Let Them Eat Cake

As the story goes, at the time of the French Queen, Marie Antoinette, French people were picketing outside Marie’s palace, so she asked. “Why, are they there?” The answer was, “They have no bread.”  The French king and queen were very much out of touch with reality.

    While nobody knows for certain whether Marie Antoinette actually spoke these words, they convey a complete disconnect between the very real problem and any possible solution. Today we have a similar disconnect between the problems in the U.S. healthcare system and proposed solutions.

Illustration by Trygve Olson

     The solutions coming from big pharma, insurance companies, government, and corporate medicine’s CEO’s have nothing to do with the problems patients have in accessing healthcare and the problems doctors have with providing the patients needed healthcare. The working environment is hostile for both patients and physicians. It is no wonder that both groups are voting with their feet. Patients are disillusioned, disenfranchised, and dismissed. Doctors are retiring or just plan leaving healthcare, at least in the traditional sense.

     Today U.S. patients and doctors are in a predicament very similar to the French people outside Marie Antoinette’s palace. Patients and doctors receive very little of value from the current dysfunctional healthcare system, and therefore they have little to lose. They have no bread—meaningful healthcare. The cake provided by corporate medicine doesn’t provide the care patients need. That’s why the patients and doctors continue to vote with their feet.

     As a nation, we spend much more money on healthcare than any other industrialized country. Yet in many cases we have the worst results. For example, our maternal mortality rate is between 25 and 70 deaths per 100,000 births. The Scandinavian countries have a rate of 2 or 3 deaths per 100,000. Our maternal death rate places us 33rd out of 36 wealthy countries. This makes our maternal death rate equivalent to that of Iran.

     Native Americans and native Alaskan maternal deaths are even higher. Their rate runs about 42 maternal deaths per 100,000 births. People of color have about 70 maternal deaths per 100,000 births. To make matters worse, these rates are increasing and so are the disparities in patient access to healthcare. There’s a lot of handwaving by professional groups claiming to be concerned about the U.S. maternal mortality rate, but none of these experts comprehend the real cause. These groups studying the high U.S. maternal mortality rate have suggested our recorded maternal mortality death rate is higher than other countries because the U.S. records maternal deaths better than other countries.  Another excuse is that the information collected on the U.S. death certificates is inconsistent and misleading. In other words, these groups trying to address why the U.S. mortality rate is so high are simply trying to manipulate the data to make the numbers look better. They are not looking at the real problems—lack of access to prenatal care and deliveries by “teams” with no one person in charge from start to finish, from the first prenatal visit to one year postpartum.

     Then there are the systems problems in the U.S. healthcare system: blaming the patient for the problem, dismissing patient complaints, delayed appointments, and electronic medical records (EMRs).

     Increasingly, patients are blamed (gaslighting) for whatever their complaints are. Many patients report that they are told they are too old, too fat, take illegal drugs, or there’s really nothing wrong with them.

     The pregnant mother who presents to labor and delivery concerned about too little fetal movement on three different occasions is sent home after the nurses tell the woman that she is just imagining things because, after all, she doesn’t really know how to check for reduced fetal movement. A week later the woman presents to labor and delivery with a dead baby in her uterus and is told she should have come in a week earlier.

     The there are the patients who may need an appointment right away, but the receptionist says they can’t be seen for a month or two. With pregnant women, this is a recipe for disaster.

     And then there is the electronic medical records (EMRs) which many physicians have clearly indicated interfere with patient care. I simply want to add that with looking at causes of maternal mortality, EMRs are an atrocity. The EMR was designed to collect data about patients so payers and corporate entities can find ways to try to cut costs. EMRs have nothing to do with providing patients better healthcare or enabling physicians to provide patients with good care. Medicare uses the data as a basis for decreasing reimbursement for primary care providers. This means primary care providers will need to see more patients for shorter periods of time to try to recover the decreases in reimbursement. For every 10-minute visit, the provider will spend 20 minutes entering required information into an EMR where the information is balkanized. Just trying to find the information here and there is like trying to pick up and collect confetti. Paper charts record patient information in a useful form physicians can quickly navigate to find the information they need without having to ignore the patient in the room.

     Every year providers have more responsibility for outcomes they have less and less control over. What most of our let-them-eat-cake problem solvers don’t understand is that our healthcare system has long passed the point where wringing more money out of the fatted calf of medical care will do anything but further deny patients access to healthcare and drive more physicians out of practice.

     We know that money and power motivate corporate decisions. We also know that these entities have no moral responsibility to patients or to doctors to look out for or guard the best interest of patients or doctors.                         Instead of increasing access to healthcare, corporate mergers get bigger and bigger. Several years ago, CVS bought Aetna for around 75 billion dollars. This merger was described by the Department of Justice (DOJ) as a brilliant move. There was nothing brilliant about this merger except the ability of corporate entities to pull off creating a bigger healthcare monopoly with the blessing of the government organization vested with preventing monopolies. The DOJ’s very bad decision has been extremely harmful to the public.

     CVS sold their notion about the merger with Aetna to the DOJ based upon the absolutely incredible argument that CVS would purchase clinics. The DOJ regarded this merger plan to be innovative. Yet federal law makes it impossible for physicians to own hospitals because physicians might charge too much for their patient care.

     Pharmacies lobbied our U.S. legislators to outlaw physician-owned hospitals in 1995. Nor can physicians own controlling interest in pharmacies. The concentration of all this power and money sets a dangerous precedent and is certainly monopolization of healthcare. Now Walgreens just bought a chain of clinics for 30 billion dollars.

     The only solution to the monopolization of healthcare by corporations is for physicians to become independent, cut out reliance upon corporate entities for reimbursement, and practice direct primary care.

     The only real choice remaining for physicians and patients is to vote with their feet. If consumers and providers leaving the system bother hospital chains, big pharma, insurance companies, Medicare and Medicaid, then these entities obviously don’t understand the real problem with U.S. healthcare. No level of our government, state or federal, should side with big money against 332 million individuals who are being denied access to healthcare. “Let them eat cake” will not solve the problem of the high U.S. maternal mortality rate or denial of patient access to healthcare.