Thursday, July 25, 2013

Does professionalism require physicians to help patients sign up for Obamacare coverage?

One of the most  disheartening developments in the unrelenting political fight over the health reform law is the organized effort by its opponents to dissuade the public from signing up for coverage. Having failed in efforts to block Obamacare in the Supreme Court, or to elect a president or Senate that would work for its repeal, they are now working to kill the law by persuading people to not sign up for coverage through the health exchanges, knowing that if not enough younger and healthier people sign up, premium costs will go up because the people who do sign up will be older and sicker.  Then, if premium costs escalate, they figure the whole law will collapse.

This effort to sabotage the law is "unprecedented and contemptible" the conservative-leaning American Enterprise Institute's congressional scholar Norm Ornstein writes in the National Journal:

"It is important to emphasize that this set of moves is simply unprecedented. The clear comparison is the Medicare prescription drug plan. When it passed Congress in 2003, Democrats had many reasons to be furious. The initial partnership between President Bush and Sen. Edward Kennedy had resulted in an admirably bipartisan bill—it passed the Senate with 74 votes. Republicans then pulled a bait and switch, taking out all of the provisions that Kennedy had put in to bring along Senate Democrats, jamming the resulting bill through the House in a three-hour late-night vote marathon that blatantly violated House rules and included something close to outright bribery on the House floor, and then passing the bill through the Senate with just 54 votes—while along the way excluding the duly elected conferees, Tom Daschle (the Democratic leader!) and Jay Rockefeller, from the conference committee deliberations.

The implementation of that bill was a huge challenge, and had many rocky moments...Almost certainly, Democrats could have tarnished one of George W. Bush's signature achievements, causing Republicans major heartburn in the 2004 presidential and congressional elections—and in the process hurting millions of Medicare recipients and their families. Instead, Democrats worked with Republicans, and with Mark McClellan, the Bush administration official in charge of implementation, to smooth out the process and make it work—and it has been a smashing success."

He continues:

"What is going on now to sabotage Obamacare is not treasonous—just sharply beneath any reasonable standards of elected officials with the fiduciary responsibility of governing...When a law is enacted, representatives who opposed it have some choices (which are not mutually exclusive). They can try to repeal it, which is perfectly acceptable—unless it becomes an effort at grandstanding so overdone that it detracts from other basic responsibilities of governing. They can try to amend it to make it work better—not just perfectly acceptable but desirable, if the goal is to improve a cumbersome law to work better for the betterment of the society and its people. They can strive to make sure that the law does the most for the Americans it is intended to serve, including their own constituents, while doing the least damage to the society and the economy. Or they can step aside and leave the burden of implementation to those who supported the law and got it enacted in the first place.

But to do everything possible to undercut and destroy its implementation—which in this case means finding ways to deny coverage to many who lack any health insurance; to keep millions who might be able to get better and cheaper coverage in the dark about their new options; to create disruption for the health providers who are trying to implement the law, including insurers, hospitals, and physicians; to threaten the even greater disruption via a government shutdown or breach of the debt limit in order to blackmail the president into abandoning the law; and to hope to benefit politically from all the resulting turmoil—is simply unacceptable, even contemptible."

Ornstein doesn't address the medical profession's role and responsibility to help their patients sign up for Obamacare coverage, but one has to wonder, will physicians who are against the law also discourage eligible patients from enrolling in it?  Will they tell their younger, healthier and uninsured patients to reject buying coverage from the exchanges and applying for the law's premium subsidies?  Will they discourage the poor and near-poor (in states that have agreed to expand Medicaid) from enrolling in Medicaid?  Or instead of actively discouraging enrollment, will they use a more passive resistance approach of doing nothing to help their patients understand the new coverage options available to them?  Or will they encourage and help their patients sign up, notwithstanding their own partisan leanings and ideological objections to Obamacare?

I would argue that the medical profession's own standards of ethics and professionalism obligate physicians to help their patients understand and take advantage of the health insurance coverage options and subsidies offered by Obamacare.  The Physician's Charter on Professionalism, which was endorsed by ACP and-dozens of other physician membership organizations including AMA, states the following:

"Commitment to improving access to care. Medical professionalism demands that the objective of all health care systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession."

ACP's ethics manual, Sixth Edition, offers the following guidance:

"The physician's first and primary duty is to the patient. Physicians must base their counsel on the interests of the individual patient, regardless of the insurance or medical care delivery setting."

And this:

"They should work toward ensuring access to health care for all persons; act to eliminate discrimination in health care; and help correct deficiencies in the availability, accessibility, and quality of health services, including mental health services, in the community."

The Institute of Medicine has concluded that lack of health insurance causes tens of thousands of people to die prematurely and unnecessarily.  Obamacare will provide access to affordable coverage to people who now can't afford it or can't obtain it because of pre-existing conditions. 

A physician's primary duty to their patient then, in my mind requires that physicians offer help to patients on obtaining coverage through the exchange or (expanded) Medicaid programs.  Accordingly, a physician who discourages patients who would benefit from such coverage would be acting in a way that is in conflict with their professional and ethical obligations as determined by their own professional societies.

To be sure, ethics and professionalism do not preclude physicians from engaging in the political process to change or repeal laws they disagree with, and to elect candidates who share their views. But when patients come to them and ask for help in understanding the coverage options available to them under Obamacare, as they will, physicians should direct them to resources to help them, independent of their personal opposition to the law. Under no circumstances should they discourage patients from obtaining coverage.

Society expects much from physicians, much more than we expect from politicians.   The medical profession rightly demands much of itself.  I hope that even the most militantly anti-Obamacare doctors will recognize that their primary duty to their patients requires that they help them sign up for Obamacare coverage, even if they wish to continue to engage in the political process to get it changed or even repealed. 

Today's questions: Do you agree that professionalism and ethics require that physicians, including those who are opposed to Obamacare, help their patients sign up for coverage?  Do you agree with Ornstein that it is "contemptible" for politicians to discourage the public from signing up for coverage in order to sabotage the law?


Ashok V. Daftary, MD, FACP. said...

I agree that is contemptible to create obstacles to access, but does the carter on professionalism demand that we sell a flawed legislation? Yes, the Meicare drug plan was a bipartisan compromise but so was the Affordable Care Act with the cornhusker compromise.
If the ACP and the author were intent on resolving access they should consider a single payer bill not support a piece of legislation engendered by a compromise with health insurers who opposed its passage till the a plan allowing competition wit them was eliminated

Harrison said...

Please tell me what is flawed about Obamacare as far as the issue of improving access is concerned?

Single payer with universal coverage would of course be the perfect solution to the access issue.
But the fact that a plan is not the perfect solution to a problem is different than being 'flawed.'

Obamacare moves us towards better access.
It does it by taking steps to make coverage possible and affordable.

The individual insurance market was not simply too expensive.
It was impossible.
Even healthy individuals who did not have access to group coverage could not get approved for health insurance, at any price. It wasn't just that the premiums were unaffordable.
It was that they were turned down without an offer of any premium level.
Then they would have to turn to some state funded 'high risk' pool and that would be poor coverage with lots of exclusions for pre-existing conditions, at a high price that was unaffordable.

So now we have exchanges.
There is a market for people who were shut out.

And the alternative to paying $300 per month for HMO coverage, which is what they will likely get in California, is the risk of having to go to an ER some day for a cold, and get charged $600.
And never get screenings.
They will get internet advice from Dr. Oz and waste lots of money on his ridiculous supplements.

By the way, why is it that the national TV experts on primary care are all telegenic superspecialists who stopped learning and practicing primary care at the end of their third years of medical school.
And now they think that primary care physicians are committing malpractice if we aren't routinely telling our patients that they need to take their Fish Oil and CoQ10 every day.


Now I'm really annoyed.
I think I'll stop.


Ashok V. Daftary, MD, FACP. said...

Since this blog has been so strident in its support of the ACA it ought to reference the attitudes of the legislators who made it a reality. Their staffers now attempt exemptions from its controls. What's sauce for the geese should be sauce for the ganders who created their problems