria, we would have paid billions for a useless drug.⁸

Legislators probably thought they were making one-small-step towards lower drug prices when they passed the Biologics Price Competition and Innovation Act (BPCI Act) of 2009. (The Europeans took similar action in 2006).   Our country now allows companies to market “interchangeables”– medications that are “different chemically” but work as well and are just as safe as a currently marketed drug.

In fact, industry had been marketing biosimilars for years.  But– in the past they didn’t “price compete.”  Companies marketed biosimilars so they could charge higher prices.  Prilosec, a drug that stops the stomach from making acid, is chemically the mirror image of Nexium.  Their actions are the same and they are similarly safe and effective.  The milligram dose is a little different.  40 mg of Nexium has the same acid lowering effect as 20 mg of Prilosec.   The new drug was introduced at a time that Prilosec was losing its hold on the market.  The owner, AstraZeneca, funded a study that showed that in people with severe erosive esophagitis, 80 mg of Nexium was more effective than 20 mg of Prilosec.  In other words doubling the dose of the drug decreased the amount of acid a stomach makes a bit more.  The idea wasn’t new.  We doctors had long been using double doses of Prilosec for severe esophagitis.  The company marketed Nexium as a new drug, and they used clever marketing to gross over $5 billion a year for a few years.  For starters they sold their old drug, Prilosec over the counter for 75 cents to a dollar a pill.  That can be $30 a month.  Nexium was a prescription and was covered by most drug plans.  So for people with good drug insurance Nexium could be purchased with a low co-pay.  That made it cheaper than Prilosec.

People who take the Prilosec or Nexium for a period of time can’t stop easily.  The medications keep the stomach parietal cells from making acid.  That’s what some gastric cells do—they make hydrochloric acid.  Over time stomachs respond to the absence of acid by growing more and bigger parietal cells.  These cells are inactive as long as a person keeps ingesting a pill a day.  When or if a chronic user stops the drug for a day or two, the parietal cells wake up and go to work.  The stomach starts producing huge quantities of acid, and many people develop chest pain or severe heartburn.⁹

Despite the cleverly crafted loopholes in the law and pressure from industry, amid a culture where there’s a tendency to mainly recognize government employees when they screw up, the FDA is doing what it’s supposed to do. It was created to keep us safe and it’s doing its job.  And that’s good.

 

HOSPITALS

In the summer of 2005, Charity Hospital, the country’s second largest, provided medical care to the poor and uninsured of New Orleans and had one of the nation’s busiest emergency rooms. Rebuilt for the sixth time in 1939, it had 2680 beds, and was a major teaching hospital for Louisiana State University. That August Hurricane Katrina struck the city and flooded the first floor of the structure. Aside for a few generators for breathing machines there was no power, no lights, and food was scarce.   On more than one occasion the thermometer topped 100 degrees.  Toilets didn’t flush. There was no water for hand washing and the port-a- potty at the end of the hall smelled.  Observing from the forsaken building, a physician painfully watched each day as helicopters evacuated patients from the roof of the nearby Tulane Hospital, a facility that was 80% owned by the for-profit Hospital Corporation of America, “while our 250 patients were evacuated by twos or threes in boats”.  It took nearly a week before the final 200 were rescued.¹⁹ 

Of the for-profit institutions, HCA, Hospital Corporation of America is the largest.  The chain was started in Nashville in 1968 by a cardiologist named Thomas Frist.  “The hospital he worked in was poorly run and equipped,” and he and a few colleagues decided to build another one.  He met and partnered with Jack Massey, the man who developed the Kentucky Fried Chicken chain.  They built Parkview hospital in Nashville and bought a second one.  When Thomas junior talked to investors he encountered skepticism.  They didn’t believe a doctor could be a good business man.  The secret of his success, he once said, was the idea of bigness itself. 

The company he founded has become quite large and has “164 hospitals and 106 freestanding surgery centers in 20 states and Great Britain”–and a “market cap” of over 9 billion dollars.

Another of the big four, Humana was established after a few Louisville realtors figured they could make money operating nursing homes. They chose the company name from a list of 500 submitted by a corporate identity consultant. After buying one, then a few hospitals they went public in 1968.  By 1972 they were running 45 hospitals.   In 1978 they took over a second hospital chain and more than doubled in size.  Then in 2018 the company paid $4.1 billion for a 40 percent stake in 76 long-term acute care and rehabilitation hospitals operated by Kindred Healthcare.    

Bob Appel founder of American Medical International worked for a medical diagnostics lab that served hospitals.  When his employer had financial problems Appel purchased the lab and later started acquiring hospitals. 

National Medical Enterprises, now Tenet was formed by three lawyers in 1967.  One was quoted as saying “doctors don’t generally know how to run a business.  A hospital is really just like a hotel.  You just have to know the medical side.¹⁵”

Community health systems of Franklin Tennessee once owned 25 of the 50 hospitals that were the nation’s most expensive.  In 2014 they controlled 200 hospitals and earned $18 billion in profits.  Then they paid $7.5 billion for a for-profit chain “that had a slew of financial and legal problems”, and they started losing money.  When their debt was close to $15 billion they sold 30 hospitals cheap and they are teetering.³

Currently about 1034 of the nation’s hospitals belong to one of several for-profit corporations.  They have stockholders, earn money, and pay taxes.  Their bottom line was boosted (and government revenues fell) in 2018 when the corporate tax rate dropped from 35% to 21%. 

Our nation’s first, Philadelphia’s “Pennsylvania Hospital’, was founded in 1751 “to care for the sick-poor and insane who were wandering the streets.” The facility was the idea of a Quaker who was medically educated in Paris a century before physicians believed bacteria and viruses cause infectious diseases.  He wanted to emulate Paris’ Hotel-Dieu, the continent’s second oldest. The Parisian facility was established by Saint Landry in 651 AD “to treat pilgrims and the poor.” By the early 21st century the facility had become central Paris’ “top casualty and emergency hospital.”  It closed in 2013.¹²

In 1811 federal legislators established and funded a home and medical clinic for military veterans. Fifty years later, after half a million fighting men died of wounds and illness in our destructive civil war (1860-64),the government created a number of veterans homes.  They “incidentally” also provided medical and hospital treatment.  50 years thereafter our nation entered the First World War (1917-18).  116,000 men lost their lives.  Many more were wounded and disabled–and a number of facilities were built. 

After they were officially launched in 1921, the Veterans Administration started building hospitals.  By 1948 there were 125, and the VA currently says they operate1600 health care facilities.⁵ They once cared for all service men and women who had been on active duty, even briefly.  After September 1980 the government began limiting the pool by requiring a “minimum length of service.” The VA and Indian health hospitals are directly and indirectly (through Medicare and Medicaid) federally funded.  

Before Medicare was passed in 1965 U.S. hospitals were largely segregated. Black physicians often couldn’t get privileges to practice at hospitals dominated by whites, and in some of our leading hospitals people of color were cared for in the basement wards of white hospitals.

After the American Civil War ended four million former slaves had abruptly been told you’re free to leave, but they had no resources and nowhere to go to-– no basic shelter.  Often cramped together in abandoned buildings, they couldn’t maintain basic hygiene, and many got sick.  Privately run institutions for the very poor existed, but there were no hospitals, and the private shelters wouldn’t accept the newly emancipated.  Former slaves died in large numbers.  In some places “their bodies were littering the streets.”  About that time there were 54,000 male and 300 female medical doctors in the U.S. and only a few were people of color.^41,42

Congress established the Freedman’s Bureau in the South.”  It “fed millions of former slaves and poor whites, built hospitals, and provided medical aid.  But its hospitals didn’t have enough beds, linens, quarantine facilities.  There were merely 120 doctors for the entire population.  And there was a smallpox outbreak.  In July of 1872, “responding to the continued hostility of white Southerners, Congress terminated the Freedman’s bureau.”

In the early post Civil war years the government founded a number of black schools and colleges.  In 1868, one of them, Howard University in Washington D.C., “became the first school to have a medical program for blacks.”².

The country’s first black surgeon, James McCune Smith, had to go abroad to get his medical degree.  He grew up in New York and had a white father and a black mother who had once been a slave. Educated in the city’s African Free School, he was denied entrance to an American University and went to college in Glasgow. In 1937 he graduated from a London medical school, returned to the U.S. and became a vocal abolitionist.  He wrote the introduction to the Frederick Douglass book “My bondage and my freedom,” and was practicing medicine in Brooklyn when the Civil War ended.⁴⁰ 

In 1864 Rebecca Lee Crumpler became the country’s first black “doctress” of medicine.  Born a “free” black in Delaware in 1831, she later wrote about her journey in the Book of Medical Discourses.  “Having been reared by a kind aunt in Pennsylvania, whose usefulness with the sick was continually sought, I early conceived a liking for, and sought every opportunity to relieve the sufferings of others.” The book was published in 1883. 

Between 1852 and 1860 Crumpler “served as a nurse under several doctors.  In 1860 she “was admitted to the New England Female Medical College, the first institution in the U.S. to train women in medicine.”  It merged with Boston University in 1873.⁴⁰ Students were “taught by rote–four lectures each day, often clocking in at eight hours total. A systematic course of study with nominal variation from college to college didn’t exist, and there were no “medical licenses” or exiting exams.” ⁴¹

Educated in the days before Pasteur and Koch discovered that bacteria—germs– cause infections, Crumpler explained that infectious diarrhea—she called it cholera infantum– was caused by “poor milk, bad air arising from old water-soaked cellars, or some atmospheric phenomena.”

Established In 1927 in the segregated south, the non-profit Houston Negro Hospital provided work for black physicians, and care for African Americans. 

In St. Louis a hospital for the cities black indigents opened its doors in 1937.  It was named for the Homer Phillips, a black lawyer from Sedalia, a small town in the middle of Missouri that was built on the main east west railroad line.  Raised in an orphanage, then by an aunt, Phillips became a lawyer at Howard University, and moved to St. Louis.  “Intensely interested in the Negro doctor”, he felt “more opportunities would be available for these men of medicine if there were a separate hospital.”  In 1922 St. Louis passed an $87 million bond issue and Phillips made sure the legislation designated one million of the dollars as funds for building a black run hospital.  Once the city had the money, it wasn’t easy to get them to turn it over.  For more than a decade Phillips fought “interests that sought to prevent the hospital’s construction.³⁹ It’s doors opened in 1937, and 2 years later Phillips needed to get additional funding.  The facility was inadequate. “Patients were crowded into dark corridors and their lives were often in jeopardy because of fire hazards.”  By 1961 the institution had trained the “largest number of black doctors and nurses in the world, and it was a leader in developing the practice of intravenous feeding and treatments for gunshot wounds, ulcers, and burns. It closed in 1979.¹

The hospital that provided a significant part of my medical training, St Louis City Hospital, was integrated and lost much of its clientele to more upscale facilities when Medicare and Medicaid became the law of the land.  The facility existed until 1985; then it closed.  City and county hospitals elsewhere (Cook County in Chicago, Bellevue in New York, San Francisco City Hospital, and Charity in New Orleans (to  name a few) remain very much alive and well.   

Cook County hospital in Chicago, the caregiver for the poor in our second largest city (committed to providing “quality care with respect and dignity regardless of their ability to pay”) gets close to 40 percent of its operating revenue from state and city taxes.  Of the remaining 60 percent, a third of the money comes from Medicaid, and 9 percent from Medicare.  I don’t know how much the institution gets from private insurance companies.  

New York City has 11 publically funded hospitals plus clinics and nursing homes.  With an annual budget exceeding $5 billion they provide emergency services and hospitalize close to a quarter of a million people a year.⁶

University hospitals, which are presumed to be “the best” by many, are staffed by esteemed professors who are often astute physicians and who write papers and books. These educational institutions provide complex services that require a team approach and interventions like liver, heart, and kidney transplants.  Many of the researchers who teach future physicians survive on research money supplied by the NIH or pharmaceutical companies.

By the 1950s all of our large cities and many small towns had a modern day facility. The government had constructed and ran military, Veterans administration, and public health service institutions.  Multiple hospitals were operated by religious groups or by university medical schools. 

According to one analysis, U.S. hospitals have been merging at a rapid pace for a decade, forming powerful organizations that influence nearly every health care decision consumers make.  The mergers have essentially banished price competition and raised prices for hospital admissions.  In one analysis of 25 metropolitan areas, between 2010 and 2013, prices rose 11 percent and 54 percent.¹⁷ 

Public and university hospitals derive their funds from private and governmental insurance, from taxpayers, and from donors. The law says that if charitable organizations want to avoid taxes they must be operated exclusively for “exempt purposes”.  None of the earnings can go to shareholders or individuals.  They can’t try to influence legislation as a “substantial part of their activities.” 

(The list of organizations that could potentially acquire tax exempt status is quite long.  It includes groups that are: “charitable, religious, educational, scientific, literary, testing for public safety, fostering national or international amateur sports competition, and preventing cruelty to children or animals.” Etc…) ⁴

Some universities and charitable hospitals make a lot of money, and their profits are not taxed.  The Affordable Care Act did not challenge their IRS exempt status.  It did, however, add a few hoops. 

The institutions are now required to have a financial assistance policy that’s written in “plain language” on their web site.  The “audience should be able to understand it the first time they read or hear it.”

They (theoretically, at least) can no longer generate inflated bills, claim they spent an unrealistic amount of money caring for a sick person.  Hospitals typically send out exaggerated bills knowing full well that Medicare or insurance companies will only pay a portion of them. They use the amplified numbers as a starting point for negotiations with insurers, and as a means of demonstrating how charitable they are.  As part of the ACA non-profit hospitals should no longer be able to generate inflated tabs—charges that are higher than the amount insurance companies and Medicare really pay for the services.  Additional charges–the portion of a hospital bill that Medicare and insurance companies don’t usually pay—can’t be pumped up. 

Finally, when a recently treated person doesn’t pay their share of the costs, these institutions are supposed to “make reasonable efforts to determine whether the individual is eligible for financial assistance” before they sick their dogs on them– before they take legal action, sell a person’s debt or notify a credit agency.

In 2013, of the ten most profitable U.S. hospitals, seven were non-profit.  They earned over $1.5 billion, and, of course, didn’t pay any taxes.  They included a few big name institutions:  Gundersen of La Crosse Wisconsin earned $300 million.   Stanford’s teaching hospital had a profit of $225 million”, and the University of Pennsylvania’s hospital in Philadelphia made 184.5 million.”  “The hospitals with the highest price markups earned the largest profits.”  These institutions could have returned some of the tax derived revenues to the government.  (Fat chance.)  They could have increased the number of non-paying patients they cared for.  Since the affordable care act went into effect, they’re often caring for fewer people who can’t pay. If we’re going to make health care affordable we should probably revisit the tax exempt status of some of these institutions.⁵

A few years back Senator Grassley considered “removing tax-exempt status from teaching hospitals and forcing them to do more for local low-income, urban communities.”   The hospitals fought him and won. 

Much of the care our hospitals provide takes place in one of the country’s 983 state and local government hospitals or in one of the 2845 community sponsored nonprofit institutions.

The people who live far from the cities are served by many smaller institutions that are the product of a community or creations of health care workers who had a dream. Some are financially struggling to exist. ⁷

In May 2020 the New York Times told how, as a result of the Coronavirus bailout, the non-profit Providence Health System received over $500 million in government funds.  The company was sitting on nearly $12 billion in cash and was earning, in a good year, over $1 billion tax free from its investments in venture capital funds. Two other for-profit hospital groups, HCA and Tenet Healthcare, had billions of dollars in reserves and received $1.5 billion from the government. Ascension Health in St. Louis, a chain that had $15.5 billion in cash, was given $211 million.  And the largest rural hospital system in eastern Kentucky got $3 million, enough for 2 weeks of payroll. 

“Even before the coronoavirus, roughly 400 hospitals in rural America were at risk of closing,” and the 2000 rural hospitals that are in the black, on average, only have enough cash to keep their doors open for 30 days.” ³⁶

In the last decade 113, mostly rural, facilities went out of business.  20 were in Texas, 12 in Tennessee and 7 each in Georgia and Oklahoma. Of the 283 rural hospitals that in 2015 were “vulnerable to closure”, those located in states that did NOT opt for Obamacare Medicaid expansion were especially hard hit.  16.5 percent of the hospitals in states that opted OUT were on the brink versus 8.5% in Medicaid and indigent patients than suburban hospitals.” 

Providing quality health care to our urban population is much more than a hospital issue.  60 million Americans—13 million of which are children lived in rural areas.  5.3 million resided in completely rural counties, 24.6 million in the mostly rural counties and 30.1 million in mostly urban counties. Their numbers have been dropping.  A non-profit: A Healthy Rural America is struggling with the problem.²³

A third of the Health Care dollar, $1.1 trillion (2017) is spent on hospital care. The Affordable Care Act led to increased hospital revenues and kept a number of smaller hospitals alive.  States that “expanded Medicaid” saw 7.4 percent more Medicaid discharges in 2014 versus 1.4 percent in non-expansion states.

Total Number of All U.S. Hospitals.18	6,210
Number of U.S. Community Hospitals	5,262
Number of Nongovernment Not-for-Profit Community Hospitals	2,968
Number of Investor-Owned (For-Profit) Community Hospitals	1,322
Number of State and Local Government Community Hospitals	972
Number of Federal Government Hospitals	208
Number of Nonfederal Psychiatric Hospitals	620
Other Hospitals	120

In 1981, a deranged 26-year-old man shot the president of the United States. A bullet hit a rib, and Ronald Reagan was in pain. At the time, neither he nor his aides sensed how close he was to death. As the presidential limousine sped to George Washington University Hospital, Reagan coughed up blood. When he tried to walk from the car to the emergency room, his legs collapsed, but his aides kept him from falling and dragged him to a gurney.  A senior surgeon arrived on the scene and realized the man had lost a lot of blood, and was still hemorrhaging. An operating room was empty and, as a gurney occupied by Reagan was wheeled in, O-negative blood was pumped into his veins. The urgent surgery and transfusions were so successful that few realized Reagan had used up one of his nine lives. 

The first U.S. level one trauma center was established in Chicago in 1970. By 2003 most states had at least one facility where surgeons, neurosurgeons, orthopedists, appropriate anesthetists and operating rooms are available 24 hours a day.  Some facilities have helicopter landing pads.³⁴ Others use nearby airports and bring the severely injured to a hospital by ambulance.  50 million Americans are unable reach one of these centers in less than an hour. 

E.R.s in the U.S. hospital clock 136 million visits a year.  Forty million of them are for minor injuries, auto accidents, and gunshot wounds.³⁵ Sixteen million of the people who are seen are admitted to the hospital.  People with myocardial infarctions who arrive by ambulance are sent to the catheterization/stent department.  Women in labor are wheel chaired to the hospital delivery areas.  The people with a new neurologic problem: a leg or arm that won’t move, inability to speak, loss of vision– are briefly assessed and routed to the CAT scan room.  An X-Ray without contrast only takes a few minutes, and doctors need to be sure the acute brain damage was not caused by a cerebral hemorrhage before can attempt to dissolve a clotted blood vessel.

A few years back (according to a colleague) the physician-in-chief of Northern California Kaiser was visiting one of our ERs and was disturbed by waiting rooms full of people. Some had minor injuries that needed a quick fix; others who were quite ill, had to wait a long time before they were triaged. He decided something needed to be done and he had clout. 

He met with the chiefs of our hospitals and an agreement was struck.  After a person entered the waiting room and registered, he or she would be taken to an exam room and evaluated by a doctor, nurse and tech within 15 minutes.  Lacerations had to be sewn shut, minor fractures casted, and a person sent home within an hour.  Sepsis, strokes, and bleeding were treated promptly.  Tests and consultations were ordered for problems of unclear significance and severity.  Efficient competent evaluation might not always be possible but that was the goal.

Then Dr Pearl retired and waiting room wait time worsened.

San Francisco General Hospital is a hybrid. It’s a trauma center and a teaching hospital. The doctors who care for patients come from the University of California Medical center. The facility also operates the city’s “Community Health Network.” 80% of its $600+ million operating budget is paid for by Medicaid, Medicare, and private insurance, and it gets the other 20% from the city’s general fund. As detailed in an earlier chapter, in response to criticism for their crazy high fees they recently lowered and capped the amount people pay when they are ill and injured and need care.  It’s too soon to tell if their billing approach will be viewed as a beacon for the rest of the country or as a hippy, odd ball gesture.    

A few decades back “the general” developed a unique approach to its visitors who slept outside in unsheltered locations. Many suffered and died prematurely from diseases caused by alcohol, smoking, exposure, and poor sanitation. Violence, mental disorders and suicides were common. San Francisco General “identified individuals who had visited their emergency room five times in 12 months. With the help of attorneys and with a staff of case managers, a primary care physician, nurse practitioner(s), and a psychiatrist, they got many of the people permanent shelter, a primary care doctor, and “benefits.” It was quite a legal feat in people who are disabled by mental illness. In time, 70-75% of the homeless were housed, and emergency department use decreased 50-75%.  That was a few years back, the homeless problem in Northern California has gotten worse and the funding has changed.¹¹

In the 1960s intensive care units were created.  By the end of the 70s each nurse in one of the units cares for one or at most two patients.  Machines monitor blood pressure, pulse, and blood oxygen levels.  Respirators filled lungs. When appropriate food is dripped into stomachs through naso-gastric conduits.  Multiple IV tubes infuse bodies with nutrients and a variety of chemicals and blood products. 

Nurses have always been “the glue that held hospitals²⁷ together.  Their numbers increased during the Second World War II.”  At the end of the conflict RNs earned an average of $2,100 a year, somewhat less than most male workers.  Their wages didn’t rise and their numbers started going down.  There increasingly weren’t enough RN’s to do the job right and those who remained had to work longer and harder.  To keep costs down hospitals froze their wages. These women were dedicated, right?  They wouldn’t quit.  By 1966 the average RN earned $5,200 a year.  At the city hospital where I was a resident one nurse passed medications and tried to handle the needs of the ill on an entire ward.  The women (and at the time they were all women) were energetic, amazing, and often exhausted.  Their wages were so low that none of their nursing school graduates wanted to work at our hospital.  When our few nurses went on strike in 1965 the papers thought their action was outrageous.

The idea that in America workers could strike if they were underpaid, was challenged when the nation’s Air Traffic Controllers struck in 1981.  President Reagan said they were federal employees and were breaking the law. He gave them 48 hours to return to work or be fired.   His anti union stance changed attitudes.  In a decade, major strikes plummeted from an average of 300 each year to fewer than 30.   Despite an average annual inflation rate of 2.9% and a huge surge in productivity, the federal minimal wage, which was $3.35 in 1981, barely doubled in the 3 post-Reagan decades.   

In the San Francisco Bay Area 2 types of union actions have continued to be effective.  The interruption of BART commuter trains by striking workers always leads to jammed freeways and lengthy commutes.  When the police struck a few decades back the chief went on T.V. and warned that criminals, murderers, and rapists would have a field day.

At Kaiser where I worked, nurses felt they were underpaid.  They knew how to take care of sick or needy patients, but they soon learned that dealing with management was something else.  Every 5 to 10 years or so their contract came up for renewal, they asked for a raise, management hung tough and the nurses decided they needed to strike. 

That was fine with Kaiser.  The insurance money kept coming in.  People didn’t like to cross picket lines unless they were quite ill.  

Before the strike started traveling nurses were hired, elective surgery was canceled, and the very ill were sent to other hospitals. I remember driving to work and seeing throngs of young and middle aged nurses carrying picket signs, and standing by the entrance of the parking structure. They were friends, colleagues.  Many hated the thought of abandoning their patients and some believed strikes were unethical. 

After three weeks of pacing in the heat of the day or under an umbrella nurses started coming back to work.  Most had loans, rent, bills, and lived from one pay check to the next.  When a majority of worses had returned to the job management offered a small raise and signed a long term contract. 

Eventually the nurses hired a labor organizer named Rose Ann DeMoro and everything changed.  In 1968 she declared a 2 day strike, and the hospital prepared.  Critical patients were moved out, elective surgery was cancelled, and traveling nurses were hired.  A few days prior to the date, the strike was cancelled, but it was rescheduled for a date 60 days hence. 

Two months passed.  As before, very ill patients were moved out, nurses brought in, and elective surgeries cancelled.  This time the nurses struck for two days and no one lost much money.  As the strike was ending the union announced it would soon strike again. Management understood what was going on and cried “uncle.” The nurses pay rose substantially and they later fought for and won the right to make improvements to the quality of care they provided.   

Nationwide, one in five nurses belong to a collective bargaining unit. On average their wages are 20% higher than the pay of the nurses who are not in unions. In 2020 the average hourly wage of a registered nurse in half the states in our country was $28 to $34.  The other half earned $35 to $48 an hour. In Hawaii and California the average hourly wage was $50 to $54. 

Inside the large multispecialty hospital where I worked there is a large birthing wing. Large rooms accommodated doulas and invited family.  Nurse midwives handled the uncomplicated vaginal deliveries.  An anesthesiologist or nurse anesthetist was always on duty and performed epidurals.  Needles are inserted into the lower back, into the space between the vertebrae and the membrane that surrounds the spinal canal and lidocaine, a numbing agent was infused. The drug blunted much of the pelvic pain of childbirth.  An obstetrician was hanging around and was available for consultation and urgent C sections. 

In the hospital’s basement 2 CAT scanners and 2 MRI machines created detailed body images far into the night.  The pictures of the sliced body sections were immediately visible on every computer screen in the facility. A radiologist sat in a dark room, carefully checked the images, and looked for anything that didn’t belong.  He or she dictated a report that was transcribed by trained worker in the facility, or increasingly by people in the Philippines, India, or some other country.

A multi bed outpatient recovery area was staffed by nurses.  They prepared and observed patients before and after interventional radiologists performed biopsies or invasive procedures.  The unit also served as the pre and post procedure area for people having an emergency heart catheterization.  A cardiologist was always on call, no more than 15 minutes from the hospital, and available 24 hours a day, to catheterize and stent the coronary arteries of people who are probably having an acute myocardial infarction.

Gastroenterologists, who sometimes worked at bedside in the intensive care unit, had a dedicated in-patient procedure room, with equipment. If needed we would insert a scope and treat people whose upper GI bleeding was ongoing or those who had a bolus of food lodged in their esophagus.

There were medical, surgical, and pediatric intensive care units and a coronary care unit.

Hospital rooms had piped in oxygen and suction, a place where a partner or parent could spend the night and an annoying T.V. on the wall. 

A special inpatient pharmacy provided a large range of medications, including specialized drugs and infusions, 24 hours a day.

Pathologists processed, stained, examined, and interpreted the significance of tissue that was removed from bodies.  Samples were often sent “out” for molecular diagnostics (DNA/RNA analysis).

Phlebotomists drew blood and brought it to the lab where it was extensively tested.  The labs also cultured and assessed stool, urine, blood, spinal fluid, sputum etc.

And there were clerks, social workers, discharge planners, janitors, patient transporters, painters, security people, guards, physical, occupational, and speech therapists, dieticians, telephone operators, IT personnel, people who provide food for the patient and staff, and engineers who regulate and repair the electrical, cooling-heating and other building systems.

In 2017 American hospitals were responsible for $1.1 trillion of the nation’s $3.5 trillion in health care expenditures, and an average day in the hospital was costing nearly $4 thousand.²⁸

I was employed by a pre-paid group, and all the physicians and surgeons were salaried.  The hospital had ten large operating spaces and the OR had a calendar that was controlled by a scheduler.  Each area was manned between 8 AM and 3 PM by a hundred or so nurses, technicians, and others.  In the late afternoon most of the rooms closed.  The few that remained open handled the overflow. One was available around the clock for urgent cases.  During the work day each of the designated areas was managed by a different surgical subspecialty, and had some unique equipment,

Gawande explained the importance of introducing the patient who will undergo surgery to everyone in the O.R., including the person who cleans the floor and the medical student.  He thinks the presentation gives everyone permission to sound an alarm if they notice a problem. Before a case starts, all the people who might play a role gather around the patient and are introduced. Then a “time out” is called.  The nurse or physician in charge would ask the patient their name and what they thought was about to happen, When indicated the involved breast or extremity was inked. (“In 1995 when a nurse told Florida Surgeon Rolando Sanchez he was cutting off the wrong leg, he kept going and she started to shake and cry. He felt he had gone too far.  The leg he had started to remove couldn’t be repaired and there was no turning back.”) ²⁹

A surgeon or team of surgeons usually performed all the cases in a morning or an afternoon block.  If three hips were replaced that half-day, one surgical team usually did them all.  After each operation, the room had to be cleaned and efficiently turned around.  In bloody cases, like a hip replacement, soaked pads were not thrown on the floor.  They were instead bagged, and the containers were tied and slipped into the hall outside the room.  Following invasive surgery, when blood in the abdomen made it hard to be sure no foreign objects remained in the area, the sponges were counted before and after the operation.  Post-operatively, people went to a recovery area where 20 to 30 nurses cared for them for variable periods of time.  If a spinal anesthetic was used, the patient remained in the observational area until the numbness had worn off.  

In fee-for-service facilities surgery accounts for a substantial part of hospital revenue.  Akron General Hospital published what it charges on its website. The bill for using the operating room at their facility, which is part of the Cleveland Clinic, depends on “the complexity” of the procedure.  Their billers created five intervention levels: For those on the lowest rungs the first hour costs $2718.  Each additional half hour adds $1100 to the bill.  For level 5 procedures—the most complex– the room cost is $4935 for the first hour and $2200 for each additional half hour.²⁰  

Free-standing facilities currently perform many of the “interventions” that were once done in hospitals: cataract surgery, colonoscopies, knee arthroscopies, cosmetic surgery, pain management, dental and ENT procedures. In 2019 there were 6100 ambulatory surgical centers in the U.S., and they performed more than half of that year’s 35 million operations and procedures.²¹

A 6 year old seemed cross eyed and saw an optometrist who realized the child had a 6th nerve palsy. The nerve that controls the lateral movement of his eye wasn’t working and that set off all kinds of alarms.  He was immediately sent to an ophthalmologist. The physician detected evidence of brain swelling and ordered an emergency MRI. That night one of the two hospital pediatric neurosurgeons told the parents their son had a brainstem tumor. The child was admitted and started on high dose steroids to decrease the pressure inside the skull. A few days later two pediatric neurosurgeons at Oakland Kaiser Hospital made a small opening in the rear of the child’s neck and removed the back of a vertebra.  They then sucked out the medulloblastoma cells (it is a friable malignant tumor) and rolled an MRI machine into the OR.  It revealed a tiny trace of tumor had invaded his spinal canal.  The vertebrae was replaced and fastened, and the wound was sewn shut.

Post operatively the child had obstructive hydrocephalus—fluid was not flowing from one chamber of the brain to the next one. It was possible he would need a shunt that transferred fluid from his brain to the space in the abdomen called the peritoneum. As a first step, under anesthesia a small hole was drilled in his skull and a thin sterile videoscope was passed through the brain into the fluid filled chamber in its middle.  The scope was maneuvered through the narrow passages that connected the ventricles, the fluid filled brain chambers. Cobweb like tissue was blocking the flow of fluids and it was pushed aside. Fluid started circulating normally and a shunt wasn’t needed.

After the child recovered from the surgery his insurer paid ¼ to ½ million dollars for proton beam radiation to destroy the small segment of tumor that remained.  It couldn’t be surgically removed without causing major neurologic damage.  Protons give off most of their energy (in a quick burst) to a precisely focused part of the body. This type of therapy decreases the amount of radiation to healthy tissues around the treated area.

The child was sent to the “Seattle Proton Therapy Center a facility where 10-foot-thick, lead-lined concrete walls isolate a particle accelerator that harnesses and fires protons generated from hydrogen gas. It was one in a national wave of costly facilities funded a decade or so back by private investors and lenders. The Seattle facility treats 500 people a year. “In 2018, after a net loss of $81 million over the prior two years, its original backers were handed a $135 million loss as part of a negotiated Chapter 11 bankruptcy.¹⁴” But they were still in business. At one time there were 27 proton centers in the U.S. They were expensive to build and maintain and their services are not covered by all insurance providers, so those that are still working are struggling financially.

Elsewhere on the planet, there are remote government funded community hospitals, in low and very low income countries—like Malawi and Bangladesh.  As described by the Harvard M.D. who spent time in Nepal, they are commonly located in far off corners of their nation and are the only options available to the poorest of the poor.  With 50 to 100 beds they serve 100,000 to a million people, and their doctors can usually perform a few orthopedic and general surgical procedures and C sections.  They have some X- ray capability, but commonly lack certain basics:  In Nepal 15% didn’t have piped in water; 20% lacked electricity; 55% didn’t have gloves, and 30% were unable to provide oxygen to those who need it²².

CHAPTER 8– OBAMACARE—THE AFFORDABLE CARE ACT

 “The people who are crazy enough to think they can change the world are the ones who do.” – Steve Jobs

 “Our healthcare insurance system is a mess.  We all know it, those who support Obamacare and those who oppose it. Something has to be done.” Senator John McCain—floor of Senate—July 25, 2017.⁹

By 2008 a number of insurance companies had instituted policies that, when investigated, troubled Congress and became the topic of exposés and newspaper articles.

People with serious pre existing medical conditions could not buy health insurance.  That now seemed to matter. 

When insurance companies couldn’t raise premiums they enhanced their profitability by creating large co-pays.  It diminished the value of health insurance and was troubling.

When someone in a small business developed an expensive problem, the cost of providing coverage to the company could exceed the value of the premiums of all the workers. In situations like this, for-profit insurance companies began substantially raising their rates.  Insurers knew that if the cost of care was high enough the companies would not renew their policies.  Aetna spent millions for technology that identified businesses that cost insurers more than the companies took in.  Health Net gave bonuses to employees who discovered them.  In the process “Aetna shed 8 million enrollees” in the early 1990s.”  

Most disturbingly there was a policy the companies called “recission”. When someone got sick their original questionnaire was scanned for minor, mostly irrelevant misstatements.  Wendell Potter tells of a man who had an angioplasty for coronary disease.  The insurer refused to pay because “he failed to disclose” a history of heartburn.  I guess it could have been angina.  It probably wasn’t, but it gave the company the foothold they then used to avoid paying $130,000 in medical costs.  The case was not unique.  When it was detailed in a Los Angeles newspaper letters poured in.

WellPoint, according to Reuters “singled out women with breast cancer for aggressive investigation.”  The company (presumably by finding insignificant misstatements in entry questionnaires) earned over a hundred million dollars by cancelling policies for females who had developed breast cancer. 

When questioned by a congressional committee, insurance companies CEOs were asked if they would end the policy of recission; and they said “no” they wouldn’t.²

In 2006 Massachusetts passed a health care law that in part became a blueprint for Obamacare.  At a time when a Republican, Mitt Romney was governor, Massachusetts extended “affordable”, compulsory, state subsidized health insurance to all its citizens, and it seemed to be working.  Vermont followed suit.  Some (perhaps Obama) wondered if this could be a model for other states.  Problem was, the Massachusetts situation was unique for a number of reasons.  When Dukakis was governor (in 1984) the legislature passed a law that helped protect the finances of people who were recovering from a catastrophic event, and that helped make sure hospitals got paid.  They established the “Uncompensated Care Pool.” It was funded by hospitals and insurance companies according to a formula, and it had accumulated a pile of usable money.  By 2003, the year Mitt Romney became governor, the (now called) Health Safety Net was bringing in $157 million a year. The state had funds they could work with. Mitt also got help from Ted Kennedy.  Through some legislative maneuver the state “secured three years of additional Medicaid funding, $1.05 billion.”

Massachusetts happened to be one of 11 states that still had a functioning 2.8 million members strong non-profit Blue Cross and Blue Shield.  The company used 90 percent of the money taken in to care for people. There were no shareholders to satisfy. For-profit companies had to compete with the premiums the Blues charged.

Medicare had been in existence since 1965.  The bureau that ran the program, the CMS, had 6000 employees and had established payment schedules for “more than 10,000 physician services”.  Prices were adjusted … “to reflect the variation in practice costs from area to area.”   The presence of an independent agency that was trying to assess the “worth” of a visit or intervention helped keep a cap on costs.³

The Massachusetts program was less comprehensive than Obama care would be.  The Affordable Care Act would pay a large part of the insurance premium for people who earned less than 400% of the federal poverty level. Massachusetts made the cut at 300%. 

By the time Obama became president in 2009, the ability of medicine to enhance the quality and quantity of most lives had grown and costs had risen dramatically.  Over 17% of the national GDP was spent on “health”.  A majority of Americans had government or business sponsored quality affordable health care, but many citizens were excluded, and the unregulated private insurance companies had grown powerful and arrogant. I voted for Barak Obama and assumed he would fix health care.  It was part of his platform; he favored the “public option”…like Medicare or Medicaid for those who want it. 

The 2008 election gave Democrats a majority in the House and Senate, but Obama believed in inclusion—working across the aisle—compromise.  And the Republicans weren’t having it.  For some it was because the nation rejected John McCain, a popular white candidate, or because of a perceived loss of status. Others were probably just sore losers. Many assumed Obama viewed the world through the eyes of a black man struggling for a better life for “his people.”  And he did.  His wife, Michelle grew up in a black, working class household in Chicago.  Barak Obama was also the son of a white mother.  When she died young Barak was raised by white grandparents.  His grandfather fought in the Second World War.  Obama had no ancestors who were former slaves, and his father was from British occupied Kenya.

The 2008 presidential election was the most racially and ethnically diverse in U.S. history and that troubled Beltway Republican politicians.⁶ On the evening of Obama’s inauguration, opposition leaders met and decided they would be against everything that he proposed.  The economy was on the edge of another great depression and Barak favored a Wall Street bail out.  Democrats voted with him and Republicans didn’t.   

He used the money to prop up the big banks, and decided to NOT punish their leaders.  The heads of the banks then gave themselves millions in bonuses.  At the same time they took homes away from people with mortgages who, as a result of the recession, had lost their jobs and couldn’t make the payments. To many it seemed like welfare for the privileged and bleak Capitalism for the common man.

Obama’s popularity declined.  It was still his first year in office and he decided to pass a health care bill based on his campaign promises and sought bipartisan support.  Republican Senators decided to oppose him, and they forced their fellow legislators to just say NO to any legislation Obama proposed.   According to Frontline, some thought the bill would be the president’s Waterloo, and that it would allow them to recapture the Senate. 

The legislative process took more than a year. The Senate would not pass a law unless 60 of the 100 senators voted for it, and there were exactly 60 Democratic senators. Obama needed every vote if he wanted to pass the bill. The insurance companies didn’t want a public option.  They wanted to require everyone to buy insurance.  The drug industry didn’t want Medicare to be able to negotiate drug prices. There were ups and downs, protests and an expensive insurance company advertising campaign.  Ultimately, to get the needed votes Obama had to “kill” the public option and water down a new, special tax on medical devices and equipment.  To obtain the vote of Nebraska’s democratic Senator, Ben Nelson, the federal government had to agree to pay the full price of his state’s Medicaid insurance. 

Then Democratic Senator Ted Kennedy died, and he was replaced by a Republican.  The Democrats no longer had a 60 vote “super majority.” 

In the end Obama campaigned hard, “expended a lot of political capital,” and Congress passed the current Affordable Care Act. In March 2010 Obamacare became law.¹ The Affordable Care Act got rid of recission.  The law prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem.  Health plans can no longer set a lifetime limit on how much an insurer had to pay to cover someone.  Insurers are required to offer a minimum package of benefits.  Preventative health services must be provided without a co-payment.  Children are allowed to stay on their parents’ policies until age 26. In an effort to get enough money into the system, to make it workable, at the insistence of the insurance companies the law required people to buy a policy.  It enacted a tax penalty for large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance.

If a state agreed, people whose incomes were a little above the poverty line were now eligible for Medicaid.  36 states signed up.  As of January 2020, fourteen states were still declining the freebie.  Without the extra patients some rural hospitals failed and people went without care.  Grace Marie Turner of the Galen institute, one of the loudest anti-expansion voices, thinks putting more people on Medicaid worsens the cycle of dependence and harms the economy.  Extra people mean more competition for the available physicians, and she worries about fraud and waste. ¹⁰

The ACA, Affordable Care Act, supplemented insurance premiums for people whose earnings were quite low but who didn’t qualify for Medicaid.

 It allowed premiums to be sensitive to the marketplace. 

The only insurer in a state can charge more. 

In the face of stiff competition companies can offer cheaper rates. 

Group policy rates are the result of bargaining.  The size and average age of the people to be insured matters. 

High deductibles are permitted. 

An older person can be charged up to three times as much as a 26 year old.  Tobacco users may be forced to pay twice as much as non users. 

Prices can’t be higher for a new enrollee who has metastatic cancer and is receiving expensive chemotherapy.  Nor can more be charged to the person who has hemophilia (and bleeds easily) or someone who just had a heart attack or a stroke.  A person’s “current health or medical history”—their pre-existing condition, can’t affect the premium’s price.  

The law’s approach runs contrary to the basic premise of insurance.  Companies evaluate risk. They charge more for flood insurance in a zone that is periodically inundated, more for fire insurance for homes in a highly wooded area, and more for earthquake insurance in California. On a societal level it’s not wrong to discourage people whose homes were washed out a few times to stop rebuilding in low lying areas that flood every few years. 

But most developed countries don’t risk assess before they decide if they will provide health care. And they don’t invoke an illness penalty. As Atul Gawande put it: A century ago the average American didn’t grow old.  When someone suffered a catastrophic event: pneumonia, a heart attack, a bad accident–- many died or were disabled but some walked away unharmed.  Modern medicine often rescues people who would have died.  We cure pneumonia, pin broken hips, and stent narrowed coronary arteries. Subsequently people may or may not be as healthy as they were, but they now have a “pre-existing condition.  Before the Affordable Care Act was enacted they found it difficult or impossible to acquire insurance⁵  

The funds insurers spend for medical care is called a loss.  If the company uses 20 percent of the money they take in for executives, payroll, and stockholders, their medical loss ratio is 80 percent.

The ACA, Affordable Care Act, capped the amount companies could keep at 20 percent for individuals and 15% for groups.  If a company spent less than 80 to 85 percent of their premiums on patient care they had to pay a fine.  (Medicare has an overhead of 3 to 5.2 percent.)⁴ 

As Elizabeth Rosenthal, author and editor of Kaiser Health News learned, a higher medical loss ratio didn’t dampen the amount the insurance company paid for patient services.  Her book tells the story of a person whose infusions at an influential hospital (NYU) cost the insurance company five times as much as they would have, had the patient received the same treatment at a nearby, presumably equally capable, facility.  Rosenthal asked herself why the insurance company was willing to pay so much. 

One possible explanation: Hospitals and physicians routinely over charge, and insurance companies pay a negotiated portion of the bill.  Then insurers show sick people the official bill and brag about the amount of money the person saved. 

 When insurers pay a higher portion of the bill and their profits fall below 15 to 20 percent they are allowed to hike the price of their premiums.  

When people pay more for insurance the company takes in more money and gets to keep 15 to 20 percent of the increased revenue. 

The establishment of an “acceptable” medical loss ratio perversely rewarded insurers who drive up the cost of medical care and insurance.  Health care premiums have risen 25% since Obamacare was enacted.   

The law was loved and decried by many.  The young and healthy had to purchase insurance and were grouped with people who had pre existing conditions.  Their premiums rose and the price increase didn’t seem fair.  Over time they had come to believe that cheap insurance was one of their unstated rights. 

Two new taxes were enacted: A medical devise tax and a “Cadillac” tax on high priced policies.

The Trump administration is establishing “association health plans.”  They still cover pre-existing illnesses but they “allow small businesses, including self-employed workers, (presumably groups that don’t have many people with serious pre-existing problems), to band together by geography or industry and obtain coverage as if they were a single large employer.”  The plans “don’t need the minimum benefits required by the ACA and they can drop maternity or mental health coverage.”  As the healthy are drawn away from the ACA, the exchange costs go up and the illness penalty returns.⁷

At 1:30 A.M on the morning on July 28, 2017, a bill that would have repealed Obamacare needed one final vote to pass. The person who cast it was Republican Senator John McCain, a man who had recently learned he had a lethal brain tumor.

He came to the Senate chamber, stood before his fellow legislators and voted thumbs down. No!   The repeal of the law failed. 

McCain was unhappy with the way Democrats had, years earlier, forced a “social and economic change as massive as Obamacare” through Congress.”  “Our healthcare insurance system is a mess. We all know it, those who support Obamacare and those who oppose it. Something has to be done.”  He didn’t suggest repairing and saving the Affordable Care Act.  But he spoke of “incremental progress, compromise, and chipping away at problems.⁹ ”

In 2018 congress repealed the law’s requirement that everyone “must “ buy insurance.  A federal judge in Texas decided that made the Affordable Care Act unconstitutional.  He argued the ACA obliges people to either buy insurance or pay a fine.  The requirement was a tax.  When Congress repealed the individual mandate the law stopped looking like a tax. 

August of 2018 the government started allowing states to take Medicaid coverage away from “people not engaging in work or work-related activities for a specified number of hours each month.”

 In Dec 2019 Congress passed a $1.4 trillion spending bill.

It repealed the medical device tax ($20 billion less for health care in a decade) The Cadillac tax ($193 billion saved by the wealthiest citizens in a decade.)  The Health insurance tax that was used to pay for the federal and state marketplace exchanges. ($164 billion over a decade.)  

The spending bill provided two years of Medicaid funding for Puerto Rico and other U.S. territories, and it barred HHS, the federal health and human services department, from ending auto-reenrollment.  They are not allowed to create a coverage gap for people who forget to enroll at the end of each year.

Atul Gawande once concluded that the United States may be the only developed country in the world where people are “unable to come to agreement” on the concept of health care as a right…….on the idea that all should be able to benefit from the medical advances of the last hundred years. Our nation’s health care road remains quite bumpy.

In 1914, when the First World War started, physicians had a better understanding of illnesses and their cause, but they still were unable to do much to prevent or treat them.  My dad was six when the family moved into a small, wooden, dirt floor, cottage in a Shtetl that straddled one of the main Ukrainian east- west highways.  That year acting on orders from the Czar, the Russian army attacked Germany, entered their enemy’s territory, and fell into a trap.  The second army was virtually` destroyed at the Battle off Tannenberg.  Thousands of the surviving soldiers retreated.  When they came through my father’s town the fleeing Cossacks burned the family home to the ground.  During the subsequent years the family crowded into one of the remaining cabins on the edge of the village.  It was owned by an elderly Ukrainian who hadn’t left for mother Russia with his family.

During the war years no one bathed or boiled their clothes.  Everyone’s garments and bedding contained body lice.  One winter there was a typhus outbreak.  The infectious disease is caused by a tiny bacterium (ricketsia) that lives in the lice.  When the creatures defecate their droppings itch, people scratch and tear their skin,   and bacteria enter their bodies.  One to two weeks later the aching starts. Many develop a severe illness: chills, high fevers, an unremitting headache, exhaustion.  My grandmother became confused and disoriented.  When the nurse from the Russian army came to inspect the house the family was unable hide her and the nurse summoned the wagon that took her to the school house, the large hall full of beds where most died.  My grandfather watched and cried as they carted her away. 

          “During the eight-year period from 1917 to 1925, over 25 million people living in Russia developed epidemic typhus; three million died.  Some claim epidemic typhus has caused more deaths than all the wars in history.³”

Antibiotics had not yet been discovered, so doctors could diagnose the disease but they had no treatment.  (In the 21^st century Typhus is easily cured and prevented with the antibiotic Doxycycline.)

My father always remembered his boyhood, and when I chose to go to medical school he shrugged.  Based on what he witnessed, he had concluded that doctors knew how to recognize and diagnose illness, but that’s all they could do.