Health Insurance For Me But Not for Thee? - How Legislators Tried to Rig the Repeal of the ACA to Keep Their Own Health Insurance Affordable

The turmoil swirling around the new Trump administration has flushed into the open some things that the public heretofore was probably not meant to see....

We have been writing a lot lately about how the insiders who run large health care organizations, and benefit mightily therefrom, try very hard to control the health care policy discourse, and keep us distracted from their wizardry behind the curtain.  Again, these days the curtain is likely to get blown away.

Sarah Kliff just reported in Vox about a provision newly inserted into the proposed American Health Care Act

Wednesday night, text leaked of a new Republican amendment to the party’s health care bill, the American Health Care Act, which was part of an ongoing effort to revive the bill in the House.

The amendment would allow states to opt out of some politically popular Obamacare provisions, like the requirement to charge sick people the same prices as healthy people, or to cover a core set of benefits.

Health law expert Tim Jost called me when he noticed something surprising on the sixth page of the amendment: an exemption for the health insurance of legislators and their staff. This means that members of Congress and their aides would be guaranteed access to Obamacare provisions that constituents could lose.

I wrote about it. It caused a stir. Twelve hours later, Republican legislators appear to be split — but not over the exemption policy itself. Instead, they have disputed whether it even exists.

This morning alone, legislators have claimed that the exemption never existed, that it does exist and was inserted by senators, and that it used to exist but has been removed. 

So, to recap, the amendment would have let individual states allow insurance companies to bill patients with pre-existing conditions at higher rates than healthy people.  That would negate the essential function of health care - to pool costs among large populations so that care is affordable for the sick.  Thus many people with pre-existing conditions would have to forego health insurance because of the cost.  However, legislators and their staffs would have had special privileges allowing them to get insurance at the low rate for healthy people even if they were to have pre-existing conditions.  For the legislators and their staffs, health care for me but not for thee.

This is conceptually like other special health care deals that insiders and the wealthy can get now, like "VIP care" at hospitals (look here, here, and here), or executive health plans for top corporate managers (look here).  Such privileges allow the American version of the nomenklatura to get better health care than the little people get (just like Soviet apparatchiks could get much better care than the proletariat, and now like Putin and his cronies will have access to a special health clinic, according to Reuters, via Business Insider.) 

It is likely that the persistence of health care dysfunction in the US has been driven in part by the ability of the rich and insiders to bypass the current system.  And this ability may have been in turn driven by how insiders have been able to manipulate the public discussion of health care policy to conceal such unpleasant truths (as noted here and here).

To ever achieve true health care reform, we need an honest discussion of what is wrong with health care, and especially of how the system has been rigged to protect the insiders who currently benefit the most from the status quo. 

ADDENDUM (4 May, 2017) - According to Sarah Kliff at Vox News (look here and here) that barely passed the US House of Representatives still allows federal legislators and their staffs to keep their own protection from discrimination due to preexisting illness.  As she noted,

Republican legislators liked this policy well enough to offer it in a new amendment. They do not, however, seem to like it enough to have it apply to themselves and their staff.

Again, this suggests that some legislators cynically believe what is good enough for their constituents is not good enough for their august legislative personages.

Pontifications About Health Care Reform Written by Insiders Who Benefit from the Status Quo - Worse Than We Think

Perceptions that the US health care system is dysfunctional and needs major reform go way back.  A timeline from the Tampa Bay Times noted President Theodore Roosevelt's proposal for a national health service in 1912.  Nonetheless, as we have discussed endlessly, most attempts at reform failed, and health care dysfunction seems to be getting worse.

One big problem may be that we don't understand how much discussion of health care reform is driven by those who benefit from the status quo. 

A Personal Anecdote

When I began my academic career in 1983, I was often in the audience for talks about how to fix health care by people billed as experts.  Often these talks seemed oddly disconnected from the realities on the ground for a junior assistant professor with a lot of clinical and teaching responsbilities.  Worse, many of the solutions they offered seemed to entail greater burdens for health care professionals, with no obvious compensation other than the warm feeling that we would be benefiting society.  Who else these solutions might benefit was not discussed. 

One talk given a bit later stands out in my memory. On November 29, 2001, one Dr John W Rowe gave the prestigious Levinger Lecture at Brown University entitled "Good Health: Can we Afford It?" (referenced here, see items for 11/14 and 11/16)  As I recall, Dr Rowe spent considerable time scolding us hard working physicians for overuse of medical interventions leading to endless increases in health care costs, and promising more burdensome bureaucratic interventions to rein in our follies.  While promising more burdens on physicians, Dr Rowe did not dwell on how the resulting cost savings might benefit him in his role as CEO and Chairman of Aetna Inc.  Aetna had purchased the notoriously physician-unfriendly US Healthcare, and thus had become a big for-profit health care insurer already known for imposing bureaucratic burdens on physicians in hopes of decreasing their utilization, while increasing the company's revenues (look here).  Were Dr Rowe's pontifications really about improving health care for all Americans, or about justifying his previous management behavior, and perhaps supporting the price of his shares in Aetna? Why was Aetna's public relations given the patina of an academic lecture?

These days, health care professionals continue to be exhorted about health care reform.  Many such pontifications may be not so much about true health care reform as about preserving the fundamental status quo which has benefited and enriched so many insiders. The interests of the pontificators are often less obvious than those of Dr Rowe.  Maybe that is so why there has been so little real reform, and what little reform there has been seems to be under continuous attack.

Two Examples of How Hard It Is to Discover the Interests of Health Care Policy Pontificators

In the last few weeks I posted about two recent ostensibly authoritative pontifications.  One was about ways to address the worsening problem of physician burn-out (see this post). It was written by the CEOs of large, non-profit hospital systems, joined by the CEO of the American Medical Association.  The other was about a health care reform proposal from the prestigious National Academy of Medicine (see this post).  A rather uncritical article in the Washington Post hailed it as a "radical idea" because it was written by "doctors." In both cases, I was skeptical, mainly because many of the proponents had conflicts of interest, mostly undisclosed, that suggested they were already benefiting mightily from the current system.

However, it gets worse.  While I thought my posts were based on reasonable efforts to find undisclosed conflicts of interest affecting the authors of these exhortations, within a few weeks I realized I had missed one important item affecting each.  The lesson is that the web of conflicts of interest that ensnares the insiders who run most of US health care is even more complex and adherent than any of us realizes.

Dr John Noseworthy, Author of the Health Affairs Post on Reducing Physician Burnout: CEO of the Mayo Clinic, But Also Now Nominated to be a Director of Merck

Dr Noseworthy, CEO of the Mayo Clinic, was the lead author of a post in HealthAffairs about reducing physician burnout.  (Oddly enough, none of the proposed action items seemed to involve increasing physician autonomy by reducing the power of managers over health care professionals.)

Two weeks after Noseworthy and colleagues' post appeared, an article on the Minnesota Public Radio website reported that Dr Noseworthy has just been nominated to a seat on the Merck board of directors.  Presumably the possibility of this nomination had been known at the time the post was published.

I had previously written that two of the authors of the Health Affairs post were on corporate boards.  One, Dr Paul Rothman, was already on the board of Merck.  As corporate directors, they have fiduciary responsibilties to promote the revenues of their corporations.  Now it turns out there were at least three such board members among the health system CEOs who had pontificated to physicians about how to reduce their burn-out.

Yet the power of such health care systems, whose management is often mission-hostile, and who often put revenue ahead of physicians' professional values (per the shareholder value theory), is arguably a major cause of physician burnout.  Furthermore, Merck, in particular, has had its share of management misbehavior as demonstrated by a recent $830 million settlement for deceiving shareholders, a mere $5.9 million 2015 settlement for deceptive marketing, and multiple setttlements, cumulatively totaling more than $1 billion, plus one guilty plea for the historic deceptive marketing of Vioxx (see this post).

So to what extent are the authors of this pontification about reducing physician burnout (without really giving physicians much new autonomy) insiders benefiting from the status quo in health care?  It may be more than what we think, even now.

Mr Leonard Schaeffer, Author of National Academy of Medicine Article on Health Care Reform: Member of the Boards of Wahlgreen Boots, Quintiles, scPharmaceuticals, but Also Long-Term Director of Amgen

Mr Schaeffer was an author of the National Academy of Medicine article, now published online in JAMA, about health care reform.  (Oddly enough, none of the "vital directions issue areas" mentioned in the article involved real challenges to the power of large health care organizations, particularly for-profit corporations, or increased autonomy for health care professionals.)

The version of the article published online by the NAM did not include any explicit disclosures of conflicts of interest.  It did note that two authors were full-time employees of health care corporations, one was a consultant to health care corporations, one was a lobbyist for health care corporations, and one was on the boards of health care corporations.  The online JAMA version added more disclosures, but these were incomplete.  In my post, I noted that fully 13 of the 19 authors had major ties to large health care corporations, as employees, lobbyists, consultants or  board members.

In particular, Mr Leonard D Schaeffer was listed in the NAM version as simply affiliated with the University of Southern California, but I found was actually on the boards of Wahlgreens Boots Alliance, Quintiles Transnational, and scPharmaceuticals Inc.  That was still an incomplete picture of his conflicts of interest.

A ProPublica article from February, 2017 recounted how big pharmaceutical companies engaged Precision Health Economics to wage public relations campaigns to try to justify high pharmaceutical prices.  The article noted the following about Mr Schaeffer.  

Amgen has ties to all three founders of Precision Health Economics. Working for other firms, Philipson has twice testified as an expert witness for Amgen, defending the company’s rights to drug patents, according to his curriculum vitae. The other two founders, Goldman and Lakdawalla, are principals at the Leonard D. Schaeffer Center for Health Policy and Economics at USC, which received $500,000 in late 2016 from Amgen for an 'innovation initiative,' according to public disclosures. Goldman said the funds were unrestricted and could be used at the center’s discretion. Robert Bradway, the CEO and chair of Amgen, is on the advisory board of the university center, and Leonard Schaeffer, a professor at USC and the namesake of the center, sat on Amgen’s board of directors for nearly a decade.

With funding from Amgen, the Schaeffer Center hosted a forum in Washington, D.C., in October 2015 on the affordability of specialty drugs. Before a panel focused on the new cholesterol treatment, Goldman cautioned against lowering drug prices.

So Mr Schaeffer, in addition to his current board positions, turns out to have had a long relationship with Amgen.  Given that according to the 2013 Amgen proxy statement, Mr Schaeffer retired from the board with at least 28,277 shares of Amgen stock and options for 15,000 more, he may have current financial ties to the company. 

So once again, to what extent were the authors of the 2017 NAM report on health care reform (which did not challenge the influence of large health care corporations over the health of US citizens) insiders benefiting from the status quo in health care?  It may be more than what we think, even now.

Summary

Health care professionals, policy makers, and the public are constantly harangued by apparently unbaised experts about health care reform.  Yet many of these authorities are insiders who benefit from the status quo.  Many of their financial connections to the corporations that make the most money from the US commercialized health care system are not disclosed.  It may take considerable investigation to determine their involvement in a web of conflicts of interest that drapes over the US health care system.

Meanwhile, audiences should demand that those who lecture us about health care reform disclose all their financial conflicts of interest.  Any whiff of deception about their personal interests should suggest intense skepticism. 

True health care reform requires honest discussion of the issues.  Honesty in this case entails complete and detailed disclosure of the discussants' conflicts of interest. Until such honesty is the rule, be very, very careful about taking sanctimonious spiels at face value. 

"A Radical Idea for Health-Care Reform: Listen to the Doctors" - Oops, I Mean Listen to the Corporate Executives, Directors, and Lobbyists

It has been the season for health care reform in the US since at least the Nixon administration.  We have endlessly discussed the unholy triad of health care dysfunction: rising costs, declining access, and stagnant quality.

These days, with all the furor over whether Obamacare should be repealed and replaced, let alone, or improved, it is still the season for health care reform.  Last week an article by David Ignatius in the Washington Post entitled "A Radical Idea for Health Care Reform: Listen to the Doctors," appeared.   Since on Health Care Renewal we are all about trying to uphold physicians' professional values, I thought this deserved a closer look, with the hope that it would provide some down-to-earth wisdom from physicians in the real clinical world.

Background - Doctors Views on the Causes of Health Care Dysfunction


As we recently discussed, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes.  Our first crude qualitative research(1) suggested  that physicians' angst was due to perceived threats to their core values, and in turn that these threats arose from the issues this blog discusses: concentration and abuse of power, health care leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and health care governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting these proposed causes of health care dysfunction. 

Other research provided some corroboration.  Written comments from a 2001 survey of Massachusetts physicians made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line.  Taken over by large corporations.  Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(2)  Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(3)  (Also, see our comments on this paper.)(4)  Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(5)   We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(6)

The Latest Attempt to Listen to the Doctors about Health Care Reform


Ignatius' WaPo article was based on the pre-publication version of a new report by the National Academy of Medicine, (formerly the Institute of Medicine) made available on its website, entitled, Vital Directions for Health and Health Care.  According to Ignatius' interpretation, the basic problem health care reformers need to address is that America "squanders money on the wrong things - expensive procedures and tests rather than preventive care and social programs."  His summary of the supposed doctor recommended cures for this problem were: 

First, providers should be paid for value — for patient outcomes, not for the volume of procedures. Second, incentives should empower people to take better care of themselves through wellness programs or lifestyle changes. Third, better connectivity is needed among doctors, patients and others to encourage data-driven advances. Finally, the Academy argues for community strategies that target the highest-need patients, who are also most costly to treat.

It sounded good at first, but I quickly thought of questions: Does it make sense to pay for patients' outcomes, when those outcomes may occur regardless of what doctors do? What sort of incentives would be needed to make patients who are not taking good care of themselves change their ways?  Why would connectivity help when health care dyfunction has gotten worse as the world has become more connected?  How to you find patients with highest need, and how would you target such patients?  And above all, how would these cures, assuming one could figure out what they mean, prevent squandering money on the wrong things?

I left the Ignatius piece confused.  Perhaps the NAM publication on which Ignatrius' WaPo article was based would provide enlightenment.

What the National Academy of Medicine Wrought


So my next step was to quickly read the underlying report.  But that did not lessen the confusion.

The report did begin with sort of a definition of health care dysfunction

Health care today is marked by structural inefficiencies, unprecedented costs, and fragmented care delivery.

However it did not go on to providing an organized list of possible causes of these problems, with justifications for these diagnoses.  At best, it sort of alluded to the following as possible causes:

- the "rapidly aging population;"
- "persisting care fragmentation and discontinuity;"
- "costs associated with unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities, and fraud;" and
- "constrained innovation" due to "outdated regulatory, education and training models," particularly "uncertaintly and unpredictability around approval" of drugs and devices; and payment models that might place "excessive burden on manufacturers to demonstrate the value of their products."

"Rapidly again population" often appears as a postulated caused of health care dysfunction.  On Health Care Renewal we frequently discuss the problem of outright criminality and corruption in health care, including fraud; and the take over of health care by managers, which can result in "excess administrative costs."  However many of the other items were either too vaguely described to assess, or did not appear with clear justification. 


Furthermore, this list also raised some obvious questions.  For example, why are US costs so much higher than those of European countries whose populations are also aging?  Who sets criteria for how "high" prices should be?  What causes prices to be excessively high? Whose uncertainty and what unpredictability affect drug and device approvals?  How is the burden on manufacturers excessive?

Here was more confusion.  More was to follow. 

The bulk of the report is about "Vital Directions Issue Areas," again sort of a list of cures for health care dysfunction     

Vital Directions Issue Areas
Better health and well-being
Systems strategies for better health throughout the life course
Addressing social determinants of health and health disparities
Preparing for better health and health care for an aging population
Chronic disease prevention: tobacco, physical activity, and nutrition for a healthy start
Improving access to effective care for people who have mental health and substance use disorders
Advancing the health of communities and populations
 High-value health care
Benefit design to promote effective, efficient, and affordable care
Payment reform for better value and medical innovation
Competencies and tools to shift payments from volume to value
Tailoring complex care management, coordination, and integration for high-need, high-cost patients
Realizing the full potential of precision medicine in health and health care
Fostering transparency in outcomes, quality, safety, and costs
The democratization of health care
Workforce for 21st century health and health care
 Strong science and technology
Information technology interoperability and use for better care and evidence
Data acquisition, curation, and use for a continuously learning health system
Innovation in development, regulatory review, and use of clinical advances
Targeted research: brain disorders as an example
Training the workforce for 21st century science

However these apparent action items were not clearly associated with the causes of health care dysfunction they were supposed to address.  The discussions of these items raised yet more questions.  For example, the report discussed how to "drive health care payment innovation providing incentives for outcomes and value," presumably related to "payment reform" in the above list.  New payment and delivery models would have the "aim to reduce waste, increase value, and improve outcomes."  What was the evidence that they would be able to do so?  The next item was to "help clinicians develop the core competencies required for new payment models."  Would physicians be willing to accept a new payment system that would not work without subjecting the same busy clinicians to extensive new training? Etc, etc, etc

So in summary, the ful report did not give a clear definiton of the health care dysfunction, did not discuss the causes of the problem, and did not provide solutions keyed to either.  Furthermore, the report does did not provide clear justification for the action items it suggested.

Instead of a clear common-sense set of reforms, the new report just muddied the waters. Listening to the doctors was not helping at all. 


Listening to Not So Much Doctors as Health Care Corporate Executives, Directors and Lobbyists

The reason may be that the National Academy of Medicine report was written more by health care corporate executives, members of health care corporations' boards of directors, and lobbyists for health care corporations than by doctos.  The report's author list appeared thus on the NAM website:

Victor J. Dzau, National Academy of Medicine; Mark McClellan, Duke University; Sheila Burke, Harvard Kennedy School; Molly J. Coye, AVIA; The Honorable Thomas A. Daschle, The Daschle Group; Angela Diaz, Icahn School of Medicine at Mount Sinai; The Honorable William H. Frist, Vanderbilt University; Martha E. Gaines, University of Wisconsin Law School; Margaret A. Hamburg, National Academy of Medicine; Jane E. Henney, National Academy of Medicine; Shiriki Kumanyika, University of Pennsylvania Perelman School of Medicine; The Honorable Michael O. Leavitt, Leavitt Partners; J. Michael McGinnis, National Academy of Medicine; Ruth Parker, Emory University School of Medicine; Lewis G. Sandy, UnitedHealth Group; Leonard D. Schaeffer, University of Southern California; Glenn D. Steele, xG Health Solutions; Pamela Thompson, American Organization of Nurse Executives; Elias Zerhouni, Sanofi

Thus two physician authors were obviously employees of large health care corporations. Both in fact were high ranking executives. Dr Lewis G Sandy, is Senior Vice President, Advancement, for UnitedHealth Group; and Dr Elias Zerhouni, is President, Global Research and Development, for Sanofi.  Also, The Honorable Michael O Leavitt was the founder of Leavitt Partners, a business consulting group, whose clients include companies in the "pharmaceuticals and biopharmaceuticals, medtech and medical devices, health IT, diagnostics" and "commercial [health care insurance] plans," according to its website.

The author information provided at the end of this version of the article also stated that "the Honorable Thomas A Daschle is Founder and CEO of The Daschle Group, a Public Policy Advisory of Baker Donelson.'  Note that Baker Donelson is a Washington, DC lobbying firm.  Furthermore the author information included the fact that The Honorable Willaim Frist is "chairman of the Executive Board of the health service private equity firm Cressey & Company." Finally, Leonard D Schaeffer was identified as "the founding Chairman & CEO of Wellpoint."

While most of the other authors were listed as affiliated with academic organizations, some searching reveals that most of them had major financial relationships with for-profit health care corporations, including some of the largest.  Many, in fact, had come to the attention of Health Care Renewal in the past because of their important conflicts of interest. 

When Dr Victor Dzau was proclaimed the new president of the then Institute of Medicine, there was little initial discussion of his major conflicts of interest.  At the time of the announcement, he was on the boards of directors of Alnylam Pharmaceuticals, device maker Medtronic, and sugary drink maker Pepsico (see our 2014 blog post).  At the time of the announcement, he owned millions of dollars of shares or share equivalents of the three companies.  In 2010, Duke University students had protested his multi-million dollar salary as Chancellor for Health Affairs (see our blog post).

We discussed in a 2013 blog post how Dr Mark McClellan transited the revolving door from his position as head of the Center for Medicare and Medicaid Services (CMS) in the Bush administration to positions as special advisor to private equity firm General Atlantic LLC, strategic advisory committee member for private equity firm Capital Royalty LP, on the advisory board for Castlight Health, and on the boards of directors of AvivReit and Johnson and Johnson.  In 2016 we discussed how Dr McClellan pretended to be an independent scholar for the Brooking Institution while he was still on the board of Johnson and Johnson.

Sheila Burke is a strategic advisor to Baker Donelson, the Washington, DC lobbying firm for which Mr Daschle also works. 

Dr Molly J Coye is currently on the boards of directors of health insurance company Aetna, and chairwoman of the board of Prosetta Biosciences Inc.

Former US Senator Thomas A Daschle's firm is actually a lobbying firm, and was officially registered as a lobbyist for Aetna in 2016 (per Politico).  His firm is now part of Baker Donelson, a larger Washington, DC lobbying firm (as noted above).

Former US Senate Majority Leader Dr William H Frist was a founder of the Hospital Corporation of America (HCA) and likely holds millions of shares of related stock (per Wikipedia), and currently serves on the boards of directors of Teledoc, and "publicly held companies Select Medical and AECOM. In addition, he serves as a board member for several of Cressey & Company’s privately-held portfolio companies." He had been on the board of the controversial diagnostic testing company Theranos (per this news release).

After Dr Margaret Hamburg was confirmed commissioner of the US Food and Drug Administration (FDA) in 2009 in the Obama administration, we discussed how she had to divest herself of shares of medical supply company Henry Schein Inc, on whose board of directors she formerly sat, and how she and her husband, a top hedge fund manager, had to divest themselves of various other holdings that entailed conflicts of interest.

We first discussed Dr Jane E Henney's multiple conflicts of interest in 2006.  Currently, she is on the board of directors of global pharmaceutical distributor AmeriSourceBergen and giant health insurance company Cigna. Recently, she had been on the boards of pharmaceutical companies AstraZeneca (through 2011), and Cubist (through 2014).

In 2011, we discussed how Michael D Leavitt, former US Secretary of Health and Human Services  under the Bush administration, transited the revolving door to a position on the board of directors of Medtronic.

Leonard D Schaeffer serves on the boards of Walgreens Boots Alliance, Quintiles Transnational Holdings, Inc. and scPharmaceuticals Inc

Dr Glenn D. Steele is on the boards of directors for medical app developer Ingenious Med; Director, PTC Therapeutics; Director, Stratus Video; biotechnology company Synaptive Medical; and again large for-profit health insurance company Wellcare Health Plans Inc (look here).

By the way, in 2010, we discussed how Dr Elias Zerhouni, former Director of the National Institutes of Health (NIH) in the Bush administration, transited the revolving door to positions on the board of directors of biotechnology company Actelion and of Danaher, which makes, among other things, medical devices, and then to a full-time position with global pharmaceutical company Sanofi.  In 2005 we discussed how Dr Zerhouni, as NIH director, lead a not very vigorous response to a series of scandals involving conflicts of interest at that august institution, after relevant government rules had been relaxed in the Clinton administration (see also this post and links backward).

Just to add to the confusion, while none of these relationships were noted in the version of the report on the NAM website, a few were listed in an online published version in JAMA.(7)  The JAMA version omitted those of Dr Dzau; all of the relationships of Dr McClellan, save an admission that he "received personal fees from Johnson & Johnson"; Ms Burke's position with Baker Donelson; Dr Coye's position on the board of Aetna; Mr Daschle's position as lobbyist for Aetna; Dr Frist's positions on the boards of Select Medical and AECOM, and former position on the board of Theranos, although the JAMA version added a position on the board of Aspire Health; Mr Leavitt's board membership; Mr Schaeffer's membership on the boards of Quintiles and scPharmaceuticals; and all of Dr Steele's board memberships.

By my count, a majority, 13 of 19 authors had major financial ties to large for-profit health care corporations.  The authors included three who worked for Washington, DC lobbying and consulting firms with major health care industry clients, including one who explicitly lobbied for for Aetna.  The authors included  top executives of UnitedHealth and Sanofi.  The authors included current or recent members of the boards of directors of Alnylam Pharmaceuticals, Medtronic(2), Castlight Health, AvivReit, Johnson and Johnson, Aetna, Prosetta Biosciences, Teledoc, Select Medical, AECOM, Theranos, Aspire Health,  AmeriSourceBergen, Cigna, AstraZeneca, Cubist, Walgreens Boots Alliance, Quintiles Transnational Holdings, scPharmaceuticals Inc, Ingenious Med, PTC Therapeutics, Synaptive Medical, and Wellcare.

The Washington Post article would better have been sub-titled, "Listen to Health Care Corporate Eexecutives, Directors, and Lobbyists." 

Summary

A recent report by the prestigious National Academy of Medicine, now published electronically in JAMA,  and an accompanying newspaper article promised common sense ideas for health care reform suggested by physicians.  On its website, the Academy did not disclose most of the multitudinous and serious conflicts of interest of its authors.  A version electronically published by JAMA disclosed a few more, but was still very incomplete.  Relationships that were not disclosed included positions on the boards of directors of for-profit health care corporations, from start-ups to some of the biggest such corporations in the US.  In my humble opinion, such incomplete and inconsistent disclosures was dishonest and deceptive.

The prevalence of health care corporate board members as authors of this report is particularly concerning.  In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]  So it should be no surprise that the NAM report did not really suggest any radical ideas for health care reform, despite Mr Ignatius' title.  Most of its authors were in a position to benefit from the status quo in health care.

Furthermore, it is no wonder the NAM report was confusing and muddled.  As Joe Collier  observed, "people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult."(8)

In my humble opinion, the NAM report represents the sort of obfuscation that has been befogging discussion of health care policy for a long time.  Wendell Potter described how years of debate on health care policy that started during the Clinton administration was defined by concepts developed by for-profit insurance company public relations departments to steer debate away from ideas would threaten their profits.  In his book Deadly Spin, (p 64) he described a the AHIP (America's Health Insurance Plans, an insurance industry lobbying group) Strategic Communications Committee discourse on

the approach the industry would be taking when the reform debate heated up.  The goal would be to divert the public's and the media's attention from the uninsured and toward problems the insurers coudl insist were beyond their control.  The industry's spin, in other words, was going to be something like this: Health care costs are out of control because new treatments and technologies are more expensive than ever, the population's getting older and sicker, too many people are seeking care they don't really need, and health care professionals and providers are all too willing to provide the care that people don't need.

These putative causes of health care dysfunction, derived from an insurance industry organized public relations effort, have become the accepted wisdom.  Note that there were vestiges of them ("rapidly aging population") among the somewhat disorganized presentation of causes of health care dysfunction in the NAM report.  That there were not more of them may reflect the fact that the NAM report was not written just by people tied to the insurance industry.  It also included many people tied to biotechnology, drug, device, etc companies.  


Now during an era in which "fake news," propaganda and disinformation are in the headlines, we still see the terms of debate seemingly engineered by powerful health care organizations.

Physicians, other health care professionals, journalists, policy makers and the public at large should be extremely skeptical of apparently authoritative pronouncements on health care reform, especially when it is not clear what financial interests the authors of the pronouncements have, or when it is clear that the authors have important financial ties to large health care organizations, particularly large for-profit health care corporations.

At a minimum, media and certainly scholarly articles on health care reform and related policy issues should have at least as rigorous disclosure of conflicts of interests as clinical research articles.  

Real health care reform would start with honest debate in which the contestants at least make clear their underlying financial interests. 


References

1. Poses MD. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link here.
2. Massachusetts Medical Society. Physician satisfaction survey (2001). Link here.
3.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link here.
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