Moral Crisis for US Physicians

June 22, 2023

A Moral Crisis of America’s Doctors
The New York Times
June 15, 2023
By Eyal Press

The corporatization of health care has changed the practice of medicine, causing many physicians to feel alienated from their work.

In July, 2018, psychiatrist Wendy Dean published an article with Simon G. Talbot, a plastic and reconstructive surgeon, that argued that many physicians were suffering from a condition known as moral injury. Doctors on the front line of America’s profit-driven health care system were susceptible to such wounds as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”

Throughout the medical system, the insistence on revenue and profits has accelerated. This can be seen in the shuttering of pediatric units at many hospitals and regional medical centers, in part because treating children is less lucrative than treating adults. It can be seen in emergency rooms that were understaffed because of budgetary constraints. And it can be seen in the push by multibillion-dollar companies like CVS and Walmart to buy or invest in primary-care practices, a rapidly consolidating field attractive to investors because many of the patients who seek such care are enrolled in the Medicare Advantage program, which pays out $400 billion to insurers annually. Over the past decade, meanwhile, private-equity investment in the health care industry has surged, a wave of acquisitions that has swept up physician practices, hospitals, outpatient clinics, home health agencies. The staffing in 30 percent of all emergency rooms is now overseen by private-equity-owned firms.

As the focus on revenue and the adoption of business metrics has grown more pervasive, young people embarking on careers in medicine are beginning to wonder if they are the beneficiaries of capitalism or just another exploited class. In 2021, the average medical student graduated with more than $200,000 in debt. In the past, one privilege conferred on physicians who made these sacrifices was the freedom to control their working conditions in independent practices. But today, 70 percent of doctors work as salaried employees of large hospital systems or corporate entities, taking orders from administrators and executives who do not always share their values or priorities.

Young doctors are noticing how the emphasis on the bottom line routinely puts them in moral binds, and they in particular are contemplating how to resist. “I think a lot of doctors are feeling like something is troubling them, something deep in their core that they committed themselves to,” Dean says. “Not only are clinicians feeling betrayed by their leadership, but when they allow these barriers to get in the way, they are a part of the betrayal. They’re the instruments of betrayal.”

Comment by: Don McCanne

Well, this is depressing. Read the full article if you’re in the mood to be in a funk. But does it really have to be this way? Do we have to put up with a health care financing system that is causing moral injury? I think that the clear answer is “no,” and I have proof.

My twin and I joined our father and brother in practice in 1966, a few months before Medicare was initiated. Just imagine what took place for our patients over 65. Suddenly essentially all financial barriers to care were removed for that patient population. We could get them all of the care that they needed. It didn’t take me long to figure out that we should expand Medicare to cover everyone, and I’ve been advocating for it ever since.

In the meantime, corporatization, such as with the Medicare Advantage plans and ACO REACH, has played havoc with the program, and CMS is continuing in that vein such as with the forthcoming 10 year “Making Primary Care” experimental program. But that does not mean that we cannot reverse these nefarious aberrations and reestablish Medicare as a traditional health care financing program like it was before, even better than other private and public insurance plans were before greed became the primary driving force.

Obviously we need reform. Absent politics, the easiest step to correct almost all of our deficiencies would be the enactment and implementation of a single payer financing system. It will be difficult to design the system to reduce the impact of corporatization so that the funds go to patient care rather than private investors. But it sure would be nice to have a health care financing system like it was for our senior patients in 1967. No longer would our young physicians feel like they are instruments of betrayal.