Doctors and Health Reform: How should a physician's politics affect their patient care?

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President Obama’s health reform bill (officially the "Patient Protection and Affordable Care Act, PL 111-48) has finally passed, but the furor over it has not died down, with Republican’s harnessing their electoral future to continued opposition. To the new law, certainly, but more significantly to anything that might actually begin to address the health care needs of the American people, to cover the uninsured, to protect those with pre-existing conditions, to provide a basis for cost control, or to improve people’s health. Opponents of the plan talk incessantly about its cost, but offer no alternative. The question for the President is whether enough of the benefits of the bill will kick in and have a positive effect on people soon enough to overcome the negative bluster.

Among the groups still trying to figure out the impact of the new law on them are health care providers, including hospitals and physicians. While physicians, as a group, tend to support the Republican party, especially on the single issue of malpractice (with the trial lawyers being, conversely, big Democratic contributors), most major medical organizations have come out in favor of health reform, and in general have endorsed proposals that go significantly beyond those of the new law. Even the AMA, which opposed every national health insurance plan including Medicare, has acknowledged the need for health reform. The two largest physician specialty organizations, the American College of Physicians (ACP – internists) and the American Academy of Family Physicians (AAFP) have endorsed universal health care. Where do they stand now?

On a recent morning news show discussing the impact of health reform on doctors, one of the regular hosts asked about malpractice, saying that “every time I go to my doctor, he talks to me about the malpractice issue”, so apparently many doctors feel fine about lobbying their patients. I don’t know any of the details; after all this patient is a newsman, and may bring up the question of health policy issues, so perhaps this is not something that doctor talks with all his/her patients about. But we recently learned of a Florida urologist who posted a sign saying “If you voted for Obama seek urologic care elsewhere. Changes to your healthcare begin right now. Not in four years.” (Urologist Posts His Politics on His Florida Office Door, Damien Cave, New York Times, April 2, 2010). Predictably, and probably correctly, the criticism focused upon whether such a sign was inappropriate, whether it was wrong to refuse to treat people because you didn’t like their politics (although the doctor, Jack Cassell, “…told the Orlando Sentinel that he has not refused to treat any patient for his or her political views and does not quiz patients about their politics, but he also does not plan to take the sign down.”)

More interesting, to me, is the question of whether the financial self-interest of doctors should be of concern to their patients, and how much that should count for in making policy. Clearly, when reimbursement is so low that the cost of running the practice is more than the revenue coming in (more likely to be the case for, say, family physicians than, say, urologists), a medical practice run as a business cannot survive. It is even true that the business needs to not only not lose money, but to make enough for the physicians to have a reasonable income. But if a physician is making, compared to most people, a very large amount of money (and I have no idea whether this is true of Dr. Cassell), is it reasonable for him/her to expect people to be compassionate if it drops to only a large amount? Should Americans be concerned if a subspecialist’s take-home pay drops from, say, $450,000 to $350,000? I know the doctor would be, but what about everyone else?

I find most interesting is how the expression of this sentiment, whether Dr. Cassell continues to treat Obama supporters or not, gets to the heart of the real issues in the health care debate. To the extent that a doctor can choose which patients to treat, or whether a patient can choose which doctor to visit, maybe this could work out. But it postulates medical care as a commodity to be sold, and that its purchase depends on a patient having sufficient money, or insurance, to buy it. It absolutely does not see medical care as a right that all people should have equal access to based on their medical need. For many of those who use a high proportion of medical care (perhaps especially urologic care) that insurance is provided by Medicare, a government-run, tax dollar supported entitlement program. Health reform as passed into law currently expands the pool of people who will have insurance coverage, and thus be able to pay the doctor. It is a far cry from Medicare-for-all, which I support, and which all people who support the current Medicare-for-some that currently exists, and are not entirely selfish, should support. If Dr. Cassell can survive as a urologist in Florida without taking those socialist Medicare dollars I would be surprised; if he is willing to take them, he should be supportive of Medicare-for-all.

Maybe he is. Maybe everyone has misinterpreted him. Maybe that is why he is so upset about the new law – that it doesn’t cover everyone fairly. If so, more power to him. If he is already refusing Medicare, at least he is logically consistent. However, if he takes Medicare but is opposed to even so mild a plan as the new health care law for expanding coverage to others, then he is just out for his own self interest.

The real issue remains: is access to medically-necessary health care a right, as it is considered in every other first-world country, or is it a commodity to be carefully husbanded by those who have it and sold to those who can meet the price? The real concern is not Dr. Cassell’s medical ethics, but his (and others’) worldview.
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