“Draining The Sink” On Drug Pricing Will Be Messy Business.

Posted on | July 26, 2023 | 9 Comments

Mike Magee

Last week’s New York Times headline said it all: “Drugmakers Are ‘Throwing the Kitchen Sink’ to Halt Medicare Price Negotiations.” It called to mind a story our aging legislators might sooner forget from two decades ago.

But how the nation gave away the bank to these corporate characters (which include not only pharma, but insurers, big drug distributors and PBM middle men) is a bit of medical history worth recounting.

The Biden administration is about to announce the first 10 medications that will be subject to price negotiations with Medicare under a new law. Drugmakers are fighting the measure in court. The action is a part of a Biden legislative victory titled the Inflation Reduction Act, which allows the government to to negotiate prices which are projected to save just under $100 billion over the next 10 years and significantly cut seniors expenditures for their prescription drugs. But to succeed, they will have to reverse history.

Let’s begin the story with the 2000 Presidential election of George W. Bush, who had courted major leaders from medicine, pharmaceuticals, hospitals, and insurers and expressed interest in privatizing the management of Medicare and Medicaid, as well as covering pharmaceutical costs for seniors over 65.

That election provided the still loosely organized MIC or “Medical-Industrial Complex” (including industry giant PhRMA, health insurers, hospitals, and the AMA) proof of concept that quietly colluding and cooperating with one another in Washington, DC, while publicly appearing to compete with one another around the country in support of patients’ interests, was a winning strategy.

After Bush’s victory, the number of MIC lobbyists grew exponentially. Pfizer government relations alone funded 82 lobbyists in 2000 to support Republican control of Congress and the White House. A year later the pharmaceutical industry as a whole spent $78 million on lobbying activities and employed 623 different lobbyists.

In the run-up to the 2002 midterms, the GOP spent just under a billion dollars, ran 1.5 million television ads, and gained eight seats in the House. More important, in achieving a net gain of two seats in the Senate, Republicans now enjoyed a majority of 51 to 49 and controlled both houses of Congress.

The MIC list of legislative objectives now was focused on Medicare prescription drug coverage and the privatization of government health plans. Funding drug insurance coverage was a high priority since it would expand sales for the pharmaceutical industry, reimburse hospitals for drug costs, and provide new sales opportunities for insurers as legions of seniors purchased partially privatized Medicare Advantage (Part C) plans.There was a growing recognition that health care resources were not unlimited and that, if cost control were to be part of their combined future, the MIC was best positioned to manage and profit from the process.

The MIC had made the calculation that it simply needed more paying customers for its existing products. Insurers would profit from sale of the policies, doctors and hospitals would have fewer “no pay” customers, and drug companies would sell more drugs. But winning the election turned out to be easier than expanding prescription coverage under Medicare.

The Bush administration pushed legislation called the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 intended to put the popular entitlement program on firmer financial footing while expanding prescription coverage. Most of Washington now agreed that reform was necessary to bring the cost of managing seniors with illnesses under control, but the bill’s proponents were hammered from both sides with arguments that private sector incentives had gone either too far or not far enough. By June 2003, budget resolutions in the House and Senate committed $400 billion for Medicare reform.

The battle centered on the Medicare Advantage or Medicare Part C plans that had been created in 1997.These federally subsidized Medicare plans offered seniors who voluntarily chose them, rather than choosing traditional fee-for-service Medicare, additional benefits like health maintenance and wellness offerings and, in varying amounts, prescription coverage. Private insurers had been recruited by the Clinton administration to manage these plans, and shared in any profits derived from management efficiencies. But absent price controls, as costs of hospitalization and drugs rose steeply in the late 1990s, insurers pulled back on extra benefits, especially pharmaceuticals, and the numbers of aging citizens choosing Medicare Part C declined.

Bush’s original plan was to provide his new prescription benefit only to seniors within Medicare who chose his partially privatized Medicare Part C—Medicare Advantage. But when the administration was presented with an outcry of unfairness from both Republicans and Democrats, he backed down and decided that a freestanding drug benefit, dubbed Medicare Part D, should be available as a voluntary choice for those who decided to stay with traditional Medicare as well.

To protect the interests of his key pharmaceutical and insurance industry supporters, Bush agreed that the plans would be administered through private insurers which, in turn, would negotiate against one another and with the newly empowered intermediary Pharmacy Benefit Management (PBM) companies like Merck’s Medco and CVS Caremark over pricing.

Insurers would be allowed to use various formularies that generally grouped drugs into two or three categories or tiers, with the best prices for consumers restricted to cost-effective drugs in column one, and higher-price options dropping into column two or three and costing consumers considerably more. Protecting the industry’s need for choice and coverage of me-too “copy-cat” drugs, the legislation also required that each category of drug have at least two options available. With this scheme, Bush committed to no direct government negotiation on Medicare drug purchases. In addition, he declared importation of Canadian low-cost drugs illegal.

To further sweeten the deal for pharmaceutical companies, Bush agreed to a rule that would force 6.5 million “dual eligible” individuals (those then covered by both Medicaid and Medicare as a result of disability or extreme poverty) into Medicare drug coverage. This group was currently receiving its drugs through state Medicaid programs which enforced “lowest cost” provisions. In transferring dual eligibles to the Medicare Part D plans, where drug costs had no government controls, Bush assured the pharmaceutical companies of an additional markup of 25 percent on drug revenues from these patients.

The American Medical Association (AMA), was an early supporter. Its’ members generally believed in expanding coverage for their patients, but their primary concern was the long-standing anxiety that any changes would be a foot in the door for socialized medicine. Once Bush established that there would be no direct government negotiation with drug companies, others lined up as well, including the American Association of Health Plans, the American Hospital Association, and the Business Roundtable.

The health insurance industry saw the legislation as a source of new revenue, and as a solution to the deteriorating Managed Medicare (Medicare Part C) situation. By establishing another source of federal dollars to cover their pharmaceutical cost, industry sponsors of Managed Medicare (Medicare Part C) plans could once again offer a range of extra benefits that would entice seniors into these lucrative options and away from less profitable traditional Medicare. If the MIC coalition held, Medicare Part D and its new drug benefits could reinforce Managed Medicare and ensure a brighter future for all.

The media was not giving a pass to this complex sweetheart deal in which the MIC was paid in full and patients were saddled with partial coverage and ever more billing complexity. E. J. Dionne, in a Washington Post story titled “Medicare Monstrosity,” wrote, “How do you know this bill is such a great deal for the drug companies and HMOs? On word of an agreement last week, share prices soared.”

Bush’s advisers had cautioned that the Iraq invasion that spring would distract Congress from focusing on the bill, and yet the Senate Finance Committee produced a “bipartisan agreement” in June. Seven days later, the two-page outline had taken on flesh, thanks to some heavy lifting by MIC lobbyists, and from there it emerged as a rather complete 90-page tome, which passed out of committee on June 13.

AARP remained the big unknown. Having sealed a profit-sharing deal with the fastest-growing national health insurer, UnitedHealthcare, to provide its members with supplemental health insurance, AARP was now more than ever heavily invested in the commercial side of the Medical Industrial Complex and positioned to be a major beneficiary of Medicare Advantage Part C and Part D plans that carried the new pharmaceutical subsidies.

Even so, it surprised the Democratic leadership to discover on the morning of November 17, 2003, that AARP had committed $7 million to a public campaign in support of the Bush bill. “The endorsement provides a seal of approval from an organization with 35 million members,” one analyst noted. “Republicans also hope it provides political cover against charges by some Democrats that the bill would undermine the federal insurance program for the elderly and disabled.”

Five days after the AARP announcement, at 3 a.m. on a Saturday, after a full day of arm-twisting and dealing, the House bill was allowed to come up for a vote. After 15 minutes, Bush’s supporters were 15 votes behind, and the bill was held open. After further concessions to individual holdouts, it was still two votes short at 216–218. With everything at stake, HHS secretary Tommy Thompson was sent to lobby on the House floor, an action seldom taken.

President Bush himself, just back from a visit with the queen of England, was awakened at 4 a.m. to lobby the few remaining undecideds. The “longest roll call vote in history,” lasting just under three hours, came in at 220–215 in favor. Three days later, after some political maneuvering, the bill passed in the Senate.

On December 8, 2003, with great fanfare, President Bush signed the Medicare Modernization Act in a heavily staged event. Declaring the legislation “a victory for America’s seniors,” he went on to say, “I’m pleased that all of you are here to witness the greatest advance in health care coverage for America’s seniors since the founding of Medicare.” With no evidence of irony, and no acknowledgment that within living memory the Republican Party had called Medicare a threat to the American way of life, he added, “And today, by reforming and modernizing this vital pro- gram, we are honoring the commitments of Medicare to all our seniors.”

With the help of Big Pharma and Big Business generally, Bush comfortably won reelection over John Kerry. The AARP and its partner, UnitedHealthcare, secured a hefty chunk of the expanding Managed Medicare (Medicare Part C) and Medicare Part D business, and the pharmaceutical industry indulged privately in a self-congratulatory celebration.

But now two full decades after these events, the most lasting impact of the deliberations that led up to the Medicare Modernization Act was the conversion of the MIC from a loose network of major sectors with casual connections to health delivery, and a penchant for joining forces only when its own status quo was threatened, into a complex syndicate committed to self-control and distributing the profits secretly among its members in the form of opaque negotiated rebates, invisible to the consumer, at the point of sale.

In the center of the food chain were the MIC’s newest creations, the Pharmacy Benefit Managers, or PBMs, designed as vehicles to organize the movement of data, drugs, and money throughout the MIC supply chain. Now two decades later, as the headline above suggests, they are more than up to the task of “‘Throwing the Kitchen Sink’ to Halt Medicare Price Negotiations.”

When It Comes To Water, Weather Matters.

Posted on | July 16, 2023 | Comments Off on When It Comes To Water, Weather Matters.

Mike Magee

We forget that the water cycle and the life cycle are one.
— Jacques Cousteau

When the Simon Pearce restaurant and glass blowing studio flooded on the banks of the Quiche Dam in Vermont during Tropical Storm Irene in 2011, it was supposed to be the result of a once in a century event. But this past week, it happened again. Welcome to New England 2023 – and multiple locations around the globe – where atmospheric rivers, and massive epic cloudbursts, have revealed not simply the effects of human induced global warming, but historic underinvestments in water infrastructure and Integrated Water Resource Management (IWRM).

Global management of water resources was first discussed at a global water summit organized by the UN in Mar del Plata, Argentina, in 1977. By 1992, water was a central theme at the World Summit of Sustainability Development in Rio. By 2009, all nations agreed on a definition for Integrated Water Resource Management (IWRM): “IWRM is a process which promotes the co-ordinated development and management of water, land and related resources, in order to maximize the resultant economic and social welfare in an equitable manner without compromising the sustainability of vital ecosystems.”

The hydrological cycle itself, throughout human history, has been dynamic. It is now generally accepted that the assessments of the Intergovernmental Panel on Climate Change have accurately identified that global temperatures will rise 1.5 C above pre-industrial levels by 2030 largely as a result of the emission of greenhouse gases especially carbon dioxide (CO₂). In response, ocean levels are rising, more energy exists in the climate system, and the global hydrological cycle is intensifying. How will this be expressed? We have already seen changes in amount and intensity of precipitation, in seasonal distribution, and in frequency. These events in turn will lead to changes in magnitude and timing of water runoff, intensity of floods and droughts, regional water supply levels, levels of surface and ground water. In short, “terrestrial components of the hydrological cycle amplify climate input.” Translation, when it comes to water, weather matters.

Precipitation across the globe is highly variable from highs of 2400 millimeters per year in the tropics to lows of 200 millimeters or less in the subtropics. Soil is a significant reservoir for water. Amounts are not only driven by the rates of precipitation and evaporation, but also by soil type and depth, vegetation, topography, and seasonality. The top two meters contain the majority of the moisture. Significant water also collects in subterranean spaces. Groundwater is the predominant strategic reservoir on Earth, some 30% of the global fresh water total and 98% of the drinkable and potential accessible supply. Critical to human development and in the past 50 years, with advances in drilling and pump technology, groundwater has rapidly become the worlds “most extracted raw material”. And compared to surface water, there is very little loss to direct evaporation.

The challenge remains how best to scientifically manage this raw material to assure long term, sustained development. This requires a better understanding of how the ground water systems function, their recharge processes and their relationships to surface water bodies. It also means managing and protecting the purity and integrity of the resource, a knowledge of the geology, better monitoring of groundwater levels, and real-time data of depth, flows, and extraction levels.

As water seeps into groundwater aquifers it also seeps out through watercourses, wetlands and coastal zones. Recharge rates are highly variable and affected by changes in surface vegetation, surface water diversion, changing water table levels, and climate cycles. Sustainability issues include inefficient use, social inequity, unsustainable extraction, icy weather reductions, aquifer damage, land compaction, and ecosystem damage. All of the above are under human control. Aquifers are far more resistant to contamination than are surface water bodies. But once contaminated, aquifer damage is difficult to reverse.

As with most enlightened policy, good planning and prevention pays off. Sound system design, proper land use rights, ongoing investment in technology, stakeholder participation, and careful monitoring, design and operation are critical. But what’s unique about water is that water flows. And in flowing, it crosses multiple jurisdictional borders. So proper management and planning require intergovernmental cooperation.

The human touch has left its mark. From industrial heavy metals to acid rain, from leaking storage tanks, accidental spillage, and domestic sewage, to municipal waste and agro-industrial effluent, people and water definitely do mix. Besides affecting the quality of drinking water, secondary impacts have become common. For example, the discharge of organic material, high in nitrogen and phosphorous, into surface water fosters abnormal and explosive plant growth depleting oxygen and affecting the entire ecosystem and the life forms it supports. Twentieth century ecosystem degradation has resulted in the loss of 2/3rds of our wetlands profoundly impacting fresh water species.

Water on the move cannot be separated from solid and particulate sediment. Much exists as suspended matter, actively in motion. In fact, more than 50 billion tons of suspended sediment are carried by river waters to the oceans each year. What lands in surface water and ground water bodies is increasingly a function of human action and planning. For example, creation of solid surfaces (contributing for example to the 500-year flood in Houston, TX in 2017) increases volume and rate of runoff, downstream flooding, and human chemical deposits into surface water. Over-mining of ground water impacts water levels and the capacity to live off the land in stressed locations around the world. High surface runoff carries with it expanded sewage runoff in urban environments. Poor liquid waste disposal and hazardous chemical spills travel rapidly above the ground and easily penetrate below the ground in many locations. And as these collective actions impact lakes, rivers and streams, habitats and species diversity declines.

There is then a natural, interconnected, and crucial water cycle upon which all life on earth depends. Humans have always required a dependable water supply to survive and thrive. As we have grown in numbers and in concentration; as we have built and infiltrated among, and at times, in opposition to other life forms, we have created future health challenges that must now be addressed. Global warming is an accelerant. The time for each of us to better understand the nature of water, and its relations to weather, ecosystems, agriculture, industry, urban planning, sanitary systems, and value of Integrated Water Resource Management (IWRM) is long overdue.

Category: Uncategorized
Tags: atmospheric rivers > global warming > Integrated Water Resource Maqnagement > IWRM > UN Sustainability > Water cycle > water cycles > weather

Is Health Tech’s Magic Wand Anti-Social?

Posted on | July 11, 2023 | Comments Off on Is Health Tech’s Magic Wand Anti-Social?

Mike Magee

In George Packer’s classic 2013 New Yorker article titled “Change the World: Silicon Valley transfers its slogans – and its money – to the realm of politics,” there is a passage worth a careful reread now a decade latter.

Packer shares an encounter with a 20-something techie critiquing his young colleagues who said, “Many see their social responsibility fulfilled by their businesses, not by social or political action. It’s remarkably convenient that they can achieve all their goals just by doing their start-up. They actually think that Facebook is going to be the panacea for many of the world’s problems. It isn’t cynicism—it’s arrogance and ignorance.”

Packer’s assessment at the time was “When financiers say that they’re doing God’s work by providing cheap credit, and oilmen claim to be patriots who are making the country energy-independent, no one takes them too seriously—it’s a given that their motivation is profit. But when technology entrepreneurs describe their lofty goals there’s no smirk or wink.”

Or, as others might say, “They believe their own bull shit.” Where many of us are currently focused on issues of values, fairness and justice, those in the shadows of Silicon Valley see the challenge to be inefficiency and incompetence, and the solution amenable to technologic engineering.

Back in 2013, a Belarusian immigrant student at Stanford named Evgeny Morozov coined the term “solutionism” for those with unshakeable confidence in hi-tech solutions. A decade latter, Evgeny is now Visiting Scholar in Liberation Technology at Stanford, and a colleague of Larry Diamond (director of Stanford’s Center on Democracy) who coined the term, “liberation technology.”

Stanford describes their focus this way: “The Internet, mobile phones, and other forms of ‘liberation technology’ enable citizens to express opinions, mobilize protests, and expand the horizons of freedom. Autocratic governments are also learning to master these technologies, however. Ultimately, the contest between democrats and autocrats will depend not just on technology, but on political organization and strategy.”

Evgeny naturally bridges this world of individual entrepreneurship and public policy. His current focus is on AGI (artificial general intelligence) and its interface with his original concept of neo-liberal “solutionism.” He believes we have all been sold a bill of goods that technology is inevitable and beneficial, and that it will expand our intelligence and fix our inhumanity.

Evgeny says that it is already clear that the rise of entrepreneurial capitalism and destructive profiteering (let alone massive income inequality and segregation of tech gazillionaires) is altering representative democracy and replacing it with libertarians on steroids.

It is useful to remind ourselves that we’ve been down this road before. For example, it was none other than Margaret Thatcher who said, “There is no such thing as society.” How has that worked out in the post-Brexit period for the UK?

Were she alive today, she would likely agree with AGI fans that private beats public, efficiency solves social troubles, and adjusting to change is a great deal quicker and easier that addressing core weaknesses in human or societal behavior.

Health tech’s recent “boom and bust” cycle laid truth to the lie that “really smart people” versus venture capitalist corporations are driving the information technology revolution. In the vast majority of cases, in health care and beyond, the “charm offensive of heavily subsidized services” is followed by “ugly retrenchment, with overdependent users and agencies shouldering the costs…”

In 2021, Health Tech managed to break all the records. The digital health market gained 43% more investors than in 2020, with $30.7 billion – a 107% rise – in venture capital. By 2022, the 85 corporations devoted to the field had collective valuations that had tripled to $73 million.

Were these ideas category-defining? Were they sustainable? Were the investors a source of expertise or wise guidance? Were any of these products driving impactful change that would equitably change the life trajectory of the humans served? Did they lessen the populations fear and anxiety? Did they expand hopefulness and community engagement. Did they make America and Americans healthy?

Not according to Evgeny. He says, “The open agenda is, in many ways, the opposite of equality and justice. They think anything that helps you to bypass institutions is, by default, empowering or liberating. You might not be able to pay for health care or your insurance, but if you have an app on your phone that alerts you to the fact that you need to exercise more, or you aren’t eating healthily enough, they think they are solving the problem.”

Category: arry diamond, Evgeny Morozov, george pavcker, liberation technology, silicon vallety, solutionism, tanford, th tech

Justice Roberts Foresaw The Ensnarement of Health Professionals By Alito’s Radicalism.

Posted on | June 28, 2023 | 5 Comments

Mike Magee

We all need affirmation and encouragement. That is why I was so grateful to receive a range of positive feedback on Hcom’s recent focus on the role of health professional oaths in supporting the foundations of democracy.

One global health care leader wrote, “Thank you for your message and all the lovely pieces you publish. You give deep insights into political, historical and cultural contexts of medicine and health that we often overlook or miss to understand.”

A U.S. thought leader in Medicine commented, “Great review of the oaths and ethical principles of medicine and nursing which are sadly being chipped away by perverse incentives, especially of corporate medicine and greed.”

And finally this, from a highly respected health policy expert, “I very much appreciated this most recent posting and agree with your three major points. While I very much share your concern with the never ending (it seems) attempts by conservative legislators to interfere in various ways and intrude on the patient-physician relationship, I would also agree that the corporate intrusion into health care and the daily practice/delivery of medicine by physicians and nurses is a far more dangerous intrusion from my perspective.”

As I have aged into my current role, as observer/commentator/recipient of care, I have begun to appreciate that health professionals are not “separate from”, but “makers of” democracy. Government, after all is “the institutional authority that rules a community of people.” To what end? “To maintain order and stability, so that people can live safely, productively, and happily.” The ultimate goal? “To protect the individual rights of liberty within conditions of order and stability.” And therein lies the tension.

Negotiating that divide, especially when two rather than just one life is at stake (as in pregnancy), is a remarkably personal, individualistic, private and complex undertaking. That is why, for many decades, it was entrusted to individuals and families supported by health professionals. A careful reading of Roe v. Wade, with its boundaries defined by three separate trimesters, was a compromise – not perfect, but workable in a real world with real people.

Authentic democracies are based on a constitution and are limited in the interest of maintaining as much individual freedom as is orderly possible. That is why, democratic constitutions around the world (including our own) purposefully “restrain and harness the powers of government…to secure the freedom and common good of the people.”

Written constitutions are not an ultimate failsafe. After all Nazi Germany, Fascist Italy, and the Soviet Union all had them. Rather it is actions, not words, that matter. Do you live up to your constitution?

Freedom to make choices – in what you do and what you say – is what liberty is all about. Civil liberties are liberties defined to be within our laws, created by our elected representatives, which govern a civil society under our constitution.

Liberties are not a green light to do anything you want. As experts attest, “Neither freedom of thought nor freedom of action is secure in a lawless or disorderly society.” And yet, controlling government over-reach and intrusion on individual’s liberties was, and remains, a primary risk to the function of our constitutional democracy.

James Madison acknowledged as much in a letter to Jefferson in 1788: “It is a melancholy reflection that liberty should be equally exposed to danger whether the Government has too much or too little power; and that the line which divides the extremes should be so inaccurately defined by experience.”

Justice Alito was well-aware of the potential political fallout when he first leaked the draft of the majority opinion in the Dobbs case. Since then he has made it clear that his respect for Stare decisis (Latin for entrenched legal precedent) was by no means etched in stone, and added insult to injury by offering a “what about” comparison to the reversal of the historic Plessy v. Ferguson “separate but equal” decision that had codified the legality of segregation.

What Alito and his majority did was go all in on an open door policy for radicalized Trump-supporting state legislatures to assault the core liberty of women over decisions related to their bodily autonomy. At the same time, they facilitated the ensnarement of health care providers into criminal territory, and endangered the very patients doctors and nurses had sworn an oath to protect.

One year after the Justice Alito led Dobbs’ decision, Red states have aggressively followed his lead. Abortion is now banned (with some exceptions) in Alabama, Arkansas, Idaho, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, West Virginia, and Wisconsin. Additionally, abortion in banned after 6 to 15 weeks of gestation in Georgia and Nebraska. Florida and North Carolina have bans that have not yet been implemented. Indiana, Montana, Ohio, South Carolina, Utah, and Wyoming have bans that are are tied up in court.

Chief Justice John Roberts attempted to steer Alito and his followers down a third path on Dobbs but failed. He stated that the “dramatic and consequential ruling is unnecessary to decide the case before us,” believing that a partial move toward a 15-week ban might be justified by the science, and that opening up the state floodgates by eliminating Roe v. Wade would destabilize our democracy.

Ironically, our constitution was designed, in the interest of individual liberty, to restrain “tyranny by the majority.” And yet the threat that has brought us to our constitutional knees in modern times is “tyranny by the minority.” Guided by religiously motivated adherents to white supremacy and patriarchal rule, a small cabal of conservative legal scholars, over a two-decade span, have redirected one of the three branches of government, toward a singular target – the overturn of Roe v. Wade.

With their success, this small band of emboldened outsiders and insiders are poised to undermine other personal liberties by exploring book banning, gender based restrictions of freedom of speech, and public funding of private and religious ventures.

Doctors and nurses, and the patients we care for, find ourselves caught in the middle of this battle, not by choice, but by necessity. We are, in fact, practitioners of democracy, perched perilously between liberty and order. Rather than shy away from conflict now, it is the time to speak up and stand tall.

Category: Uncategorized
Tags: Constitutional Democracy > Dobbs decision > doctors > Freedom > Government > Justice Roberts > Liberty vs. Order > nurses > Roe v. Wade > Samuel Alito

The Danger to Our Democracy in Moving Nurses and Doctors From The Front Line.

Posted on | June 21, 2023 | 2 Comments

Mike Magee

The 4.2 million registered nurses and 1 million doctors in America who are agents of democracy are being sidelined, with a noticeable negative impact on the health of our representative democracy. As such, we must be careful how we select, train, and utilize this resource, and take care to expand rather than diminish their personal human contact with our citizens.

The three most prominent missteps are:

Corporate Dislocation – To assure maximum reimbursement, doctors and nurses are routinely asked to prioritize time and contact with data over time and access to patients.
Health technology and AI Substitution – Rather than engineering solutions to expand real-time patient contact, most innovations are further distancing patients from healthcare professionals.
Legislative Intrusion – Complex medical decisions, long entrusted to the patient-health professional relationship to negotiate, are being transferred to ultra-conservative legislators.

We live under a constitutional and representative democracy, as do two-thirds of our fellow citizens in over 100 nations around the world. The health of these democracies varies widely. Winston Churchill famously wrote, “Democracy is the worst form of government, except all those other forms that have been tried from time to time.”

The case for democracy emphasizes its capacity to enhance dignity and self-worth, promote well-being, advance equal opportunity, protect equal rights, advance economic productivity, promote peace and order, resolve conflicts peacefully, hold rulers accountable, and achieve legitimacy through community based action.

The argument against democracy is that it is inherently inefficient and corrupt, makes unwise decisions, handicaps excellence and ingenuity, overplays equality, over-encourages dissent and division, and erodes authority.

One of the challenges of democracy is to find the right balance in pursuing “the common good” which has dual (and often competing) arms. One arm is communitarian well-being and the other, individual well-being.

Nations tilt one way or the other. America clearly leans toward individualism, while a country like Japan favors the communitarian version of democracy. Blending personal and public interests is complex. In health, one might argue, this tension led to our dual system – one, largely profit driven, interventional and science discovery based, and the other largely public, preventive and focused on communitarian public health.

Both nursing and medicine have embraced professionalism, and launched new graduates by voicing “oaths” or promises to themselves, their colleagues, and our society as a whole. These lists of promises or pledges, their language and priority ordering, helps reveal both the history and intent of these noble professions.

Of course, the most famous oath in Medicine is the Hippocratic Oath reaching back some 2000 years to Greece. In pledging to a grouping of ancient deities, it recognized that interventions should “do no harm,” and that confidentiality was paramount. By 1964, this oath was sufficiently out of date that many medical schools embraced an updated version written by Louis Lasagna, MD, an historical luminary in the creation of the Medical-Industrial Complex.

Not surprisingly, top line status in that Oath reads: “I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.”

The “art of medicine” and the avoidance of human arrogance earn line 3 and line 4 mentions:

(3) “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”

(4) “I will not be ashamed to say ‘I know not,’ nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.”

The final pledge in the Lasagna oath suggests a role in communitarian democracy: “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

Over the past half century, the Oath has continued to be refined, and in some cases rewritten. For example the Penn State 2022 Oath gives top billing for the first time to the patient, with the oath to them, not to the gods: “By all that I hold highest, I promise my patients competence, integrity, candor, personal commitment to their best interest, compassion, and absolute discretion, and confidentiality within the law.”

Arguably the most balanced, comprehensive, and modern Oath for Medicine however dates back to 1948, and has undergone six revisions since then. It is the work of the Geneva based World Medical Association. Its list of pledges in their Declaration of Geneva in order of appearance include:

the service of humanity
patents first
patient autonomy and dignity
respect for human life
absence of bias or prejudice on any basis
commitment to patient privacy
guided by professional conscience and dignity
honor the noble traditions of the profession
respect and gratitude to teachers, colleagues and students
share knowledge to advance health care
commit to personal health and well-being
never violate human rights.

Nursing has also relied on professional Oaths. The first was the Nightingale Pledge, created in 1893 by the Farrand Training School for Nurses and named after Florence Nightingale. It is believed to be based on the Hippocratic Oath, and was modernized in 1935. In the 1950’s, the American Nurses Association (ANA), created a formal Code of Ethics, which largely supplanted it, and in 2015 added 9 pledges to its four pillared Code which celebrated Autonomy (patient self-determination), Beneficence (kindness and charity), Justice,(fairness) and Nonmaleficence (do no harm).

Nursing’s 9 Provisions (or Pledges) commit to: compassion and respect, patient-focus, advocacy, active decision making, self-health, ethical environment, scholarly pursuit, collaborative teamwork, professional integrity and social justice.

John J. Patrick PhD, in his book Understanding Democracy, lists the ideals of democracy to include “civility, honesty, charity, compassion, courage, loyalty, patriotism, and self restraint.”

It is largely self-evident that the more than five million health professionals, engaged and embedded in communities across this land, possess stated values that closely align with those of a healthy democracy,

These health professionals should be encouraged to live up to the values they pledged in their Oaths. After all, these jobs are tough on body and soul. But this is the job they signed up for.

At the same time, we as a nation should guard against the destruction of our Democracy from within. One of the surest ways to do that is to, by profit-driven design or political malfeasance, remove our nation’s nurses and doctors from the front line.

Category: Uncategorized
Tags: ama > ANA > Democracy > ethics in medicine > health and democracy > healthy democracy > Medical Oths > Nursing Oaths

Nurses and Doctors: Defenders of Democracy.

Posted on | June 14, 2023 | 2 Comments

Mike Magee

My recent post, featuring North Carolina’s K-12 lesson plan on “The Rule of Law,” broke records for traffic, but drew this admonishment from one subscriber, “This is a strange post for a health care blog.”

Since focusing on the social science of Medicine in the 2000 in Philadelphia, it has been an uphill battle to convince leaders in and out of Medicine that doctors and nurses are critical to the success of democracy. Recently, I’ve come to the conclusion that this may have more to do with a general lack of knowledge of democracy and its workings than a misunderstanding of the stabilizing effect of professional doctors and nurses.

What is democracy? For an answer I turned to John J. Patrick PhD, professor emeritus in history, civics and government at the Indiana University. In his “Understanding Democracy,” he explains that democracy as we know it is a “startling new development.” The practice of rule (krater) by the people (demos), or “demokratia,” dates back 2500 years to Athens, Greece. Citizens did rule by majority vote, but only free males of Greek descent could rise to the status of “citizen.” In those days, individual freedoms took a back seat to unconditional support of the city-community.

Establishing a modern democracy in America has been a bit of a struggle. Our concept of a “representative democracy” allowed elected representatives to act on behalf of the citizens with the goal of achieving “majority rule in tandem with protection of minority rights.” By 1920, democracy was somewhat more inclusive and slowly gaining global recognition as a form of government. At the time, there were 15 democracies worldwide. But by the end of the 20th century, there were 100 representing 2/3rds of the global population.

The ascendant nature of democracy reflected changes and adjustments of the ancient model. Dr. Patrick has highlighted a few of those changes including:

“Democracy in our world implies both collective and personal liberty.”
“Differences in opinions and interests are tolerated and even encouraged in the public and private lives of citizens.”
“Unlike democracy in ancient times, which directed citizens primarily to serve the community, the primary purpose of government in a modern democracies is to serve and protect all persons under its authority and especially to secure their inherent rights to liberty and safety.”
“In an authentic democracy, the citizens or people choose representatives in government by means of free, fair, contested, and regularly scheduled elections in which all adults have the right to vote and otherwise participate in the electoral process.”
“Popular sovereignty prevails; the government rules by consent of the people to whom it is accountable.”

Democracies are anchored by Constitutions which define the the responsibilities of the various counter-balancing branches of government, and jury a system of laws or rules that apply to all citizens. The Constitution defines the limits on the power of government. It is a tricky balance. The democratic government must be powerful enough to maintain law and order. Yet it must be sufficiently restrained to avoid oppressing individual liberty.

Federalist No.51, dealt with this delicate balance, stating: “If angels were to govern men, neither external nor internal controls on government would be necessary. In framing a government which is to be administered by men over men, the great difficulty lies in this: you must first enable the government to control the governed, and in the next place oblige it to control itself.”

Dr. Patrick suggests that the rapidly expanding popularity of democracy as a form of government is its promise to deliver “ordered liberty…combining liberty and order in one constitutional government…an authentic democracy.”

This requires confidence and trust that is able to reach down into the community. It requires liberal amounts of compassion, understanding and partnership. It requires real time processing of individual fears and worries. And it requires hope.

The roughly 1 million physicians and 4.2 million Registered Nurses at their best, deliver all of the above to all comers. They are neither saints nor sinners. They are human. Those of us who have spent time educating and managing this workforce, have appealed to their sense of professionalism and their oaths of duty. We’ve reinforced that living under our impossibly high expectations is, after all, what they signed up for. Historically, in most cases, they have delivered beyond our expectations.

But as this morning’s New York Times headline, The Moral Crisis of America’s Doctors, spotlights, there is growing concern that the monetarization and corporatization of nursing and medical professions by hospital and insurance power houses, have seriously undermined the mental health and ethical effectiveness of health care professionals. The pandemic has only heightened the crisis.

I see health professionals as front-line educators and defenders of democracy. As Dr. Patrick notes, “If there would be ‘government of the people, by the people, and for the people’ – Abraham Lincoln’s pithy phrase about the meaning of democracy – then there must be education of the people about what it is, how to do it, why it is good, or at least better than the alternatives to it.”

But learning in democracy, as in health care, is an intimate affair. It requires that people “touch each other.” As Ralph Waldo Emerson wrote long ago, “To interpret Christ, it needs a Christ…to make good the cause of freedom against slavery you must be…Declaration of Independence walking.” Health professionals must be encouraged to continue to “walk the walk.” Neither AI, nor the latest mRNA technology, can cure “what ails us.” The solutions are distinctly human.

Category: Uncategorized
Tags: Democracy > doctors > Federalist No.51 > healthy democracy > John J. Patrick PhD > nurses > rule of law > understanding democracy

Trump Earns a Dunce Cap in North Carolina.

Posted on | June 11, 2023 | 4 Comments

Mike Magee MD

Events over the past year clearly have confirmed that we are a “work in progress” even as we stubbornly affirm our good intentions to create a society committed to “life, liberty, and the pursuit of happiness.”

With the Dobbs’ decision, our Supreme Court has unleashed long-abandoned regressive state laws designed to reinforce selective patriarchy and undermine the stability and confidence of America’s women and families. As a result, our nation’s health professionals, and the patients they care for, potentially find themselves “on the wrong side of the law.”

It calls to mind the well-worn phrase of mothers everywhere to their bossy children, “Who died and left you boss?”

Since our former President, on the eve of his latest indictment, decided to deliver a message to North Carolina Republican supporters this past weekend, claiming that he was engaged in the “final battle” with “corrupt” forces, most especially the “Deep State” that was “out to get him,” I decided to fact check his claims with the kids of North Carolina.

North Carolina’s K-12 lesson plan, titled “The Rule of Law,” begins with the Teddy Roosevelt quote, “No man is above the law, and no man is below it” from his 1903 State of the Union address.

In the very first paragraph, the plan affirms that law is fundamental to societal health stating:

“Every day, we are touched by rules and laws. They pervade every aspect of our lives, from traveling on the road to shopping at the mall. In this lesson, students will explore the rule of law in American democracy and its impact on every individual. Through class discussion and role play, students will gain an understanding of:

what the rule of law means in terms of American government,
the functions laws play in our society, and
the role all citizens and community members, from a student to the President, play in adhering to and upholding the rule of law.”

The plan cues up questions that students will need to address, including:

“From when and where does our system of law originate?”
“What functions do laws serve in our society?”
“What role does our government’s separation of powers play in ensuring adherence to the rule of law?”
“Why is an independent judiciary fundamental to the rule of law?”
“How might our society be different if we had no laws?”

A bit further on, students are informed that:

“The rule of law is basically an agreement that everyone will play by the rules. This allows us to enjoy a more peaceful and safe existence. The rule of law also ensures the protection of certain rights for each of us. Ideally, the rule of law applies equally to everyone, meaning you are treated fairly and equally, under the same set of rules, regardless of who you are.”

The curricular plan then explores laws themselves helping students to uncover these insights:

“How do laws affect each of us? What functions do laws serve in our society? Ensure students discuss the following functions of laws:

1.“Laws serve as standards of conduct and dictate the ways people should behave and what activities are permitted or prohibited under certain conditions (e.g., drinking under age, driving, speeding, etc.)
2. Laws maintain order, ensure predictability, and provide security (e.g., they require that people drive on a certain side of the road; they require that people pay for services rendered.)
3. Many laws in America grant and protect particular individual rights and freedoms, ensure equality, and advocate for the common good.
4. Laws also guarantee certain benefits to citizens (e.g., schools, health services, etc.)
5. Laws assign responsibilities to citizens (e.g., paying taxes.)
6. Laws define what duties the government will perform and can also limit the power of governmental officials.
7. Laws can facilitate different forms of change (e.g., toxic waste disposal, anti-discrimination, prohibition of spousal abuse, etc.)
8. Laws are used to manage different forms of conflict, relying on courts, lawyers, and judges for such.
9. In summary, laws serve many different purposes. Ideally, laws should be well designed to ensure justice; they should be designed so that the average citizen can interpret, understand, and thus follow them.”

Finally there is a homework assignment. Students are provided with a copy of chapter 28 in Justice Sandra Day O’Connor’s “The Majesty of the Law,” to read.

In follow-up, the teacher is instructed to ask students: “When Justice O’Connor writes, ‘A nation’s success or failure in achieving democracy is judged in part by how well it responds to those at the bottom and the margins of the social order,’ what message was she conveying and how does it relate to the rule of law?”