July 13, 2017
Area(s) of Interest: Access to Care
By Steve Heilig
Heilig is director of public health and education for the San Francisco Marin Medical Society, co-editor of the Cambridge Quarterly of Healthcare Ethics, a former hospice director and caregiver, a clinical ethics consultant for numerous hospitals, and received the California Medical Association Foundation’s Sparks Leadership Award for contributions to community health. His views here are his own; this piece originated as a letter published in the New York Times.
As a health care ethicist, I am regularly called upon to help physicians and others make tough decisions for people who are very ill — regardless of their finances or insurance status.
Beyond their sense of human decency, these medical professionals have taken oaths that compel them to do all they can to keep their patients healthy and thriving.
In California during the 1960s, especially in San Francisco, the concept of providing some minimum standards of a “right” to health care spread within the medical and broader community. At UC San Francisco (UCSF) Medical Center, a so-called “summer of love” was just getting underway when a large health policy forum was held 50 years ago, featuring both then-UCSF Chancellor Philip Lee, M.D. and a young postdoctoral fellow, David Smith M.D.
Lee had come to UCSF from service in the Lyndon Johnson administration as U.S. Assistant Secretary of Health, where he was charged with implementing the new Medicare and Medicaid programs, as well as desegregating hospitals in the south. Dr. Smith, a recent UCSF medical graduate who lived in the neighboring Haight-Ashbury district where “hippies” were congregating, saw a public health and moral crisis brewing. Other hospitals and even the local health department were refusing to see the legions of young arrivals and just wanted them to go away.
Dr. Smith, doing laboratory toxicology research with LSD and other psychoactive drugs, would walk home and see similar experimentation on the streets by humans, not to mention experiencing a wide range of more traditional pathologies. When somebody at the UCSF policy forum said something Dr. Smith found objectionable, he stood and said: “Health care is a right, not a privilege.”
That slogan became the guiding principle of the pioneering Haight-Ashbury Free Clinic that Smith soon opened in an empty dental office. That clinic has thrived and evolved to this day, with millions of patient encounters, and served as a model for many other such clinics. The medical subspecialty of “Addiction Medicine” gained official legitimacy out of these actions as well, since substance abuse was a big part of their patient load and mission.
And when President Obama signed the Affordable Care Act (ACA) into law, he echoed Dr. Smith’s original declaration that health care is a right, not a privilege.
But what does that mean in practice? Of course granting “rights” is a tricky thing, and on health care especially so. What are the limits? Surely we cannot (and should not?) enshrine a right to anything a patient or even their clinicians might want to provide. Perhaps we might call for “evidence-based” rights?
But in any event, the slogan in practice has meant a right to primary care, including emergency care as mandated by federal laws such as the Emergency Medical Treatment and Labor Act (EMTALA). Without the EMTALA, patients would otherwise wind up in the emergency room (which is much more expensive than primary care) or die outside hospital doors — not to mention the larger and less visible toll of premature morbidity and mortality.
In the current Republican efforts to repeal the ACA, replacing it or not, one element seems enshrined — tax cuts for the highest earners. One striking detail is that the total amount of funding the Republicans want to cut from Medicaid is remarkably close to the total amount of those tax cuts. Correlation? Causation? Random, if statistically remarkable, chance?
Few disagree that the U.S. must do better regarding the economics of health care. Other smart and civilized nations have produced better outcomes with fewer dollars — and it always seems to be a question of priorities.
Where to save public funds without hurting people? Perhaps the military, which takes by far the largest share of our tax dollars? My father was, for lack of a kinder term, an arms merchant. Late in his life he and his military colleagues freely admitted that much, if not most, of what was spent on military contracting was a waste, at least in any practical sense; the “military-industrial complex,” as General/President Eisenhower so memorably warned, was mostly about private profit.
Might some of that cash be better devoted to imperatives like finding new antibiotics and combating the resistance thereof, addressing our addiction epidemic, training and focusing more on primary care needs, better nutritional habits and interventions — just to name a few of the challenges I witness on a frequent basis.
For those who read the medical and health policy literature on such issues, hearing about political plans for health care can be a jarring experience. It’s often as if the politicians never ask real experts what might be best.
For the clinicians among us, one analogous experience might be that of having an insurance company clerk deny a claim as being “not medically indicated.” Based upon what? Not training, evidence or expertise — somehow financial wishes seem to lurk behind it all.
The disconnect between evidence and what might be called “fake science” is large and seems to be increasing, especially in such contested arenas as reproductive and environmental health, to name just two. Couldn’t we have something like “evidence-based politics”?
The “right” to health care is only one of the elements of progress rooted in the fabled 1960s, along with civil rights, women’s rights, anti-war, environmentalism, and more — all of which are currently experiencing a bit of a political backlash.
But as elected officials, Congress take oaths to serve the American people — not corporations, or some ideology or even the president. As in medicine, policies must be based on facts and evidence.
Virtually every relevant physician-based and medical organization opposes Trumpcare and a full ACA repeal (especially without a replacement!) because it would hurt millions of Americans. U.S. Senators voting for anything similar to the current GOP repeal proposal should gut check their conscience to prevent violating their oath of office.
As they consider their vote, I hope they will remember that. Future historians — and voters — certainly will.