We live in interesting times. I am writing this column as I travel to Washington, DC, to participate in a fly-in where representatives of NASS and other specialty groups gather together to discuss the political and regulatory issues that affect our practices and our patients. We will have an audience with Health and Human Services Secretary Tom Price and I hope to have an audience with Paul Ryan, the Speaker of the House who happens to be from my home state. I have met both of these gentlemen before on past visits and I have found them to be highly intelligent, well meaning and well educated on the issues of health reform. I also look forward to meeting with staff representatives of my Democratic Senator, Tammy Baldwin and Congressman, Mark Pocan. While in the past we have not seen eye to eye on several issues, I have always been treated professionally and am optimistic that in the new political landscape we may find some common ground.
In past meetings, we have discussed the problems that “Obamacare” creates for those of us on the front lines. We have had good discussions about the problems and costs associated with the mandated use of electronic health record (EHR) systems that are not actually health record systems, frustrations related to the lack of interoperability of these systems, and frustration related to the explosion in “quality improvement” reporting requirements which are burdensome yet have no demonstrated value in actually improving quality. Some of these discussions have borne fruit as there has been a definite shift toward decreasing new regulatory burdens, encouraging crosstalk between EHR systems as well as between such systems and patient registries.
Now, in the era of the Trump administration, we are faced with a potential re-organization of government involvement in medical care. As I prepare to be briefed on the relevant pieces of legislation, both on what the proposals mean as well as on what the odds are of the proposal getting passed, I reflect on what led up to our current mess.
The history of organized medicine meddling in politics and politicians meddling in medicine goes back years. Doomsayers have been decrying the death of the medical specialty at the hands of the government for decades, if not centuries. In the 1960s, when Medicare was proposed, the American Medical Association (AMA) and all of organized medicine vigorously opposed the institution of government involvement in the practice of medicine. Ronald Reagan spoke out against socialized medicine on a recording distributed to physicians (shown at left). The LP record, distributed as part of the AMA’s “Operation Coffee Cup,” expressed significant reservations about the government interfering with the patient/physician relationship. The basic message of the recording is that government-run medicine is socialism which undermines American freedom. The record was distributed to physicians and was intended to be played at coffee meetings hosted by physicians’ wives. Why was the AMA so opposed to Medicare? Based on statements by its leadership, there was a significant concern that “compulsory security” would take away individual responsibility and lead to a “weakening of national caliber” and undue uninformed interference with the patient/physician relationship.
Medicare was passed despite these objections in 1965. What happened? We can, and probably should, argue about the effects on “national caliber,” but there is no argument that the institution of Medicare was a tremendous cash cow to practicing physicians. With large segments of the population now covered for medical care and with FICA contributions the only cost for seeking such care, more care was sought and more care was delivered.
Medical expenditures grew substantially beginning in 1965, going from about 1.5% of the GDP in 1965 to approximately 8% of the GDP in 50 years. This compares to a drop from 10% to 5% of the GDP in defense spending during the same time interval, and a steady 5% expenditure on education. During this same time period, physician salary growth outpaced every other profession and inflation by a significant margin.2 To be fair, there was a concomitant increase in the average life span of about eight years between the 1960s and late 2000s (albeit compared to an increase of nearly 14 years between 1900 and 1960—tough to beat clean water and antibiotics!).3-5 In any case, more patients were getting care, life expectancy increased, and physicians were making a great living. What’s not to love? *This is an excerpt from the July/August 2017 issue of SpineLine. To read the entire column, click here.