You Can't Tell the (Health Care Policy Op-Ed) Players Without a Scorecard

With the run-up to the US presidential election starting in earnest, public discussion of health care policy issues is ramping up. As has occurred before, we hear a lot from people apparently on the right who advocate for a laissez faire approach to health care free of government involvement. Such people often tend to approve of much of what health care corporations do. We also hear a lot from those apparently on the left who favor government operation of particular segments of the health care system, particularly health insurance. They tend to be very critical of corporate health care, but to approve of much of what the government does.

These discussions often take place in the most prominent fora in the main stream media. For example, last week Dr Scott Gottlieb wrote "Stop the War on Drugs," a commentary for the Wall Street Journal. Gottlieb focused on how the US Food and Drug Administration and the Department of Justice challenge off-label marketing by pharmaceutical companies. He noted cases in which he contended that the government prosecuted companies for "educational" dissemination of information already widely available in the medical literature. Further, he implied that these attempts are part of efforts to make "off label" into "dirty words in the conventional lexicon." Gottlieb did not address cases in which companies promoted off-label use which was not supported by good evidence, e.g., the Neurontin case, and seemed to conflate marketing with education. His main point seemed to be that overly strict regulators were hindering physicians' education and hence keeping people from getting the drugs they need.

Also last week, Dr David Himmelstein and Dr Steffie Woolhandler wrote "I Am Not a Health Reform," a commentary for the New York Times. The thrust of this article was to discredit the employer mandate approaches now advocated by some presidential candidates to reform health care. They called the "mandate model" "economic nonsense." Instead, they asserted "only a single-payer system of national health care can save what we estimate is the $350 billion wasted annually on medical bureaucracy and redirect those funds to expanded coverage." Himmelstein and Woolhandler did not address any deficiencies in how our current national single-payer system, Medicare, allocates money, in particular how it follows reccommendations by the secretive, proceduralist-dominated RBRVS Update Committee (RUC) that have lead to a relentless squeeze on primary care. Their main point seemed to be that only government run health insurance will solve our current problems.

Thus, much of the debate seems to be between those who see any government involvement in health care as ill-conceived or worse, and those who see government operation of whole health care segments as the only solution. Rarely discussed are ways in which government could better regulate health care to improve health and safety, without actually running it; or ways to re-invigorate the involvement of not-for-profit organizations in health care so they actually fulfill their missions, or revitalize the health professions so they can rediscover their professional values.

Perhaps this domination of the debate by those on the extreme ends of the spectrum would lessen if the audience knew more about who was trying to sway them.

Dr Scott Gottlieb, for example, was described in the WSJ as "a practicing physician and resident fellow at the American Enterprise Institute, [who] was deputy commissioner of the FDA from 2005 to 2007." However, Dr Gottlieb has more relationships with health care corporations than were revealed by this one-sentence biography.

Just before he took that job, the Seattle Times reported, "Only a month ago, Dr. Scott Gottlieb was a Wall Street insider, promoting hot biotech stocks to investors." Also, "he also has consulted for, and written positively about, a major matchmaking firm that links doctors with Wall Street investors, the Gerson Lehrman Group in New York."A few months later, the Boston Globe reported that as FDA Deputy Commissioner, Dr Gottlieb had to recuse himself from discussions about dealing with an avian flu epidemic

because his past consulting work for [large public relations firm] Manning Selvage & Lee involved companies whose products would be used to combat a flu pandemic. Gottlieb's former clients include Roche -- manufacturer of the highly sought antiviral Tamiflu -- and Sanofi-Aventis, parent company of the nation's sole flu vaccine manufacturer.

Manning Selvage & Lee paid Gottlieb a $12,500 monthly retainer for nine months for business development projects that included eight companies. Other firms regulated by the FDA he was involved with include Inamed Corp., one of two companies seeking to return silicone gel implants to the market. He also did private consulting work for VaxGen Inc., a California firm that won a $878 million federal contract to supply 75 million doses of anthrax vaccine for the nation's protective stockpile. The $9,000 he accepted from VaxGen for consulting work between May and July prevents him from doing FDA work related to that company until August 2006.

Furthermore, Gottlieb was recently appointed to the board of directors of Molecular Insight Pharmaceuticals, a "a biopharmaceutical company specializing in the emerging field of molecular medicine." As a member of the board, Gottlieb is supposed to have "unyielding loyalty" to the company's stock-holders.

Readers of Gottlieb's opinions about health care, especially those that favor a laissez faire approach to regulating pharmaceutical companies, need to wonder the extent that these beliefs are influenced by his former and current ties to the industry.

On the other hand, Dr Himmelstein and Dr Woolhandler were identified as "professors of medicine at Harvard and co-founders of Physicians for a National Health Program." While Dr Himmelstein and Dr Woolhandler have long used the friendly Canadian example of single-payer government health insurance to buttress their arguments to the public,(1) in the past, and did so again in their latest op-ed, they previously acknowledged that their approach was frankly "Marxist," rather than Canadian.

They authored apparently pure Marxist analyses of health care in the late 1980s.(2-3) Previously, they had openly advocated for "socialized medicine."(4) They praised the operations of the communist health care system under Tito in what was then Yugoslavia.(5)

Readers of Dr Himmelstein's and Dr Woolhandler's opinions about health care, especially those that favor the government running health care insurance, need to wonder about the extent that these beliefs are influenced by their ideological ties to Marxist and communist theories that in retrospect have been discredited.

Those who opine on major health policy issues should at least reveal where they are coming from. In any case, the debate would benefit from some fresh voices not tied either to health care corporations or Marxist ideology.

References

1. Woolhandler S, Himmelstein DU. A national health program: northern light at the end of the tunnel. JAMA 1989; 262: 2136-2137.
2. Himmelstein DU, Woolhandler S. The corporate compromise: a Marxist view of health maintenance organizations and prospective payment. Ann Intern Med 1988; 109: 494-501.
3. Woolhandler S, Himmelstein DU. Ideology in medical science: class in the clinic. Soc Sci Med 1989; 28: 1205-1209.
4. Himmelstein DU, Woolhandler S. Socialized medicine: a solution to the cost crisis in the United States. Int J Health Services 1986; 16: 339-354.
5. Himmelstein DU, Lang S, Woolhandler S. The Yugoslav health system: public ownership and local control. J Public Health Policy (9) 1984; 423-431.