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An Impending Catastrophe

An Interview with Dr. Quentin Young

By JESSICA CURRY

Quentin Young, M.D., makes his diagnosis clear-America's health care system is failing. With more than 44 million Americans lacking health insurance, the argument for universal coverage has never been more relevant, he says. Dr. Young has been fighting to abolish profit-driven managed care for most of his medical career, which has spanned more than 50 years. After graduating from Northwestern Medical School, he completed his residency at Cook County Hospital, where he served as chairman of the Department of Internal Medicine through the early 1980s.

The 80-year-old doctor still practices three days a week in Hyde Park and can often be heard as an expert guest on WBEZ, Chicago public radio. He's a clinical professor of preventive medicine and community health at the University of Illinois Medical Center and senior attending physician at Michael Reese Hospital. Despite remaining active in the medical community, Dr. Young devotes most of his time to combatting the corporate takeover of medicine in America. In 1980, he founded the Health & Medicine Policy Research Group, of which he is currently chairman. Additionally, Dr. Young has mobilized the Chicago-based Physicians for a National Health Program, acting as the organization's national coordinator. Currently, PNHP consists of more than 10,000 physicians who support a single payer national health insurance. Dr. Young discusses his health care plan, its goals, obstacles and what America has in its favor.

What must Americans keep in mind when debating health care, a topic that intimidates many due to its apparent complexity?

This is a question that's vital to our national experience because of the huge crisis in health care, and in our mind the answer is beautifully simple. Our plan isn't based on fantasy-it's based on the experience of other democratic industrial societies of the world, like Western Europe, Scandinavia, Great Britain, Canada and Japan. Each of them has, in the past century, adopted the central notion that providing health services is a societal responsibility and that the government or some surrogate of the government should handle the finances. It turns out that not only is this extremely humane and totally consistent with our democratic ethics, but it also is enormously efficient in garnering the resources for health services in the most expedient and prudent way.

How would you structure the health care system in America?

We look at our plan as Medicare for all. The Medicare system currently offers coverage for anyone over 65 or disabled. Those two groups in America enjoy an insurance benefit as an entitlement. Everyone's in, and nobody's out. We would expand that element to include everyone in America. The second feature, the so-called single payer, is equally uncomplicated. It means that you replace the 1,600 different insurance companies now in the system with a single payer, a single insurance company. And that would be the federal government. Arguably, it could be the state or regional government. Canada, for example, has a provincial system, where each of the provinces has their own plan. However, there is a national standard determined by the Canadian Health Act of 1967, which lists in a very explicit way the standards for the health system. To enjoy federal support, each province does and must fulfill these standards, which include elements like port-ability, where if you're a native of British Columbia suggest suspect head. I'm obviously being facetious, but there's no question we do an awful lot of high-tech procedures with high costs that aren't dictated by the best practices. Best practice is a term we use in the medical practice to mean taking the collective experience of the profession to accumulate wisdom. This is constantly changing. Just, for example, as we talk, hormone replacement therapy for post-menopausal women has in 10 years gone from something doctors enthusiastically recommended, almost as the fountain to youth, to something almost entirely discredited. This is an extreme example of best practice. We now as a profession are discouraging women from getting this treatment. I predict, though, in a few short years, some women will take this therapy for very specific and limited symptoms for limited periods of time. I mention this example because this is what medicine should constantly be doing. The single payer system allows for this through the ability to accumulate data and publicize correct preferred practices. And I'm not talking about cookbook medicine or government coercion-I'm talking about the ethics of medicine, where you share knowledge for the best solution.

Many people fear that universal health care would halt or slow research and breakthroughs in medicine. Is this at all true?

This is a scurrilous argument. First of all, the bulk of the advances in medications, not to mention other biomedical issues, is based on government-funded research through the National Institutes of Health-undoubtedly the most successful way of distributing precious research dollars in a competitive, honorable way. It is, therefore, categorically the basis for America's prominence in biomedical issues. The discoveries, financed through government grants, are picked up by pharmaceutical companies for a minimal license fee. For $100,000, they get the patent life protection of 17 years. I might add, they've discovered many imaginative ways to extend the 17 years. For example, if they claim there's a new use for a drug whose patent is about to run out, they can immediately get another six months while the issue's being debated. They do this and a six-or 12-month extension for the drugs we're talking about is literally hundreds of millions of dollars. While drug companies do conduct research, it's worth noting that, according to their reports, marketing expenditures now exceed research in dollars spent. A good deal of the research they do is on me-too drugs, which are very valuable drugs like antibiotics, antihistamines or any other drug that has great results with few side effects. Drug companies chemically modify these drugs, without changing their efficacy, potency or safety. They simply modify the drug with one chemical addition, like a hydroxy or something, enabling them to get a whole new drug for their money. This is why they are called me-too drugs. The best example of this is very contemporary and is on everyone's television screens-the Purple Pill, Nexium. What's the story behind that? Prilosec, the first of the so-called proton pump inhibitors, which means it suppresses the formation of stomach acid, worked marvelously and reliably well in preventing troublesome heartburn. Heartburn occurs in millions of people, but only in a few is it serious. Prilosec worked very well, and five or six other companies put out similar kinds of drugs. Time passed, and after making an awful lot of money, the Prilosec patent ran out, and it went over the counter. It went from costing about $3 a pill to about 30 to 40 cents a pill. So what does the company do? They go on a massive campaign, having developed another drug called Nexium. If you look closely, they do not claim it's less toxic, more effective or better than Prilosec in any way. It's just patented and can therefore be sold for $3 a pill. And they have the hutzpah to say, "From the people who gave you Prilosec, here's the Purple Pill." They never claim it's better than Prilosec because it isn't. Not only does Prilosec cost less, you can get it over the counter. This Purple Pill will literally cost billions of dollars over the next few years. This is, on one hand, the perfect expression of marketing, marketplace and super profits. On the other hand, this shows absolute irresponsibility with regard to maintaining the health status of the American people.

Do you think we should nationalize the drug industry?

I'm not prepared to say we should nationalize the drug industry. Our proposal contemplates it, but what's perfectly clear, regardless, is that the pharmaceutical industry needs enormous regulation. Through the Food and Drug Administration, we have the apparatus in place to regulate drugs. It just depends on how much the drug industry has captured the FDA. Today, their main function is to threaten that buying drugs like Canada-mind you, the same drugs as you get here-might violate regulation. It's clearly showing, it seems to me, that the FDA is being co-opted by the industry they're supposed to regulate and contain. They should, if anything, be taking safeguards to make sure that imported drugs are safe and using the same mechanisms they use with domestic drugs, like testing and branding. It's interesting to note that in the few years importing has been going on, there have been no indications or evidence that these drugs are unsafe, and yet that is the issue that's always raised as an argument against importing. There have been, as you know, adulterated drugs and scams in this country, but we have the mechanisms for screening and protecting.

Why would physicians prescribe an expensive prescription drug when an over-the-counter inexpensive drug that is basically the same is available?

That question gets at a degradation of doctor autonomy, ethics and doctor-patient relations that are a biproduct of this commodity-driven arrangement. I'm a practicing physician and have been for 52 years. So, I've been practicing for a long time, and in this last half-century, particularly in the last decade, I have seen the encouragement of the marketplace solutions that started under Nixon. By that I mean the fostering of competitive agencies and hospitals. Years ago, we used to have virtually no for-profit hospitals. They got all sorts of tax breaks, and more than that, they got all kinds of support from the grateful community for providing round-the-clock emergency services and care. The system was responsive and community based. A quick way to get what I'm saying is to look at the names of the hospitals in any area of Chicago: Swedish Memorial, Illinois Masonic, Mount Sinai, Mercy. The names, of course, reflect that a private group of concerned citizens felt the need to have a hospital. That's a very American and very valuable energy. The hospitals were a civic creation and had a social compact with the government, where they'd get tax breaks, subsidies and urban renewal. There were a lot of cases of this happy collaboration. Enter the current for-profit status of hospitals, and you have a complete distortion and undermining of this once wholesome civic arrangement. The biggest hospital chain in the world is the Hospital Corporation of America, which has around 650 hospitals. Most of those hospitals are in Americaand were bought, not built, at marked-down prices as they, for other reasons, went into economic struggles. These companies bought public and private hospitals, forgoing the tax-free status for profits. This has not been a happy moment for America. Each one of these hospitals must make a profit, and not just any profit, a certain level of profit determined by the corporation. These companies say to their stockholders that if there isn't a profit of 10, 12, 15 percent, close the hospital down and put the money where you can get a good return. They have done a number of things to distort the market of health care. First and foremost, they cherry pick, which means they pick patients who are well. This hospital corporation was founded by the brother and father of the present majority leader, Dr. Bill Frist. The most recent find for gouging Medicare brought the total fines paid to $1.7 billion over the past year. Nobody ever goes to jail-they just pay these fines, smile, go into their treasury and get fined again. These fines are for egregious behavior, for criminally exceeding the allowed Medicare payment. When you're getting these fines, you've violated en masse. The government doesn't just come in and fine you $1 million for a $10 overcharge. The government audits and finds that they have been systematically overcharging, and in that way they distort the system.

How have HMOs earned such a bad reputation?

The HMOs, for their part, have been all-but-totally discredited as the public has become aware that ultimately their central driving force is finding ways to deny care. The start of HMOs was interesting. At the time, America was looking for some way to curb the rising national costs for health care, which today seem laughable (then, they were about $70-80 billion per year, and today they are $1.7 trillion a year). We had this terrible blunder of World War II, where we put payments for health benefits in the workplace. Businesses started complaining they couldn't afford to pay, and people started to suffer wage cuts or job cuts. And this is really where we are today, only it's worse. HMOs were an attempt to mimic another very successful health finance and delivery plan. There were these various group health organizations across the country, which were successful in their markets, but only affected 15 to 20 million Americans. They were resisted mightily by organized medicine for ideological reasons, but what they were, in essence, was a progressive idea. The group created an economy of scale and provided service to its members. We have learned lessons from this, and it helped establish best practice because of the large numbers of patients doctors would see. The costs, relative to the rest of the system, were very favorable, and you could never be turned down. The deal was, if you're in, you're in. You'd never get dumped if you were sick. Nixon liked the idea-he was not my favorite president, but he had a number of ideas that were ahead of his time-so he put forth Health Maintenance Organizations (HMOs), which were based on these group plans. It was fine in its day, but once you add market competition, people get left out. Now I'm not some wild-eyed radical-market places can work. You can look out the window and see 20 examples of that. But, market places are ill-fitted for health care. Why? Because the money is to be made, by and large, by denying people care. You as a patient and we as a nation don't want a system that's founded on denying care. If the profit made people give more or better care, that would be fine, but it does the opposite.

How does America currently pay for health care?

We pay for health care in three ways: one is taxes, which have two components-direct taxes and tax credits. The government pays for 60 percent of our health care in just those two taxes. The other 40 percent comes from out-of-pocket. Despite our huge government expenditure, we still pay more out-of-pocket than any other country. The third way we pay for our health care is-in lieu of wages-employee benefits. Notice I said "in lieu of wages." In economic sense, when you have a worker, you can only pay so much, and insurance is part of wages. This is why employers try to find ways to reduce insurance costs. I have a marvelous statement signed by the three big CEOs of American car companies, Ford, GM and Daimler Chrysler. They joined with the head of the Canadian Auto Workers to categorically endorse the Canadian public health system. They said it would give them an economic advantage, amounting to several more dollars-per-hour of labor. That's big. And this has always been one of the big mysteries to us-why American business, which always looks for the advantage, does not see the wisdom in universal health care. In every other country with national health insurance, the labor movement in that country was the instigator and main voice in getting it. As soon as they get health insurance off the table, they can go for wages, hours and other perks. What keeps the business sector from supporting a national health plan?

Labor has the ability to not drag its feet around this and to make it a central issue. And indeed, they can convince management to fight for this. We would love to see this happen, but what stands in the way is the ideology of American business. Employers don't like the idea of anything being run by the government, and they don't like taxes. Our plan is embodied in House Bill 676, sponsored by Reps. Kucinich, McDermott and Conyers. We've fashioned the bill, and it excludes for-profit entities delivering health care. Without this exclusion, our dream of single-payer health care would never work. It would grow broke in six months because there would be no overhead. We're being corrupted to think health care can be profitable.

What has your organization, PNHP, done to garner support in the medical community?

We organize doctors and medical students. You don't even need to know much about this issue to know how hard it is to organize doctors. They are, by definition, independent. However, we've had what we consider stunning success. Our position was recently published in the Journal of the American Medical Association, which was marvelous for us because our biggest problem is not that people out-argue us-it's getting our message out there. Some people in Congress said that we were radicals in our field and that mainstream medicine didn't support us. We knew better. Not only do leaders in the medical community support our proposal, there are surveys showing that among academics in the medical community, 57 percent favor a single-payer insurance. What it's come down to is that doctors have learned there's something worse than government, and that's corporations. We decided to have a congressional hearing. With the former editor of the New England Journal of Medicine as our spokesperson, I convened 19 doctors, including two past presidents of the American College of Physicians, the then-president of the Academy of Pediatrics, the president of the American Medical Women's Association, and so on, to fashion a new proposal to update the one from 1987. It turned out very well. Twenty-five members of Congress attended, and after the presentation, everyone stood up and applauded. Several people in Congress said they'd never seen a better presentation. This made the deal for the writing of our bill. We came back realizing that we'd need to make a serious effort to get to the American doctors, so we started writing individual letters asking them to endorse this bill. We did this nationally over the past six months, and though we haven't had the resources to write to all 600,000 doctors in America, we've had an incredible response. So far, we've heard from more than 10,000 doctors, and we hope to soon be up to about 25,000. And these are doctors who've signed their names, addresses and agreed to be published.

With the presidential election drawing near, which of the candidates do you feel has the best health care plan?

Regarding politics, I admire Dennis Kucinich. He's taciturn, almost shy. He won my heart by fighting for my bill. He's had a courageous political career. My personal preferences for president aren't important, but we do feel that health care can only be resolved politically. I think it will happen when we realize that this economic/social contradiction must be resolved. Like slavery, we will need something written into the Constitution, which at the time may contradict our economy. We see similar incidences in the past, like women's rights or social security. These resolutions were, at one time, considered out of the question, but became absolutely necessary. I believe that health care, with its vast impact on everyone's lives, has reached that stage, and we have the perfect storm. We have corporate greed, lack of morale in the medical profession, and anger and depression in the public. Each year, 15 percent of the public faces a serious illness, and the critical mass is growing. It's a very dangerous, unstable situation.

Gov. Blagojevich has recently pushed providing lower-cost Canadian drugs to state workers and the elderly. What do you think of this step for Illinois health care?

I like any reform that has the elements of entitlement. I think Gov. Blagojevich's plan is a good start. People bash Canada's plan, but they get drugs for 60 percent less and most people are covered, which is better than what we have.

Politically, what do we need to do to get the momentum moving for a national health program?

Every person running for office should present a stand on health care. It should be the reason someone gets elected or doesn't get elected. It's that simple. We only need 20 people in Congress to get this going.

Published: December 01, 2003