Income Inequality is Everyone’s Problem – Including Physicians

A group of medical students (myself included!) rally to support Single Payer – one of the most important campaigns health professionals can participate in to combat income inequality.

The publication of Thomas Piketty’s book Capital in the Twenty First Century has really shook the economics community, and along with Robert Reich’s documentary Inequality For All has thrust the debate about income inequality into the spotlight. I haven’t yet read it, but it’s hard to ignore all of the publicity it’s been getting from highly influential people. Bill Moyer’s interview with Paul Krugman as he discusses the book and its importance is well worth a watch. As I understand it, the thesis of the book can be summed up in the Intro (available to preview for free on Amazon!),

When the rate of return on capital exceeds the rate of growth of output and income, as it did in the nineteenth century and seems quite likely to do again in the twenty-first, capitalism automatically generates arbitrary and unsustainable inequalities that radically undermine the meritocratic values on which democratic societies are based. There are nevertheless ways democracy can regain control over capitalism and ensure that the general interest takes precedence over private interests, while preserving economic openness and avoiding protectionist and nationalist reactions.

 

I don’t think this book could have come at a more important time. With the following egregious facts coming to light (CEOs now making 354 times the amount of the average worker), nicely summed up by John Case’s article for People’s World:

The wealth of the 1 percent, and even more the .1 percent, is increasing at 2-3 times the overall growth rate of the economy (GDP). The median income worker, on the other hand, received virtually no gains from increased productivity. And workers who fall below median income have seen their share of national wealth and income dramatically cut.

It seems that Americans are more open to realizing that the super-rich didn’t necessarily do anything of value to earn that money, and that it is harmful for everyone for wealth (and increasingly, political power) to be concentrated in the hands of fewer and fewer.

As a member of the Millennial generation, I grew up being told I could be anything I wanted to be. Inherent in that statement is the idea of upward mobility. The idea that working hard is a surefire way to success in America. Yet, increasingly, this is a myth, and reviews of this book indicate this is something that Piketty addresses. In a review by Christopher Matthews for CNNMoney, he writes,

[Joseph] Stiglitz was equally taken by the work, arguing that Americans would not be bothered by increased inequality if it were based on merit within a society that enables class mobility. But the U.S. is near the bottom when it comes to social mobility [emphasis added].

 

Now we see a student debt crisis and the related social and economic effects of this on our generation, yet we are blamed for being lazy and entitled when we can’t find meaningful work that allows us to support ourselves as well as generate new ideas and technology.

Why should physicians care?

• Medical students are a privileged few who have managed with a hearty dose of luck and generous social support to forge the beginnings of meaningful careers, but we face financial and occupational insecurity never before faced by the profession.  According to the AMA,

AAMC data show that median private medical school tuition and fees increased by 50 percent (in real dollars) in the 20 years between 1984 and 2004. Median public medical school tuition and fees increased by 133 percent over the same time period. 

 

• Accelerating consolidation of hospitals and insurance corporations, leading to huge behemoths of systems with unprecedented power and exploding costs. The ACA has been a driver of this trend, and this is a HUGE topic that’s worthy of much closer examination that I only superficially address here. Yet there is no doubt this relates to concentrations of influence.

• Concurrently, physicians are changing from an employing to an employed class. This is also related to many other factors, such as the fact that employed physicians typically have more predictable work hours, a guaranteed salary, and maybe a better work-life balance. But, because they are employees, they have a boss that they are accountable to, who may or may not possess an MD and understand the challenges of the profession. Will this mean that doctors’ voices will be less influential in healthcare in the future? In a 2014 Medscape survey asking what doctors dislike about being employees, 45% of employed doctors reported limited influence in decision-making, and 30% reported “being ‘bossed around’ by management. If this doesn’t sound like the classic worker-boss struggle… Yet as a “profession” instead of a “trade,” doctors generally do not participate in typical collective bargaining efforts like strikes (and many, including myself, have ethical concerns with doctors striking).

To me, the direction this is pointing is that physicians no longer have the power and influence they once did, and they will likely continue to experience declines. I don’t think this is entirely a horrible thing in itself; like all groups, physician self-interest has not always aligned with what’s best for the public (ie., the AMA was one of the biggest opponents of Medicare for all back in the day, and its official position does not support single payer still.)

This change in status will force physicians to pay attention to the concerns of the working class – because physicians now belong to it. 

Our organizing strategies will have to reflect this emerging reality. The good news is that tons of groundwork of labor movements has already been laid. Once physicians join the voices of other allied health professionals and working people, all of our voices will be much stronger. This means physicians must publicly support the struggles of much lower-income workers in living wage campaigns (as these health professional students did, this physician did, and this group of physicians did), attempts at better working conditions, and yes, single payer healthcare.

• Finally, and probably most importantly, physicians should care about income inequality because it drastically affects the health of our patients. Check out these graphs charting life expectancy by income.

If true democracy is the key to solving the problem of income inequality, physicians can play an integral role. Now, more than ever, we’re in this together.

Students for a National Health Program Summit

Over the past few months, I’ve been helping to organize the 2nd annual Students for a National Health Program summit – a conference designed to help health professions students learn more about how to advocate for single payer national health insurance. It’s getting down to the wire – the conference is this Saturday, May 11 at Physicians for a National Health Program headquarters in Chicago. It’s been a pretty sizable amount of work – I feel like I’m sending a million emails a day – but it’s shaping up to be a great conference. This is the first time I’ve helped to organize something like this, and I’ve actually kind of enjoyed it, despite never considering myself someone who was particularly good at logistics or details. I’ve been incredibly impressed with the other organizers who are all busy med students too. It seems like this has run WAY more smoothly than I anticipated, and it’s no doubt because the other students are doing it because they believe strongly in the cause (not to mention they’re super smart and talented!). I’ve noticed that when counting on people who are volunteering their time, you can unfortunately expect about a third to half of them to flake on some tasks, even if they specifically said they would do them. It just seems to be the nature of the beast. These guys have not only NOT done that, but they’ve been incredibly proactive in volunteering to take on extra work during our organizing conference calls. It’s made me work even harder to ensure we provide a good conference for the other attendees.

One of the things I’m really excited about (which was also true last year when I attended the first conference) is that the group chose to invite other health professions students, and I was able to meet with people in different training programs – nursing, public health, etc. We have several other professions represented this year too, including some premeds, which is great! I think interacting with other health professionals is something that my school has been a bit weak on so far. We’re all working towards the same goal and we’re all in the same system, yet sometimes we don’t even understand what the other’s role is.

We’re going to start the day with an introduction to single payer and a presentation about the role of advocacy that health professionals have played in the past, and what we can do in the future.Then we’re going to talk about HR 676, the House single-payer bill. From there, we’re giving students options of attending one of two breakout sessions which are designed to be more interactive. I’m helping with two of them. The first is a co-presentation with Paul Demos, a former drug rep who is now a medical student. We’re giving a presentation about – my favorite topic – the role of privatization and for-profit corporations in health care! And who better to speak about this than someone who has been in the trenches and really knows what it’s like as a former drug rep. The next presentation that I’m giving is really going to be an interactive session about communication/conversation skills and responding to difficult questions about single payer. I was feeling a bit uncomfortable giving this, to be honest! I was wondering if I even have these skills – sometimes I feel after walking away from someone who disagrees with me we’ve both just annoyed the other. I kind of tried to get out of this presentation or at least get someone to help, but then I realized that it’s completely fine to admit that effective communication skills are a constant learning process. Expecting to always be perfectly poised, articulate, and calm when speaking with someone about something you feel passionate about is unrealistic. The healthcare system is complicated (to say the least), and understanding the economics behind it is something I feel like I’m only beginning to grasp. Instead of giving a presentation, I tried to come up with a framework where we could all learn from each other. There is no doubt that some of the people attending will be much better at this than me, naturally, and I hope that we’ll be able to learn from them. So I designed a couple of scenarios for people to act out. I hope this will be a good experience for everyone, but we shall see! Other presentations/breakout sessions focus on transitioning from sympathizer to activist, a workshop on writing letters to the editor/speaking out, healthcare economics, and more! I have really high hopes for the conference and I hope that I can learn to better convey my optimism that single payer is the most realistic, humane goal for a better future.

Market-based ideas: option or coercion?

I recently saw the new film Escape Fire and felt like it provided a pretty good introduction to the problems with American health care at the moment. It was up to date in detailing why Obamacare is an imperfect solution, and it did explore the issue of why for-profit corporations might not be in the best position to reduce health care costs. Just because of the wide variety of issues the filmmakers chose to look into, it was naturally limited in the depth it could go, but it seemed to provide a reasonably fair assessment overall.

I was struck by one example of lowering costs and improving health that I hadn’t heard about before – that of the grocery store Safeway. Faced with rising health insurance premiums like most companies, Safeway decided to implement a behavioral motivation program where it based the costs of its (non-union) employees’ premiums on a variety of health indicators: “tobacco usage, healthy weight, blood pressure and cholesterol levels” according to an article written in the WSJ by Safeway CEO Steven Burd in 2009. He claimed that insurance costs almost immediately stabilized after implementation of the program in 2005 and that they were “building a culture of health and fitness.” The idea, of course, is that if people are financially motivated to behave themselves in a way that will reduce their future need for health care utilization, everyone will benefit.The movie showed happy-looking employees jogging around the building.

I got a feeling of unease when I heard this story, although I couldn’t immediately figure out why. What’s wrong with giving people an extra reason to improve their own health? After all, they’re the ones who are benefiting from losing weight, quitting smoking, etc. It took me awhile, and I had to dig into it a little bit, but I think I have an explanation.

Burd’s tone in the article struck me as condescending and infantilizing to the workers, although I’m sure he didn’t see it that way. To me, the subtext was, “if only these fat smokers would just QUIT IT ALREADY, they would save us all a ton of money.” He emphasized that 70% of health care costs are the direct result of behavior. (I wasn’t able to find sources in his article, but it very well may be true.) Regardless, such statements are oversimplifications that grossly devalue the truly transformative experience of changing an unhealthy habit. And it shames and punishes people who are unable to make the changes.

Why is that a problem? If 70% of health care costs truly are the result of unhealthy behaviors, then that must mean those behaviors are probably pretty hard to change. I don’t think that people were totally ok with making themselves ill and just looking for an insurance discount to provide that final incentive to get rid of their pesky congestive heart failure caused by a combo of uncontrolled hypertension, high cholesterol, and diabetes-induced heart attacks.

What seems to be difficult for most super-rich people to grasp is that behaviors aren’t just about an individual’s choices. An individual isn’t isolated from the influences around them, but certainly does suffer from them. Not having a car because you are poor, work a low-paying job with weird hours, take a bus home to a neighborhood where there aren’t any grocery stores, and as a result end up eating crap from the local corner store which contributes to your early-onset diabetes certainly could be considered a “behavior” but I think it’d be more accurate to call it a “complete failure of our unjust society.” Granted, most people’s situations are not that drastic, but it’s an illustration of how even calling something a “behavior” neglects the complexities inherent to real people’s lives.

I’m reminded of a (by all accounts middle-class, relatively privileged) person I met whose weight-loss efforts had stalled recently because of severe depression accompanied by some pretty terrible family and social circumstances through absolutely no fault of their own. Any one of us would have found it difficult to continue losing weight in their shoes, despite this individual being highly motivated. It seems incredibly uncompassionate to just toss that person into the policy. It contributes to the myth that meeting these objective, population-based benchmarks are possible for every person at every time if they’d just work hard enough and take personal responsibility, dammit!  It pits workers against each other – hey, fatty 2 cubicles over! Put down the donut and take a walk around the damn building to get your blood pressure down! I don’t wanna have to pay for your expensive, fancy diabetes drugs!

And perhaps most frustrating of all, it’s based on the premise that absolutely everything, even our own health and well-being, has a price and can be commodified.

I should note that in no way am I attempting to minimize the accomplishments of Safeway employees who actually did make these changes and come out far healthier. I have no doubt that such a program was just what some people needed to provide that extra oomph to get the exercise ball rollin’. But even if that were the case for every employee, isn’t it a bit creepy and invasive that your boss cares so much about your waistline and your cholesterol level?  A “culture of health and fitness” starts to look a little more like a culture of coercion, shame, and anxiety.

And what does this market-based solution do to fundamentally address the inequities in accessing health care? That is, even if every employer had a similar program, what would that mean for people who are unemployed due to say, chronic illness? Would they be further shamed and isolated from society? The program is based, by definition, on employees, so that means the people participating were at least healthy enough to work. Almost certainly this would mean that the care of the very sick would continue to fall in the public domain, decreasing private, corporate health care expenditures, but further increasing publicly funded healthcare (ie., Medicare). Though this type of system, Medicare will continue to be fantastically expensive, making it easier to demonize until we finally move toward a total privatization of health care, dissolution of Medicare and Medicaid entirely, with safety nets only being provided by voluntary, charity care.

Well, it turns out that even though Safeway medical costs did stabilize from 2005-2009, it may not have really been related to the incentive program at all and was heavily weighted towards the early years. That is, costs dropped 12.5% in 2005 when the company drastically changed the benefits it was offering. However, 2009 was the first year that insurance premiums were tied to test results at Safeway. According to David Hilzenrath in the Washington Post, “Even as Burd claimed last year to have held costs flat, Safeway was forecasting that per capita expenses for its employees would rise by 8.5 percent in 2009. According to a survey of 1,700 health plans by the benefits consultant Hewitt Associates, the average increase nationally was 6.1 percent.”  When Safeway Senior Vice President Ken Shachmut was asked why premiums rose so much despite their terrific program, he said “we frankly did not have as much control over things as we should have.”

Maybe they had too much control.

Of note, the idea of financial incentives being not only ineffective in reducing health care costs and improving societal health, but actually impeding these goals is one that I intend to explore in future posts!