Issue LXII: The Neoliberal’s Health “Reformer”

7 Oct

Few people’s reputations are so sancrosanct in my field as the reputation of the surgical oncologist and New Yorker health policy journalist, Dr. Atul Gawande.  Nary a criticism of him gets published in either the popular or medical press (Russell Mokhiber’s one article is all I can find). But behind his strangely class-free, race-free, and context-free view of the history of American medicine lays the worst instincts of technocratic market liberalism. An avatar of progress he is not.

This week Dr. Gawande, in an echo of Hillbilly Elegy, decides to wander around his hometown in Ohio (my current state of residence) looking for a consensus on health care as a human right. Being from Texas, I have come to violently disagree with his much-hailed 2009 New Yorker article about McAllen, Texas. His naive traipse through southeast Ohio talking to people is just that: naive.

He finds that, golly gee, health care is expensive, and even conservatives cannot pay their $6000 deductibles, immunosuppressant medications are outrageously costly, and surgery bills keep people up at night. In this region where people repair their own cars and shoot their own deer (a symbol for real America), people can’t repair their own appendix! And they hate freeloaders.

Liberal or conservative, everyone agrees there has to be some sort of level playing field where everyone contributes, costs are controlled, and people will have the freedom to work or start businesses as they please without worrying about insurance. Just like how we do not worry about police and fire protection. Despite his Rhodes Scholarship in Philosophy, Politics, and Economics at Oxford, Dr. Gawande just now seems to be coming around the concept of positive rights and how these guarantees enhance liberty. But then he goes backwards and ponders if Americans have a right to garbage pickup… and then declares the idea irrelevant.

The muddled thinking of the Harvard doctor extends to his use of region and history. It may shock Bostonians, but Athens County is actually the most consistently Democratic county in Ohio. Historically, Appalachian Ohio has allied with Northeast Ohio (Cleveland) to form the bulwark of the Democratic Party in opposition to Southwest Ohio (Cincinnati). The last Democratic governor of Ohio, Ted Strickland, hails from the region and progressive Senator Sherrod Brown still wins in the region.

This coal and union region is economically liberal and socially conservative like its neighbor West Virginia but (as documented brilliantly by this magazine) has rapidly been shifting to the Republicans since 1992.

While he writes about the irrelevant Vaccine Act of 1813 to prove the point that Jefferson and Madison supported some concept of public health (as if that evidence will convert the Right!), he avoids discussing class or race as potential reasons why a logical health system never developed in the United States. When he notes that Athenians love Medicare but hate unemployed, idle people on Medicaid, he neglects look at the relevant legislative history of Medicare and Medicaid. Congressman Wilbur Mills (D-AR), chairman of the Ways and Means Committee, deliberately separated Medicare and Medicaid to create a two tier system in 1965. The elderly would get a national Medicare program while the poor (often black and minority) would get an inferior, unequally implemented, joint state-federal program called Medicaid. De-linking the poor from the elderly has cost Medicaid politically for decades, and it was deliberate strategy.

Elitism In, Elitism Out

What do we expect from a man who took time away from medical school to campaign for Bill Clinton in 1992, who proudly worked for Blue Dog Congressman Jim Cooper, and supported Al Gore in 1988? His national profile ignores his essentially conservative and elitist politics.

Dr. Gawande (who gained fame nationally bashing greedy doctors in South Texas) has never mentioned how regional hospital monopolies result in higher prices for all, including his employer Partners HealthCare. The 2000 merger of Massachusetts General and Brigham & Women’s Hospitals into Partners HealthCare, as noted by the Boston Globe’s Spotlight team, led to bullying of insurance companies to pay them much more per visit and procedure than local non-chain hospitals. Elite hospitals’ price-gouging is fine, but these unscrupulous border physicians and hospitals are just so gauche. Robbery and health care profiteering has to have a proper pedigree. In one ludicrous article, Dr. Gawande extolled hedge fund takeovers of Catholic hospital chains and how they should make hospitals more like the Cheesecake Factory. Seriously.

Stumbling on Solutions

Based on his on the ground conversations in Athens, Ohio, the logical political, moral, and marketable answer to the health care crisis would be Medicare for all. The simple appeal of everyone in and nobody out with direct tax contributions would seem to pass the moral and practical conditions of all these victims of the American health care system.

But Dr. Gawande, perish the thought, cannot make that clean leap in logic.

Instead he buries the idea in fatuous maxims about tradeoffs and the social compact. He does not even seem to answer the question of health care (or even garbage pickup) being a right. He thinks Medicare for all, Medicaid buy in by state, and even health savings accounts are all equally morally acceptable solutions. His bias, as always, is towards a hodgepodge of regional incremental solutions.

And he seems to fear a transition more than any lasting, political solution. And he never mentions Bernie Sanders’s new Medicare for all bill or the collapse of the private insurance system or non-profit hospital price gouging and mergers.

If we are to have Medicare for all and a not for profit health system, we will need to abandon “thought leaders” like Dr. Atul Gawande. They hold us back with their faith in MBA-style management of health care from above and small, incremental, unscaleable experiments in health delivery from below.

We will need a dedicated cadre of physician and public health leaders who understand the role of the public sector in finally providing and implementing the Alma Ata Declaration’s promise of Health for All in the United States. It is only with such dedicated leaders who know that only by confronting the inequalities in wealth, power, geography, and race directly, we can produce a healthy society and finally join the civilized world in guaranteeing health care as a human right.

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