Big Think Interview With Oliver Fein

Question: What are some of the common arguments forwarded by opponents of a single-payer healthcare system?


Fein: Number one, that this is in some ways contrary to American culture that, you know, we are free and independent nation. Secondly that free markets which is what they usually are advocating are the best way to distribute resources within an economy and they argued that that would be best for health care. And thirdly, I think the problem is that they often represent those entities which indeed get the benefit from having our present system. Namely they are insurance companies, private health insurance companies, the pharmaceutical industry, those are the most common folks who speak against a Single-Payer National Health Insurance Program.


Question: What healthcare system do you propose?


Fein: Okay, let’s start with what we’re calling a single-payer National Health Insurance Program and let me be very clear that that’s confusing to people. I’ve had people come up and tell me you mean I have to be single to qualify for your health plan? No.

What we are talking about is a program that essentially provides automatic enrollment for anyone who lives in the United States, that’s what real universal coverage is. Somebody presents to an emergency room they don’t have health insurance, let’s take the opportunity and sign you up right there because you should be automatically enrolled. There is no private health insurance company in the United States that would enroll you when you came to the emergency room.

The second principle is that the coverage should be really comprehensive. Everything from preventive care, through doctor, hospital, mental health, dental, to nursing home care all medically necessary services.

The third principal is that it should be financed by a public system in essence. The way in which we finance private health insurance today is using premiums. And premiums are really relatively unfair. The president of the company pays the same premium as the secretary yet their incomes are so widely different. Public financing means that it would be scaled according to income.

And, the fourth principle is that all of this should be done through a much more simple administration and that’s what single payer is. For instance, the Medicare program, which is our one example of a single payer program in the United States, has a 4% overhead, 3 to 4%, whereas private health insurance can be anywhere from 20 to 30%.

And finally, all of these should be delivered essentially through a, how to describe it, a private delivery system. It’s public financing, private delivery.

Let me say that in addition to that there should be free choice of doctor and hospital and really that’s what a single-payer program would offer. That, right now in private health insurance you are limited to a network of doctors and a network of hospitals. You have to pay, frequently, substantially more if you want to go outside that network, whereas in single payer you can go to any doctor and hospital.

So you might ask the question, “Is there any health insurance program in the United States that resembles what we are talking about?” And I would like to say, “Yes. It’s the traditional Medicare program.” It’s essentially a program that is publicly financed but privately delivered and that’s what we are talking about.


Topic: White House Summit on Healthcare and healthcare reform


Fein: Okay, well let me start with the White House conference. We were invited largely because initially someone representing the single-payer position had not been invited including Representative Conyers who was the major sponsor of H.R. 676, the bill that in the last congress had 93 co-sponsors in the house, it had the most co-sponsors that any healthcare bill but he wasn’t invited, and then no one was invited from our organization, Physicians for National Health Program. So we, you know, call the White House, we had people from around the country get involved, we actually even threaten to do a white coat demonstration outside the White House and we were finally invited, literally, myself the day before the conference itself. So that was how we got there.

When we were there, we were able to be full participants and the essential agenda of the White House Summit on Healthcare I think was three things.

One was it was all broadcast on C-Span so the president was saying, “I am being transparent. I want you to see what’s happening in healthcare reform.”

Secondly, he invited quite a few Congress people, probably 52 if I count correctly, senators and representatives from the house but from both parties. So the second message was, I’m going to try to be bipartisan from the beginning.

And then the third message of the Summit was I am not going to dictate to Congress what they come out with. I’m handing all the significant issues over to Congress.

So, the overall message I think was I’m doing this different from Hilary Clinton and the Clinton’s in general. I’m trying to approach this with transparency, bipartisanship, and letting Congress take the initiative.

Now, the problem with that is that I think the president is going to have to take leadership here particularly if we’re going to get a significant reform and so far the notion that you can include the private health insurance industry and maintain a multi-payer system essentially I think really flies in the face of the evidence that it’s possible to do this.

First, you know, there isn’t going to be the dollars to grant access to all those who are uninsured nor to improve the policies for people who are under insured. The way single payer does that is that it removes a lot of the administrative cost of private health insurance but even more importantly, the administrative cost in my office of having to have an extra person to deal with all the multiple insurance companies each of whom have their own rules. In fact, hospitals will have smaller administrative cost.

We compare Toronto General with a similarly sized hospital in the United States. Toronto General has 3 billers. It is in the single payer system in Canada. We had over 300 billers in the comparable sized, US hospital. So if we convert it to a single-payer program, there would be the funds there without increasing the overall cost to the system. There would be the funds there to grant universal coverage automatic enrollment and to improve the kinds of policies that people have, that they are now getting from private health insurance companies.


Oliver Fein: What is it that allows an individual to express their humanity, to essentially be able to fulfill their human promise? Well, there are certain things, like education, that we think allow for that, like political expression, freedom of expression; but, if you don’t have health, all the education will mean nothing.

My name is Oliver Fein and I am a physician working at the Weill Cornell Medical College where I am the Associate Dean and also Professor of Clinical Medicine and Clinical Public Health.


Question: What obstacles limit access to quality healthcare?


Oliver Fein: The financial access is extremely important as a primary baseline. That’s why I’m interested in the issue of national health insurance. But, once you get over that barrier, there are going to be other barriers that have to be transcended. Among those, it seems to me, are things like health literacy, the degree to which things are interpreted for people so they really understand the decisions that they’re making when they access healthcare. In terms of the rural side of the United States, there is a whole issue of geographic accessibility, the ability to get to healthcare and frankly we’re going to be able to do some great things in that territory, given the whole internet and ways in which consultations should be possible for physicians and nurse practitioners that are in remote areas. They’ll be able to use technology to get to consultations with specialists, that kind of thing.

And then thirdly, there’s the whole issue of the doctor-patient relationship and communication within it. There I think what we should be moving towards is what increasingly is being called the “patient-centered medical home.” Everybody should feel that they have a medical home in this country. What does that home consist of? Not just a doctor, not just a nurse practitioner, but a whole team of people who are there to provide care to people.


Question: How would you design a medical home?


Oliver Fein: The way it works, in my mind, is that there would be a group of providers, so to speak, in an office. If I am dealing with patients who have diabetes and hypertension, a number of chronic illnesses, I will have access, right in that office, to a nutritionist who could advise patients how to alter their diets, to deal with their problems with diabetes, with obesity, with hypertension, those kinds of things.

That in addition, there might be an outreach worker in the office. Someone misses an appointment, they’re called up, and we ascertain why they missed the appointment. We might even arrange for some kind of a home visit to that patient as a way of really having the office extend beyond just the office.

And then thirdly, and very importantly, is that a lot of what we would do is coordinate a person’s care, be able to link them to the appropriate specialist when that was needed, to become a real gateway to care. I’m no talking about this whole idea of a gate keeper that kind of keeps people away from care, but rather facilitates and coordinates the care that people get from specialists.


Question: How can we improve healthcare outcomes?


Oliver Fein: When we measure quality in healthcare, there are kind of three different types of metrics.

One of them is what we call a structural method. Do you have a license? That means have you passed an exam of some kind. Not a very really good measure of quality, to be honest, because it’s not continuing and so forth.

Secondly, are process measures like, did the doctor actually get a mammogram on a woman to rule out breast cancer? Did the doctor do a test for diabetes? Those kinds of measures, and they’re good, but they’re important but the goal standard usually is outcome.

Has there been a difference made in terms of the control of the diabetes, the control of the blood pressure and so on? So increasingly there is discussion about, do we reimburse doctors? Do we pay them in any way relative to quality? And do we pay them to perform well? I think that’s a good idea provided that one is aware of some of the pitfalls, and the vulnerable populations are the pitfalls, frankly. Let’s say we’re going to pay people more if, in fact, they did preventive interventions, had good outcomes, and what happened was that we would pay people less who didn’t have that, doctors who didn’t have that, and those doctors frequently might be serving poor communities where people didn’t always take their medications because they couldn’t afford them. Where there might have been problems with the job they got lost, and they got unemployed and really their health was the second priority, getting the job was the first.

We would have to think of ways to deal with those kinds of circumstances in a, what we will call pay for performance system, so that the doctors serving the vulnerable populations didn’t get paid less and less because they weren’t able to provide the outcomes that somebody who was dealing with an Upper East Side population was dealing with.


Question: Is there hope for a fully integrative medicine?


Oliver Fein: Actually, integrative medicine is an important component of what medicine should be delivering today. By that I mean, let’s think in terms of, again, diabetes, hypertension, obesity, those chronic illnesses that are very prevalent in our society. The physician intervention is frequently, take this pill, or take insulin for the diabetes, and the pill for the hypertension. But we we need to pair that with nutritionists who are helping people deal with their diet, weight loss and things of that sort. We need to pair that, frankly, in high blood pressure, with stress reducers. We should be, in fact, incorporating in our practices referrals for exercise training, maybe even yoga training to deal with stress. That’s why this team-based care that I was describing earlier, the patient-centered medical home, which had really a whole variety of providers in it, not just doctors, seems to me be the way to move. So, integrative medicine should be very much a part of what doctors are involved with.


Question: How important are electronic medical records to your practice?


Oliver Fein: I can say, from my own practice, that we are completely paperless now. The hospital is just about completely paperless.

What it means for patients is that when I’m not able to be on call, let’s say over a weekend, but my partner is, my partner can go directly to my medical record, and see what the patient’s medication are, can see what’s happened recently, what the latest laboratory studies were, and so on. It really provides a way of improving the quality of the relationship between doctor and patient.

Then the other thing is, that it does lead to things that I would call better patient safety. That is to say that, prescriptions that used to be handwritten could be misinterpreted, particularly with my handwriting, by the pharmacist. Now, all of my prescriptions are printed out. There is no chance for this kind of misinterpretation.

What we’re not doing, now, in medical records is that my medical records aren’t accessible if my patient is in Florida, or on the West Coast, or for that matter, frankly, going to another hospital here in New York City.

Somebody is brought by an ambulance to St. Luke’s Roosevelt, rather than to New York Presbyterian, they don’t know what I’ve done. And that interconnectivity of medical records is really the promise of a good computerized medical records system.

Question: What is the next big medical breakthrough?

Oliver Fein: The real thing that I think isn’t talked about a lot is the phenomenon of what is now being called epigenetics. What that means is that the gene may not be as important as the environment in which it develops. That gets back to the medical home, that gets back to trying to truly alter essentially the problem of obesity, which is rampant now in the country. If we can deal with those epigenetic phenomenon, if we can create practices that are really able to embrace dealing with those problems, then in fact, the true benefit of genetic technology will be able to be realized. But up until that time, the epigenetics are going to shape a lot of what’s possible in the genetic revolution.


A conversation with the Associate Dean of Weill Cornell Medical College.

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Yale scientists restore brain function to 32 clinically dead pigs

Researchers hope the technology will further our understanding of the brain, but lawmakers may not be ready for the ethical challenges.

Still from John Stephenson's 1999 rendition of Animal Farm.
Surprising Science
  • Researchers at the Yale School of Medicine successfully restored some functions to pig brains that had been dead for hours.
  • They hope the technology will advance our understanding of the brain, potentially developing new treatments for debilitating diseases and disorders.
  • The research raises many ethical questions and puts to the test our current understanding of death.

The image of an undead brain coming back to live again is the stuff of science fiction. Not just any science fiction, specifically B-grade sci fi. What instantly springs to mind is the black-and-white horrors of films like Fiend Without a Face. Bad acting. Plastic monstrosities. Visible strings. And a spinal cord that, for some reason, is also a tentacle?

But like any good science fiction, it's only a matter of time before some manner of it seeps into our reality. This week's Nature published the findings of researchers who managed to restore function to pigs' brains that were clinically dead. At least, what we once thought of as dead.

What's dead may never die, it seems

The researchers did not hail from House Greyjoy — "What is dead may never die" — but came largely from the Yale School of Medicine. They connected 32 pig brains to a system called BrainEx. BrainEx is an artificial perfusion system — that is, a system that takes over the functions normally regulated by the organ. The pigs had been killed four hours earlier at a U.S. Department of Agriculture slaughterhouse; their brains completely removed from the skulls.

BrainEx pumped an experiment solution into the brain that essentially mimic blood flow. It brought oxygen and nutrients to the tissues, giving brain cells the resources to begin many normal functions. The cells began consuming and metabolizing sugars. The brains' immune systems kicked in. Neuron samples could carry an electrical signal. Some brain cells even responded to drugs.

The researchers have managed to keep some brains alive for up to 36 hours, and currently do not know if BrainEx can have sustained the brains longer. "It is conceivable we are just preventing the inevitable, and the brain won't be able to recover," said Nenad Sestan, Yale neuroscientist and the lead researcher.

As a control, other brains received either a fake solution or no solution at all. None revived brain activity and deteriorated as normal.

The researchers hope the technology can enhance our ability to study the brain and its cellular functions. One of the main avenues of such studies would be brain disorders and diseases. This could point the way to developing new of treatments for the likes of brain injuries, Alzheimer's, Huntington's, and neurodegenerative conditions.

"This is an extraordinary and very promising breakthrough for neuroscience. It immediately offers a much better model for studying the human brain, which is extraordinarily important, given the vast amount of human suffering from diseases of the mind [and] brain," Nita Farahany, the bioethicists at the Duke University School of Law who wrote the study's commentary, told National Geographic.

An ethical gray matter

Before anyone gets an Island of Dr. Moreau vibe, it's worth noting that the brains did not approach neural activity anywhere near consciousness.

The BrainEx solution contained chemicals that prevented neurons from firing. To be extra cautious, the researchers also monitored the brains for any such activity and were prepared to administer an anesthetic should they have seen signs of consciousness.

Even so, the research signals a massive debate to come regarding medical ethics and our definition of death.

Most countries define death, clinically speaking, as the irreversible loss of brain or circulatory function. This definition was already at odds with some folk- and value-centric understandings, but where do we go if it becomes possible to reverse clinical death with artificial perfusion?

"This is wild," Jonathan Moreno, a bioethicist at the University of Pennsylvania, told the New York Times. "If ever there was an issue that merited big public deliberation on the ethics of science and medicine, this is one."

One possible consequence involves organ donations. Some European countries require emergency responders to use a process that preserves organs when they cannot resuscitate a person. They continue to pump blood throughout the body, but use a "thoracic aortic occlusion balloon" to prevent that blood from reaching the brain.

The system is already controversial because it raises concerns about what caused the patient's death. But what happens when brain death becomes readily reversible? Stuart Younger, a bioethicist at Case Western Reserve University, told Nature that if BrainEx were to become widely available, it could shrink the pool of eligible donors.

"There's a potential conflict here between the interests of potential donors — who might not even be donors — and people who are waiting for organs," he said.

It will be a while before such experiments go anywhere near human subjects. A more immediate ethical question relates to how such experiments harm animal subjects.

Ethical review boards evaluate research protocols and can reject any that causes undue pain, suffering, or distress. Since dead animals feel no pain, suffer no trauma, they are typically approved as subjects. But how do such boards make a judgement regarding the suffering of a "cellularly active" brain? The distress of a partially alive brain?

The dilemma is unprecedented.

Setting new boundaries

Another science fiction story that comes to mind when discussing this story is, of course, Frankenstein. As Farahany told National Geographic: "It is definitely has [sic] a good science-fiction element to it, and it is restoring cellular function where we previously thought impossible. But to have Frankenstein, you need some degree of consciousness, some 'there' there. [The researchers] did not recover any form of consciousness in this study, and it is still unclear if we ever could. But we are one step closer to that possibility."

She's right. The researchers undertook their research for the betterment of humanity, and we may one day reap some unimaginable medical benefits from it. The ethical questions, however, remain as unsettling as the stories they remind us of.

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