Why not reform, too? People need healthcare now.

BY:Flavio Casoy, MD| July 7, 2021
Why not reform, too? People need healthcare now.


The following is a response to a proposal of the West Philadelphia Club to strengthen the Party’s position on healthcare.

I am very pleased to read such a comprehensive and well-written proposal to address the deep injustices in our healthcare system and am deeply thankful to the West Philadelphia Club for taking the time to write and share it. I am a public-sector psychiatrist and for many years have been deeply committed to building an equitable, affordable, quality healthcare system for everyone.

There are many points with which I agree, but some which I do not. I will detail here some of the points where I disagree.

The West Philly Club argues that supporting a loosely defined notion of healthcare for all, where sometimes the priority is to defend the Affordable Care Act (ACA) and sometimes it is to push for a Medicare for All (M4A) Canadian-type system, robs the Party of intellectual credibility among healthcare workers because both the ACA and M4A fail to explicitly address working conditions of healthcare workers.

It is important to remember that the Party’s platform must reflect a political analysis of the current political situation in addition to articulating a policy position that reflects our aspirations. It must be stated that millions of people in the U.S. were able to obtain healthcare, including preventive care, rehabilitative care, mental health care, substance use disorder treatment, contraception, palliative care, immunizations, and many, many other life-saving interventions because of the struggle of millions and millions of healthcare workers, their unions, and allies spanning the political center and left.

The struggle for the ACA required the creation of deep and broad coalitions of hundreds of organizations and trained a generation of healthcare activists. For those of us whose work in fighting for healthcare justice started before 2009, it is clear the struggle for the ACA not only created a significant improvement in quality and access to care, but it also fundamentally and qualitatively changed our capacity to understand and push for healthcare reforms.

With the passage of the ACA, the arena of struggle has shifted in a more progressive direction.

The West Philly Club is correct that deep injustices were not addressed by the ACA, but it would be wrong to affirm that defending the ACA is a mistake. The Party has an important role to play in working with the many healthcare unions, advocacy groups, and others who have defended the ACA since its initial passage. This is a front in the fight against the most reactionary elements of the Republican Party and the far right. Prior to the ACA, comrades will remember the constant fights during the Bush administration to protect Social Security, Medicare, Medicaid, and the Children’s Health Insurance Program. Because we were able to pass and defend the ACA, the arena of struggle has shifted in a more progressive direction.

Similarly, many progressive groups coalesced around the idea of M4A. It is not the only way to reach the goal of universal quality care, but conceptually it allows us to describe the enormous bureaucratic waste generated by the for-profit insurance industry, not to mention the obscene profits. It makes sense for the Party to have a seat among these progressive groups who are pushing for this approach. While there have been other interesting ideas along the way — VA for All, American NHS, regional healthcare utilities, etc. — this is the one that has wind in its sails, both at the federal and state levels. It would be a mistake for us to raise the flag of a perfect policy and sit alone on the sidelines, shouting that everyone else is wrong. We know that what ultimately is passed will always have to be changed, adapted, and improved as the material conditions on the ground continuously change.

The West Philly Club’s analysis of the impact of education debt on making medicine unrepresentative in terms of class and race and of the impact on medical specialty selection is dead-on. I would suggest that the West Philly Club explore taking a position on expanding the Pell grant program, the Perkins loans program, the National Health Service Corps, and the NIH scholars program as vehicles to expand the pipeline into medical education and reduce the crushing debt burden. If we make undergraduate education more affordable, medical education will be more affordable too. If we tie grants to a service commitment, we will be able to better provide care for underserved areas.

The discrepancy in pay between primary care and specialty care is driven by many factors. The analysis is incomplete and fails to consider the impact of the Medicare Payment Advisory Commission on payment of healthcare services, the role of chronic federal underfunding of Medicaid over the last 50 years, failure to enforce Mental Health and Substance Use Parity laws, and many other significant structural factors that emanate from the political struggles in the early 1960s when Medicare and Medicaid were first passed.

Poor people need endoscopies too.

I would remind the authors that there are significant shortages of general surgeons and medical specialists in many parts of the country, particularly rural areas. Training to become a specialist can take significantly longer. Neurosurgeons, for example, must complete a seven-year residency, compared to three years for family medicine or four years for psychiatry. We cannot reduce the argument to “specialists bad, primary care good.” Poor people need endoscopies too.

The proposal is misleading when it describes the length of medical training and the need to complete a residency. U.S. medical students complete eight years of study before residency, including four in undergraduate college and four in medical school. This is not that different from other industrialized countries. The proposal argues that medical school should start right after high school, but the length of the degree would have to be extended to allow teaching of the prerequisite (i.e., premed) classes. There is value in delaying the start of medical education until after college because it allows for a little more maturity, and there is less risk that young students feel regret and “stuck” in the profession, an outcome that is extremely costly and undesirable, although still too common in the U.S. There is also value to having physicians with a broad-based, liberal arts education who have been exposed to other areas of knowledge because this adds depth to medical understanding.

The proposal voices a very hostile attitude toward individuals who pursue MDs and business degrees, calling them “opportunists” or “business-minded bureaucrats.” I maintain that this is unnecessarily divisive and based on gross simplifications and stereotypes. There is great heterogeneity in the individuals who pursue medicine, and there would be more if we had more fair payment schemes that did not result in massive debt. There is also great heterogeneity in individuals who pursue MBAs. It is dismissive and meant to write off a whole category of people based on their interest or choice of field. This attitude does not belong in a Party program.

The mean-spiritedness is repeated in the attack against osteopathic medicine. I am an allopathic physician, but it does not take too much effort to understand that osteopathy has a history and identity of its own and brings a different and welcome perspective into the house of medicine. Frankly, much in the history of allopathic medicine is also pseudoscientific, and much of what we do now may be recognized as quackery in the future. Humility is a cornerstone of a good physician. Two sayings come to mind: “as the radius of knowledge increases, so does the circumference of our ignorance” and “medicine is the art of transitory truths made permanent for egotistical reasons.” Let us not forget the extensive racism, homophobia, misogyny, etc., that fills the allopathic medicine history books.

Let’s celebrate and expand the gains made in working conditions of interns and residents.

The proposal is correct in detailing the ongoing abuses of resident physicians and violations of work hour rules. It is important, however, not to minimize the gains of the 2003 and 2011 ACGME (Accreditation Council for Graduate Medical Education) reforms. As one of those doctors who trained partially in the, as the authors put it, “good old days” (it was anything but) and partially after the 2011 reforms, there was a clear and significant change in my quality of life and ability to safely care for patients. These reforms came about with a lot of struggle by the American Medical Student Association, Public Citizen, Committee of Interns and Residents, and others. The Party has been part of the long history for improved intern and resident working conditions, starting with the Association of Interns and Medical Students (AIMS) in the late 1930s. These victories must be celebrated and expanded.

I would encourage the West Philly Club to consider the contributions of resident physician unions to the struggle for improving working conditions for healthcare workers and for making the healthcare system more just. For example, the Committee of Interns and Residents/SEIU Healthcare is the nation’s largest union of resident physicians, and it has just won recognition in several new hospitals and continues to fight for its members and their patients despite Janus and other adverse Supreme Court decisions. Doctors’ Council/SEIU and the Union of American Physicians and Dentists (UAPD) proudly represent physician members all over the country. I am a physician and a member of my public-sector union. I would argue that the struggle to improve the working conditions of residents is tied to the overall struggle of improving working conditions of all healthcare workers, and of all workers in general.

Doctors need not fear being replaced by physician assistants.

The section on nurse practitioners and physician assistants seems to reflect more the writers’ sense of grievance and threatened social position than anything else. In the real world, I have met as many bad physicians as bad nurse practitioners. I have worked with nurse practitioners who are committed, caring, smart, dedicated, informed, well-read, and deeply kind. We are all enriched by their presence, and I am deeply thankful for their work. Doctors need not fear being replaced. There is certainly no need for physicians to lead, although we have valuable input to give and should be heard and respected. Why not have patients lead the team, or at least patient advocates?

There is ongoing debate about whether there is a healthcare worker shortage or a “maldistribution”; although when one is trying to run and staff a clinical service, that debate is meaningless. It is true that Medicaid reimbursement does not cover the pay of all the clinicians that safety-net healthcare systems need.

Again, let’s push for an expansion of the ACA or M4A or 100% federal coverage of Medicaid or any other system that can help address this difficulty. Let’s not let the perfect be the enemy of the good because people need care now.

Image: Molly Adams (CC BY 2.0).



    Flávio Casoy, MD is a psychiatrist in New York City who specializes in public mental health systems and treating individuals with serious and persistent mental illness. He works to ensure that individuals with the most serious psychiatric disorders have access to community-based services that can help them stay out of hospitals or jails and lead fulfilling lives. He has also spent over a decade pushing to make sure that everyone in the United States has access to quality and affordable health care.

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