By Kristin Story Held, M.D.
We physicians have lost control of our profession, our patients’ safety, and our ability to freely practice patient- centered Hippocratic medicine in the United States.
In 1984 I began my last year of medical school and cast my first vote for President of the United States. I voted for bold leader, humble servant, and champion of freedom, the 40th President, Ronald Wilson Reagan. I was filled with hope, and eager to put my hard-earned knowledge and skills into action to help patients—to fix them when they break, alleviate their pain, cure their diseases, improve their quality of life, and prolong their lives.
My medical school tuition that fall semester at the University of Texas Medical School at San Antonio was $300. A $60 health service fee, $10 activity fee, $25 malpractice fee, and $35 diploma fee brought the total to $430.
Texas needed hard-working, well-trained doctors, so the state provided funds to medical schools and made medical education affordable. We regarded our medical education as a privilege, and we provided plenty of labor to help care for the state’s uninsured and needy, from whom we learned to be physicians. State, county hospital district, and local and private charity provided money for hospitals and inpatient care. We did not need to take out exorbitant loans to pay for our education, so we were able to set out and set up our medical practices across the state and nation, unleveraged. Most physicians were self-employed in private practice. Most, like me, stayed in our communities.
In 2018-2019, tuition at the University of Texas Medical School at San Antonio, one of the lowest-cost schools in the nation, is $19,783 for in-state tuition and fees.1 According to the Association of American Medical Colleges (AAMC), the average cost for one-year tuition, fees, and health insurance at a public medical school was $37,556 for in-state students and $62,194 for out-of-state students in 2019-2020.2
Hospitals now use medical students as data collectors for billing and collecting, taking federal and state money for themselves. States allocate less money to medical education. A student-loan industry has ballooned, and medical schools respond to the available money by increasing tuition nonstop. According to the AAMC, the median student medical school debt was $194,000 in 2018. Encumbered with such debt, young physicians are no longer free to set up practice on their own. The AMA reported that 47.4% of practicing physicians were employed, and 45.9% owned their own practices in 2018. Employed physicians now exceed those who own their practices.3
Young physicians are leaving medicine before they start, settling for “PRN” work and being replaced by mid- level “providers,” nurse anesthetists, nurse practitioners, optometrists, and a never-ending cascade of “eligible clinician” promoted to physician by politicians, bureaucrats, and private-equity corporatists. Anesthesiologists on a “PRN” list are called whenever an opportunity to do a case happens to open up. Work is not only part time but unpredictable. Hours are the least desirable and cannot even be scheduled. This is how an anesthesia group that was bought out by a private- equity group treats junior physicians.
We physicians, unlike these “physician extenders,” are subject to intense testing and training, state licensing and specialty board certification throughout medical school, internship, and residency, and remain subject to continuing medical education and maintenance of certification for the rest of our professional careers. While the cost of medical education and staying in practice has gone up, physician payment has gone down. “Physician Reimbursement for Cataract Surgery” shows how the allowable Medicare Physician Fee Schedule for cataract surgery with an IOL (CPT 66984) has dropped from $1,000 in 1996 to $557 in 2020.4,5
The National Debt Crisis
In President Reagan’s Address to the Nation on the Federal Budget and Deficit Reduction, on Apr 24, 1985,6 he forewarned the American people of the dangers of continuing down the well-trodden path of government fiscal irresponsibility. At that time, the national debt was $1.8 trillion. Today, a mere 34 years later, according to the National Debt Clock (usdebtclock. org), the national debt has exploded to $23 trillion.
In his book The 5000 Year Leap: A Miracle That Changed the World, Cleon Skousen7 delineates 28 Principles of Freedom. The 27th Principle is Avoiding the Burden of Debt: “The burden of debt is as destructive to human freedom as subjugation by conquest.” Our founders believed that passing debt from one generation to another was immoral. Benjamin Franklin warned, “Think what you do when you run in debt, you give another power over your liberty.” Thomas Jefferson said, “I place…public debt as the greatest of dangers to be feared. To preserve our independence, we must not let our leaders load us with perpetual debt.”7
A substantial part of this debt can be attributed to what is now lumped into the category called “healthcare.” We currently spend more than $3.2 trillion, more than a fifth of our economy, on “healthcare” annually. This is not only unsustainable, but it is irresponsible and morally untenable. Medicare will be insolvent within the next decade. Medicaid is quickly becoming the top state budget expense.
A Conflict of Visions
Politicians differ drastically about solutions to this crisis. Democrats forcefully propose, with their media megaphones, plans such as Vermont socialist Sen. Bernie
Sanders’ and Rep. Pramila Jayapal’s HR 1384, Senate and House versions of single-payer healthcare legislation, each called the Medicare for All Act. This would destroy the U.S. economy in short order.8 Democrats want to centralize medical care, putting the federal government in control of our medical care and legally eliminating private medical insurance.
Democrat “healthcare reform” architects share a particular worldview. President Obama’s key adviser on the Affordable Care Act (ACA), Ezekiel Emanuel, M.D., wrote the telling piece, “Why I Hope to Die at 75: An argument that societies and families—and you—will be better off if nature takes its course swiftly and promptly,” published in The Atlantic.9 He bemoaned the fact that doctors take the Hippocratic Oath too seriously, “as an imperative to do everything for the patient.” He believes doctors’ ethical obligations should be redefined and medical students should be trained “to provide socially sustainable, cost-effective care” instead of thinking only about their own patient’s needs. President Obama’s first CMS head, Donald Berwick, M.D., opined that federal government must step in between doctors and patients to curb and redistribute the use of medical resources.10
Such non-elected bureaucrats believe that groups, not individuals, are the units of concern. They believe innovation is too expensive. They believe government knows best. Everyone recalls President Obama’s telling words at a healthcare town hall11 in 2009: “At least we can let doctors know, and your mom know, that you know what? Maybe this isn’t gonna help. Maybe you’re better off not having the surgery, but taking the painkiller.”12 Their impact on the philosophy of current healthcare policy cannot be overstated.
The result of ACA is that premiums on the individual market have doubled, even tripled in some states since ACA regulations took effect. Current CMS head Seema Verma says, “Consider a 60 year old couple living in Grand Island, Nebraska who earn $70,000 a year, the lowest cost silver plan cost $38,000 a year in premiums, with an $11,000 deductible,…. more than two thirds of their income.”13
After the failure of ACA, “Medicare for All” is the next step, possibly intended from the beginning. Supporters use two main false arguments to support the government takeover of medicine:
Argument (Myth) 1 is the“The Medical Care Is Unaffordable” myth, claiming that medical care is so expensive that you must go without if you don’t have health insurance, and health insurance is so expensive that government (other peoples’ money) needs to pay for it.
Argument (Myth) 2 is that if you get sick, you will go bankrupt if you don’t have insurance, which takes us back to Myth 1.
The “Medicare for All” truth is that the plan is nothing more than a mammoth money redistribution scheme. The cost has been estimated to be $32 trillion over a decade by liberal and conservative think tanks. Abolishing private insurance could cause more than 540,000 people to lose their jobs, and people would lose their retirement funds when billions of dollars disappear from the stock market. Taxes would go up immensely. Medicare itself would ironically be gone as its funds are transferred to the new government plan. Care would be rationed, and the seniors for whom Medicare was created will be pushed to the end of the line. Doctors and hospitals would be required to perform abortions, which would be taxpayer funded.8 Right-of-conscience objections would be a thing of the past.
Republicans want to personalize medical care and decentralize it, decreasing regulation and returning power to the states and individuals in the form of expanded and more flexible health savings accounts that give individuals who buy plans directly the same tax advantages as those getting insurance through their employers. They timidly propose, without media magnifiers, plans such as A Framework for Personalized Affordable Care—Republican Study Committee Healthcare Plan Part One and HR 3594, The Healthcare Freedom Act of 2019, sponsored by my congressman, Rep. Chip Roy (R-Texas-21). Such attempts to devolve the system and return money and power to individual citizens and states are promising. Proponents believe that individuals are the best custodians of their own money and medical decisions.
The problem of high costs can’t be fixed without understanding cost drivers and the perverse business practices inherent in the current system. The money games, as exposed by Marty Makary, M.D., involve price gouging, the mark-up/ discount game, predatory billing, middlemen, kickbacks, hidden costs, insider deals, and patient shakedowns. Solutions require transparency (truth), competition, innovators, disruptors, visionaries, free-market medicine, and fighting back. 14
AAPS has developed and promulgated a White Paper 15 and one-page summary 16 outlining important principles for fixing the current healthcare debacle.
Can Physicians Remain Physicians?
Clearly, government is trying to replace us. ACA and subsequent laws allocate huge sums of money to train nurses. ACA and the Medicare Access and Chip Reauthorization Act (MACRA) redefine “physician” and employ a new designation “eligible clinician,” which includes physicians, dentists, podiatrists, optometrists, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and any clinical group that includes any one of the physicians listed, plus audiologists, speech pathologists, dieticians, physical therapists, and more. The MACRA Rule further states: “We intend to consider using our authority under section 1848(q)(1)(C)(i)(II) of the Act to expand the definition of MIPS eligible clinician to include additional eligible clinicians…through rulemaking in future years.” Rapid-fire succession of laws and rules such as the Health Insurance Portability and Accountability Act (HIPAA), Health Information Technology for Economic and Clinical Health Act (HITECH), Comparative Effectiveness Research (CER), ACA, MACRA, 21st Century Cures Act, and more, written by bureaucrats and special interests, have transformed physicians into glorified billers entering data, so employers, hospitals, and private-equity firms can code and bill to the highest levels using nonsensical ICD-10 codes and violating patient privacy. Physicians spend hours and dollars kowtowing to third-party insurance companies that profit from delay and denial of treatment, including operations, and pleading with pharmaceutical benefits managers, who in conjunction with their sister insurance companies and “Big Pharma” delay and deny patients’ medications as prices soar and access is limited. Drug shortages and contaminated drugs are commonplace. If Medicare for All becomes law, this will continue as inherent features of the system, “business as usual.”
Physicians Must Stand Up
We have the power to change things. Do we have the will power?
In 1985 President Reagan said, “We’re all going to have to pitch in together. But if we refuse, if we go back to the old pattern of business as usual, then let there be no mistake: Business as usual will eventually destroy our prosperity and all the blessings it has given us.”6
I just want to be able to take care of my patients. I want to work in an alternate universe where individual freedom, common sense, compassion, and respect for life itself trump government coercion that forces me to implement and comply with insanity and inhumanity. I want to be able to provide medical and surgical care directly to patients while living within our means. This was going to be tough as a cataract surgeon. On Oct 1, 2015, I severed all third-party agreements with commercial insurers and opted out of Medicare. This was my personal Medical Independence Day.
I found the courage to do this following trails blazed by brilliant physician innovator-disrupter-leaders like Keith Smith, M.D. (Surgery Center of Oklahoma), Josh Umbehr, M.D. (Atlas MD), and Jane Orient, M.D. (AAPS), who served as my mentors, my flashlights to the exit door of the smoking room, my bridges to my patients and medical freedom. Were it not for these physician leaders, my Medical Independence Day, and my loyal patients whom I love beyond description, I would no longer be practicing medicine in the current oppressive, corrupt environment. I encourage you to join us. AAPS has been invaluable.
Doctors must establish personal relationships with their national and state legislators. And sometimes they must go to court. Currently, with the help of co-plaintiff, Texas physician Michael Garrett, M.D., I am fighting to reclaim the right for Texas doctors to dispense medications directly to our patients at the point of care, as is done in 45 other states and the District of Columbia. This is crucial in our fight to care for our patients in that little lane of freedom.
Ask yourself what you can do! If enough physicians muster the courage to open the escape hatch, the downward spiral would end in short order. The powers-that-be can’t do this without us, at least for now. They can take away everything but our minds and hearts. They cannot take away our skills, knowledge, experience, love of our patients, and code of ethics. They do not possess what they peddle to our patients. It’s time to opt out of government-corporate-medical-industrial complex-run medicine. It’s time to take responsibility, not continue to be complicit in the destruction of the patient- physician relationship, the profession of medicine, and the entire U.S. economy.
It’s our choice.
As President Reagan said in his State of the Union Address, Jan 25, 1984: “Let us be sure that those who come after us will say of us in our time we did everything that could be done. We finished the race; we kept them free; we kept the faith.”
Kristin S. Held, M.D., is an ophthalmologist practicing in San Antonio, Tex. She serves as president of AAPS.
- Kowarski I. 10 public medical schools with low in-state tuition. US News, Apr 9, 2019. Available at: https://www.usnews.com/education/best– graduate-schools/the-short-list-grad-school/articles/public-medical- schools-with-the-lowest-in-state-tuition-and-fees. Accessed Nov 7, 2019.
- AAMC. Medical Education: Tuition and Student Fees Reports; October 2019, Available at: https://www.aamc.org/data-reports/reporting-tools/ report/tuition-and-student-fees-reports. Accessed Nov 7, 2019.
- Henry TA. Employed physicians now exceed those who own their practices. AMA; May 10, 2019. Available at: https://www.ama-assn.org/ about/research/employed-physicians-now-exceed-those-who-own- their-practices. Accessed Nov 11, 2019.
- Corcoran KJ, Johnson MP. Cataract reimbursement revisited. Ophthalmology Management, Jun 1, 2001. Available at: https://www. ophthalmologymanagement.com/supplements/2005/june-2005/ coding-for- cataract-surgery/cataract-reimbursement-revisited. Accessed Nov 11, 2019.
- Ohio Ophthalmological Society. New Physician Fee Schedule Proposed. News, Aug 6, 2019, Available at: http://www.ohioeye.org/aws/OOS/pt/ sd/news_article/246349/_PARENT/layout_details/false. Accessed Nov 11, 2019.
- Quotations of Ronald Reagan. Carlisle, Mass.: Applewood Books; 2013:23.
- Skousen C. The 5000 Year Leap: A Miracle That Changed the World. National Center for Constitutional Studies; 1981:291-303.
- Jacobs C. The Case against Single Payer: How “Medicare for All” Will Wreck America’s Health Care System—and Its Economy. Alexandria, Va.: Republic Book Publishers; 2019.
- Emanuel EJ. Why I hope to die at 75: an argument that societies and families—and you—will be better off if nature takes its course swiftly and promptly. Atlantic, October 2014. Available at: https://www.theatlantic. com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/. Accessed Nov 7, 2019.
- McCaughey B. ObamaCare’s latest whopper. NY Post, Jan 1, 2014. Available at: https://nypost.com/2014/01/01/obamacares-latest- whopper/?utm_source=email_sitebuttons&utm_medium=site%20 buttons&utm_campaign=site%20buttons. Accessed Nov 11, 2019.
- ABC News. Transcript: ‘Questions for the President: Prescription for America.’ ABC News; Jun 24, 2009. Available at: https://abcnews.go.com/ Politics/HealthCare/story?id=7920012. Accessed Nov 11, 2019.
- Wall St J. Obama’s health future: rationing, and not only withholding care from the elderly. Wall St J, Jun 29, 2009. Available at: https://www. wsj.com/articles/SB124597492337757443. Accessed Nov 7, 2019.
- Verma S. Remarks by Administrator Seema Verma at the American Hospital Association Regional Policy Board Meeting. CMS.gov Newsroom; Sep 10, 2019. Available at: https://www.cms.gov/newsroom/ press-releases/remarks-administrator-seema-verma-american-hospital- association-regional-policy-board-meeting. Accessed Nov 11, 2019.
- Makary M. The Price We Pay: What Broke American Healthcare—and How to Fix It. New York, N.Y.: Bloomsbury Publishing; 2019.
- Orient JM. White Paper: after the Affordable Care Act: freedom for all vs. Medicare for all. J Am Phys Surg 2019;24:24-30.
- AAPS. 10 solutions to increase options, encourage competition, and unwind unsustainable spending in American medicine. Policy Statement. Available at: https://aapsonline.org/10-solutions-to- increase-options-encourage-competition-and-unwind-unsustainable- spending-in-american-medicine/. Accessed Nov 7, 2019.
Article in PDF format: https://jpands.org/vol24no4/held.pdf