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As promised during his campaign, and under pressure from many quarters, President-elect Barack Obama may seek badly needed changes in the way the United States finances and delivers health care. Responding to public interest and perceived need, several previous presidents have attempted to enact some kind of national health insurance: Harry Truman in the 1940s, Richard Nixon in the 1970s, and most recently Bill Clinton in the 1990s. These attempts went nowhere. In pursuing comprehensive health care reform, President-elect Obama should be aware of four major reasons why, in the past, we heard so much talk and saw so little action.
First, many organizations and individuals prefer the status quo. This category includes health insurance companies; manufacturers of drugs, medical devices, and medical equipment; companies that employ mostly young, healthy workers and therefore have lower health care costs than they would if required to help subsidize care for the poor and the sick; high-income employees, whose health insurance is heavily subsidized through a tax exemption for the portion of their compensation spent on health insurance; business leaders and others who are ideologically opposed to a larger role of government; highly paid physicians in some surgical and medical specialties; and workers who mistakenly believe that their employment-based insurance is a gift from their employer rather than an offset to their potential take-home pay. These individuals and organizations do not account for a majority of voters, but they probably have disproportionate influence on public policy, especially when their task is simply to block change.
Second, as Niccoló Machiavelli presciently wrote in 1513, “There is nothing more difficult to manage, more dubious to accomplish, nor more doubtful of success . . . than to initiate a new order of things. The reformer has enemies in all those who profit from the old order and only lukewarm defenders in all those who would profit from the new order.” This keenly observed dynamic, known as the “Law of Reform,” suggests that a determined and concentrated minority fighting to preserve the status quo has a considerable advantage over a more diffuse majority who favor reform but have varying degrees of willingness to fight for a promised but uncertain benefit.
Third, our country's political system renders Machiavelli's Law of Reform particularly relevant in the United States, where many potential “choke points” offer opportunities to stifle change. The problem starts in the primary elections in so-called safe congressional districts, where special-interest money can exert a great deal of influence because of low voter turnout. The fact that Congress has two houses increases the difficulty of passing complex legislation, especially when several committees may claim jurisdiction over portions of a bill. Also, a supermajority of 60% may be needed to force a vote in the filibuster-prone Senate.
Fourth, reformers have failed to unite behind a single approach. Disagreement among reformers has been a major obstacle to substantial reform since early in the last century. According to historian Daniel Hirshfield, “Some saw health insurance primarily as an educational and public health measure, while others argued that it was an economic device to precipitate a needed reorganization of medical practice. . . . Some saw it as a device to save money for all concerned, while others felt sure that it would increase expenditures significantly.”1 These differences in objectives persist to this day.
Currently, many health care reformers favor an approach based on comprehensive mandates and generous subsidies. This approach would leave in place employment-based insurance and income-tested insurance, such as Medicaid, attempting to shore up these systems rather than replace them with a more unified method of financing care. Other reformers favor “Medicare for all,” an approach that is often referred to as “single payer.” Still others want to combine the single-payer approach with choice and competition through a system of universal vouchers for enrollment in competing health plans that take responsibility for the care and costs of their enrollees. These approaches, and others that have been proposed, vary in their objectives and in the methods they would use to achieve those objectives. Differences among approaches are not easily reconciled, because they reflect differences in values and analyses. Even if a substantial majority of the public and legislators favors some kind of reform, we will continue to witness much talk and little action unless they can unite behind a single approach.
This type of review of the obstacles to health care reform is of more than theoretical or historical interest. It could help the Obama administration find a successful path to reform. Consider the groups that seem to prefer the status quo. They may not be as unified as they first appear. Some individuals and organizations might realize that they could benefit from changes in the health care system. For example, some of the large health care insurers or managers, such as Anthem, UnitedHealth, and Aetna, would flourish in a system where relatively few competing health plans are equipped to assume responsibility for large numbers of enrollees in return for risk-adjusted capitation payments. Reformers need to try to secure their support or, at a minimum, to blunt their opposition. Similarly, though some physicians would probably see their income fall under comprehensive reform, others might see an increase, and all would probably prefer a system in which no one is uninsured. Even in the pharmaceutical industry, where opposition to reform is traditionally strong, some firms are beginning to embrace a goal of high-value innovation; such companies would move to the head of the industry under a well-designed new system.
Under the best of circumstances, however, a major Obama reform initiative will still face strong defenders of the status quo. Machiavelli's Law of Reform highlights the importance of galvanizing those who favor reform into a more vigorous, aggressive source of political pressure. The success of Obama's campaign team in involving millions of supporters through the Internet points the way toward such an outcome. The U.S. political system will still have its numerous choke points, but skill and determination on the part of leaders in the executive and legislative branches may prevail, especially if high unemployment, a financial squeeze on Medicaid, an influenza pandemic, or some other crisis increases the political dangers for legislators who oppose reform.
One argument against comprehensive reform that is sure to surface is that it is not politically feasible. That may well be true, for the reasons mentioned above. But U.S. history is studded with major policy changes that were not politically feasible — until they were. Examples include the emancipation of slaves, the creation of a strong and independent central bank, the establishment of Social Security, the fluctuation of foreign exchange rates, and most recently, more than $1 trillion devoted to bailing out large financial institutions. Six months ago, a bailout of this nature and size was not even close to being politically feasible. Comprehensive health care reform must happen, if for no other reason than to avert a national fiscal crisis. The big questions are when it will happen and what form it will take.
In my judgment, it is far more important to get the right answer to the question of “what” than “when.” It would be a shame to let short-term political feasibility dominate the discussion. Political leaders who aspire to greatness first decide what needs to be done and then set about making it politically feasible. If the current health care reform initiative is limited to questions of coverage, without serious attention to cost control and coordination of care, the “crisis” in health care will continue to plague us for years to come.
We have frequently discussed the anechoic effect, how it is just not done to discuss certain topics, particularly those related to the adverse effects of bad (ill-informed, incompetent, self-interested, conflicted, or corrupt) leadership and bad (opaque, unaccountable, mission-hostile, unethical) governance of health care organizations. We have discussed many possible causes of the anechoic effect, but one particularly obvious cause is the silencing of dissenters and whistle-blowers.
Three recent stories illustrate old and new tactics to reinforce the anechoic effect.
A Classic Case - ValleyCare Medical System Nurse Fired
From the San Francisco Chronicle,
An Alameda County jury awarded more than $344,000 in damages this week against ValleyCare Medical System for refusing to rehire a Castro Valley operating nurse who claimed the hospital was retaliating against her for complaints she made about patient safety issues, including concerns about surgical equipment left inside patients.
Kristeen Klaas, a 15-year veteran at ValleyCare and a registered nurse for more than 30 years, sued the hospital system, which has services in Pleasanton and Livermore, after she quit in distress in May 2008 and hospital managers failed to respond to her request to be rehired days later.
The 54-year-old Klaas, who now works at Alta Bates Summit Medical Center in Oakland and San Leandro Hospital, had brought numerous safety complaints about the Pleasanton hospital to the attention of ValleyCare's management over the two years prior to her resignation.
Klaas complained about a fellow nurse who brought a dog into the operating team's break room and jumped rope with an electrical cord in the operating room, as well as a surgical technician who brought a rifle into the operating room office to sell. She also complained that a tip of a surgical instrument went missing during a surgery and was never found, and that an instrument was left in a patient because the hospital did not have a formal policy of counting instruments after surgery.
She also accused a supervisor of forging her signature on a performance evaluation after she refused to sign an evaluation that was backdated to comply with state regulations.
Here is the tactic allegedly used to silence the whistle-blowing nurse:
On her last day on the job, Klaas got permission from her supervising nurse to leave work because she was in distress after a colleague, the subject of three of her complaints, screamed at her.
'She realized, for the patient's safety, she couldn't continue to go forward that day in the operating room because she was so upset,' he said.
But then a supervisor called her at home and accused her of leaving without permission, prompting Klaas to resign, he said.
This is the classic, rather blunt way to do it: just make the would-be truth-teller's job experience so miserable that she quits.
Now we will present two examples of a more subtle approach, one directly from health care, one at least from a sphere with major health care implications.
A New Approach: A Contract Preventing Communication “Inimical” to a Pharmaceutical Company's Business
This case was documented by a personal narrative by Marc Lipsitch, a Professor of Epidemiology and the Harvard School of Public Health, published in the Chronicle of Higher Education,
I received a request from a large pharmaceutical company to assist in the design of a clinical trial, and the proposed terms seemed to require that I sign away my right to criticize the product. One provision would prohibit me from entering into 'any agreement or relationship to render services as … adviser or consultant to, any other individual, firm, or corporation that would be inimical to or in conflict with' the aspects of the company's business covered by the agreement. Another would forbid me to engage, in any capacity, directly or indirectly, in “any business,” with or without compensation, relating to the class of products under discussion—not just for the term of the contract, but for the year after as well. Those provisions could restrain me from providing candid advice to a regulator, a government official, or the editor of a peer-reviewed journal about the class of products on which I was consulting, even if the advice were based on publicly available information. I objected to those terms, as did a colleague who was offered the same arrangement.
Prof Lipsitch also noted that government research funding agencies and universities may not provide any protections to their faculty against such agreements. He also noted that the contract he was asked to sign was not one of a kind:
Discussions with my colleagues suggest that the problem is not limited to one pharmaceutical company ….
We and many others have frequently discussed the conflicts of interest that may be generated by physicians or health care academics having financial relationships with industry. The Institute of Medicine's definition of conflict of interest (in a health care context) found in its report, Conflict of Interest in Medical Research, Education, and Practice, is:
Conflicts of interest are defined as circumstances that create a risk that professional judgments or actions regarding a primary interest will be unduly influenced by a secondary interest. Primary interests include promoting and protecting the integrity of research, the quality of medical education, and the welfare of patients. Secondary interests include not only financial interests….
Thus the concern is that a faculty member,for example, who is paid to consult for a drug company might tend to favor the company, its products, or policies to its advantage in his or her clinical teaching, scholarly talks and writing, or public policy opinions. That might happen even if the consulting work is technical or scientific and not directly related to the particular topic about which communication might be influenced.
However, the situation described by Prof Lipsitch is much worse. Were he to have signed the contract, he would have been constrained by this legal agreement from writing or saying anything “inimical to or in conflict with” the company's business.
Last week, a similar, but more wide-spread example surfaced (pardon the pun) in a domain that is at least related to health care.
Another Version of the New Approach: the BP Consulting Contracts Making Any Communication Between the Company and the Consultant Confidential
Originally reported by the BBC,
The head of the American Association of Professors has accused BP of trying to 'buy' the best scientists and academics to help its defence against litigation after the Gulf of Mexico oil spill.
'This is really one huge corporation trying to buy faculty silence in a comprehensive way,' said Cary Nelson.
The BBC has obtained a copy of a contract offered to scientists by BP. It says that scientists cannot publish the research they do for BP or speak about the data for at least three years, or until the government gives the final approval to the company's restoration plan for the whole of the Gulf.
It also states scientists may perform research for other agencies as long as it does not conflict with the work they are doing for BP.
And it adds that scientists must take instructions from lawyers offering the contracts and other in-house counsel at BP.
Here are some examples of the wording of the contract as obtained by the BBC about confidentiality.
Confidentiality. All communications (including non-public information disclosed in such communications) between you (and your agents), BP Attorneys and/or other BP representatives in the course of your performance of the BP NRDA Services are deemed to be incidental to the rendering of legal services and are to be privileged and confidential. You shall maintain a strict confidentiality of such non-public communications and information unless or until a person from whom you are authorized to take instructions informs you in writing that this restriction is no longer applicable to any particular non-public communications and information. In the event you are required to disclose such privileged and confidential non-public communication and information by an order entered by a court or by similar judicial process, or by a judicial or administrative subpoena, you shall notify a person from whom you are authorized to take instructions as soon as practicable, and you are required to cooperate with BP if BP decides to seek relief from such required disclosure, including commencement of a legal or administrative proceeding to prevent or limit disclosure of such privileged or confidential information.
Here is the description of those from whom the signer of the contract must take orders.
Instructions. You agree to take your instructions only from me, from other lawyers in my firm, from Brian Israel or other lawyers in the Arnold & Porter law firm, and from Donna Ward or other in-house counsel at BP (collectively 'BP Attorneys').
Note that the contract defines privileged, confidential information as any communication between BP and its representatives and the contract signer. Thus, to make something confidential, all BP would have to do is mention it in a communication. It appears that this would allow BP to render off-limits any topic it chose. Also, since by the same mechanism, it appears that the contract itself, once signed, would also become privileged and confidential.
Summary
I submit that ideally medicine and health care ought to be a very transparent calling. Physicians are obliged to keep confidential the information disclosed to them by patients, enabling the patients to trust physicians sufficiently to provide them the accurate information needed for optimal care. However, it is hard to think of much other information or communication in health care that ought to be kept secret, (other than the processes used by commercial firms to manufacture drugs or devices.)
Yet as health care becomes more of a business and less of a calling, businesspeople's proclivity to keep as much as possible secret to avoid giving any advantage to a competitor has become more influential. Furthermore, those leading big organizations have realized that it is easier to maintain their power if they can keep their mistakes, if not misconduct secret. So businesspeople's proclivity to mount overwhelming legal defenses of their interests may lead to persuading or fooling people who might be inclined to delve into such mistakes and misconduct to sign contracts to keep them silent through confidentiality clauses, requirements to protect privileged or proprietary information, non-disparagement clauses and the like. The result will be better coddled self-interests, but more opacity that is inimical to good patient care, teaching, research, and public policy discussion.
To truly reform health care, we need more transparency. To produce more transparency, we need constraints on contracts that inhibit needed clinical, teaching, research and public policy communication.
Meanwhile, as my father, who was an attorney, done told me: “don't sign a contract you don't understand, and don't sign a contract giving away any right you need to keep.”
