A doctor who embraces change, personally and politically
By Stacey Butterfield
In an era when even small changes to the health care system are highly controversial, leading a campaign for a single-payer system might seem like a daunting task to some. But Andrew D. Coates, MD, FACP, the new president of Physicians for a National Health Program (PNHP), has already tackled unusual challenges in his career.
Dr. Coates didn’t start medical school until he was in his 30s. Prior to attending Columbia University College of Physicians and Surgeons in New York City, he worked in carpentry, factories and a feed mill. “I did hard jobs. ... I had a little bit of an adventure in terms of living in different cities and taking manual labor jobs,” he said. “Then I went to graduate school in history.”
Switching things up again, Dr. Coates turned down opportunities to turn his MA in history into a PhD and instead applied to medical schools. “When I was young I really wanted to be a doctor. I just assumed by the choices I made in college that after that it wasn’t going to happen,” he said. “I hadn’t taken any science classes since 11th grade, so it was a winding road.”
At the end of that road was internal medicine training, and then practice, in upstate New York. But even after settling down there, with children and lifelong connections, and attaining specializations in hospital medicine and palliative care, he grabbed an opportunity to mix things up.
“I took a temporary job at the Northern Navajo Medical Center in Shiprock, New Mexico, and we went as a family ... I needed an interpreter, a cultural interpreter as well as a language interpreter, when meeting specific patients,” said Dr. Coates. “The cultural insights were inspiring. Overall I gained a deeper conviction about what medicine has to offer every human being.”
Today, Dr. Coates offers his services as a community hospitalist in Troy, N.Y. “The needs are enormous and we often work over 200 hours a month. We also take turns doing nights, to make sure that one of our group is always available on the floors as well as to do the admissions. I went there because I wanted the experience of practicing the full spectrum of hospital medicine, and I love it,” he said.
Picking up another piece of the medical spectrum, he also serves as a medical director of a local public nursing home, which he describes as having great clinical care (“In recent years, no patient here has gotten a decubitus ulcer,” he said) but crumbling infrastructure (“The roof leaks”).
A recent proposal to privatize the nursing home holds the potential to damage the quality of care, he worries. “We have a great respiratory therapist and superb wound care and rehab nurses, for instance. For-profit nursing homes simply lack the kind of clinical depth that our patients count upon,” he said. “The nursing home experience has raised my consciousness about why public care is superior to private, for-profit care.”
In his newest role, at the helm of the nonprofit PNHP (his two-year term started Jan. 1), he hopes to raise physicians’, patients’ and policymakers’ consciousness about making a clean break with what he characterizes as the “dysfunctional and wasteful” private health insurance model of financing care.
He sees the present costs faced by individuals as hazardous to health: “The evidence shows that co-pays, deductibles and co-insurance schemes cause our patients to avoid necessary care.”
He doubts that reforms currently under way will reorganize how the profession interacts with society.
“If the goal remains to reduce costs and improve quality, I don’t think these things will work. Eventually, we’ve got to deal with the evidence,” he said. “The elements touted to save costs—electronic health records, accountable care organizations—these are not proven to save costs.”
Dr. Coates and his colleagues in the education-oriented, 18,000-member PNHP advocate for a publicly financed, streamlined single-payer model that he says would reduce costs by slashing administrative waste.
“This would free physicians from a mountain of worry about how our patients’ care will be reimbursed, and thus restore the physician-patient relationship,” he said. “There is no question that we could provide best-quality, comprehensive care to all patients. We have all of the necessary resources—especially great health professionals—to do it. It’s just a question of our consciousness.”
Something I wish I’d learned in medical school: Economics.
Personal hero: Rudolf Virchow, the 19th century pathologist and public health advocate.
Favorite ways to spend free time: Cooking for our family, hiking mountains.
Most recent book read: “Medicine and Public Health at the End of Empire” by Howard Waitzkin, MD, PhD.
Regret: Not showing as much kindness as I feel toward others.
If I weren’t a physician, I would be: Working for a living (That’s a joke, y’all).
Where ACP stands
ACP published a position paper in the Jan. 1, 2008, Annals of Internal Medicine titled “Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries.” The position paper offered several policy recommendations, including the following.
Recommendation 1a: Provide universal health insurance coverage to assure that all people within the United States have equitable access to appropriate health care without unreasonable financial barriers. Health insurance coverage and benefits should be continuous and not dependent on place of residence or employment status. The ACP further recommends that the federal and state governments consider adopting one or the other of the following pathways to achieving universal coverage:
1. Single-payer financing models, in which one government entity is the sole third-party payer of health care costs, can achieve universal access to health care without barriers based on ability to pay. Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than systems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satisfaction, and high performance on measures of quality and access. They may require a higher tax burden to support and maintain such systems, particularly as demographic changes reduce the number of younger workers paying into the system. Such systems typically rely on global budgets and price negotiation to help restrain health care expenditures, which may result in shortages of services and delays in obtaining elective procedures and limit individuals’ freedom to make their own health care choices.
2. Pluralistic systems, which involve government entities as well as multiple for-profit or not-for-profit private organizations, can assure universal access, while allowing individuals the freedom to purchase private supplemental coverage, but are more likely to result in inequities in coverage and higher administrative costs (Australia and New Zealand). Pluralistic financing models must provide 1) a legal guarantee that all individuals have access to coverage and 2) sufficient government subsidies and funded coverage for those who cannot afford to purchase coverage through the private sector.
The full position paper is available online.
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