The Remarkable Arthur Kleinman

How did I never hear of this guy? He’s prominent, he’s outstanding, his views mirror my own, he’s written 40 books (which is 39 more than I’ve written), he is professor of medicine (psychiatry) at my medical school alma mater, Harvard Medical School, he has another professorship at another one of my alma maters, Harvard College, in one of my favorite departments, anthropology, where he was funded by another Harvard grad of the anthro department, Michael Crichton, who was a close friend of mine at both undergrad and medical school and with whom I almost wrote an anatomy textbook that actually read like a book (Mike suggested we write it together, but I was hesitant), and while I started in Boston and wound up in the Bay Area at UCSF and Cal and sold my practice eventually to Stanford, he started at Stanford for undergrad and med school and ended up back at Harvard. Two ships in the night, one prominent (him), one obscure (me). And we’re exactly the same age.

There has to be a reason I wasn’t aware of him. It could be competitive – I’m a competitive person, and if someone is like me in some way, while I can find some consonance and celebrate it, I’m just as likely to find myself opposed, avoiding the obvious point that he or she has succeeded better than I have, or is more recognized, and that I’m envious, even if I’ve got plenty to be proud of. I’m competitive. So maybe that’s it. Actually, I think I heard of him and just didn’t pay attention.

Which appears to be my loss, for this is a remarkable guy, Arthur Kleinman. Originally from New York – so a New York Jew, while I’m originally a Philadelphia Jew – as soon as he arrived at Stanford he appears to have picked up a remarkable California wife – as did I around Cal. I heard him on this podcast last month -- https://radioopensource.org/the-soul-of-care/. Then, inspired by his deep feelings, remarkable journey, and spiritual insight, I read the book he was talking about, his latest, The Soul of Care: The Moral Education of a Husband and a Doctor: https://www.amazon.com/Soul-Care-Education-Husband-Doctor/dp/0525559329/ref=tmm_hrd_swatch_0?_encoding=UTF8&qid=1585083881&sr=1-1.

Here’s what happened. While he and his wife Joan were in the midst of their remarkable careers – and I mean remarkable, this guy routinely juggled 3 or 4 very difficult career balls at once, it’s just amazing to hear, and she was an expert in Chinese studies – right in the midst of it, at age 59, Joan developed early onset Alzheimer’s Disease. This was not a bump in the road, this was falling into a crevasse. Early onset Alzheimer’s is not only earlier than later onset Alzheimer’s, it’s more severe. In her case the amyloid encroachment of her brain started in the occiput, where the center of sight is, and she became blind, and then progressed to become demented over a ten year period, when she mercifully died with her family, and loyal caretaker whom she had first rejected but then had come to love and depend on, around her. 

What Arthur discovered (I call him by his first name because, after I heard the podcast I emailed him, and he emailed back, so we are in contact, and when you’re on line, it’s generally first names, an interesting development in social relations that has been little commented upon, but I am aware of it and I bet Arthur is, too, since we are both anthropologically and sociologically aware), was that everything that he had preached – that the medical care system was overly focused on the science of care, too often to the exclusion of the process of actual caring for the patient, which is actually performed by family and friends and community and social agencies and housing agencies – was now settling in on him.

The devastation of the love of his life, his confrontation with his dependency upon her psychologically and logistically, and the tasks that he must now face, crowded in on him, after he and Joan together faced the now obvious and forbidding path forward – we all know that we will die sometime, no matter how strong our psychological defense of denial, but we are shocked when we find that we know how and approximately when. She asked him not to let her “linger,” and he assented, even though he knew he wouldn’t be able to administer the coup de grâce she was asking for. Arthur doesn’t mention survivor’s guilt, but I bet it was there. Later on, as he struggled with care, he does own up to sometimes feeling put upon, and then feeling guilty for that feeling. But that was only at the edges. He doesn’t mention directly that her affliction actually brought them closer – at least I don’t think he mentions this, he might – now that dependency was acute and he fulfilled all she ever could have wished for in a loving husband. After all, as soon as the diagnosis came, he knew what he had to do. He would have to care for her, personally, to the best of his ability, and he is an exceptionally able man. It was this automatic, inescapable decision that has given the ultimate meaning to his life. Was it the Greeks who would say, when asked if someone has led a meaningful life, we’ll have to wait and see? I think we see with Arthur.

Both Arthur and I are well aware of the frustrations inherent in our medical care system. And so, predictably, the formal medical channels failed him. They failed from the start when, despite the august grandeur of Harvard, they couldn’t make a prompt diagnosis when visual problems were the presenting sign. He was referred here and there, but it took his going to someone he knew to be a superb diagnostician, a move only an insider could make, for the diagnosis to be made. Everyone else dropped the ball, and didn’t seem to care all that much as they did. Some asshole had the temerity to call her a “fascinoma,” repulsive jargon I first heard as a student at HMS, that typifies viewing the patient as “a case” for intellectual “enjoyment,” rather than a person in even more distress than if the diagnosis were actually known. 

Then the doctors failed to care for her and about her – what about that, you jerks? When the diagnosis is made, is it off your plate, not your department? Everything Arthur had preached about, had inveighed against, presented itself to him with his most beloved. (One thing I did miss in the book is her shortcomings, how she disappointed – no one is perfect – but I forgive him for that.) He had to reach out on his own, find support and direction where he could, rely on his two kids and some friends who came close while others moved away.

 

What he found out about himself was that, amazingly to himself perhaps, he was totally capable of caring, of doing those things he had seen families do, of doing the things he had urged his students to understand, as he had understood from visits to patients’ homes (a rarity now – my neurosurgeon father had told me that when doctor and patients ceased to share a cup of coffee at the family kitchen table, something irreplaceable was missed), of doing the things he had seen in China, where Joan was an expert and where he became an expert in cross cultural medical anthropology. He found that his Chinese friends knew how to help him. Yes, he could care. 

And then he thought – I let her do all these things for me, keeping the house and the family going while I pursued my career, and I didn’t notice? Well, I noticed, but I didn’t really give it the credit it deserved? And then, he thought – I missed a lot of life when I delegated it all to her. He might have thought that she actually could have insisted that he do some of those things and taught him how better to relate to people, and he would have benefited from it, but I agree, that would have been churlish. She was a wonderful wife, and their summation as a couple was what was important.

I’m reminded of the scene in Ram Dass’s Be Here Now when his mother dies and he finds himself with his father in the kitchen, performing some routine household task like cutting or peeling, and finding consolation in doing it. Consolation in doing the everyday things that care for others and oneself. Not to be underestimated.

I sent him this link to my recent essay on what an outrage it is that doctors are not taught well how to convey bad news, and how to care: http://buddshenkin.blogspot.com/2019/06/death-and-other-bad-news.html. I recommended that medical students go on rounds with desperately ill patients as soon as they start their first-year training, and learn that what they are there for is to care, that the science of medicine is a means, not the end. Arthur responded that yes, we saw things the same way, and that I didn’t need to read his book, but he still hoped that I would, and tell him what I thought.

What I think is this: the book is a winner. And so is he.

Budd Shenkin

On The Bloomberg Candidacy

I started out being for Amy. Then I switched to Elizabeth Warren. Then I did a full 180° away from her, favored Amy again and Mike Bloomberg (tentatively), and that's where I stand today. I doubt that my course is aberrant; many people are searching.

But as I'm searching, hoping for the magic bullet that will displace the affliction named Trump and install a high-quality new President, as I listen to what other people think, I worry that Bloomberg's entry into the race is too much of a deus ex machina solution, and maybe I'm overlooking the effect of a billionaire parachuting in. Is it unfair, and is it destructive, just in the way it is being done? Forget his policies for the moment, just look at the method.

That's what I did, and here's what I came up with.

Money and politics have never been strangers to each other – “money is the mother's milk of politics” – and the Michael Bloomberg candidacy has illuminated the connection anew. Rich people have run before, big money has been behind many candidates for a very long time, there have been “kingmakers” with access to money, and even George Washington is reported to have been one of the richest men in the country. But the Bloomberg candidacy is unique. His money is not hidden but in full view, and his bankroll is so immense that he can finance not only his own campaign but the campaigns of many others with no help from others. One man, one bankroll.

I want to examine the criticisms of Bloomberg's campaign, but first, let me briefly mention what some of his proponents say about this kind of campaign. Trump actually made a mendacious defense of his own campaign that could fairly be applied to Bloomberg's – funding ones own campaign avoids entanglements with other funders who will often expect favors in return, if only for access. A second defense is that a very large campaign chest will be necessary to meet Trump's huge cash advantage. Third, proponents rightly declare that Bloomberg's candidacy is not a vanity project, that he is a known political actor who has used his wealth in the past for many worthy causes: gun control, coal factory abatement, public health and hospitals, and many others. Fourth, many welcome his entry to the field as an anyone-but-Trump effort by someone who can arguably win. And finally, many welcome him simply for his qualifications – no candidate rivals him for his combination of private and governmental executive experience, reminding us that New York City has a larger population than 38 of the states.

But those points having been made, others are not so sanguine. Besides criticism on the issues, which I will not take up here, the very fact of a billionaire self-funded candidacy seems to have two basic critiques. One centers simply on his being a member of the billionaire class, who are not to be trusted. The other centers on how the process of running for office is unfairly easier for a billionaire than for someone with more ordinary means. Each observation deserves scrutiny.

Billionaires Are Suspect

Some say that billionaires are objectionable, obnoxious, selfish, exploitative possessors of ill-gotten gain, and probably a lot more. Some say a billionaire will inevitably protect their own interests and the interests of other billionaires, will lower taxes on themselves, maintain their deductions, protect the banks and instruments of capitalistic concentration. Some say they have no feeling for the situation of ordinary people, especially those of color, and will therefore inevitably shortchange them.

I don't know any billionaires personally, but I have no doubt that many billionaires would fit these descriptions. (I love one scientific study that posted observers at a difficult intersection and found that the more expensive cars were more likely than the less expensive cars to disobey the law.) We know that the wealthy and large corporations have lobbied their way to unfair governmental favoritism. To put it the issue more generously, we know that every person has perceptual limitations, and that each person is especially cognizant of conditions of their own background, which is why Sonia Sotomayor and before her, Thurgood Marshall, have been so very valuable on the Supreme Court. Billionaires would be no exception to this rule of thumb.

But while we can be suspicious of how a billionaire might act, we also know how unfair it is to assign attributes of any group to a member of that group – be it gender group, sexual orientation group, religious group, national group, income group, professional group, regional group, political group, racial group. Makimg this assumption is, in fact, the very definition of prejudice. Calling Bloomberg “just another billionaire” is a lazy attribution. For one thing, just look at how different are the billionaires who have been running this last year – Howard Schultz, Tom Steyer, Bloomberg, and (possibly) Trump.

Maybe the most inspirational way to make this point is to cite example of President Franklin Roosevelt. No one could have a more patrician background than FDR, yet no one could have been a better friend to the poor and the working and middle classes than he was. Perhaps triggered by his being afflicted by polio and making friends with the poor white people near Warm Springs, Georgia, whom he befriended when he established his therapeutic community there, certainly reinforced by his equally patrician wife Eleanor, FDR's mission as President was to be a protector of the common person, so much so that he was called “a traitor to his class.”

Would Bloomberg qualify as a neo-FDR? Probably not; who would? But the point is, it's possible, and dismissing Bloomberg as simply “another billionaire” is foolish.

Self-funders Have An Unfair Advantage In Running

It is undoubtedly true that billionaires who self-fund face markedly fewer obstacles to their candidacies in comparison to the usual candidate. The American system of financing political campaigns is in itself unfair and inefficient. Fundraising diverts the time of candidates and congresspeople away from their actual work in policy and politics. The built-in conflicts are obvious, not only for those who take the traditional route of cultivating wealthy donors, but even for those taking only small donations. The poor cannot contribute, and a decision to take only small donations contributes to social conflict – witness the fury against the rich manifested by Sanders and Warren, both of whom refuse large contributions and eschew super-PACs.

(In fact, if you think about it, it's amazing that so much about a campaign is focused on money. How to raise it, who is raising it, who gains favor by it, how people vote with their pocketbooks as to who gets to be on the debate stage, that it is to some extent a microcosm of how much our whole society concentrates on money. It's really quite an indictment of our society, from an anthropological point of view.)

Clearly, a self-funded campaign avoids the pitfalls of raising money that others face. I can well understand the fury of those candidates who have had to scrape and beg for money and been hamstrung by its lack, and who now face the disadvantage of not being able to match, despite their efforts, the huge Bloomberg resources for advertising and campaigning.

Nonetheless, can one really say that he is “buying the nomination?” I think not. If so, Schultz and Steyer would be more relevant. Yes, you can buy access and attention, but the voters still have to like what is presented to them, and the media will give free rein to those who would criticize.

Moreover, if one could buy the nomination, why didn't Bloomberg come in early and sweep the field preemptively? He did quite the opposite, waiting until is was almost too late. When his early analysis led him to conclude that he was an unlikely winner – despite his resources – he let the game play out without him. It was only when Biden showed weakness and Sanders showed strength that Bloomberg concluded that he was needed, and that he had a chance.

Moreover, it's not only billionaires who have enhanced access to running. What about movie actors? Their fame provides access, which can be viewed as unfair – what does fame have to do with governing? But they have not been able to sweep into office any more than Bloomberg can, although if they perform well they can be elected. Generals have also had access to nominations that others don't enjoy, and some have measured up while others haven't. Bloomberg is not just some random billionaire who thought to himself, hey, it would be nice to be President. He is arguably one of the best prepared people in our history to take on the job.

Conclusion and Suggestion

So, in sum, I think it's hard to say that Bloomberg has no business using his money to leverage himself into the race. He will still have to sell himself to the people, and it might be an uphill battle. In the end, he will have to prove himself acceptable as a prospective President, and as someone who would have the total capacity to beat Donald Trump. If he can prove himself worthy, we shouldn't deny him the nomination just because he is a billionaire. We shouldn't cut off our nose to spite our face.

Finally, presumptuously, let me offer a couple of suggestions.

I have always been taken by the brave way JFK chose to address the Catholic issue in 1960, when he gave his famous Houston speech to the Protestant ministers, asserting that a Catholic could be a good President, and how he received a standing ovation. I don't think Bloomberg has Kennedy's oratorical gift, but it might make sense for him to give a speech “Why I Am Not A Bad Billionaire.” He could take on the issues directly – Will I try to protect my billions and those of my rich friends? Why are my taxes better than Warren's wealth tax? What objectives of Bernie and Elizabeth and the other candidates do I share? (I would go for anti-trust and universal health care with lower copays and deductibles)?

Then I would take Amy Klobuchar's example of FDR's poor mourner, “I didn't know him, but he knew me.” I would praise Amy for citing that. I would say, we should all aspire to that. Then I'd say, none of us can be everything, so we all need to work together to give the country leadership. I see huge strengths in this party and in the other candidates. My hope would be to assemble us all as a team, to overcome the depredations of the last four years, to return to lawfulness, to return to decency, to return to humanity, to correct the course of this country, to raise the level of our prosperity for everyone, to become an ever fairer country, to be good global citizens, and to establish an order of dealing with the environment in a way that will last beyond our years.

I have no idea what kind of a President Bloomberg would make, or if any of the suggestions I make here will turn out to make sense for him. I'm hopeful. I'd love to see a good President come in. And it's vital, of course, to beat Trump and to foil his ongoing coup.

But we shall see.

Budd Shenkin

Adding Insult To Injury - Discoordinated Care In Large Medical Centers

How Hospitals Abuse The Fathers Of Physician-Daughters

Discoordinated inpatient care for acute conditions is a chronic disease in Academic Medical Centers, and other large medical centers as well. No one is in charge! No one person takes responsibility! Too many of the “team members” - what a misnomer that is! – partake of “it's off my plate” disresponsibility. I'm using the prefix “dis” rather then “un” because it seems to me there is a sense of active neglect, not just passive. J'accuse!

With any task, two basic factors affect your performance – incentive and ability. Is there something that makes you want to do it? It can be internal ideals – I want to be a good doctor, I want to help these patients. Or it can be external influences – it makes me money, or it helps my prestige.

The second factor is ability. Do you have to tools to bring to the task? Has the necessary procedure been invented, and all you have to do is apply it? Or, if the procedure isn't at hand, can you invent it? Are you smart enough to apply the tools, or invent them?

So, why is it that we hear so repeatedly about the discoordinated care, the poor quality care for an individual patient so often? I've blogged about this before, referring to a Health Affairs article where a doctor-daughter was unable to intercede in her father's acute cardiac care at a big medical center to forestall obviously poor actions by the doctors and nurses. http://buddshenkin.blogspot.com/2018/10/the-hazards-of-hospital-care.html. 

Now comes a similar article in the current New England Journal of Medicine – https://www.nejm.org/doi/full/10.1056/NEJMp1910499.

Here, a geriatrician-daughter finds her 72 year old father grievously mistreated after a high intensity cardiac event that brings him to an academic medical center, where team after team prescribes drugs discoordinating with the other teams, and where her father becomes severely delirious. Ironically, it is the daughter herself who in the past invented exactly the procedures to use in an inpatient setting to prevent delirium – the large medical center has not implemented these procedures, and or course she is unable to intervene in the rigid procedures of the discoordinated team to help her father. Luckily, he recovers and even goes back to his medical practice for a number of years, as did the father of the Health Affairs patient. Both cases have successful outcomes, thanks to advanced medical science, despite the severe errors and thus over-extended medical stays because of complications due to discoordination.

Why does this continue to happen? Why isn't a single person held responsible for each patient? Why isn't this obvious, repetitive problem solved? Why are not proved administrative procedures instituted universally?

Is there sufficient incentive? I guess there isn't. No doubt there are many doctors and others within the system who see the problem and wish it could be solved, but most don't understand the problems and see possible solutions, and those who do are in no position to effect the changes they would like to see.. In large bureaucratic operations, the power at the top is separated by many layers from the problems down below – and indeed, insulated from the human relations that impel any decent human being to want to solve the problem. Are they blissful in their ignorance? Maybe. Administrators are a different lot from doctors, and even doctors who become administrators can be sucked into the administrative maelstrom of ignorance and focus on goals other than patient care. If you have been a doctor, you know what problems beset the ill, you know what procedures militate against good integrative quality. If you are an administrator, you lack that experience. The best ball teams have former players at the top, some of whom are brilliant and can build great teams based on their knowledge and ability. Where are the Jerry Wests of medicine?

So, those in power might not have the knowledge necessary to detect the problem, and those with the knowledge might not have the power. So, the power of ideals is blunted by bureaucratic structure. What about external incentives, like money and prestige? Would they accrue from overcoming the iron structure of poor bureaucratic medicine? Would quality measures detect the better care afforded by coordinated care? Probably not; maybe a little. Certainly not enough so as to be palpable proof that “we are a superior medical center!” Local areas tend to be monopolistic, so in the end there are no local comparisons, and even nationally, they are hard to detect and not well publicized. Yes, there are awards and there are groups of hospitals that sign up for progressive high-quality agendas, but it takes a lot of effort to do this, and it's not clear that one receives any competitive advantage for aspiring to these higher ideals. If you are a high ideals leader of a medical center, you can do it, you can lead a medical center to high quality, just don't expect anything other than internal satisfaction and team celebration from having done it. Once again, as we are seeing in national politics, “high character” is essential.

But say the incentives are in place -- are there tools available? In a word, yes. Here in the NEJM article the anti-delirium protocols are poignantly present in the very person of the patient's daughter. I don't know the field well enough – I was an outpatient doctor – to know all the coordination tools available for high intensity inpatient care, but I'm sure they are there. They could be picked up and used, if there were a structure amenable to their use.

But in the end, of course, money rules. The medical centers are doing just fine, making lots of money, protected by their deep roots in the campaign financing lobbying system that we currently enjoy. If there were big bucks available for coordinating care, the resources of medical centers would be employed to drill those wells. ACO's might possibly supply some incentive, but it's minor in extent, and the fight over who gains what part of the extra bucks can be exhausting and disincentivizing – it's just not worth it, much of the time.

To coin a phrase, if we are to improve medical care, we need “deep structural change.” Until we have that, we will continue to read rueful articles where parents of doctors are enfolded in the arms of large systems of care where poor care is administered and the doctor-daughters find themselves unable to affect the machine they see abusing their parents and they issue a cri du coeur and the medical journal regretfully publishes it and we read of the horror and say to ourselves, maybe we'll go quickly, and we won't have to endure the insult medical centers add to injury.

Budd Shenkin

On Pete Buttigieg

Pete Buttigieg is, basically, a great example of chutzpah, trying to vault ahead of the pack with one great step. He must figure, nothing ventured, nothing gained. But accommodating to his audacity of hope by nominating him would be a vast mistake.

Let me explain.

Pete Buttigieg is an eloquent, fast-thinking, intelligent and stately young man. Some have said that he's an old person's idea of a young man, but let's just say he seems to have a wonderful temperament. He is well educated, Harvard and Oxford, has management advisory experience from working at corporate consultant firm McKinsey, has military experience at a low level in a combat venue, and has been a mayor without spectacular achievement and with some notable weaknesses, of a small city. Nice resumé for a promising young man.

But is it enough? My analogy: “I just met a really nice guy! He really seems to understand surgery, from what he says. I was so impressed! He has worked in many different settings, progressing from an aide to a medic to a physician's assistant. He is critical of many of the surgeons he has seen work. I'm thinking of asking him to do my hip replacement.”

Picture this instead: his name is placed before a corporate board. He is interviewed and his work history is reviewed. Discussion ensues; everyone has been impressed. His chief advocate to the board says, “This guy is so terrific, I think he should be our CEO!” The board members look at each other; one smiles, another smiles, and the board then erupts in laughter, understanding that it must be a joke. The laughter dies down, no one knows what to say, and then they turn expectantly to the most respected senior member of the board. She says, “Yes, you're right, he's a wonderful find for us, and the mark of a superior organization is to be able to identify quality, attract quality, nurture quality, promote quality, and utilize quality. Let's not miss our chance with this wonderful candidate. Let's jump over a couple initial steps. What division could we offer him to be the head of? Let's make sure he's on track! Let's see if he can fulfill his promise.”

He'd make a wonderful cabinet officer, wouldn't he?

Budd Shenkin

A Matter Of Sexual Taste

Colombian-American actress, model, and business-woman Sophia Vergara (https://en.wikipedia.org/wiki/Sof%C3%ADa_Vergara) has trouble ridding herself of her Spanish accent, even after years in an English-speaking environment. A mean-spirited woman observed that she speaks English as though she had a penis in her mouth.

Vergara had an amazing retort: What's wrong with having a penis in your mouth?

We think of blowjobs as something shameful. Vergara makes the point eloquently – sexual practices are not a question of morality. It's better to think of them as a matter of taste.

Budd Shenkin

A Friend's Reaction To Dershowitz's Performance

Thought this email sent by a friend to Alan Dershowitz after his impeachment performance was worth noting:

Subject: You are a fucking cunt

Aloha Professor Dershowitz,

I won’t waste your time I want you to know that I think that you are a fucking CUNT.

The arguments you made today are treasonous and I hope that a righteous America governed by our children with remember you as a charlatan. You, sir, are the definition of a self-righteous academic narcissist. Your belief in your intelligence has guided you to take such asinine positions as the one you have now made your own.

TL:DR; Fuck you, have a stroke, get hit by a car, we lost Kobe but kept YOUR shit ass??????

Sent from my iPhone

Budd Shenkin

Conservative Groups Fight Back To Preserve Surprise Billing

There is no stronger incentive than the profit motive.  Public good vs. private gain?  Capitalists will go for the latter over the former every time. 

What is the answer?  It could be regulation, but only if the government were stronger than it is.  It's really hard to think that anything positive is possible without election financing reform.

Here are the details of how reform of surprise billing is looking worse and worse.  The alternative to the Pallone-Alexander-Walden-Murray solution mentioned here, sponsored by conservative forces, which would force a bill by bill review of disputed charges, rather than a systemic revision of the system of billing out of network, is clearly unworkable, as I detailed earlier -- http://buddshenkin.blogspot.com/2019/03/regulating-to-fix-surprise-billing-and.html.

Here are the details: https://thehill.com/policy/healthcare/478818-conservative-groups-aim-to-sink-bipartisan-fix-to-surprise-medical-bills.

And to save you the trouble of clicking the link, here is the text of their account: (by the way, note involvement of Democrat Richie Neal, Chairman of Ways and Means, who has gone so easy on the Trump Administration.  (https://prospect.org/power/democrats-richie-neal-problem/)

Conservative groups are gearing up for battle with GOP leaders over bipartisan health care legislation that lawmakers view as one of the few election-year bills that has a shot at making it to President Trump’s desk.

A broad swath of free-market conservative groups is mobilizing to oppose a measure that would ban the so-called “surprise” medical bills patients sometimes receive from hospitals and providers when their services aren’t covered by insurance.

The strategy, in part, is to link the bipartisan proposal to “Medicare for All,” the single-payer health care plan backed by some progressive presidential candidates like Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.).

“There’s not much legislation out there that will make it to the president’s desk this year and this has a chance,” said Brandon Arnold, president of the National Taxpayers Union (NTU), which has spent more than $1 million attacking the bill.

Arnold warned that proponents of the measure are “going to run into broad opposition from a wide array of conservative groups who are united on this.”

“We plan to have an impact,” he added.

Patients are subject to surprise bills when they go to a hospital or emergency room that is in-network but treated by an out-of-network doctor.

A bipartisan deal reached last year by the leaders of the House Energy and Commerce and the Senate Health, Education, Labor and Pensions (HELP) committees would essentially ban providers from sending surprise bills and instead require insurers to pay them. The cost would be based on the average price for the services provided, a method called “benchmarking.”

But groups like NTU and Heritage Action argue the legislation is on par with “price controls” or “rate-setting” that would give the government too much power in the private sector and pave the way for Medicare for All, even though Republican backers of the bill proposal fiercely oppose Medicare for All.

“I’ve heard all the terminology,” said Rep. Greg Walden (Ore.), the top Republican on the Energy and Commerce Committee, in response to the “rate-setting” criticisms.

“It’s not. That’s an easy moniker to throw at it,” he said. “At the end of the day, we didn’t ask for this problem, but we’re going to solve it. We just see it as good policy.”

About a dozen right-leaning groups have come out against the bill, including some of the most well-known fiscally conservative organizations in Washington, like Club for Growth and FreedomWorks. The groups join a high-dollar fight launched last year by hospitals, insurance companies, doctors and private equity groups that are all trying to tilt the measure in their favor. 

After facing angry lawmakers and headlines about patients getting saddled with expensive bills, insurers and providers now agree patients shouldn’t be receiving them. But the two sides have engaged in an all-out war over who should take the biggest hit if changes are made.

Insurers favor the proposal offered by Walden, Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.), Senate HELP Committee Chairman Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.), the ranking member on the HELP panel. The lawmakers had planned to include their bipartisan measure in the 2019 year-end government funding package, but it was left out amid opposition from hospitals and providers and after a rival proposal was offered by the House Ways and Means Committee.

Lawmakers are now pushing to include the legislation in a May spending package, setting the stage for a new round of fights with conservative groups.

Alexander and Walden are retiring at the end of this term, putting extra pressure on them to get the legislation passed.

“I get it. You serve for a long time and think you’re doing what you should for your constituents, and I respect that. But we disagree with this legislation,” said David Williams, president of the Taxpayers Protection Alliance, which opposes the bill. “But it’s not the right thing for the health care industry. I won’t begrudge the effort, but I’ll disagree and make sure it won’t get passed.”

The concerted effort of influential conservative groups has irritated GOP lawmakers who had already been hearing from constituents about separate ads airing in their districts sponsored by private equity groups.

Envision and TeamHealth - staffing firms backed by Blackstone Group Inc. and KKR & Co. - spent a combined $54 million on ads last year targeting the proposal.

NTU piled on, spending more than $1.2 million since early December on radio and television ads across the country, including in states and districts represented by lawmakers who are working on the legislation.

Last month, NTU spent $38,000 on 165 radio spots that aired in Nashville, Tenn.
“The only people who don’t want to protect innocent patients from unaffordable surprise medical bills are the people profiting from this anti-competitive flaw in our health care system,” said a GOP official for the Senate HELP Committee.

“Chairman Alexander will continue to keep his bipartisan, bicameral agreement to end the practice of surprise billing at the top of Congress’ to-do list until it is done,” the official said, noting that the measure has President Trump’s backing.

NTU also spent more than $261,000 on ads in the Houston market, which is in part represented by Rep. Kevin Brady (Texas), the top Republican on the Ways and Means Committee.

That spending included $112,000 for an ad that ran Jan. 12 on local TV station KHOU during a Houston Texans playoff game.

In December, Brady and Rep. Richard Neal (D-Mass.), the chairman of the Ways and Means Committee, released a competing approach to ending surprise billing favored by doctors and hospitals. Their measure would still ban providers from sending surprise bills to patients, but it would let a neutral, outside party determine how much the insurer will pay the doctor if an agreement can’t be reached privately.

The proposal is cautiously backed by some of the conservative groups opposing the Pallone-Alexander-Walden-Murray measure, though they are reluctant to offer their full-throated support until the legislative language is introduced.

“The early outline provided by Ways and Means is a step in the right direction and we look forward to working with them more closely,” said Heritage Action Executive Director Tim Chapman in a statement.

Regarding the other measure, Chapman said, “We view this as a direct step towards Medicare for All and government-controlled healthcare.”

The introduction of the Ways and Means proposal complicates matters since the committee also has jurisdiction over health care.

Pallone and Neal are to meet soon to discuss their plans and find a path forward, Neal said this past week. Walden and Brady’s teams are also talking.

“I actually think we are closer together than people realize,” Walden said. “Our teams are talking. Frank [Pallone] and I remain joined at the shoulder, the hip and probably the ankle too on this matter because consumers are getting ripped off and it’s time to move.”

Budd Shenkin