Universal health care after a calling became a job

I think the battle for health care is lost.

It started with HMOs in the 1980s and 1990s, which turned doctors into assembly-line workers. It got worse with the supposedly protective measure of work-hour restrictions, further turning a “calling” into a “job.” That well-intended change had several unintended consequences. It shifted the applicant pool for medical school toward people who wanted to clock out at 5 p.m. A sense of responsibility to the patient, of seeing a problem through, was lost. The new doctors were also more inclined to follow employer mandates and less independent.

It continued with the electronic health record (EHR), which was never interoperable, so it failed the original stated goal of portable records. Institutions offset the exorbitant costs of these EHRs by turning doctors into billing and coding clerks, saving the salaries of the schedulers, billers, and coders they no longer had to staff. The unintended consequences were an erosion of the patient-physician relationship: introducing a device that sat between the patient and the physician, apparent distraction of the physician by data entry, loss of eye contact. Keeping up with the inbox and the records extended physician hours. Again, these changes degraded the calling of medicine and made it a less attractive profession.

It continues with prior authorization, where the medical professional is no longer in charge of making diagnostic or treatment decisions. Instead, they have to submit their plan to a for-profit insurance company that ultimately decides what is or is not allowed. It turns out that insurance companies are not even bound by these prior auths, as they rescind approval after the care is given.

The final blow is the almighty patient satisfaction score, which has replaced outcomes as the measure of a doctor. Doctors are now rated on scales just like nail salon technicians or barbers. Were they on time? Were they pleasant? Did they accommodate the customer’s requests for voodoo medicine instead of proven therapies?

The employer-insurance trap

There is one more chapter to this tragedy, and it sits on the patient side of the equation: the employer-provided health insurance “perk.” Most people do not realize that this benefit is really an often untaxed part of their salary, and the second-order effects are all harmful to patients. This perk for full-time employees leads many employers to hire a bunch of part-time workers instead of one full-time employee, to save on the cost of benefits. The employee representative who is negotiating with the insurer often has no clue what they are negotiating for, so critical goods and services get excluded to keep the cost of the insurance low. You do not know what has been negotiated away until you need it, like a bone marrow transplant for blood cancer.

Sometimes the employer opts for higher deductible and copay plans to control costs, again to the detriment of those insured. When deductibles and copays are high, people do not go in for health care. It is effectively like not having insurance. Sometimes the employer changes insurers, leaving employees with a policy that no provider accepts. This only enriches the substandard insurer by providing premiums that are never used. And many employees are afraid to leave an unsatisfying job for fear of losing this benefit, especially if they have a preexisting condition.

The solution, as always, is universal health care.

I am sure I missed some chapters in this tragedy. Maybe I will update this post as I remember them.

All I can say is, I am sure glad I am not at the start of my career. And I sure hope I can die without having to be a patient.

Banu Symington is a hematology-oncology physician.