Health Care Dysfunction Makes it to the Presidential Debate

In last night's debate which included leading candidates from the Democratic Party for its presidential nomination, as reported by Mother Jones, Senator Bernie Sander (D-VT) said (per Mother Jones).

the current health care system is not only cruel, it is dysfunctional

The video is here.



So the concept of health care dysfunction has officially made it to the big time.

You Heard It Here First

What took so long?

We have been talking about health care dysfunction for a very long time, starting with a publication in 2003.

To better understand health care dysfunction, I interviewed doctors and health professionals, and published the results in Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).  In that article, I postulated that US physicians were demoralized because their core values were under threat, and identified five concerns:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research stuides

After that my colleagues and I have tried to raise awareness of these and related issues, now mainly through the Health Care Renewal blog.  We also set up FIRM - the Foundation for Integrity and Responsibility in Medicine,  a US non-profit organization, to try to provide some financial support for the blog.

Health Care Dysfunction is Multi-Dimensional

Unfortunately, one sentence in a presidential debate hardly does justice to a huge and multi-faceted set of concerns.  

Since 2003 we have broadened our thinking about what constitutes and causes US (and more global) health care dysfunction. Early on we noticed a number of factors that seemed to enable increasing dysfunction, but were not much discussed.  These factors notably distorted how medical and health care decisions were made, leading to overuse of excessively expensive tests and treatments that provided minimal or no benefits to outweigh their harms.  The more we looked, the more complex this web of bad influences seemed.  Furthermore, some aspects of it seemed to grow in scope during the Trump administration.

A brisk summary of these often complex issues follows.


 Threats to the Integrity of the Clinical Evidence Base

The clinical evidence has been increasingly affected by manipulation of research studies.  Such manipulation may benefit research sponsors, now often corporations who seek to sell products like drugs and devices and health care services.  Manipulation may be more likely when research is done by for-profit contract research organizations (CROs). When research manipulation failed to produce results to sponsors' liking, research studies could simply be suppressed or hidden.  The distorted research that was thus selectively produced was further enhanced by biased research dissemination, including ghost-written articles ghost-managed by for-profit medical education and communications companies (MECCs). Furthermore, manipulation and suppression of clinical research may be facilitated by health care professionals and academics conflicted by financial ties to research sponsors.

 Deceptive Marketing

The distorted evidence base was an ingredient that proved useful in deceptive marketing of health care products and services. Stealth marketing campaigns became ultimate examples of decpetive marketing.  Deceptive marketing was further enabled by the use of health care professionals paid as marketers by health care corporations, but disguised as unbiased key opinion leaders, another example of the perils of deliberate generation of  conflicts of interest affecting health care professionals and academics.

Distortion of Health Care Regulation and Policy Making

Similarly, promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.

More recently,  as we noted here, we became aware of efforts by foreign powers to spread such disinformation for political, not just financial gain, e.g., in April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak

Furthermore, companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.

In the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers (look here).   We found multiple managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting - wait for it - big health care corporations, a staggering intensification of the problem of the revolving door.

Bad Leadership and Governance

Health care leadership was often ill-informed.  More and more people leading non-profit, for-profit and government have had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.  Lately, during the Trump administration, we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics look here).  We had not previously expected leaders of government to be personally knowledgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values. Often business trained leaders put short-term revenue ahead of patients' or the public's health.  In addition, we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients' and the public's health, and even  corporate revenues. Then, we started seeing appointed government health care leaders who lacked medical, health care or public health background or expertise but also whose agenda also seemed to be overtly religious or ideological, without even a nod to patients' or the public' health (look here).
 
Leaders of health care organizations increasingly have conflicts of interest.   Moreover, we have found numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.


In the Trump administration, corrupt leadership extends from the corporate world to the highest levels of the US government.  We discussed the voluminous reports of conflicts of interest and corruption affecting top leaders in the executive branch, up to and including the president and his family (look here).  One cannot expect effective enforcement of ethics rules and anti-corruption laws in such an environment

Abandonment of Health Care as a Calling

A US Supreme Court decision was interpreted to mean that medical societies could no longer regulate the ethics of their members, leading to the abandonment of traditional prohibitions on the commercial practice of medicine.  Until 1980, the US American Medical Association had  ruled that the practice of medicine should not be "commercialized, nor treated as a commodity in trade."  After then, it ceased trying to maintain this prohibition. Doctors were pushed to be businesspeople, and to give making money the same priority as upholding their oaths. Meanwhile, hospitals and other organizations that provide medical care are increasingly run as for-profit organizations. The physicians and other health care professionals they hire are thus providing care as corporate employees, resulting in the rise of the corporate physician.  These health care professionals may befurther torn between their oaths, and the dictates of their corporate managers.

Perverse Incentives Put Money Ahead of Patients, Education and Research

We have extensively discussed the perverse incentives that seem to rule the leaders of health care. Financial incentives may be large enough to make leaders of health care organizations rich.  Incentives often prioritize financial results over patient care.  Some seem to originate from the shareholder value dogma promoted in business school, which de facto translates into putting current revenue ahead of all other considerations, including patient care, education and research (look here).

 Cult of Leadership

Health care CEOs tend now to be regarded as  exalted beings, blessed with brilliance, if not true "visionaries," deserving of ever increasing pay whatever their organizations' performance.  This pheonomenon has been termed "CEO disease" (see this post).  Afflicted leaders tend to be protected from reality by their sycophantic subordinates, and thus to believe their own propaganda.

Managerialism

Leadership of health care organizations by managers with no background in actual health care, public health, or biomedical science has been promoted by the doctrine of managerialism which holds that general management training is sufficient for leaders of  all organizations, regardless of their knowledge of the organizations' fundamental mission.

Impunity Enabling Corrupt Leadership

Most cases involving corruption in large health care organizations are resolved by legal settlements.  Such settlements may include fines paid by the corporations, but not by any individuals.  Such fines are usually small compared to the revenue generated by the corrupt behavior, and may be regarded as costs of doing business.  Sometimes the organizations have to sign deferred prosecution or corporate integrity agreements.  The former were originally meant to give young, non-violent first offenders a second chance (look here).  However, in most instances in which corruption became public, are no negative consequences ensue for the leaders of the organizations on whose watch corrupt behavior occurred, or who may have enabled, authorized, or directed the behaviors.

Taboos

Some of the above topics rarely appeaedr in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant. We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  Those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.

However,in the Trump administration,  we began to also note examples of government officials attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control (look here).



What a witches' brew, surely leading to a cruel and dysfunctional system.

Discussion

In 2017, we said that it was time to consider some of the real causes of health care dysfunction that true health care reform needs to address, no matter how much that distresses those who currently most personally profit from the status quo.

Furthermore, in 2019 we asserted that all the trends we have seen since 2017 are towards tremendous government dysfunction, some of it overtly malignant, and much of it likely enabling even worse health care dysfunction.

Now that health care dysfunction is in the headlines, we hope health care and public health professionals, patients, and all citizens will have a much more vigorous response to it.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who?  

Note (25 November, 2019): This post was re-posted by the Naked Capitalism blog here. 

The New (Ab)normal in Health Care Dysfunction

Introduction: The Issues Ignored by Discusisons of Health Care Reform

After the failed attempt to "repeal and replace" the Affordable Care Act (ACA, Obamacare) in 2017, we summarized what we thought were the main issues that traditional discussions of health care reform in the US (and sometimes in other countries) did not address.Despite some protestations to the contrary (e.g., here), the US health care system has been plagued by dysfunction.  According to a recent Commonwealth Fund study, the US was ranked 11 out of 11 in health care quality, but 1 out of 11 in costs.  Traditionally, health care reform has targeted ongoing problems in the cost, accessibility and quality of health care.  The ACA notably seems to have improved access, but hardly addressed cost or quality.

Now, in 2019, these issues also seem to only be getting more so.  So a little more than two years into the Trump regime, I thought we should assess the new (ab)normal in health care dysfunction, trying as best as possible to use the framework from our 2017 summary, with examples from our blog posts.


Distortion of Health Care Regulation and Policy Making: the Rise of the Incoming Revolving Door

We had previously noted that companies selling health care products and services further enhanced their positions through regulatory capture, that is, through their excessive influence on government regulators and law enforcement.  Their efforts to skew policy were additionally enabled by the revolving door, a species of conflict of interest in which people freely transitioned between health care corporate and government leadership positions.  Up to the Trump era, nearly all those cases involved people who left government who were offered corporate positions in firms that might have been affected by regulations or policies influenced by the government agencies for which they formally worked, the outgoing revolving door.

However, in the Trump era, we saw a remarkable increase in the incoming revolving door, people with significant leadership positions in health care corporations or related groups attaining leadership positions in government agencies whose regulations or policies could affect their former employers.


- We noted a stealth marketer for health care corporations becoming a key Trump economic adviser (look here)

- We found numerous more examples in October, 2017, including two people from the same lobbying firm, Greenberg Traurig Alston & Bird, which that year had  "earned more than $4.4 million lobbying so far this year for health care companies and trade groups including Novartis AG, Verax Biomedical, the American Hospital Association, St. Jude Children’s Research Hospital, and Aetna....," given top Department of Health and Human Services (DHHS) positions.

- A little later that month, we noted that one of those two former lobbyists, Mr Eric D Hargan, had become acting Secretary of DHHS (look here).

- Slightly later that month, there was an even more striking example, the new (permanent) Secretary of DHHS, Mr Alex Azar, who replaced Mr Hargan, was a former top executive of pharmaceutical company Eli Lilly.

- In November, 2017, an advocate for the discredited former CEO of UnitedHealth become an Assistant Secretary of DHHS. 

-  Later in November, we found two more examples of the incoming revolving door, including a lobbyist for pharma/ biotech company Gilear becoming director of health programs for the Office of Management and the Budget (OMB) here.

- In March, 2018, we posted a long list of industry figures, including a slew of lobbyists appointed to DHHS leadership positions.

- in April, 2018, we posted the next list, of top industry executives going to major executive branch positions.  The most striking example was a vice president at CVS, formerly at Pfizer, becoming a senior advisor to the Secretary of DHHS (who is a former Eli Lilly executive) for drug price reform. Pfizer and Eli Lilly alumni in charge of drug price reform, what could possibly go wrong?

- In July, 2018, the next list included a senior advisor at again Eli Lilly appointed to head an FDA division.

- In February, 2019, the list included a person with multiple leadership positions in for-profit health insurance companies, including WellPoint, and most recently a Medicaid managed care insurance provider, appointed to lead "health care reform" for DHHS.  Again, from the insurance industry to lead health care reform, what could possibly go wrong.

- In March, 2019, we noted that the newly appointed acting director of the FDA had founded and/ or was on boards of directors of multiple biotech companies.

This was a staggering record of managers from and lobbyists for big health care corporations being put in charge of regulation of and policy affecting - wait for it - big health care corporations, a staggering intensification of the problem of the revolving door, which some have already asserted should be regarded as not merely severe conflicts of interest, but of corruption.  

Distortion of Health Care Regulation and Policy Making: Stealth Policy and Advocacy Morphing into Propaganda and Disinformation, Now may be Orchestrated by a Hostile Foreign Power

We had previously noted that promotion of health policies that allowed overheated selling of overpriced and over-hyped health care products and services included various deceptive public relations practices, including orchestrated stealth health policy advocacy campaigns.  Third party strategies used patient advocacy organizations and medical societies that had institutional conflicts of interest due to their funding from companies selling health care products and services, or to the influence of conflicted leaders and board members.  Some deceptive public relations campaigns were extreme enough to be characterized as propaganda or disinformation.  Now this information may be connected to, or even organized by a hostile foreign power  

In March, 2018, based on revelations of what appeared to be an organized disinformation effort engineered by Cambridge Analytica and associates, using large amounts of personal data liberated from Facebook, to promote the Trump campaign, we started to ask how we could address deceptive public relations, propaganda, and disinformation in health care under a regime that had so benefited from foreign based disinformation efforts?

In April, 2019, we discussed evidence that Russia had orchestrated a systemic disinformation campaign meant to discredit childhood vaccinations, particularly for the measles, which was likely partly responsible for the 2019 measles outbreak, and possibly for some of the unsupported assertions made about measles and measles vaccinationa by government leaders (see below).  The Soviet Union, which of course then included Russia, had orchestrated a disinformation campaign about HIV in the 1980s.  Erroneous beliefs generated by this campaign persist to this day.  The USSR had a principle role in the development of disinformation and other active measures meant to destablize western democracies.

 As recently documented in the redacted version of the Mueller report, Russia launched a disinformation campaign to swing the election to its preferred candidate, Donald Trump.  The role of a hostile foreign power which had used active measures during the election also using active measures to spread disinformation about medicine and public health should not be dismissed. 


Bad Leadership and Governance: Ill-Informed Leadership Now Approaching Flagrant Ignorance While Eschewing Expertise

We have long decried leaders of big health care organizations who seemed to have little background in or knowledge of biology, medicine, health care, or public health.  Typically, these were leaders of big health care corporations, such as pharma/device/ biotech companies, health insurance companies, hospitals and hospital systems, etc who were trained in management, and thus could be called managerialists.  

However, during the Trump regime we began to find striking examples of top government officials expressing ill-informed, if not outright ignorant opinions about medical, health care and public health topics.  We had not previously expected leaders of government to be personally knoweldgeable about health related topics, but traditionally they consulted with experts before making pronouncements.

Since the Trump regime began, perhaps inspired by examples from Trump himself, various political/ government leaders began to publicly say ignorant or downright stupid things about such topics.

-  For example, in September, 2017, we noted a series of examples showing some basic ignorance of health policy, including fundamental confusion about the nature of health insurance.

- In August, 2018, we noted that Trump had long been an apologist for asbestos, which is known to cause asbestosis, lung cancer, and mesothelioma, claiming that those opposing use of asbestos were associated with organized crime, while more recently Trump's EPA seemed willing to relax regulation of asbestos, at a time when Russia seemed ready to become the major US supplier of it.

Bad Leadership and Governance: From Incompetence (in the Colloquial Sense) to Cognitively Impaired or Demented Leadership

Again, previously we had discussed  ill-informed and incompetent leadership in terms of leaders who had no training or experience in actually caring for patients, or in biomedical, clinical or public health research.

However, we began to note concerning examples suggesting that the top leader of the US executive branch, President Trump himself, could be cognitively impaired perhaps from a dementing, neurological or psychiatric disorder.

- In October, 2017, we first started cataloging pronouncements by President Trump on health care and related topics that started with a grossly cavlier attitude toward health policy (e.g., it is only about fixing somebody's back or their knee or something," and ended with word salad:

Well, I’ve — I have looked at it very, very strongly. And pretty much, we can do almost what they’re getting. I — I think he is a tremendous person. I don’t know Sen. Murray. I hear very, very good things.

I know that Lamar Alexander’s a fine man, and he is really in there to do good for the people. We can do pretty much what we have to do without, you know, the secretary has tremendous leeway in the — under the Obama plans. One of the things that they did, because they were so messed up, they had no choice but to give the secretary leeway because they knew he’d have to be — he or she would have to be changing all the time.

And we can pretty much do whatever we have to do just the way it is. So this was going to be temporary, prior to repeal and replace. We’re going to repeal and replace Obamacare.

As we were taught in medical school, word salads may be produced by patients with severe neurological or psychiatric disorders.


- In January, 2018, we discussed more examples of Trump's confused, incoherent comments on health care.

- In May, 2018, we noted attempts by Trump Organization functionaries to intimidate Trump's former personal physician, presumably to prevent him from revealing details of the president's medical history.

- In December, 2018, we cataloged Trump's counter-factual, and often severely incoherent pronouncements - basically more examples of word salad - about public health, health care and other topics, at times interspersed with claims of his high intelligence.

Health care led by people with business or legal training who are willing to get advice from health care, public health and medical specialists may be as good as it gets.  Health care led by such people who do not consult experts if worrying.  Health care led by people who report to a cognitively impaired, demented or psychotic leader is extremely worrying (as is government with such leadership.)

Bad Leadership and Governance: Mission-Hostile Management Now Driven Less by Pecuniary Considerations, More by Ideology, Partisanship, and Religious Sectarianism

We had previously noted that health care leaders often were unfamiliar with, unsympathetic to, or frankly hostile to their organizations' health care mission, and/or health care professionals' values.  The example we cited then was a hospital CEO who allegedly over-ruled medical leadership to hire a surgeon despite reports that his patients died more frequently than expected, gamed reports of clinic utilization, and associated with organized crime (look here).  Most such examples seemed to be generated by leaders who put their organization's revenue, often in parallel with their own compensation ahead of patients' and the public's health.

We also began seeing examples of how politically appointed officials of health related government agencies who had no experience or expertise in health care or related fields began to assert control over health care professionals in the agencies to facilitate the Trump regime's political agenda apparently regardless of the effects on health. Sometimes the problem seemed to carry over from the leaders' previous management, rather than medical, health care or public health experience.  For example, in February, 2018, we noted that the physician who was Secretary of the Veterans Administration was challenged by a political a political appointee who used to run a brewery.

However, we then began noting leaders who also lacked medical, health care or public health background or expertise whose agenda seemed to be overtly religious or ideological, without even a nod to patients' or the public' health.


- In April, 2018, we noted a host of appointments of people who flagrantly lacked any health care or public health related experience or expertise to leadership positions in government agencies whose agenda seemed to be overtly religious or ideological, without even a nod to patients' or the public' health. For example, a 23-year old whose only experience after college was in Trump's campaign was given a significant position in the Office of National Drug Control.

- In April, 2018, we posted another such list, including a blogger who promoted racism and conspiracy theories given the Deputy Directorship of Communications for DHHS.

- In July, 2018, we noted the appointment of a physician to a leadership position in family planning within the DHHS who cited "facts" completely unsupported by evidence to justify religiously based health care policies, e.g., using her argument that adopting a child is like a "second death" to argue that mothers should not give their children up for adoption.

- In August, 2018, we discussed  three political appointees to DHHS, none of whom had any health care or public health related experience or expertise, all of whom made pointedly political public comments after their appointments, from deriding their political opponents as "clueless" and "crazy"to alleging Hillary Clinton arranged a murder.

 - In November, 2018, we noted pronouncements about health care or public health by federal agencies under the Trump regime, right-wing politicias who back Trump, and propagandists who back Trump which were unsupported by evidence, but seemed designed to support right-wing ideology or sectarian religious belief.  These included assertions that immigrants and asylums seekers carried infectious disease, that intersex patients do not exist, that contraception causes cancer and violent death, that pornography is a major public health hazard, etc.

- In March, 2019, our list included examples of multiple leaders at the state level, all Republicans, including the Kentucky Governor asserting that zombie television shows cause mass shootings, but exposure to extreme cold does not harm schoolchildren; and numerous unsupported pronouncements by state legislators about measles, including the Texas state representative who stated antibiotics can treat measles.

- In April, 2019, we discussed another batch of bizarre statements about the measles and vaccination policy made by President Trump, again the Republican Governor of Kentucky, and various Republican state legislators.  

Again, basing health care and public health decisions primarily on money seems likely to be bad for patients' and the public's health, but basing them purely on political ideology or religious belief seems worse. In some cases, the resulting mission-hostility seems to translate into violations of the US constitution.  For example, making health care decisions based on a particular religion's beliefs could be harmful for patients or citizens who do not share these beliefs, plus violate the Constitution's guarantee of freedom of a government establishment of religion.

Bad Leadership and Governance: Mission-Hostile Management by Now Partisan Corporate Leadership  

Again, previously the mission-hostile management we noted at the corporate level seemed mainly driven by pecuniary concerns, putting corporate revenues and resulting management compensation ahead of patients' and the public's health.  However,we began to see evidence that leaders of health care corporations were using their power for partisan purposes, perhaps favoring their personal political beliefs over their stated corporate missions, patients' and the public's health, and even  corporate revenues.

- In June, 2018, we first noted how a large health care corporation, the huge pharmacy chain CVS, had been secretly making contributions to an ostensibly non-profit organization which actually served solely to promote Trump regime policies, including some that seemed to subvert claims the corporation had made about social responsibilty.  The contributions themselves seemed to conflict with the corporation's charitable giving policies.

- In September, 2018, we noted that big health care corporations often make high-minded public pledges about supporting patients' and the public's health, and sometimes social responsibility, but have been found to be covertly supporting policy initiatives that seemed to subvert these goals, using "dark money."  The dark money groups they used to channel this money often had explicitly partisan leadership and direction, usually right-wing and Republican.

 - In October, 2018, we discussed important but incomplete revelations about corporate contributions to such dark money groups that mainly favored again right-wing ideology, the Republican party, and Trump and associates.

- In November, 2018, we noted that health care corporations funneled funds through dark money organizations to specifically attack designated left-wing, Democratic politicians.

- In March, 2019, we noted a Transparency International study of policies on political engagement of multinational pharmaceutical companies, all of which operate in the US.  Only one disavowed the revolving door, and only two eschewed direct corporate political contributions.

- Also, in March, 2019, we discussed a study of the personal political contributions of CEOs of large corporations.  In the 21st century, the CEOs' contributions were increasingly partisan, that is individual CEOs gave predominantly or exclusively to one party, and for the vast majority, to the Republican party.

This suggests yet another route towards government putting ideology and partisanship ahead of patients' and the public's health.


Bad Leadership and Governance: Conflicted, Corrupt Corporate Leaders Now in the Context of Flagrant Conflicts of Interest and Corruption at the Highest Levels of the US Government

We had previously discussed numerous examples of frank corruption of health care leadership.  Some have resulted in legal cases involving charges of bribery, kickbacks, or fraud.  Some have resulted in criminal convictions, albeit usually of corporate entities, not individuals.  One would hardly expect corrupt leadership to put patients' and the public's health ahead of the leaders' ongoing enrichment.

Prior to July, 2017, we had discussed some particular cases in which Donald Trump and his family had been involved in ethically questionable activities prior to his becoming president.  However, by  August, 2017, we started to discuss the corruption at the top of the regime. 


- In January, 2018, we first discussed the accumulating evidence of pervasive corruption at the top of the US executive branch, based on articles in the media, and the launch of a website devoted to tracking such corruption.

- In July, 2018, we summarized new sources of evidence about top level government corruption.

- In October, 2018, we posted yet another update, including summarizing a new and very lengthy report about the scope of Trump and associates' conflicts of interest and corruption, which at the time required 26 pages to print. It documented multiple ongoing instances of the Trump Organization, whose biggest owner is Trump, receiving large ongoing payments from foreign governments, the US government, and state governments.  The former payments seemed to explicitly violate the "foreign emoluments clause" of the US  Constitution, which bans presidential conflicts of interst involving foreign governments, and the "domestic emoluments clause," which bans those involving the federal and state governments.

- In October, 2018, we discussed the latest advances in understanding of global corruption, via Tranparency International's global meeting, which included description of trans-national kleptocratic networks, which now seems to describe Trump and the Trump Organization.

- In April, 2019, we posted our latest discussion of pervasive high-level corruption, which referenced updates from sources mentioned earlier, plus three new sources.

Prior to the Trump regime we had criticized law enforcement for a lack of interest in vigorously prosecuting health care corruption.  We documented numerous examples of the impunity of top health care corporate executives who almost always escaped any negative personal consequences even when their organizations paid large fines for bribery, kickbacks, fraud and the like.  We often attributed this laxity to excessive sensitivity respect of the value of these corporations and their products.  However, the potential for encouraging health care (and other kinds of) corruption under a regime that is itself frankly corrupt is mind boggling.

[picture of Trump International Hotel in Washington, which is frequently patronized by foreign government officials, whose payments to Trump via the Trump Organization appear to amount to the "foreign emoluments" prohibited by the US Constitution.]

Overarching Issue: Taboos Previously Enabled by Private Organizational Behavior, Now by Government Agencies and Officials, Despite the First Amendment

When we started Health Care Renewal, such issues as suppression and manipulation of research, and health care professionals' conflicts of interests rarely appeared in the media or in medical and health care scholarly literature.  While these issues are now more often publicly discussed, most of the other topics listed above still rarely appear in the media or scholarly literature, and certainly seem to appear much less frequently than their importance would warrant.  For example, a survey by Transparency International showed that 43% of US resondents thought that American health care is corrupt.  It was covered by this blog, but not by any major US media outlet or medical or health care journal.  We have termed the failure of such issues to create any echoes of public discussion the anechoic effect.

Public discussion of the issues above might discomfit those who personally profit from the status quo in health care.  As we noted above, the people who profit the most, those involved in the leadership and governance of health care organizations and their cronies, also have considerable power to damp down any public discussion that might cause them displeasure. In particular, we have seen how those who attempt to blow the whistle on what really causes health care dysfunction may be persecuted.  But, if we cannot even discuss what is really wrong with health care, how are we going to fix it?

Since the beginning of the Trump administration,  we began to note more examples of government officials under Trump attempting to squelch discussion of scientific topics that did not fit in with its ideology, despite constitutional guarantees of speech and press free from government control.

- In September, 2017, we noted an attempt for Trump political appointees to blockade information released from the Department of Health and Human Services (DHHS) that the regime found offensive.

- In February, 2018, we noted attempts by a consultant for the Center for Medicare and Medicaid Services (CMS), a major component of DHHS, to intimidate a health care journalist.

- In April, 2018, it became apparent that the head of CMS has directed millions in contracts to a Republican public relations firm, partly to burnish her image, and that firm had hired the consultant noted above.

- We also found attempts to squelch attempts by current or former government workers to criticize Trump and his policies.  In August, 2018, we noted Trump had White House staffers sign non-disclosure agreements, which seems to expressly violate first amendment protections of free speech and federal law.

Given how hard it was to reverse the anechoic effect in the past, how much harder will it be to open discussion of what is really wrong with health care when the power of the US government is used to censor ideas which the regime dislikes?


Discussion

For years, I thought that health care dysfunction was primarily about individuals and private organizations, including but not limited to pharmaceutical, biotechnology and device companies; hospitals and hospital systems; insurance companies, academic medical institutions; physicians and their practices; etc, etc, etc.  Consequently, I thought these individuals and organizations needed better awareness of health care dysfunction to provoke them to improve matters.  I thought of the government as being involved, but mainly because of well-intentioned, sometimes bumbling government actions and policies that often had unintended effects, and sometimes excess coziness with the health care industry.  While I knew that the government was subject to regulatory capture and various leadership problems, its role, at least in the US, seemed almost secondary.

But in the Trump era, there is a new (ab)normal.  All the trends we have seen since our last discussion of health care reform are towards tremendous government dysfunction, some of it overtly malignant, especially in terms of corruption of government leadership of unprecedented scope and at the highest levels, and overt influence of government-favored political ideology and religious beliefs on health care policy and other policies and actions.

I hope that the above attempt to summarize these new trends will urgently point health care and public health professionals, patients, and all citizens towards a much more vigorous response.  US health care dysfunction was always part of the broader political economy, which is now troubled in new and dangerous ways.  We do not have much time to act.

If not now, when?

If not us, who? 



        

The Case of the Brew Master's Plot - Was the Veterans Affairs Secretary's Travel Spending Scandalous, or Was He Framed in a Plot to Oust a Political Moderate?

"Come, Watson, come! The brew is afoot."

The Veterans Affairs Secretary's Apparently Scandalous Travel

On February 14, 2018, the Washington Post reported that the Department of Veterans Affairs (VA) Inspector General (IG) severely faulted travel arrangments made for a trip to Europe by the Department's Secretary, Dr David Shulkin.

Veterans Affairs Secretary David J. Shulkin’s chief of staff doctored an email and made false statements to create a pretext for taxpayers to cover expenses for the secretary’s wife on a 10-day trip to Europe last summer, the agency’s inspector general [IG] has found.

Vivieca Wright Simpson, VA’s third-most-senior official, altered language in an email from an aide coordinating the trip to make it appear that Shulkin was receiving an award from the Danish government, then used the award to justify paying for his wife’s travel, Inspector General Michael J. Missal said in a report released Wednesday. VA paid more than $4,300 for her airfare.

At first impression this seemed like just another travel scandal for the administration, which seemed to have made a practice of appointing top agency leaders who felt entitled to high-end travel options.  The Post article noted,

Shulkin is one of five current and former Trump administration Cabinet members under investigation by agency inspectors general over travel expenses, an issue that forced Tom Price to resign as health and human services secretary in the fall. Shulkin and other Cabinet officials have said their travel, often on private and military planes or to speak at political events, was approved by agency ethics officials.

One Republican Congressman immediately called for Dr Shulkin to resign because of "corruption," according to the Atlanta Journal Constitution.

As of February 16, 2018, VA Chief of Staff Viveca Wright Simpson did resign, according to CNN.

A Murky Brew

"the foam thickens"

On closer reading, however the details of the current case were at least somewhat murky.

The IG charged that the VA Chief of Staff, Viveca Wright Simpson, had altered an email to make it appear that Dr Shulkin would receive some sort of award at the US Embassy in Copenhagen, which would have apparently justified paying for Shulkin's wife's travel.  Yet, "In an interview with investigators, Wright Simpson said she did not recall whether she altered the email, Missal wrote."

The Secretary and his wife received tickets for events at the Wimbledon tennis tournament.  Dr Shulkin stated that the person who gave them the tickets was a friend of his wife, but the IG noted that when called, the person who gave them the tickets could not recall his wife's first name.  However, later that person provided a statement saying

The investigators unexpectedly called me on my mobile phone whilst I was driving on a very busy highway,

then,

I felt like the investigators were twisting my words and trying to put words into my mouth.

The IG concluded that the awarding of tickets was improper, Ms. Gosling gave a gift of the Wimbledon tickets, valued at thousands of dollars on the secondary commercial market, because of Secretary Shulkin’s official position.” However, "Shulkin’s attorneys said the secretary was not prohibited from accepting the tickets, because Gosling neither does nor seeks to do business with VA."

The IG also contended that a VA staffer was excessively helpful in making travel arrangements for Dr Shulkin's wife, and that some travel expenses were poorly documented.

Finally,

In his formal response to Missal, Shulkin wrote that VA staffers suggested his wife’s travel be paid for by the agency. He called the inspector general’s portrayal of the trip 'entirely inaccurate' and said it 'reeks of an agenda.'

'It is outrageous that you would portray my wife and me as attempting to take advantage of the government,' he wrote.

Of course, a high government official in trouble for this sort of thing might make that sort of response.

But wait, there is more, including substantial evidence about that "agenda."

A Political Plot?

Political Appointees Scheme to Oust Dr Shulkin

One day later, a New York Times story suggested it was all a lot more complicated.  The background is that

Dr. Shulkin was an unexpected but popular choice for secretary. After the 2016 election, Mr. Trump considered several critics of the department as possible nominees to head the agency. But to the relief of most veterans’ organizations, he chose Dr. Shulkin, a moderate who headed the agency’s health care system under President Barack Obama.

Dr Shulkin also is a fan of having the VA continue to directly provide care to most of its veteran clients/ patients. Note that,

The department currently operates its own health system, with more than 1,200 hospitals and clinics across the country where about nine million veterans receive treatment at little or no cost to them.

However,

Some conservatives, including some advisers to the White House, [who] favor gradually dismantling that system and allowing veterans to choose to receive taxpayer-subsidized care from private doctors instead.

Veterans’ groups have overwhelmingly opposed that idea. But Mr. Trump promised during his election campaign that 'vets will have the right to go to a V.A. facility or the right to see a private doctor or clinic of their choice — whatever is fastest or best for the vet.'

Note that those who favor privatizing or out-sourcing VA health care functions have apparently provided no evidence from clinical or health services research that doing so would provide benefits to veterans that outweigh their harms.  Nonetheless, it appears that some VA officials who were political appointees of the Trump administration did not think Dr Shulkin was doing enough to privatize VA sevices.

In December, according to congressional staff members, political appointees in the department quietly bypassed the secretary to advance legislation that would open the way for more privately provided health care for veterans. The bill was introduced by Senator Jerry Moran, Republican of Kansas, who has received substantial campaign donations from the Koch brothers.

Meanwhile, the NYT reported that a campaign began to remove Dr Shulkin.

An email sent in December by Jake Leinenkugel, the White House senior adviser on veterans affairs, expressed frustration with Dr. Shulkin and listed ways to topple the leadership of his department once key legislation was passed.

The email was addressed to Camilo Sandoval, a former data manager for the Trump campaign who was given a political post at the department. In it, Mr. Leinenkugel, a former brewery executive, wrote that although he initially had a positive impression of the secretary, they had fallen out over staffing and policy issues.

The tactics proposed for this sort of an in-house coup were:

Mr. Leinenkugel, who has an office in the department, proposed 'solutions' in the email, including using a continuing investigation of the secretary’s travel to remove Dr. Shulkin’s chief of staff, Vivieca Wright Simpson; replacing the deputy secretary, Thomas G. Bowman, with Mr. Leinenkugel; and replacing Dr. Shulkin with a 'strong political candidate.'

Re that "strong political candidate":

Mr. Leinenkugel’s suggested replacement for Dr. Shulkin would be likely to spark controversy: Michael J. Kussman, a former under secretary who has been associated with Concerned Veterans of America, a group funded largely by the billionaire conservative activists Charles G. Koch and David H. Koch that advocates shifting spending on veterans’ health care to the private sector.

Note that Mr Leinenkugel apparently has no training, experience, or expertise in medicine, health care, or public health.  Rather he is a former executive of a family owned brewery that had been sold off to MillerCoors (look here).  Mr Leinenkugel did serve as a Marine for six years, but in the Phillipines, and Korea, apparently not seeing combat (look hereand here).  As the executive and presumably part owner of a substantial brewery, it seems doubtful that he ever had to personally seek care at a VA facility.

Furthermore, Mr Leinenkugel was working with Camilo Sandoval, a former data operations manager for the Trump campaign, with no known health care or public health background, or military experience (look here).

Dr Shulkin Fights Back and the Influence of More Political Operatives Revealed

Dr Shulkin suggested that the alleged plotter might not have been acting to promote the best interests of veterans, saying

he was investigating a number of political appointees in his department for misconduct and possible removal. On Thursday, he spoke directly to the White House chief of staff, John F. Kelly, about concerns that political appointees were trying to undermine his agency, according to department officials.

'If there are people here who don’t want the V.A. to succeed, I want them out,' Dr. Shulkin said in the interview.

Whether Dr Shulkin will prevail is a big question.Turmoil at the department seems to be growing.  Last week the Washington Post quoted unnamed White House officials who said Mr. Bowman, the deputy secretary, would soon be fired as a “warning shot” to “knock Shulkin down a peg or two” for not pushing harder for privatization.

Also, per the NY Times,

In another sign of division, John Ullyot, a former top Trump campaign official who now runs the press office, told staff members in an email on Wednesday that reporters’ requests for comment should not be forwarded to the secretary or deputy secretary; instead, he would be referring them all to the White House.

The move forced Dr. Shulkin to do much of his communication with the media over the travel investigation on his personal cellphone.

Then, per CNN on February 16, Viveca Wright Simpson, VA Chief of Staff, had resigned, and in response Dr Shulkin stated,

'This was a personal decision,' Shulkin said, adding that Wright Simpson called him on Friday morning to inform him. 'She just didn't feel that it was the right thing for her and her family to continue in that type of environment.'

Furthermore, her replacement, Peter O'Rourke, appears to be something of a political appointee,

the VA announced that Peter O'Rourke would replace Wright Simpson as chief of staff, effective immediately. O'Rourke currently serves as executive director for VA's Office of Accountability and Whistleblower Protection. O'Rourke's job will be 'ensuring that the department works closely with the White House going forward,' according to a statement from VA Press Secretary Curt Cashour.

O'Rourke is a Navy and Air Force veteran and previously worked for Trump's presidential campaign, according to his LinkedIn profile.

Furthermore,also on Feb 16, Pro Publica in conjunction with Politico published a long article on the background to the political dispute about privatizing or out-sourcing VA clinical functions.  It turns out that this is been going on for a while, and that the privatization/ out-sourcing agenda is mainly being pushed by the Concerned Veterans for America (CVA), a group backed by the Koch brothers.

The Pro Publica article provided more information about the roster of de facto political commissars attached by White House operatives to the VA.  One was Darin Selnick, a retired Air Force Captain, who had a career as a business consultant, and led "faith-based" initiatives at the VA under President George Bush, according to his LinkedIn profile. I can find no evidence he has any training,  experience or expertise in health care or health policy.

Trump picked Darin Selnick for the 'landing team'that would supervise the transition at the VA. Selnick had directed CVA’s policy task force, which in 2015 recommended splitting the VA’s payer and provider functions and spinning off the latter into a government nonprofit corporation.

Then,

He joined the VA as a 'senior advisor to the secretary.' Though he reported to Shulkin, he quickly began developing his own policy proposals and conducted his own dealings with lawmakers, according to people with knowledge of the situation. In mid-2017 Shulkin pushed him out — sort of.

Selnick left the VA offices and took up roost in the White House’s Domestic Policy Council. There he started hosting VA-related policy meetings without informing Shulkin, according to people briefed on the meetings.

Another was Dr Shulkin's own press secretary, Curt Cashour.  According to his LinkedIn profile, he previously worked for Republican Scott Walker's campaign for governor of Wisconsin, is not a veteran, and has no health care or health policy training, experience or expertise. Cashour also was a former staffer of Representative Jeff Miller:

Jeff Miller, then the chairman of the House veterans committee. Miller, who retired from Congress in January 2017, was a close ally of CVA and a scathing critic of Obama’s VA.

Miller became one of the first congressmen to endorse Trump, in April 2016. He did so a few weeks after attending a meeting of the campaign’s national security advisers. (That meeting, and the photo Trump tweeted of it, would become famous because of the presence of George Papadopoulos, who is cooperating with investigators after pleading guilty to lying about Russian contacts. Miller is wearing the light gray jacket in the front right. Now a lobbyist with the law firm McDermott Will & Emery, he didn’t reply to requests for comment.)

At one time, Dr Shulkin directed Cashour to

update its motto, to be inclusive of servicewomen. (Adapted from Abraham Lincoln’s second inaugural address, the original reads, 'To care for him who shall have borne the battle and for his widow, and his orphan.' The new version would read: 'To care for those who shall have borne the battle and their families and survivors.')

Cashour told The Washington Post the motto wouldn’t change. A few days later, the secretary’s strategic plan went out using the updated, gender-neutral motto. Cashour then denied the change a second time, telling the Post that was 'not VA’s position.' A new document with the Lincoln quote restored subsequently appeared on the VA’s website. Shulkin was stunned at being disobeyed by his own spokesman, two people briefed on the incident said. (Cashour denied defying the VA secretary. “The premise of your inquiry is false,” he told ProPublica. Cashour said Shulkin never approved the letter regarding the updated motto and authorized the restoration of the original one.)

So, to summarize, Dr Shulkin, a previous appointee of President Obama, who was appointed to head the Department of Veterans Affairs by President Trump, with the unanimous approval of the Senate, was under seige because he did not support proposals to privatize or out-source many of the VA's clinical functions.   The main functions of the VA involve providing health care to Veterans.   Out-sourcing/ privatization was mainly supported by a Koch backed organization, the CVA, apparently for ideological reasons, but not apparently based on evidence that it would provide benefits to veterans that would outweigh its harms.  Much of the seige work was accomplished by Trump administration political appointees, none of whom had training, experience or expertise in health care or health policy. 

Summary and Discussion

Dr David Shulkin, a holdover appointee of President Obama who was nominated to be Secretary of Veterans Affairs by President Trump, was alleged by the VA Inspector General to have committed various ethical violations involving a trip to Europe the Secretary took with his wife.  This appeared to be just the latest in a string of travel-related scandals by top officials of the Trump administration.

When this was first reported, I was inclined to see Dr Shulkin as an entitled, and conflicted  former health care executive who ran afoul of the government's strict ethical standards.  (Dr Shulkin's official VA biography lists his previous positions, including "chief executive roles at Morristown Medical Center, and the Atlantic Health System Accountable Care Organization. He also served as President and CEO of Beth Israel Medical Center in New York City." His 2016 federal financial disclosure, according to Open Secrets, listed assets of $9,342,201 to $24,966,000.  Also, he had served on advisory boards and boards of directors of numerous commercial health care firms, and held stock options from some of these positions.)

Note that the NY Times editorial page just supported that position, lumping his case with that of other Trump cabinet members with "dubious ethics."

But on review, his travel improprieties did not seem as serious as those of some other administration figures (for example, now ex-Secretary of Health and Human Services Dr  Tom Price, had flown multiple times on private aircraft costing the government hundreds of thousands of dollars, per Politico.)

Furthermore, subsequent reports raise doubts about whether Dr Shulkin committed any improprieties, and suggested rather that he was targeted for removal because he was insufficiently "political," presumably meaning insufficiently beholden to President Trump, and unenthsiastic about dismantling the VA health system and handing its work over to the commercialized health care private sector.  Furthermore, considerable opposition to Dr Shulkin came from within his own department, apparently organized by political appointees devoted to Trump, and an ideological agenda of privatization and out-sourcing, who seemed to be acting like old-style Stalinist political commissars.

Note that USA Today just reported that three big veterans' groups weighed in with their support for Dr Shulkin, suggesting that his travel misdeeds were minor, and his efforts to improve care for veterans major.

But what really happens remains something of a mystery.  Perhaps a modern day Sherlock Holmes would help?

In any case, the events do not reflect well on the Trump regime management of the Department of Veterans Affairs.  Either it placed an entitled, and possibly previously conflicted physician in charge, who was then cavalier about government ethics rules; or worse, it put in charge a perhaps politically clumsy physician who was nonetheless dedicated to the welfare of veterans, but then undermined him when he proved to be insufficiently politically loyal, and perhaps not interested enough in promoting private commercial health care interests ahead of veterans' care. 

Nothing in this story suggests that the Trump regime really cares that much about veterans, other than as means to political ends and to economic benefits to corporate cronies.  Note that privatizing VA clinical functions would provide a huge new patient population to private, including for-profit hospital systems, many of which may not be equipped to deal with the needs of veterans who need rehabilitation for complex and severe injuries, or suffering from the extreme psychological effects of the battlefield.  Privatizing would also presumably provide a physician pool suddenly free from tight VA restrictions on conflicts of interest, who would suddenly become vulnerable to drug, device, biotechnology and other companies bearing money.

Speaking of true health care reform in the time of Trump seems almost silly, but true health care reform requires putting patients' and the public's health ahead of private greed and lust for political power.

A Clear-Headed Defense of Comparative Effectiveness Research

We have tried to argue why comparative effectiveness research is a good idea. To cut and paste what I wrote in a previous post,

Physicians spend a lot of time trying to figure out the best treatments for particular patients' problems. Doing so is often hard. In many situations, there are many plausible treatments, but the trick is picking the one most likely to do the most good and least harm for a particular patient. Ideally, this is where evidence based medicine comes in. But the biggest problem with using the EBM approach is that often the best available evidence does not help much. In particular, for many clinical problems, and for many sorts of patients, no one has ever done a good quality study that compares the plausible treatments for those problems and those patients. When the only studies done compared individual treatments to placebos, and when even those were restricted to narrow patient populations unlike those patient usually seen in daily practice, physicians are left juggling oranges, tomatoes, and carburetors.

Comparative effectiveness studies are simply studies that compare plausible treatments that could be used for patients with particular problems, and which are designed to be generalizable to the sorts of patients usually seen in practice. As a physician, I welcome such studies, because they may provide very useful information that could help me select the optimal treatments for individual patients.

Because I believe that comparative effectiveness studies could be very useful to improve patient care, it upsets me to see this particular kind of clinical study get caught in political, ideological, and economic battles.

In particular, we have discussed a number of high profile attacks on comparative effectiveness research, which often have featured arguments based on logical fallacies. While some of the people making the attacks have assumed a conservative or libertarian ideological mantle, one wonders whether the attacks were more driven by personal financial interests. For example, see our blog posts here, here, here, and here.

Therefore, it was refreshing to see this defense of comparative effectiveness research in the opinion pages of the New York Times, which demonstrated that the issues here are really not ideological.

Drawing upon the ideas of the Harvard economist David Cutler, the Obama administration talks of empowering an independent board of experts to judge the comparative effectiveness of health care expenditures; the goal is to limit or withdraw Medicare support for ineffective ones. This idea is long overdue, and the critics who contend that it amounts to 'rationing' or 'the government telling you which medical treatments you can have' are missing the point. The motivating idea is the old conservative chestnut that not every private-sector expenditure deserves a government subsidy.

This was written by Tyler Cowen, a well known academic economist, a Professor in that department at George Mason University with impeccable libertarian credentials. (Prof Cowen also blogs on Marginal Revolution.) Prof Cowen reminded us how the current health care reform debate could benefit from some clear thinking that eschews ideological posturing.

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.

Censored Surgeons General

Several major newspapers (including the Los Angeles Times, New York Times, and Washington Post) just reported on testimony of three former US Surgeons General about politically based attempts to censor them. Most of the emphasis was on the testimony of Dr Richard H Carmona, former Surgeon General under President George W Bush. To quote the Washington Post's story,

Former surgeon general Richard H. Carmona yesterday accused the Bush administration of muzzling him on sensitive public health issues....

Political appointees in the administration routinely scrubbed his speeches for politically sensitive content and blocked him from speaking out on public health matters....

'Anything that doesn't fit into the political appointees' ideological, theological or political agenda is often ignored, marginalized or simply buried,' he said. 'The problem with this approach is that in public health, as in a democracy, there is nothing worse than ignoring science or marginalizing the voice of science for reasons driven by changing political winds.'

Particular issues about which Carmona charged he was censored included stem cell research,

He was told not to speak out during the national debate over whether the federal government should fund embryonic stem cell research, which President Bush opposes.

'Much of the discussion was being driven by theology, ideology, [and] preconceived beliefs that were scientifically incorrect,' said Carmona, one of three former surgeons general who testified at yesterday's hearing. 'I thought, 'This is a perfect example of the surgeon general being able to step forward, educate the American public.' . . . I was blocked at every turn. I was told the decision had already been made -- 'Stand down. Don't talk about it.' That information was removed from my speeches.'

Also, there was sex education,

Carmona said that when the administration touted funding for abstinence-only education, he was prevented from discussing research on the effectiveness of teaching about condoms as well as abstinence. 'There was already a policy in place that did not want to hear the science but wanted to just preach abstinence, which I felt was scientifically incorrect,' Carmona said.

And second hand smoke, according to the New York Times,

Top officials delayed for years and tried to 'water down' a landmark report on secondhand smoke, he said. Released last year, the report concluded that even brief exposure to cigarette smoke could cause immediate harm.

Carmona was even warned about attending the Special Olympics,

And administration officials even discouraged him from attending the Special Olympics because, he said, of that charitable organization’s longtime ties to a 'prominent family' that he refused to name.

'I was specifically told by a senior person, ‘Why would you want to help those people?’ ' Dr. Carmona said.

The Special Olympics is one of the nation’s premier charitable organizations to benefit disabled people, and the Kennedys have long been deeply involved in it.

When asked after the hearing if that 'prominent family' was the Kennedys, Dr. Carmona responded, 'You said it. I didn’t.'

And some reports are still on ice, according to the New York Times,

Dr. Carmona said drafts of surgeon general reports on global health and prison health were still being debated by the administration. The global health report was never approved, Dr. Carmona said, because he refused to sprinkle the report with glowing references to the efforts of the Bush administration.

Two other Surgeons General testified. They were Dr David Satcher, who served under President Bill Clinton, and briefly under President George H W Bush and Dr C Everett Koop, who served under Ronald Reagan. Both also cited politically driven attempts to censor them. As the Post put it,

Two other former surgeons general, David Satcher and C. Everett Koop, said at the hearing that political interference appears to have grown worse under Bush, although they noted that this administration has not been the only one to take a political approach toward the office.

Under Clinton, Satcher was censored about health and sexuality,

Satcher, Carmona's predecessor, who served from 1998 to 2002, said that under President Bill Clinton he could not release a report on sexuality and public health, in part because of sensitivities triggered by the Monica Lewinsky scandal.[WaPo]

The Washington Post article also noted,

Clinton also forced out Joycelyn Elders as surgeon general in 1994 after her controversial remarks that public schools should consider teaching about masturbation.

Satcher also was censored about substance abuse,

Dr. Satcher said that the Clinton administration discouraged him from issuing a report showing that needle-exchange programs were effective in reducing disease. He released the report anyway.

Under Reagan, Koop was told of political pressures on Reagan, but apparently was shielded from them by the President,

Koop, who served as surgeon general under President Ronald Reagan, spoke out on AIDS, despite political pressure not to do so. He said Reagan was pressured to fire him every day -- but he did not.

'If he had not been the kind of person he was, I would not be here today,' Koop said [WaPo]

On Health Care Renewal, we often discuss cases in which research results have been suppressed, or discussion of various health care issues has been discouraged. Often those doing the censoring in these cases appeared to have been acting out of economic self-interest.

These new and not so new stories remind us that people with political vested interests may also be eager to shape the debate about health care issues, and even try to completely shut up people whose positions offend them.

On the other hand, as we have said many times, for patients and doctors to make the best possible clinical decisions, they need access to the best possible evidence about tests and treatments. Furthermore, to make the best possible health policy decisions, people and policy-makers need access to all relevant evidence and view-points.

Stifling dissemination of information or debate to serve vested interests, whether these interests are primarily economic or political, is bad for patients and bad for people in general.