San Diego cardiologist Dr. Eric Adler wasn’t thrilled by President-elect Donald Trump’s appointment of Dr. Tom Price to head the federal agency that pays for services to Medicare and Medicaid patients.
Far from it. Adler was distressed enough that he was among 6,000 physicians across the country — some 63 in San Diego County and more than 1,000 in California — to sign an online letter in protest. It’s titled “The AMA Does Not Speak For Us.”
Specifically, Adler opposes the American Medical Association’s Nov. 29 statement of strong support for Price, an AMA member, orthopedic surgeon and U.S. congressman from Georgia whose conservative policies have positioned him to run the U.S. Department of Health and Human Services in Trump’s cabinet. The influential AMA is the largest group of physicians in the nation.
Dr. Robert Hertzka, a San Diego anesthesiologist active in the AMA, called the petition signers “naive.” In the Trump administration, he said, it’s important to have someone who listens to the AMA’s point of view, and Price, who AMA members know, will do that.
But doctors across the country took the unusual step to sign because they say they fear federal programs that have helped people get health care coverage will disappear, or will have impossible restrictions attached.
“I feel strongly that health care is a right not a privilege,” said Adler, a specialist in congestive heart disease at UCSD’s Thornton Hospital. “And I take care of my patients not constantly thinking about what kind of insurance they have.” Price’s thinking, he said, “is incongruent with that.”
Should he be confirmed, Adler said, Price would make it more difficult and more expensive for people to get covered, and if they are covered, they could face higher costs under high deductible plans.
In particular, Adler is concerned that Price’s track record of advocating for privatization of federal health-care programs would in effect mean fewer dollars for patient care, and more denials from commercial plan administrators. With private health insurance, “a greater percentage of dollars go to overhead, and the only way to make up for that is to limit services to patients,” Adler said. He emphasized that he is not speaking for UCSD.
‘The most dangerous individual’
Dr. Patrick Romano, director of a California-contracted quality and safety research program at UC Davis in Sacramento, said in an email that Price “may be the most dangerous individual ever nominated to lead” the agency since Medicare began in the 1960s.
“He offers a veneer of credibility and prestige, (as an orthopedic surgeon and former Emory University professor), an engaging personal manner according to those who have worked with him and strong relationships with Congressional leaders,” wrote Romano, who also is co-editor of AcademyHealth’s journal Health Services Research.
But, Romano continued, “his underlying agenda is to dismantle the essential programs that he will be responsible for managing.”
His “old school” agenda is focused on “protecting the privileges of doctors rather than the rights and accessibility of patients,” such as allowing doctors to “balance bill” Medicare enrollees, That’s a practice in which patients pay the difference between what Medicare allows for the service and what the doctor charges, beyond the typical 20 percent co-payment.
Romano also is concerned with Price’s positions that would let Medicare and exchange health plans contract with “any willing provider,” and pre-empt “any state laws limiting physician or hospital charges.”
Grassroots clinicians
The online protest is led by the newly formed Clinician Action Network, set up by a trio of physicians at the University of Pennsylvania’s Perelman School of Medicine.
One of them, internist Dr. Jane Zhu, said the group was “galvanized to take action” by Trump’s campaign promise to repeal the Affordable Care Act.
Their concerns grew when Trump named Price, whose policies the protest letter said “threaten to harm our most vulnerable patients and limit their access to healthcare.” They accuse him of wanting to dismantle Medicaid, reduce funds for the Children’s Health Insurance Program, and threaten health benefits like treatment for opioid use disorder, prenatal care and access to contraception.
Specifically, Zhu, and University of Pennsylvania colleagues Dr. Manik Chhabra and Dr. Navin Vij , said in an interview that they were surprised that the AMA board chairman, Dr. Patrice Harris, showered Price with such praise.
“The best case scenario is that none of his policies come to fruition,” Zhu said. She is especially concerned about his support for letting states run their own Medicaid programs (Medi-Cal in California) with federal block grants, which she believes would greatly reduce spending and benefits.
Medicaid covers 73 million adults and children, more than 13 million in California, and nearly 1 million in San Diego County.
Vij added that Price has said the Center for Medicare & Medicaid Innovation, which was formed by the Affordable Care Act to test models of care that reward doctors who provide better outcomes and reduce costs, “has exceeded its authority.”
“We think that (the ACA’s goal) the triple aim (improving quality of care, improving health of populations and reducing per capita costs) has now been put into question,” he said.
Asked for comment about the doctors’ protest, AMA spokesman Robert Mills urged a reporter to make sure the signatures were real and to ask about the group’s status as an organization.
He later sent the reporter a link to a letter from board chairwoman Harris that ran Tuesday in a national column by Dr. Kevin Pho, KevinMD. The AMA touted Price’s experience as a physician, the only doctor to lead the agency since President George H.W. Bush appointed Lewis Sullivan to lead the agency in 1989, and only the third in the agency’s 63-year history.
Price is the ‘best option’
Hertzka, who chaired the AMA’s political action committee, said the online protest against the AMA is unusual, but nothing compared to some past controversies faced by the organization.
Decades ago, the AMA decided to put its logo on some Sunbeam products, like medical cuffs, “that struck a chord with (doctors) who felt that cheapened the organization.” Doctors flooded the AMA and the media with letters, pushing the issue onto page one of most daily newspapers. The AMA rescinded its agreement. Other controversies have divided the association, such as when the AMA endorsed a bill banning some types of abortion in 1997, and in 2009 and 2010, some doctors resigned their membership after the AMA supported versions of what became the ACA.
Hertzka, former president of the California Medical Association and the San Diego County Medical Society, staunchly defends the AMA’s support of Price. He knows the AMA is “not some interest group clamoring for money, but are actually doctors like Tom Price, taking care of patients.”
The protesters should consider what Trump’s philosophies are, with respect to Obamacare, he said. “He (Trump) clearly wants to get rid of it and demolish it. And he’s adamant about (reforming) Medicaid and Medicare. So whoever was going to get nominated was going to believe in those things.
“In the context of Donald Trump, Tom Price is hands down the best option,” he said.
Many California doctors interviewed said they are concerned about Price’s proposal to replace the current system of Medicaid funding to states with block grants.
Dr. Ted Mazer, president-elect of the California Medical Association and a San Diego-based ear, nose and throat physician, did not sign the Clinician Action Network’s letter. But he said in a recent interview that for California, block grants “would be devastating …You have Trump and Price thinking that’s the way to go. And we’re going to have to do a lot of fighting and a lot of pushing back on that, because if you want to see Medi-Cal collapse, it’s block grants.”
California has a lot at risk. One in three people are on Medi-Cal, the state’s version of the Medicaid program for the poor.
Mazer said that in a block grant program, the state would receive an “actuarially based amount of money for the year” instead of the current $1 federal match for every $1 the state spends. “The feds would say, that’s yours. Spend it. But if you go over that, it’s your problem.”
As expenses rise, “the first thing that would happen is they’re going to cut physicians’ payments more. That’s always the first thing on the block.”
And fewer doctors would be willing to take Medi-Cal patients, he said.
In San Diego, Scripps Health physician Dr. Cynthia Kao gave 20 reasons why she signed the letter opposing the AMA’s support of Price. Among her arguments: his “zero rating from Planned Parenthood,” his opposition to marriage equality and transgender rights in schools, his vote against job discrimination based on sexual orientation, and his desire to defund the Children’s Health Insurance Program.
Dr. Neha Bahadur, a child and adolescent psychiatrist in Clairemont, said her biggest concern “is the threat of a repeal of Obamacare, without any semblance of a plan for how to cover those millions of people that will be losing their health insurance.” She signed to protect her patients, who are mostly Medi-Cal enrollees.
