Doctors and the Next President

Tonight may mark the beginning of a better future or the continuation of a downward spiral in the fortune and well being of the American people. The two presidential candidates offer drastically different pathways toward change in the health care system. The merits of each plan may be debatable, yet the greatest concern I hear from the mouths of a vocal handful of resident physicians and medical students has little to do with health care reform: instead, they are concerned with income tax. Some resent being “in the same tax bracket as Donald Trump,” while others find disgust in the notion of a welfare state. To those who believe this, I offer this challenge:

According to an analysis done by the nonpartisan Tax Policy Center on the tax plans of the two candidates, families with incomes up to $603,402 (99% of the population) will see a reduction or no change in taxes from the current level. Given the current level of physician salaries (most ranging between $100,000-$300,000), would you still be sufficiently opposed to a tax increase for the top 1% of income such that you would vote against a candidate actually willing to address health care issues?

It is clear from his policies that McCain has little to offer for American health care, let alone other domestic concerns. For most of the past century, America’s health needs has subsisted on a combination of employer-based health insurance that gives employers tax credits and the government-based (“welfare state”) Medicare and Medicaid programs. For the first time, a presidential candidate (McCain) wants to remove the incentives for employers to provide health insurance and replace health care plans with an insufficient tax credit: he seeks to reduce demand for health services by making patients keep track of their own health care bills. This runs contrary to the efforts of physicians, public health professionals, and policy makers toward improving preventive and primary care: the odds are currently stacked against the routine provision of preventive care to patients, and making patients pay for their health care bills out of pocket will further weaken primary care. The idea of “catastrophic health insurance” is attractive for a population of optimal health, but anyone with familiarity with the dual problem of increased out of pocket payments and increasing health care costs experienced in other countries understands the inapplicability of this idea at this time.

Obama’s health care plan is far from perfect, but it offers guidelines for improvement, and more importantly, room for expert participation:

Electronic Health Information Technology: Obama plans to spend $10 billion per year over the next five years to develop a standardized electronic medical records system which will help with quality measurements, reduce medical errors, and reduce costs from redundancy (e.g. reordering the same or unnecessary tests after transferring a patient). It is absolutely essential for physicians to be involved in the process of developing such a standardized system as it is partly due to the lack of adequate physician participation that we have disorganized, expensive, and user-unfriendly EMR systems. Here is a push from the top for a standard approach: all we need to do is say what we want.

Disease Management Programs: These programs are designed to aid patients in managing chronic diseases by providing information, reminders, and cost-effective services to coordinate care. Unfortunately, these are services that should be provided by physicians who are sometimes failing to routinely provide them, often due to time pressures imposed by their practices or their payers. My step-mother, a physician, is a staunch opponent of these programs for she believes that they disrupt the physician-patient relationship and lack coordination with a patient’s physician. I agree with her reasons for opposition, but I do not see these programs as necessarily evil: I believe they are a product of a lack of communication and coordination that we can improve upon.

Pay for Performance: Medicare and a newly formed health insurance exchange would both use P4P measures to incentivize better care rather than increased volume of care provided. Currently, the measures are variable in quality, and again, this is an important area for physicians to participate with respect to refining performance measures to match medical and health care quality!

Address health care disparities: One of the more complicated issues in medicine is the fact that people of different races and backgrounds get different types of health care for not entirely known reasons. In keeping with the our professional code, it is important for physicians to constantly strive for equality and just practice in medicine.

Address malpractice: Obama’s plan intends to reduce malpractice insurance costs for physicians by strengthening antitrust laws. This will help, but I think that physicians can help address patient safety and improve the patient-physician relationship (goals of the Obama plan) by setting up better methods of screening and evaluating malpractice cases (e.g. health care courts or panels) and delivering more, smaller compensation payments to those who need them.

Cheaper drug prices through importation, Medicare price negotiation, and forbidding anti-competitive measures: We want cheaper drug prices for our patients. There are enough reasons and issues that might hinder a patient from adhering to a medical regimen, and we don’t want cost to be one of them!

Reduce catastrophic expenses: Obama’s plan intends to have the government assist employers in providing health insurance to their patients by reimbursing them for catastrophic health expenses. The current estimate is that five percent of American patients account for 49% of expenses each year (although that five percent isn’t necessarily the same people from year to year). I’m not certain how Obama’s administration will cover these costs, but it is important for physicians to make sure that costs are not cut from other important health care provisions to address this issue.

Establish a National Health Insurance Exchange: In addition to the overall benefits of reduced paperwork, portability and simplified enrollment, having a good national plan (in addition to other private offerings and Medicare and Medicaid) can help reduce the amount of uninsured or underinsured patients with the promise of guaranteed eligibility: patients with preexisting conditions, often screened out by insurance companies who don’t want to pay their health care costs, won’t be penalized for being sick.

Health Care for All Children: It is shameful that the country with the most advanced medicine and the greatest potential for political, social, and financial freedom is unable to provide healthcare for all of its children and young adults. Obama’s plan includes a mandate to provide health care for children under 18, expansion and support for the safety net programs Medicaid and SCHIP, and better options for young adults up to age 25. In the past, physicians (pediatricians) reversed standard practices and stepped forward to protect children from child abusers and sexual abuse. It is time again for physicians to advocate for America’s children to give each one a chance at being a healthy, productive member of society.

Preventive health care: Obama’s plan seeks to address preventive health care at multiple levels, from individuals to schools to employers to cities and states. In order to properly address health care and medical issues, this vision requires experts. Who will step up to the plate and provide the information and leadership to make this happen?

For a long time, the large infrastructure of insurance, health management, and pharmaceutical/biotechnology companies have manipulated physicians and lulled them into a false sense of security and autonomy. Some physicians cling to the notion that they are able to practice independently from the influence of these powers and that if they fight health care reform (from the “big bad government”), they will retain what little autonomy they have left. This is a delusion, and failing to address the larger problems in health care will further weaken the role of physicians as independent operators and leaders in health care and in society. For the first time in recent history, a future President is offering a compelling vision for a better future that is neither unilateral nor drastic in the intensity of change. Instead, we have before us a picture of a path toward gradual, thoughtful reform. It is our job to bolster its strengths, correct its flaws, and do what is best for our patients and ourselves.

  1. Ben said:

    It’s like you were waiting for me to respond 😀

    I’m actually only going to make one point, because I agree with most of the points you bring up (and actually feel that they’ve been a part of EVERY healthcare plan that I’ve seen in the past 2 elections — McCain’s website talks about all of these, as did Kerry’s, Bush’s, Clinton’s, Gore’s, etc. etc.) and that point is that people are GROSSLY mischaracterizing McCain’s plan (and this is probably his own campaign’s fault).

    The facts:
    1. Almost EVERYBODY would be better off under McCain’s healthcare plan on a dollars-by-dollars basis (– so no, McCain is not destroying healthcare

    2. People oftentimes forget that Obama’s own healthcare and economic policy advisors, before they became affiliated with the Obama campaign, advocated strongly for a plan that is much closer to McCain’s plan than Obama’s.

    Now, it’s a fair point to argue that McCain wouldn’t push for these other initiatives that you’ve described here — I frankly am not informed enough to argue one way or the other (although history tells us that b/c both parties have always backed most of these initiatives, and they haven’t been done yet, they probably will never be done) — but I find the characterization that McCain’s healthcare plan is some capitalistic abomination to be very suspect.

  2. Apollo said:

    Fair points. Although, I’m amused that your source is the WSJ, which I’ve come to view as the Fox News equivalent of health care reporting in terms of bias and (lack of) quality. They have some of the worst/most biased health care writers.

    My overall point isn’t that McCain plan is catastrophic, but rather, it lacks the drive, forethought, or motivation to make helpful changes. Health care under McCain would be either status quo (slowly getting worse) or actively getting a bit worse. But fortunately, we’ll never have to know.

  3. Eric said:

    I agree with Ben, in that McCain clearly didn’t articulate his plan well; the Economist is also another supporter of McCain’s health plan, and they have a good analysis, though they ultimately threw their overall support behind Obama.

    Unfortunately, I don’t think either candidate really addressed one of the big problems, which is the lack of top doctors going into primary care, and the subsequent increase in the cost of primary care visits (both in money and time).

    Personally, I do think that getting rid of the ties between employment and health care are important, and it’s the main part of McCain’s plan that I agree with. I’d rather that the employers just pay the equivalent amount in salary to the employees instead of providing the health care, thereby allowing employees to choose the health care best suited for them.

    Maybe a national pool of insurance like Obama’s plan is better, maybe having a completely private system is better, but in the end, the more control a consumer has, the more efficient the system is, in that people get to choose a system that’s best for themselves. This mechanism would also be less convoluted for creating a better safety net for those who have catastrophic health care payments; the aid could go directly to the person who needs it, rather than going through the employer as an intermediary, which just increases transaction costs.

    I think a big problem with health care is that there are so many layers between consumers and doctors, and so there is no real economic incentive for efficiency and preventative measures to pierce all these layers. Patients don’t feel as much of a need to keep visiting primary care regularly, because they aren’t paying (directly) for their own health insurance — their employer is. Doctors don’t get reimbursed by patients; they get reimbursed by insurance companies, and get many of their fees dictated to them by those companies. Those companies aren’t influenced by what patients want, because they get paid by employers, who just want to keep costs down, since they’re not the direct beneficiaries of the care.

    That’s what I think is mainly broken in health care. The proper incentives are nowhere to be found.

  4. Although not specifically addressed , I predict that Obama’s healthcare plan will demand accountability on the part of all health care providers. His plan will stress preventive care, retrict payment for only medically necessary benefits, and will insist of quality care with an emphasis on reducing medication errors and preventable complications of care.

    Hopefully, at some point in time, the blatant abuse of the present healthcare system will be recognized. No one, and no health care plan that advocates a system of letting costs escalate and then raises premiums, deductibles, and co-pays to offset the cost, will answer the problem of reforming our present health care system. I am a medical director in a large hospital system and I encounter the above abuse every day.

    Providing affordable, universal, basic healthcare for every resident in the country, and offering an option of insurance coverage above basic to anyone willing to pay the price should be the objective of the new administration. For a suggestion of the definition of Basic Healthcare, go to my website: and scroll down to Speaking Out/Basic Healthcare.

    It can be done–yes, we can.

    Charles Clark

  5. Apollo said:

    Eric: I agree with the problem of excess layering. On another note, I can’t remember when he said it, but I somewhat remember Obama mentioning the idea of expanding loan forgiveness programs for physicians going into primary care (which can be a compelling incentive). However, this is a relatively small measure that doesn’t fully address the problem.

  6. Edgar said:

    Hello. My name is Edgar and I’m an editor at, the debate website. Since we both cover health issues, I thought I’d drop you a note. I would’ve e-mailed you but I couldn’t find an address.
    See, we’re currently having a discussion about whether the U.S. should have universal healthcare. See it here:
    Although vetted experts are the ones doing the debating, anyone can contribute by choosing a side and posting comments about the experts’ arguments.
    Check it out and, if you have the time, let me know what you think at

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